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

The EINC protocol (Unang Yakap) organizes the first minutes and hours of newborn life into four sequential, time-bound steps. These steps are not optional—they are the gold standard of newborn care in the Philippine context and are heavily tested on the MLE. **Step 1: Immediate and Thorough Drying (First 30 seconds)** The moment the baby is born, drying is the first action. The midwife uses a clean, warm, dry cloth to gently but thoroughly dry the newborn's entire body, including the head, face, and creases. This serves two critical purposes: (1) it prevents heat loss through evaporation, the fastest mechanism of heat loss in newborns, and (2) it stimulates the baby to cry and breathe. The key principle here is that a wet baby loses heat rapidly and is unlikely to cry effectively. After drying, the midwife uses a fresh dry cloth to avoid wet cloth remaining on the skin. Importantly, do NOT wipe off the vernix caseosa (the white, waxy coating)—this is protective and will be absorbed or gently rubbed in over the first few hours. This first 30 seconds sets the tone for successful transition and prevents the cascade of hypothermia that can complicate the newborn's first hours. **Step 2: Early Skin-to-Skin Contact (Immediately after drying)** Without delay, place the naked, dried baby prone (chest-to-chest) on the mother's bare chest or abdomen. Cover both mother and baby with a warm, dry blanket or cloth, and place a bonnet on the baby's head (heat loss through the head is significant). This position—often called Kangaroo Care or Ka-Mother Care in the Philippine context—provides thermoregulation, promotes bonding, stabilizes the baby's heart rate and respiration, and initiates the process of normal flora colonization. The mother's chest acts as a "heat source" and the close contact triggers oxytocin release in both mother and baby, promoting uterine contraction (reducing postpartum hemorrhage) and later facilitating breastfeeding. This step should occur immediately after drying and continues uninterrupted unless the baby is not breathing or requires resuscitation. **Step 3: Properly Timed Cord Clamping (1–3 minutes after birth)** The umbilical cord continues to transfer blood from the placenta to the baby for several minutes after birth. The old practice of immediate cord clamping (within seconds) is now known to deprive the newborn of 70–100 mL of blood, reducing iron stores and increasing the risk of anemia later in infancy. Current evidence supports delayed cord clamping: clamp and cut the cord ONLY AFTER cord pulsations have stopped, which typically occurs 1 to 3 minutes after delivery. For a baby on skin-to-skin, this clamping can occur while the baby is still against the mother. The cord is clamped with two clamps (or ties) placed approximately 2 cm apart, then cut with a sterile blade between them. The placenta is then delivered. If the baby is not breathing or requires immediate resuscitation, clamp and cut the cord promptly so the baby can be moved to a warm surface and managed without delay; in this case, the benefit of oxygen transfer must be weighed against the urgent need to establish breathing. **Step 4: Non-Separation and Early Breastfeeding (Within 90 minutes)** Keep the mother and baby together (rooming-in) from birth onward. In the first 90 minutes, the baby often enters a quiet alert state—a perfect window for the first breastfeed. The midwife supports the baby's instinctive "crawl" to the breast and helps with the first latch, teaching the mother proper positioning. Early breastfeeding confers multiple benefits: colostrum provides antibodies and nutrients, it stimulates oxytocin (aiding uterine contraction and milk letdown), and it promotes bonding and thermoregulation. Separation for routine procedures (weighing, bathing, eye drops, injections) should be minimal and brief; all procedures should ideally occur with the baby in view of or on the mother when safe to do so.

The EINC protocol includes explicit guidance on what NOT to do in the first hours of newborn life. These are heavily tested on the MLE because they represent a shift from older, harmful practices. Awareness of what NOT to do is as important as knowing what TO do. **Do NOT Routinely Suction the Newborn** Suctioning of the mouth and nose is NOT a routine procedure for every newborn. Routine suctioning (especially aggressive deep suctioning) can cause vagal stimulation, bradycardia, and respiratory depression, and may increase the risk of infection. The only indication for suctioning is if the baby is NOT breathing or is gasping, or if there is obvious thick meconium or blood obstructing the airway. If the baby is breathing, crying, and has good tone, do not suction. If the baby is born with meconium-stained fluid but is vigorous, do NOT suction—just proceed with routine EINC. Suctioning delays skin-to-skin and bonding, and there is no evidence it improves outcomes for vigorous babies. **Do NOT Bathe the Baby Immediately** The "first bath" should be delayed at least 6 hours after birth, ideally 24 hours. Early bathing washes away the protective vernix, increases heat loss, and disrupts skin flora colonization. If the baby is visibly soiled with blood or stool, gentle wiping with a warm damp cloth is acceptable, but full immersion bathing is delayed. The vernix will be absorbed or will gently rub away with skin-to-skin contact—there is no need to wash it off. Many mothers appreciate being taught that the waxy coating is protective and beneficial, reducing parental anxiety about a "dirty" baby. **Do NOT Separate Mother and Baby for Routine Procedures** All routine procedures—weighing, measuring, eye drops, injections, newborn screening—should be performed with the mother present and, when possible, with the baby on the mother's chest or within arm's reach. Separation increases the risk of hypothermia, increases stress for both baby and mother, and interferes with bonding and the establishment of breastfeeding. If a procedure requires the baby to be removed (e.g., for full infant examination), the baby should be returned to the mother immediately afterward. Rooming-in is not a luxury—it is a mandated part of normal newborn care. **Do NOT Do Foot-Printing and Identification Before Skin-to-Skin** Some facilities have a practice of footprinting, fingerprinting, and photographing the baby immediately after delivery for identification and record-keeping. While identification is important, these procedures should NOT be done before skin-to-skin contact with the mother is established. Foot-printing is a distraction and delays bonding. Once skin-to-skin is well underway (after the first 15–30 minutes), identification procedures can be done discreetly without separating mother and baby. **Do NOT Wait for APGAR to Start Resuscitation** The APGAR score is a communication tool used at 1 minute and 5 minutes to describe the baby's condition; it is NOT a resuscitation trigger. If a baby is not breathing or has a heart rate below 100 at birth, begin resuscitation immediately—do not wait for the 1-minute APGAR score. Resuscitation is guided by the presence or absence of spontaneous breathing and the heart rate, not by the score. This distinction is crucial and frequently tested on the MLE.

