Midwife Licensure Exam Midwifery Pharmacology & Newborn Procedures — Mandated Newborn Procedures by the MidwifeRevision Notes

Exam Tips

• Memorize the four EINC steps in ORDER: Dry (30 s) → Skin-to-skin → Delayed cord clamping (1–3 min) → Non-separation for breastfeeding (within 90 min).
• Any question asking about a 'vigorous baby with meconium': the answer is PROCEED with routine EINC, NO suctioning.
• Any question asking about a 'non-breathing baby': the answer involves the GOLDEN MINUTE and PPV, plus referral.
• The phrase 'Unang Yakap' = EINC — treat them as synonyms in MLE questions.
• EINC 'do not do' items are classic MLE distractors presented as correct choices — know them cold.

Key Points

• EINC stands for Essential Intrapartum and Newborn Care; 'Unang Yakap' (First Embrace) is its popular name in the Philippine DOH program.
• EINC organizes newborn care into FOUR time-bound steps performed in strict sequence immediately after birth.
• Step 1 — IMMEDIATE AND THOROUGH DRYING: Dry the newborn's body and head for the first 30 seconds using a clean, dry, warm cloth. This prevents hypothermia (evaporative heat loss) and stimulates breathing. DO NOT wipe off the vernix caseosa.
• Step 2 — EARLY SKIN-TO-SKIN CONTACT: Place the naked, dried baby prone on the mother's bare chest or abdomen. Cover both mother and baby with a warm dry cloth and place a bonnet on the baby's head.
• Step 3 — PROPERLY TIMED CORD CLAMPING: Clamp and cut the cord ONLY after cord pulsations completely stop — approximately 1 to 3 minutes after birth. Delayed cord clamping (DCC) significantly improves the newborn's iron stores and reduces risk of anemia.
• Step 4 — NON-SEPARATION FOR EARLY BREASTFEEDING: Keep mother and baby together; support the baby's breastfeeding crawl and first latch within the FIRST 90 MINUTES of life.
• EINC 'DO NOT DO' list (heavily tested): Do NOT suction routinely; Do NOT give early bath (delay at least 6 hours, ideally 24 hours); Do NOT separate mother and baby; Do NOT do foot-printing before skin-to-skin; Do NOT wipe off vernix.
• Routine suctioning is only performed if the baby has obvious airway obstruction OR is not breathing — never routinely.
• For a VIGOROUS baby with meconium-stained fluid (crying, good tone, HR ≥ 100): proceed with routine EINC — NO suctioning.
• For a NON-BREATHING baby: call for help, clamp and cut cord promptly, move to a warm firm surface, position, clear airway if obstructed, and begin PPV within the GOLDEN MINUTE (first 60 seconds). Arrange referral. Breathing takes priority over ALL routine procedures.

Definitions

Section Title

EINC / Unang Yakap — The Four Core Steps

Common Mistakes

• Confusing 'delayed cord clamping' as waiting indefinitely — the correct answer is waiting until cord pulsations STOP, about 1–3 minutes.
• Thinking suctioning is always part of normal delivery care — it is NOT; it is only for airway obstruction or non-breathing.
• Forgetting that bathing is delayed a MINIMUM of 6 hours (ideally 24 hours) — early bathing causes hypothermia.
• Thinking DCC is contraindicated in all cases — it is standard for normal birth; the only reason to cut early is if immediate resuscitation is needed.
• Mixing up the sequence — drying comes FIRST, before any other step including cord clamping.

Formulas

Exam Tips

• Use the mnemonic 'A-P-G-A-R' — Appearance, Pulse, Grimace, Activity, Respiration — in that order.
• Memorize the score ranges: 7–10 good; 4–6 moderate; 0–3 severe.
• Normal vitals to memorize as a set: RR 40–60, HR 120–160, Temp 36.5–37.5°C, Weight 2,500–4,000 g.
• In MLE questions, if a scenario says 'APGAR 4 at 1 minute,' the next action is stimulation/support — not immediate referral yet. If APGAR remains 0–3, prepare to refer.
• Acrocyanosis in the first minutes = NORMAL. Central cyanosis = ABNORMAL → assess breathing and refer.

