NLE Antepartum, Intrapartum & Postpartum Care — Normal Labor & DeliveryRevision Notes

Exam Tips

• If the NLE asks for the MOST FAVORABLE fetal position → LOA (Left Occiput Anterior).
• If the NLE asks for the MOST FAVORABLE pelvic type → GYNECOID.
• If the NLE asks about the presenting part in vertex presentation → the OCCIPUT is the denominator/reference point.
• Remember: Full FLEXION = smallest diameter = favorable. Extension = larger diameter = unfavorable.
• The 'Five Ps' mnemonic covers all causes of dystocia (prolonged/arrested labor) — if labor is not progressing, assess all five Ps systematically.

Key Points

• The Five Ps are: Passenger, Passage, Powers, Position (maternal), and Psyche — all must be favorable for normal labor to progress.
• PASSENGER refers to the fetus. Key aspects are: fetal LIE (relationship of fetal spine to maternal spine — longitudinal is normal), PRESENTATION (part entering the pelvis first — cephalic/vertex is ideal), POSITION (relationship of presenting part to maternal pelvis — LOA = Left Occiput Anterior is the most common and most favorable), and ATTITUDE (degree of fetal flexion — full flexion presents the smallest diameter, the suboccipitobregmatic diameter ~9.5 cm).
• PASSAGE includes the bony pelvis and soft tissues. The GYNECOID pelvis is the most favorable female type for vaginal delivery (rounded inlet). Other types: android (heart-shaped, unfavorable), anthropoid (oval A-P), platypelloid (flat).
• POWERS = primary power (uterine contractions) + secondary power (maternal pushing/bearing down effort, used in the 2nd stage). Contractions should be regular, progressive, and coordinated.
• POSITION (maternal): Upright, ambulating, or left-lateral positions enhance descent and prevent aortocaval compression, improving uteroplacental perfusion.
• PSYCHE: Fear, anxiety, and lack of support increase catecholamine release, which can inhibit uterine contractions and heighten pain perception. Continuous labor support (doula, family) is evidence-based.
• LOA (Left Occiput Anterior) is the most common fetal position. The occiput (back of fetal head) faces the left anterior quadrant of the maternal pelvis.

Definitions

Section Title

The Five Ps of Labor

Common Mistakes

• Confusing fetal LIE with fetal POSITION — lie is the axis relationship (longitudinal vs. transverse); position is the denominator-to-pelvis relationship (LOA, ROA, etc.).
• Assuming all cephalic presentations are vertex — face and brow presentations are also cephalic but abnormal and often require cesarean.
• Forgetting that the ANDROID pelvis (not gynecoid) is associated with difficult labor and higher cesarean rates.
• Neglecting the Psyche component — continuous emotional support is a nursing intervention backed by evidence and is testable on the NLE.

Exam Tips

• NLE classic question: 'What is the DEFINITIVE sign of true labor?' → PROGRESSIVE CERVICAL DILATION AND EFFACEMENT.
• True labor intensifies with walking; false labor eases with walking — this is a common NLE differentiator.
• Bloody show = normal, expected sign. Bright red vaginal bleeding = ABNORMAL, report immediately (think placenta previa or abruption).
• Lightening = easier breathing + more urinary frequency. Remember: breathe easy, pee more.
• Effacement percentage and dilation in centimeters are both reported in a vaginal exam — know both measurements.

Key Points

• PREMONITORY (pre-labor) signs occur days to weeks before true labor: lightening (fetal descent into the pelvis), Braxton Hicks contractions, cervical ripening, nesting/energy burst, slight weight loss (1–3 lbs), and passage of the bloody show (blood-tinged mucus plug).
• LIGHTENING occurs 2–4 weeks before labor in primigravidas; may occur just hours before labor in multigravidas. The mother breathes easier (fundus drops) but urinates more frequently.
• BLOODY SHOW = passage of the cervical mucus plug mixed with blood as the cervix begins to efface and dilate. It is a reliable sign of impending labor within hours to days.
• TRUE LABOR contractions are REGULAR, INCREASINGLY frequent, longer, and stronger; they are felt from BACK to FRONT (fundus-dominant); they INTENSIFY with walking; and most importantly, they cause PROGRESSIVE CERVICAL DILATION AND EFFACEMENT.
• FALSE LABOR (Braxton Hicks) contractions are IRREGULAR, do not increase in intensity, are felt mostly in the ABDOMEN, often EASE or STOP with walking or position change, and cause NO cervical change.
• CERVICAL CHANGE (progressive dilation and effacement) is the DEFINITIVE and most reliable sign of true labor — this is the key NLE differentiator.
• EFFACEMENT is the shortening and thinning of the cervical canal, expressed as a percentage (0% = uneffaced, 100% = fully effaced, paper-thin). In primigravidas, effacement typically precedes dilation; in multigravidas, both occur simultaneously.

