Midwife Licensure Exam Midwifery Pharmacology & Newborn Procedures — Mandated Newborn Procedures by the MidwifeCheat Sheet

Common Values

Section Title

EINC / Unang Yakap — The Four Sacred Steps (First Minutes)

Important Facts

• STEP 1 — IMMEDIATE & THOROUGH DRYING (first 30 seconds): Dry the entire body and head with a clean, warm, dry cloth. Do NOT wipe off vernix. Purpose: prevent hypothermia and stimulate breathing.
• STEP 2 — EARLY SKIN-TO-SKIN CONTACT (immediately after drying): Place naked, dried baby prone on mother's bare abdomen/chest. Cover both with a warm, dry cloth. Put a bonnet on baby. Purpose: maintain warmth, promote bonding, facilitate crawling to breast.
• STEP 3 — PROPERLY TIMED CORD CLAMPING (1–3 minutes after birth): Clamp and cut cord ONLY AFTER cord pulsations stop completely. Delayed cord clamping improves newborn iron stores and reduces anemia risk.
• STEP 4 — NON-SEPARATION FOR EARLY BREASTFEEDING (ideally within 90 minutes): Keep mother and baby together continuously. Support baby's crawl to breast and first latch. Facilitate rooming-in.
• DO NOT routine suction, routine early bathing (delay ≥6 h, ideally 24 h), routine suctioning of meconium if baby is vigorous, or separate mother and baby.
• Suctioning ONLY if baby is not breathing or has obvious airway obstruction; never routine.
• Meconium-stained amniotic fluid (MSAF): If baby is VIGOROUS (breathing/crying, good tone, HR ≥100), treat as normal and do NOT suction. If baby is NOT breathing or gasping, call for help, clamp cord, begin bag-mask ventilation within 60 seconds (golden minute).

Key Definitions

Diagrams To Know

• Sequence of four EINC steps with timing labels
• Skin-to-skin positioning diagram (baby prone on mother's abdomen)
• Delayed cord clamping timeline (1–3 min post-birth)

Common Values

Section Title

APGAR Score & Immediate Assessment

Important Facts

• APGAR is NOT a resuscitation trigger; breathing, tone, and HR guide resuscitation, which begins immediately if needed—do not wait for 1-minute score.
• Score 7–10 = GOOD/NORMAL; score 4–6 = MODERATELY DEPRESSED (needs stimulation, possible support); score 0–3 = SEVERELY DEPRESSED (active resuscitation + referral).
• Score at 1 minute AND 5 minutes (then every 5 min up to 20 min if depressed).
• If 1-minute score is 0–3, continue resuscitation and recheck at 5, 10, 15, 20 minutes.
• Appearance (color): 0 = blue/pale all over, 1 = body pink/extremities blue, 2 = completely pink.
• Pulse (HR): 0 = absent, 1 = <100/min, 2 = ≥100/min.
• Grimace (reflex irritability): 0 = no response, 1 = grimace, 2 = cry/cough/sneeze.
• Activity (muscle tone): 0 = limp, 1 = some flexion, 2 = active motion.
• Respiration: 0 = absent, 1 = slow/irregular/weak cry, 2 = good strong cry.

Key Definitions

Diagrams To Know

• APGAR scoring table with 5 components and 0–2 point ranges
• APGAR interpretation flowchart (score → action pathway)

Common Values

Section Title

Thermoregulation & Vital Signs

Important Facts

• Normal axillary temperature: 36.5–37.5 °C.
• Below 36.5 °C = hypothermia; above 37.5 °C = hyperthermia (less common).
• Newborns lose heat via evaporation (fastest, during drying), conduction, convection, radiation.
• Room temperature should be 25–28 °C (warm and draft-free).
• Skin-to-skin contact is the PRIMARY heat source; use bonnet to prevent head heat loss.
• Delayed bathing (≥6 h, ideally 24 h) preserves vernix and prevents heat loss.
• Normal newborn RR: 40–60 breaths/min (may be irregular in first hours).
• Normal newborn HR: 120–160 bpm (lower during sleep, higher during crying/activity).
• Hypothermia is an emergency in small/preterm babies; refer if does not correct with warmth.

