Midwife Licensure Exam Normal Pregnancy, Labor & Postpartum — Prenatal Care & Maternal NutritionRevision Notes

Formulas

Exam Tips

• NLE frequently asks the DOH-recommended minimum number of ANC visits — answer is FOUR (4). If the item references the 2016 WHO model, answer is EIGHT (8).
• Memorise the visit frequency schedule as a pattern: q4wk → q2wk → q1wk (28 then 36 weeks are the two turning points).
• Leopold's Manoeuvres order: 1st manoeuvre = fundal grip (what's in the fundus); 2nd = lateral grip (fetal back); 3rd = Pawlik's grip (presenting part); 4th = pelvic grip (attitude/descent).
• When an NLE item asks 'what is assessed at EVERY prenatal visit?' — the answer includes BP, weight, urine dipstick, fundal height, FHR, and danger-sign review.
• Naegele's Rule calculation is a reliable NLE computation item — practice multiple examples.

Key Points

• The primary goals of ANC are: (1) promote maternal and fetal health, (2) detect and manage complications early, (3) prepare the woman for safe birth, breastfeeding, and newborn care.
• DOH Philippines standard: at least FOUR (4) ANC visits throughout pregnancy.
• WHO 2016 updated model: at least EIGHT (8) contacts for improved perinatal outcomes — expect this to appear in more recent NLE item sets.
• Traditional visit frequency schedule: Every 4 weeks until 28 weeks → every 2 weeks from 28–36 weeks → every week from 36 weeks until delivery.
• High-risk pregnancies (hypertension, GDM, multiple gestation, previous cesarean, prior fetal loss) require more frequent visits.
• The FIRST (booking) visit is the most comprehensive — full history, physical exam, pelvic exam, EDD calculation, and baseline laboratory workup.
• GTPAL is the obstetric history tool: G=Gravida, T=Term births, P=Preterm births, A=Abortions/losses, L=Living children.
• Naegele's Rule for EDD: LMP + 9 months + 7 days (or LMP − 3 months + 7 days + 1 year).
• Every visit must include: weight, blood pressure, urine dipstick (protein + glucose), fundal height, fetal heart rate (FHR: 110–160 bpm), and review of danger signs.
• Fundal height in centimeters approximates gestational age in weeks after 20 weeks (McDonald's rule).
• Leopold's Manoeuvres are performed from 28 weeks onward to assess fetal lie, presentation, and position.
• Fetal kick counts (count-to-ten method) are taught after quickening (~18–20 weeks primiparas; ~16–18 weeks multiparas).
• Screening tests by timing: OGTT for GDM at 24–28 weeks; ultrasound for dating (1st trimester most accurate) and anatomy scan at 18–22 weeks; Group B Streptococcus (GBS) screen at 36–37 weeks.
• Oral glucose tolerance test (OGTT): fasting then 75g glucose load; GDM diagnosed if fasting ≥92 mg/dL, 1hr ≥180 mg/dL, or 2hr ≥153 mg/dL (WHO criteria).

Definitions

Section Title

Goals and Schedule of Antenatal Care (ANC)

Common Mistakes

• Confusing Gravida (total pregnancies) with Para (births after 20 weeks) — a woman pregnant for the 3rd time who had one term birth and one abortion at 16 weeks is G3 T1 P0 A1 L1, NOT simply 'para 1'.
• Applying Naegele's Rule to irregular cycles without adjustment — the rule assumes a 28-day cycle with ovulation on day 14; adjust for longer/shorter cycles.
• Forgetting that FHR 110–160 bpm is normal; values outside this range (bradycardia <110, tachycardia >160) are abnormal and require action.
• Missing that the OGTT for GDM is at 24–28 weeks — not at the first visit.
• Forgetting that fundal height approximation only applies AFTER 20 weeks.

