Midwifery Pharmacology — The Limited Formulary - Cheat Sheet
Your last-minute exam companion: condensed drug protocols, doses, routes, and contraindications. Master the AMTSL sequence, newborn regimens, and the critical 'refer' boundary. Every fact here is testable.
AMTSL & Oxytocics — The PPH Prevention & Treatment Core
Formulas
Oxytocin AMTSL = 10 IU IM within 1 minute of baby delivery
Meaning
IU = international units; IM = intramuscular; timing is after ruling out second twin
Watch out
NEVER give oxytocin before the baby is born (risk of uterine rupture, fetal death). NEVER use oxytocin to induce or augment labor in the first or second stage — that is physician-only.
When to use
Immediately after the baby is born (before placenta is delivered) — the single most important action to prevent PPH
Oxytocin PPH treatment (IV infusion) = 20–40 IU in 1 litre isotonic fluid
Meaning
Given as drip while arranging urgent referral; the dose and dilution vary by setting and protocol
Watch out
Oxytocin IV must flow over 10–40 minutes minimum (too fast = hypotension). Always have IV access secure before starting; use isotonic saline or Ringer's, not dextrose solutions.
When to use
Active PPH with IV access; maintain while referring for high-dependency care
Common values
Value
10 IU intramuscular
Symbol
Oxt AMTSL
Quantity
Oxytocin AMTSL dose
Value
3–5 minutes
Symbol
t onset (IM)
Quantity
Oxytocin IM onset
Value
30–60 minutes
Symbol
t duration (IM)
Quantity
Oxytocin IM duration
Value
0.2 mg IM
Symbol
Erg dose
Quantity
Ergometrine standard dose
Value
600 mcg orally
Symbol
Miso AMTSL
Quantity
Misoprostol AMTSL
Value
800 mcg
Symbol
Miso PPH
Quantity
Misoprostol PPH treatment
Important facts
- Oxytocin is the FIRST-CHOICE uterotonic because it does NOT raise blood pressure (safe even when BP status unknown).
- Ergometrine is second-line; absolutely forbidden in hypertension/pre-eclampsia/eclampsia.
- Misoprostol 600 mcg orally is a heat-stable alternative for AMTSL where cold chain unavailable; 800 mcg for PPH treatment (per DOH protocol).
- PPH priority actions in order: CALL/REFER → Massage uterus → Give oxytocin → Empty bladder → Check for tears.
- Uterine massage is done immediately after placental delivery, then every 15 minutes for the first 2 hours postpartum to maintain contraction and prevent atony.
- Oxytocin onset is rapid (IV: <1 min; IM: 3–5 min); duration IM ~30–60 min, so IM dosing may need repeating.
- Always rule out a second twin or retained placenta BEFORE giving oxytocin to a woman bleeding actively.
- Oxytocin for labor induction/augmentation in first/second stage is a PHYSICIAN ONLY act — midwife's oxytocin use is confined to AMTSL and PPH (third stage onward).
Key definitions
Active Management of Third Stage Labor (AMTSL)
Example
You deliver the baby, check for a second twin, inject oxytocin IM immediately, then wait for a strong contraction before gentle cord traction while guarding the uterus.
Three-step protocol: (1) oxytocin 10 IU IM within 1 min of birth; (2) controlled cord traction with counter-traction; (3) uterine massage every 15 min × 2 hours postpartum.
Postpartum Hemorrhage (PPH)
Example
A mother delivers normally but continues to bleed heavily 30 minutes postpartum; blood-soaked pads, pale, weak pulse. This is PPH — massage uterus, check for retention/tears, give oxytocin, call for help.
Loss of ≥500 mL blood within 24 hours of vaginal delivery (or ≥1000 mL after cesarean) — the #1 direct cause of maternal death in the Philippines.
Ergometrine (methylergometrine)
Example
Woman with known high BP goes into labor — use oxytocin, NOT ergometrine, for AMTSL to avoid worsening hypertension.
Uterotonic alternative to oxytocin; 0.2 mg IM; CONTRAINDICATED in hypertension, pre-eclampsia, eclampsia, heart disease (causes vasoconstriction and BP rise).
Diagrams to know
- Three-component AMTSL sequence (oxytocin → cord traction → massage)
- PPH decision tree: Is uterus atonic? Are there tears? Is placenta retained?
- Timeline of oxytocin action: onset, peak, duration by route (IM vs IV)
Newborn Prophylaxis — Vitamin K & Eye Protection
Formulas
Vitamin K1 (phytomenadione) term = 1 mg IM
Meaning
mg = milligrams; IM = intramuscular into vastus lateralis (anterolateral thigh); for infants ≥1.5 kg at birth
Watch out
Do NOT give IV push (risk of kernicterus and thrombosis). Do NOT delay — early administration is protective. Verify correct site (thigh, not buttock).
When to use
Within first hour(s) after delivery to every term newborn; single dose prevents Vitamin K Deficiency Bleeding (VKDB).
Vitamin K1 preterm/LBW = 0.5 mg IM
Meaning
For newborns <1.5 kg (preterm or LBW); smaller dose due to smaller body mass
Watch out
Do not confuse with term dose (1 mg); always check birth weight. If birth weight unknown, use 1 mg (safe) unless very clearly small/preterm.
