Midwife Licensure Exam Midwifery Pharmacology & Newborn Procedures — Midwifery Pharmacology — The Limited FormularyRevision Notes

Exam Tips

• When an MLE question asks 'What is the midwife's first action?' for a complication like eclampsia or severe PPH, the answer always includes 'REFER' — with the loading dose as the pre-referral stabilizing measure.
• If a question names an unfamiliar drug, ask yourself: 'Does this fit the midwife's normal-birth/prevention role?' If not, the answer is likely REFER.

Key Points

• RA 7392 defines the midwife as an independent primary provider of NORMAL maternal, newborn, and family-planning care — not a prescriber for disease management.
• The midwife's formulary covers: oxytocics (AMTSL and PPH first-aid), newborn drugs (Vitamin K, eye prophylaxis), micronutrients (iron, folic acid, Vitamin A), vaccines (Td/TT), family planning drugs (COCs, POPs, DMPA), and one emergency anticonvulsant loading dose (MgSO4).
• Outside the formulary: antibiotics for ongoing infection treatment, labor induction/augmentation drugs, anesthesia, antihypertensives, insulin, anticoagulants, and any drug that treats a diagnosed disease rather than supporting normal birth.
• The safest MLE heuristic: 'Does this drug support NORMAL birth or prevent a defined deficiency/infection?' YES = midwife can give it. NO = REFER.

Definitions

Section Title

Why the Midwife Has a Limited Formulary

Common Mistakes

• Thinking the midwife can give antibiotics for treatment of infection — she can only give a pre-referral stabilizing dose under specific protocol, then REFER.
• Confusing 'administer' with 'prescribe' — midwives administer from a defined list; they do not prescribe independently.
• Forgetting that any drug used to TREAT a complication (e.g., antihypertensives for severe hypertension) is outside the midwife's scope — detect and REFER.

Formulas

Exam Tips

• Board exam favorite: 'Drug of choice for AMTSL?' Answer: Oxytocin 10 IU IM within 1 minute of birth.
• Always pair the oxytocin answer with the reason: 'Does not raise blood pressure.'
• Ergometrine contraindication questions are very common — memorize: hypertension, pre-eclampsia, eclampsia, heart disease = CONTRAINDICATED.
• For PPH priority order in MLE: REFER + call for help → massage uterus → give oxytocin → empty bladder → check for tears.

Key Points

• Postpartum hemorrhage (PPH) is the NUMBER ONE direct cause of maternal death in the Philippines — oxytocics are the most critical drugs in the midwife's formulary.
• AMTSL (Active Management of the Third Stage of Labor) has THREE components: (1) Oxytocin 10 IU IM within 1 minute of birth (after ruling out second twin), (2) Controlled cord traction with counter-pressure on the uterus during a contraction, (3) Uterine massage after placenta delivery, then every 15 minutes for 2 hours.
• Oxytocin 10 IU IM is the DRUG OF CHOICE for AMTSL because it is effective AND does NOT raise blood pressure — safe even when BP status is unknown.
• Ergometrine 0.2 mg IM is SECOND-LINE for PPH and is ABSOLUTELY CONTRAINDICATED in hypertension, pre-eclampsia/eclampsia, and heart disease because it causes vasoconstriction and raises BP.
• Misoprostol 600 mcg orally after birth is an accepted AMTSL alternative where there is no cold chain (heat-stable advantage); 800 mcg orally may be used for PPH treatment per DOH/WHO community protocols.
• Priority actions for PPH: REFER, massage uterus, give oxytocin, empty the bladder, check for lacerations/tears.
• Oxytocin for LABOR INDUCTION or AUGMENTATION is a PHYSICIAN ACT — the midwife NEVER gives oxytocin before the baby is born to speed up labor. This can cause uterine rupture and fetal death.