Exam Tips

• The NLE loves to test 'which Td dose protects the newborn?' — answer is always TD2.
• Remember the mnemonic '4-6-1-1' for intervals between doses: Td1→Td2 = 4 weeks; Td2→Td3 = 6 months; Td3→Td4 = 1 year; Td4→Td5 = 1 year.
• Protection durations in order: Td2=3yrs, Td3=5yrs, Td4=10yrs, Td5=lifetime — memorise as 3-5-10-lifetime.
• If an NLE item asks about contraindicated vaccines in pregnancy, the answer is LIVE vaccines (MMR, varicella, oral polio) — NOT inactivated ones.
• Site of administration: DELTOID, IM, 0.5 mL — these three details appear in NLE questions about technique.

Key Points

• Goal: prevent MATERNAL TETANUS and NEONATAL TETANUS (tetanus neonatorum), which is a leading cause of neonatal death in developing countries.
• Vaccine used: Tetanus-Diphtheria (Td) — NOT the old TT (tetanus toxoid); Td provides dual protection.
• Route and dose: 0.5 mL intramuscular (IM), deltoid muscle.
• Td1: Given at the FIRST prenatal contact (as early as possible in pregnancy) — provides NO protection yet.
• Td2: Given at least 4 WEEKS after Td1, AND at least 2 WEEKS before the expected delivery date — this dose PROTECTS the newborn from neonatal tetanus and gives the mother approximately 3 years of protection.
• Td3: Given at least 6 months after Td2 — extends protection to approximately 5 years.
• Td4: Given at least 1 year after Td3 — approximately 10 years of protection.
• Td5: Given at least 1 year after Td4 — LIFETIME protection for the mother.
• A newborn protected by maternal Td immunisation is called a Child Protected at Birth (CPAB).
• Women who have completed prior Td doses (e.g., in school) should continue from where they left off — they do not restart the series.
• Live vaccines (MMR, varicella/chickenpox) are CONTRAINDICATED during pregnancy — they may infect the fetus.
• Inactivated influenza vaccine IS safe during pregnancy and is recommended, especially during flu season.

Definitions

Section Title

Tetanus Immunisation — Philippine Td Schedule

Common Mistakes

• Stating Td1 protects the newborn — it does NOT; only Td2 (and beyond) provides neonatal protection.
• Forgetting the '2 weeks before delivery' requirement for Td2 — adequate time for antibody transfer is needed.
• Confusing the minimum interval: Td1→Td2 is AT LEAST 4 WEEKS; Td2→Td3 is AT LEAST 6 MONTHS; Td3→Td4 is AT LEAST 1 YEAR; Td4→Td5 is AT LEAST 1 YEAR.
• Administering MMR or varicella to a pregnant patient — CONTRAINDICATED; these are live attenuated vaccines.
• Forgetting that the Td series does NOT restart — it continues from the last valid dose received.

Exam Tips

• The NLE formula to memorise: DOH iron supplement = 60 mg elemental iron + 400 mcg folic acid daily.
• The key phrase for folic acid timing is 'before conception' or 'at least 1 month before pregnancy' — NLE items frequently test this.
• When asked about what to AVOID with iron: milk, tea, coffee, antacids — and what HELPS absorption: Vitamin C.
• High-dose Vitamin A = teratogenic — this is a clear NLE distractor; do not confuse with safe doses of Vitamin A.
• RA 8172 (ASIN Law) may appear in items combining maternal nutrition with Philippine public health law.