When to use
Preterm or low-birth-weight newborn at delivery; same timing and route as term dose
Erythromycin ophthalmic ointment eye prophylaxis = thin ribbon each lower conjunctival sac
Meaning
Concentration = 0.5%; apply to both eyes; no quantified volume because it is applied as a ribbon from tube
Watch out
Do NOT irrigate eyes after application — the ointment must remain in contact. Apply AFTER bonding/drying to avoid washing away. Do NOT use silver nitrate (outdated; can cause irritation).
When to use
Within the first hour after birth to prevent ophthalmia neonatorum (gonococcal/chlamydial conjunctivitis)
Common values
Value
1 mg IM
Symbol
VitK1 term
Quantity
Vitamin K1 term infant dose
Value
0.5 mg IM
Symbol
VitK1 preterm
Quantity
Vitamin K1 preterm/LBW dose
Value
0.5% ophthalmic ointment
Symbol
Eryth oint
Quantity
Erythromycin concentration
Value
1% ophthalmic ointment
Symbol
Tetra oint
Quantity
Tetracycline alternative concentration
Important facts
- VKDB prevention is a core newborn right under Unang Yakap/EINC protocol.
- Vitamin K is fat-soluble; IM absorption is rapid and reliable (better than oral in resource-limited settings).
- Erythromycin ointment is the DOH-preferred eye prophylaxis agent; tetracycline 1% is an alternative.
- Eye prophylaxis is applied after the cord is cut, baby dried, and mother-infant bonding initiated (usually within 1 hour, but exact timing varies by facility).
- Do NOT irrigate the eyes after ointment — this washes away the protective agent.
- Vitamin K 1 mg term + erythromycin ointment are routine, non-negotiable newborn preventions.
- If birth weight is very uncertain, give 1 mg (safe for all; slightly 'over-dose' for tiny baby but not harmful).
- Vitamin K may be refrigerated (2–8 °C) but check expiry; heat-sensitive.
Key definitions
Vitamin K Deficiency Bleeding (VKDB)
Example
An unimmunized newborn presents with spontaneous GI or intracranial bleeding at 2–7 days old; preventable by routine Vitamin K prophylaxis at delivery.
Potentially fatal bleeding in the newborn caused by lack of Vitamin K-dependent clotting factors; preventable by IM phytomenadione within hours of birth.
Ophthalmia Neonatorum
Example
Mother with untreated chlamydia delivers vaginally; baby develops purulent conjunctivitis within 5–14 days if not protected by erythromycin ointment.
Newborn conjunctivitis caused by gonococcus (N. gonorrhoeae) or Chlamydia trachomatis acquired during vaginal delivery; prevented by topical antibiotic/antimicrobial prophylaxis.
Vastus Lateralis
Example
Vitamin K 1 mg is given IM into the outer front thigh, not the buttock or arm, to avoid damage to the sciatic nerve or other structures.
Anterolateral aspect of the mid-thigh; the recommended IM injection site for newborn vaccines and Vitamin K (away from nerves and blood vessels).
Diagrams to know
- Newborn prophylaxis timeline: birth → Vit K IM (first hour) → eye ointment → bonding
- IM injection site anatomy: vastus lateralis (safe zone) vs. neurovascular structures to avoid
- VKDB risk periods and bleeding manifestations (cephalohematoma, GI, ICH)
Maternal Micronutrients — Iron, Folic Acid, Vitamin A
Formulas
Iron + folic acid (pregnancy standard) = 60 mg elemental Fe + 400 mcg (0.4 mg) folic acid, once daily
Meaning
Elemental iron = the bioavailable form (ferrous sulfate 200 mg tablet ≈ 60 mg elemental); folic acid in micrograms (mcg) or mg
Watch out
Do NOT confuse elemental iron (60 mg) with salt weight (ferrous sulfate 200 mg) — know the conversion. Do NOT continue high-dose iron indefinitely postpartum (3 months is standard). Iron may cause constipation; advise high-fiber diet and hydration.
When to use
Every pregnant woman, throughout pregnancy and continued for 3 months postpartum for anemia prevention and to restore postpartum iron stores.
Iron + folic acid (anemia treatment) = 60 mg elemental Fe twice daily (or per protocol)
Meaning
In frankly anemic pregnant women (Hb <7 g/dL or moderate-severe anemia), iron is doubled
Watch out
Higher doses increase GI side effects (nausea, constipation). Counsel on spacing apart from tea/coffee and calcium (inhibit absorption). Expect delayed response (slow rise in Hb over weeks).
When to use
Diagnosed anemia in pregnancy; midwife may follow facility/DOH protocol for intensified dosing
Postpartum Vitamin A (where DOH policy permits) = 200,000 IU single dose
Meaning
IU = international units; given within first weeks postpartum (exact timing per protocol)
Watch out
HIGH-DOSE Vitamin A (≥10,000 IU/day or single doses >200,000 IU) is TERATOGENIC and ABSOLUTELY CONTRAINDICATED IN PREGNANCY. Never give high-dose Vit A to pregnant women. Only postpartum dosing is safe.
When to use
Postpartum supplementation in settings with Vitamin A deficiency risk; part of some DOH/MNCHN protocols.