Definitions

Section Title

Oxytocics — The Core of AMTSL

Common Mistakes

• Giving oxytocin BEFORE the baby is born to 'help labor progress' — this is the most dangerous error; it is a physician act and can rupture the uterus.
• Giving ergometrine to a woman with high blood pressure or unknown BP — always check BP history before ergometrine.
• Forgetting to rule out a second twin before giving the uterotonic — giving it with a second baby inside can trap the baby.
• Thinking AMTSL is only the uterotonic injection — it has THREE components; all must be performed.
• Confusing misoprostol doses: 600 mcg for prevention (AMTSL), 800 mcg for treatment (PPH).

Formulas

Exam Tips

• MLE will test: 'Where do you inject Vitamin K in a newborn?' Answer: Anterolateral thigh (vastus lateralis), NOT the deltoid.
• Dose differentiation is frequently tested: ≥1.5 kg = 1 mg; <1.5 kg = 0.5 mg.
• Eye prophylaxis question often asks about the agent — answer: erythromycin 0.5% ophthalmic ointment per DOH protocol.
• Remember the sequence: Unang Yakap steps first (dry, skin-to-skin, delayed cord clamping at 1–3 min, early breastfeeding) → THEN eye ointment and Vitamin K within the first hour.

Key Points

• Every newborn must receive TWO drugs at birth (as part of Unang Yakap/EINC): Vitamin K1 IM and eye prophylaxis.
• Vitamin K1 (phytomenadione) prevents Vitamin K Deficiency Bleeding (VKDB), formerly called hemorrhagic disease of the newborn.
• Vitamin K1 dose: 1 mg IM for term infants (birth weight ≥ 1.5 kg); 0.5 mg IM for preterm or LBW infants (birth weight < 1.5 kg). Injection site: anterolateral thigh (vastus lateralis muscle).
• Eye prophylaxis (Credé's prophylaxis) prevents ophthalmia neonatorum — gonococcal and chlamydial conjunctivitis from maternal genital tract.
• DOH-preferred eye prophylaxis agent: erythromycin 0.5% ophthalmic ointment (thin ribbon in each lower conjunctival sac). Alternative: tetracycline 1% ointment.
• IMPORTANT: Apply eye prophylaxis AFTER the eye-to-eye bonding and skin-to-skin contact. Do NOT irrigate the eyes after applying the ointment.
• Timing: Vitamin K and eye ointment are given within the first hour after birth (after the initial Unang Yakap steps: dry, skin-to-skin, cord clamp at 1–3 minutes, early breastfeeding initiation).

Definitions

Section Title

Newborn Drugs — Vitamin K and Eye Prophylaxis

Common Mistakes

• Giving Vitamin K1 into the deltoid — correct site is the anterolateral thigh (vastus lateralis) in newborns, NOT the arm.
• Using the same dose (1 mg) for preterm/LBW infants — the correct dose for birth weight < 1.5 kg is 0.5 mg.
• Irrigating the eyes after eye ointment — do NOT rinse the eyes; the ointment needs to stay in contact with the conjunctiva.
• Applying eye ointment before skin-to-skin bonding — per Unang Yakap, ointment is applied after bonding and drying steps.
• Confusing silver nitrate (historical) with the current DOH-preferred agent erythromycin 0.5% ophthalmic ointment.

Formulas

Exam Tips

• Memorize the exact dose: 60 mg elemental iron + 400 mcg folic acid ONCE daily.
• High-yield: Vitamin A is SAFE postpartum (200,000 IU) but TERATOGENIC in pregnancy — this distinction is frequently tested.
• Duration of iron supplementation: throughout pregnancy AND 3 months postpartum — the postpartum continuation is often forgotten.

Key Points

• The midwife dispenses iron-folic acid to every pregnant woman as routine antenatal care — this is a core RHU/BHS function.
• Standard DOH dose: 60 mg elemental iron + 400 mcg (0.4 mg) folic acid ONCE DAILY throughout pregnancy and for 3 months postpartum.
• For women with confirmed anemia, the iron dose may be increased to TWICE DAILY under protocol.
• Folic acid's most critical role: prevents neural tube defects (NTDs) — ideally started at least 1 month BEFORE conception, but given throughout pregnancy.
• HIGH-DOSE Vitamin A (≥ 10,000 IU daily) is ABSOLUTELY CONTRAINDICATED during pregnancy — it is teratogenic and can cause fetal malformations.
• Vitamin A postpartum (where current DOH policy allows): 200,000 IU capsule given to the mother within the first weeks after delivery — NOT during pregnancy.
• Counseling point for iron: take on an empty stomach if tolerated (better absorption); Vitamin C-rich foods enhance absorption; tea, coffee, and calcium-rich foods reduce absorption.

