Midwife Licensure Exam Midwifery Pharmacology & Newborn Procedures — Maternal & Child Nutrition Counseling (Midwife-led)Study Notes

The period from conception to 24 months of life is a critical window when nutrition shapes immune function, brain development, and lifelong disease resistance. Maternal undernutrition in pregnancy leads to low birth weight, preterm delivery, and increased risk of postpartum hemorrhage (PPH), maternal anemia-related death, and poor milk production. Infant undernutrition in the first 6 months slows brain growth and immune development, and continued inadequate nutrition from 6–24 months causes stunting (short height), which may be irreversible and affects school performance and earning potential. Conversely, optimal nutrition—adequate maternal iron and folate, timely and exclusive breastfeeding, appropriate complementary feeding, and micronutrient supplementation—is one of the highest-impact, lowest-cost interventions a midwife can deliver. The midwife working at the BHS or in the community is the gatekeeper of this knowledge and the person most trusted to counsel mothers on what to eat, when to feed the baby, and how to know if the child is growing well.

Maternal micronutrient deficiency is common in the Philippines and directly threatens both mother and fetus. The midwife's role is to ensure every pregnant woman starts supplementation at the first prenatal visit and complies through delivery and 3 months postpartum. The DOH standard prenatal supplement contains: **Iron-Folic Acid (IFA):** The workhorse supplement is **60 mg elemental iron + 400 micrograms (0.4 mg) folic acid, taken once daily**. Iron prevents and treats anemia, which is the most common micronutrient deficiency in Filipino pregnant women and a major contributor to maternal death (anemia increases PPH risk and reduces the mother's ability to tolerate blood loss). Folic acid prevents neural tube defects (NTDs)—spina bifida and anencephaly—with maximum protection when taken **before conception and through the first trimester**; the midwife counsels women of reproductive age and those planning pregnancy to take folate early. The midwife teaches **proper iron absorption technique:** iron is absorbed best on a relatively empty stomach, with vitamin-C-rich foods (citrus, guava, tomato, papaya), and away from inhibitors like tea, coffee, and milk (consumed at a different time). She reassures the mother that **black/dark stools are normal** and not a reason to stop—they show the iron is working. For diagnosed anemia (hemoglobin below 10 g/dL), the dose may be **doubled to 120 mg iron twice daily** under protocol, with physician referral if severe (Hb < 7 g/dL). **Vitamin A:** High-dose Vitamin A (>10,000 IU/day) is **absolutely contraindicated in pregnancy** because it is teratogenic and increases risk of birth defects. The midwife must never give a Vitamin A capsule to a woman who could be pregnant. Postpartum, after delivery is confirmed and the woman is not pregnant, she may receive a **high-dose Vitamin A 200,000 IU** within the first 4 weeks (classically within the 40-day postpartum "confined" period while still amenorrheic and breastfeeding) to replenish her stores and enrich her breast milk. This one dose has a lasting protective effect for her infant's Vitamin A status. **Calcium:** Adequate dietary calcium (from milk products, leafy greens, small fish with bones) reduces pre-eclampsia risk, especially in low-intake populations. In some contexts, calcium supplementation may be recommended. **Iodine:** The midwife promotes the use of **iodized salt** (RA 8172, the "ASIN Law") throughout the pregnancy and lactation, as iodine is critical for thyroid function and fetal brain development. Iodine deficiency causes endemic goiter and cretinism (severe intellectual disability with growth stunting), preventable by iodized salt.