Common values
Value
60 mg Fe + 400 mcg folic acid, once daily
Symbol
Fe/FA std
Quantity
Standard iron + folic acid (pregnancy)
Value
60 mg Fe twice daily
Symbol
Fe intensified
Quantity
Intensified iron (frank anemia)
Value
3 months postpartum
Symbol
Fe duration PP
Quantity
Duration of postpartum iron
Value
200,000 IU single dose
Symbol
VitA PP
Quantity
Postpartum Vitamin A dose
Value
<11 g/dL
Symbol
Hb anemia
Quantity
Anemia Hb threshold (1st/3rd trimester)
Important facts
- Iron supplementation in pregnancy reduces anemia risk and postpartum hemorrhage complications.
- Folic acid prevents neural tube defects (NTDs); ideally started 3 months before pregnancy, but at least from first ANC visit.
- Iron absorption is enhanced by vitamin C (citrus, tomatoes) and inhibited by tea, coffee, and dairy (counsel mothers on timing).
- Constipation and dark stool are normal with iron — reassure mothers; laxative use may be needed.
- Ferrous (Fe2+) forms are better absorbed than ferric (Fe3+); ferrous sulfate is standard.
- Postpartum iron supplementation for 3 months restores depleted stores after pregnancy blood loss.
- High-dose Vitamin A in pregnancy (>200,000 IU) is teratogenic; only postpartum dosing is permitted.
- Midwife role: dispense iron + folic acid routinely, counsel on adherence and side effects, monitor for severe anemia (refer if Hb <7 or signs of cardiac strain).
Key definitions
Elemental Iron
Example
A mother is told to take 'ferrous sulfate 200 mg daily' — this provides 60 mg of actual usable iron, not 200 mg.
The bioavailable form of iron (Fe) in a supplement; ferrous sulfate 200 mg tablet contains approximately 60 mg elemental iron.
Folic Acid
Example
Every pregnant woman should receive folic acid from the start of pregnancy to prevent cleft palate and spina bifida in the fetus.
Water-soluble B vitamin; essential for DNA synthesis and prevention of neural tube defects; 400 mcg standard prophylactic dose in pregnancy.
Pregnancy Anemia
Example
A mother with Hb 8 g/dL is frankly anemic; iron dose is increased to twice daily until Hb rises to safe level (target ≥11 g/dL before delivery).
Hemoglobin <11 g/dL in the first/third trimester or <10.5 g/dL in the second trimester; iron deficiency is the most common cause in low-resource settings.
Diagrams to know
- Iron absorption pathway: factors that enhance (vitamin C) vs. inhibit (tea, phytates)
- Timeline of folic acid supplementation: preconception → pregnancy → postpartum
- Anemia severity grades and when to refer (Hb thresholds)
Immunization in Pregnancy — Tetanus/Td & Schedule
Formulas
Td (Tetanus-Diphtheria) vaccine = 0.5 mL IM per dose
Meaning
mL = millilitre; IM into deltoid (arm); each dose is 0.5 mL regardless of age/weight
Watch out
Do NOT give more than 0.5 mL per injection. DO space doses according to minimum intervals (4 weeks minimum between TT1–TT2, 6 months minimum TT2–TT3, 1 year TT3–TT4, 1 year TT4–TT5). Do NOT count a dose given less than the minimum interval after the previous dose.
When to use
Pregnant women (especially first contact/ANC visit); follows TT1–TT5 schedule for full protection and neonatal tetanus prevention.
Common values
Value
0.5 mL IM
Symbol
Td/inj
Quantity
Td dose per injection
Value
4 weeks
Symbol
TT1→TT2
Quantity
Minimum interval TT1 to TT2
Value
6 months
Symbol
TT2→TT3
Quantity
Minimum interval TT2 to TT3
Value
1 year
Symbol
TT3→TT4
Quantity
Minimum interval TT3 to TT4
Value
1 year
Symbol
TT4→TT5
Quantity
Minimum interval TT4 to TT5
Value
~3 years
Symbol
Prot TT2
Quantity
Protection after TT2
Value
Lifetime
Symbol
Prot TT5
Quantity
Protection after TT5
Important facts
- Every pregnant woman should receive Td as part of ANC; it is one of the core MNCHN interventions.
- TT1–TT5 schedule is rigid: TT1 (as soon as possible), TT2 (≥4 weeks after TT1), TT3 (≥6 months after TT2), TT4 (≥1 year after TT3), TT5 (≥1 year after TT4).
- A woman with TT5 completion is fully protected for all remaining reproductive years (lifetime protection).
- TT5 completion also protects the newborn (passive transfer of maternal antibodies); neonatal tetanus is rare in fully immunized mothers.
- Doses must be administered IM into the deltoid (arm), not the gluteus; injection into the deltoid is preferred for vaccine efficacy.
- Mild local reaction (pain, redness at injection site) is normal and not a contraindication to future doses.
- Severe allergic reaction is rare but manage with adrenaline; mild fever post-vaccine is not a contraindication.
- Midwife role: administer Td per schedule, document every dose in FHSIS registers, counsel on protective timeline, refer for facility birth if TT coverage is <TT2.