Key Points

• APGAR is scored at 1 MINUTE and 5 MINUTES after birth; if depressed, repeat every 5 minutes up to 20 minutes.
• APGAR is a tool for ASSESSING transition — it is NOT used to decide when to start resuscitation. Resuscitation starts immediately based on: Is the baby breathing/crying? Is there good muscle tone? What is the heart rate? Never wait for the 1-minute APGAR to resuscitate.
• Score of 7–10: Good/Normal — routine newborn care.
• Score of 4–6: Moderately Depressed — needs stimulation and close monitoring; may need supplemental oxygen or bag-mask support.
• Score of 0–3: Severely Depressed — needs active resuscitation (PPV) and REFERRAL.
• APGAR mnemonic — A: Appearance (color); P: Pulse (heart rate); G: Grimace (reflex irritability); A: Activity (muscle tone); R: Respiration.
• Each sign scored 0, 1, or 2; maximum total = 10.
• Normal newborn RR: 40–60 breaths/min; Normal HR: 120–160 bpm; Normal axillary temp: 36.5–37.5°C; Normal weight: 2,500–4,000 g.
• Low birth weight (LBW) = birth weight LESS THAN 2,500 g — reason for referral and special care.
• Midwife performs a quick head-to-toe exam: check for gross anomalies, patency of anus (anal atresia detection), cleft palate, extra digits, etc.
• Anus patency check: insert a soft catheter or observe for meconium passage within 24 hours — imperforate anus is a surgical emergency requiring immediate referral.

Definitions

Section Title

APGAR Score and Immediate Newborn Assessment

Common Mistakes

• Waiting for the 1-minute APGAR before starting resuscitation — WRONG. Resuscitation starts immediately if the baby is not breathing.
• Scoring APGAR A=0 for acrocyanosis — acrocyanosis (pink body, blue extremities) = score of 1, not 0.
• Forgetting that APGAR is scored TWICE (1 min and 5 min) as standard; if depressed, continue every 5 min up to 20 min.
• Confusing normal HR (120–160) with normal RR (40–60) — these are frequently swapped in distractors.
• Labeling LBW as any baby less than 3,000 g — the correct cutoff is less than 2,500 g.

Exam Tips

• Normal axillary temp = 36.5–37.5°C — this is the single most tested thermoregulation value.
• Room temperature for newborn care = 25–28°C.
• Hypothermia first action at BHS = skin-to-skin (KMC); referral if not corrected.
• Delayed bathing is both a thermoregulation AND EINC topic — connect them.
• Four routes of heat loss (Evaporation, Conduction, Convection, Radiation): expect scenario-based questions identifying which route is being prevented by a given action.

Key Points

• Newborns are highly vulnerable to HEAT LOSS through four mechanisms: Evaporation (wet skin), Conduction (cold surfaces), Convection (cold drafts/air), and Radiation (cold nearby objects).
• The midwife maintains the WARM CHAIN: a series of steps to prevent hypothermia from birth onward.
• Warm chain components: Immediate drying (30 s), early skin-to-skin contact, placing a bonnet, delayed bathing (≥6 h, ideally 24 h), warm draft-free room (25–28°C), warm hands and instruments, warm surfaces.
• Normal axillary temperature: 36.5–37.5°C.
• Hypothermia: axillary temp BELOW 36.5°C. Classify as mild (36.0–36.4°C), moderate (32–35.9°C), or severe (below 32°C).
• First response to hypothermia at primary level: SKIN-TO-SKIN / KANGAROO MOTHER CARE (KMC) — place the naked baby on the mother's bare chest, cover both.
• If hypothermia does not correct or is severe, REFER to a higher-level facility.
• Delay bath to at LEAST 6 hours (WHO/DOH recommends up to 24 hours) to prevent evaporative heat loss.
• Kangaroo Mother Care (KMC) is the gold-standard intervention for keeping small/preterm babies warm in primary care settings — it also supports breastfeeding and bonding.

Definitions

Section Title

Thermoregulation and the Warm Chain

Common Mistakes

• Advising early bathing 'to clean the baby' — bathing must be delayed ≥6 hours (ideally 24 h) to prevent hypothermia.
• Forgetting the bonnet — the head accounts for a large proportion of newborn heat loss.
• Thinking any cold baby should go straight to the hospital — try skin-to-skin first, then refer if it fails.
• Using a cold room, cold surfaces, or blowing fan near the newborn — all break the warm chain.