Exclusive breastfeeding is the single most effective nutrition intervention for infants and is mandated by Philippine law. The midwife's role is to initiate breastfeeding within the first hour of life (part of EINC and Unang Yakap protocols), teach correct technique to prevent problems, support the mother through any difficulties, and counsel continuation alongside complementary foods until age 2 and beyond. **Legal Framework:** - **RA 7600 (Rooming-In and Breastfeeding Act of 1992):** Mandates that newborns remain with the mother and that health facilities support breastfeeding initiation. - **EO 51 (The Milk Code, amended by RA 8976):** Prohibits advertising and promotion of breast-milk substitutes and feeding bottles, forbids health workers from accepting or distributing formula samples, and bans infant-formula advertising in media. - **RA 10028 (Expanded Breastfeeding Promotion Act of 2009):** Requires lactation stations and lactation breaks at workplaces and public facilities; mandates support for breastfeeding in health facilities and the community. **The DOH/WHO Recommendation:** - **Initiate breastfeeding within the first hour** of life (ideally at delivery or immediately after). - **Exclusive breastfeeding for the first 6 months:** breast milk only—no water, no formula, no other food or drink, not even "a little water" even in hot climates or if the mother is working. Exclusive means breast milk and nothing else. - **Continue breastfeeding alongside appropriate complementary foods from 6 months to 2 years and beyond.** **Why Breastfeeding Matters:** - **Colostrum** (the thick, yellowish milk produced in the first few days) is the most nutrient-dense and antibody-rich food and should **never be discarded** or replaced with formula. - Breast milk provides ideal nutrition (proteins, fats, carbohydrates, vitamins, minerals in optimal proportions), living immune cells (antibodies, white blood cells), and protection against infection (diarrhea, respiratory illness, otitis media). - Breastfeeding triggers maternal oxytocin, which contracts the uterus (reducing PPH risk) and promotes bonding. - **LAM (Lactational Amenorrhea Method)** provides contraceptive protection if the infant is under 6 months old, exclusively breastfed, and the mother's menses have not returned; effectiveness is ~98% under these conditions. - Breastfed infants have lower rates of infection, allergy, obesity, and type 2 diabetes later in life. **Good Positioning and Latch (Attachment):** The midwife teaches that poor latch causes 90% of breastfeeding problems, not insufficient milk. The **four keys to good positioning** are: 1. **Baby's head and body in a straight line** (not twisted or bent). 2. **Baby held close** to the mother's body. 3. **Whole body of the baby supported** (not just the head). 4. **Baby facing the breast, nose to nipple.** **Signs of a good latch:** - **More areola visible above the baby's mouth than below** (the lower jaw has more areola to move). - **Baby's mouth wide open** (not pursed or closed on just the nipple). - **Lower lip turned outward (everted)** and **chin touching the breast**. - **No dimpling or pinching of the cheeks** during sucking. - **No pain** to the mother (breastfeeding should not hurt; if it does, the latch needs fixing). **Signs of effective feeding (milk transfer):** - **Slow, deep sucks with pauses** (not rapid, shallow sucks). - **Audible or visible swallowing** after every 1–2 sucks, especially early in the feed. - **Baby releases the breast when satisfied** (not staying glued after 5 minutes of comfort sucking). - **Mother feels a letdown (milk-ejection reflex)** — tingling or mild cramping sensation. **Feeding frequency and output:** - **8–12 feeds per 24 hours** in the first weeks (the baby leads, "on demand"). - **At least 6 wet diapers per day** and **at least 3–4 stools per day** (yellow, seedy stools in a breastfed baby are normal; constipation is rare). - **Adequate weight gain:** minimal loss in the first 3–5 days, then regaining birthweight by 10–14 days, then gaining ~20 g/day in the first 3 months (equivalent to ~150–200 g/week or 600–800 g/month). **Troubleshooting Common Breastfeeding Problems:** **Sore or cracked nipples:** Almost always caused by poor latch. The midwife observes a feed, corrects positioning and latch, and applies remedies: keep nipples dry (air-dry after each feed), apply a small amount of expressed breast milk to the nipple (it has healing antibodies), use lanolin or purified nipple balm if available, and if pain is severe, temporarily use a nipple shield or express and feed by cup. Reassure the mother that with correct latch the soreness usually resolves in 3–5 days. **"Not enough milk" (perceived insufficient supply):** Most mothers who think they don't have enough milk actually do. The midwife reassures and advises: (1) **Feed more frequently** and ensure the baby feeds long enough to reach the fat-rich hindmilk (visible as the milk changes from watery white to creamy). (2) **Feed both breasts at each session** to stimulate supply. (3) **Include night feeds**—prolactin (the milk-making hormone) rises at night, so skipping night feeds lowers supply. (4) **Ensure a good latch** so the baby empties the breast. (5) Genuine insufficient lactation is rare and shown by poor weight gain (< 100 g/week after 2 weeks), fewer than 6 wet diapers, or persistent yellow stools. If these signs are present, refer for physician evaluation. (6) Remind the mother that her own nutrition (an extra ~500 kcal/day) and hydration support lactation, but even a modestly nourished mother makes adequate milk. **Engorgement (swollen, hard, painful breasts):** Common in the first 1–2 weeks. Advise: feed frequently (every 1–2 hours), apply warm compresses before feeding to aid letdown, express a little milk to soften the areola so the baby can latch (not to drain the breast, which signals the body to make more), apply cold compresses (cold cabbage leaves, ice packs) after feeds to reduce swelling, and take paracetamol or ibuprofen if needed. Engorgement resolves within days with frequent feeding. **Working mothers:** RA 10028 guarantees **lactation breaks** (time to express milk) and **lactation stations** (safe, clean spaces to express and store milk). The midwife teaches expression technique: hand expression or breast pump, storing milk in a clean, labeled container, and safe storage (room temperature up to 4 hours, refrigerator up to 5 days, freezer up to 3 months). Expressed breast milk can be fed by cup, spoon, or syringe (never a bottle, which contradicts the Milk Code). This allows the mother to maintain exclusive breastfeeding even while working.

