Midwife Licensure Exam The Midwife's Public Health Service Delivery — BEmONC and MNCHN from the Midwife's RoleStudy Notes

The Maternal, Newborn, Child Health and Nutrition (MNCHN) Strategy is formalized under Department of Health Administrative Order 2008-0029 and is the DOH's flagship approach to rapidly reduce maternal and neonatal deaths in the Philippines. The strategy is built on a simple yet powerful principle: most maternal and newborn deaths are caused by a predictable, small set of complications that are treatable if a skilled provider and a functioning facility are available at the critical moment. The MNCHN approach has two core pillars: (1) define a comprehensive package of evidence-based services that follow a woman and child across the entire reproductive continuum—from pre-pregnancy through adulthood; and (2) organize health facilities into a linked network (the Service Delivery Network, or SDN) so that no woman is left without an escalation path when complications occur. The MNCHN service packages are organized chronologically: **Pre-Pregnancy Services** aim to prepare a woman before she becomes pregnant. These include family planning counseling and contraceptive services (to support healthy timing and spacing of pregnancy), folic acid supplementation (to prevent neural tube defects), nutrition and iron counseling, screening and management of anemia, identification and treatment of reproductive tract infections, and health education on healthy lifestyles. A woman with well-planned pregnancies and good nutritional status starts pregnancy at lower risk. **Pregnancy (Prenatal) Services** are the first encounter point for most women in the community. At minimum, a pregnant woman should receive four antenatal care (ANC) visits—one in each trimester and one in the third trimester. At each visit, the midwife screens for danger signs (vaginal bleeding, severe headache, severe abdominal pain, edema, and visual disturbances), measures blood pressure and dipstick urine, gives tetanus toxoid or Td (tetanus-diphtheria) immunization if needed, provides iron-folic acid and calcium supplementation, counsels on nutrition and danger signs, and helps develop a birth plan. The birth plan names the facility where the woman will deliver, identifies her escort, and discusses transport and financing in advance. Recognizing and referring complications like pre-eclampsia, anemia, and infection at this stage prevents emergency situations during labor. **Childbirth (Intrapartum) Services** center on facility-based delivery with a skilled birth attendant. The birth setting must be a BEmONC-capable facility available 24/7. During labor, the midwife conducts essential intrapartum care, monitors for complications, and performs AMTSL at the third stage to prevent postpartum hemorrhage. Newborns receive immediate care including drying, skin-to-skin contact, delayed cord clamping, and early breastfeeding (Unang Yakap). Any complication detected—maternal convulsions, severe bleeding, obstructed labor, or non-breathing newborn—triggers immediate referral to CEmONC. **Postpartum and Newborn Services** continue within 24 hours and then within 7 days of delivery. The midwife checks the mother for postpartum hemorrhage, infection, or eclampsia, monitors breastfeeding, screens the newborn for infection and jaundice, gives vitamin K and eye prophylaxis, performs early immunizations (BCG, hepatitis B), and counsels on danger signs for both mother and baby. Postpartum family planning is discussed before the woman leaves the facility. **Child Care Services** extend the continuum through the first five years of life, with immunizations, growth monitoring, and management of childhood illness. A central and non-negotiable MNCHN policy is **facility-based delivery with a skilled birth attendant**. Home births, even those attended by traditional birth attendants (*hilots*), are actively discouraged because life-threatening emergencies like postpartum hemorrhage can kill within minutes to hours, and a home has no drugs, no transport, and no escalation route. The midwife's prenatal role includes educating every pregnant woman and her family about the benefits of institutional delivery and systematically enrolling her in a named BEmONC facility. The success of MNCHN depends on the midwife at the Barangay Health Station acting as the sentinel and gateway—identifying risks early, preventing complications through good prenatal care, and decisively referring when danger appears. When MNCHN is working, mothers and babies reach safe care in time.

Emergency Obstetric and Newborn Care (EmONC) is measured not by the size of the facility or the degrees on the wall, but by concrete, life-saving interventions that the facility can actually perform, right now, 24 hours a day. These interventions are called **signal functions**. A **Basic Emergency Obstetric and Newborn Care (BEmONC)** facility must be able to deliver seven signal functions: **1. Administer Parenteral (Intravenous or Intramuscular) Antibiotics** Abiotics like ampicillin, ceftriaxone, or gentamicin are essential for maternal sepsis, chorioamnionitis (infection of the amniotic fluid membranes), prolonged rupture of membranes (>18 hours), and postoperative infection. A midwife in a BEmONC setting is trained to give the initial parenteral antibiotic dose and continue administration per protocol while the patient is prepared for referral if needed. Sepsis can progress to septic shock and maternal death within hours if untreated. **2. Administer Parenteral Oxytocic (Uterotonic) Drugs** Oxytocin (Pitocin) given intravenously or intramuscularly causes the uterus to contract strongly and regularly. It is used for two purposes: (a) to prevent postpartum hemorrhage (PPH) by triggering uterine contraction that compresses bleeding vessels after the placenta detaches, and (b) to treat postpartum hemorrhage once it occurs. A trained midwife under RA 7392 is explicitly authorized to give oxytocin. In BEmONC, oxytocin is part of AMTSL (see below). **3. Administer Parenteral Anticonvulsants (Magnesium Sulfate)** Magnesium sulfate (MgSO4) is the drug of choice for severe pre-eclampsia and eclampsia. When a pregnant woman convulses or shows signs of severe pre-eclampsia (severe headache, vision changes, epigastric pain, usually with very high blood pressure and proteinuria), MgSO4 is given immediately—typically a 4-gram IV loading dose over 5–20 minutes—to stop seizures and prevent further ones. A trained midwife is authorized to give the loading dose as a stabilizing, life-saving action before and during referral to CEmONC for definitive management (delivery). MgSO4 is the single most important drug in obstetrics for preventing maternal death from eclampsia. **4. Perform Manual Removal of the Placenta** When the placenta does not separate and deliver spontaneously within 30 minutes of the baby's birth (retained placenta), or if there is severe hemorrhage and the placenta must be removed immediately, a trained provider performs manual removal of the placenta (MRPO). The provider's gloved hand enters the uterus, locates the placental edge, gently separates it from the uterine wall, and withdraws it. This is typically a midwife or doctor in BEmONC. After MRPO, the uterus is massaged and oxytocin is given to contract it and control bleeding. **5. Perform Removal of Retained Products of Conception** When abortion (either spontaneous miscarriage or induced) leaves products of conception (fetal tissue, placental fragments, or blood clots) in the uterus, they cause infection and hemorrhage. Removal is done by manual vacuum aspiration (MVA), in which a hand-held syringe with a suction cannula evacuates the contents. MVA can be performed by trained midwives or doctors in BEmONC. (Note: In the Philippine context, MVA is restricted by law and regulation; midwives trained in MVA perform it under clear, documented protocols and only for post-abortion care, not for