Midwife Licensure Exam Midwifery Pharmacology & Newborn Procedures — Mandated Newborn Procedures by the MidwifeDetailed Explanation

Examples

Applications

• Applied in every normal delivery at the BHS, RHU, or lying-in clinic
• Used to counsel mothers and families about why the baby is not bathed immediately
• Framework for educating birth companions and BHWs during pre-natal and community health education
• Basis for evaluating quality of intrapartum care in BEmONC assessments
• Referenced in DOH MNCHN program audits

Misconceptions

• MISCONCEPTION: Suctioning is always done first to clear the airway. FACT: Routine suctioning of a vigorous baby is NOT done — it is an EINC 'do-not-do.' Suctioning is only for non-breathing or airway-obstructed babies.
• MISCONCEPTION: Cord clamping should be done as quickly as possible to prevent blood loss. FACT: Delayed cord clamping (waiting until pulsations stop, 1–3 minutes) benefits the baby by allowing placental blood transfusion.
• MISCONCEPTION: The vernix should be wiped off because it is dirty. FACT: Vernix is NOT wiped off — it is a protective, antimicrobial, moisturizing coating that should remain on the baby's skin.
• MISCONCEPTION: Bathing the baby soon after birth is hygienic. FACT: Early bathing causes hypothermia and removes vernix — it is delayed at least 6 hours, ideally 24 hours.
• MISCONCEPTION: Foot-printing can be done before skin-to-skin to document the birth. FACT: Foot-printing is done AFTER skin-to-skin and breastfeeding initiation, not before.

Related Concepts

• Thermoregulation and Hypothermia Prevention
• APGAR Score Assessment
• Newborn Resuscitation — Golden Minute
• Early Breastfeeding and Colostrum
• Cord Care and Omphalitis

Common Exam Questions

Key Points To Remember

• Four EINC steps in order: Dry (30 sec) → Skin-to-skin → Delayed cord clamping (1–3 min, after pulsations stop) → Non-separation for early breastfeeding (within 90 min)
• Do NOT routinely suction a vigorous, breathing baby
• Delay bathing at least 6 hours, ideally 24 hours after birth
• Do NOT wipe off the vernix caseosa
• Skin-to-skin: baby prone on mother's bare chest/abdomen, cover both, put bonnet on baby
• Delayed cord clamping improves iron stores and reduces anemia risk
• Early breastfeed ideally within first 90 minutes of life
• Suctioning is ONLY done when the baby is not breathing or has obvious airway obstruction

Examples

Applications

• Used in every delivery as a standardized communication tool among health workers
• Documents the newborn's condition at birth for the partograph and birth certificate
• Guides the decision to observe vs. stimulate vs. refer the newborn
• Basis for NBS timing decisions (a depressed baby needing referral may have NBS done before discharge or at referral facility)
• Used in BEmONC quality assurance and maternal-neonatal death reviews

Misconceptions

• MISCONCEPTION: You must wait for the 1-minute APGAR score before deciding whether to resuscitate. FACT: Resuscitation is based on breathing, tone, and HR observed immediately at birth — you begin within the Golden Minute without waiting for a formal score.
• MISCONCEPTION: Acrocyanosis (blue hands and feet) in the first minutes means the baby needs oxygen. FACT: Peripheral cyanosis/acrocyanosis is NORMAL in the first minutes and scores 1 for Appearance, not 0. Central cyanosis (blue lips, tongue, trunk) is the concern.
• MISCONCEPTION: A normal APGAR at 5 minutes means all is well and no further monitoring is needed. FACT: A baby with a low 1-minute APGAR still needs close monitoring even if the 5-minute score improves, and must be documented and reported.