The APGAR score, named after Dr. Virginia Apgar, is a rapid, simple assessment of how well the newborn is transitioning to extrauterine life. It is scored at 1 minute and 5 minutes of age (and every 5 minutes up to 20 minutes if the baby is depressed). The score is NOT used to decide whether to resuscitate—resuscitation is guided by the baby's breathing, heart rate, and tone. Rather, APGAR is a communication tool that describes the baby's condition at specific moments and helps track improvement or deterioration. **The Five Components of APGAR:** **A = Appearance (Skin Color)** - 0 points: Entirely blue or pale (cyanosed all over) - 1 point: Body is pink but extremities (hands, feet) are blue (acrocyanosis—common and normal in the first minutes) - 2 points: Entirely pink **P = Pulse (Heart Rate)** - 0 points: Absent (no pulse felt in the cord or at the base of the heart) - 1 point: < 100 beats per minute (slow heart rate despite stimulation) - 2 points: ≥ 100 beats per minute (normal or rapid) The heart rate is felt by palpating the umbilical cord (the simplest method in the first minutes) or by listening with a stethoscope. A rate below 100 indicates depression and suggests the need for ventilation support. **G = Grimace (Reflex Irritability / Response to Stimulation)** - 0 points: No response to stimulation (limp, unresponsive) - 1 point: Grimace or weak cry in response to stimulation (suction, slap, or handling) - 2 points: Vigorous cry, cough, or sneeze in response to stimulation This component assesses the baby's responsiveness and protective reflexes. A baby who grimaces or cries in response to suctioning or handling is showing some protective response. **A = Activity (Muscle Tone)** - 0 points: Limp, no muscle tone (baby is floppy like a rag doll) - 1 point: Some flexion of arms and legs (hypotonic, weak tone) - 2 points: Active motion, well-flexed posture (normal newborn tone—arms and legs are flexed, baby resists extension) Assess tone by handling the baby gently; a normally toned baby will resist passive extension of the limbs. **R = Respiration (Breathing Effort)** - 0 points: Absent (no breathing effort, apneic) - 1 point: Slow, irregular, weak cry (gasping, shallow efforts, weak vocalization) - 2 points: Good, strong cry and spontaneous breathing (vigorous cry, regular respirations) **Interpreting the APGAR Score:** - **7–10 = Well/Normal**: The baby is pink, breathing well, has a strong cry and good tone, and a heart rate > 100. Most term babies score 8–9 at 1 minute (acrocyanosis is normal). These babies require routine care and observation only. - **4–6 = Moderately Depressed**: The baby has some signs of difficulty (e.g., slow heart rate, weak cry, hypotonia). These babies benefit from stimulation, gentle positioning, and possibly assisted ventilation. They require close observation and reassessment at 5 minutes. Most moderately depressed babies improve with stimulation and support. - **0–3 = Severely Depressed**: The baby is significantly compromised (apneic or gasping, heart rate < 100, limp, no response). These babies require immediate resuscitation (bag-and-mask ventilation or intubation), and this is a clear indication for referral to a facility with neonatal resuscitation capability (BEmONC/MNCHN center). **Key Principle: APGAR Does NOT Trigger Resuscitation** Resuscitation must begin immediately based on the baby's breathing and heart rate—NOT based on waiting for the 1-minute APGAR score. A baby born apneic or with a heart rate < 100 should be receiving positive-pressure ventilation within the first 60 seconds (the "golden minute") regardless of the APGAR score. Waiting for a score delays life-saving intervention. **Midwife's Role in Assessment** At the RHU, BHS, or home delivery attended by a midwife, the APGAR assessment is performed by the midwife herself. She observes color, counts the heart rate (easiest via umbilical cord palpation in the first minute), assesses tone, and notes the breathing effort and cry. At 1 minute, she documents the score and reassesses at 5 minutes. If the score is 7–10, the baby is well and routine care continues. If the score is 4–6 at 1 minute, the midwife provides stimulation and support (positioning, gentle drying, encouragement to cry) and reassesses at 5 minutes; most babies improve. If the score remains 4–6 or is 0–3 at 5 minutes, the baby is at high risk and MUST be referred urgently to a facility with neonatal resuscitation and monitoring capability. **Other Immediate Assessments Beyond APGAR** While performing APGAR, the midwife simultaneously: - **Counts respirations**: Normal rate is 40–60 breaths per minute in the first minutes; tachypnea (> 60) or bradypnea (< 40) warrant observation. - **Palpates the heart rate**: Normal rate is 120–160 beats per minute; sustained tachycardia or bradycardia is abnormal. - **Assesses temperature**: Axillary temperature should be 36.5–37.5 °C within the first hour; hypothermia (< 36.5 °C) is common and requires correction with skin-to-skin and rewarming (see Thermoregulation section). - **Performs a quick head-to-toe examination**: Look for gross abnormalities (e.g., cleft palate, limb deformities, abdominal wall defects, birth marks). These do not require immediate intervention but do need documentation and parental counseling. - **Checks patency of the anus**: Gently insert a thermometer or small tube to confirm the anus is patent; if not patent, this is a surgical referral. - **Checks for obvious signs of infection or distress**: Rashes, pustules, tremors, or seizures warrant investigation and possible referral. - **Weighs and measures**: Normal birth weight is 2,500–4,000 g; low birth weight (LBW) is < 2,500 g and requires closer monitoring and possible referral if the baby is also preterm or has other risk factors. Length is typically 48–52 cm and head circumference is 33–36 cm. All findings are documented in the birth record.

Newborns lose heat rapidly and are unable to generate sufficient heat to compensate, making thermoregulation one of the most critical aspects of immediate newborn care. Hypothermia (core temperature < 36.5 °C) increases the risk of hypoglycemia, metabolic acidosis, respiratory depression, and even death. In the Philippine context, where many deliveries occur in warm ambient environments, this may seem counterintuitive—yet hypothermia is common even in tropical settings because of evaporative cooling and the baby's large surface area relative to mass. The midwife must understand the mechanisms of heat loss and the interventions to prevent it. **Mechanisms of Heat Loss in Newborns:** 1. **Evaporation**: Heat is lost when amniotic fluid or sweat evaporates from the baby's wet skin. This is the fastest and most significant mechanism immediately after birth. A wet baby loses heat rapidly even in a warm room. 2. **Conduction**: Direct contact with cold surfaces (cold delivery table, cold hands, cold instruments) transfers heat from the baby to the surface. 3. **Convection**: Heat loss to cooler air currents in the room. 4. **Radiation**: Heat loss to cooler objects in the environment (walls, windows, uncovered surfaces) even without direct contact. The newborn has limited ability to generate heat through shivering or metabolic activity and cannot seek warmth independently. Therefore, the environment and caregiver must provide thermoregulation. **The Warm Chain: Seven Essential Steps** The **Warm Chain** is a systematic approach to preventing heat loss from conception through the first days of life: 1. **Warm, Dry Delivery Room**: The delivery room (whether home, RHU, or lying-in) should be maintained at **25–28 °C** (77–82 °F). In home deliveries in the Philippines, if the room is very hot, leave windows partially open to allow air circulation but keep it above 25 °C. Remove drafts that cause convective cooling. 2. **Warm, Dry Towels and Blankets**: Have warm towels ready before delivery. Keep towels warm by placing them in a warmed container or dryer (if available at the RHU). In home settings, towels can be warmed by placing them near a heat source momentarily (not too hot—test against the inner arm to confirm warmth without burning). Use dry, clean towels only; wet towels conduct heat away from the baby. 3. **Warm Hands**: The midwife's hands should be warm when handling the newborn. If hands are cold, warm them by rubbing together or placing in warm water before touching the baby. Cold hands cause conductive heat loss. 4. **Immediate Drying**: Within the first 30 seconds, completely dry the baby, including the head and creases. Wet skin (whether from amniotic fluid, meconium, or blood) causes rapid evaporative cooling. Change the first wet cloth for a fresh dry cloth immediately. 5. **Skin-to-Skin Contact and Covering**: Place the naked, dried baby prone on the mother's bare chest or abdomen, cover both with a warm dry blanket or cloth, and place a bonnet on the baby's head. This is the most important single intervention: the mother's body acts as a constant heat source (maintaining temperature at ~37 °C), the baby's heat loss is minimized by direct contact, and the bonnet prevents head heat loss. Kangaroo Mother Care (Ka-Mother Care in the Philippine context) is not only for low-birth-weight babies—it is appropriate for all newborns. 6. **Delayed, Warm Bathing**: Do NOT bathe the baby in the first 6 hours (ideally 24 hours). The warm amniotic fluid and vernix on the skin provide insulation. When bathing is necessary (typically after 24 hours), use warm water (~37–38 °C, tested on the inner wrist to avoid burns), work quickly, and return the baby to skin-to-skin or warm clothing immediately. Bathe the baby in a warm room and keep the baby covered except the area being washed. 7. **Warm Transport and Environment After Birth**: Maintain the warm chain even after the immediate newborn period. In the first week, avoid exposure to air conditioning or fans unless the ambient temperature is excessive. Keep the baby in light clothing (warm enough but not too much, which can also overheat) and continue skin-to-skin as much as possible. **Monitoring and Management of Temperature** The midwife checks the baby's axillary temperature (armpit) within the first hour of life and regularly thereafter (at each contact). To take axillary temperature, place the thermometer (digital is fastest and most accurate) in the axilla (armpit), keep the arm against the chest for at least 1 minute, and read. Normal axillary temperature is **36.5–37.5 °C**. **If Temperature Is Low (< 36.5 °C = Hypothermia):** - **Mild hypothermia** (36–36.4 °C): Increase skin-to-skin contact, add a blanket over the mother-baby dyad, ensure the environment is warm, and recheck in 30 minutes. Most mild hypothermia corrects with these measures. - **Moderate to severe hypothermia** (< 36 °C): This requires more aggressive intervention. Continue skin-to-skin, add a blanket, ensure the room is warm, give warm drinks (expressed breast milk or water) if the baby is alert enough to suckle, and recheck frequently. If the temperature does not improve within 1–2 hours or if the baby shows signs of illness (lethargy, poor feeding, seizures), refer urgently to the hospital for evaluation. Hypothermia in combination with other symptoms (e.g., weak feeding, jaundice, difficulty breathing) is a red flag for sepsis or other serious illness. **If Temperature Is High (> 37.5 °C = Fever/Hyperthermia):** - Remove extra blankets and bonnets, reduce skin-to-skin contact temporarily, ensure good air circulation, and recheck temperature. - A fever in a newborn (temperature > 37.5 °C, especially > 38 °C) can indicate infection and warrants investigation. Refer to the hospital if the baby has a fever along with any signs of illness (poor feeding, lethargy, irritability, rash, vomiting, or diarrhea). **Kangaroo Mother Care (Ka-Mother Care) as Thermoregulation** In the Philippine public health system, Kangaroo Mother Care is promoted as both a thermoregulation strategy and a bonding technique, particularly for low-birth-weight (LBW) babies. Even for term babies, skin-to-skin contact in the first hours and days provides superior thermoregulation compared to any artificial heat source. The mother's temperature automatically adjusts: if the baby is cold, the mother's skin temperature increases; if the baby is warm, it decreases. This is more effective than any isolette or warmer. **Common Pitfalls in Thermoregulation:** - **Over-wrapping**: While keeping the baby warm is important, over-wrapping in excessive blankets (especially in a warm Philippine room) can cause overheating. The goal is thermal stability, not maximum heat. - **Bathing immediately after birth**: This is a common practice in some communities, and it is harmful. Bathing removes the protective vernix and causes heat loss. Explain to families that delaying the bath is medically recommended. - **Separating the baby for cleaning or procedures**: Leaving a naked baby on a cold metal table or exposed to air conditioning causes heat loss. All procedures should be done with the baby on or near the mother or under a heat source. - **Using cold instruments or surfaces**: Metal instruments and stainless steel tables conduct heat away from the baby. Pre-warm any instruments and surfaces that will contact the baby, or keep contact time minimal.