At 6 completed months of age, breast milk alone no longer provides enough energy and micronutrients to meet the growing infant's needs. The midwife counsels on the timely, safe, and adequate introduction of complementary foods **while continuing to breastfeed**. The DOH framework uses four principles: **timely, adequate, safe, and properly fed**. **Timing: Start at 6 Months** Not before 6 months (the baby's digestive system is not ready, and formula or other foods increase infection risk and displace breast milk), and not much after 6 months (by 7–8 months, the baby's iron and energy needs exceed what breast milk alone provides). Introduce one new food at a time, waiting a few days before adding another, to watch for allergic reactions (though true allergies are rare; more common is temporary loose stools as the gut adjusts). **Frequency and Amounts by Age:** **6–8 months:** 2–3 meals per day of soft, mashed, energy-dense foods. Examples: pureed porridge with a little oil, mashed ripe banana, soft-cooked egg yolk, well-cooked meat or fish finely minced, soft vegetables. Portion size: start with 2–3 spoonfuls and gradually increase to a small bowl (100–150 mL) as the child shows interest. Continue breastfeeding on demand (8–10+ times per day). **9–11 months:** 3–4 meals per day, plus 1–2 nutritious snacks (e.g., fruit, soft bread with a little oil). Meals should be thicker (minced or small pieces rather than pureed) and begin to resemble family food. Portion size: ~150–200 mL per meal. Continue breastfeeding. **12–23 months:** 3–4 meals per day plus 1–2 snacks. Foods should approach family table foods (though soft enough to mash with the gum or swallow without choking). Portion size: ~200–250 mL per meal. Continue breastfeeding on demand (usually 3–4 times per day by 12 months, 2–3 times by 18–24 months as solids increase). **Composition: Iron-Rich Foods and Variety** The midwife emphasizes iron-rich complementary foods because infants' iron stores (acquired from the mother before birth) are depleted by 6 months, and breast milk is low in iron. Without adequate complementary iron, anemia develops. Include: - **Animal-source iron** (best absorbed): meat (beef, pork, chicken), liver, fish, egg yolk. - **Plant-source iron** (less absorbed but important): fortified rice, beans, lentils, dark leafy greens (spinach, malunggay). - **Vitamin C at the same meal** (citrus, tomato, papaya, guava) enhances iron absorption. - **Fruits and vegetables** for fiber, vitamins, and micronutrients: mashed avocado, soft banana, cooked carrot, pumpkin, green beans, malunggay leaves finely chopped. - **A little added fat or oil** (coconut oil, vegetable oil, or butter) for energy and nutrient absorption; about 1 teaspoon per meal. - **Gradually introduce family meals** so the child eats what the family eats, adapted to the child's stage (soft, no added salt/sugar if possible). **Safe Preparation:** - **Strict food and water hygiene** to prevent diarrhea: wash hands before preparing food and feeding, use clean water, cook food thoroughly, feed immediately after cooking, discard uneaten portions after 1–2 hours. - **Avoid choking hazards** in children under 3: whole nuts, popcorn, hard candy, whole grapes, whole cherry tomatoes, chunks of meat (mince finely). - **Avoid added salt and sugar** to protect the kidney and prevent future obesity and hypertension. - **Avoid tea, coffee, and sugary drinks** (they displace nutritious foods and tea binds iron). - **Never use feeding bottles** (bottles are prohibited by the Milk Code; use a cup, spoon, or bowl). **Responsive Feeding** The midwife teaches the mother to feed **responsively**: watch for the child's hunger and fullness cues, let the child feed at their own pace, allow the child to decide when to stop (do not force-feed), and interact warmly during meals. This builds healthy eating habits and prevents overfeeding. **Growth and Monitoring** During the complementary feeding period (6–24 months), the child's growth curve is a guide to whether nutrition is adequate. The midwife plots weight and length/height on the growth chart at monthly or bi-monthly visits. A growing, climbing curve indicates adequate complementary feeding. A flattening or falling curve signals that foods are inadequate in amount, frequency, or quality; the midwife reassesses the mother's feeding practice, checks for illness (diarrhea, infection), and counsels on improvement.