Key definitions
Tetanus Toxoid (TT) / Tetanus-Diphtheria (Td)
Example
A 20-year-old primigravida books ANC at 8 weeks gestation with no prior tetanus vaccination history; she receives Td1 immediately, Td2 at 4 weeks, Td3 at 6 months, Td4 at 1 year (all during pregnancy or early postnatal period), and Td5 one year later to complete full protection.
Inactivated vaccine against tetanus and diphtheria; administered IM to pregnant women in a 5-dose series to achieve lifelong protection and prevent maternal and neonatal tetanus (MNT).
Maternal and Neonatal Tetanus (MNT)
Example
A newborn with no clean delivery care and unimmunized mother develops classic neonatal tetanus (trismus, opisthotonus) at day 3–5 — 100% preventable by maternal Td5 completion.
Potentially fatal infection in mother or newborn caused by spore-forming bacterium Clostridium tetani; prevents by full (TT5) maternal immunization.
Protective Immunity (TT schedule)
Example
A woman who received only TT1 has zero protection; after TT2 (4 weeks later), she has 3-year protection, adequate for her first pregnancy; after TT5, she is protected for all future pregnancies.
Level of antibodies sufficient to prevent disease; each TT dose confers progressively longer-lasting protection: TT2 ~3 years, TT3 ~5 years, TT4 ~10 years, TT5 ~lifetime.
Diagrams to know
- TT1–TT5 dosing timeline with minimum intervals and protective periods
- Protective immunity level at each dose (TT2 = ~3 yr, TT3 = ~5 yr, TT4 = ~10 yr, TT5 = lifetime)
- Decision tree: Is mother protected for this pregnancy? (Check TT dose history and dates)
Family Planning Contraceptives — Pills, Injectables, Barriers
Formulas
DMPA (Depot Medroxyprogesterone Acetate) = 150 mg IM every 3 months
Meaning
mg = milligrams; IM intramuscular; given once every 12 weeks (84 days) for contraceptive coverage
Watch out
Injection site must be alternated (left and right buttock, or left and right deltoid per protocol) to avoid local adverse effects. If >12 weeks overdue, pregnancy must be ruled out before re-injection. Weight gain is common side effect; counsel proactively. Return-to-fertility may be delayed after last injection (up to 12 months).
When to use
Highly effective long-acting reversible contraception; preferred in lactating women (does not impair milk supply, unlike combined oral contraceptives).
Common values
Value
150 mg IM every 3 months
Symbol
DMPA dose
Quantity
DMPA standard dose
Value
84 days (12 weeks)
Symbol
DMPA interval
Quantity
DMPA interval (days)
Value
Day 1 of menses (immediate protection) or day 2–5 (backup x7 days)
Symbol
COC start
Quantity
COC starting day
Value
28 pills (no pill-free interval)
Symbol
POP pack
Quantity
POP pill count (pack)
Value
6 months postpartum (exclusive breastfeeding)
Symbol
LAM duration
Quantity
LAM duration
Important facts
- COCs are contraindicated in smokers >35 years (increased cardiovascular risk), uncontrolled hypertension (SBP >160 or DBP >100), and history of VTE/stroke.
- POPs and DMPA are preferred in breastfeeding women (do not suppress lactation like estrogen does).
- COCs should ideally be started on day 1 of menses (immediate protection); if started after day 5, backup contraception (condoms) needed for 7 days.
- DMPA is highly effective (>99% if given on schedule) and convenient (every 3 months); injection can be IM deltoid or buttock per protocol.
- Condoms provide dual protection (pregnancy + STI prevention) and are suitable for all women; no medical contraindications.
- IUD and implants require specialist insertion and are not administered by midwives in primary care; midwife refers to trained provider (though she may counsel and support user).
- Side effects must be counseled: COC (nausea, slight weight gain, breast tenderness), DMPA (weight gain, delayed return to fertility), POP (irregular bleeding).
- Midwife screens for contraindications at every FP visit: BP, smoking history, VTE/stroke history, current medications, breastfeeding status.
Key definitions
Combined Oral Contraceptive (COC)
Example
A non-breastfeeding woman starts a 28-day COC pack on the first day of menses; she takes one pill daily for the first 21 days, then follows the placebo week (withdrawal bleed occurs) before starting the next pack.
Pill containing both estrogen and progestin; taken daily for 21 days, then 7-day pill-free interval (or 28-day pack with placebo pills); typical contraceptive efficacy ~91%.
Progestin-Only Pill (POP) / Minipill
Example
A lactating woman is given POP (e.g., norethisterone 0.35 mg) to take daily starting day 1 postpartum; it provides contraception without affecting milk supply (unlike COC).
Pill containing progestin alone (no estrogen); taken daily without a pill-free interval; mechanism is primarily cervical mucus thickening; preferred in breastfeeding women (does not suppress milk).
Breastfeeding Amenorrhea Method (LAM)
Example
A mother exclusively breastfeeds her newborn 8+ times daily; she is protected by LAM for the first 6 months postpartum without additional contraception, but must transition to POP or DMPA if she wishes to continue breastfeeding beyond 6 months while preventing pregnancy.
Natural contraceptive effect of exclusive breastfeeding; provides ~98% protection if fully exclusive, frequent (8+ feeds/day), and within 6 months postpartum; requires counseling on when to add backup method.