Exam Tips

• When the MLE asks 'What do you apply to the cord?' — the answer is NOTHING (dry cord care). Do not be distracted by alcohol or antiseptic options.
• Omphalitis danger signs = reason to return immediately and refer — this is a 'detect and refer' scenario.
• Cord separation: 5–15 days. Any question asking 'when does the cord normally fall off?' = this range.
• Diaper folded BELOW the stump — always. This is a patient-education point the MLE may test as a practical question.

Key Points

• After DCC (once pulsations stop, ~1–3 min), place TWO clamps/ties on the cord and cut with a STERILE blade or scissors between them.
• Modern DOH policy: DRY CORD CARE — keep the cord stump CLEAN and DRY. Fold the diaper BELOW the stump. Expose it to air.
• DO NOT apply anything to the cord: no alcohol, no antiseptic, no povidone-iodine, no herbal preparations, no 'pusod' concoctions, no dressings.
• Exception: In HIGH-RISK settings (community with high neonatal infection rates), local protocol may specify application of CHLORHEXIDINE 7.1% gel to the stump.
• Teach the mother to watch for OMPHALITIS danger signs: redness/erythema spreading to the skin around the cord, foul-smelling discharge, swelling, warmth — these are signs of infection requiring IMMEDIATE RETURN and REFERRAL.
• Normal cord stump drying time: the stump typically separates in 5–15 DAYS.
• If the cord has not separated by 3 weeks, or if signs of omphalitis appear, refer.

Definitions

Section Title

Cord Care

Common Mistakes

• Applying alcohol or antiseptic to the cord 'for cleaning' — this is the OLD practice; current DOH/EINC policy is dry cord care (apply nothing).
• Covering the cord stump with the diaper or a dressing — the stump should be exposed to air and the diaper folded below it.
• Thinking early cord separation in 3–4 days is normal — normal separation takes 5–15 days.
• Confusing chlorhexidine cord care as routine — it is only in HIGH-RISK/specific protocol settings, not standard practice.

Exam Tips

• Dose summary: 1 mg IM term; 0.5 mg IM preterm (<1.5 kg) — both in the anterolateral thigh.
• Purpose = prevent VKDB. Drug = Vitamin K1 (phytomenadione). Route = IM. Site = anterolateral thigh.
• Vitamin K3 (menadione) = WRONG choice for newborns — pick Vitamin K1 on the MLE.
• Remember the sequence: Dry → Skin-to-skin → Cord clamping → Breastfeeding support → THEN Vitamin K (after bonding, before bleeding-risk procedures like NBS heel-prick).

Key Points

• PURPOSE: Prevents Vitamin K Deficiency Bleeding (VKDB) — previously called Hemorrhagic Disease of the Newborn (HDN).
• VKDB can cause serious bleeding (intracranial hemorrhage, GI bleeding) because the newborn liver is immature and cannot produce clotting factors II, VII, IX, X without adequate Vitamin K.
• DRUG: Vitamin K1 (Phytomenadione) — NOT Vitamin K3 (Menadione), which is contraindicated in newborns.
• ROUTE: IM ONLY (intramuscular). Oral formulations are less reliable.
• SITE: ANTEROLATERAL THIGH (vastus lateralis muscle) — the standard IM injection site for newborns.
• DOSE: 1 mg IM for TERM or normal-weight baby; 0.5 mg IM for PRETERM or low-birth-weight baby (< 1.5 kg).
• TIMING: Single dose given within the first hour(s) after birth — AFTER drying and skin-to-skin contact, BEFORE procedures that could cause bleeding.
• Vitamin K should be given BEFORE the heel-prick for newborn screening where sequencing allows.
• It is a SINGLE dose — no repeat injection needed for normal term babies.
• The midwife documents the dose, route, site, and time of administration.