Vitamin A deficiency is a leading preventable cause of blindness in children and increases susceptibility to infection and death. The midwife is responsible for delivering Vitamin A supplementation on schedule as part of the DOH Vitamin A and deworming program (often called the 'Guaranteed Health Programs' or 'Garantisadong Pambata' rounds). The schedule is precise and frequently appears on the MLE. **Postpartum Maternal Vitamin A (Already Covered Above)** Postpartum mothers receive **200,000 IU once**, within the first 4 weeks postpartum (while still amenorrheic and breastfeeding), to replenish maternal stores and enrich breast milk. **High-dose Vitamin A is never given during pregnancy.** **Infant and Child Vitamin A Schedule:** **Ages 6–11 months:** **100,000 IU, single dose**. This may be given as a capsule or liquid dropped into the baby's mouth. If the infant is exclusively breastfed and the mother received her postpartum Vitamin A dose, the baby's Vitamin A status is usually adequate, but the supplement is still given per DOH protocol to ensure coverage. **Ages 12–59 months (1–5 years old):** **200,000 IU every 6 months**. The DOH typically organizes two nationwide rounds per year (commonly February and August, though dates vary by region). The midwife participates in these rounds at the BHS or barangay outreach, delivering Vitamin A to all children in the target age group. Each dose is recorded in the child's health record and the mother's child-health book to avoid duplicate dosing (Vitamin A is fat-soluble and accumulates; overdosing can cause toxicity). **Children below 6 months of age:** Routine high-dose Vitamin A supplementation is **not given** to breastfed infants below 6 months because they receive adequate Vitamin A from breast milk, especially if the mother received her postpartum dose. **Special Circumstances:** - **Vitamin A in measles cases:** High-dose Vitamin A (dose varies by age and severity per protocol) is given as an adjunct to measles treatment to reduce complications and death. - **Vitamin A in severe illness/hospitalization:** Children hospitalized with severe infections or malnutrition may receive Vitamin A per protocol. - **Vitamin A deficiency disorders:** If a child shows signs of night blindness or Bitot spots (foamy patches on the conjunctiva), Vitamin A is given urgently and the child is referred for ophthalmologic evaluation. **Midwife's Role in Vitamin A Program** - **Deliver doses on schedule:** Know the DOH round dates and ensure all eligible children in the area receive Vitamin A (aim for >95% coverage). - **Record every dose:** Document in the child's health book and in the BHS/health center register, including date, dose, and batch number (for safety surveillance). - **Counsel mothers on benefits:** 'Vitamin A keeps your child's eyes healthy and strong, and helps fight infections. It's free at the health center.' - **Monitor for adverse effects:** Vitamin A is safe at the recommended doses; the midwife reassures mothers. Very rarely, diarrhea or vomiting may occur for a day or two after supplementation. - **Link to immunization and deworming:** Vitamin A rounds are often combined with deworming and immunization updates, so the midwife coordinates these services.