Vitamin K Deficiency Bleeding (VKDB), formerly called hemorrhagic disease of the newborn, is a rare but life-threatening condition in which the newborn bleeds due to inadequate vitamin K-dependent clotting factors (factors II, VII, IX, and X). In the Philippines, the Expanded Newborn Screening program and DOH guidelines mandate vitamin K prophylaxis for all newborns to prevent VKDB, which can present as intracranial hemorrhage, gastrointestinal bleeding, or other serious bleeding. Maternal vitamin K does not adequately cross the placenta, newborn intestinal flora (which produce vitamin K) are not fully established, and breast milk has low vitamin K content; hence, every newborn is at risk and requires supplementation. **Types of VKDB:** VKDB has three presentations, depending on when it occurs: 1. **Early VKDB** (< 24 hours of age): Rare, usually associated with maternal use of certain medications (anticonvulsants, anticoagulants). Not prevented by routine prophylaxis—requires treatment if bleeding occurs. 2. **Classic VKDB** (2–7 days of age): Most common form. Prevented effectively by intramuscular vitamin K prophylaxis. Presents with bleeding from the gastrointestinal tract, cord stump, or skin (bruising, bleeding from circumcision site if present). 3. **Late VKDB** (> 1 week, typically 2–12 weeks of age): Occurs especially in exclusively breastfed babies (breast milk is low in vitamin K) or babies with underlying malabsorption (cystic fibrosis, cholestasis). Prevented by IM vitamin K and/or oral vitamin K given in multiple doses over time. Presents with intracranial hemorrhage (subdural hematoma), gastrointestinal bleeding, or other serious bleeding. **Vitamin K Prophylaxis: The Midwife's Role** **Timing**: Vitamin K1 (phytomenadione) is given intramuscularly as a **single dose within the first hours after birth**—ideally after drying and skin-to-skin contact but before other invasive procedures (e.g., before heel-prick for newborn screening, if scheduling allows). If the baby is on the mother's chest, the injection can be given with the baby in that position or with brief gentle movement. **Dose**: - **Term or normal-weight newborn (≥ 2,500 g)**: 1 mg (0.1 mL of a 10 mg/mL solution or 0.5 mL of a 2 mg/mL solution, depending on the formulation available at the RHU/facility). - **Preterm newborn or low-birth-weight (< 2,500 g)**: 0.5 mg (0.05 mL of a 10 mg/mL solution or 0.25 mL of a 2 mg/mL solution). The dose depends on birth weight, not age. Always check the weight before administering and use the correct dose. **Route**: **Intramuscular (IM) only**. Vitamin K is given IM into the **vastus lateralis muscle** (the lateral aspect of the thigh, upper outer quadrant) using a 25–27 gauge needle and a 1 mL syringe. IM administration is superior to oral or intravenous routes because it ensures reliable absorption and levels. Oral vitamin K is less reliable and does not prevent late VKDB without multiple doses; IV vitamin K is not recommended in routine prophylaxis. **Technique for IM Injection**: 1. Identify the **vastus lateralis**: The thigh is divided into three vertical sections; the injection is in the **middle third of the outer thigh** (lateral aspect). This muscle is well-developed even in newborns and minimizes the risk of hitting a blood vessel or nerve. 2. Cleanse the site with an alcohol swab and allow to air-dry briefly (alcohol burns if not dried and is irritating). 3. Gently support the thigh, insert the needle at a 90-degree angle quickly and cleanly, and aspirate briefly (to check for blood—if blood is withdrawn, withdraw and try another site; if no blood, proceed). 4. Inject the vitamin K solution slowly to reduce pain and local irritation. 5. Withdraw the needle, apply gentle pressure with a clean cloth if needed, and comfort the baby. **Storage and Handling**: - Vitamin K is light-sensitive and should be stored in a dark container or opaque syringe. Do not expose to direct sunlight. - Store at room temperature (15–25 °C) unless the label specifies otherwise. - Check the expiration date before use. - Do not mix vitamin K with other drugs in the same syringe. **Documentation**: Record in the baby's health record: - Name of the medication (Vitamin K1 or phytomenadione) - Dose (e.g., 1 mg for a 3 kg baby, or 0.5 mg for a 2 kg baby) - Route (IM) - Site (right vastus lateralis or left vastus lateralis) - Time of administration - Batch/lot number (for traceability) - Name of the person administering **Common Errors to Avoid**: - **Incorrect dose based on age instead of weight**: Vitamin K dose is determined by weight, not age. A 2.2 kg term baby born at 35 weeks is still considered preterm/LBW and should receive 0.5 mg, not 1 mg. - **IV administration**: IV vitamin K is NOT recommended for routine prophylaxis and increases the risk of adverse reactions. - **Giving vitamin K before the baby is born**: Vitamin K is for the newborn AFTER birth. Giving it during pregnancy or immediately before delivery (e.g., to an unborn twin during a multiple delivery) is incorrect and harmful. - **Delaying vitamin K beyond the first few hours**: While vitamin K can be given up to a few days after birth, it is most effective when given early. Delays reduce efficacy in preventing classic VKDB. - **Forgetting to give vitamin K**: This is a critical omission. Every normal newborn should receive vitamin K as part of the mandated newborn package. In the MLE, questions often ask whether vitamin K is indicated in a particular scenario—the answer is nearly always yes for a newborn born vaginally or by cesarean section, with few exceptions. **Vitamin K and Breastfeeding**: Even breastfed babies receive the standard IM vitamin K dose. Breast milk is naturally low in vitamin K, and exclusively breastfed babies are at higher risk for late VKDB. IM vitamin K provides protection. The midwife should counsel the mother that vitamin K does not interfere with breastfeeding and should encourage exclusive breastfeeding.

Ophthalmia neonatorum is a serious eye infection in newborns caused most commonly by **Neisseria gonorrhoeae** or **Chlamydia trachomatis** from maternal genital infection during vaginal delivery. The infection presents in the first few days of life with conjunctival erythema, swelling, and purulent discharge. If untreated, it can cause corneal scarring and blindness. Even in the era of better maternal screening in the Philippines, some cases are missed, and the consequences are severe enough that eye prophylaxis is mandated for ALL newborns regardless of maternal history. **Causative Organisms:** - **Neisseria gonorrhoeae** (gonorrheal ophthalmia): Most common cause. Presents with severe conjunctivitis and purulent discharge within 2–3 days of birth. Can cause corneal ulceration and blindness within a few days if untreated. - **Chlamydia trachomatis** (chlamydial ophthalmia): Presents slightly later (3–14 days of life) with milder conjunctivitis initially but persistent discharge. Can also cause chronic keratitis and scarring. - Other bacteria (Staphylococcus, Streptococcus, Pseudomonas): Less common but possible with poor hygiene during delivery. **Eye Prophylaxis: The Midwife's Role** **Medication**: The standard agent is **erythromycin 0.5% ophthalmic ointment** (or tetracycline 1% ophthalmic ointment if erythromycin is unavailable). These are broad-spectrum antibiotics effective against gonorrhea and chlamydia. Silver nitrate 1%, once widely used, is now less common because it can cause chemical irritation and has been replaced by the gentler antibiotic ointments. **Timing**: Eye prophylaxis is applied **after the first breastfeed/bonding**, ideally **within the first 1–2 hours of life**. Some protocols allow it up to 12 hours, but earlier is better. The rationale for waiting until after the first breastfeed is to avoid coating the eyes with ointment before the baby has an opportunity to see and bond with the mother clearly. In practice, eye prophylaxis is often one of the last routine procedures, done after vitamin K and before weighing and measurement (or interspersed with other procedures as the midwife's workflow allows). **Technique**: 1. **Prepare the eyes**: Gently wipe away any secretions or blood with a clean, warm cloth. Use a separate cloth for each eye to avoid cross-contamination. 2. **Position the baby**: Hold the baby's head gently, with the chin slightly downward to allow any excess ointment to drain. 3. **Apply the ointment**: - Using a small tube or ointment dispenser, place a thin ribbon (approximately the size of a grain of rice to a small pea, about 0.5–1 cm) of ointment into the **lower conjunctival sac** (lower eyelid area) of the right eye. - Gently pull the lower eyelid down slightly and place the ointment along the conjunctival sac from the **inner canthus (inner corner) to the outer canthus (outer corner)**. - Release the eyelid to allow the ointment to spread across the eye. - Repeat the process for the left eye using a fresh application (do not reuse ointment from the first eye). 4. **Do NOT irrigate the eyes** with normal saline or water after applying the ointment. The ointment should remain in the eyes for its protective effect. Some discharge or mild redness may occur over the next few hours as the eyes adjust—this is normal. 5. **Allow the baby to close the eyes**: The ointment will coat the cornea and conjunctiva, providing protection. The baby's eyes will naturally tear and blink away excess ointment over time. **Storage and Handling**: - Ophthalmic ointments are sterile and should be stored at room temperature (15–25 °C). - Once opened, most ointments should be used within 28 days or discarded according to local protocol. - Always check the expiration date before use. - Do not touch the tube tip to the eye or any non-sterile surface. **Documentation**: Record in the baby's health record: - Name of the medication (e.g., Erythromycin 0.5% ophthalmic ointment) - Both eyes treated (specify: right and left, or OD and OS) - Time of application - Any adverse reactions or unusual findings - Name of the person administering **Common Errors to Avoid**: - **Using wrong strength or wrong medication**: Ophthalmic ointments are specifically formulated for eye use. Do NOT use systemic antibiotics or non-sterile preparations. Verify the label states "ophthalmic ointment." - **Irrigation after application**: Rinsing the ointment away with saline defeats the purpose. The ointment should remain in the eyes. - **Applying to only one eye**: Always apply to BOTH eyes even if only one eye appears potentially exposed to infection (the partner eye is also at risk). - **Delaying application unnecessarily**: While application can be deferred until after the first breastfeed, excessive delay (> 12 hours) reduces efficacy in preventing early ophthalmia. Apply within the first few hours when possible. - **Forgetting eye prophylaxis**: Like vitamin K, this is a mandated procedure that is easy to omit in the busy flow of birth. Eye prophylaxis is a requirement for every newborn. **When to Refer for Eye Concerns**: If the baby develops signs of conjunctivitis AFTER prophylaxis has been applied (which can happen if the organism is resistant or if maternal infection is very heavy), the midwife refers the baby to a facility for evaluation and treatment. Signs include: - Purulent discharge persisting beyond the first 24–48 hours - Eyelid swelling or erythema - Eye redness or apparent discomfort - Any sign of keratitis (corneal involvement—haze or cloudiness in the pupil area) These require urgent evaluation and possibly topical and systemic antibiotics.