Definitions

Section Title

Signs of Impending and True Labor

Common Mistakes

• Choosing 'regular contractions' as the definitive sign of true labor — regular contractions alone are NOT sufficient. Cervical change is the definitive sign.
• Confusing bloody show with pathologic bleeding — bloody show is scant, mucoid, and pink/brownish; pathologic bleeding is bright red, frank, and heavier.
• Forgetting that in MULTIGRAVIDAS, effacement and dilation often happen simultaneously (unlike primigravidas where effacement comes first).
• Thinking lightening only improves breathing — it also INCREASES urinary frequency and pelvic pressure/discomfort.

Exam Tips

• Memorize the transition phase boundaries: 8–10 cm. Key nursing action: PREVENT premature pushing — coach panting or blow-breathing.
• The LONGEST stage = First stage. The MOST PAINFUL transition = transition phase. The HIGHEST PPH RISK = Fourth stage.
• Signs of placental separation: GUSH of blood + LENGTHENING cord + GLOBULAR firm uterus + RISING fundus. All 4 must be present before cord traction.
• In the fourth stage, assess fundus, lochia, VS, and bladder every 15 minutes × 1 hour, then every 30 minutes × 1 hour.
• Boggy uterus = MASSAGE FIRST, then reassess. If still boggy, administer oxytocin per order and notify physician.

Key Points

• Labor has FOUR STAGES: First (onset of true labor to full 10 cm dilation), Second (full dilation to birth of baby), Third (birth of baby to delivery of placenta), Fourth (first 1–2 hours postpartum — recovery).
• FIRST STAGE has three phases: LATENT (0–3/4 cm, some sources extend to 5–6 cm), ACTIVE (~4–7 cm), and TRANSITION (8–10 cm). The first stage is the LONGEST stage.
• LATENT PHASE: Contractions mild, every 5–10 minutes, duration 20–40 seconds. Woman is sociable, talkative, able to cope. Nursing: encourage ambulation, oral hydration, rest, and support.
• ACTIVE PHASE: Contractions moderate to strong, every 3–5 minutes, duration 40–60 seconds. Woman becomes serious, inward-focused, may request analgesia. This is the typical time for epidural placement. Nursing: frequent FHR and contraction monitoring, pain management, positioning.
• TRANSITION PHASE: Most INTENSE phase. Contractions every 2–3 minutes, duration 60–90 seconds, very strong. Woman may be irritable, trembling, nauseated, vomiting, and feels an URGE TO PUSH due to rectal pressure. CRITICAL: The woman MUST NOT push until fully dilated (10 cm) to prevent cervical edema, lacerations, and fetal head trauma.
• SECOND STAGE: From full dilation (10 cm) to birth. Characterized by involuntary urge to bear down. The CARDINAL MOVEMENTS of labor occur during this stage. The nurse assists with pushing and prepares the delivery field.
• THIRD STAGE: From birth of baby to delivery of the placenta, normally 5–30 minutes. Signs of placental separation must be awaited before applying traction. Do NOT pull on the cord prematurely.
• FOURTH STAGE: First 1–2 hours after delivery — the highest-risk period for POSTPARTUM HEMORRHAGE (PPH). Assess fundus, lochia, perineum, vital signs, and bladder every 15 minutes in the first hour.
• Signs of placental separation (3rd stage): (1) GUSH of blood, (2) LENGTHENING of the umbilical cord, (3) uterus becomes GLOBULAR and FIRM, (4) fundus RISES in the abdomen.
• Placenta may deliver by SCHULTZE mechanism (shiny fetal side first — most common, central separation) or DUNCAN mechanism ('dirty Duncan' — dull maternal side first, marginal separation, associated with more bleeding).