Related Concepts

• EINC / Unang Yakap Four Steps
• Newborn Resuscitation — Golden Minute
• Thermoregulation
• Normal Newborn Vital Signs
• Referral and Detection of High-Risk Newborn

Common Exam Questions

Key Points To Remember

• APGAR at 1 minute AND 5 minutes; every 5 min up to 20 min if depressed
• Score 7–10 = Normal; 4–6 = Moderately depressed; 0–3 = Severely depressed → refer
• APGAR is a measure of transition, NOT a resuscitation trigger
• Resuscitation begins on breathing/HR assessment, NOT on APGAR score
• Normal RR: 40–60/min; Normal HR: 120–160/min; Normal Axillary Temp: 36.5–37.5°C
• Normal birth weight: 2,500–4,000 g; LBW < 2,500 g; Macrosomic > 4,000 g
• Check anal patency in all newborns
• Golden Minute: establish breathing within first 60 seconds

Examples

Applications

• Every newborn delivery at the BHS or lying-in requires warm chain implementation
• Counseling mothers on why rooms should be warm during delivery
• Teaching BHWs about the four mechanisms of heat loss during community orientations
• KMC promotion for LBW babies as part of the Philippine DOH KMC program

Misconceptions

• MISCONCEPTION: A baby in a warm room does not need a bonnet or blanket. FACT: A newborn needs a bonnet because up to 25% of body heat is lost through the head. Even in a warm room, a bonnet and covering are part of the warm chain.
• MISCONCEPTION: Bathing the baby with warm water will not cause hypothermia. FACT: Even warm-water baths cause significant heat loss through evaporation as the baby is dried — this is why bathing is delayed at least 6 hours.

Related Concepts

• EINC / Unang Yakap
• Kangaroo Mother Care (KMC)
• LBW and Preterm Newborn — Detect and Refer
• APGAR Score
• Warm Chain

Common Exam Questions

Key Points To Remember

• Four mechanisms of heat loss: Evaporation, Conduction, Convection, Radiation (mnemonic: ECCC or Every Cold Child Radiates)
• Normal axillary temperature: 36.5–37.5°C
• Hypothermia = axillary temp < 36.5°C → initiate KMC and recheck; refer if persistent
• Warm Chain: dry immediately, skin-to-skin, bonnet, delay bath, warm room (25–28°C), warm hands/surfaces
• Kangaroo Mother Care (KMC) is the primary intervention for mild hypothermia
• Do NOT bathe the baby until at least 6 hours after birth (ideally 24 hours) — early bathing causes hypothermia
• Vernix caseosa is protective — do not remove it

Examples

Applications

• Applied in every normal delivery at BHS, RHU, and lying-in
• Part of the Essential Newborn Care package of the DOH MNCHN program
• Midwife must have Vitamin K1 in the delivery kit at all times
• Basis for recognizing late VKDB — if a breastfed baby presents with sudden bleeding or neurological signs, the midwife refers immediately to the hospital

Misconceptions

• MISCONCEPTION: Only breastfed babies need Vitamin K. FACT: ALL newborns — formula-fed and breastfed — receive Vitamin K1 IM at birth, because all newborns are born with inadequate stores.
• MISCONCEPTION: Oral Vitamin K is equivalent to IM for prevention. FACT: IM is the gold standard and is what Philippine DOH protocols require. Oral Vitamin K has lower absorption and requires multiple doses — it is not the mandated form in Philippine practice.
• MISCONCEPTION: The dose for preterm babies is 0.5 mg regardless of weight. FACT: The 0.5 mg dose is for babies weighing LESS THAN 1.5 kg — weight is the threshold, not just gestational age.

Related Concepts

• Newborn Immunization — BCG and Hepatitis B
• Newborn Screening Heel-Prick
• VKDB / Hemorrhagic Disease of the Newborn — Detect and Refer
• Anterolateral Thigh Injection Technique
• Newborn Physical Examination

Common Exam Questions

Key Points To Remember

• Vitamin K1 (phytomenadione) IM: 1 mg for term; 0.5 mg for preterm/LBW < 1.5 kg
• Site: Anterolateral thigh (vastus lateralis muscle)
• Timing: First few hours after birth, after drying and skin-to-skin
• Purpose: Prevention of Vitamin K Deficiency Bleeding (VKDB) / Hemorrhagic Disease of the Newborn
• Give BEFORE procedures that could cause bleeding (e.g., before heel-prick where sequencing allows)
• VKDB types: Early (< 24 h), Classic (2–7 days), Late (2 wk–6 mo)
• Oral Vitamin K is NOT as effective as IM for prevention
• Every newborn receives this regardless of maternal history