induced termination of pregnancy.) **6. Perform Assisted Vaginal Delivery** When labor stalls or the fetus is in distress and vaginal delivery can be accomplished quickly, the provider may perform vacuum extraction (using a soft cup placed on the fetal head and gentle traction as the mother pushes) to shorten the second stage and deliver the baby vaginally rather than having to resort to emergency cesarean section. Vacuum extraction is a skilled procedure performed in BEmONC by an appropriately trained provider (often a doctor or a senior midwife with additional training). It requires careful selection—the cervix must be fully dilated, the membranes ruptured, the head low in the pelvis, and there must be a clear indication. Improper vacuum application can cause scalp trauma and cephalohematoma in the newborn. **7. Perform Basic Newborn Resuscitation** When a newborn is born limp, apneic, or with a very low heart rate, immediate resuscitation is performed using the standard ABC (Airway, Breathing, Circulation) approach: clear the airway if needed, provide bag-and-mask ventilation at 40–60 breaths per minute, and perform chest compressions if the heart rate remains below 100 bpm. Every midwife is trained in newborn resuscitation. In BEmONC, oxygen, a bag-and-mask system, and trained personnel are always available. The ability to resuscitate newborns is non-negotiable—a non-breathing baby left unattended is a dead baby within minutes. These seven signal functions define the minimum capability of a BEmONC facility. In the Philippines, a BEmONC facility is typically an upgraded Rural Health Unit (RHU), a birthing home certified as BEmONC-capable, or a municipal hospital. It operates 24/7 and is staffed by a team: a physician (ideally), a nurse, and a midwife. The DOH standard aims for approximately one BEmONC facility per 125,000 population, ensuring that no woman in labor is more than 2 hours' transport from emergency obstetric care. A **Comprehensive Emergency Obstetric and Newborn Care (CEmONC)** facility performs all seven basic functions plus two additional ones: **8. Perform Cesarean Section (Surgical Delivery)** When vaginal delivery is impossible, contraindicated, or too risky, the fetus is delivered through a surgical incision in the lower uterus. Common indications are cephalopelvic disproportion (the baby's head is too large for the mother's pelvis), placenta previa (placenta covering the cervix), abruption placentae (placenta separates prematurely), fetal distress that cannot be resolved vaginally, cord prolapse, and failed induction or augmentation of labor. Cesarean section is performed by a surgeon (obstetrician or general surgeon) in an operating theatre with anesthesia, and it is the definitive rescue for obstructed labor and many other emergencies. The midwife's role at cesarean is preparation, support, and postoperative monitoring; the surgery itself is the surgeon's scope. **9. Perform Blood Transfusion** When severe hemorrhage or anemia requires replacement of blood volume and oxygen-carrying capacity, transfusion of typed and cross-matched whole blood or blood products is given. CEmONC facilities have blood banks or access to blood products, trained personnel for safe transfusion, and the ability to manage transfusion reactions. Transfusion may be lifesaving in massive postpartum hemorrhage, uterine rupture with hemorrhage, or severe anemia with cardiac compromise. These nine signal functions (7 basic + 2 comprehensive) define the gap between what a midwife and the RHU team can do, and what requires a hospital. The phrase "7 basic + 2 = 9 comprehensive" is a high-yield MLE fact. **The Midwife's Scope Within BEmONC** Under Republic Act 7392 (the Philippine Midwifery Act) and DOH-approved protocols, a midwife working in BEmONC has direct responsibility for: • Administering the **first dose of parenteral oxytocin** (10 IU IM) as part of AMTSL to prevent and treat postpartum hemorrhage. • Administering the **loading dose of magnesium sulfate** (4 g IV) for a woman in convulsions or with severe pre-eclampsia, as a stabilizing action before referral to CEmONC. • Administering the **initial parenteral antibiotic** (e.g., ceftriaxone 1 g IM) for sepsis, chorioamnionitis, or prolonged rupture of membranes. • Performing **newborn resuscitation** with bag and mask, and continuing resuscitation measures. • Performing **manual removal of the placenta** (MRPO) when retained, as a stabilizing measure, especially in settings where a physician is not immediately available. (Some older protocols required physician presence; current DOH training supports trained midwife MRPO under supervision and with clear protocols.) • Performing **bimanual uterine compression** to control hemorrhage temporarily while oxytocin is given and transfer is arranged. • Performing **AMTSL** (see next section) at every single birth—this is the midwife's non-negotiable responsibility. Procedures beyond the midwife's independent scope include MVA in complex cases, vacuum extraction (which many RHUs delegate to trained providers, but remains a procedural skill requiring additional training), and anything requiring surgery or blood transfusion. When a midwife recognizes that a patient needs cesarean section or transfusion, the referral is initiated immediately, and the midwife's role becomes stabilization and accompaniment.

Postpartum hemorrhage (PPH) is the leading cause of maternal death worldwide and in the Philippines. It occurs when the uterus fails to contract after the placenta is delivered, leaving blood vessels open and bleeding uncontrolled. A woman can lose 500 mL of blood in minutes and 1000 mL (fatal) in an hour. There is no time for diagnosis and debate—action must be immediate. **Active Management of the Third Stage of Labor (AMTSL)** is the single most important and evidence-proven intervention to prevent and treat postpartum hemorrhage. It is *not* optional or contingent on risk factors; it is performed at *every* birth by the midwife. AMTSL has three essential steps, performed in strict sequence: **Step 1: Give Oxytocin 10 IU Intramuscularly (IM) Within One Minute of the Baby's Birth** As soon as the baby is born and breathing, and *after you have ruled out a second baby by palpating the abdomen and listening for a second heartbeat*, you give oxytocin 10 IU IM (intramuscular injection). Oxytocin causes the uterus to contract strongly and tetanically (sustained contraction), compressing the blood vessels that were feeding the placenta and stopping bleeding before it starts. The 10 IU dose is standard in the Philippines; some guidelines use 5–10 IU, but 10 IU is the common Philippine protocol. The injection is given *immediately* to the mother (not the baby—a common exam mistake). Why IM and not IV? Because IM oxytocin acts more slowly (2–3 minutes) but sustains the contraction for 30+ minutes, whereas IV oxytocin acts rapidly (seconds) but the effect wanes. For *prevention* of PPH, IM is preferred. (IV oxytocin is used in emergencies when rapid effect is needed, such as treating hemorrhage that has already started.) Why one minute? Because the third stage—the time from baby's birth to placental delivery—is the window when PPH risk is highest. The window is open for only 30 minutes normally; oxytocin must be on board immediately. Why *not* if there is a second baby? Because if an unsuspected twin is present and you give oxytocin before it is born, the uterus contracts and traps the second baby inside, creating an obstetric emergency. Always palpate the abdomen and listen for a second fetal heart before giving oxytocin in cases where multiples are even remotely possible. **Step 2: Deliver the Placenta by Controlled Cord Traction With Counter-Traction on the Uterus** Once oxytocin is given and the uterus is contracting, you wait for signs that the placenta has separated: (a) a gush of blood from the vagina, (b) the cord lengthens (the placenta descends in the uterus), or (c) the uterus becomes more globular/firm and rises in the abdomen. When you see these signs, you perform **controlled cord traction** (CCT): you hold the umbilical cord gently and apply steady, downward traction, while your other hand applies **counter-traction** by pressing upward on the uterus just above the pubic bone (suprapubic pressure). This prevents uterine inversion—the uterus turning inside-out, a rare but catastrophic complication. The placenta is gently extracted. The procedure should take 5–10 minutes. If the placenta does not deliver within 30 minutes despite oxytocin and CCT, it is retained, and you must perform manual removal of the placenta (MRPO) or refer for it. **Step 3: Perform Uterine Massage Immediately After Placental Delivery, Then Monitor Uterine Tone** Once the placenta is out, you immediately place your hand on the lower abdomen over the uterus and perform circular massage—rubbing the uterus through the abdominal wall—to stimulate further contraction. The uterus should feel hard and firm (like a grapefruit), not boggy or soft. If it is soft (atonic), massage continues, oxytocin infusion (if IV access exists) is started, and you check for causes of atony: a full bladder (which prevents contraction), retained products, or uterine rupture. In the first 2 hours postpartum, you repeat abdominal palpation every 15 minutes to ensure the uterus stays contracted. If the uterus becomes soft again (losing tone), you massage and recheck. Bleeding is measured and recorded. **The Timing and Sequence Are Non-Negotiable** AMTSL must be performed in this exact order: oxytocin first, then CCT and placental delivery, then uterine massage. Deviations invite disaster. For example, if you perform CCT before giving oxytocin, the uterus may not be contracting, and you pull hard and invert it. If you forget oxytocin and rely only on massage, bleeding may not be controlled. If you are careless with CCT and don't use counter-traction, inversion occurs. **AMTSL in Normal and High-Risk Births** AMTSL is standard at every birth—normal primigravida, multipara, high parity, previous PPH, anemia, or any other factor. There is no exception. Some older or alternative protocols suggest reserving it for women at high risk of PPH, but the evidence is clear: AMTSL reduces PPH by ~60% and should be universal because PPH is unpredictable and can kill any woman. Moreover, the procedure is safe and beneficial; there is no downside to giving it universally. **Common Exam Questions on AMTSL** - *When is oxytocin given?* **Within one minute of baby's birth, after ruling out twins.** - *What dose?* **10 IU IM (or 5–10 IU, but 10 IU is most common in Philippines).** - *What is the purpose of counter-traction?* **To prevent uterine inversion while applying cord traction.** - *If the placenta doesn't deliver in 30 minutes, what do you do?* **Perform manual removal of the placenta (MRPO) or refer to CEmONC.** - *What does a contracted uterus feel like?* **Hard and firm (like a grapefruit), not boggy or doughy.** - *Why IM and not IV for prevention?* **IM acts slower but sustains contraction longer; IV is rapid but short-acting, reserved for treating PPH already occurring.**

Essential Intrapartum and Newborn Care (EINC), known in the Philippines as **Unang Yakap** ("First Embrace"), is a standardized, evidence-based protocol of four sequential, time-bound interventions performed at every birth to ensure the newborn's immediate safety, warmth, feeding, and bonding with the mother. These interventions are simple, require no expensive equipment, and are within the midwife's scope everywhere—even in a home setting (though institutional delivery is preferred). Unang Yakap is as important to your practice as AMTSL is to preventing maternal hemorrhage. The protocol follows the newborn's first critical minutes of life and is grounded in physiology: a newborn born wet and exposed loses heat rapidly and can become hypothermic in minutes, hypothermia impairs breathing and feeding, and separation from the mother delays breastfeeding and bonding. Unang Yakap corrects all of these by simple, sequential actions. **Step 1: Immediate and Thorough Drying (First 30 Seconds)** The moment the baby is born, you immediately dry the entire body (head, trunk, limbs) with a pre-warmed, clean, dry cloth or towel. This drying must be done **thoroughly and briskly**—not gently, but with firm, repeated strokes, especially on the head and trunk. Drying serves two critical purposes: 1. **Stimulates breathing**: The tactile stimulation of rapid drying activates the newborn's respiratory reflex, triggering the first breath. A baby submerged in amniotic fluid is not breathing; drying gets the baby gasping and crying. 2. **Prevents hypothermia**: Evaporation of amniotic fluid from wet skin causes rapid heat loss. A wet newborn can lose 0.2°C of body temperature per minute. Within 10 minutes, a wet baby in an air-conditioned room can drop from 37°C to 35°C (hypothermia), which impairs metabolism, breathing, and feeding. Drying prevents this. The cloth used must be pre-warmed (placed in the sun, a warm room, or even under the mother's clothing before birth) and must be discarded after drying; it should not be reused as a blanket, because it is now damp and will cool the baby further. Note: Do not put the baby in a bath or expose the baby to water; Unang Yakap does not involve bathing. Drying only. **Step 2: Early Skin-to-Skin Contact (Immediate, Within 1 Minute of Birth)** Immediately after drying, the baby (still wet from delivery, but now dried) is placed **prone (belly-down) on the mother's bare chest or abdomen**, with the baby's skin touching the mother's skin. The mother's warm body acts as an incubator, maintaining the baby's temperature. This is called **skin-to-skin contact** or **kangaroo care**. Why prone and not supine? Because a prone baby, with its mouth at the level of the mother's breast and body pressed against her, is in the optimal position for finding the breast and beginning to suckle. A supine (face-up) baby is farther from the breast and less likely to feed early. Skin-to-skin contact provides: - **Continued warmth** from the mother's body (thermoregulation). - **Stimulation for feeding**: The baby smells the mother's skin and breast, hears her heartbeat, and is positioned to self-attach and suckle. - **Bonding and olfactory imprinting**: The baby learns the mother's scent; the mother sees and touches her baby; the release of oxytocin in both facilitates bonding and helps the mother's uterus contract. - **Reduced stress**: The baby's heart rate, breathing, and glucose metabolism stabilize. For skin-to-skin to work, the baby must be dry and the mother must not be draped with wet cloths or blankets. If ambient temperature is very cold, a dry blanket can be placed *over* the baby and mother together (keeping skin contact intact underneath), but the baby itself must be dry. **Step 3: Properly Timed Cord Clamping—After Cord Pulsations Stop (1–3 Minutes, Usually)** The umbilical cord continues to pulse and deliver blood from the placenta to the baby for several minutes after birth. The cord should **not be clamped immediately**. Instead, you wait until the cord pulsations have slowed or stopped, usually 1–3 minutes after birth. This **delayed cord clamping** allows the baby to receive additional placental blood—extra iron, oxygen, and blood volume—which benefits the baby's hemoglobin and iron stores in the first 6 months of life. Research shows that delayed cord clamping reduces the risk of anemia in infancy and improves neurodevelopmental outcomes. Why this matters: A newborn born at term has lower hemoglobin than an adult; any advantage in iron stores is important, especially in a setting where infant anemia is common and iron supplementation may not be reliably available. Delayed cord clamping is a simple, cost-free way to boost the baby's iron reserves. How to recognize when to clamp: Feel