Midwife Licensure Exam Midwifery Pharmacology & Newborn Procedures — Midwifery Pharmacology — The Limited FormularyConcept Map

Concept

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)

Concept

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

Concept

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

Concept

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

Concept

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

Concept

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

Concept

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

Concept

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

Concept

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

To

Active Management of Third Stage of Labor (AMTSL)

From

Oxytocin 10 IU IM within 1 minute of birth

Strength

strong

Relationship

Is the core first component of AMTSL; triggers the other two (controlled cord traction and uterine massage)

To

Prevention of Postpartum Hemorrhage (PPH)

From

AMTSL

Strength

strong

Relationship

Is the evidence-based, life-saving protocol that dramatically reduces maternal mortality from the #1 direct killer

To

Ergometrine 0.2 mg IM

From

Oxytocin 10 IU IM

Strength

strong

Relationship

Are alternative uterotonics; oxytocin is preferred because it does NOT raise blood pressure

To

Hypertension & Pre-eclampsia contraindication

From

Ergometrine 0.2 mg IM

Strength

strong

Relationship

Ergometrine is absolutely contraindicated in hypertensive women because it causes vasoconstriction and raises BP dangerously

To

Vitamin K Deficiency Bleeding (VKDB) prevention

From

Vitamin K1 phytomenadione

Strength

strong

Relationship

Single IM injection prevents hemorrhagic disease of the newborn in the first weeks of life

To

Ophthalmia neonatorum prevention

From

Eye prophylaxis with erythromycin 0.5%

Strength

strong

Relationship

Prevents gonococcal and chlamydial conjunctivitis, a cause of blindness if untreated

To

Maternal anemia prevention in pregnancy

From

Iron 60 mg + Folic acid 0.4 mg daily

Strength

strong

Relationship

Routine supplementation prevents iron-deficiency and folate-deficiency anemia throughout pregnancy and postpartum

To

3-month postpartum continuation

From

Iron & Folic Acid

Strength

moderate

Relationship

DOH standard requires continuation for 3 months after delivery to maintain maternal iron stores and prevent late PPH from anemia

To

Teratogenicity contraindication in pregnancy

From

High-dose Vitamin A (200,000 IU)

Strength

strong

Relationship

High-dose Vitamin A is absolutely contraindicated in pregnancy due to teratogenic effects; given postpartum only per DOH policy

To

Maternal and Neonatal Tetanus (MNT) prevention

From

Tetanus-Diphtheria (Td) toxoid 0.5 mL IM

Strength

strong

Relationship

The TT1–TT5 schedule protects both the mother and newborn; 5 doses provide lifetime protection

To

Protection of current pregnancy

From

Td2 (≥4 weeks after Td1)

Strength

strong

Relationship

TT2 offers ~3 years of protection, ensuring that the current pregnancy and delivery are protected against neonatal tetanus

To

Contraindications in smoking >35 years, HTN, thromboembolism

From

Combined Oral Contraceptives (COCs)

Strength

strong

Relationship

COCs are avoided in these high-risk groups due to increased cardiovascular/thrombotic risk; midwife must screen

To

Preferred in breastfeeding women

From

Progestin-Only Pills (POP) & DMPA

Strength

strong

Relationship

POPs and DMPA are safe during lactation and do not reduce milk supply, unlike COCs which are less ideal

To

Every 3-month administration

From

DMPA injectable 150 mg IM

Strength

strong

Relationship

Requires IM injection every 3 months; midwife can administer at BHS/community level

To

Referral required

From

IUD and implant insertion

Strength

strong

Relationship

These methods require specialized training and certification beyond basic midwife scope; midwife counsels and refers

To

Severe pre-eclampsia & eclampsia emergency

From

Magnesium sulfate loading dose (4 g IV + 10 g IM)

Strength

strong

Relationship

Is the only emergency anticonvulsant the midwife gives as first-aid before urgent physician referral

To

Respiratory rate ≥12, urine ≥30 mL/hr, patellar reflex present

From

MgSO4 safety monitoring

Strength

strong

Relationship

Three mandatory signs must be checked before and between doses to detect toxicity early

To

Calcium gluconate 1 g (10 mL 10%) slow IV antidote

From

MgSO4 toxicity

Strength

strong

Relationship

Is the specific reversal agent for magnesium toxicity; midwife must know this for safety

To

PROHIBITED before delivery of the baby

From

Oxytocin for labor induction/augmentation

Strength

strong

Relationship

Is a critical scope-of-practice boundary; using oxytocin to speed labor is a physician act only, due to risk of uterine rupture

To

PROHIBITED independent use; refer

From

Antibiotics for infection treatment

Strength

strong

Relationship

Systemic antibiotic treatment is a physician/prescription act; pre-referral stabilization is an exception

To

Cold-chain integrity, sterile technique, correct injection sites

From

Safe medication administration

Strength

moderate

Relationship

Universal principles ensure drug safety and efficacy; vaccines and oxytocin must be stored 2–8°C

To

Normal birth + prevention + emergency first-aid + detect & refer complications

From

Midwife's role

Strength

strong

Relationship

The midwife's limited formulary is designed to support normal physiology and prevent diseases; anything treating pathology is referred

To

Scope of independent practice: normal prenatal, intranatal, postnatal care

From

RA 7392 Philippine Midwifery Act

Strength

strong

Relationship

Is the legislative foundation that defines the midwife's authority and limitations in drug use

To

Eye prophylaxis erythromycin ointment

From

Vitamin K IM in vastus lateralis

Strength

moderate

Relationship

Are two sequential first-hour newborn prophylaxis procedures given in the same period

To

If drug treats disease = refer to physician

From

Midwife limited formulary principle

Strength

strong

Relationship

Is the overarching heuristic for exam questions: anything beyond support of normal physiology is outside scope