Relative Contraindication (for COC)
Example
A 38-year-old smoker requests COC; this is a relative contraindication (increased VTE/stroke risk); midwife counsels risks and offers alternatives (POP, DMPA, condom) as preferable options.
Condition that warrants caution but does not absolutely forbid use (e.g., age >35 with smoking, controlled hypertension); risk-benefit is assessed case-by-case by provider.
Absolute Contraindication (for COC)
Example
A woman with a history of deep vein thrombosis (DVT) must NOT receive COC; midwife offers POP, DMPA, or condom instead.
Condition that forbids use of the drug due to unacceptable risk; examples: uncontrolled hypertension, history of thromboembolism, active breast cancer.
Diagrams to know
- Decision tree: Breastfeeding yes/no? → COC vs. POP vs. DMPA vs. condom
- COC pack structure: 21 active pills + 7-day pill-free interval (or 28-pack with placebos)
- DMPA injection timeline: every 12 weeks (84 days), alternate injection site
Magnesium Sulfate — Eclampsia Loading Dose & Emergency Anticonvulsant
Formulas
MgSO₄ Loading IV = 4 g (20% solution) slow IV over 5–20 minutes
Meaning
g = grams; IV = intravenous; 20% = 20 g in 100 mL solution; dilute in normal saline or give undiluted per protocol; must infuse SLOWLY (not IV push)
Watch out
NEVER give IV push (risk of hypermagnesemia, cardiac arrhythmia, respiratory arrest). ALWAYS check for safety signs (RR ≥12, urine ≥30 mL/hr, patellar reflex present) BEFORE each dose. Infuse slowly over at least 5 minutes; 20 minutes is safer.
When to use
First-aid emergency measure for severe pre-eclampsia or eclampsia; given before and during referral to a facility capable of high-dependency care.
MgSO₄ Loading IM = 5 g (50% solution) deep IM into each buttock (10 g total) + 1 mL 2% lignocaine per injection
Meaning
g = grams; IM = intramuscular (deep, into gluteus maximus); 50% = 50 g per 100 mL; lignocaine is added to reduce pain; this is given concurrently with IV dose
Watch out
MUST be deep IM (not subcutaneous). Alternate buttocks for the two injections (left and right). Lignocaine reduces local pain and can be mixed into the syringe before injection. Risk of abscess if technique is poor; use sterile needle and aseptic technique.
When to use
Part of the complete loading regimen (given at the same time as IV dose, not after) to achieve rapid therapeutic MgSO₄ levels for seizure prevention.
Common values
Value
4 g (20% solution) over 5–20 minutes
Symbol
MgSO4 IV load
Quantity
MgSO₄ loading IV dose
Value
10 g (5 g × 2 buttocks, 50% solution) with 1 mL 2% lignocaine each
Symbol
MgSO4 IM load
Quantity
MgSO₄ loading IM total
Value
1 g (10 mL of 10% solution) slow IV
Symbol
Ca glu antidote
Quantity
Calcium gluconate antidote dose
Value
≥12–16 breaths/minute
Symbol
RR safe
Quantity
Safety threshold: Respiratory rate
Value
≥30 mL/hour (≥100 mL/4 hours)
Symbol
UO safe
Quantity
Safety threshold: Urine output
Value
Present (brisk)
Symbol
Reflex safe
Quantity
Safety threshold: Patellar reflex
Important facts
- MgSO₄ is the ONLY emergency anticonvulsant administered by midwives; phenytoin and other anti-epileptics are physician drugs.
- Loading dose (IV 4 g + IM 10 g) is given as a complete package, not sequentially — IV and IM injections are given at the same time or within minutes.
- Maintenance dose (5 g IM every 4 hours in alternate buttocks for 24 hours postpartum or per facility protocol) is a PHYSICIAN/FACILITY responsibility; midwife role is loading dose only.
- Three safety checks MANDATORY before and between every MgSO₄ dose: (1) Respiratory rate ≥12–16 breaths/min; (2) Urine output ≥30 mL/hr (or ≥100 mL in 4 hours); (3) Patellar reflex present (not diminished/absent).
- If ANY safety sign is abnormal, STOP MgSO₄ and check for toxicity; if reflexes lost or RR <12, give antidote calcium gluconate 1 g (10 mL of 10% solution) slow IV.
- Calcium gluconate 1 g IV is the ANTIDOTE to MgSO₄ toxicity; keep it available at the bedside whenever giving MgSO₄.
- MgSO₄ has neuroprotective and seizure-preventive effects; it reduces the risk of eclampsia by ~50% in pre-eclampsia.
- Midwife gives loading dose before referral; the mother travels with a companion who continues monitoring (RR, reflex, urine output) during transport.
Key definitions
Severe Pre-Eclampsia
Example
A woman at 32 weeks is found to have BP 165/115, proteinuria 3+, and severe headache unrelieved by paracetamol; this is severe pre-eclampsia — give MgSO₄ loading and refer urgently.
Hypertension (SBP ≥160 or DBP ≥110 mmHg) + proteinuria (≥2+ on dipstick or ≥300 mg/L) + at least ONE of: headache, visual disturbance, epigastric pain, seizure/eclampsia, pulmonary edema, oliguria, fetal distress.