The **Newborn Screening Act of 2004 (RA 9288)** mandates that every newborn in the Philippines undergo screening for selected metabolic, endocrine, and hemoglobinopathy disorders that cause intellectual disability or death if untreated but are entirely treatable or manageable when detected early. For the midwife, this is not just a procedure—it is a legal responsibility. The midwife must ensure the newborn screening sample is collected, inform the parents of its purpose and benefits, and follow up on results. **Purpose of Newborn Screening:** Newborn screening detects disorders that: 1. Are serious and life-threatening if undetected (cause intellectual disability, organ damage, or death). 2. Are treatable or manageable if caught early. 3. Are detectable through a simple, non-invasive test (blood spot). 4. Have a reasonable prevalence in the population. The classic example tested in the MLE is **congenital hypothyroidism (CH)**: if undetected, it causes severe, irreversible intellectual disability (cretinism). But thyroxine replacement therapy started in the first weeks of life prevents disability entirely. This exemplifies why early screening is so important. **The Philippine Newborn Screening Panel (Expanded Newborn Screening - ENBS):** The expanded panel screens for multiple disorders: 1. **Congenital Hypothyroidism (CH)**: Thyroid dysgenesis or enzyme defect preventing thyroid hormone synthesis. Incidence ~1 in 1,000–3,000 newborns. Manifests in the first weeks to months with poor feeding, constipation, jaundice, poor growth, and developmental delay if untreated. Treatment: Thyroxine (levothyroxine) replacement started by 2 weeks of age prevents all intellectual disability. 2. **Congenital Adrenal Hyperplasia (CAH)**: Most commonly caused by 21-hydroxylase deficiency, leading to cortisol and aldosterone deficiency and elevated androgens. Incidence ~1 in 10,000. Classic salt-wasting form presents at 1–4 weeks with vomiting, dehydration, hyponatremia, and shock if missed. Virilization of female genitalia occurs in utero (ambiguous genitalia). Treatment: Steroid and mineralocorticoid replacement. Early diagnosis prevents life-threatening adrenal crisis and allows appropriate management of ambiguous genitalia. 3. **Galactosemia (GAL)**: Deficiency of galactose-1-phosphate uridyltransferase (GALT), leading to accumulation of galactose. Incidence ~1 in 40,000–50,000. Presents with feeding intolerance, vomiting, jaundice, hepatomegaly, and cataracts if untreated. Treatment: Galactose-restricted diet (lactose-free formula for infants). Early diagnosis prevents cataracts and intellectual disability. 4. **Phenylketonuria (PKU)**: Phenylalanine hydroxylase deficiency, leading to accumulation of phenylalanine and its metabolites. Incidence ~1 in 10,000. Manifests in the first months with musty odor of urine, light skin and hair, seizures, and severe intellectual disability if untreated. Treatment: Phenylalanine-restricted diet (special formula). Early diagnosis and dietary management prevent intellectual disability. 5. **Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD)**: An enzyme deficiency predisposing to hemolysis with oxidative stress (e.g., from certain foods like fava beans, or drugs like aspirin, sulfonamides). Incidence high in the Philippines (~1 in 200–400, especially in males). Asymptomatic until trigger exposure. Triggers include fava beans, antimalarial drugs, and some infections. Screening does not treat the disease but allows parents to avoid triggers and recognize hemolytic episodes early. Important in the Philippine context because G6PD is prevalent and fava beans are consumed in some regions. 6. **Maple Syrup Urine Disease (MSUD)**: Deficiency of branched-chain amino acid dehydrogenase, leading to accumulation of leucine, isoleucine, and valine. Incidence low but serious. Manifests at 2–7 days with poor feeding, lethargy, hypertonia, seizures, and cerebral edema if untreated. Sweet-smelling (maple syrup-like) urine is pathognomonic. Treatment: Specialized low-branched-chain amino acid formula. Early dietary intervention prevents neurologic damage. The **expanded panel** may also include: - **Hemoglobinopathies**: Sickle cell disease (HbSS), thalassemia, and other abnormal hemoglobins. Incidence varies by ethnicity; important in populations at higher risk. Early detection allows prophylaxis (penicillin), pain management, and counseling. - **Biotinidase deficiency**: Rare but treatable with biotin supplementation; prevents neurologic sequelae. - **Cystic fibrosis (CF)**: Detected by elevated immunoreactive trypsinogen (IRT); confirmed by genetic testing. Early diagnosis allows early pancreatic enzyme and airway clearance therapy, improving outcomes. **Newborn Screening: The Collection Process** **Timing - CRITICAL**: - **Ideal timing: 24 to 72 hours after birth** (most accurate; allows time for the disorder to manifest in the blood spot and reduces false positives). - **Before 24 hours**: If the baby must be discharged earlier (e.g., home delivery with early discharge), the sample MAY be collected as early as **24 hours**; however, a **REPEAT sample is required by 2 weeks of age** because early samples have a higher false-negative rate, particularly for CAH (17-OHP/17-hydroxyprogesterone can be falsely low before 24 hours) and other conditions. - **Never before 6 hours**: Samples collected before 6 hours are unreliable and should be rejected. The midwife must understand that if she collects the sample before 24 hours (which may happen in a home delivery that the mother does not return to an RHU), she has a legal obligation to inform the parents that a repeat sample is required within 2 weeks. This is often missed, and babies are lost to follow-up. **Collection Method - Heel-Prick (Heel-Stick)**: 1. **Prepare the heel**: The baby is allowed to warm up (warm water footbath or warm cloth on the foot for 3–5 minutes) to improve blood flow. Warming the foot brings blood to the surface and makes collection easier and less traumatic. 2. **Choose the puncture site**: The heel is used, specifically the **lateral (outer) or medial (inner) aspect of the heel**, avoiding the center (midline), which has the calcaneal bone and large blood vessels. A common mnemonic is the "safety zone" (lateral and medial aspects of the heel); avoid the center arch. 3. **Perform the heel prick**: Using a sterile lancet (blade or automated device, typically 2.0 mm depth), make a quick, clean puncture perpendicular to the skin. The blade should be sterile and single-use. Automated heel-prick devices (e.g., Tenderfoot, BD Microtainer) are gentler and more consistent than manual lances. 4. **Collect the blood**: Allow blood to flow freely from the heel; gently squeeze the foot if blood flow is sluggish, but do NOT "milk" the foot aggressively as this can dilute the blood with tissue fluid. The first drop is wiped away (as it may be diluted), and subsequent drops are allowed to fall onto the special **filter-paper card** (Guthrie card). 5. **Fill the spots**: The filter-paper card has multiple circles (usually 5–6 spots). Blood drops are allowed to saturate through the paper on both sides, creating a blood spot approximately the size of the circle (about 0.5 cm diameter). Fill all required spots per the card's instructions. The spots should be filled completely without excess (which could contaminate other spots) and without gaps or thin areas. 6. **Dry the card**: After collection, the card is air-dried at room temperature for several hours (at least 2–4 hours, ideally overnight) in a clean, dry location away from direct sunlight and heat. Some cards are then placed in a drying rack or envelope provided with the kit. 7. **Label the card**: The card is labeled with the baby's name (or ID if that is protocol), date and time of birth, date and time of sample collection, mother's name, and the attending midwife's name. Accurate, legible labeling is essential for correct identification and tracking. 8. **Submit the card**: The dried card is sent to the authorized newborn screening laboratory (e.g., University of the Philippines, Research Institute for Tropical Medicine, or accredited private laboratories) for testing. The card is placed in the envelope or protective cover provided and sent via secure mail or courier. The timeline for submission should be as soon as possible after drying (within 24–48 hours) to prevent sample degradation. **Laboratory Testing and Results**: The laboratory performs **tandem mass spectrometry (MS/MS)**, which screens for multiple metabolites simultaneously. Results are reported as: - **Negative/Normal**: No elevated markers detected; baby has a very low likelihood of the screened disorders. - **Positive/High-Risk**: One or more markers are elevated; the baby requires **urgent confirmatory testing** (repeat newborn screening, specific enzyme assays, hormonal testing, or genetic testing depending on which disorder is suspected). - **Inconclusive**: Results are borderline; a repeat sample is requested. **The Midwife's Responsibility in Newborn Screening:** 1. **Legal obligation**: The midwife is legally responsible for ensuring newborn screening is performed. Under RA 9288, every newborn has a right to screening, and the midwife must facilitate this. 2. **Parental counseling**: The midwife must inform the parents/guardians of: - What newborn screening is and why it is important. - Which disorders are screened. - The benefits of early detection. - The procedure (heel prick, painless, quick). - When results will be available. - What to do if the baby is referred (further testing, follow-up). - That newborn screening does NOT diagnose disease—positive results need confirmatory testing. 