Key Points

• DOH standard supplementation: 60 mg elemental iron + 400 micrograms (mcg) folic acid DAILY throughout pregnancy, continued postpartum during breastfeeding.
• IRON prevents and treats iron-deficiency anaemia, the most common nutritional deficiency in pregnant Filipino women.
• FOLIC ACID (folate) is critical for neural tube closure — the neural tube closes by approximately WEEK 4 (28 days post-conception), often before the woman knows she is pregnant.
• Folic acid should ideally begin AT LEAST 1 MONTH BEFORE CONCEPTION (preconceptional folate) and continue through at least the first 12 weeks — this is the single most effective prevention for neural tube defects (spina bifida, anencephaly).
• Iron absorption is ENHANCED by Vitamin C (ascorbic acid) — teach patient to take iron with citrus juice (calamansi, dalandan).
• Iron absorption is INHIBITED by: milk, tea, coffee, antacids, calcium supplements — do NOT take these together with iron.
• Ideally, iron is taken on an empty stomach; if GI upset occurs, take with a small amount of food (NOT the inhibitors listed above).
• Expected side effects of iron: DARK/BLACK STOOLS (harmless — explain to patient to prevent alarm); constipation; nausea.
• Manage iron-related constipation: increase dietary fibre (vegetables, fruits), increase fluid intake, and encourage moderate activity.
• CALCIUM: supports fetal skeletal development and may reduce pre-eclampsia risk in populations with low dietary calcium intake (DOH/WHO recommendation for supplementation where dietary intake is insufficient).
• IODINE: essential for fetal thyroid function and brain development; addressed in the Philippines by the ASIN Law (RA 8172, Iodine Deficiency Disorders Prevention Act) which mandates iodisation of salt.
• VITAMIN A: necessary for fetal development, but HIGH-DOSE (megadose) Vitamin A is TERATOGENIC — can cause fetal malformations. Do not exceed recommended daily allowance. Isotretinoin (Vitamin A derivative for acne) is absolutely contraindicated in pregnancy (Category X).
• Iron tablets/syrup must be stored safely out of reach of children — accidental iron overdose is a paediatric emergency.

Definitions

Section Title

Prenatal Supplements — Iron, Folic Acid, and Others

Common Mistakes

• Advising the patient to start folic acid only AFTER confirming pregnancy — the neural tube is already closed by this point; preconceptional start is essential.
• Telling patients to take iron WITH milk — milk (calcium) INHIBITS iron absorption.
• Alarming the patient about dark stools from iron — this is NORMAL and harmless; failure to explain this leads to non-compliance.
• Recommending high-dose Vitamin A supplements — teratogenic at megadoses; stay within RDA.
• Forgetting that iodine deficiency in pregnancy causes CRETINISM (irreversible intellectual disability in the child) — not just maternal goitre.

Formulas

Exam Tips

• Memorise the IOM weight gain table by BMI category — NLE items frequently give a BMI and ask for the correct weight gain range.
• The simplified extra calorie teaching is +300 kcal/day (classic NLE answer); more detailed options list +340 kcal (2nd trimester) and +450 kcal (3rd trimester).
• Malunggay is your go-to Philippine food example for iron, vitamins, and lactation support — cite it whenever local food sources are asked.
• 'No safe amount of alcohol in pregnancy' = absolute contraindication (FAS is the reason).
• Caffeine limit is ≤200 mg/day — remember this specific number for NLE computation or selection items.

Key Points

• Good maternal nutrition is the foundation of fetal growth, prevention of low birth weight (LBW <2,500g), and preparation for lactation.
• Weight gain recommendations depend on pre-pregnancy BMI (Institute of Medicine / IOM guidelines): Underweight (<18.5) = 12.5–18 kg; Normal (18.5–24.9) = 11.5–16 kg; Overweight (25–29.9) = 7–11.5 kg; Obese (≥30) = 5–9 kg.
• Pattern of weight gain (normal BMI): approximately 1–2 kg in the first trimester; then approximately 0.4 kg per week in the second and third trimesters.
• SUDDEN, EXCESSIVE weight gain accompanied by oedema (especially of face and hands) is a WARNING SIGN for pre-eclampsia — do not dismiss as 'eating more.'
• Extra caloric needs: +300 kcal/day (simplified NLE teaching); more precisely +340 kcal/day in the 2nd trimester and +450 kcal/day in the 3rd trimester. The 1st trimester requires minimal extra calories.
• Extra protein: approximately +25 g/day above pre-pregnancy needs for fetal and placental growth. Sources: isda (fish), itlog (eggs), manok (poultry), monggo (mung beans), tofu, gatas (milk).
• Key micronutrients and Philippine food sources: Iron → malunggay, kangkong, meat, fish, monggo; Folate → dark green leafy vegetables, legumes, citrus; Calcium → gatas (milk), dilis (small fish eaten whole with bones), tofu, dark greens; Iodine → iodised salt, seafood; Vitamin C → calamansi, guava, tomatoes.
• MALUNGGAY (Moringa oleifera) is a culturally significant, affordable, iron- and vitamin-rich Philippine superfood that also supports breast milk production — nurses should actively promote its use.
• Substances to AVOID: Alcohol (no safe amount — causes Fetal Alcohol Syndrome/FAS); Smoking and secondhand smoke (causes LBW, IUGR, prematurity); Caffeine (limit to ≤200 mg/day = approximately 1–2 cups of coffee); High-mercury fish (tuna, shark, swordfish in large amounts); Raw/undercooked meat, fish, eggs (Listeria, Toxoplasma risk); Unpasteurised dairy products.
• PICA (craving and eating non-food items: clay, ice, soil/lupa) may indicate iron deficiency — assess and counsel; refer for further evaluation.
• Nausea management (first trimester): small, frequent meals; dry crackers or toast before rising (before getting out of bed); avoid strong odours; eat cold foods (less odour); ginger tea may help.
• Constipation management: increase dietary fibre (vegetables, fruits, legumes), increase fluid intake (at least 8 glasses water/day), encourage walking; constipation is worsened by iron supplements.
• Adolescent pregnancies and pregnancies spaced less than 2 years apart carry higher nutritional risk — require extra assessment and support.

