Midwifery Pharmacology — The Limited Formulary - Concept Map
The Midwife's Limited Drug Formulary under RA 7392
Related concepts
Oxytocics & Active Management of Third Stage of Labor (AMTSL)
Sub concepts
- Oxytocin 10 IU IM within 1 minute of birth (drug of choice for AMTSL)
- Ergometrine 0.2 mg IM (second-line, contraindicated in hypertension)
- Misoprostol 600–800 mcg (heat-stable, DOH alternative where provided)
- AMTSL components: oxytocin + controlled cord traction + uterine massage
- PPH response: refer → massage uterus → oxytocin → empty bladder → check for tears
Relationship to central
Core drugs for preventing and treating the #1 direct maternal killer—postpartum hemorrhage (PPH)
Newborn Protection Drugs
Sub concepts
- Vitamin K1 (phytomenadione): 1 mg IM (term) or 0.5 mg IM (preterm) to prevent VKDB
- Eye prophylaxis: erythromycin 0.5% ophthalmic ointment (or tetracycline 1%) to prevent ophthalmia neonatorum
- Administration timing and sites (Vitamin K in vastus lateralis thigh)
- Credé's prophylaxis technique and contraindications
Relationship to central
Essential preventive drugs given to every newborn within the first hours after birth
Micronutrient & Vitamin Supplementation
Sub concepts
- Iron + Folic Acid: 60 mg elemental iron + 400 mcg folic acid once daily throughout pregnancy and 3 months postpartum
- Anemia management: dose adjustment to twice daily if frankly anemic
- Vitamin A: 200,000 IU postpartum (NEVER high-dose in pregnancy—teratogenic)
- DOH standard protocols for micronutrient supplementation
Relationship to central
Maternal and infant nutritional supplements to prevent deficiency diseases and support normal pregnancy/lactation outcomes
Immunizing Agents
Sub concepts
- Tetanus-Diphtheria (Td) toxoid: 0.5 mL IM, deltoid
- TT1–TT5 protective schedule (5 doses = lifetime protection)
- Timing: Td1 (early pregnancy), Td2 (≥4 weeks after Td1), Td3–Td5 (≥6–12 months apart)
- Prevention of maternal and neonatal tetanus (MNT)
- Booster timing and documentation in maternal records
Relationship to central
Vaccines administered by midwives to prevent vaccine-preventable diseases, especially maternal & neonatal tetanus
Family Planning & Contraceptive Methods
Sub concepts
- Combined oral contraceptives (COCs) with contraindication screening (age >35 + smoking, HTN, thromboembolism history)
- Progestin-only pills (POPs): preferred in breastfeeding women
- DMPA injectable: 150 mg IM every 3 months (preferred during lactation over COCs)
- Condoms and barrier methods counseling
- Referral for IUD and implant insertion (requires specialized training/certification)
- Postpartum family planning timing and lactational amenorrhea method (LAM)
Relationship to central
Contraceptive services and counseling within the midwife's scope of community/primary-care practice
Emergency Anticonvulsant—Magnesium Sulfate for Eclampsia
Sub concepts
- Loading dose: 4 g MgSO4 IV over 5–20 min + 10 g IM (5 g each buttock, mixed with 1 mL 2% lignocaine)
- Safety monitoring: respiratory rate ≥12–16/min, urine ≥30 mL/hr (≥100 mL/4 hr), patellar reflex present
- Maintenance is physician/facility responsibility; midwife gives loading dose only
- Toxicity signs and antidote: calcium gluconate 1 g (10 mL of 10%) slow IV
- Immediate referral after loading dose
Relationship to central
The single life-saving first-aid drug for severe pre-eclampsia/eclampsia before urgent physician referral
Prohibited Drug Categories & Actions (Outside Midwife's Scope)
Sub concepts
- Antibiotics for infection treatment (refer for suspected infection; pre-referral stabilization is exception)
- Oxytocin for labor induction or augmentation (only for 3rd stage/PPH; never before baby is born)
- General, regional/spinal anesthesia and narcotic analgesics
- Antihypertensives, insulin, anticoagulants, corticosteroids, chronic-disease drugs
- Ergometrine in hypertensive women (absolute contraindication)
- Instrumental or operative interventions
- Heuristic: if drug treats disease/complication → refer to physician
Relationship to central
Critical scope-of-practice boundaries: what the midwife may NOT give independently
Safe Medication Administration Principles
Sub concepts
- The 'Rights': right patient, drug, dose, route, time, documentation, allergy/expiry check
- Cold-chain integrity (vaccines & oxytocin stored 2–8°C)
- Sterile single-use needle policy
- Correct injection sites: deltoid (vaccines), vastus lateralis (newborn Vitamin K)
- Anaphylaxis watch and adrenaline availability
- Safe sharps disposal
- Complete record documentation in maternal/newborn records and FHSIS registers
Relationship to central
Universal standards for safe drug administration in midwifery practice at BHS/lying-in level
Legal & Policy Framework
Sub concepts
- Republic Act No. 7392 (Philippine Midwifery Act of 1992)
- Midwife scope: normal prenatal, intranatal, postnatal care + first aid/emergency in absence of physician
- DOH protocols and guidelines for community midwifery practice
- Integration with EINC/Unang Yakap, BEmONC, MNCHN programs
- Community-level settings: RHU, BHS, lying-in clinics
- Referral protocols and BEmONC linkage
Relationship to central