3. **Documented consent**: Parents have the right to accept or refuse newborn screening. If they refuse, this must be documented in the health record with the reason for refusal. However, in practice, most parents accept screening once informed of its benefits. 4. **Proper collection**: The midwife ensures the sample is collected correctly: - At the right timing (24–72 hours ideally; not before 24 hours unless a repeat is planned). - From the correct site (lateral or medial heel). - With adequate blood saturation on the filter paper. - Properly labeled and dried. 5. **Timely submission**: The sample is sent to the laboratory promptly after drying (within 24–48 hours). 6. **Follow-up and referral**: The midwife follows up on the screening results. If results are positive/high-risk, she immediately refers the baby to an appropriate facility (RHU physician, pediatrician, or hospital) for confirmatory testing and management. She does NOT delay referral waiting for the parents to seek care. **High-Yield MLE Points on Newborn Screening:** - **RA 9288 mandates newborn screening for all newborns**: It is not optional. - **Heel-prick capillary blood** is the collection method. - **Ideal timing: 24–72 hours after birth**; not before 24 hours; if collected before 24 hours, a repeat is required by 2 weeks. - **Congenital hypothyroidism** is the classic example: undetected → intellectual disability; early thyroxine → normal development. - **Other key disorders**: CAH (adrenal crisis if missed), galactosemia (cataracts/disability if missed), PKU (intellectual disability if missed), G6PD (hemolysis on triggers). - **Positive result = high-risk, not confirmed diagnosis**: Requires urgent confirmatory testing and referral. - **The midwife is legally responsible** for collection and informing parents; she arranges referral if results are positive. **Common Errors to Avoid in the MLE Context:** - **Thinking newborn screening is optional or only for at-risk babies**: It is mandated for all newborns. - **Collecting the sample before 24 hours without mentioning a repeat**: This is an omission. If the sample is early, a repeat is mandatory. - **Thinking a positive newborn screening result means the baby is definitely ill**: A positive result is a flag for further testing; it does not confirm disease. - **Delaying referral when results are positive**: The midwife must refer urgently; delay in confirmatory testing can allow irreversible damage in conditions like CH or CAH.

The **Universal Newborn Hearing Screening and Intervention Act of 2009 (RA 9709)** mandates hearing screening for every newborn to detect congenital hearing loss early so that intervention can begin by **6 months of age**, preserving speech and language development. The goals are simple but profound: detect hearing loss before the baby is discharged (or within the first month, up to 3 months at the latest), refer for confirmatory testing if results are unclear, and ensure early intervention (hearing aids, cochlear implants, sign language, speech therapy) for babies with confirmed hearing loss. **Epidemiology and Impact:** Congenital hearing loss affects approximately 1–3 per 1,000 newborns (higher in newborns with risk factors such as prematurity, intrauterine infections like TORCH, low birth weight, or family history). If undetected until the child is older, the critical window for language acquisition is lost, leading to permanent speech and language delays. Early detection and intervention—starting by 6 months of age—allow most children with hearing loss to develop normal or near-normal speech and language skills. This is a preventive public health triumph similar to newborn screening for metabolic disorders. **Methods of Hearing Screening:** Two primary methods are used, both painless and quick: **1. Otoacoustic Emissions (OAE)** OAE detects sound waves produced by the inner ear (cochlea) in response to sound stimuli. How it works: - A small soft earpiece is placed in the baby's ear canal. - The device emits soft clicks or tones. - Sensitive microphones measure sound waves produced by the cochlea in response. - If the cochlea is functioning normally, the emissions are detected ("pass"). - If emissions are absent or weak, the result is "refer" (suggesting possible hearing loss or middle ear fluid). **Advantages of OAE**: - Quick (5–10 minutes). - Non-invasive, no electrodes or stimulation needed. - Can be performed while the baby is sleeping or resting. - Good at detecting cochlear (sensorineural) hearing loss. **Limitations**: - Cannot detect all types of hearing loss (specifically, auditory neuropathy/dyssynchrony—a condition where the cochlea is normal but the auditory nerve or central auditory pathways are dysfunctional). - Can give false results if there is middle ear fluid (common in the first days of life), which can clear spontaneously. **2. Automated Auditory Brainstem Response (AABR)** AABR measures electrical brain activity in response to sound. How it works: - Three small electrodes are placed on the baby's forehead and ears. - Sound clicks are delivered via earphones. - The device measures neural responses (brainstem waves) to the sound. - Normal responses = "pass"; abnormal or absent responses = "refer". **Advantages of AABR**: - Can detect some types of hearing loss that OAE may miss (including auditory neuropathy). - Measures the entire auditory pathway from cochlea to brainstem. - Specific and reliable. **Limitations**: - Slightly longer than OAE (10–15 minutes). - Requires placement of electrodes; some babies may be irritated. - May give false results if the baby is moving a lot or crying. **Combined Screening Protocol:** Many facilities use a **two-step approach**: 1. **First screen: OAE** (quick and easy). - If PASS: Reassure parents, no further immediate testing needed (though follow-up at 4 weeks is often recommended for those with OAE/refer in first ear initially, as middle ear fluid may clear). - If REFER: Proceed to second screen or schedule confirmatory testing. 2. **Second screen: AABR** (more specific for auditory pathway problems). - If PASS: Reassure parents. - If REFER: Urgent referral for diagnostic testing (formal audiometry, imaging if needed). This approach balances efficiency (OAE is quick) with sensitivity (AABR catches cases OAE might miss). **Results Interpretation:** - **PASS**: The baby's hearing is likely normal. No further immediate testing needed. However, permanent hearing loss can develop later in infancy or childhood, so families are counseled to monitor for normal developmental milestones (response to sounds, language development) and return if concerns arise. - **REFER**: The screening suggests possible hearing loss or inability to adequately assess hearing at this time (e.g., due to middle ear fluid, excessive movement). REFER does NOT mean the baby is deaf or definitely has hearing loss—it means confirmatory testing is needed. Many babies with a "refer" result have normal hearing confirmed on follow-up testing. **Timing and Setting:** - **Ideal timing: Before hospital discharge** (or before discharge from the lying-in or RHU). - **At minimum: Within the first month of life** (by 4 weeks). - **Latest acceptable: Within 3 months of life** (per RA 9709). In practice, many newborns are screened in the hospital before discharge. For home deliveries or early discharge, the midwife must refer the baby to a facility with screening capability for screening within the first month. **The Midwife's Role in Newborn Hearing Screening:** 1. **Parental counseling**: The midwife explains: - Why hearing screening is important (early detection allows early intervention and normal language development). - How the test works (quick, painless, non-invasive). - That a "refer" result does not mean the baby is deaf—it means further testing is needed. - When and where the test will be done. 2. **Ensuring screening is performed**: At the RHU, BHS, or hospital with screening equipment, the midwife ensures the test is done before discharge or within the agreed timeline. She documents the result (PASS or REFER). 3. **Referral if not available locally**: If the RHU or lying-in does not have hearing screening equipment, the midwife refers the newborn to a facility (hospital, diagnostic center) that does have OAE and/or AABR capability. She documents the referral and advises the parents of the location and timing. 