Definitions

Section Title

Maternal Nutrition During Pregnancy

Common Mistakes

• Telling ALL pregnant women to gain the same amount of weight regardless of pre-pregnancy BMI — weight gain goals are individualised by BMI.
• Dismissing sudden, rapid weight gain with oedema as 'normal pregnancy swelling' — this is a pre-eclampsia red flag requiring immediate BP and urine protein assessment.
• Advising the patient that she should 'eat for two' and double calorie intake — extra need is only about 300–450 kcal/day, NOT double intake.
• Overlooking pica as a cultural habit without assessing for underlying iron deficiency.
• Forgetting that caffeine restriction (not elimination) is the recommendation — ≤200 mg/day, NOT complete avoidance of all caffeine.

Exam Tips

• Pre-eclampsia triad on NLE: BP ≥140/90 + proteinuria + oedema (after 20 weeks). The 'after 20 weeks' qualifier distinguishes it from chronic hypertension.
• RhoGAM: given to Rh-NEGATIVE mother, at 28 WEEKS prenatally, and within 72 HOURS after delivery — memorise these three time points.
• HBsAg-positive mother's baby: HBV vaccine + HBIg within 12 HOURS of birth — the 12-hour window is NLE-testable.
• GDM complication to remember: macrosomia → neonatal hypoglycaemia is the classic chain tested on the NLE.
• GBS screen at 36–37 weeks → intrapartum IV penicillin — the timing and treatment route are both tested.