Definitions

Section Title

Vitamin K Prophylaxis

Common Mistakes

• Giving Vitamin K ORALLY in primary care — the standard route is IM; oral is less reliable and not the Philippine protocol.
• Giving 1 mg to ALL babies regardless of weight — preterm/LBW babies (<1.5 kg) get 0.5 mg.
• Injecting into the deltoid — the correct site for newborns is the ANTEROLATERAL THIGH (vastus lateralis).
• Thinking multiple doses are needed — it is a SINGLE dose for normal term babies.
• Confusing Vitamin K1 (phytomenadione, SAFE) with Vitamin K3 (menadione, CONTRAINDICATED in newborns).

Exam Tips

• Drug = Erythromycin 0.5% ophthalmic ointment. Route = lower conjunctival sac. Direction = inner to outer canthus. Both eyes.
• Applied AFTER initial bonding/first breastfeed — within 1 hour.
• DO NOT irrigate after application — this is a classic 'what NOT to do' MLE question.
• Purpose = prevent ophthalmia neonatorum (gonococcal). Causative organism = Neisseria gonorrhoeae.

Key Points

• PURPOSE: Prevents OPHTHALMIA NEONATORUM (gonococcal conjunctivitis), which can cause blindness if untreated.
• Ophthalmia neonatorum is caused by Neisseria gonorrhoeae transmitted from infected birth canal during delivery.
• DRUG: Erythromycin 0.5% ophthalmic ointment (PREFERRED in PH protocol) OR Tetracycline 1% ophthalmic ointment.
• Silver nitrate 1% drops (Credé's method) is the OLD method — no longer recommended due to chemical conjunctivitis.
• ROUTE/METHOD: Apply a THIN RIBBON of ointment into the LOWER CONJUNCTIVAL SAC of EACH EYE, from the INNER CANTHUS to the OUTER CANTHUS.
• TIMING: Applied AFTER the first breastfeed/bonding is established, ideally WITHIN THE FIRST HOUR of life.
• DO NOT IRRIGATE the eyes after application — this washes away the medication.
• Applied to BOTH EYES regardless of maternal history — it is MANDATORY for every newborn.
• Some mild transient conjunctival redness after application is normal — teach the mother this is expected.

Definitions

Section Title

Eye Prophylaxis

Common Mistakes

• Irrigating the eyes after applying the ointment — this removes the medication and defeats the purpose.
• Applying before the first breastfeed — the EINC sequence places eye prophylaxis AFTER the initial bonding/breastfeed.
• Applying only to one eye — BOTH eyes must be treated.
• Using silver nitrate drops — this is the old method; current practice is erythromycin ointment.
• Applying from outer to inner canthus — the correct direction is INNER to OUTER canthus.

Exam Tips

• RA 9288 = Newborn Screening. RA 9709 = Hearing Screening. Know which law covers which procedure.
• Timing: 24–72 hours after birth. Not before 24 h. If before 24 h, repeat by 2 weeks.
• Classic MLE scenario: 'The baby will be discharged at 12 hours — when should NBS be done?' Answer: As early as possible but repeat within 2 weeks.
• Six core disorders: CH, CAH, GAL, PKU, G6PD, MSUD — memorize using mnemonic 'CH-CAG-PM' or any method that works for you.
• Positive NBS result → refer for confirmatory testing (midwife detects and refers, does NOT treat).
• Congenital hypothyroidism: classic high-yield disorder where early treatment (thyroxine) prevents intellectual disability.

Key Points

• Legal basis: NEWBORN SCREENING ACT OF 2004 (RA 9288) — makes newborn screening MANDATORY and a routine part of newborn care.
• METHOD: HEEL-PRICK (heel-stick) — capillary blood collected from the lateral heel and absorbed onto a special filter-paper card (Guthrie card).
• IDEAL TIMING: 24 to 72 HOURS after birth. This window is critical — too early (before 24 h) risks false results (especially for CAH/17-OHP); too late misses the treatment window.
• If unavoidably done BEFORE 24 hours: a REPEAT specimen is required within 2 weeks of age.
• The ATTENDANT (midwife) is LEGALLY RESPONSIBLE for ensuring the sample is collected and for informing parents of the availability and benefits of screening.
• Parents may REFUSE after being informed — refusal must be DOCUMENTED; the midwife may not proceed without informed consent.
• CORE PANEL (standard NBS): Congenital Hypothyroidism (CH), Congenital Adrenal Hyperplasia (CAH), Galactosemia (GAL), Phenylketonuria (PKU), G6PD Deficiency (G6PD), Maple Syrup Urine Disease (MSUD).
• EXPANDED PANEL (ENBS): also includes hemoglobinopathies, biotinidase deficiency, cystic fibrosis, and others.
• All screened conditions share: TREATABLE when caught early, but cause DEATH or IRREVERSIBLE MENTAL RETARDATION if missed.
• HIGH-YIELD EXAMPLE: CONGENITAL HYPOTHYROIDISM (CH) — if undetected, causes severe, irreversible intellectual disability (cretinism); if detected early and treated with oral thyroxine, the baby develops normally.
• A POSITIVE/HIGH-RISK result does NOT confirm disease — it means the baby must be REFERRED URGENTLY for CONFIRMATORY TESTING.
• The midwife does not diagnose or treat NBS-positive results — she refers.