4. **Follow-up on "refer" results**: If the screening result is REFER, the midwife: - Explains to the parents that further testing is needed (confirmatory audiometry). - Refers the baby urgently to an audiologist or ENT specialist. - Documents the referral and follows up to ensure the family completes confirmatory testing. - Does NOT alarm the parents but emphasizes the importance of follow-up. 5. **Counseling on developmental milestones**: The midwife advises parents to monitor for normal hearing development: - By 3 months: Baby should startle to loud sounds. - By 6 months: Baby should turn toward sounds, babble in response to voices. - By 12 months: Baby should understand words like "mama" and "bye-bye," and may say first words. - If developmental milestones are delayed (no babbling by 6 months, no understanding of words by 12 months), this is a red flag and warrants audiological evaluation even if newborn screening was normal (hearing loss can develop later in infancy). **High-Yield MLE Points on Newborn Hearing Screening:** - **RA 9709 mandates hearing screening for all newborns**: Before discharge or within 1 month (3 months latest). - **Methods: OAE and/or AABR**, both painless and quick. - **PASS = normal hearing, REFER = needs confirmatory testing** (not a diagnosis of deafness). - **Early detection allows intervention by 6 months**, which preserves language development. - **The midwife is responsible for ensuring screening is done** or referring if equipment is unavailable locally. - **Follow-up on "refer" results is mandatory**; the midwife refers for confirmatory testing. **Common Pitfalls in Newborn Hearing Screening:** - **Omitting the screening**: Like newborn screening and eye prophylaxis, hearing screening is easy to miss in the busy flow of newborn care. It must be scheduled and documented. - **Misinterpreting "refer" as a diagnosis**: Explaining to parents that "refer" means the baby is deaf is incorrect and harmful. Explain that further testing is needed to clarify the result. - **Not referring for confirmatory testing if "refer" result**: A "refer" result is a flag; the family must follow up with an audiologist or ENT for definitive testing. Delaying this risks a missed hearing loss. - **Assuming hearing is normal if screening is unavailable**: If a facility lacks screening equipment, the baby is referred to another facility; the midwife does not assume the baby's hearing is normal without testing. - **Not counseling on developmental milestones**: Even after a normal newborn hearing screen, parents should be counseled to monitor language development; some hearing loss develops later and would be missed without continued vigilance.

After the umbilical cord is clamped and cut, the cord stump (remainder attached to the baby's abdomen) becomes a potential entry point for infection. Omphalitis is umbilical cord infection, which can progress to serious bloodstream infection (sepsis) if not recognized early. While rare in facilities with good hygiene, omphalitis remains a significant cause of neonatal morbidity and mortality in low-resource settings. The midwife's role is to provide education and counsel on proper cord care and to teach the mother and family to recognize danger signs. **Modern Cord Care: Dry Care is Standard** Historically, various substances were applied to the cord stump (alcohol, betadine, antibiotic ointments, local remedies like toyo, garlic, herbal powders, salt, or ash). Current evidence and DOH policy favor **dry cord care**: keep the cord stump **clean and dry**, apply **nothing** (no alcohol, no antiseptic, no traditional remedies), fold the diaper below the cord (so it is exposed to air), and allow it to air-dry and separate naturally. **Rationale for Dry Cord Care**: 1. **Promotes drying and separation**: The cord stump dries faster when exposed to air. A dry environment is hostile to bacterial growth. 2. **No chemical irritation**: Harsh agents like alcohol can irritate the delicate tissue and delay separation. 3. **Lower infection rates**: Studies show dry cord care is at least as safe as (and possibly safer than) application of various agents, with lower rates of infection in most settings. 4. **Cost-effective**: No expensive preparations are needed. 5. **Culturally acceptable**: In many communities, simple, familiar care is more likely to be followed. **Exception - Chlorhexidine in High-Risk Settings:** In some high-risk or resource-limited settings (particularly in developing countries with high sepsis burden), a **single application of 4% chlorhexidine** to the cord stump at birth has been shown to reduce omphalitis rates significantly. Some health systems (including some Philippine public facilities in high-risk areas) may include chlorhexidine application as part of the cord care protocol. If this is your facility's protocol, follow it; if not, dry care is appropriate. Chlorhexidine is safe, gentle, and does not delay separation. **Steps in Cord Care at Delivery:** 1. **Clamping and cutting**: Two clamps or ties are placed on the cord approximately 2 cm apart. The cord is cut between the clamps using a sterile blade or scissors. A clean cut (not crushed or ragged) helps the stump dry faster. 2. **Inspect the stump**: Look at the cut end. It should be bleeding minimally (perhaps a few drops). If bleeding is brisk, apply gentle pressure with a clean cloth until it stops, or add a small sterile gauze to the stump. Persistent bleeding suggests a bleeding disorder and warrants referral if not easily controlled. 3. **Maintain cleanliness**: Keep the stump clean and dry. It is normal for a small amount of clear or slightly blood-tinged fluid to ooze in the first hours. Gently wipe with a clean cloth if needed. 4. **Diaper placement**: Fold the baby's diaper so that the waistband is below the level of the cord stump, leaving the cord exposed to air. This prevents urine and stool from soiling the cord. 5. **Air exposure**: The cord stump is left uncovered and exposed to air as much as possible. Do not cover with gauze or cloth unless there is active oozing (in which case a loose, non-adherent gauze may be applied and changed daily). **Cord Stump Separation and Timeline:** The cord stump typically separates (falls off) **5–15 days after birth**, with an average of 7–10 days. The stump dries from the outside in, gradually darkening from reddish-pink to brown to black. When it separates, there may be a small amount of serosanguinous discharge and sometimes a small plug of blood. This is normal. The navel heals over the following few days to weeks, and the skin usually epithelializes by 2–3 weeks of age. **Counsel to the Mother on Cord Care:** The midwife should teach the mother (and other caregivers) the following: 1. **Keep it clean and dry**: "Wash your hands before touching the cord. If the cord or the area around it becomes soiled with urine or stool, gently wipe with a clean, dry cloth. Do not apply anything to the cord—no oils, no powders, no herbal remedies." 2. **Diaper placement**: "Fold the diaper below the level of the cord so it stays dry. If the top of the diaper touches the cord, it will get wet and may become infected." 3. **Bath timing**: "Do not bathe the baby in water until the cord has separated. If you need to clean the baby, use a damp cloth to wipe gently; keep the cord dry. After the cord falls off, you can bathe the baby normally." 4. **What is normal**: "The cord will gradually darken and dry up. It will smell a bit—this is normal. When it separates (usually around 1–2 weeks), there may be a little blood or clear fluid. This is normal. The belly button will look raw and pink for a few days after the cord falls off; it will heal." 5. **Danger signs—when to return immediately**: The midwife should explicitly list signs of infection: - **Redness or swelling around the cord or at the base** (the skin around the cord becomes red). - **Pus or foul-smelling discharge** (not just a little clear fluid, but yellow or green discharge with a bad smell). - **Bleeding from the cord stump** (more than occasional drops; continued oozing). - **Fever in the baby** (axillary temperature > 37.5 °C, especially > 38 °C). - **Baby is lethargic, not feeding, or unusually irritable**. - **Rash or pustules on the baby's abdomen or around the cord**. If any of these signs appear, the mother should bring the baby to the health facility immediately. Omphalitis can progress rapidly to sepsis, and early antibiotic treatment is critical. **Managing Omphalitis - When to Refer** If the midwife (at home visit or clinic) observes signs of omphalitis, she does NOT treat it at the BHS. Instead: 1. **Assess for signs of systemic infection**: Take the baby's temperature, assess feeding, note any irritability, lethargy, or rash. 2. **Refer urgently** to the RHU or hospital for evaluation, blood culture, and antibiotics if needed. 3. **Document findings** and the referral. 4. **Do not delay** trying home remedies or waiting for follow-up. Omphalitis with fever or systemic signs (poor feeding, lethargy) suggests neonatal sepsis and is a medical emergency requiring hospital evaluation and IV antibiotics. **Distinction Between Normal Cord Healing and Omphalitis:** - **Normal**: Stump is dark, dry, gradually separating. No redness, no swelling, no discharge other than minimal serosanguinous drainage. Belly button looks raw and pink after separation but is healing cleanly. - **Omphalitis**: Redness and swelling at the base of the cord or around the navel area, pus or foul-smelling discharge, possible fever in the baby, possible general signs of illness (poor feeding, lethargy). A midwife should educate families that a little blood or clear fluid during separation is normal, but pus, foul odor, or surrounding erythema is not and warrants medical evaluation.