Definitions

Section Title

Stages and Phases of Labor

Common Mistakes

• Forgetting there are FOUR stages — many students only recall three. The fourth stage (first 1–2 hours postpartum) is the highest PPH risk period.
• Allowing the patient to push during the transition phase (8–10 cm) before full dilation — this is a patient-safety error.
• Pulling on the umbilical cord before signs of placental separation — this risks uterine inversion.
• Confusing Schultze and Duncan: Schultze = shiny (fetal side, central), Duncan = dull/dirty (maternal side, marginal, more bleeding).
• Thinking the third stage has no time limit — if the placenta is not delivered within 30 minutes, it is considered a retained placenta requiring intervention.

Exam Tips

• Memorize the mnemonic: 'Every Decent Family In Elk Ridge Enjoys' for the 7 cardinal movements in correct order.
• NLE questions often ask: 'What occurs when the fetal head delivers under the symphysis pubis?' → EXTENSION.
• After the head is delivered and the occiput turns back to face the thigh = EXTERNAL ROTATION/RESTITUTION.
• Engagement = Station 0 = biparietal diameter through inlet. This is the first cardinal movement.
• Internal rotation aligns the fetal head with the A-P (anteroposterior) diameter of the pelvic outlet — this is why it is necessary.

Key Points

• The cardinal movements describe the positional changes the fetal HEAD makes as it passes through the maternal pelvis during the second stage of labor.
• There are 7 cardinal movements in order: ENGAGEMENT → DESCENT → FLEXION → INTERNAL ROTATION → EXTENSION → EXTERNAL ROTATION (Restitution) → EXPULSION.
• Mnemonic: 'Every Decent Family In Elk Ridge Enjoys' (Engagement, Descent, Flexion, Internal rotation, Extension, External rotation/Restitution, Expulsion).
• ENGAGEMENT: The widest transverse diameter of the fetal head (biparietal diameter, ~9.5 cm) passes through the pelvic inlet. Station 0 is achieved.
• DESCENT: The downward movement of the fetal presenting part through the pelvis. It occurs throughout labor and is necessary for all other movements.
• FLEXION: The fetal chin flexes onto the chest, reducing the presenting diameter from the larger occipitofrontal to the smaller suboccipitobregmatic (~9.5 cm). Facilitates passage through the pelvis.
• INTERNAL ROTATION: The fetal occiput rotates from transverse (LOT) to the anterior position (OA) under the symphysis pubis, aligning with the maternal pelvic outlet (which is A-P oriented). This is the most complex movement.
• EXTENSION: As the fetal head reaches the vaginal outlet (perineum), the occiput pivots under the symphysis pubis and the head extends (chin lifts off chest), delivering the head: occiput first, then brow, nose, mouth, and chin.
• EXTERNAL ROTATION (RESTITUTION): After delivery of the head, the occiput rotates back to its original position (left or right), aligning the fetal head with the fetal shoulders. The shoulders rotate into the A-P diameter of the outlet.
• EXPULSION: Delivery of the rest of the fetal body — the anterior shoulder delivers first under the symphysis pubis, followed by the posterior shoulder, then the trunk and lower extremities.
• The nurse must check for a NUCHAL CORD (umbilical cord around the fetal neck) during delivery of the head. If present and loose, slip it over the head; if tight, clamp and cut before delivery of the shoulders.

Definitions

Section Title

Cardinal Movements (Mechanisms) of Labor

Common Mistakes

• Mixing up the order of cardinal movements — especially placing extension before internal rotation. The correct order: Engagement → Descent → Flexion → Internal Rotation → Extension → External Rotation → Expulsion.
• Thinking all cardinal movements happen in sequence without overlap — descent is continuous and occurs alongside all other movements.
• Forgetting to include Engagement as the first cardinal movement — some students start the list with Descent.
• Confusing external rotation (restitution) with internal rotation — internal rotation happens inside the pelvis (occiput to anterior); external rotation happens after the head is delivered.