Examples

Applications

• Applied in every delivery at BHS, RHU, and lying-in
• Midwife ensures erythromycin ophthalmic ointment is in every delivery kit
• If an infant presents days later with purulent eye discharge, the midwife refers immediately for diagnosis and treatment — late presentation suggests prophylaxis failure or late infection
• Part of the Universal Newborn Care standards under DOH MNCHN

Misconceptions

• MISCONCEPTION: Silver nitrate drops are the standard eye prophylaxis. FACT: Silver nitrate is outdated and is no longer used in the Philippines. Current DOH protocol uses erythromycin 0.5% ophthalmic ointment.
• MISCONCEPTION: Eye prophylaxis is only for babies born to mothers with known gonorrhea. FACT: Eye prophylaxis is UNIVERSAL — given to every newborn regardless of maternal STI status.
• MISCONCEPTION: The eyes should be washed after applying the ointment to prevent irritation. FACT: Do NOT irrigate. The ointment must remain in contact with the conjunctiva to work.

Related Concepts

• Ophthalmia Neonatorum — Detect and Refer
• Vitamin K Prophylaxis
• EINC Sequencing
• Newborn Physical Examination
• STI in Pregnancy — Refer

Common Exam Questions

Key Points To Remember

• Drug: Erythromycin 0.5% ophthalmic ointment (or tetracycline 1%)
• Purpose: Prevention of Ophthalmia Neonatorum (gonococcal and chlamydial eye infection)
• Apply to BOTH lower conjunctival sacs, from inner to outer canthus
• Do NOT irrigate/wash out the eyes after application
• Given to EVERY newborn regardless of maternal history
• Timing: After first skin-to-skin and breastfeed, ideally within 1 hour of birth
• Do NOT use silver nitrate drops — this was the old method; modern practice uses erythromycin
• Ophthalmic ointment only — not regular (systemic) erythromycin tablets or syrup

Examples

Applications

• Performed by the midwife on every baby born at BHS, RHU, or lying-in within 24–72 hours
• Part of the DOH MNCHN and EINC newborn package
• NBS cards are submitted to DOH-accredited laboratories (e.g., NIH-NSC, regional NBS labs)
• Midwife counsels families during prenatal visits about the importance of returning for NBS at 24–72 hours
• Community-based tracking: midwife follows up babies whose NBS was not done
• If a baby is born at home, midwife ensures NBS is done at nearest BHS or RHU within the window

Misconceptions

• MISCONCEPTION: NBS should be done as early as possible, even at birth. FACT: NBS should NOT be done before 24 hours — doing so can lead to false results, especially for CAH (17-OHP levels are naturally elevated in the first 24 hours).
• MISCONCEPTION: Only babies with risk factors or family history need NBS. FACT: NBS is UNIVERSAL — every baby born in the Philippines is mandated by RA 9288 to have NBS done.
• MISCONCEPTION: A normal NBS result means the baby is completely healthy. FACT: NBS screens for specific metabolic and endocrine disorders only. It does not screen for all genetic conditions, structural anomalies, or infections.
• MISCONCEPTION: If parents refuse, the midwife has no further responsibility. FACT: The midwife must document the refusal and re-counsel. The refusal must be in writing, and the midwife should continue to encourage the family to reconsider.