Key Definitions

Diagrams To Know

• Warm chain sequence diagram (5–6 practices in order)
• Heat loss mechanisms in newborn (evaporation, conduction, convection, radiation)

Common Values

Section Title

Cord Care & Management

Important Facts

• Delayed cord clamping (DCC) timing: 1–3 minutes AFTER birth, AFTER cord pulsations stop (not before).
• DCC benefits: increases placental blood volume → higher hemoglobin and iron stores in baby → reduces anemia risk.
• Cord is cut with sterile blade/scissors between two clamps or ties.
• After clamping, fold the diaper BELOW the cord to expose it to air.
• Dry cord care: keep clean and dry. Do NOT apply alcohol, chlorhexidine (unless high-risk), antiseptic, or any dressing in routine settings.
• Cord stump separates naturally in 5–15 days.
• Teach mother the DANGER SIGNS of omphalitis: redness, swelling, foul-smelling discharge, bleeding from the cord.
• If omphalitis suspected, refer immediately; do NOT treat at home.
• Document cord care counseling in delivery notes.

Key Definitions

Diagrams To Know

• Timeline of delayed cord clamping (pulsation → wait 1–3 min → clamp)
• Cord care steps (clamping position, cutting, stump care, diaper folding)

Formulas

Common Values

Section Title

Vitamin K Prophylaxis (VKDB Prevention)

Important Facts

• Every newborn receives Vitamin K1 (phytomenadione) IM as routine prophylaxis.
• Dose: 1 mg IM for term or normal-weight baby.
• Dose: 0.5 mg IM for preterm or LBW baby (<1.5 kg).
• Route: ALWAYS intramuscular (IM), NEVER intravenous (IV). IV causes hemolysis and is fatal.
• Site: Anterolateral thigh (vastus lateralis muscle)—safest, least pain, no nerve/vessel damage.
• Timing: Within first hour(s) after birth, AFTER drying and skin-to-skin.
• Give Vitamin K BEFORE newborn screening heel-prick if possible (reduces bruising/bleeding risk).
• Can be given during first breastfeed without delaying feeding.
• Document: time, dose, route, site, batch number of vaccine.

Key Definitions

Diagrams To Know

• Vitamin K prophylaxis checklist (dose, route, site, timing)
• Vastus lateralis injection site diagram

Formulas

Common Values

Section Title

Eye Prophylaxis (Ophthalmia Neonatorum Prevention)

Important Facts

• Mandated eye prophylaxis for EVERY newborn (regardless of maternal history).
• Agent: Erythromycin 0.5% ophthalmic ointment (or tetracycline 1% ointment as alternative).
• Method: Instill thin ribbon of ointment into EACH lower conjunctival sac, from inner canthus to outer canthus.
• Timing: After first breastfeed/bonding, ideally within first hour of birth.
• Do NOT irrigate after instillation; ointment must stay in contact with conjunctiva.
• Check both eyes are treated; do NOT skip one eye.
• No adverse effects from erythromycin ointment in newborn eyes.
• Document: agent used, both eyes treated, time, any reaction.

Key Definitions

Diagrams To Know

• Eye anatomy diagram showing lower conjunctival sac and application technique (inner to outer canthus)
• Step-by-step eye prophylaxis procedure

Common Values

Section Title

Newborn Screening (RA 9288)

Important Facts

• RA 9288 (Newborn Screening Act of 2004) makes NBS mandatory for every newborn.
• Method: Heel-prick (capillary blood) onto special filter-paper card.
• Ideal timing: 24 to 72 hours after birth. Do NOT collect before 24 h (false results, esp. 17-OHP/CAH).
• If baby discharged before 24 h, collect at 24 h anyway; if discharged before 24 h is possible, REPEAT screen by 2 weeks of age.
• Attendant (midwife) is LEGALLY RESPONSIBLE for collecting sample and informing parents of availability/benefits.
• Parents may refuse ONLY after being fully informed; refusal must be documented.
• Expanded panel screens: Congenital Hypothyroidism (CH), Congenital Adrenal Hyperplasia (CAH), Galactosemia (GAL), Phenylketonuria (PKU), Glucose-6-Phosphate Dehydrogenase deficiency (G6PD), Maple Syrup Urine Disease (MSUD), plus hemoglobinopathies, biotinidase deficiency, cystic fibrosis (in expanded panels).
• Congenital Hypothyroidism (CH): Prevents severe intellectual disability with early thyroxine. Most common screened disorder.
• Positive/High-risk results: Family referred urgently for confirmatory testing (serum TSH, free T4, 17-OHP, etc.). Do NOT delay.
• Second-tier screening: Some high-risk results get second-tier test (reflex testing) before notifying family to reduce false positives.
• Midwife documents: timing of collection, card number, baby's name, date of birth, mother's name, serial number, and sends to regional NBS center.

