Midwife Licensure Exam The Midwife's Public Health Service Delivery — Prenatal Home-Based and Postnatal Home CareDetailed Explanation

The Public Health Bag and Bag Technique

The public health bag is the midwife's portable clinic. Because home environments are not sterile—there may be animals, dirt floors, or crowded living spaces—the midwife needs a standardized method to deliver safe care without spreading infection to the family or contaminating her bag. This standardized method is called the BAG TECHNIQUE. Think of the inside of the bag as a 'clean zone' and everything outside (including the house environment) as a 'potentially contaminated zone.' The goal of bag technique is to keep these two zones separate throughout the entire visit. The four guiding principles of bag technique are: 1. The bag and its contents must be CLEAN and WELL-ARRANGED at all times, with all needed articles ready before the visit. 2. The technique must MINIMIZE OR PREVENT the spread of infection—both from the home to the bag and from the bag to the family. 3. It must SAVE TIME AND EFFORT through orderly, deliberate movements (no going back and forth unnecessarily). 4. It must REFLECT THE MIDWIFE'S PROFESSIONALISM and show families the value of good technique. The CLASSIC SEQUENCE on arrival: Step 1 — Place the bag on a CLEAN, FLAT SURFACE. If no clean surface is available, use the bag's own paper lining as a barrier between the bag and the surface. Step 2 — Open the bag and take out the PAPER LINING to create a clean working field. Step 3 — Take out soap dish and handwashing supplies from the bag. Step 4 — WASH HANDS THOROUGHLY and dry with your personal towel from the bag. Step 5 — Take out ONLY the articles needed for that specific procedure. Close the bag between removals to maintain cleanliness. Step 6 — Perform the care (vital signs, abdominal exam, FHT, health teaching, etc.). Step 7 — After the procedure: clean used articles, WASH HANDS AGAIN, record the visit, and give the family the next appointment and instructions. CRITICAL EXAM POINT: The VERY FIRST action upon arrival is placing the bag on a clean surface (or its lining). The VERY FIRST action before touching the client is WASHING HANDS. These two are frequently tested in sequence questions.

Prenatal Home-Based Care: Schedule, Content, and Danger Signs

Prenatal or antenatal care (ANC) delivered at home is one of the midwife's most critical public health contributions. It allows the midwife to assess not just the pregnant woman but her entire environment—her food, water, support system, and ability to reach a facility when labor begins. SCHEDULE OF ANC VISITS: The DOH standard requires a minimum of FOUR (4) antenatal visits: • 1st visit: First trimester (as early as possible—ideally within the first 12 weeks) • 2nd visit: Second trimester (around weeks 20–26) • 3rd visit: Third trimester (around 28–32 weeks) • 4th visit: Third trimester again (around 36 weeks or shortly before expected delivery) The newer WHO model (which is now being adopted by DOH) recommends EIGHT (8) contacts for a more positive pregnancy experience. MLE questions most often test the DOH minimum of 4 visits with their trimester placement. CONTENT OF EACH PRENATAL HOME VISIT (the 'Pregnancy Package'): 1. HISTORY AND RISK ASSESSMENT — Age, parity, obstetric history, medical history, LMP, and EDD computation. This identifies high-risk conditions for referral. 2. PHYSICAL ASSESSMENT — Weight, blood pressure (EVERY VISIT), fundal height measurement, fetal heart tones (FHT), and Leopold's maneuvers (from 3rd trimester onward) for fetal position. 3. TETANUS IMMUNIZATION (TT/Td) — A 5-dose schedule that protects the mother and newborn from tetanus. The midwife checks the woman's TT immunization status at the first visit. 4. MICRONUTRIENT SUPPLEMENTATION: • IRON WITH FOLIC ACID — Given daily throughout pregnancy (and continued postpartum) • CALCIUM supplementation — Especially important to prevent pre-eclampsia • IODINE — For fetal brain development • DEWORMING — Given in the 2nd or 3rd trimester (NOT in the 1st trimester) 5. LABORATORY SCREENING — Blood type, hemoglobin/hematocrit, urinalysis, RPR/syphilis screening (VDRL), and others where available. 6. HEALTH TEACHING — Nutrition, rest, breastfeeding preparation, activity, and most importantly, DANGER SIGNS OF PREGNANCY. DANGER SIGNS OF PREGNANCY (Always Refer): The midwife's core skill is recognizing these warning signs and REFERRING the woman immediately to a BEmONC or CEmONC facility. She does NOT manage these—she detects and refers. Memory tip 'VSHE CAMF-WB' or just learn them by category: • BLEEDING: Vaginal bleeding at any time • HEAD/VISION: Severe headache, blurring of vision (pre-eclampsia signs) • SWELLING: Swelling of face and hands (edema, pre-eclampsia sign) • CONVULSIONS: Fits or seizures (eclampsia—life-threatening) • FEVER: High fever (infection) • ABDOMINAL PAIN: Severe abdominal or epigastric pain • VOMITING: Persistent, severe vomiting (hyperemesis gravidarum) • MOVEMENT: Decreased or absent fetal movement (fetal distress) • DISCHARGE: Watery vaginal discharge (premature rupture of membranes/PROM) or foul-smelling discharge • BREATHING: Fast or difficult breathing Each of these is a REFERRAL TRIGGER. The midwife's action is: document → stabilize if possible → REFER IMMEDIATELY to BEmONC/CEmONC. THE BIRTH PLAN: Birth planning is a required activity during prenatal care and is the midwife's tool for combating the 'Three Delays' (delay in deciding to seek care, delay in reaching a facility, delay in receiving care at the facility). A complete birth plan includes: 1. PLACE OF DELIVERY — A BEmONC-capable facility with a Skilled Birth Attendant (SBA). The DOH promotes FACILITY-BASED DELIVERY; home births attended by hilot/traditional birth attendants (TBA) are NOT recommended. 2. SKILLED BIRTH ATTENDANT — The midwife, nurse-midwife, or physician who will conduct the delivery. 3. TRANSPORT — Identified vehicle or ambulance and a BACKUP transport plan. 4. COMPANION — Named person to accompany the mother. 5. FUNDS/SAVINGS — Money set aside for delivery costs and emergencies (PhilHealth enrollment). 6. BLOOD DONOR — Identified compatible blood donor in case transfusion is needed. 7. RECOGNIZING SIGNS — The family knows the signs of labor AND the danger signs that mean 'go NOW.'