Related Concepts

• Newborn Hearing Screening — RA 9709
• Congenital Hypothyroidism — Classic NBS Disorder
• G6PD Deficiency — Most Common in Philippines
• Heel-Prick Technique
• Vitamin K Prophylaxis (done before heel-prick where possible)
• Referral and Follow-Up of Abnormal NBS Results

Common Exam Questions

Key Points To Remember

• Law: RA 9288 — Newborn Screening Act of 2004
• Method: Heel-prick on lateral heel, blood on filter-paper card (Guthrie/NBS card)
• Ideal timing: 24 to 72 hours after birth — NOT before 24 hours
• If done before 24 hours: REPEAT required by 2 weeks of age
• Midwife/birth attendant is legally responsible for ensuring NBS is done
• Inform parents — they may refuse only after being fully informed; document refusal
• Classic screened disorder: Congenital Hypothyroidism (CH) — prevented with early thyroxine
• Positive result = refer urgently for confirmatory testing
• 6 core disorders: CH, CAH, GAL, PKU, G6PD, MSUD
• G6PD deficiency is the most common inherited metabolic disorder in the Philippines

Examples

Applications

• Midwife includes hearing screening referral in every newborn discharge plan when OAE is unavailable at BHS
• Counseling parents during prenatal visits about hearing screening at birth
• Documenting hearing screening status in the baby's health records and FHSIS
• Coordination with DOH hospitals and audiologists for confirmed cases
• Part of the BEmONC quality assessment of newborn care

Misconceptions

• MISCONCEPTION: Hearing screening is only for babies with a family history of deafness. FACT: RA 9709 mandates UNIVERSAL hearing screening — for every baby, regardless of risk factors.
• MISCONCEPTION: A 'refer' result means the baby is confirmed deaf. FACT: 'Refer' means the screening was inconclusive and repeat/confirmatory testing is needed — it is NOT a diagnosis of hearing loss.
• MISCONCEPTION: Hearing screening can wait until the baby is talking age to see if there is a problem. FACT: The critical window for intervention is BY 6 MONTHS — waiting until the child is talking (18 months+) means the intervention window has already been missed.

Related Concepts

• Newborn Screening — RA 9288
• Congenital Hearing Loss — Referral
• Normal Newborn Sensory Development
• OAE and AABR Techniques
• BEmONC and Newborn Quality Standards

Common Exam Questions

Key Points To Remember

• Law: RA 9709 — Universal Newborn Hearing Screening and Intervention Act of 2009
• Methods: OAE (Otoacoustic Emissions) and/or AABR (Automated Auditory Brainstem Response)
• Timing: Before discharge or within first month; maximum 3 months for screening
• Intervention (hearing aids, therapy) must begin by 6 months of age for best outcomes
• Result: PASS or REFER — 'Refer' does NOT mean confirmed hearing loss
• If equipment unavailable at BHS: REFER to nearest hearing screening facility
• Universal — every newborn, not just those with risk factors
• Both tests are painless and can be done while baby sleeps

Examples

Applications

• Cord care counseling is done at discharge from BHS or lying-in
• Part of the Well-Baby follow-up visit checklist at the BHS (cord inspection at Day 3 visit)
• If omphalitis is detected during home visit or BHS consultation, immediate referral to RHU or hospital
• Midwife documents cord condition at all newborn visits in the first 2 weeks

Misconceptions

• MISCONCEPTION: Alcohol should always be applied to the cord to sterilize it. FACT: Alcohol application is NO LONGER recommended by DOH. Dry cord care (clean and dry, nothing applied) is the current evidence-based standard.
• MISCONCEPTION: The cord stump should be covered with a dressing or cloth to protect it. FACT: Covering the cord prevents air circulation and moisture evaporation, slowing separation and increasing infection risk. The cord should be EXPOSED to air.

Related Concepts

• Properly Timed Cord Clamping — EINC
• Omphalitis — Detect and Refer
• Neonatal Tetanus — Prevention
• Newborn Home Visit Checklist
• EINC / Unang Yakap

Common Exam Questions

Key Points To Remember

• Dry cord care: keep clean and dry, fold diaper below stump, expose to air
• Do NOT apply alcohol, antiseptics, iodine, herbal preparations, or dressings
• Cord stump separates in 5–15 days
• Chlorhexidine 4% may be used in HIGH-RISK settings only — not routine
• Teach mother signs of omphalitis: redness, foul/purulent discharge, swelling, baby appears ill
• Omphalitis → refer immediately (can progress to neonatal sepsis)
• Cut cord with STERILE blade/scissors between two sterile clamps or ties
• Properly-timed clamping: after pulsations stop, 1–3 minutes after birth