Eclampsia
Example
A woman in labor suddenly develops a generalized tonic-clonic seizure (previously had HTN and proteinuria); this is eclampsia — give MgSO₄ loading immediately, protect airway, and refer emergently.
Hypertension + proteinuria + generalized seizure(s) occurring during pregnancy/labor/postpartum; a medical emergency that can recur; requires MgSO₄ and urgent referral.
Hypermagnesemia / MgSO₄ Toxicity
Example
After giving MgSO₄, the woman's respiratory rate falls to 10 breaths/minute and her patellar reflex is absent — these are signs of toxicity; stop MgSO₄ immediately and give calcium gluconate 1 g IV.
Overdose of magnesium causing loss of reflexes, respiratory depression (RR <12), oliguria, weakness, and potentially cardiac dysrhythmia and arrest; reversed by calcium gluconate.
Patellar Reflex (Knee-Jerk Reflex)
Example
Before each MgSO₄ dose, tap the woman's patellar tendon with a small hammer; a brisk response means magnesium levels are safe; loss of reflex signals toxicity.
Brisk reflex contraction of the quadriceps muscle in response to light tap on the patellar tendon; one of the three safety signs monitored during MgSO₄ therapy.
Diagrams to know
- MgSO₄ loading regimen: 4 g IV over 5–20 min (run-time) + 5 g IM left buttock (run-time) + 5 g IM right buttock (run-time), all at the same time
- Safety monitoring triangle: Respiratory rate ≥12 → Urine ≥30 mL/hr → Patellar reflex present
- Decision tree: Signs of severe pre-eclampsia/eclampsia detected → Give MgSO₄ loading → Refer immediately → Ongoing monitoring during transport
Reactions or equations
MgSO₄ toxicity reversal: MgSO₄ + Calcium Gluconate → normalization of Mg effects
Note
Calcium gluconate 1 g (10 mL of 10% solution) slow IV reverses magnesium toxicity within minutes; an antidote, not a sustained treatment.
Conditions
Toxicity is defined by loss of patellar reflex OR respiratory rate <12 OR oliguria; calcium is given if these occur
Prohibited & Referral Drugs — What the Midwife MAY NOT Give
Important facts
- ANTIBIOTICS: Midwife may give ONE pre-referral dose of a broad-spectrum antibiotic (e.g., ceftriaxone) for severe infection/sepsis, then MUST refer for ongoing treatment (not the midwife's role).
- OXYTOCIN MISUSE: Using oxytocin to induce or augment labor in the first or second stage is STRICTLY FORBIDDEN (risk of uterine rupture, fetal death). Oxytocin is ONLY for AMTSL and PPH (third stage onward).
- ANESTHESIA: General, regional, spinal anesthesia and controlled/narcotic analgesics are PHYSICIAN ONLY (never by midwife).
- ANTI-HYPERTENSIVES: Drugs to treat hypertension (nifedipine, methyldopa, hydralazine) are PHYSICIAN acts; midwife role is detection and referral. MgSO₄ is not an anti-hypertensive; it is for seizure prevention in pre-eclampsia.
- INSULIN & DIABETES DRUGS: Management of gestational/pre-existing diabetes is physician/endocrinologist; midwife refers and supports adherence but does not prescribe.
- ANTICOAGULANTS: Heparin, warfarin, DOACs are PHYSICIAN drugs; midwife does not manage thromboembolism.
- CORTICOSTEROIDS: Antenatal corticosteroids (betamethasone for fetal lung maturation <34 weeks) require physician authorization and facility-based administration.
- ERGOMETRINE: Absolutely contraindicated in hypertension/pre-eclampsia; if BP is unknown or elevated, use oxytocin instead (safer).
- INSTRUMENTAL/OPERATIVE ACTS: Forceps, vacuum, cesarean section, episiotomy repair, and all drugs accompanying them are PHYSICIAN/SPECIALIST acts.
- DEFAULT RULE: If the drug 'treats a disease' or 'manages a complication' rather than 'supporting normal birth' or 'preventing a defined deficiency,' the answer is REFER.
Key definitions
Limited Formulary (RA 7392)
Example
A midwife can give oxytocin for AMTSL but cannot prescribe antibiotics for ongoing infection treatment (refer to physician). She can give Vitamin K to the newborn but cannot give insulin to a diabetic mother (refer).
Under Philippine Midwifery Act, a midwife is authorized to give a defined set of safe, life-saving drugs for NORMAL birth and prevention; all other drugs require physician prescription and referral.
First-Aid / Pre-Referral Drug
Example
A mother shows signs of severe infection (fever, purulent lochia, tachycardia); midwife gives one IV dose of ceftriaxone 1 g as emergency stabilization, then immediately arranges transport to a facility where the physician will continue antibiotic therapy.
A single emergency dose of a drug (e.g., first IV dose of antibiotics, first dose of MgSO₄) given by the midwife to stabilize the mother during the critical period before referral; not a substitute for definitive care.