Key Definitions

Diagrams To Know

• NBS timeline (24–72 h after birth, ideal 48 h)
• Heel-prick sampling technique (site, needle angle)
• Expanded panel disorders and their preventable sequelae

Common Values

Section Title

Newborn Hearing Screening (RA 9709)

Important Facts

• RA 9709 (Universal Newborn Hearing Screening and Intervention Act of 2009) mandates screening for every newborn.
• Methods: Otoacoustic Emissions (OAE) and/or Automated Auditory Brainstem Response (AABR)—both painless, quick (<5 min).
• Timing: Before discharge from hospital/BHS, or within first month of life (latest by 3 months).
• No special preparation needed; baby can be sleeping or awake.
• Purpose: Early detection of congenital hearing loss to enable intervention by 6 months and prevent speech/language delay.
• Results: 'Pass' = normal hearing; 'Refer' = needs repeat/confirmatory testing (NOT confirmed hearing loss, just needs follow-up).
• Positive/Refer result: Schedule follow-up audiologic evaluation (otoacoustic emissions, auditory brainstem response, behavioral testing).
• At RHU/BHS without screening equipment: Midwife counsels on importance, provides written referral to screening facility, documents referral and date.
• Risk factors for hearing loss: Family hx of hearing loss, prematurity, low birth weight, maternal infections (TORCH), aminoglycoside exposure, birth asphyxia.
• Document: screening date, method used (OAE/AABR), result (pass/refer), follow-up plan, referral given if needed.

Key Definitions

Diagrams To Know

• Newborn hearing screening pathway (screening → pass/refer → follow-up)
• OAE and AABR testing techniques (simple diagram)

Common Values

Section Title

Birth Immunizations (BCG & Hepatitis B)

Important Facts

• BCG vaccine: Dose 0.05 mL (intradermal, not IM), given into upper arm within 24 hours of birth.
• BCG creates a small papule at site; ulceration and healing is normal (BCG-itis is expected).
• Hepatitis B (HBV) vaccine: 0.5 mL IM (intramuscular), given within 24 hours of birth.
• If mother is HBsAg-positive: Give HBV + HBIG (Hepatitis B Immune Globulin) within 6–12 hours (urgent).
• Both vaccines are part of Philippine EPI (Expanded Program on Immunization) and are mandatory.
• BCG and HBV do NOT have to be simultaneous; can be given separately.
• Sites: BCG in upper arm (intradermal); HBV preferably in anterolateral thigh (IM) to avoid confusion with vitamin K injection site.
• Document: vaccine name, dose, route, site, time, batch number, mother's HBsAg status (for HBV).
• Inform mother: BCG will ulcerate and drain—this is normal; no dressing needed; baby should not have repeated TB tests (BCG causes false positive TB skin test).

Key Definitions

Diagrams To Know

• Birth immunization schedule (BCG and HBV within 24 h)
• Injection sites (BCG arm, HBV thigh) to avoid overlap

Common Values

Section Title

Recognition & Referral of Complications (Detect & Refer)