Postnatal Home Care: Mother and Newborn Assessment

The postpartum and newborn period—especially the first 7 days—is when the highest risk of maternal and neonatal death occurs. This makes postnatal home visits critically important. Many women and newborns who die do so at home, in between contacts with health workers. The midwife's role is to DETECT any developing complication early and REFER before it becomes fatal. SCHEDULE OF POSTNATAL HOME VISITS (DOH Standard): • VISIT 1: Within 24 HOURS after delivery (the most critical visit) • VISIT 2: Around the 7th day (1 week) postpartum • VISIT 3: Around 6 weeks postpartum (the '6-week check') The WHO postnatal contact model (now being adopted) adds visits on Day 3 and Days 7–14, reflecting the same intent of MORE frequent early follow-up. For the MLE, know the DOH minimum: AT LEAST 2 check-ups (within 24 hours and at 7 days), plus the 6-week visit. ASSESSMENT OF THE POSTPARTUM MOTHER at each visit: 1. VITAL SIGNS — Temperature (fever = infection), blood pressure, pulse, respiration. 2. UTERINE INVOLUTION — The fundus should be firm and DESCENDING by approximately 1 fingerbreadth (1 cm) per day. By Day 10, it should no longer be palpable above the symphysis pubis. 3. LOCHIA — Assess amount, color, and odor: • Lochia RUBRA — Days 1–3: Red/dark red (normal) • Lochia SEROSA — Days 4–10: Pinkish/brownish (normal) • Lochia ALBA — Days 11 to up to 6 weeks: Whitish/yellowish (normal) Heavy bleeding OR foul-smelling lochia at any stage = DANGER SIGN → REFER. 4. PERINEUM/WOUND — Check healing of any laceration or episiotomy; look for signs of infection (REEDA: Redness, Edema, Ecchymosis, Discharge, Approximation). 5. BREASTS — Check for engorgement, cracked nipples, mastitis. Strongly support EXCLUSIVE BREASTFEEDING. 6. BLADDER AND BOWEL FUNCTION — Assess for urinary retention, urinary tract infection, and constipation. 7. SIGNS OF POSTPARTUM DEPRESSION — Mood, appetite, sleep, ability to care for baby. 8. FAMILY PLANNING COUNSELING — Discuss postpartum family planning options. Iron supplementation should be CONTINUED postpartum. POSTPARTUM DANGER SIGNS (REFERRAL TRIGGERS for the mother): • Heavy vaginal bleeding (soaking more than 1 pad per hour, or passing large clots) • Foul-smelling lochia • Fever (temperature 38°C or above) • Severe headache or visual changes • Convulsions • Painful, red, swollen breast (mastitis or breast abscess) • Calf pain or swelling (deep vein thrombosis—DVT) • Difficulty breathing (pulmonary embolism) • Signs of severe postpartum depression or psychosis ASSESSMENT OF THE NEWBORN at each visit: 1. FEEDING — Is the baby feeding well? Exclusive breastfeeding on demand. Check for good latch and adequate output (wet diapers, stool pattern). 2. CORD CARE — Keep the cord stump CLEAN AND DRY. No traditional practices like applying herbs, ash, or oil. Watch for redness, swelling, discharge, or foul smell (omphalitis = infection → REFER). 3. WARMTH — Prevent hypothermia. Normal axillary temperature is 36.5°C–37.5°C. Teach kangaroo care (skin-to-skin) especially for small babies. 4. WEIGHT AND GROWTH — Birth weight, current weight. A weight loss of up to 10% of birth weight in the first week is normal. 5. NEWBORN SCREENING — The EXPANDED NEWBORN SCREENING (heel-prick blood sample) should be taken between 24 and 72 HOURS of life (NOT before 24 hours—inaccurate results). Also confirm NEWBORN HEARING SCREENING was done. 6. IMMUNIZATIONS — Confirm BCG and HEPATITIS B BIRTH DOSE (given within 24 hours of birth) were administered. Set the schedule for subsequent EPI vaccines. NEWBORN DANGER SIGNS (REFERRAL TRIGGERS—any = URGENT REFERRAL): • POOR FEEDING or not feeding at all • CONVULSIONS (seizures) • FAST BREATHING: 60 breaths per minute or MORE, or severe chest indrawing • FEVER (feels hot to touch, axillary temp ≥37.5°C) or HYPOTHERMIA (feels cold, axillary temp <36.5°C) • NO MOVEMENT even when stimulated (lethargy) • JAUNDICE of the palms and soles (pathological jaundice—yellow palms and soles appearing within 24 hours or persisting beyond 2 weeks) • REDNESS, SWELLING, OR PUS around the cord stump or eyes (omphalitis, conjunctivitis) EINC/UNANG YAKAP CONNECTIONS: The midwife reinforces the four core EINC practices at postnatal visits: 1. Immediate and thorough DRYING (warmth) 2. Early SKIN-TO-SKIN contact (bonding and temperature) 3. Properly TIMED CORD CLAMPING (done at birth by SBA, explained to family) 4. Non-separation of newborn from mother and early BREASTFEEDING INITIATION