Definitions

Section Title

Newborn Screening — RA 9288

Common Mistakes

• Collecting the NBS sample BEFORE 24 hours — this is incorrect timing that risks false positive/negative results (especially for CAH). Only do this if unavoidable, then repeat within 2 weeks.
• Thinking a positive NBS result means the baby HAS the disease — it means the baby needs CONFIRMATORY TESTING.
• Thinking parents cannot refuse NBS — they CAN refuse after being fully informed; the midwife documents the refusal.
• Forgetting the midwife is LEGALLY RESPONSIBLE for ensuring the sample is taken under RA 9288.
• Naming the NBS as 'RA 9709' — RA 9709 is for HEARING screening; NBS is RA 9288.

Exam Tips

• RA 9709 = hearing screening. Timing = before discharge or within 1 month (3 months latest).
• Methods: OAE (first-line) and AABR (confirmatory). Both are PAINLESS.
• Intervention goal: begin by 6 MONTHS for best language outcomes.
• 'Refer' result ≠ deaf — it means the baby needs follow-up/repeat testing.
• If no equipment at BHS: REFER to accredited facility and DOCUMENT — this is the midwife's responsibility under RA 9709.

Key Points

• Legal basis: UNIVERSAL NEWBORN HEARING SCREENING AND INTERVENTION ACT OF 2009 (RA 9709).
• PURPOSE: Early detection of CONGENITAL HEARING LOSS so that intervention begins by 6 MONTHS of age — this is the critical window for preserving speech and language development.
• TIMING: Ideally BEFORE DISCHARGE from the facility; at the latest, within the FIRST MONTH of life (acceptable up to 3 MONTHS).
• METHODS: Otoacoustic Emissions (OAE) and/or Automated Auditory Brainstem Response (AABR) — both are PAINLESS, QUICK, and non-invasive.
• OAE measures sounds produced by the outer hair cells of the cochlea in response to a stimulus — fast and easy; first-line screening.
• AABR measures electrical brainwave responses to sound — more specific for auditory pathway; used for confirmation or when OAE fails.
• A 'PASS' result: hearing is likely normal at the time of screening.
• A 'REFER' result: does NOT confirm hearing loss — the baby needs REPEAT OR CONFIRMATORY TESTING. The midwife explains this clearly to parents.
• If the BHS/RHU does not have screening equipment, the midwife REFERS the newborn to an accredited screening facility and DOCUMENTS it.
• Intervention by 6 months: hearing aids, cochlear implants, or specialized therapy — this is managed at specialized centers, NOT by the midwife.
• Early intervention (before 6 months) leads to significantly better speech and language outcomes than late detection.

Definitions

Section Title

Newborn Hearing Screening — RA 9709

Common Mistakes

• Telling a parent that 'refer' result means the baby is deaf — a 'refer' result only means REPEAT/CONFIRMATORY TESTING is needed.
• Confusing the law: RA 9709 = HEARING screening; RA 9288 = METABOLIC (NBS) screening.
• Thinking hearing screening is optional — it is MANDATORY under RA 9709.
• Forgetting to refer if equipment is unavailable — the midwife must still facilitate screening at an accredited facility.
• Confusing OAE and AABR methods — OAE is first-line; AABR is used for confirmation or when OAE refers.