the cord with your fingers. When you no longer feel pulsations (or feel only very slow, weak beats), the placental transfusion is complete, and you can clamp and cut the cord. This is usually 1–3 minutes post-birth. If the baby is gasping or cyanotic (blue), you do not wait; you clamp immediately, cut, and hand the baby to the mother or resuscitate as needed. But in a normal, vigorous newborn, wait for the pulsations to stop. After you cut the cord, the baby and mother are still in skin-to-skin contact and are not separated. **Step 4: Non-Separation of Mother and Baby and Early Initiation of Breastfeeding (Within 90 Minutes, Ideally Within 30–45 Minutes)** The baby remains with the mother, in skin-to-skin contact, continuously. No bathing, no separation to another room, no weighing, no heel prick for screening, no ointment in the eyes—*none of these* is done in the first 90 minutes. The sole focus is warmth, bonding, and breastfeeding. **Breastfeeding** should begin as soon as the baby shows signs of readiness (usually within 30–45 minutes of birth): rooting (turning the head toward the breast when the cheek is touched), hand-to-mouth movements, or suckling. The baby may not be hungry (receiving colostrum and comfort is the goal, not milk volume), but early suckling stimulates the mother's oxytocin release, which aids uterine contraction (helping with the third stage), and establishes the breastfeeding reflex. If the baby is very sleepy or not rooting by 60 minutes, gently encourage: rub the baby's lips with the mother's nipple, express a tiny drop of colostrum on the nipple, or change the baby's position. Some babies take 2–3 hours to feed actively; this is normal. Do not leave the mother and baby unattended; watch for danger signs in mother (hemorrhage, shock) and baby (abnormal breathing, extreme lethargy). Why 90 minutes? Because this is the alert period: the newborn is awake and interested in feeding, the mother's oxytocin is high (aiding uterine contraction and milk letdown), and early breastfeeding establishes the latch, reduces neonatal jaundice risk, and ensures the baby receives colostrum (rich in antibodies). After 90 minutes, the baby often sleeps; feeding can resume later, but the first feed is a critical window. **Unang Yakap in Complications** If the baby requires resuscitation (not breathing, gasping, very slow heart rate), resuscitation takes immediate priority: clear the airway, provide bag-and-mask ventilation, perform chest compressions if needed. As soon as the baby is breathing and responsive, the protocol resumes: drying, skin-to-skin, delayed cord clamping (or clamping immediately if the cord is in the way of care), and breastfeeding as soon as feasible. If the mother has severe hemorrhage, shock, or convulsions, the mother's life comes first: emergency management and referral proceed. But the baby should be kept with the mother (in a second pair of hands if available) or in close observation; separation is minimized. **Common Unang Yakap Mistakes** Exam questions often test knowledge of what *not* to do: - **Do NOT bathe the baby in the first 90 minutes.** (Wait at least 6 hours; even then, wait until the baby's temperature is stable.) - **Do NOT separate the mother and baby for routine procedures.** (Weight, measurements, heel prick, and eye ointment can wait.) - **Do NOT clamp the cord immediately.** (Wait for pulsations to stop, unless resuscitation is needed.) - **Do NOT use wet cloths or blankets on the baby.** (Use a dry, pre-warmed cloth for drying, then remove it; use skin-to-skin for warmth.) - **Do NOT formula-feed or give sugar water unless the baby cannot breastfeed.** (Colostrum is all the baby needs in the first hours; it is concentrated, rich in antibodies, and laxative, promoting passage of meconium.) - **Do NOT delay breastfeeding to perform routine checks.** (Early feeding is more important than on-time weighing.)

The **continuum of care** is the unbroken chain of services that follows a woman and child across two dimensions: *time* (from pre-pregnancy through pregnancy, birth, postpartum, and childhood) and *place* (from home and community to health facility to hospital). A break in this chain at any point—a missed danger sign at a prenatal visit, a delay in recognizing complications during labor, an unavailable ambulance, or a delayed response at the hospital—is where mothers and newborns die. The Philippine DOH organizes this continuum through the **Service Delivery Network (SDN)**, a linked system of health facilities that together provide the full MNCHN package. The SDN has three tiers: **Tier 1: Community and Barangay Health Station (BHS)** The midwife at the BHS is the entry point and sentinel. She: - Conducts family planning and pre-pregnancy care (folic acid, iron, contraception). - Identifies and registers all pregnant women in the barangay, documents their risk factors (age, parity, comorbidities, previous complications), and enrolls each in a facility for delivery. - Provides prenatal care (4+ ANC visits with screening for hypertension, proteinuria, edema, and danger signs; tetanus immunization; iron-folic acid and calcium supplementation; health education). - Develops a birth plan with each pregnant woman: names the facility, identifies the mother's escort, discusses transport, discusses financing, and reviews danger signs. - Provides postpartum and newborn care in the home (within 24 hours, 3 days, 7 days, and 14 days) and immunizations. - Recognizes when a condition requires immediate referral and initiates it. - Uses the Field Health Services Information System (FHSIS) and Target Client List (TCL) to track all pregnant women and births, and reports monthly to the municipal health office. **Tier 2: Rural Health Unit (RHU) / Basic Emergency Obstetric and Newborn Care (BEmONC) Facility** The RHU or a certified BEmONC birthing home serves a municipal population (usually 50,000–125,000) and is the primary delivery facility. It: - Operates 24/7 with a doctor (or trained midwife if no doctor), a nurse, and a midwife. - Provides skilled birth attendance, AMTSL, and Unang Yakap at every delivery. - Has the capability to perform the seven BEmONC signal functions: parenteral antibiotics, oxytocics, anticonvulsants, manual placental removal, MVA, vacuum extraction, and newborn resuscitation. - Recognizes obstetric and neonatal complications and stabilizes patients for referral (e.g., starting oxytocin and referral for massive PPH, starting MgSO4 and referring for eclampsia, resuscitating a non-breathing newborn). - Refers to CEmONC when needed and ensures transport, communication, and a written referral note accompany the patient. - Provides immediate postpartum and newborn care and early discharge planning for uncomplicated cases. **Tier 3: Comprehensive Emergency Obstetric and Newborn Care (CEmONC) Hospital** The CEmONC hospital typically serves a provincial or regional population (500,000+) and is the referral center. It: - Performs all nine EmONC signal functions: the seven basic functions plus cesarean section and blood transfusion. - Has an obstetric surgical team (obstetrician, anesthetist, nurses), a neonatal team, blood bank, operating theatre, and ICU capability. - Admits patients referred from RHUs and lower facilities for complications that cannot be managed at BEmONC. - Provides definitive surgical and critical care (cesarean section, transfusion, treatment of eclampsia, management of uterine rupture, neonatal intensive care). - Communicates outcomes back to the referring RHU so the midwife can learn and follow up. **The Midwife's Referral Role: Recognize, Stabilize, Communicate, Accompany, Follow Up** When a midwife recognizes a complication that requires escalation, her role is **not** to manage it independently, but to expertly and quickly move the patient up the chain. A competent referral has five elements: **1. Recognize** the danger sign early. The midwife must know the warning signs of