Examples

Applications

• BCG and Hep B birth dose recorded in the baby's immunization card (pink card) at birth
• Midwife fills out EPI immunization record at the BHS
• For sick or preterm babies referred to hospital, the midwife documents that BCG is deferred and follow-up is needed at RHU
• Counseling parents about normal BCG reaction reduces unnecessary return visits

Misconceptions

• MISCONCEPTION: BCG is given IM like other vaccines. FACT: BCG is strictly INTRADERMAL — given into the skin layer, not the muscle. Incorrect route reduces efficacy.
• MISCONCEPTION: A pustule or scar after BCG means the vaccine was given incorrectly. FACT: This is the EXPECTED, NORMAL reaction confirming successful BCG administration.
• MISCONCEPTION: The Hepatitis B birth dose is optional or can be given at the 6-week visit. FACT: The birth dose is specifically timed to prevent vertical (mother-to-baby) transmission — it must be given within 12–24 hours of birth to be effective.

Related Concepts

• DOH Expanded Program on Immunization (EPI)
• Hepatitis B in Pregnancy — Detect and Refer
• Tuberculosis Prevention
• Newborn Physical Examination
• Newborn Discharge Checklist

Common Exam Questions

Key Points To Remember

• BCG: 0.05 mL INTRADERMAL, RIGHT deltoid, within 24 hours of birth
• Hepatitis B vaccine birth dose: 0.5 mL IM, anterolateral thigh, within 12–24 hours
• Both vaccines given within 24 hours of birth as part of DOH EPI
• BCG normal reaction: papule → pustule → ulcer → scar (2–4 weeks) — counsel parents
• BCG deferred for sick, very preterm (< 32 wk), or VLBW (< 1,500 g) babies
• Hep B birth dose important for HBsAg-positive mothers — give within 12 hours
• HBIG for HBsAg-positive mothers' babies — hospital level intervention
• Intradermal technique for BCG: creates a bleb/wheal — confirm correct route

Examples

Applications

• Part of the mandatory BEmONC competency training for midwives
• Neonatal resuscitation equipment (bag, mask, suction bulb) must be in every delivery kit
• The midwife's resuscitation skills are audited in BEmONC assessments
• Any baby requiring resuscitation at the BHS is referred to the RHU or hospital even if she initially responds — there is risk of secondary apnea

Misconceptions

• MISCONCEPTION: If meconium is present, always suction the baby deeply before anything else. FACT: A vigorous baby with meconium needs no suctioning. A non-vigorous baby needs initial resuscitation steps first — deep tracheal suctioning is a hospital procedure.
• MISCONCEPTION: If the baby begins to breathe after PPV, no further action is needed. FACT: Any baby who required PPV at birth must be REFERRED even if breathing improves, because of the risk of secondary apnea and the need for monitoring.

Related Concepts

• APGAR Score — Not a Resuscitation Trigger
• EINC — Vigorous vs Non-Vigorous Baby
• BEmONC Competencies
• Neonatal Asphyxia — Detect and Refer
• Meconium-Stained Amniotic Fluid

Common Exam Questions

Key Points To Remember

• Golden Minute: establish breathing within first 60 seconds of birth
• Initial assessment: term? breathing/crying? good tone? If any NO → resuscitate
• Vigorous baby + meconium: proceed with EINC, no suctioning needed
• Non-vigorous baby: position, clear airway if obstructed, stimulate — if still not breathing → PPV
• PPV: bag and mask at 40–60 breaths/min, 20–25 cmH2O
• HR < 100 and not breathing → continue PPV and refer IMMEDIATELY
• APGAR does NOT guide when to start resuscitation
• Resuscitation at BHS level: bag-mask ventilation + immediate referral

Problem

A midwife delivers a term baby at the BHS at 6:00 PM. The baby cries immediately and has good tone. She dries the baby, initiates skin-to-skin, and waits for cord pulsations to stop (1.5 minutes) before clamping. She then supports the first breastfeed. At 7:00 PM (1 hour after birth), she gives Vitamin K1 and erythromycin eye ointment. At 8:00 PM, she gives BCG and Hepatitis B vaccine. She plans to collect the NBS heel-prick at 8:00 AM the next day (14 hours after birth). Is this timing correct? What should she do?