Growth monitoring is a routine, high-impact midwife activity that detects faltering early, allows early intervention, and prevents severe malnutrition. The midwife weighs the infant or child regularly (usually monthly for infants, every 2–3 months for older children), plots the weight on the Growth Monitoring Chart in the mother-child health book or clinic record, and interprets the **direction of the growth curve** to assess nutritional adequacy. A **flat or falling line warns of a problem earlier than a single low weight,** so the midwife's eye is trained on the curve, not just the number. **How to Conduct Growth Monitoring:** **1. Weigh the child** on a calibrated scale (zero the scale before each child; if using a hanging scale, ensure the infant is calm and the scale is secured safely). Record the weight to the nearest 0.1 kg. **2. Plot the weight** on the **Growth Monitoring Chart** or **WHO/NCHS Growth Reference** in the child's health book or clinic card. The chart has curved lines (called 'growth channels' or 'percentiles'): the middle line represents the average weight for age, and lines above and below represent well-nourished and malnourished children, respectively. Plot the current weight and connect it with a line to the previous weight. **3. Interpret the curve:** - **Climbing curve** (moving upward or staying in the normal channel): The child is growing well; nutrition is adequate. Counsel the mother that she is doing well and continue current feeding. - **Flat curve** (not moving up, or moving sideways): The child is not gaining weight as expected. This is an **early warning sign** of inadequate nutrition or illness. Assess recent illness (diarrhea, cough, fever), feeding practice (frequency, types of food, breastfeeding compliance), and the mother's own health. Counsel on improvement and arrange a follow-up visit in 2 weeks. - **Falling curve** (moving downward, crossing lines downward): The child is losing weight or gaining at a very slow rate. This indicates a **serious problem** and requires investigation and intervention. Assess and refer as needed (see below). **4. Classify nutritional status** using one of these systems: **Weight-for-Age Classification:** - **Normal:** Weight is in the normal channel (between the 50th and 97th percentile, or above the reference line minus 1 SD). - **Underweight:** Weight below the normal channel (< 50th percentile or below -1 SD). This includes mild and moderate malnutrition. - **Severely underweight:** Weight well below normal (typically < -2 SD or below the critical line on the chart). This includes severe malnutrition. **Mid-Upper Arm Circumference (MUAC)** (for children 6–59 months, especially in acute malnutrition assessment): - **MUAC ≥ 12.5 cm:** Normal nutritional status. - **MUAC 11.5–12.4 cm:** At risk of malnutrition (mild-to-moderate acute malnutrition, MAM). - **MUAC < 11.5 cm:** Severe acute malnutrition (SAM). **This is a red flag for referral.** **Presence of edema (swelling) in both feet (bilateral pedal edema):** Indicates severe protein malnutrition (kwashiorkor). **Refer immediately.** **5. Counsel and intervene:** - **Climbing curve or normal status:** Praise the mother, reinforce current practices, ensure continued breastfeeding and age-appropriate complementary feeding, and schedule the next visit (usually monthly for infants, 2–3 monthly for older children). - **Flat curve or mild-to-moderate malnutrition:** Counsel the mother on improved feeding (increase frequency and variety, ensure iron-rich foods, add oil for energy, continue breastfeeding, check for diarrheal illness). Provide nutritional counseling and arrange a follow-up visit in 2 weeks. If the child has diarrhea or infection, refer or treat per protocol. - **Falling curve, severe malnutrition (weight < -2 SD, MUAC < 11.5 cm, or edema):** **Refer immediately to a physician or therapeutic feeding program.** The child may need inpatient care, micronutrient repletion, and management of complications (infection, electrolyte imbalance). The midwife documents the referral and follows up to ensure the child is seen. **Integrating Other Services:** Each growth-monitoring visit is an opportunity to provide or update other services: - **Vitamin A supplementation** on schedule (6-monthly for ages 6–59 months). - **Deworming** on schedule (6-monthly or 4-monthly depending on DOH protocol; **albendazole 400 mg for children 1–5 years, 200 mg for 12–23 months**). - **Immunization check and update** (ensure DPT, polio, MMR, etc., are current). - **Feeding counseling** specific to the child's age (breastfeeding support for infants, complementary feeding guidance, transition to family foods). - **Micronutrient assessment** (signs of anemia, Vitamin A deficiency, iodine deficiency) and supplementation if indicated. **Documentation:** The midwife records in the child's health book and in the BHS register: date of visit, weight, classification (normal/underweight/severely underweight), MUAC if applicable, counseling given, any supplements or services provided (Vitamin A, deworming, immunization), and plans (follow-up date, referral if applicable). **Growth Monitoring as Health Promotion:** Beyond detecting malnutrition, growth monitoring is a **health promotion and community engagement tool.** When the midwife weighs the child, explains what the curve means, and praises good feeding, she is empowering the mother. Mothers see visually that their feeding practices work (climbing curve = good food choices and breastfeeding). They also understand early that a flat curve means something needs to change, and they have the midwife's support. This builds maternal confidence and community trust in the BHS.