Diagrams to know
- Decision tree: Is this within the midwife's normal formulary? (Yes → give; No → refer)
- Spectrum of care: Midwife gives (AMTSL, Vit K, eye care, iron, vaccines) vs. Physician manages (complications, disease treatment)
Must remember
OXYTOCIN 10 IU IM within 1 minute of baby delivery (after ruling out second twin) — cornerstone of AMTSL; prevents PPH, the #1 direct maternal killer in the Philippines.
NEVER use oxytocin to induce or augment labor in first/second stage — it is ONLY for AMTSL/PPH (third stage onward). Using it for labor acceleration causes uterine rupture and fetal death.
ERGOMETRINE 0.2 mg IM is CONTRAINDICATED in hypertension, pre-eclampsia, eclampsia, and heart disease (causes vasoconstriction and BP rise) — use OXYTOCIN instead (BP-neutral, safer).
VITAMIN K1: 1 mg IM term infant (≥1.5 kg) or 0.5 mg preterm/LBW (<1.5 kg), single dose, vastus lateralis, within first hour(s) — prevents Vitamin K Deficiency Bleeding (VKDB).
EYE PROPHYLAXIS: Erythromycin 0.5% ointment thin ribbon in each lower conjunctival sac within first hour (after bonding/drying) — prevents ophthalmia neonatorum; do NOT irrigate afterward.
IRON + FOLIC ACID: 60 mg elemental Fe + 400 mcg (0.4 mg) folic acid once daily throughout pregnancy, continued 3 months postpartum — anemia prevention and treatment (double dose if frank anemia, per protocol).
HIGH-DOSE VITAMIN A (>200,000 IU) is TERATOGENIC and ABSOLUTELY CONTRAINDICATED IN PREGNANCY — only safe postpartum (200,000 IU single dose, where policy permits).
TD/TETANUS SCHEDULE: TT1–TT5 (0.5 mL IM each). TT2 protects ~3 years, TT5 lifetime. Minimum intervals: 4 weeks (TT1→2), 6 months (TT2→3), 1 year (TT3→4), 1 year (TT4→5). Every dose must be documented.
DMPA (DEPO-PROVERA) 150 mg IM every 3 months (84 days); preferred in breastfeeding women (POPs are also suitable). DOES NOT suppress lactation. Alternate injection site (left/right buttock).
MAGNESIUM SULFATE LOADING for severe pre-eclampsia/eclampsia: 4 g IV over 5–20 min + 10 g IM (5 g each buttock with 1 mL 2% lignocaine) given together, then REFER. Check three safety signs before each dose: RR ≥12, UO ≥30 mL/hr, patellar reflex present. Antidote: calcium gluconate 1 g IV if toxicity.
Last minute tips
OXYTOCIN TIMING: It must be given WITHIN 1 MINUTE of the baby being born (after excluding second twin) — delays increase PPH risk. After the cord is cut is too late; after placenta is delivered is too late. 'Within 1 minute of delivery of the baby' is the exact wording.
If an exam question asks 'What is the safest uterotonic when BP is unknown/elevated?' the answer is OXYTOCIN (not ergometrine), because oxytocin does NOT raise BP. This is asked repeatedly.
VITAMIN K & EYES are ROUTINE newborn preventions given at every vaginal delivery — if the question mentions 'normal vaginal delivery' and does not specify the newborn received these, the midwife MUST give them. They are non-negotiable.
MgSO₄ SAFETY SIGNS are tested as a 'pick all that apply' or fill-in-the-blank: RR ≥12 (not <12), UO ≥30 mL/hr, patellar reflex PRESENT. If ANY of these is abnormal, STOP MgSO₄ and give calcium gluconate. Memorize this triplet cold.
When a question says 'the midwife may NOT give' or 'this is outside the midwife's scope,' the correct answer is almost always 'refer' for anything that manages disease/complication (antibiotics for infection, insulin for diabetes, antihypertensives, anesthesia). The midwife's formulary is for NORMAL birth + prevention, not disease management.