Solution

The NBS timing is INCORRECT. The sample at 14 hours is before the 24-hour minimum for NBS collection. The midwife should defer the heel-prick until the baby is at least 24 hours old — in this case, not before 6:00 PM the next day. She should schedule the mother to return at 6:00 PM (24 hours) up to 6:00 PM two days later (72 hours) for the NBS sample. All other procedures described (drying, skin-to-skin, delayed cord clamping, breastfeed, Vitamin K, eye ointment, BCG, Hep B) were done correctly and in appropriate sequence.

Problem

Calculate the APGAR score for the following newborn at 1 minute: The baby is all pink from head to toe. HR is 130. When the nose is stimulated with a suction catheter, the baby sneezes vigorously. The baby is actively moving all limbs. The baby has a strong, lusty cry. What is the score and interpretation?

Solution

Appearance = 2 (completely pink all over), Pulse = 2 (HR 130, which is ≥ 100), Grimace = 2 (sneezes vigorously = strong response), Activity = 2 (active motion of all limbs), Respiration = 2 (strong, lusty cry). Total APGAR = 10. Interpretation: Normal. The baby is doing excellent and requires only routine EINC care.

Problem

A mother at the BHS tells you she heard from a neighbor that applying betadine (povidone-iodine) to the cord stump will prevent infection. Her baby is 2 days old and the cord stump looks dry and clean. What is the correct advice?

Solution

Advise the mother NOT to apply betadine or any other substance to the cord stump. The current DOH recommendation is dry cord care — keep the stump clean and dry, fold the diaper below the stump, and let it be exposed to air. Applying betadine or other antiseptics is no longer recommended because it can actually delay cord separation and alter the normal skin flora in a way that may not be beneficial. The best thing she can do is keep it clean and dry.

Problem

A 33-week preterm baby weighing 1.3 kg is delivered at the BHS. The baby is breathing and crying. What modifications are needed in the mandated newborn procedures for this baby?

Solution

(1) EINC: Proceed with drying (30 sec), skin-to-skin for warmth (KMC), delayed cord clamping — all apply. However, this baby is at high risk for hypothermia and should immediately go to KMC to maintain temperature. (2) Vitamin K1: Give 0.5 mg IM (reduced dose for < 1.5 kg). (3) BCG: DEFER — BCG is deferred for very preterm (< 32 weeks) and VLBW (< 1.5 kg) babies. This baby is < 1.5 kg — BCG is deferred until the baby is stable and reaches appropriate weight. (4) Hepatitis B birth dose: Give 0.5 mL IM within 24 hours — the Hep B birth dose is NOT deferred. (5) Eye prophylaxis: Apply as normal. (6) NBS: Done at 24–72 hours as usual; note that preterm babies may require repeat NBS. (7) Hearing screening: Refer to appropriate facility. (8) MOST IMPORTANTLY: This baby is at high risk and should be REFERRED to the nearest hospital/NICU for monitoring and specialized care. Arrange transport while maintaining warmth (KMC during transport).

Problem

A midwife applies erythromycin eye ointment to a newborn's eyes BEFORE the baby starts breastfeeding, at 5 minutes of life, saying she wants to 'finish all the procedures early.' What is the problem with this timing, and when should eye prophylaxis ideally be given?

Solution

The problem is that erythromycin ointment blurs the baby's vision temporarily after application. If applied before the first skin-to-skin and breastfeeding initiation, it interferes with the baby's ability to see the mother's face and breast clearly during the critical bonding and breastfeed crawl reflex period. Eye prophylaxis should be applied AFTER the first skin-to-skin contact and after the baby has had a chance to initiate or attempt the first breastfeed — ideally within the first hour of life, but not before the initial bonding and breastfeed opportunity.