Intestinal worm infections are extremely common in the Philippine community, especially in areas with poor sanitation. Worms compete with the child for nutrients, cause intestinal blood loss (leading to anemia), and impair growth and cognitive development. **Deworming is not a treatment of disease but a preventive public health measure**, and the midwife supports the DOH deworming schedule as part of integrated nutrition and health promotion. **Deworming Schedule:** **Children aged 1–5 years:** **Deworming twice yearly** (typically in February and August, aligned with the Vitamin A and immunization rounds). The standard dose is: - **Albendazole 400 mg** for children 2 years and older. - **Albendazole 200 mg** (half tablet or liquid suspension) for children 12–23 months (aged 1–2 years). - Children below 12 months are generally not dewormed routinely unless indicated by signs of heavy parasitization. The deworming can be given as a tablet, chewable tablet, or liquid suspension depending on what is available and the child's age. It is given as a **single dose** and does not require fasting or any special food restrictions. **School-aged children (5–15 years):** The DOH conducts periodic deworming campaigns in schools, typically once yearly. The midwife may not directly administer these, but she is aware of the program and can refer families to school-based services. **Pregnant women:** Pregnant women **in the second and third trimester** (after the first trimester) can be dewormed if worm infection is suspected, per protocol, to reduce anemia and improve fetal growth. The dose and timing are determined by the health worker with the pregnant woman's informed consent. **Midwife's Role in Deworming:** - **Deliver doses on schedule** at BHS clinics and community outreach rounds. - **Record every dose** in the child's health book and in the register (similar to Vitamin A documentation). - **Counsel mothers:** 'We give this medicine to get rid of worms that may be in your child's tummy. It's safe and free. Give it twice a year, in February and August, with or without food.' Explain that worms steal nutrients, causing anemia and slow growth. - **Coordinate with hygiene promotion:** Teach handwashing before eating and after toilet, proper latrine use, and boiling drinking water or using a water filter. Deworming alone, without hygiene, is temporary. - **Link to other services:** Deworming rounds are often combined with growth monitoring, Vitamin A supplementation, and immunization, so the midwife coordinates these integrated services. **Mechanism and Safety:** Albendazole is a benzimidazole anthelmintic that paralyzes and expels adult worms. It is very safe in the recommended doses—adverse effects are minimal and usually mild (occasional loose stools, abdominal discomfort). Mothers need reassurance that deworming is not painful or dangerous. **Integrated Nutrition Programs:** Deworming is one element of a broader **Nutrition and Micronutrient Program** that the midwife supports. The typical package includes: 1. **Iron-folic acid** in pregnancy (covered above). 2. **Vitamin A postpartum** to mothers and **Vitamin A supplementation to children 6–59 months** on a fixed schedule. 3. **Deworming** of children and pregnant women on a fixed schedule. 4. **Iodized salt** (RA 8172) promotion and use. 5. **Food fortification** (RA 8976) — support for iron-fortified rice, fortified cooking oil, fortified flour — by promoting their use and explaining their benefits. 6. **Breastfeeding protection and promotion** via counseling and community advocacy. 7. **Growth monitoring** to track progress and catch faltering early. 8. **Feeding programs for malnourished children,** linking families to government or NGO assistance. The midwife, working with the health center team, **coordinates the delivery of these services** at regular BHS clinics and during community outreach rounds, aiming for high coverage (>90%) and consistent messaging about nutrition.

