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

The public health bag is the midwife's mobile clinic—a clean, organized container of equipment and supplies designed for safe, efficient home-based care. Bag technique is the standardized method of using the bag so that procedures are performed cleanly in a non-sterile home environment while minimizing infection risk. The guiding principles are: (1) the bag and contents must be clean and well-arranged; (2) the technique must prevent spread of infection from the home into the bag and from the bag to the family; (3) it must save time and effort through orderly movements; and (4) it must demonstrate the midwife's professionalism. On arrival at a home, the midwife places the bag on a clean, flat surface (or her own lining if necessary), asks for water and soap, washes her hands thoroughly, opens the bag to create a clean working field, and takes out only the articles needed for the specific procedure. The critical principle is that the inside of the bag is always treated as clean and must never be contaminated by dirty hands or used items. After each procedure, used articles are cleaned and replaced, hands are washed again, and the bag is closed.

The DOH standard is a minimum of four antenatal care (ANC) visits during pregnancy, spaced as: (1) the first visit in the first trimester (as early as possible), (2) the second in the second trimester, and (3) two visits in the third trimester. The WHO now recommends eight contacts, and services are gradually moving toward that standard. Each prenatal home visit delivers the pregnancy package: history and risk assessment (age, parity, obstetric and medical history, LMP, EDD), physical assessment (weight, blood pressure at every visit, fundal height, fetal heart tones, and fetal position by Leopold's maneuvers in the third trimester), tetanus immunization (TT/Td following the five-dose schedule for lifelong protection), micronutrient supplementation (iron with folic acid daily, calcium, and iodine), deworming in the second or third trimester, laboratory screening where available (blood typing, hemoglobin, urinalysis, syphilis and infection screening), and health teaching—particularly about danger signs. Blood pressure monitoring at every visit is a key requirement, as hypertension is a red flag for pre-eclampsia.

Danger signs of pregnancy are symptoms or findings that indicate a woman needs immediate facility-based assessment and care. Teaching the woman and her family to recognize these signs is a central task of every prenatal contact and is essential for the three-delays framework. The danger signs of pregnancy include: (1) vaginal bleeding (any amount); (2) severe headache or blurring of vision (pre-eclampsia); (3) swelling of the face and hands (edema, a sign of hypertension); (4) convulsions or fits (eclampsia); (5) high fever (infection); (6) severe abdominal or epigastric pain (abruption, acute abdomen); (7) persistent, severe vomiting (dehydration, hyperemesis); (8) decreased or absent fetal movement (fetal distress); (9) watery vaginal discharge (rupture of membranes); (10) foul-smelling vaginal discharge (infection); and (11) fast or difficult breathing (cardiac or respiratory compromise). Any one of these is an absolute referral trigger—the midwife arranges immediate transfer to a BEmONC or CEmONC facility. The midwife does NOT attempt to manage these; she recognizes and refers.

The birth plan is a written, family-centered document created during the prenatal period that identifies in advance the decisions and arrangements needed for a safe, timely delivery. It directly addresses the three delays (delay in deciding to seek care, delay in reaching care, and delay in receiving care) by ensuring that the family, the midwife, and the community have a coordinated, rehearsed response to labor and emergency. The birth plan must include: (1) the place of delivery—always a facility with a skilled birth attendant (BEmONC-capable), never a home birth with a traditional birth attendant; (2) the skilled birth attendant who will conduct the delivery; (3) a planned transport method and a backup plan; (4) a named companion and arrangements for other children; (5) identified savings or funds to cover delivery and emergency costs; (6) a blood donor identified in advance in case transfusion is needed; and (7) clear recognition of labor signs and danger signs that mean "go now." The birth plan is written, discussed with the family, and kept accessible. When reviewed by the family multiple times, it transforms emergency response from chaos into rehearsed action.

The postpartum and newborn period, especially the first 24 to 48 hours and the first week, carries the highest risk of death for both mother and baby. The DOH standard is at least two postpartum check-ups: the first within 24 hours of delivery and the second on about the 7th day (one week) postpartum, with an additional visit at around 6 weeks. The newer WHO postnatal-contact model adds contacts at day 3 and days 7-14, reflecting the same intent of frequent early follow-up to catch complications before they become lethal. Each postnatal visit includes assessment of the mother (vital signs, uterine involution, lochia, perineum/wound healing, breasts, bladder and bowel function, mood), assessment of the newborn (feeding, cord care, warmth, growth, immunization status, newborn screening status), health teaching (especially breastfeeding support and family planning), and documentation on the mother-and-child record and TCL. The 6-week visit marks the end of the intensive postpartum period and is often when family planning counseling is finalized.

At each postnatal visit, the midwife systematically assesses the mother for recovery and early signs of complications. Assessment includes: (1) vital signs, with particular attention to temperature (fever suggests infection—commonly endometritis, episiotomy infection, or urinary tract infection); (2) uterine involution—the fundus should be firm and descending by about one fingerbreadth per day (by day 10, the fundus is usually no longer palpable); (3) lochia—amount, color, and odor; early lochia is red (rubra) and scant, then becomes pinkish-brown (serosa), then whitish-yellow (alba); heavy bleeding or foul-smelling discharge is abnormal and suggests infection or retained products; (4) perineum and any tear or episiotomy for signs of healing, infection, or dehiscence; (5) breasts for engorgement, cracked or bleeding nipples, signs of mastitis (localized heat, redness, hardness, pain), and support for exclusive breastfeeding; (6) bladder and bowel function—delayed voiding or constipation is common and should be managed; (7) emotional state—ask about sleep, mood, and ability to cope, as postpartum depression is common and can be severe. Postpartum danger signs (referral triggers) include: heavy vaginal bleeding, foul-smelling lochia, fever, severe headache or visual changes (eclampsia), convulsions, painful/red/swollen breast (mastitis), calf pain or swelling (thrombophlebitis), difficulty breathing, and signs of severe depression or suicidal thoughts.