In addition to vitamin K, eye prophylaxis, newborn screening, and hearing screening, the newborn also requires two critical immunizations at birth: **Bacille Calmette-Guérin (BCG)** vaccine and **Hepatitis B** vaccine. These are part of the **Philippine Immunization Program** and are mandated as part of normal newborn care. The midwife is often the first healthcare provider after delivery and, in some settings, may administer these vaccines (or ensure they are administered within the first 24 hours). **BCG Vaccine at Birth** **Purpose**: BCG protects against **tuberculosis (TB)**, specifically the severe forms in infants (TB meningitis, miliary TB). While BCG does not provide 100% protection against all forms of TB, it significantly reduces the incidence of severe TB in infants and young children. In the Philippines, where TB burden is substantial, BCG vaccination at birth is essential. **Timing**: BCG is given **within 24 hours of birth**, ideally as soon as possible after birth (can be given at the same time as hepatitis B but at a different anatomical site). **Dose and Route**: - **0.05 mL (0.1 mL of a 1:10 dilution if dilution is required per manufacturer)** intradermally (ID) into the **deltoid region of the upper arm** (over the deltoid muscle). - The vaccine is given intradermally, not intramuscularly. A **25 gauge needle (short, thin needle)** is used, and the needle is inserted at a 10–15 degree angle just into the dermis (the layer of skin below the epidermis). A small bleb (raised, pale nodule) should form immediately, confirming proper intradermal placement. If no bleb forms, the injection was likely given too deep (subcutaneously instead of intradermally) and may be less effective; it should be repeated at another site. **Site**: **Right upper arm (deltoid)**, marking the site with ink or documenting the location. The left arm is often reserved for hepatitis B vaccine, though they can both be given in one arm at different sites if necessary. **Observation After BCG**: - After BCG, a pustule may develop at the injection site over the following weeks (2–4 weeks). This is a normal, expected response (the immune system reacting to the vaccine). The pustule may weep serous fluid, crust, and eventually heal, leaving a small scar. Parents should NOT apply anything to the pustule and should NOT cover it (allow air exposure). If the pustule becomes very large, drains extensively, or shows signs of secondary infection, refer to the clinic. - Some infants may develop a nodule in the regional lymph nodes (axillary lymphadenopathy) in response to BCG. If the node becomes very large (> 3 cm) or drains, refer for evaluation; this is rare and usually not serious. **Hepatitis B Vaccine at Birth** **Purpose**: Hepatitis B vaccine protects against **Hepatitis B virus (HBV) infection**, which can cause acute hepatitis and can progress to chronic infection, cirrhosis, and hepatocellular carcinoma. Infants infected with HBV have a high risk of chronic infection (~90%), making prevention at birth critical. The birth dose is particularly important because it prevents mother-to-baby transmission in infants born to HBsAg-positive (HBV-infected) mothers. **Timing**: Hepatitis B vaccine is given **within 24 hours of birth** (ideally at the same visit as BCG). **Dose and Route**: - **10 mcg (0.5 mL of standard vaccine concentration; some formulations are 20 mcg/mL, so the volume varies—always check the vial label)** intramuscularly (IM) into the **anterolateral thigh (vastus lateralis)** or, alternatively, the **upper arm (deltoid)**. The thigh is often preferred in newborns because the muscle is more developed and easily identifiable. If vaccinating the arm, use the deltoid (same region as other arm vaccines). - A 25 gauge needle and 1 mL syringe are used. - The injection is given deep into the muscle (true IM, not subcutaneous). **Site**: Typically the **right vastus lateralis (right thigh)** is used for Hepatitis B to avoid confusion with the left arm designated for BCG. Alternatively, if both vaccines are given in the arm, BCG is given in the right deltoid and Hepatitis B in the left deltoid. **Important Note on Maternal HBsAg Status**: - If the mother is known or suspected to be **HBsAg-positive (HBV-infected)**, the infant requires **both the birth-dose vaccine AND Hepatitis B immunoglobulin (HBIG) within 12 hours of birth** (ideally both within the first few hours). HBIG provides immediate passive immunity while the active vaccine stimulates the infant's immune response. This combination is highly effective at preventing vertical transmission. At the BHS or RHU, if a mother is HBsAg-positive, the midwife ensures both vaccine and HBIG are given and documents this clearly. - If maternal status is **unknown**, the infant still receives the standard birth-dose vaccine. The mother's HBsAg status should be tested urgently (during prenatal care or at delivery if not tested antenatally). If she is later found to be positive, the infant should receive HBIG as soon as possible (ideally within 24 hours, though benefit extends up to 7 days; the sooner the better). **Subsequent Hepatitis B Doses**: The birth dose is the first of three or four doses in the Philippine Immunization Program schedule: - **Dose 1 (birth)**: At birth or within 24 hours. - **Dose 2**: At 4 weeks (typically at the first clinic visit for routine checks). - **Dose 3**: At 14 weeks (6 months). - Some schedules include a **booster at 18 months**. The midwife documents the first dose clearly so that follow-up doses are not missed. **Storage and Handling of Vaccines**: - Both BCG and Hepatitis B vaccines are sensitive to light and heat. - **BCG** is freeze-dried and sensitive to heat; it must be stored at **2–8 °C (refrigerated)** in the dark and reconstituted with the provided diluent just before use. Reconstituted BCG is valid for **4–6 hours** and must be discarded afterward if unused. - **Hepatitis B** is a liquid vaccine; it is stored at **2–8 °C (refrigerated)** and must NOT be frozen. It is light-sensitive and should be kept in its original dark container. - Both vaccines should be transported in a **vaccine cold chain** (insulated box with ice packs) to prevent temperature excursions. - Check expiration dates before use. Expired vaccines should not be used. **Injection Technique and Safety**: 1. Use **sterile, single-use needles and syringes** for each vaccine. 2. **Do not mix vaccines in the same syringe** (they are given at different sites with separate injections). 3. Cleanse the injection site with an alcohol swab and allow to air-dry briefly. 4. Inject using aseptic technique. 5. For BCG: Observe for the characteristic bleb after intradermal injection; if no bleb forms, repeat at another site. 6. After injection, gently apply pressure with a clean cloth; avoid excessive rubbing (which can disperse the vaccine in subcutaneous tissue). **Documentation**: Record for each vaccine: - Vaccine name (e.g., BCG Vaccine, Hepatitis B Vaccine) - Dose and volume - Route (ID for BCG, IM for Hepatitis B) - Site (right arm/left arm/right thigh, etc.) - Time of administration - Batch/lot number (for traceability and in case of recall) - Name of the person administering - Any adverse reactions or unusual observations - Maternal HBsAg status (positive/negative/unknown) if relevant to Hepatitis B - Whether HBIG was given (if maternal HBsAg-positive) **Contraindications and Precautions**: - **BCG contraindications**: Severe immunosuppression (though this is rare in healthy newborns) or proven sensitivity to any component. BCG should NOT be given to infants with symptomatic HIV (though asymptomatic infants born to HIV-positive mothers may receive it in some settings; follow local guidelines). - **Hepatitis B contraindications**: Severe allergy to yeast (Hepatitis B is produced in yeast cell cultures) or proven sensitivity to any component. Otherwise, there are very few absolute contraindications in newborns. - **Mild illness** (small fever, cough, diarrhea) is NOT a contraindication to vaccination. Vaccines should be given on schedule unless there is a moderate to severe acute illness (fever > 39 °C, sepsis); in that case, defer vaccination until recovery and reschedule. **Adverse Effects**: - **BCG**: Local pustule/ulceration at the injection site (expected immune response), regional lymphadenopathy (usually mild and self-limited). Severe reactions (BCG-itis, disseminated BCG disease) are very rare in immunocompetent infants. - **Hepatitis B**: Usually very mild; local pain/redness at injection site is common and transient. Fever is uncommon. Serious adverse events are extremely rare. **High-Yield MLE Points:** - **BCG**: 0.05 mL ID into right deltoid within 24 hours; expect bleb and later pustule (normal response). - **Hepatitis B**: 10 mcg (0.5 mL) IM into right vastus lateralis within 24 hours; if maternal HBsAg-positive, also give HBIG within 12 hours. - **Both vaccines given at birth are part of the mandated newborn package**; do not omit them. - **Store at 2–8 °C (refrigerated), protect from light, respect expiration dates**. - **Document everything**: vaccine names, doses, routes, sites, lot numbers, maternal HBsAg status (if positive).