Key Points

• ANAEMIA: Screened by haemoglobin at booking visit and in the third trimester. Hgb <11 g/dL (1st and 3rd trimester) or <10.5 g/dL (2nd trimester) = anaemia. Managed with iron-folic acid supplements, dietary counselling, and if severe, referral for further work-up or blood transfusion.
• GESTATIONAL HYPERTENSION: BP ≥140/90 mmHg after 20 weeks gestation WITHOUT proteinuria. Detected by every-visit BP monitoring.
• PRE-ECLAMPSIA: BP ≥140/90 mmHg after 20 weeks PLUS proteinuria (≥300 mg/24hr or 1+ on dipstick). Severe features: BP ≥160/110, severe headache, visual disturbances (blurring, scotoma), epigastric/right upper quadrant pain, thrombocytopenia, impaired liver function, renal insufficiency. Every-visit BP and urine protein dipstick are the front-line screen.
• Danger signs of pre-eclampsia to teach every visit: SEVERE HEADACHE, VISUAL CHANGES (blurring, seeing spots), EPIGASTRIC PAIN, FACIAL/HAND SWELLING (puffiness), rapidly increasing oedema.
• ECLAMPSIA = pre-eclampsia + convulsions/seizures — a true obstetric emergency requiring MgSO4 and delivery.
• GESTATIONAL DIABETES MELLITUS (GDM): Screened with OGTT at 24–28 weeks. Risk factors: obesity, family history, previous GDM, previous macrosomic baby (>4 kg), glucosuria on dipstick. Complications: macrosomia, shoulder dystocia, neonatal hypoglycaemia, increased C-section risk.
• UTI / ASYMPTOMATIC BACTERIURIA: Screened with urinalysis and urine culture. Must be treated in pregnancy to prevent ascending infection → pyelonephritis → preterm labour. A urine dipstick showing nitrites and leukocytes suggests infection.
• SYPHILIS (VDRL/RPR): Screened at booking visit; active syphilis treated with penicillin to prevent congenital syphilis (stillbirth, neonatal syphilis with rash, hepatosplenomegaly, bone abnormalities).
• HIV: Screened at booking; PMTCT (Prevention of Mother-to-Child Transmission) program provides antiretroviral therapy, safer delivery planning, and infant prophylaxis.
• HEPATITIS B (HBsAg): Screened at booking; HBsAg-positive mothers' babies receive Hepatitis B vaccine + HBIg (Hepatitis B immune globulin) within 12 hours of birth.
• RH INCOMPATIBILITY: Rh-negative mothers carrying Rh-positive fetuses can develop anti-D antibodies → haemolytic disease of the newborn (HDN) in subsequent pregnancies. Prevention: Anti-D immunoglobulin (RhoGAM) 300 mcg IM at approximately 28 weeks (prophylactic) AND within 72 hours after delivery of an Rh-positive baby.
• Indications for anti-D immunoglobulin beyond delivery: also given after miscarriage, abortion, ectopic pregnancy, amniocentesis, or abdominal trauma in Rh-negative women.
• GROUP B STREPTOCOCCUS (GBS): Screened by vaginal-rectal swab at 36–37 weeks; GBS-positive women receive intrapartum IV penicillin to prevent early-onset neonatal GBS sepsis.
• ABNORMAL FETAL GROWTH: Fundal height deviations ≥3 cm from expected → ultrasound for IUGR (small for gestational age) or macrosomia (large for gestational age).

Definitions

Section Title

Common Conditions Screened in Prenatal Care

Common Mistakes

• Confusing gestational hypertension (no proteinuria) with pre-eclampsia (hypertension + proteinuria ± symptoms) — the presence of proteinuria distinguishes them.
• Forgetting that anti-D immunoglobulin (RhoGAM) is given to Rh-NEGATIVE mothers, NOT Rh-positive — and only if the BABY is (or may be) Rh-positive.
• Missing the 72-hour window for postpartum RhoGAM administration — after 72 hours, effectiveness decreases significantly.
• Forgetting that asymptomatic bacteriuria in pregnancy MUST be treated — unlike in non-pregnant adults where monitoring may be acceptable.
• Stating that GDM is screened at the first visit — it is screened at 24–28 WEEKS (unless high-risk factors warrant earlier screening).

Exam Tips

• The MOST IMPORTANT prenatal health teaching according to NLE rationale is always DANGER SIGN RECOGNITION — it has the highest impact on maternal survival.
• Left lateral position = best position for pregnant women at rest (improves placental blood flow, prevents supine hypotension) — this appears repeatedly in NLE items.
• For immunisation in pregnancy NLE items: always select Td and inactivated influenza as SAFE; always select MMR and varicella as CONTRAINDICATED.
• Seatbelt positioning is a frequently missed health teaching point on the NLE — lap belt BELOW the belly, not across it.
• Exclusive breastfeeding = 6 months — this number appears in DOH, WHO, and NLE consistently; do not confuse with 'continued breastfeeding up to 2 years.'