Recording, Documentation, and the FHSIS

Good home-based care is only half the job. The other half is DOCUMENTATION—recording every prenatal contact, postnatal visit, immunization, and referral on the proper forms. This is what allows the health system to function. KEY RECORDING TOOLS for the midwife: 1. TARGET CLIENT LIST (TCL) — The midwife's master tracking register. It lists ALL identified pregnant women, postpartum mothers, and newborns in the barangay. It shows who has received care and who has defaulted (missed appointments). The midwife uses this to plan follow-up home visits. 2. INDIVIDUAL CLIENT RECORDS: • Mother's Record (Prenatal Card) — Records each ANC visit findings, immunizations, supplementation, lab results. • Postpartum Record — Records postnatal visit findings for the mother. • Child Health Record (Baby Book/Child Development Card) — Records newborn and child visits, immunizations, growth monitoring. 3. FIELD HEALTH SERVICES INFORMATION SYSTEM (FHSIS) — The national health information system that aggregates all clinic and community data. The midwife's TCL and individual records feed into monthly/quarterly FHSIS reports submitted to the RHU and district health office. These reports generate the national maternal and neonatal indicators used to evaluate the MNCHN strategy. WHY DOCUMENTATION MATTERS FOR THE MLE: The MLE tests that students understand documentation not just as paperwork but as a SYSTEM FUNCTION. Poor documentation means: • Defaulters are not identified → missed complications • Program coverage cannot be measured → poor MNCHN evaluation • Referral continuity is broken → duplicated or missed care • Medico-legal protection for the midwife is absent A well-documented TCL lets the midwife look at her barangay list on Monday morning and immediately see: 'Maria has not come for her 3rd ANC visit—I need to schedule a home visit this week.' This is PROACTIVE, COMMUNITY-BASED care.

The sequence is: First, protect the bag from environmental contamination by placing it on a clean surface or lining (B). Then, access handwashing supplies from the bag (D). Wash hands before touching anything else (A). Take out only needed items, closing the bag between removals (C). Perform the actual care (E). Then clean up, wash hands again, and document (F). This sequence always appears in MLE ordering questions.

At 28 weeks (3rd trimester): Deworming is appropriate (2nd or 3rd trimester only). Iron with folic acid is given at every visit. BP is checked at EVERY visit. Leopold's maneuvers are appropriate from the 3rd trimester to assess fetal position. TT/Td status is reviewed and updated at any visit. Birth plan discussion should begin by the 3rd trimester at the latest. A common trap in MLE is listing deworming in the 1st trimester—this is WRONG.

This newborn has FOUR danger signs simultaneously—this is a serious newborn emergency, likely neonatal sepsis. The midwife does NOT administer antibiotics or any home treatment. She (1) documents all findings, (2) informs the parents urgently, (3) arranges the fastest available transport to a BEmONC facility, and (4) completes the referral form. On the MLE, any single newborn danger sign = referral; four signs = the most urgent scenario possible.

This tests the student's ability to distinguish NORMAL early postpartum findings from danger signs. Lochia rubra (dark red) is NORMAL on Day 1. Fundus at the umbilicus is NORMAL immediately postpartum (descends 1 fingerbreadth/day). Temperature 37.1°C is NORMAL (fever = 38°C or above). The key action here is the newborn screening reminder—the heel prick cannot be done until 24 hours of life (8 PM tonight) and no later than 72 hours (8 PM in two days).

This tests the concept of DEFAULTER TRACKING using the TCL. A pregnant woman at 32 weeks who misses an ANC visit may have developed a complication or may face barriers to care. The midwife cannot simply wait—she must actively follow up. Home visits are the tool for reaching defaulters in community-based midwifery. The midwife will conduct the full ANC assessment at the home and address any barriers to continued care.