Exam Tips

• For NLE deceleration questions, use the 3Cs: Early = Head Compression (Benign); Variable = Cord Compression (Reposition); Late = Circulatory/Placental insufficiency (Ominous — act now).
• The intrauterine resuscitation bundle acronym: STOP-R-O-I-N: Stop oxytocin, Turn/Reposition, Oxygen, Increase fluids, Notify MD.
• Normal FHR = 110–160 bpm. If asked about REASSURING FHR characteristics: normal baseline + moderate variability + accelerations present + no late/variable decelerations.
• Uterine hyperstimulation trigger for stopping oxytocin: contractions <2 min apart OR >90 seconds duration OR resting tone never relaxes.
• Accelerations with fetal movement = reactive NST = reassuring = no immediate intervention needed.

Key Points

• NORMAL BASELINE FETAL HEART RATE (FHR) = 110–160 bpm. Memorize this range — it is a high-yield NLE value.
• FETAL TACHYCARDIA = FHR baseline >160 bpm (causes: maternal fever, fetal infection, early fetal hypoxia, maternal medications like terbutaline).
• FETAL BRADYCARDIA = FHR baseline <110 bpm (causes: prolonged cord compression, profound hypoxia, maternal hypotension — ominous if sustained).
• BASELINE VARIABILITY = fluctuations in FHR between contractions. MODERATE VARIABILITY (6–25 bpm fluctuation) is REASSURING — indicates an intact autonomic nervous system and adequate fetal oxygenation. ABSENT or MINIMAL variability is CONCERNING.
• ACCELERATIONS = transient increases in FHR (≥15 bpm above baseline, lasting ≥15 seconds). REASSURING sign — indicates fetal well-being and adequate oxygenation. A reactive non-stress test (NST) has at least 2 accelerations in 20 minutes.
• EARLY DECELERATIONS: Gradual FHR decrease that mirrors the contraction (onset with contraction onset, nadir at contraction peak, returns to baseline when contraction ends). Caused by FETAL HEAD COMPRESSION during contractions. BENIGN — no intervention needed.
• VARIABLE DECELERATIONS: Abrupt FHR decreases that vary in timing, shape, and duration relative to contractions. Caused by UMBILICAL CORD COMPRESSION. SIGNIFICANT if severe (<70 bpm, lasting >60 seconds) or repetitive. Nursing action: REPOSITION mother (left lateral or knee-chest).
• LATE DECELERATIONS: Gradual FHR decreases that begin AFTER the contraction peak and return to baseline AFTER the contraction ends (offset from the contraction). Caused by UTEROPLACENTAL INSUFFICIENCY (reduced oxygen delivery to the fetus during contractions). OMINOUS — requires IMMEDIATE intervention.
• INTRAUTERINE RESUSCITATION BUNDLE for late/variable decelerations or fetal distress: (1) STOP oxytocin infusion, (2) REPOSITION to LEFT LATERAL (or knee-chest for cord prolapse), (3) GIVE OXYGEN by mask at 8–10 L/min, (4) INCREASE IV fluids (correct hypotension), (5) NOTIFY the physician/obstetrician. This bundle addresses the underlying causes: cord compression, uteroplacental insufficiency, and hypotension.
• Contraction assessment parameters: FREQUENCY (start to start of consecutive contractions), DURATION (beginning to end of one contraction), INTENSITY (mild/moderate/strong by palpation), and REST INTERVAL.
• UTERINE HYPERSTIMULATION: Contractions <2 minutes apart, duration >90 seconds, or uterus that never fully relaxes. Risk of fetal hypoxia and uterine rupture. STOP OXYTOCIN IMMEDIATELY.

Definitions

Section Title

Fetal Heart Rate Monitoring and Interpretation

Common Mistakes

• Mixing up early and late decelerations — the KEY difference is TIMING relative to the contraction: Early = mirrors contraction (same time); Late = begins after contraction peak and returns after contraction ends.
• Treating early decelerations as an emergency — they are BENIGN and require no intervention.
• Forgetting the correct normal FHR range — 110–160 bpm (not 120–160 bpm). The lower limit is 110.
• Omitting 'stop oxytocin' as the FIRST step in the intrauterine resuscitation bundle when oxytocin is infusing.
• Confusing frequency and duration of contractions: FREQUENCY = start-to-start interval; DURATION = beginning to end of ONE contraction.