The midwife's nutrition responsibilities span the entire reproductive and early childhood period. To synthesize the chapter, here are her **priority actions in order of impact** and the **documentation she maintains**: **Highest-Impact Actions (Focus First on These):** **1. Protect exclusive breastfeeding:** - Initiate breastfeeding within the first hour of delivery (EINC/Unang Yakap). - Ensure no prelacteal feeds (no water, formula, or other liquid or food). - Support the mother with positioning and latch correction in the first days (prevent sore nipples and low milk supply beliefs). - Counsel against formula advertising and bottle use (Milk Code, RA 10028). - For working mothers, promote expressed breast milk and lactation rights. **2. Ensure every pregnant woman takes iron-folic acid:** - Distribute **60 mg iron + 400 mcg folic acid** at the first antenatal visit. - Counsel on absorption (empty stomach, with Vitamin C, away from tea/coffee), on expected black stools, and on compliance through pregnancy and 3 months postpartum. - Recheck hemoglobin at 24–28 weeks; if anemia, escalate dose or refer. **3. Deliver postpartum Vitamin A on time:** - Give **200,000 IU Vitamin A** within the first 4 weeks postpartum (while menses not yet returned and breastfeeding). - Enrich breast milk and replenish maternal stores with one timely dose. **4. Deliver infant Vitamin A on schedule:** - **100,000 IU at 6–11 months**; **200,000 IU every 6 months for ages 12–59 months** (DOH rounds). - Record each dose; aim for >95% coverage. **5. Guide complementary feeding at 6 months:** - Counsel on timing (6 months, not before or much after), frequency (2–3 meals at 6–8 months, 3–4 + snacks at 9–23 months), and composition (include iron-rich foods, fruit, vegetable, oil, mashed to soft texture, no choking hazards, no bottles). - Counsel on responsive, hygienic feeding. **6. Track the growth curve:** - Weigh the child monthly (infants) or 2–3 monthly (older children). - Plot the weight; watch for a climbing, flat, or falling curve. - A **flat or falling curve is an early warning sign**; investigate and counsel on improved feeding. - **MUAC < 11.5 cm, bilateral edema, or severe underweight: refer immediately.** **7. Coordinate deworming and Vitamin A rounds:** - Participate in integrated outreach (Guaranteed Health Programs) to deliver Vitamin A, deworming, and immunization together. - Aim for >90% coverage in the target population. **Documentation the Midwife Maintains:** The midwife maintains **two main records**: the **individual client/child's health book** (given to the mother/family) and the **BHS/clinic register** (kept at the health facility for supervision and planning). **In the Mother's Antenatal Record / Maternal Health Book:** - **Iron-folic acid supplementation:** dates started, batch/lot numbers, compliance observations, hemoglobin result and date. - **Counseling notes:** on iron absorption, folic acid benefits, balanced diet in pregnancy, iodized salt use. **In the Child's Health Book (Mother-Child Health Book / PMMB):** - **Vitamin A doses:** date given, dose (100,000 or 200,000 IU), batch/lot number. - **Deworming doses:** date given, medication and dose, batch/lot number. - **Growth monitoring chart:** weight, date, plot on curve. - **Classification:** normal / underweight / severely underweight (with date). - **Feeding counseling:** breastfeeding initiation and continuation, complementary feeding advice, food hygiene. - **Immunization status:** up-to-date or needs catchup. - **Referrals:** date, reason, facility referred to, outcome if known. **In the BHS/Health Center Register (For Supervision and Data):** - **Vitamin A round:** child's name, age, date, dose given, batch/lot number. - **Deworming round:** similar. - **Antenatal clinic:** pregnant woman's name, weeks of gestation, hemoglobin (if tested), IFA issued, counseling given. - **Growth monitoring clinic:** child's name, age, weight, classification, referrals. These registers allow the health center nurse or supervisor to: - Verify that all eligible children received Vitamin A and deworming (coverage). - Identify which lots had adverse events (safety surveillance). - Plan the next round and allocate resources. - Monitor midwife performance and provide feedback. **Communication and Counseling Style:** The midwife's counseling on nutrition is most effective when it is: - **Simple and culturally appropriate:** use local food names, respect local beliefs, avoid jargon. - **Respectful and non-judgmental:** never shame a mother for poverty or past mistakes; assume she wants the best for her family and help her make the best choices possible within her resources. - **Evidence-based but practical:** explain WHY (e.g., 'Iron prevents anemia which can cause you to bleed dangerously after delivery'), not just WHAT. - **Encouraging:** praise what the mother is doing right ('Your baby is growing beautifully'; 'You are giving the right foods') and guide on what could improve. - **Repeated and reinforced:** Nutrition requires sustained behavior change; a single conversation at the first visit is not enough. Counsel at each visit, ask about compliance, and troubleshoot barriers (cost, time, family beliefs).