Important Facts

• REFER IF BABY NOT BREATHING AT 1 MIN: Do NOT wait for APGAR score. Begin resuscitation (positioning, airway, ventilation) immediately within golden minute.
• REFER IF APGAR 0–3 AT 5 MIN: Continue resuscitation, maintain warmth, prepare for transfer to hospital.
• REFER IF SEVERE BIRTH ASPHYXIA SIGNS: Central cyanosis not resolving, gasping, extreme lethargy, absent reflexes—begin resuscitation, notify family, transfer emergently.
• REFER IF HYPOTHERMIA (<36.5°C) not correcting: Keep skin-to-skin, recheck in 30 min; if persistent despite warmth, refer.
• REFER IF OMPHALITIS SUSPECTED: Cord redness, swelling, foul discharge—do NOT treat at RHU; refer to hospital for IV antibiotics.
• REFER IF OMPHALOCELE/GASTROSCHISIS: Abdominal wall defect with intestines visible or in sac. Do NOT manipulate. Cover with clean dry cloth, keep warm, refer immediately.
• REFER IF SEVERE JAUNDICE IN FIRST 24 H: Bilirubin phototherapy needed; refer to hospital.
• REFER IF SIGNS OF INFECTION: Fever (>38°C axillary), hypothermia (<36.5°C), lethargy, poor feeding, respiratory distress, pustules, umbilical cellulitis.
• REFER IF RESPIRATORY DISTRESS: RR >60, grunting, nasal flaring, retractions, cyanosis—refer to hospital for oxygen/CPAP.
• REFER IF SEVERE BLEEDING: Cord bleeding >5 min after clamping, cephalohematoma with signs of hypovolemia, petechiae/purpura (sepsis risk).
• REFER IF GROSS ANOMALIES: Cleft palate, major cardiac defect, Down syndrome phenotype, ambiguous genitalia (needs evaluation).
• REFER IF POOR FEEDING/LETHARGY: Weak suck, refusal of breast despite positioning, extreme sleepiness—may indicate infection, jaundice, metabolic problem.
• REFER IF SEIZURES/ABNORMAL MOVEMENTS: Jitteriness that does NOT stop with gentle handling, true seizures—refer for evaluation.
• At RHU/BHS: Midwife recognizes danger signs early, informs family clearly, documents reason for referral, arranges transport, and if possible, accompanies or sends written referral with baby.

Key Definitions

Diagrams To Know

• Newborn danger signs checklist (respiratory, thermal, infectious, hemorrhagic, neurologic)
• Referral flowchart (sign detected → action → transfer)

Section Title

Procedural Sequence & Timing Summary

Important Facts

• MINUTE 0–1: Delivery. Dry baby (30 s). Assess breathing/crying. If NOT breathing → golden minute resuscitation + referral.
• MINUTE 1: APGAR score at 1 minute.
• MINUTE 1–3: Skin-to-skin contact. Support early breastfeeding initiation. Delayed cord clamping (wait until pulsations stop).
• MINUTE 5: APGAR score at 5 minutes.
• WITHIN 1 HOUR: Vitamin K1 IM (1 mg term, 0.5 mg preterm), eye prophylaxis (erythromycin), BCG IM (0.05 mL intradermal), HBV IM (0.5 mL).
• WITHIN 24 HOURS: Complete weight, length, head circumference. Full head-to-toe exam. Cord care (dry, expose, diaper below). Counseling on danger signs, omphalitis, feeding, thermal care.
• AT 24–72 HOURS: Newborn screening (heel-prick filter-paper card) collected, ideally at 48 hours.
• BEFORE DISCHARGE / WITHIN 1 MONTH: Newborn hearing screening (OAE/AABR) or referral for screening if no equipment.
• DELAYED (6–24 HOURS): First bath (after stable, normothermic, feeding established).
• ONGOING: Rooming-in, exclusive breastfeeding, thermal monitoring, cord care, observation for danger signs.

Diagrams To Know

• Timeline of mandated procedures (first hour, first 24 h, 24–72 h, before discharge)

Rows

Columns

• Component
• 0 Points
• 1 Point
• 2 Points

Table Title

APGAR Scoring Breakdown

Rows

Columns

• Score Range
• Interpretation
• Midwife Action

Table Title

APGAR Interpretation & Action

Rows

Columns

• Category
• Birth Weight
• Dose
• Route
• Site

Table Title

Vitamin K1 Dosing by Birth Weight/Maturity

Rows

Columns

• Parameter
• Normal Range
• Abnormal / Referral Threshold

Table Title

Normal Newborn Vital Signs & Physical Findings

Rows

Columns

• Disorder (Abbreviation)
• Presentation if Untreated
• With Early Detection/Treatment

Table Title

Newborn Screening (RA 9288) Disorders