Exam Tips

• NLE oxytocin rule: ALWAYS titrated IV infusion for induction — NEVER IV push. High-alert drug = requires double-check and infusion pump.
• Epidural priority assessment: BLOOD PRESSURE after placement. If hypotension → left lateral, increase fluids, O2, notify MD, ephedrine PRN.
• Opioids in labor + delivery <1–4 hours later = have NALOXONE ready for the newborn.
• Oxytocin STOP criteria: contractions <2 min apart, >90 sec duration, or uterus never relaxes, or late decelerations develop.
• Post-delivery standard in Philippine DOH facilities: Oxytocin 10 units IM as part of active management of the 3rd stage (Unang Yakap/AMTSL protocol).

Key Points

• OXYTOCIN (Pitocin) is used for labor induction/augmentation and postpartum hemorrhage prevention/treatment. It is classified as a HIGH-ALERT DRUG by the PRC and international patient safety standards.
• For INDUCTION/AUGMENTATION: Oxytocin is ALWAYS given as a DILUTE INTRAVENOUS INFUSION via an infusion pump, titrated according to contraction response. NEVER give as an IV bolus/push for labor induction — this causes sudden intense contractions, uterine hyperstimulation, fetal distress, and possible uterine rupture.
• For POSTPARTUM HEMORRHAGE PREVENTION: After delivery of the placenta, oxytocin 10 units IM OR added to IV fluids per DOH/hospital protocol is the standard of care in the Philippines (part of active management of the third stage).
• MONITOR for uterine hyperstimulation and fetal distress when oxytocin is infusing. If hyperstimulation occurs: STOP the infusion immediately, reposition left lateral, give O2, increase IV fluids, and notify the physician.
• EPIDURAL ANALGESIA: The most effective and commonly used labor pain relief. The woman remains awake and can push. Anesthetic agent (e.g., bupivacaine) ± opioid is infused into the epidural space.
• MAIN RISK OF EPIDURAL = MATERNAL HYPOTENSION (due to sympathetic blockade causing vasodilation). Prevention: IV fluid bolus (preload) before epidural placement. Treatment: left lateral position, increase IV fluids, oxygen, and ephedrine (vasopressor) if ordered.
• A hypotensive mother has reduced placental perfusion → late decelerations → fetal distress. This is why epidural hypotension is a priority nursing concern.
• SYSTEMIC OPIOIDS (e.g., NALBUPHINE, MEPERIDINE/PETHIDINE): Reduce pain perception but do not eliminate it. Main nursing concern: neonatal respiratory depression if given close to delivery. AVOID giving within 1–4 hours of expected delivery. Keep NALOXONE (Narcan) readily available in the delivery room to reverse neonatal opioid-induced respiratory depression.
• PUDENDAL BLOCK / LOCAL INFILTRATION: Provides perineal anesthesia for vaginal delivery, episiotomy, and repair. Does not affect FHR or maternal blood pressure.
• NON-PHARMACOLOGIC PAIN MANAGEMENT: Lamaze breathing techniques, ambulation, position changes (upright, hands-and-knees for back labor), hydrotherapy (warm shower/bath), massage, hot/cold packs, counter-pressure on the sacrum, and continuous labor support. Evidence shows continuous support reduces need for analgesia, shortens labor, and improves maternal satisfaction.

Definitions

Section Title

Pharmacology in Labor and Delivery

Common Mistakes

• Thinking oxytocin can be given as an IV push/bolus for labor induction — this is WRONG and DANGEROUS. Induction doses must be titrated via infusion pump.
• Forgetting the most common side effect of epidural analgesia: HYPOTENSION (not headache — post-dural puncture headache occurs only if the dura is accidentally punctured).
• Confusing nalbuphine/meperidine timing — the concern is neonatal respiratory depression within 1–4 hours of delivery, not immediately after administration.
• Omitting naloxone availability as a nursing preparedness measure when opioids are used in labor.
• Not stopping oxytocin immediately during uterine hyperstimulation — some students try to 'slow down' the rate first, but the correct first action is to STOP the infusion.