Definitions

Section Title

Micronutrient Supplements — Iron, Folic Acid, and Vitamin A

Common Mistakes

• Giving high-dose Vitamin A to a pregnant woman — it is teratogenic; only postpartum women receive the 200,000 IU dose.
• Stopping iron supplementation after delivery — it should continue for 3 months postpartum to replenish stores.
• Confusing folic acid dose: the standard is 400 mcg (0.4 mg), not 4 mg (which is the high-risk dose for women with previous NTD pregnancy — physician-directed).
• Forgetting to counsel on factors that affect iron absorption (enhancers: Vitamin C; inhibitors: tea, coffee, dairy, antacids).

Formulas

Exam Tips

• High-yield MLE: 'Which dose first protects the current pregnancy?' Answer: TT2 (at least 4 weeks after TT1).
• Memorize the protection duration sequence: TT2 = 3 years, TT3 = 5 years, TT4 = 10 years, TT5 = lifetime.
• Dose: always 0.5 mL IM into the deltoid — this exact figure is tested.

Key Points

• The midwife administers Td (tetanus-diphtheria) vaccine to pregnant women to prevent maternal and neonatal tetanus (MNT) — a major cause of preventable neonatal death.
• Dose: 0.5 mL IM into the deltoid muscle.
• Classic TT1–TT5 schedule: TT1 (first contact/as early as possible in pregnancy, no protection yet) → TT2 (≥4 weeks after TT1, ~3 years protection, protects current pregnancy) → TT3 (≥6 months after TT2, ~5 years protection) → TT4 (≥1 year after TT3, ~10 years protection) → TT5 (≥1 year after TT4, lifetime/all childbearing years protection).
• A woman who has completed 5 doses (fully immunized) and her newborn are protected against neonatal tetanus.
• At a minimum, a pregnant woman needs TT2 (at least 4 weeks before delivery) to protect the current pregnancy.
• The midwife screens for vaccination history before giving each dose and records on the mother's health card and FHSIS.

Definitions

Section Title

Immunizing Agents — Tetanus-Diphtheria (Td) Vaccine

Common Mistakes

• Forgetting that TT1 gives NO protection — protection starts with TT2 (at least 4 weeks after TT1). Giving only TT1 does not protect the pregnancy.
• Giving the wrong injection site — Td is given in the DELTOID (upper arm), not the thigh (thigh is for newborn Vitamin K).
• Confusing the dose intervals — TT2: ≥4 weeks; TT3: ≥6 months; TT4 and TT5: ≥1 year each.
• Not screening vaccination history — a woman who already has 2–5 doses does not need to restart the series.

Formulas

Exam Tips

• MLE frequently asks: 'A breastfeeding mother wants contraception — what is appropriate?' Answer: POP or DMPA (progestin-only).
• DMPA dose and interval: 150 mg IM every 3 months — memorize both numbers.
• For COC contraindications, remember the mnemonic ACHES: Abdominal pain (severe), Chest pain, Headache (severe/migraine with aura), Eye changes (vision disturbances), Severe leg pain (thromboembolism) — these are warning signs requiring referral.

Key Points

• The midwife provides contraceptive counseling and supplies the following: COCs (combined oral contraceptives), POPs (progestin-only pills), DMPA injectable, and condoms.
• DMPA (depot medroxyprogesterone acetate): 150 mg IM every 3 months (4×/year). Given by IM injection.
• COCs are avoided in: smokers over 35 years old, uncontrolled hypertension, history of thromboembolism (blood clots), migraine with aura, and liver disease.
• COCs are NOT the first choice for BREASTFEEDING women — estrogen suppresses milk production. Instead, use POPs or DMPA (progestin-only methods are safe during lactation).
• POPs: taken daily without a pill-free interval; must be taken at the same time each day. Safe for breastfeeding women.
• IUD insertion and subdermal implant insertion require specific training/certification beyond basic midwifery — midwife REFERS for these.
• Midwife must counsel on proper use, benefits, side effects, and warning signs for each method.