major obstetric complications: - **Maternal**: vaginal bleeding (antepartum, intrapartum, postpartum), severe headache, visual disturbances or epigastric pain (pre-eclampsia / eclampsia signs), high fever (infection), abdominal pain and tenderness (abruption, uterine rupture), foul-smelling vaginal discharge (infection), and fainting or signs of shock (hemorrhage, sepsis). - **Fetal**: decreased fetal movement, fetal distress (bradycardia, meconium-stained fluid), or non-reassuring fetal heart rate patterns. - **Neonatal**: gasping, apnea, cyanosis, extremely low birth weight, or respiratory distress. Early recognition—at the BHS during prenatal care, or at the RHU during labor—is the first step. A woman with severe pre-eclampsia at 28 weeks is recognized at the prenatal visit and referred then, not when she convulses. **2. Stabilize** the patient using available first-aid and BEmONC interventions while transfer is arranged. Examples: - For a convulsing mother: give MgSO4 loading dose 4 g IV, lay her on her side, clear the airway, keep her calm and dark, start IV fluids. - For postpartum hemorrhage: give oxytocin, perform uterine massage, start IV fluids, keep her NPO (in case surgery is needed), elevate the legs. - For a non-breathing newborn: give bag-and-mask resuscitation, keep the baby warm and monitored. Stabilization buys time for transport and ensures the patient arrives at CEmONC in the best possible condition. **3. Communicate ahead** to the receiving CEmONC facility (or RHU if referring from BHS to RHU) so that the facility is prepared. A phone call or radio message should include: - **Patient name and age**. - **Diagnosis or suspected complication** (e.g., "28-week primigravida with severe pre-eclampsia, BP 170/120, convulsed once, given MgSO4 loading dose"). - **Status and vital signs**. - **Interventions already given** (oxytocin given, IV started, etc.). - **ETA (expected time of arrival)**. This warning allows the receiving facility to prepare a room, call in the obstetric team, ensure blood is available, and ready the operating theatre if cesarean is likely. **4. Accompany the patient** or arrange for a trained escort (nurse, midwife, or health worker) to go with her. The referral should never be a one-way journey; someone from the sending facility should travel with the patient to: - Provide continuity of care and monitoring during transport. - Give the receiving facility firsthand account and answer questions. - Ensure the patient reaches the facility (not left on the roadside or at a shop). - Provide emotional support to the mother and family. If the midwife cannot accompany due to other patients, a nurse, a health worker, or even a trained community health volunteer can go, but *someone* must. **5. Carry a Written Referral Note** that includes: - **Patient demographics**: name, age, address, contact. - **Obstetric history**: gravidity, parity, date of last menstrual period, expected date of confinement, previous complications. - **Current complaint and findings**: vital signs, relevant physical exam (e.g., blood pressure, urine dipstick, abdominal findings, fetal heart rate). - **Diagnosis or suspected diagnosis**. - **Interventions already given** with **times**: e.g., "Oxytocin 10 IU IM given at 2:15 p.m.," "MgSO4 4 g IV loading dose given at 9:30 a.m.," "Two units of normal saline IV started at 3 p.m." - **Current status**: vital signs, mental status, fetal heart rate if applicable. - **Reason for referral** (e.g., "Retained placenta not delivered after AMTSL and 45 minutes of waiting," "Eclampsia—convulsion at labor onset, BP 165/110"). - **Sender's name, facility, and time of referral**. The written note ensures the information is clear, accurate, and not lost in the confusion of urgent care. It is a legal document that protects both the sending and receiving facility. **Follow up** after referral: Once the patient has been referred, the midwife or RHU should contact the receiving facility after 24–48 hours to ask about the outcome (was the baby born vaginally or by cesarean? did the mother survive? is the baby alive?). Follow-up serves three purposes: (1) it ensures the patient actually arrived and was not lost, (2) it confirms the diagnosis and referral decision, and (3) it provides feedback so the midwife can improve her recognition and management of similar cases. A midwife who refers a woman with severe pre-eclampsia and learns that the woman later convulsed and had a stillbirth due to delayed arrival learns that her threshold for referring must be even lower. This is how the health system improves. **The Three Delays Model and How MNCHN Overcomes Them** Maternal and neonatal deaths are analyzed using the **three delays framework**: (1) delay in *deciding* to seek care, (2) delay in *reaching* care, and (3) delay in *receiving* care at the facility. The MNCHN strategy and the midwife's role attack all three: **Delay 1: Deciding to Seek Care** The midwife addresses this by: - Teaching danger signs at every prenatal visit and encouraging the woman to go to the facility immediately if she experiences any. - Developing a written birth plan that includes the name of the facility, the person who will escort her, and the transport arranged in advance (not decided on the day of labor). - Educating the family and community (especially the husband and mother-in-law) about the importance of facility delivery and the risks of home delivery and traditional birth attendants. - Identifying high-risk pregnancies early (anemia, hypertension, previous complications) and counseling these women that they must deliver at CEmONC or a well-staffed BEmONC, not at home. Example: During prenatal care, the midwife teaches a pregnant woman: "If you have bad bleeding, severe headache, vision changes, or the baby stops moving, do not wait—go to the RHU immediately. Do not wait for a doctor or elder to say so. You may die." The woman knows the danger signs and will decide quickly to seek care. **Delay 2: Reaching Care** The midwife addresses this by: - Incorporating transport into the birth plan: "Who will take you to the RHU? When will you go? Do you have money for transport?" - Identifying the nearest facility and ensuring it is BEmONC-capable and open 24/7. - In some areas, arranging a community ambulance service (motorbike or truck) and ensuring the driver knows the mother is expected. - Advocating for good roads and transport infrastructure (though this is beyond the midwife's direct control, it is part of the health system's obligation). Example: A pregnant woman lives 15 km from the RHU. At prenatal visit, the midwife helps her arrange a motorbike with a neighbor who has agreed to take her when labor starts. The neighbor's phone number is written in the birth plan. When labor starts, the woman calls the neighbor immediately; transport is not a surprise or an obstacle. **Delay 3: Receiving Care at the Facility** The midwife addresses this by: - Ensuring BEmONC and CEmONC facilities are well-staffed, equipped, and open 24/7 (a policy-level issue, but the midwife advocates for it). - When referring, stabilizing the patient so she arrives in the best possible condition, communicating ahead so the facility is ready, and ensuring someone accompanies her. - Using good referral notes so the receiving facility understands the case and does not waste time re-evaluating. Example: A woman arrives at the RHU in active labor and is found to have a high fever and foul-smelling discharge—likely chorioamnionitis. The RHU midwife calls ahead to the CEmONC hospital: "28-week primigravida, fever 39.5°C, foul discharge, likely chorioamnionitis, given ceftriaxone 1 g IM and gentamicin 80 mg IM at 7 a.m., IV fluids started, ETA 8:30 a.m." The hospital puts an obstetrician on standby and preps the nursery for a likely preterm birth. When the woman arrives, the team does not start from scratch; they know what has been done and what to expect. Delays in care are minimized.