Exam Tips

• Cord prolapse sequence: Trendelenburg/Knee-chest → Gloved hand lifts presenting part → O2 → moist cord → emergency CS.
• For any vaginal exam or rupture of membranes, the FIRST nursing action is ALWAYS to check the FETAL HEART RATE.
• BOGGY uterus = uterine atony = #1 PPH cause → MASSAGE the fundus FIRST, then give oxytocin.
• Shoulder dystocia = McRoberts + suprapubic pressure. NEVER fundal pressure.
• Green amniotic fluid = meconium = call NICU/pediatrician. Be ready for neonatal resuscitation.

Key Points

• CORD PROLAPSE: The umbilical cord descends into the vaginal canal AHEAD of or ALONGSIDE the presenting part after membrane rupture. The presenting part compresses the cord → cuts off fetal blood supply → fetal bradycardia/variable decelerations → life-threatening fetal emergency.
• Risk factors for cord prolapse: premature rupture of membranes with an unengaged presenting part, polyhydramnios, multiple gestation, breech presentation, transverse lie.
• NURSING PRIORITIES FOR CORD PROLAPSE — in order: (1) CALL for help (shout code/activate emergency). (2) Place mother in KNEE-CHEST or TRENDELENBURG position to move the presenting part off the cord by gravity. (3) INSERT a GLOVED HAND into the vagina and MANUALLY LIFT the presenting part OFF the cord — do NOT remove the hand until delivery. (4) Administer OXYGEN by mask. (5) Keep the cord MOIST with warm saline-soaked gauze if it protrudes externally. (6) Prepare for EMERGENCY cesarean section. NEVER attempt to push the cord back into the uterus.
• RUPTURE OF MEMBRANES — Assessment priorities: Note the TIME, COLOR (clear = normal; GREEN/meconium-stained = fetal distress; foul-smelling = infection/chorioamnionitis), ODOR, and AMOUNT (TCOA mnemonic). IMMEDIATELY assess FETAL HEART RATE to rule out cord prolapse.
• MECONIUM-STAINED AMNIOTIC FLUID: Indicates possible fetal distress (hypoxia caused fetal passage of meconium in utero). Thick, green fluid requires preparation for neonatal suctioning/resuscitation at delivery. Notify pediatrics/neonatology team.
• UTERINE HYPERSTIMULATION: Signs — contractions <2 min apart, >90 sec duration, uterus does not relax. Risk: fetal hypoxia, uterine rupture. Action: STOP oxytocin immediately, reposition, give O2, increase IVF, notify MD.
• UTERINE RUPTURE: A rare but life-threatening emergency. Signs: sudden severe abdominal pain (may describe 'tearing' sensation), loss of uterine contraction pattern, fetal parts palpable abdominally, fetal distress, maternal shock. Emergency cesarean + blood transfusion required.
• POSTPARTUM HEMORRHAGE (PPH): Blood loss >500 mL after vaginal delivery or >1,000 mL after cesarean. LEADING CAUSE = uterine atony. First sign: BOGGY (soft, not firm) uterus. PRIORITY action: FUNDAL MASSAGE until firm; administer oxytocin per order; monitor vital signs.
• AMNIOTIC FLUID EMBOLISM (AFE): Rare, catastrophic emergency. Amniotic fluid enters maternal circulation, causing sudden cardiovascular collapse, respiratory failure, and DIC. Requires ICU-level resuscitation.
• SHOULDER DYSTOCIA: Impaction of the fetal shoulder behind the maternal pubic symphysis after delivery of the head. Emergency maneuvers: McRoberts maneuver (hyperflexion of maternal thighs), suprapubic pressure (NOT fundal pressure — which worsens impaction), Rubin/Woods maneuver, Gaskin maneuver (all-fours position).

Definitions

Section Title

Complications During Labor: Recognition and Priority Nursing Actions

Common Mistakes

• Applying FUNDAL PRESSURE during shoulder dystocia — this is contraindicated because it worsens the impaction of the shoulder. The correct maneuver is SUPRAPUBIC pressure.
• Trying to push the prolapsed cord back into the uterus — this is CONTRAINDICATED; keep it moist and lift the presenting part off it manually.
• Forgetting to check FHR IMMEDIATELY after rupture of membranes — cord prolapse assessment is the priority, not memrane color documentation.
• Omitting oxytocin assessment from PPH management — fundal massage is first, but oxytocin administration is equally critical.
• Confusing atony (boggy uterus = most common PPH cause) with retained placenta or lacerations — these are also causes of PPH but less common.