The legislative and regulatory basis for the midwife's defined, limited formulary
Concept connections
- Oxytocin 10 IU IM within 1 minute of birthActive Management of Third Stage of Labor (AMTSL)Is the core first component of AMTSL; triggers the other two (controlled cord traction and uterine massage)
- AMTSLPrevention of Postpartum Hemorrhage (PPH)Is the evidence-based, life-saving protocol that dramatically reduces maternal mortality from the #1 direct killer
- Oxytocin 10 IU IMErgometrine 0.2 mg IMAre alternative uterotonics; oxytocin is preferred because it does NOT raise blood pressure
- Ergometrine 0.2 mg IMHypertension & Pre-eclampsia contraindicationErgometrine is absolutely contraindicated in hypertensive women because it causes vasoconstriction and raises BP dangerously
- Vitamin K1 phytomenadioneVitamin K Deficiency Bleeding (VKDB) preventionSingle IM injection prevents hemorrhagic disease of the newborn in the first weeks of life
- Eye prophylaxis with erythromycin 0.5%Ophthalmia neonatorum preventionPrevents gonococcal and chlamydial conjunctivitis, a cause of blindness if untreated
- Iron 60 mg + Folic acid 0.4 mg dailyMaternal anemia prevention in pregnancyRoutine supplementation prevents iron-deficiency and folate-deficiency anemia throughout pregnancy and postpartum
- Iron & Folic Acid3-month postpartum continuationDOH standard requires continuation for 3 months after delivery to maintain maternal iron stores and prevent late PPH from anemia
- High-dose Vitamin A (200,000 IU)Teratogenicity contraindication in pregnancyHigh-dose Vitamin A is absolutely contraindicated in pregnancy due to teratogenic effects; given postpartum only per DOH policy
- Tetanus-Diphtheria (Td) toxoid 0.5 mL IMMaternal and Neonatal Tetanus (MNT) preventionThe TT1–TT5 schedule protects both the mother and newborn; 5 doses provide lifetime protection
- Td2 (≥4 weeks after Td1)Protection of current pregnancyTT2 offers ~3 years of protection, ensuring that the current pregnancy and delivery are protected against neonatal tetanus
- Combined Oral Contraceptives (COCs)Contraindications in smoking >35 years, HTN, thromboembolismCOCs are avoided in these high-risk groups due to increased cardiovascular/thrombotic risk; midwife must screen
- Progestin-Only Pills (POP) & DMPAPreferred in breastfeeding womenPOPs and DMPA are safe during lactation and do not reduce milk supply, unlike COCs which are less ideal
- DMPA injectable 150 mg IMEvery 3-month administrationRequires IM injection every 3 months; midwife can administer at BHS/community level
- IUD and implant insertionReferral requiredThese methods require specialized training and certification beyond basic midwife scope; midwife counsels and refers
- Magnesium sulfate loading dose (4 g IV + 10 g IM)Severe pre-eclampsia & eclampsia emergencyIs the only emergency anticonvulsant the midwife gives as first-aid before urgent physician referral
- MgSO4 safety monitoringRespiratory rate ≥12, urine ≥30 mL/hr, patellar reflex presentThree mandatory signs must be checked before and between doses to detect toxicity early
- MgSO4 toxicityCalcium gluconate 1 g (10 mL 10%) slow IV antidoteIs the specific reversal agent for magnesium toxicity; midwife must know this for safety
- Oxytocin for labor induction/augmentationPROHIBITED before delivery of the babyIs a critical scope-of-practice boundary; using oxytocin to speed labor is a physician act only, due to risk of uterine rupture
- Antibiotics for infection treatmentPROHIBITED independent use; referSystemic antibiotic treatment is a physician/prescription act; pre-referral stabilization is an exception
- Safe medication administrationCold-chain integrity, sterile technique, correct injection sitesUniversal principles ensure drug safety and efficacy; vaccines and oxytocin must be stored 2–8°C
- Midwife's roleNormal birth + prevention + emergency first-aid + detect & refer complicationsThe midwife's limited formulary is designed to support normal physiology and prevent diseases; anything treating pathology is referred
- RA 7392 Philippine Midwifery ActScope of independent practice: normal prenatal, intranatal, postnatal careIs the legislative foundation that defines the midwife's authority and limitations in drug use
- Vitamin K IM in vastus lateralisEye prophylaxis erythromycin ointmentAre two sequential first-hour newborn prophylaxis procedures given in the same period
- Midwife limited formulary principleIf drug treats disease = refer to physicianIs the overarching heuristic for exam questions: anything beyond support of normal physiology is outside scope
Diagrams
Midwifery Pharmacology — The Limited Formulary: Complete Concept Map
Comprehensive mind map showing the entire midwifery pharmacology limited formulary organized by drug category, indications, routes, doses, and contraindications. This is the foundational visual for understanding what drugs the midwife CAN use, HOW to use them safely, and what is PROHIBITED. The map emphasizes the key MLE high-yield points: AMTSL oxytocin, newborn prophylaxis, emergency MgSO4 loading dose, and the critical principle that anything treating disease = refer to physician.