The preceding sections have outlined individual procedures—EINC, APGAR, vitamin K, eye prophylaxis, newborn screening, hearing screening, cord care, and immunizations. In real practice at a BHS, RHU, lying-in, or home delivery, the midwife must sequence these procedures efficiently while prioritizing the baby's safety and maintaining bonding. There is no single "correct" order, as priorities shift based on the baby's condition and facility context. However, a logical sequence minimizes disruption to the mother-baby dyad and ensures critical procedures are not omitted. **Ideal Sequence for a Healthy, Vigorous Term Newborn (EINC-Guided):** **Minutes 0–1 (The Golden Minute—Assess and Stabilize)** 1. **Dry the baby** with a warm cloth (30 seconds). If breathing is absent or weak, proceed to resuscitation (positioning, airway clearance, ventilation) immediately, delaying all other procedures until the baby is breathing effectively. 2. **Assess breathing and tone** quickly. If the baby is crying and pink, proceed to skin-to-skin. If not breathing or gasping, call for help and begin resuscitation. **Minutes 1–3 (Skin-to-Skin and Cord Management)** 3. **Place baby skin-to-skin on mother's bare chest**, cover both with warm blanket, place bonnet on baby. This begins thermoregulation, bonding, and preparation for early breastfeeding. 4. **Perform APGAR assessment at 1 minute** while baby is on mother's chest: observe color, palpate cord pulse (easiest method in first minute), assess tone and cry. Document the score. If 7–10, proceed to routine care. If 4–6, stimulate and observe. If 0–3, begin resuscitation. 5. **Perform delayed cord clamping**: After 1–3 minutes (when cord pulsations diminish or stop), clamp and cut the cord. If the baby is breathing well and on the mother, this can be done with the baby on mother's chest. **Minutes 3–15 (Procedures While on Skin-to-Skin or Brief Separation)** *At this point, several procedures are needed. Some can be done on the mother's chest (cord care, assessment), others may require brief separation (vitamin K, immunizations). The goal is to minimize separation:* 6. **Inspect and care for the cord stump** (keep clean and dry; no application; fold diaper below stump). This takes < 1 minute. 7. **Do a quick head-to-toe examination** for gross anomalies and check anus patency. This can be done with the baby on mother's chest. Takes < 5 minutes. 8. **Check vital signs** while baby is still on mother: count respirations and estimate heart rate (from cord if still visible, or by palpation). Take axillary temperature using a digital thermometer (1–2 minutes). 9. **Administer vitamin K 1 mg IM** into the right vastus lateralis. This takes < 1 minute and can be done with the baby briefly lifted off the mother's chest, administered quickly, and then returned to skin-to-skin. 10. **Administer BCG 0.05 mL ID** into the right deltoid and **Hepatitis B 0.5 mL IM** into the right thigh (or as facility protocol dictates), both within the first 24 hours (ideally within the first few hours). These can also be done with the baby briefly separating from mother and then returning to skin-to-skin. At 30 minutes to 2 hours of age is typical, but immediately after vitamin K (within 15–30 minutes) is also acceptable. **Approximately 30 minutes to 2 hours of age: Support Early Breastfeeding** 11. The baby and mother should have been together throughout. Around 30 minutes to 2 hours, the baby enters a quiet alert state—a prime window for the first breastfeed. The midwife supports the baby's instinctive crawl to the breast and helps with the first latch. This is a crucial bonding and feeding milestone and should not be rushed or omitted. **After Breastfeeding is Underway (1–2 hours of age):** 12. **Administer eye prophylaxis**: Erythromycin 0.5% ointment to both eyes. This is done after the first breastfeed is established so the ointment does not interfere with early bonding and vision during feeding. Takes < 2 minutes. 13. **Weigh and measure the baby** while mother is present. Ideally, the baby is returned to skin-to-skin immediately after weighing. Takes 3–5 minutes. 14. **Full systematic physical examination**: At 2–4 hours of age, when bonding and first feeding are established, perform a thorough head-to-toe exam (has already been done quickly earlier, but a more detailed assessment is done now). Document findings. Takes 10–15 minutes. 15. **Reassess APGAR at 5 minutes** (if not already done at 1 minute) or if any concerns. If the baby was doing well at 1 minute and remains well, a 5-minute APGAR is not mandatory, but it is good practice to document the baby's status at 5 minutes as well. **At 24–72 Hours After Birth (Can Be in Hospital or at Home):** 16. **Newborn screening**: Heel-prick capillary blood collected on filter-paper card. Ideally at 24–72 hours. Performed by the midwife or at an RHU clinic. The midwife ensures it is done and documents the result. 17. **Hearing screening**: OAE and/or AABR. Performed before discharge (if in hospital) or referred to be done within the first month. Documented and follow-up on any "refer" results. **Special Scenarios: Sequencing When the Baby Is Not Vigorous** **Scenario: Baby is born limp, not breathing, heart rate < 100** 1. **Immediate action (golden minute)**: Dry briefly, call for help, position the airway, provide positive-pressure ventilation with a bag and mask at 21% oxygen (or room air initially). Do NOT waste time on any routine procedures. 2. **Cord clamping**: Clamp and cut the cord quickly (within 1 minute) so the baby can be moved to a warm surface unencumbered if needed. 3. **Resuscitation continues** until the baby has spontaneous breathing, heart rate > 100, and improving tone. This may take 10–20 minutes. 4. **Arrange referral** immediately. Even as resuscitation continues, notify the hospital and arrange transport. 5. **APGAR is NOT the resuscitation guide**: Assess breathing, heart rate, and tone; begin ventilation if indicated. APGAR is documented at 1 and 5 minutes for communication, not as a decision tool. 6. **Procedures deferred**: Vitamin K, eye prophylaxis, BCG, Hepatitis B are deferred until after the baby is stabilized (breathing, heart rate > 100, pink). Once stable (even if at the referral hospital), these procedures are completed before or shortly after transfer. **Scenario: Mother-baby pair is bonding well, but some procedures cannot wait** The midwife can administer vitamin K and immunizations while the baby is on the mother's chest (using the thigh for IM injection while the baby is cradled). She can check temperature with the baby in place. She can perform a general exam by gently handling the baby. Only eye prophylaxis and weighing may require the baby to be off the mother's chest, but these are brief and followed by immediate return to skin-to-skin. **Checklist for Mandated Newborn Procedures (to prevent omissions):** Use this mental or written checklist at each newborn visit to ensure nothing is missed: **At Delivery/First Hour:** - [ ] EINC: Dry, assess breathing → Skin-to-skin → Delayed cord clamping (1–3 min) → Non-separation, early breastfeeding support - [ ] APGAR at 1 minute (and 5 minutes if needed) - [ ] Quick head-to-toe exam, check anus patency - [ ] Vital signs: RR, HR, temperature, weight - [ ] Vitamin K 1 mg IM (or 0.5 mg if < 2,500 g) within first hours **At 30 Min–2 Hours:** - [ ] BCG 0.05 mL ID right deltoid (within 24 hours) - [ ] Hepatitis B 0.5 mL IM right thigh (within 24 hours; also HBIG if mother HBsAg+) - [ ] Support first breastfeed - [ ] Eye prophylaxis (erythromycin 0.5% ointment) after breastfeeding **At 2–4 Hours:** - [ ] Full physical examination - [ ] Cord care (dry, exposed, diaper folded below) - [ ] Thermoregulation check (skin-to-skin maintained, temperature normal) **At 24–72 Hours:** - [ ] Newborn screening (heel-prick, filter-paper card) — if not done at delivery in hospital setting - [ ] Hearing screening (OAE/AABR) or referral if not available locally **At Discharge/Follow-Up:** - [ ] Cord care education - [ ] Danger signs education (omphalitis, fever, poor feeding, lethargy) - [ ] Breastfeeding support and follow-up - [ ] Follow-up appointment scheduled - [ ] Results of newborn screening and hearing screening communicated; referral arranged if positive **Documentation: What to Record** For each procedure, document: - **Vitamin K**: Name, dose, route, site, time, lot number, administrator. - **Eye prophylaxis**: Name (e.g., erythromycin 0.5%), both eyes, time, administrator. - **BCG**: Dose, route (ID), site, time, lot number, bleb observed (yes/no), administrator. - **Hepatitis B**: Dose, route (IM), site, time, lot number, administrator, maternal HBsAg status, HBIG given (if applicable). - **Newborn screening**: Sample collected date/time, age at collection, filter-paper card labeled, lot number, submitted date. - **Hearing screening**: Method (OAE/AABR), result (PASS or REFER), time, facility/provider, follow-up planned. - **Cord care**: Cut cleanly, bleeding controlled, stump inspected, dry care explained to mother, danger signs taught. - **APGAR**: Scores at 1 minute and 5 minutes, any resuscitation initiated, reason if scores low. - **Immunizations follow-up**: Scheduled date for next doses (Hepatitis B dose 2 at 4 weeks, dose 3 at 14 weeks). Clear, thorough documentation ensures continuity of care and prevents procedures from being repeated or omitted at subsequent visits.