Key Points

• DANGER SIGNS — the nurse must reinforce these at EVERY single prenatal visit because timely reporting saves lives. Danger signs include: vaginal bleeding; leaking or gush of fluid (ROM); severe headache; visual changes (blurring, scotoma, flashing lights); swelling of face, hands, and feet (sudden); epigastric pain (right upper quadrant); fever with chills; painful urination (UTI/pyelonephritis risk); decreased or absent fetal movement; preterm contractions before 37 weeks; convulsions.
• ACTIVITY AND REST: Moderate exercise (walking 30 minutes most days) is beneficial for circulation, mood, and weight management. Left-lateral position during rest improves placental perfusion (relieves compression of the inferior vena cava by the gravid uterus) and prevents supine hypotensive syndrome. Avoid overheating (saunas, hot baths), contact sports, and activities with risk of falls or abdominal trauma.
• SUPINE HYPOTENSIVE SYNDROME (Aortocaval Compression Syndrome): occurs when the gravid uterus compresses the inferior vena cava in the supine position → reduced venous return → maternal hypotension → fetal distress. Intervention: TURN TO LEFT LATERAL POSITION.
• SEXUALITY: Sexual intercourse is generally SAFE in uncomplicated pregnancy. Contraindicated if: vaginal bleeding, placenta previa, premature rupture of membranes (PROM), or risk of preterm labour.
• SUBSTANCE AND MEDICATION SAFETY: No alcohol (FAS); no smoking (LBW, prematurity); caffeine ≤200 mg/day; no unprescribed medications or herbal supplements without provider approval; avoid NSAIDs especially in the 3rd trimester (risk of premature closure of ductus arteriosus).
• IMMUNISATION DURING PREGNANCY: SAFE = Td (tetanus-diphtheria), inactivated influenza, Hepatitis B. CONTRAINDICATED = MMR, varicella (chickenpox), oral polio — all live/live-attenuated vaccines.
• ORAL HEALTH: Dental check-up and treatment (including extractions with local anaesthesia) are safe during pregnancy. Hormonal changes cause pregnancy gingivitis (increased gum bleeding and inflammation) — reinforce brushing and flossing. Periodontal disease is associated with preterm birth.
• SEATBELT USE: Lap belt positioned BELOW the belly (across hips/pubic area), shoulder strap BETWEEN the breasts and to the side of the belly — never across the abdomen.
• PREPARATION FOR BIRTH: Encourage facility-based delivery (hospital or lying-in clinic with skilled birth attendant), birth plan discussion, recognition of true vs. false labour, when to go to the hospital (5-1-1 rule: contractions every 5 minutes, lasting 1 minute, for 1 hour).
• BREASTFEEDING: Promote EXCLUSIVE BREASTFEEDING for the first 6 MONTHS of life per DOH and WHO policy. Antenatal breast examination (assess for inverted nipples, flat nipples) and nipple preparation counselling; breast milk is the gold standard for infant nutrition and immunity.
• NEWBORN CARE PREPARATION: Essential newborn care (ENC) protocol — immediate drying, skin-to-skin contact, delayed cord clamping (at least 1–3 minutes), early breastfeeding initiation within 1 hour of birth, vitamin K injection, eye prophylaxis, newborn screening.
• SOCIAL DETERMINANTS: Screen for intimate partner violence (IPV), financial stress, housing, and support systems at every visit; connect to DOH programs (Philhealth, DSWD, 4Ps/Pantawid Pamilyang Pilipino Program) and refer to social work as needed.
• NURSE'S ROLE under RA 9173: Nurses are legally mandated to provide health education, conduct assessments, implement care plans, make referrals, and collaborate with the interprofessional team. Continuity of care across prenatal visits is key — missed appointments are a social risk red flag requiring outreach.

Definitions

Section Title

Health Teaching Across Pregnancy and Nursing Priorities

Common Mistakes

• Teaching danger signs only at the first visit — they must be reviewed EVERY visit because women forget and situations change.
• Telling a patient with placenta previa that sexual intercourse is fine — pelvic activity is contraindicated with placenta previa.
• Positioning a pregnant patient flat on her back during examination without wedging or tilting to the left — always tilt 15–30 degrees to the left to avoid supine hypotension.
• Forgetting to assess for intimate partner violence (IPV) — the prenatal period is a critical window for detection and intervention.
• Not explaining the 5-1-1 rule for hospital admission in labour, leading to the patient arriving too early or too late.