At each postnatal visit, the midwife assesses the newborn for feeding, growth, infection, and developmental progress. Assessment includes: (1) feeding—exclusive breastfeeding on demand; check for good attachment (baby's mouth covers most of the areola, cheeks rounded, no clicking sounds), adequate milk transfer (baby swallows audibly), and adequate output (at least 6-8 wet diapers per day by day 3-4); (2) cord care—keep the stump clean and dry; watch for redness, discharge, or foul smell, which suggest infection (omphalitis) requiring referral; (3) warmth—assess for signs of hypothermia (cold to touch, lethargy) or hyperthermia (hot to touch), and teach kangaroo care (skin-to-skin) for small or cold babies; (4) weight and growth monitoring—newborns lose about 5-10% of birth weight in the first few days, regaining it by about day 10; significant losses or failure to gain suggest inadequate feeding; (5) newborn screening—confirm that the heel-prick blood sample for Expanded Newborn Screening (ENS) was taken between 24 and 72 hours of life (never before 24 hours) and that newborn hearing screening was done; if not, arrange them immediately; (6) immunization—confirm that BCG and Hepatitis B birth doses were given and set the EPI schedule for subsequent vaccines; (7) jaundice assessment—physiologic jaundice appears after 24 hours and peaks at day 3-5; jaundice of the palms and soles at any time is pathologic and requires referral; (8) general condition—assess for alertness, muscle tone, cry quality. Newborn danger signs (referral triggers) include: poor feeding or not feeding at all, convulsions, fast breathing (60 breaths per minute or more) or severe chest indrawing (respiratory distress), fever (axillary temperature above 37.5°C) or hypothermia (below 36.5°C), no movement even when stimulated (lethargy), jaundice of the palms and soles, redness/swelling/pus around the cord or eyes (infection), and severe abdominal distension or vomiting (bowel obstruction).

Every home visit, prenatal contact, immunization, and postnatal check is recorded on the mother-and-child record (MCR) and the Target Client List (TCL), which feeds into the Field Health Services Information System (FHSIS). The TCL is a simple, practical tool that lists all pregnant women and new mothers in a given barangay or population with their contact information, expected date of delivery, and follow-up dates. The TCL enables the midwife to know who is due for what visit, who has defaulted, and who needs urgent follow-up. The FHSIS is the national system for aggregating maternal and neonatal health data, and the data submitted from the field (via the TCL and MCR) are used to track progress on the MNCHN indicators: number of pregnant women registered, number receiving antenatal care, number delivering in a facility, number receiving postnatal care, immunization rates, and newborn screening rates. Accurate, timely documentation is essential not only for individual client tracking but also for the health system's ability to monitor program performance and allocate resources. The midwife's records are the primary source of data for maternal and neonatal health accountability.

The prenatal care package delivered at home includes several evidence-based interventions: (1) Tetanus Toxoid/Tetanus-Diphtheria (TT/Td) immunization following a five-dose schedule—dose 1 and 2 given 4 weeks apart, dose 3 at 6-12 months, dose 4 at 12 months, and dose 5 at age 5 years; completion of the five-dose series confers lifelong protection against tetanus for the mother and protection against neonatal tetanus (tetanus neonatorum) for the baby, which is why it is emphasized as a core intervention; (2) iron with folic acid supplementation daily throughout pregnancy and for 3 months postpartum to prevent anemia, which increases risk of hemorrhage and poor recovery; (3) calcium supplementation, recommended at 1000-1200 mg daily (particularly in the 2nd and 3rd trimesters) to reduce risk of pre-eclampsia and improve bone health; (4) iodine supplementation to ensure fetal neurologic development; (5) deworming with a safe anthelmintic (such as albendazole) in the 2nd or 3rd trimester to reduce parasitic burden and improve maternal nutrition; (6) laboratory screening where available—blood typing (to know ABO and Rh status), hemoglobin (to detect anemia), urinalysis (to detect proteinuria or glycosuria as signs of disease), and screening for syphilis and other infections. The midwife ensures that the woman knows why she is taking each supplement and screens for any adverse effects.

Health teaching is an integral part of every prenatal home visit and represents the midwife's role as educator and counselor. Teaching during prenatal visits should focus on: (1) recognition and response to danger signs—the woman and her family must know the signs listed above and must know that any one of them means "go to the health facility immediately"; (2) nutrition—adequate intake of protein, calcium, iron, and calories; local foods that are affordable and accessible; and the importance of eating well to support fetal growth; (3) rest and activity—the importance of adequate sleep and rest, the value of light activity and walking for labor preparation, and recognition that excessive physical work increases risk of complications; (4) breastfeeding preparation—how to position the baby, signs of good attachment, the plan to breastfeed exclusively for the first 6 months, and management of common concerns like sore nipples; (5) preparation for labor and delivery—recognition of labor signs (regular contractions, bloody show, rupture of membranes), the importance of going to the facility as soon as labor begins, and the birth plan (facility, attendant, transport, companion); (6) family planning—discussion of spacing and methods to be used after delivery, with the understanding that lactational amenorrhea (exclusive breastfeeding) provides some protection but is not reliable for spacing; (7) postpartum care—what to expect (lochia, perineal discomfort, healing), the importance of rest and support, hygiene practices, and when to seek help. Teaching should be tailored to the woman's and family's level of understanding, should involve the partner and key family members (particularly the mother-in-law, who often makes decisions about care), and should be reinforced at each visit.