The EINC step that comes next
The Department of Health (DOH) Essential Intrapartum and Newborn Care (EINC) protocol sets a time-bound sequence for the first minutes after birth. Immediate thorough drying and skin-to-skin contact come first. After that, the birth attendant palpates the mother's abdomen to exclude a second baby and then gives oxytocin 10 units intramuscularly within 1 minute of birth. In this scenario the baby is already dried and on the mother's chest, the clock is at 40 seconds, and no uterotonic has been given. The nearest deadline is the 1-minute oxytocin, so the nurse checks for a second baby and gives oxytocin now.
Why the second baby must be excluded first
Oxytocin makes the uterus contract strongly. If an undiagnosed second twin is still in the uterus, a uterotonic can compromise that baby by reducing placental blood flow and making the uterus clamp down. A quick abdominal palpation takes only seconds and protects against this. Only when a second baby is ruled out is oxytocin given as part of active management of the third stage of labor, the most important measure for preventing postpartum hemorrhage.
Why cord clamping waits
EINC promotes delayed (non-immediate) cord clamping. The cord is clamped once pulsations stop, usually about 1 to 3 minutes after birth, which allows placental blood to transfer to the newborn and improves iron stores. At 40 seconds the cord is still pulsating, so it is too early to clamp and cut. The first pair of gloves is removed just before the cord is clamped, but that step belongs later in the sequence. Watch out! The option that starts with removing gloves looks like a correct EINC action, but it is out of order here.
Why controlled cord traction and waiting are wrong
Controlled cord traction delivers the placenta only after the uterotonic has been given and the uterus has contracted, with counter-traction applied above the symphysis pubis to support the uterus. Doing it now, before oxytocin and before the cord is clamped, risks uterine inversion and is out of sequence. Waiting for signs of placental separation before giving oxytocin describes expectant management, which EINC does not use; oxytocin is given within 1 minute of every birth.
Key point! When the nurse is the only birth attendant, the order of the first minute matters even more, because one person must perform every task. The practical sequence is: dry thoroughly, place skin-to-skin, check for a second baby, give oxytocin, remove the first gloves, clamp and cut the cord after pulsations stop, then perform controlled cord traction when the uterus contracts.
Exam takeaway
In EINC, oxytocin within 1 minute comes before cord clamping, and cord clamping comes before controlled cord traction. When an item gives a time stamp, compare each option against the time-bound steps and choose the one whose deadline is closest and whose prerequisites are already met.