Definitions

Section Title

Family Planning Drugs Within the Midwife's Scope

Common Mistakes

• Giving COCs to a breastfeeding woman — the estrogen component reduces breast milk; use POPs or DMPA instead.
• Giving COCs to a hypertensive woman or a smoker over 35 — these are contraindications; refer for appropriate method.
• Forgetting that IUD and implant insertion are NOT in the basic midwife's scope without specific additional training/certification.
• Scheduling DMPA injections incorrectly — the interval is every 3 months (13 weeks), not every 2 months.

Formulas

Exam Tips

• This is one of the MOST HEAVILY TESTED topics in MLE pharmacology — memorize every number: 4 g IV, 5 g each buttock (10 g IM), 20% IV, 50% IM, 1 mL 2% lignocaine.
• Three safety signs mnemonic: R-U-K — Respiration (≥12/min), Urine (≥30 mL/hr), Knee-jerk (present). If ANY is absent/low = STOP MgSO4.
• Antidote: Calcium gluconate 1 g (10 mL of 10%) slow IV — know both the drug name AND the dose.
• The MLE may describe a patient with absent knee-jerk or RR of 10 and ask 'What should the midwife do?' Answer: Stop MgSO4, give calcium gluconate 1 g IV.

Key Points

• MgSO4 is the midwife's ONE authorized emergency drug for severe pre-eclampsia and eclampsia — given as the LOADING DOSE before and during URGENT REFERRAL to a higher facility.
• The midwife gives the LOADING DOSE ONLY. The maintenance dose is a physician/hospital responsibility.
• Loading regimen (Pritchard/DOH standard): 4 g MgSO4 (as 20% solution) slow IV over 5–20 minutes, PLUS 5 g MgSO4 (as 50% solution) deep IM into EACH buttock (10 g total IM), each IM dose mixed with 1 mL of 2% lignocaine to reduce injection pain.
• BEFORE each dose and every 4 hours during transport, CHECK the THREE SAFETY SIGNS: (1) Respiratory rate ≥ 12–16 breaths/min, (2) Urine output ≥ 30 mL/hr (or ≥ 100 mL/4 hours), (3) Patellar (knee-jerk) reflex PRESENT.
• MgSO4 TOXICITY signs: respiratory depression (RR < 12), loss of patellar reflex, oliguria — STOP MgSO4 immediately.
• ANTIDOTE for MgSO4 toxicity: Calcium gluconate 1 g (10 mL of 10% solution) slow IV — always have this ready when giving MgSO4.
• After the loading dose: REFER IMMEDIATELY to BEmONC/CEmONC facility — do not delay transport.

Definitions

Section Title

The One Emergency Anticonvulsant — Magnesium Sulfate (MgSO4)

Common Mistakes

• Thinking the midwife gives the MAINTENANCE dose — she gives ONLY the LOADING dose before referral. Maintenance is hospital/physician responsibility.
• Forgetting the THREE safety signs — giving MgSO4 without checking RR, urine output, and patellar reflex is dangerous.
• Not having calcium gluconate ready — it MUST be prepared and accessible whenever MgSO4 is given.
• Confusing the solutions: IV dose uses 20% MgSO4; IM dose uses 50% MgSO4.
• Delaying referral to 'observe the patient' after the loading dose — after MgSO4, IMMEDIATE referral is mandatory.

Exam Tips

• If the MLE asks about oxytocin and the baby is NOT yet born, the answer is almost always REFER — unless the scenario is clearly about AMTSL (after birth) or PPH.
• For antibiotic questions: if the scenario says the midwife is in a remote area and the woman has signs of sepsis, the answer may include 'give pre-referral antibiotic dose AND immediately refer' — not 'prescribe antibiotics for treatment.'
• Anti-hypertensives = PHYSICIAN only — the midwife detects elevated BP, monitors, and REFERS urgently for severe hypertension (≥ 160/110 mmHg).