To aid exam preparation, here are the high-yield facts that appear frequently on the PRC Midwife Licensure Examination and must be memorized exactly: **Maternal Supplementation in Pregnancy:** - **Iron-folic acid: 60 mg elemental iron + 400 mcg (0.4 mg) folic acid, once daily, from first prenatal visit through pregnancy and 3 months postpartum.** - Folic acid prevents neural tube defects (spina bifida, anencephaly); critical in the first trimester. - Iron absorbed best with vitamin-C foods, on empty stomach, away from tea/coffee/milk. - Black stools are normal and expected (not a side effect to stop treatment). - **High-dose Vitamin A is contraindicated (teratogenic) in pregnancy.** - For anemia (Hb < 10 g/dL): double iron dose to **120 mg twice daily**; refer if Hb < 7. **Postpartum Vitamin A:** - **200,000 IU, within first 4 weeks postpartum** (while menses not yet returned, breastfeeding). - Replenishes maternal stores and enriches breast milk. **Breastfeeding (RA 10028, RA 7600, EO 51 Milk Code):** - **Initiate within the first hour of life** (EINC/Unang Yakap). - **Exclusive breastfeeding for 6 months:** breast milk only, no water, no formula, nothing else. - **Continue breastfeeding with complementary foods until 2 years and beyond.** - **Four keys to good positioning:** straight head-body line, baby held close, whole body supported, facing breast with nose to nipple. - **Signs of good latch:** more areola above than below, mouth wide open, lower lip everted, chin on breast, no pain to mother. - **Signs of effective feeding:** slow deep sucks with pauses, audible/visible swallowing, 8–12 feeds/day, ≥6 wet diapers, good weight gain. - **LAM (Lactational Amenorrhea Method):** effective if baby < 6 months, exclusively breastfed, menses not returned (~98% effective). - **Working mothers:** entitled to lactation breaks and stations (RA 10028); can express and store milk (room temp 4 hours, fridge 5 days, freezer 3 months); feed by cup/spoon, never bottle. **Complementary Feeding (from 6 Months):** - **Start at 6 completed months, while continuing breastfeeding.** - **Frequency:** 2–3 meals at 6–8 months, 3–4 meals + 1–2 snacks at 9–23 months. - **Composition:** soft/mashed foods, iron-rich (meat, liver, fish, egg, fortified rice, beans, greens), with vitamin-C foods, a little oil/fat (1 tsp/meal), fruits and vegetables, no choking hazards, no added salt/sugar. - **Safe preparation:** clean water, thorough cooking, feed immediately, discard uneaten after 1–2 hours, strict hygiene to prevent diarrhea. - **No feeding bottles** (Milk Code). - **Responsive feeding:** watch hunger/fullness cues, let child decide when to stop. **Infant and Child Vitamin A Schedule:** - **6–11 months: 100,000 IU, single dose.** - **12–59 months (1–5 years): 200,000 IU every 6 months** (twice yearly DOH rounds). - **Below 6 months:** not routinely given (breastfed infants get it from breast milk). - Document every dose (Vitamin A is fat-soluble; avoid overdosing). **Deworming:** - **Children 1–5 years: twice yearly** (Feb and Aug, or per DOH schedule). - **Albendazole 400 mg for children 2+ years; 200 mg for 12–23 months.** - Single dose, no fasting required. - Document every dose. **Growth Monitoring:** - **Plot weight and interpret the curve.** A **flat or falling line warns of problems early** — earlier than a single low weight. - **Classify nutritional status:** normal, underweight, severely underweight. - **MUAC < 11.5 cm in children 6–59 months = severe acute malnutrition; refer immediately.** - **Bilateral pedal edema = severe protein malnutrition (kwashiorkor); refer immediately.** - **Monthly weighing for infants, 2–3 monthly for older children.** **Key Laws and Programs:** - **RA 7392:** Midwives are independent providers of normal maternal-child care; nutrition counseling and supplementation are core functions. - **RA 7600 (Rooming-In and Breastfeeding Act):** Support breastfeeding initiation in facilities. - **EO 51 (Milk Code):** Prohibit formula promotion and advertising; ban feeding bottles. - **RA 10028 (Expanded Breastfeeding Promotion Act):** Require lactation breaks and stations; support breastfeeding in community. - **RA 8172 (ASIN Law):** Promote iodized salt to prevent iodine deficiency. - **RA 8976 (Food Fortification Law):** Support iron-fortified rice, fortified oil, and fortified flour. - **EINC (Essential Intrapartum and Newborn Care):** Includes breastfeeding initiation within the first hour. - **Unang Yakap (First Embrace):** Skin-to-skin contact and early breastfeeding for term infants (and supportive care for preterm/low-birthweight). - **DOH Guaranteed Health Programs (Garantisadong Pambata):** Provide Vitamin A and deworming to all eligible children, integrated with immunization, twice yearly.