Exam Tips

• BCG: intradermal, RIGHT deltoid, 0.05 mL, within 24 hours.
• HBV birth dose: IM, anterolateral thigh, 0.5 mL, within 24 hours.
• Both within 24 hours — they share the same timing window.
• A wheal at the BCG site = NORMAL; do not aspirate before intradermal injection.

Key Points

• BCG (Bacillus Calmette-Guérin) vaccine: given at BIRTH (within 24 hours). Protects against severe forms of tuberculosis (TB meningitis, disseminated TB).
• BCG route: INTRADERMAL, RIGHT deltoid area. Dose: 0.05 mL for newborns. A small wheal forms at the injection site — this is normal.
• Hepatitis B birth dose: given within 24 HOURS of birth. Prevents mother-to-child transmission (vertical transmission) of Hepatitis B virus.
• HBV birth dose route: INTRAMUSCULAR, ANTEROLATERAL THIGH. Dose: 0.5 mL.
• Both vaccines are part of the DOH Expanded Program on Immunization (EPI) and are mandatory components of the newborn package.
• BCG and HBV birth dose together with Vitamin K make up the standard injection package at birth.
• Different sites: BCG = intradermal RIGHT deltoid; Vitamin K = IM anterolateral thigh; HBV = IM anterolateral thigh (different leg or site from Vitamin K).
• The midwife documents all vaccines on the child's immunization card and health records.

Definitions

Section Title

Birth Immunization — BCG and Hepatitis B

Common Mistakes

• Giving BCG intramuscularly — BCG is INTRADERMAL only.
• Giving BCG in the LEFT deltoid — the standard site is the RIGHT deltoid.
• Delaying HBV birth dose beyond 24 hours — vertical transmission prevention depends on timely administration.
• Confusing injection sites: BCG = right deltoid (intradermal); Vitamin K and HBV = anterolateral thigh (IM).

Exam Tips

• When a question presents a scenario with a non-breathing baby AND asks what to do first: the answer is ALWAYS the resuscitation step — never a routine procedure.
• When a question asks about the midwife's role after a positive NBS: REFER for confirmatory testing.
• The sequence of procedures is logical: life-sustaining steps first, preventive medications second, diagnostic tests third.
• For any MLE scenario involving a complication in a newborn: the midwife's role = detect, stabilize if possible, refer. Never 'manage' the complication independently.

Key Points

• The COMPLETE sequence the midwife follows at birth: 1) Dry and assess (APGAR/breathing) → 2) Skin-to-skin and warmth → 3) Delayed cord clamping (1–3 min) and cord care → 4) Support first breastfeed (within 90 min) → 5) Vitamin K IM → 6) Eye prophylaxis → 7) Weigh/measure and full physical exam → 8) BCG and Hepatitis B birth dose (within 24 h) → 9) Newborn screening heel-prick (24–72 h) → 10) Hearing screening (before discharge/within 1 month).
• The OVERRIDING PRIORITY at ALL times is: ESTABLISHING BREATHING and PREVENTING HYPOTHERMIA. A warm, breathing, breastfeeding baby comes before any routine procedure.
• If a non-breathing baby is identified: abandon the routine sequence, begin resuscitation steps within the Golden Minute, and arrange REFERRAL.
• High-yield law-procedure matches: RA 9288 = NBS heel-prick; RA 9709 = Hearing screening; RA 7392 = Midwifery Practice Act (defines midwife's scope); EO 51/DOH = EINC/Unang Yakap protocol.
• Midwife's role in ALL high-risk findings: DETECT the problem, initiate first aid/immediate steps if applicable, and REFER to a higher facility. The midwife does NOT independently manage complications.
• Key 'detect and refer' findings: APGAR 0–3 (non-breathing), hypothermia not corrected by KMC, omphalitis, positive NBS result, imperforate anus, cleft palate, gross anomalies, LBW not improving, 'refer' hearing screen result.

Section Title

Complete Newborn Procedure Sequence and High-Yield Summary

Common Mistakes

• Performing routine procedures (eye drops, Vitamin K) on a non-breathing baby before establishing breathing — WRONG. Breathing ALWAYS comes first.
• Forgetting that the midwife's role with positive findings is to REFER, not to diagnose and manage independently.
• Mixing up the two laws: RA 9288 (NBS) and RA 9709 (Hearing) — know which law governs which procedure.