Understanding each of the seven BEmONC signal functions—what they are, when they are indicated, what the midwife does, and when to refer—is essential to exam success and clinical practice. Let us go through each, focusing on the midwife's scope and the detect-and-refer model. **Signal Function 1: Administer Parenteral Antibiotics** *Indications*: Maternal infection or high risk of infection: - Chorioamnionitis (inflammation of the amniotic membranes due to bacterial infection)—fever, foul-smelling amniotic fluid, maternal tachycardia, fetal tachycardia. - Prolonged rupture of membranes (PROM > 18 hours)—risk of ascending infection, even if the mother is asymptomatic. - Sepsis or suspected sepsis—fever, rigors, hypotension, tachycardia, tachypnea, altered mental status. - Postoperative infection (after cesarean section or MVA)—fever, wound tenderness, purulent discharge. - Maternal wounds—episiotomy tear that is infected, or laceration with signs of infection. *Common First-Line Antibiotics in the Philippines*: - **Ceftriaxone** 1 g IM or IV every 12 hours (broad-spectrum, good for obstetric infections). - **Ampicillin** 1–2 g IV every 4–6 hours (often paired with gentamicin for gram-negative coverage). - **Gentamicin** 80–120 mg IM or IV (dosing varies; often 3–5 mg/kg) for gram-negative organisms. - **Metronidazole** 500 mg IV or orally for anaerobic coverage (often used for postoperative or abortion-related infections). *Midwife's Role*: - Recognize signs of infection: fever, foul discharge, maternal malaise, or abnormal vital signs. - Administer the *first* parenteral antibiotic dose as per protocol (e.g., ceftriaxone 1 g IM) immediately at the point of care. - Start an IV line if not already present and infuse supportive fluids. - Refer to RHU/CEmONC if the mother is unwell, septic, or after an unsafe abortion procedure (to ensure complete evacuation of retained products and control of infection). - Continue antibiotics as instructed if the mother remains at the lower facility; if referred, send the patient with documentation of the dose and time given. *Common Exam Questions*: - *A woman with 20 hours of ruptured membranes presents to the BHS in latent labor. She is well. What do you do?* **Screen for fever and foul discharge (signs of chorioamnionitis). If asymptomatic and afebrile, give the first dose of antibiotics per protocol (e.g., ceftriaxone 1 g IM) and refer her to the RHU for labor management with continued antibiotics. Even without fever, prolonged PROM warrants antibiotics to prevent ascending infection.** - *A woman delivers at the BHS and the next day runs a fever of 38.8°C with foul-smelling lochia. What is your diagnosis and first action?* **Postpartum sepsis, likely from endometritis. Give parenteral antibiotics immediately (e.g., ceftriaxone 1 g IM or IV) and refer to the RHU/CEmONC. Do not delay waiting for lab results.** **Signal Function 2: Administer Parenteral Oxytocic (Uterotonic) Drugs** *Indications*: - **Prevention of postpartum hemorrhage** (as part of AMTSL at every birth). - **Treatment of postpartum hemorrhage**—when active bleeding is occurring despite the initial oxytocin given at delivery. - **Augmentation of labor**—when contractions are inadequate (hypotonic or infrequent), oxytocin is infused IV to strengthen contractions. (Note: this is intrapartum use; some curricula include it as part of BEmONC, though labor augmentation may also be considered a more specialized skill.) *Common Oxytocic Drugs*: - **Oxytocin (Pitocin)** 10 IU IM (for prevention/AMTSL) or IV infusion 10–20 IU in 500 mL normal saline (for treatment of PPH or augmentation). Onset IM is 2–3 minutes, duration 30+ minutes. Onset IV is seconds, duration shorter. - **Ergotamine (Ergot)** 0.2 mg IM (causes sustained, tetanic uterine contraction; used for PPH treatment). Onset 30 seconds to 1 minute; lasts 1–3 hours. **Contraindicated in hypertension** (risk of hypertensive crisis and stroke). - **Misoprostol** 800 mcg rectally (in low-resource settings, sometimes used for PPH prevention or treatment; not standard in the Philippines but emerging in some RHUs). Slower onset than oxytocin; less commonly used. *Midwife's Role*: - Give **oxytocin 10 IU IM within one minute of baby's birth** as part of AMTSL (before placental delivery). This is *your* responsibility and is done at every birth. - Recognize postpartum hemorrhage: bleeding that does not slow with massage and oxytocin given, or that restarts after the placenta is delivered. If bleeding is heavy (soaking multiple perineal pads in 15–20 minutes) and the mother shows signs of shock (pale, weak, tachycardic, low BP), this is massive PPH. - Give a **second dose of oxytocin** 10 IU IM if PPH develops; if IV access is available, start oxytocin infusion (10–20 IU in 500 mL normal saline, run fast). - Perform bimanual uterine compression—place one hand on the abdomen and one inside the uterus—to physically compress the bleeding vessels. This is a life-saving but uncomfortable procedure; it is done while the mother is being prepared for transport. - Refer immediately to RHU/CEmONC if massive PPH is not controlled by oxytocin, massage, and fluids. The mother may need ergotamine (if BP is not elevated), or more advanced interventions (uterine packing, angiographic embolization, or hysterectomy) at CEmONC. *Note on Ergot and Hypertension*: Ergotamine should **never** be given to a woman with hypertension or signs of pre-eclampsia/eclampsia because it causes vasoconstriction and can precipitate a hypertensive crisis, stroke, or myocardial infarction. Always check BP before considering ergot. In the Philippines, many RHUs stock only oxytocin, which is safe in all BP states; ergot is less commonly used. *Common Exam Questions*: - *What is the dose of oxytocin for AMTSL?* **10 IU IM, given within one minute of baby's birth, after ruling out twins.** - *A woman delivers at the RHU. After AMTSL, her bleeding slows. But at 2 hours postpartum, her lochia becomes very heavy, soaking 3 perineal pads in 10 minutes. Her BP is 90/60, pulse 120, and she feels faint. What is happening and what is your immediate action?* **Postpartum hemorrhage, likely with early shock. Immediately: (1) keep mother NPO and lie flat with legs elevated, (2) give a second dose of oxytocin 10 IU IM (if not given recently) or start IV oxytocin infusion, (3) perform uterine massage and bimanual compression if trained, (4) start IV fluids (normal saline or lactated Ringer's) wide open, (5) check for signs of bleeding (lochia, fundal height—is the uterus enlarged/filled with blood?), (6) call RHU/CEmONC immediately for urgent referral (she may need transfusion or surgery), and (7) do not leave her unattended.