AMTSL & PPH Response: The Midwife's Oxytocin Protocol
Step-by-step flowchart of the midwife's AMTSL protocol and PPH emergency response. Shows the critical timing of oxytocin (within 1 minute, after excluding a second twin), the three components of AMTSL (oxytocin + controlled cord traction + uterine massage), and the immediate 5-point response when PPH is detected: refer → massage → oxytocin → empty bladder → check for tears. This is a high-yield MLE procedure.
Eclampsia Loading Magnesium Sulfate: First-Aid Protocol
Critical emergency protocol for magnesium sulfate loading in severe pre-eclampsia/eclampsia. Highlights the loading regimen (4 g IV + 10 g IM), the three mandatory safety monitoring parameters (RR ≥12, urine ≥30 mL/hr, patellar reflex present), toxicity recognition, and the antidote (calcium gluconate). Emphasizes that this is a first-aid, pre-referral measure only—maintenance is the physician's responsibility. This item is heavily tested on the MLE.
Newborn First-Hour Interventions: Vitamin K & Eye Prophylaxis
Sequential protocol for the two essential newborn prophylactic medications in the first hour of life: Vitamin K1 (phytomenadione) to prevent hemorrhagic disease, and eye prophylaxis (erythromycin 0.5% ointment) to prevent ophthalmia neonatorum. Shows correct dosing by birth weight, injection site (vastus lateralis), and the critical principle that eyes must NOT be irrigated after prophylaxis. This is a fundamental EINC/Unang Yakap skill.
Iron & Folic Acid Supplementation in Pregnancy & Postpartum
Comprehensive flowchart for iron and folic acid supplementation from early pregnancy through 3 months postpartum. Distinguishes between standard dosing (60 mg iron + 0.4 mg folate once daily) and higher doses in frank anemia (twice daily under protocol). Emphasizes counseling on side effects, compliance, and the critical 3-month postpartum continuation period per DOH guidelines. This is essential community practice.
Tetanus Toxoid (Td) Immunization Schedule in Pregnancy
The classic Td/TT immunization schedule showing all 5 doses and their protective durations. TT1 is given as soon as possible in pregnancy (no protection yet); TT2 ≥4 weeks later (protects that pregnancy and ~3 years); TT3–TT5 are given postpartum at 6–12 month intervals (progressive protection up to lifetime). Five completed doses protect the woman and her newborn against maternal and neonatal tetanus for all future pregnancies. This is a high-yield MLE item with the exact schedule.
Family Planning Contraceptive Method Selection: Decision Path for Midwife
State diagram showing the midwife's decision pathway in family planning contraceptive method selection. Starting with assessment and screening for contraindications (smoking >35 years, hypertension, thromboembolism history), the diagram branches to five options: COCs (avoided in high-risk women), POPs (preferred in breastfeeding), DMPA injectable (150 mg IM every 3 months, safe postpartum), condoms, and referral for IUD/implant insertion. Emphasizes that the midwife can counsel, dispense, and inject but must refer for implant and IUD insertion.
The Midwife's Drug Formulary Composition: What is IN vs OUT
Pie chart showing the composition of the midwife's limited formulary. About 80% is supportive/preventive (oxytocics for normal 3rd stage, newborn prophylaxis, micronutrients, vaccines, FP). About 10% is emergency first-aid (MgSO4 loading dose for eclampsia). About 20% represents PROHIBITED categories (drugs the midwife absolutely cannot give: antibiotics for treatment, labor induction/augmentation drugs, anesthetics, etc.). The visual emphasizes that the midwife works within clear, defined boundaries.