Formulas

Exam Tips

• Memorize EINC's 4 steps in order: DRY → SKIN-TO-SKIN → DELAYED CORD CLAMPING (after pulsations stop, 1–3 min) → NON-SEPARATION/BREASTFEEDING within 1 hour.
• Apgar mnemonic: Appearance, Pulse, Grimace, Activity, Respiration. Score at 1 and 5 minutes. Normal = 7–10.
• NLE question: 'When should the cord be clamped under EINC?' → After cord pulsations stop, approximately 1–3 minutes after birth.
• NLE question: 'What is the FIRST action after delivery of the newborn under Unang Yakap?' → IMMEDIATE AND THOROUGH DRYING.
• Vitamin K and eye prophylaxis are given AFTER the first hour of breastfeeding under EINC — NOT immediately at birth.

Key Points

• Unang Yakap means 'First Embrace' in Filipino. It is the DOH Philippines' implementation of the WHO's Essential Intrapartum and Newborn Care (EINC) protocol, mandated in all Philippine hospitals and birthing facilities.
• The protocol has FOUR TIME-BOUND, SEQUENTIAL CORE STEPS that must be performed at every birth:
• STEP 1 — IMMEDIATE AND THOROUGH DRYING: Within the first seconds of birth, dry the newborn thoroughly with a clean, dry cloth/towel. This stimulates breathing and prevents HYPOTHERMIA. Replace the wet cloth with a dry one. Do NOT bathe the newborn immediately.
• STEP 2 — EARLY SKIN-TO-SKIN CONTACT: Place the dried baby PRONE on the mother's abdomen or chest, with direct skin-to-skin contact. Cover both mother and baby with a blanket. This maintains newborn temperature, promotes bonding, colonization with maternal flora, and initiates breastfeeding.
• STEP 3 — PROPERLY TIMED CORD CLAMPING: Wait for cord pulsations to STOP (approximately 1–3 minutes) before clamping and cutting the cord. This is called DELAYED CORD CLAMPING. It allows an additional 80–100 mL of placental blood to transfuse to the newborn, increasing iron stores and hemoglobin, reducing the risk of iron-deficiency anemia.
• STEP 4 — NON-SEPARATION OF MOTHER AND BABY FOR EARLY BREASTFEEDING: The baby is NOT separated from the mother. The baby is left skin-to-skin to find the breast on its own (breast crawl) and latch within the first hour of life (the 'golden hour'). Early breastfeeding provides colostrum, promotes uterine involution (oxytocin release), and establishes milk supply.
• EINC also prescribes: NO routine suctioning of the airway (unless baby is not breathing), NO early bathing (delays for at least 6 hours), NO separation of mother and baby for routine procedures.
• APGAR SCORE is assessed at 1 minute and 5 minutes after birth (and at 10 minutes if the 5-minute score is <7). Components: Appearance (color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), Respiration. Each scored 0–2; total 0–10. Score 7–10 = normal; 4–6 = moderate compromise; 0–3 = severe, immediate resuscitation needed.
• Under EINC, Vitamin K (Phytonadione 1 mg IM) and Erythromycin eye ointment are given AFTER the first hour of breastfeeding — not immediately — to avoid interrupting the golden hour.

Definitions

Section Title

Unang Yakap (EINC) — Essential Intrapartum and Newborn Care

Common Mistakes

• Thinking the cord should be clamped immediately after birth — under EINC, clamping is DELAYED until pulsations stop (~1–3 minutes).
• Bathing the newborn immediately after delivery — EINC recommends delaying bath for at least 6 hours to prevent hypothermia and preserve vernix caseosa.
• Suctioning the newborn routinely — EINC does NOT recommend routine airway suctioning; suction only if the baby is not breathing or airway is obstructed.
• Separating the baby from the mother for routine procedures (weighing, eye care, Vitamin K) during the first hour — these are deferred until after the first breastfeed.
• Confusing Apgar score timing: it is at 1 and 5 MINUTES (not 5 and 10 minutes). If the 5-minute score is <7, repeat at 10 minutes.