** **Signal Function 3: Administer Parenteral Anticonvulsants (Magnesium Sulfate)** *Indications*: Severe pre-eclampsia or eclampsia—either the mother has convulsed, or she shows signs of severe pre-eclampsia (severe headache, epigastric pain, visual disturbances, very high BP ≥160/110, and usually proteinuria) even without seizure. Do not wait for a convulsion to give MgSO4. *Standard Loading Dose*: - **Magnesium sulfate (MgSO4) 4 g IV loading dose**, given over 5–20 minutes (infused slowly to avoid flushing and discomfort). Common protocol: 4 g in 50–100 mL normal saline, infused over 5–10 minutes via IV. - **Maintenance dose** (if labor is to continue): 1 g/hour IV or 5 g IM every 4 hours (varies by protocol; many RHUs use the loading dose only and refer). *Mechanism*: MgSO4 works by blocking calcium channels in neurons, reducing excitability and preventing or stopping seizures. It also lowers blood pressure somewhat and improves cerebral perfusion. *Signs of Toxicity* (overdose or toxicity from impaired renal clearance): - Loss of deep tendon reflexes (patellar reflex becomes absent—a sign to monitor; check DTRs before and after MgSO4). - Loss of urine output (oliguria—stop the infusion if urine output drops below 100 mL in 4 hours). - Respiratory depression (danger—if respiratory rate drops below 12, stop the drug and be ready to ventilate). - Flushing, nausea. *Antidote*: If toxicity occurs, **calcium gluconate 1 g IV over 2–3 minutes** reverses the effects immediately. *Midwife's Role*: - Recognize severe pre-eclampsia or eclampsia: in prenatal care, a woman with BP ≥160/110 and symptoms (headache, epigastric pain, visual changes) or proteinuria warrants MgSO4; in labor, a convulsing woman or a woman with severe symptoms needs MgSO4 immediately. - Administer the **loading dose of MgSO4 4 g IV** at the point of care (BHS or RHU). This is a life-saving stabilizing intervention and is within the midwife's scope. Do not wait for a doctor. - While giving MgSO4, prepare the mother for referral to CEmONC for delivery (definitive management of severe pre-eclampsia is delivery of the fetus and placenta). - Check deep tendon reflexes before and 30 minutes after the MgSO4 dose; if DTRs are lost (brisk → normal → diminished → absent as MgSO4 accumulates), the level is too high; monitor closely and consider reducing or stopping the infusion if other signs of toxicity appear. - Monitor urine output; if <100 mL/4 hours, the drug is accumulating and should be stopped. - Refer urgently to CEmONC; arrange transport and ensure the mother is accompanied, with a note documenting the MgSO4 dose and time given. - Continue MgSO4 maintenance (if within scope) or stop and let the receiving facility decide. *Common Exam Questions*: - *A pregnant woman at 36 weeks presents to the BHS with a severe headache, BP 165/100, and 3+ proteinuria. You suspect severe pre-eclampsia. What is your management?* **(1) Admit her or transfer to RHU, (2) give MgSO4 4 g IV loading dose to prevent/treat seizures, (3) keep her in a quiet, dark room (stimuli can trigger seizures), (4) start IV fluids, (5) check DTRs (baseline), (6) monitor vital signs and urine output, (7) arrange urgent referral to CEmONC for delivery (induction or cesarean, depending on gestational age and BP control).** - *A woman is convulsing at the RHU. What is the first drug you give?* **Magnesium sulfate 4 g IV, as fast as safely given (over 5–20 minutes is safe). Do not give phenytoin or diazepam first; MgSO4 is the drug of choice in pregnancy and lactation.** **Signal Function 4: Perform Manual Removal of the Placenta** *Indications*: - **Retained placenta**: placenta not delivered despite AMTSL (oxytocin, uterine massage, controlled cord traction) after 30 minutes. - **Placental abruption with hemorrhage**: heavy bleeding and the placenta not separating; manual removal is faster than waiting. - **Abnormal placentation** (rare in the primary care setting but recognized at birth). *Procedure*: 1. **Analgesia**: Ideally, give parenteral analgesia (pethidine IM, paracetamol IV, or inhaled nitrous oxide if available) to reduce discomfort. If not available, proceed (unpleasant but necessary). 2. **Preparation**: Ensure IV access, blood draw for type and cross-match, and patient is NPO. Have oxytocin ready for postoperative contraction. 3. **Hand Entry**: The provider (midwife or doctor) scrubs and dons sterile gloves. One hand enters the vagina and cervix into the uterus, following the umbilical cord to the placenta. 4. **Separation**: The provider's fingers locate the edge of the placenta and gently separate it from the uterine wall with a sweeping motion, layer by layer. Do not force; this causes uterine perforation. 5. **Removal**: Once separated, the placenta is gently withdrawn through the vagina. 6. **Inspection**: The placenta is examined to ensure it is complete (no fragments left behind). The uterine cavity is swept with the fingers to check for retained products. 7. **Oxytocin Administration**: After the placenta is out, oxytocin is given (10 IU IM) to contract the uterus and control bleeding. 8. **Postoperative Monitoring**: Close observation for hemorrhage, infection, uterine atony, or perforation in the hours after MRPO. *Midwife's Scope*: A trained midwife under DOH protocols can perform MRPO. This is not a surgical procedure but a skilled manual intervention within the BEmONC scope. Some facilities may require physician presence; others permit midwife MRPO under clear supervision and protocols. Know your facility's policy. *Referral Trigger*: If the placenta cannot be removed manually after reasonable effort (≤15–20 minutes of careful attempt), or if the mother is hemorrhaging heavily and cannot wait, refer urgently to CEmONC. The hospital may need to take her to theatre for removal under anesthesia or for other interventions (transfusion, hysterectomy if there is perforation or massive hemorrhage). *Common Exam Questions*: - *After 45 minutes of AMTSL, the placenta has not delivered. The mother is well, not bleeding heavily. What is your diagnosis and action?* **Retained placenta. Call the RHU (if at BHS) or, if at RHU, perform MRPO if you are trained and if no physician is immediately available. If MRPO fails or if heavy bleeding develops, refer to CEmONC.** **Signal Functions 5, 6, and 7: MVA (Removal of Retained Products), Vacuum Extraction, and Newborn Resuscitation** *Manual Vacuum Aspiration (MVA)* is used to remove retained products of conception after abortion (miscarriage or induced). It is a skilled procedure, usually performed by a midwife or doctor with training. Indications include fever, bleeding, or incomplete evacuation after abortion. The midwife's role is recognition of post-abortion complications and referral or performance if trained. *Vacuum Extraction* is an advanced procedure for assisted vaginal delivery, performed by a doctor or highly trained provider when labor stalls or fetal distress is present and vaginal delivery is possible (head low in pelvis, fully dilated cervix). The midwife's role is detection of prolonged labor or fetal distress and referral; midwives do not routinely perform vacuum extraction unless they have received specialized training (e.g., EORP—Emergency Obstetric Referral Program—training in some provinces). The risk of scalp trauma and cephalohematoma requires care and skill. *Newborn Resuscitation* is performed by the midwife using the ABC approach (Airway, Breathing, Circulation). Every midwife must be trained in this. Indications: birth asphyxia (apnea, gasping, very low heart rate <100, poor tone). The sequence is: 1. **Clear airway**: Wipe face with a cloth; if meconium and the baby is not breathing, suction the mouth and nose. 2. **Stimulate and assess**: Dry, stimulate (rub the back, flick the feet), and assess heart rate (by umbilical cord pulsation or chest palpation). If HR ≥100 and improving respiratory effort, continue stimulation; if not breathing, give bag-and-mask ventilation. 3. **Bag-and-Mask Ventilation**: Apply a mask over the baby's nose and mouth, seal it, and squeeze the bag at 40–60 breaths/minute. Watch for chest rise. Continue for 15–30 seconds, then reassess HR. If HR is ≥100, continue; if not, and if the baby remains apneic, continue ventilation. 4. **Chest Compressions**: If HR drops below 60 after 15–30 seconds of ventilation, start chest compressions (two thumbs on the lower third of the sternum, compress 1/3 of chest depth, 120 compressions/minute, with ventilation at 40–60/minute in a 3:1 ratio [compressions:breaths]). Continue until HR ≥100. 5. **Ongoing Support**: Keep the baby warm, monitor ongoing breathing and heart rate, and if the baby does not respond or remains cyanotic, prepare for referral to neonatal ICU. The midwife's role is immediate resuscitation and then referral if the baby remains unresponsive or needs ongoing support. A severely asphyxiated baby born at the BHS and resuscitated may still have brain damage; transport to NICU is urgent.