Key Points

• A midwife REFERS to a physician for any drug that TREATS a disease or manages a complication beyond first-aid stabilization.
• NEVER: Oxytocin or any uterotonic to INDUCE or AUGMENT labor before the baby is born — this is a physician act; incorrect use can cause uterine rupture and fetal death.
• NEVER: Antibiotics for ongoing treatment of infection (a pre-referral first dose under specific protocol is a stabilizing measure, not independent treatment).
• NEVER: General or regional anesthesia (spinal, epidural), or narcotics/controlled analgesics.
• NEVER: Antihypertensives (e.g., hydralazine, nifedipine) — detect high BP and REFER; the midwife does not independently adjust BP medications.
• NEVER: Insulin, anticoagulants (heparin, warfarin), corticosteroids for disease management, or other chronic-disease drugs.
• NEVER: Ergometrine in a known hypertensive woman — this is a drug-specific absolute prohibition.
• Rule of thumb: If you are unsure whether a drug is in the midwife's scope, ask: 'Is this for NORMAL birth support OR prevention of a defined deficiency/infection?' If YES — check the formulary. If NO — the answer is REFER.

Definitions

Section Title

Prohibited Categories — What the Midwife May NOT Give

Common Mistakes

• Thinking the midwife can 'just give a little oxytocin to speed up a slow labor' — this is one of the most dangerous errors in midwifery; it can rupture the uterus.
• Confusing 'pre-referral first-dose antibiotic' (acceptable emergency measure) with ongoing antibiotic treatment (physician responsibility).
• Thinking that because the midwife can give MgSO4 for eclampsia, she can also give antihypertensives — she cannot; MgSO4 is anticonvulsant, not antihypertensive.

Exam Tips

• The 7 Rights are tested in professional practice questions — know all seven.
• Anaphylaxis treatment: Epinephrine (adrenaline) 0.3–0.5 mg IM — this specific dose may be tested.
• Cold chain question: If oxytocin was not refrigerated, it may be degraded — use misoprostol (heat-stable) as an alternative in such settings.

Key Points

• The 7 RIGHTS of medication: Right PATIENT, Right DRUG, Right DOSE, Right ROUTE, Right TIME, Right DOCUMENTATION, Right to REFUSE (client informed consent).
• COLD CHAIN: Vaccines and oxytocin must be stored at 2–8°C. Check cold-chain integrity before every use. If cold chain is broken, the drug may be ineffective (vaccines) or degraded (oxytocin).
• Use STERILE SINGLE-USE needles and syringes for every injection — never reuse.
• CORRECT INJECTION SITES: Deltoid = vaccines (Td) and DMPA; Anterolateral thigh (vastus lateralis) = newborn Vitamin K; Deep IM gluteal = MgSO4 maintenance (hospital); Vastus lateralis or deltoid = oxytocin.
• SHARPS DISPOSAL: All used needles and syringes go directly into a puncture-proof sharps container — never recap needles with two hands.
• Watch for ANAPHYLAXIS after any injection (within 15–30 minutes): flushing, urticaria, difficulty breathing, hypotension. Treatment: epinephrine (adrenaline) 0.3–0.5 mg IM — have it available whenever giving injectable drugs.
• DOCUMENTATION: Record every drug given on the mother's/newborn's health record (MCH book, delivery record) and in the FHSIS registers — medicolegally required.
• Always check EXPIRY DATE and DRUG INTEGRITY before administration.

Definitions

Section Title

Principles of Safe Medication Administration

Common Mistakes

• Recapping needles with two hands — always use the one-hand scoop method or a needle recapper to prevent needlestick injuries.
• Not checking expiry dates — expired drugs may be ineffective or harmful.
• Skipping documentation — incomplete records are a medicolegal risk and compromise continuity of care.
• Not observing the patient for 15–30 minutes after injection for signs of anaphylaxis.