Comparison tables
Oxytocics: Oxytocin vs. Ergometrine vs. Misoprostol
| Feature | Oxytocin | Ergometrine | Misoprostol |
|---|---|---|---|
| Mechanism | Uterine smooth muscle contraction | Vasoconstriction + uterine contraction | Receptor agonist; uterine contraction |
| AMTSL dose | 10 IU IM | 0.2 mg IM (second-line) | 600 mcg orally |
| Onset (IM) | 3–5 minutes | 5–7 minutes | 10–15 minutes |
| Duration (IM) | 30–60 minutes | 45 min–3 hours | 30–60 minutes |
| Effect on BP | No rise (safe) | Raises BP (contraindicated if HTN) | No significant rise |
| Contraindication | None (universal first choice) | Hypertension, pre-eclampsia, eclampsia, heart disease | Severe asthma (rare) |
| Advantage | Effective, rapid, safe, first-line | Longer duration (useful if recurrent bleeding) | Heat-stable (no cold chain needed) |
| Use in PPH | Yes; 10 IU IM repeated, or IV infusion | Yes; 0.2 mg IM if oxytocin insufficient | 800 mcg (per DOH protocol) |
Newborn Vitamin K: Term vs. Preterm/LBW
| Parameter | Term Infant (≥1.5 kg) | Preterm/LBW (<1.5 kg) |
|---|---|---|
| Dose | 1 mg IM | 0.5 mg IM |
| Route | IM (intramuscular) | IM (intramuscular) |
| Site | Vastus lateralis (anterolateral thigh) | Vastus lateralis (anterolateral thigh) |
| Timing | Within first hour(s) after birth | Within first hour(s) after birth |
| Number of doses | Single dose | Single dose |
| Frequency of repeat | No repeat; once per lifetime | No repeat; once per lifetime |
Eye Prophylaxis Agents
| Agent | Concentration | Application | Advantage | Note |
|---|---|---|---|---|
| Erythromycin ointment | 0.5% | Thin ribbon each lower conjunctiva | DOH preferred; effective against N. gonorrhoeae and C. trachomatis | Do NOT irrigate after application |
| Tetracycline ointment | 1% | Thin ribbon each lower conjunctiva | Alternative to erythromycin; broader spectrum | Less commonly used than erythromycin |
| Silver nitrate | 1% | 1 drop each eye | Historical agent; very effective | Largely replaced; can irritate eyes; requires careful dosing |
Iron Supplementation: Pregnancy vs. Postpartum
| Phase | Dose | Duration | Purpose |
|---|---|---|---|
| Pregnancy (standard) | 60 mg elemental Fe + 400 mcg folic acid once daily | Throughout pregnancy | Anemia prevention; maintain fetal oxygen supply |
| Pregnancy (frank anemia) | 60 mg Fe twice daily (or per protocol) | Until Hb rises to safe level | Rapid correction of low Hb (Hb <7); reduce transfusion risk |
| Postpartum | 60 mg elemental Fe + folic acid once daily | 3 months postpartum | Restore iron stores depleted by pregnancy/labor blood loss |
Td/Tetanus Vaccination Schedule (TT1–TT5)
| Dose | Minimum Interval from Previous Dose | Duration of Protection | Protective Level | |
|---|---|---|---|---|
| TT1 (First dose) | As soon as possible (first ANC visit) | — | No protection (0 years) | Not yet protective |
| TT2 (Second dose) | ≥4 weeks after TT1 | At least 4 weeks | ~3 years | Protective for first pregnancy |
| TT3 (Third dose) | ≥6 months after TT2 | At least 6 months | ~5 years | Protective for first 2–3 pregnancies |
| TT4 (Fourth dose) | ≥1 year after TT3 | At least 1 year | ~10 years | Extended protection |
| TT5 (Fifth dose) | ≥1 year after TT4 | At least 1 year | Lifetime | Full lifelong protection |
Contraceptive Methods: Suitability in Breastfeeding
| Method | Breastfeeding Suitable? | Rationale | Timing |
|---|---|---|---|
| Combined Oral Contraceptive (COC) | NO (avoid if possible) | Estrogen may reduce milk supply | Not ideal in exclusive breastfeeding; may introduce formula prematurely |
| Progestin-Only Pill (POP) | YES (preferred) | Progestin alone does NOT suppress lactation | Can start day 1 postpartum; no impact on milk |
| DMPA (Depo-Provera) | YES (highly preferred) | Progestin alone; does NOT suppress lactation | Can give 6 weeks postpartum; every 3 months thereafter |
| Condoms | YES (always suitable) | Barrier method; no hormonal effect | Can use from day 1; dual protection (pregnancy + STI) |
| Breastfeeding Amenorrhea Method (LAM) | YES (natural method) | Exclusive breastfeeding provides natural contraception | Only for first 6 months AND if exclusively breastfeeding; after 6 mo. or if partial feeding, add backup method |
MgSO₄ Safety Monitoring: The Three Safety Checks
| Safety Parameter | Safe Threshold | Dangerous Finding | Action if Dangerous |
|---|---|---|---|
| Respiratory Rate (RR) | ≥12–16 breaths/minute | RR <12 (respiratory depression) | STOP MgSO₄; give calcium gluconate 1 g IV; monitor closely |
| Urine Output (UO) | ≥30 mL/hour (≥100 mL/4 hours) | UO <30 mL/hr (oliguria/acute kidney injury) | STOP MgSO₄; check Foley catheter patency; monitor electrolytes; consider toxicity |
| Patellar Reflex | Present and brisk | Absent or diminished (loss of reflexes) | STOP MgSO₄ immediately; give calcium gluconate 1 g IV slow; this is a sign of severe toxicity |
Diagrams
AMTSL & PPH Prevention Sequence
Step-by-step flowchart of Active Management of Third Stage of Labor (AMTSL) and the decision pathway for postpartum hemorrhage (PPH) detection and action.
Midwife's Limited Formulary — What's IN vs. OUT
Mind map showing the boundary of the midwife's limited formulary: drugs she can safely give vs. those that require physician referral.
MgSO₄ Loading Dose Administration & Safety Monitoring
Sequence diagram showing the concurrent IV and IM administration of MgSO₄ loading dose and the safety monitoring checks before and during referral.
Tetanus Immunity Timeline (TT1–TT5)
State diagram showing the progression through the TT1–TT5 tetanus vaccination schedule, the minimum intervals between doses, and the protective duration after each dose.
Contraceptive Method Selection in Breastfeeding
Decision flowchart for contraceptive selection in breastfeeding women, highlighting methods to prefer (POP/DMPA) vs. methods to avoid (COC with estrogen).