The midwife's work is not complete when the patient leaves the facility or the home. It must be recorded and reported in the **Field Health Services Information System (FHSIS)**, the DOH's routine data collection and reporting system. FHSIS captures all maternal, newborn, and child health services provided at the BHS and RHU and rolls them up through municipal, provincial, and national levels to track whether MNCHN is working and where improvements are needed. **What is Recorded** The **Target Client List (TCL)** is a line-by-line, name-and-address registry of all pregnant women, delivered mothers, and children in the barangay. For each pregnant woman, the midwife records: - **Name, age, address**. - **Obstetric history**: gravidity, parity, date of last menstrual period (LMP). - **Prenatal care visits**: dates of ANC 1, 2, 3, 4; whether given tetanus toxoid, iron-folic acid, and calcium; whether screened for danger signs; whether given a birth plan. - **Delivery**: date of delivery, place (home, BHS, RHU, hospital), attendant (traditional birth attendant, midwife, doctor). - **Outcome**: live birth, stillbirth (intrapartum, fresh stillbirth, macerated). - **Complications detected**: vaginal bleeding, severe headache, convulsions, retained placenta, postpartum hemorrhage, infection. - **Referral**: if referred, where (RHU, hospital), reason, and outcome if known. - **Postpartum visits**: dates of PNC at 1 day, 3 days, 7 days, 14 days; findings; counseling given. - **Newborn care**: exclusive breastfeeding, immunizations (BCG, hepatitis B), vitamin K, eye ointment, screening (weight, jaundice, infection). - **Neonatal outcome**: live, stillbirth, neonatal death (if any). For each child aged 0–5 years: - **Immunizations given** (BCG, DPT, OPV, hepatitis B, measles, pneumococcal). - **Growth monitoring**: monthly weights and heights; flagged if underweight or stunted. - **Maternal and child nutrition**: counseling on breastfeeding, complementary feeding, vitamin A. - **Illness episodes**: diarrhea, pneumonia, malaria, dengue, other infections; treatment given; referral. **Monthly FHSIS Report** At the end of each month, the midwife tabulates data from the TCL and prepares a **monthly FHSIS report** that is submitted to the Municipal Health Office (MHO). The report includes: - **Prenatal care indicators**: number of pregnant women registered, number receiving 4+ ANC visits, number receiving tetanus toxoid, iron-folic acid, calcium; percentage of women screened for danger signs; percentage receiving a birth plan. - **Delivery and newborn indicators**: number of deliveries attended, number at a facility (institutional delivery rate), number with a skilled birth attendant, number with AMTSL performed, number receiving Unang Yakap. - **Complication indicators**: number with maternal hemorrhage, hypertension/pre-eclampsia, infection, retained placenta; number of referrals made; number of referrals that resulted in live births vs. maternal or fetal death. - **Postpartum and neonatal indicators**: percentage receiving PNC visits (1-day, 7-day); percentage exclusively breastfed; neonatal mortality rate (neonatal deaths per 1000 live births); early neonatal death (within 7 days) vs. late (8–28 days). - **Child health indicators**: percentage of children 0–5 receiving full immunizations, percentage with adequate growth, prevalence of malnutrition. These monthly reports are aggregated at the MHO and submitted to the Provincial Health Office (PHO) and DOH, where they inform the **Maternal Mortality Ratio (MMR)** and **Neonatal Mortality Rate (NMR)**—the key indicators of MNCHN success. **Why FHSIS Matters** 1. **Program Monitoring**: FHSIS data tells the DOH whether the MNCHN strategy is working. If a province has high MMR, the DOH can ask: Are enough women getting 4 ANC visits? Are they being referred for complications? Are facilities equipped to manage emergencies? Data drives action. 2. **Accountability**: The midwife's FHSIS report is a record of the care she provided. If a maternal death occurs, the report shows what prenatal care was given, what danger signs were detected, and whether referral was made. This is both a learning tool and a legal document. 3. **Equity and Resource Allocation**: If one RHU has a high referral rate and low complication rate while another has few referrals but high maternal deaths, the data signals quality differences. Resources and training can be directed to underperforming facilities. 4. **Burden of Disease**: FHSIS data reveals the prevalence of specific complications (hypertension, anemia, infection) in the population, guiding public health campaigns and prevention strategies. **Common FHSIS Errors and Best Practices** - **Incomplete data**: Some midwives skip fields or estimate numbers. FHSIS must be accurate and complete; if you do not know a datum, record it as missing, not as zero or a guess. - **Late submission**: Reports are due by the 5th of the following month. Late reports delay aggregation and decision-making. Submit on time. - **Duplication**: If a woman delivers at the BHS and is then transferred to an RHU for complications, ensure she is counted once in the system (either BHS or RHU, not both). - **Lost to follow-up**: If a pregnant woman registered at the BHS is not heard from again, record her as "lost to follow-up," not as "no delivery." This signals that she may have delivered elsewhere or had an adverse outcome. **RA 7392 and Midwife Accountability** Under the Philippine Midwifery Act, the midwife is accountable for the care she provides. FHSIS recording is part of that accountability. If a maternal death occurs and the FHSIS record shows the woman received no prenatal care and had no birth plan, this reflects poorly on the midwife's practice and may result in professional sanction. Conversely, accurate FHSIS documentation that shows the midwife recognized danger signs, referred appropriately, and documented the referral is a defense. **Good documentation protects you.** **High-Yield FHSIS Points for the Exam** - FHSIS is the DOH's routine data system for monitoring MNCHN; all midwives must participate. - The **Target Client List (TCL)** is the foundation: a registry of every pregnant woman and child in the midwife's catchment. - **Monthly reports** include prenatal care coverage, facility delivery rate, complication rate, referral rate, postpartum care, and child health indicators. - FHSIS data roll up to the **MMR (Maternal Mortality Ratio)** and **NMR (Neonatal Mortality Rate)**, the national measures of success. - Accurate, timely FHSIS reporting is a professional and legal obligation under RA 7392. - Errors: incomplete data, late submission, duplication, and misclassification—avoid these. - **Use FHSIS to identify gaps in care and plan interventions** (e.g., if ANC attendance is low, hold education sessions; if referral rate is high, assess facility capability).

You are now equipped to understand and implement the MNCHN strategy and BEmONC signal functions as a midwife in the Philippine health system. Here is how it all comes together: **At the Barangay Health Station (BHS)** You are the frontline provider. You identify every pregnant woman, register her, provide four ANC visits, screen for danger signs (hypertension, proteinuria, edema, headache, visual changes, bleeding), give iron-folic acid and tetanus toxoid, develop a written birth plan, and educate the family on facility delivery and danger signs. You detect complications early—anemia, hypertension, infection—and refer before they become emergencies. You perform postpartum and newborn home visits, support breastfeeding, and immunize children. You record everything in the TCL and submit monthly FHSIS reports. You are the sentinel; your work prevents emergencies. **At the RHU or BEmONC Facility (Your Secondary Setting)** When you attend a birth here (called to the RHU by the woman's family, or staffing the facility), you perform skilled birth attendance. You conduct labor assessment, monitor the progress and the fetus, recognize complications (prolonged labor, obstructed labor, fetal distress, hemorrhage, infection), and perform AMTSL at every delivery without exception. You perform the Unang Yakap protocol with every newborn. You are authorized to give the first doses of oxytocin, MgSO4 loading dose, antibiotics, and to perform newborn resuscitation and manual removal of the placenta (if trained). You recognize when complications exceed your capability—when cesarean section, blood transfusion, or intensive neonatal care is needed—and you refer urgently to CEmONC, with stabilization, communication, written documentation, and accompaniment. **When Referring to CEmONC** You do not send a woman and walk away. You stabilize her (give oxytocin for hemorrhage, MgSO4 for eclampsia, antibiotics for infection), you call ahead so the hospital is ready, you write a clear referral note with all interventions and times, and you ensure she is accompanied. You follow up in 24–48 hours to learn the outcome and improve your future practice. **Using FHSIS to Improve** Every month, you tally your data, see where gaps exist (low ANC attendance, delayed referrals, high complication rate), and plan corrections. You attend trainings, supervise your health workers, and advocate for your community's needs. This is the midwife's public health role: **prevent, detect, refer, stabilize, and improve**. Mastering BEmONC and MNCHN is how you save lives in your community and prepare for success in the PRC Midwife Licensure Examination.