Situation: A 25-year-old primigravida at 40 weeks' gestation is in labor at a birthing facility that follows the Department of Health (DOH) Essential Intrapartum and Newborn Care (EINC) protocol. Her companion of choice stays with her, and her labor has been uncomplicated. The client gives birth to a term baby who cries at birth. In what order should the nurse carry out these EINC steps? 1. Remove the wet cloth and place the baby prone on the mother's chest, skin-to-skin 2. Apply eye ointment to the baby 3. Clamp and cut the cord once pulsations stop 4. Dry the baby thoroughly on the mother's abdomen

EINC is a time-bound sequence: immediate, thorough drying on the mother's abdomen in the first 30 seconds while breathing is checked, then removal of the wet cloth and skin-to-skin contact, then properly timed cord clamping after pulsations stop (about 1 to 3 minutes). Eye ointment is a routine newborn procedure done after the first full breastfeed, with mother and baby kept together until then.

Understanding the EINC sequence

The DOH Essential Intrapartum and Newborn Care (EINC) protocol is built around a time-bound sequence that prioritizes non-separation of mother and baby, immediate skin-to-skin contact, and delayed cord clamping. For a term baby who cries at birth, the nurse must follow the steps in a specific order to maximize thermoregulation, bonding, and physiologic transition.

The first action is immediate and thorough drying on the mother's abdomen for about 30 seconds. This removes amniotic fluid, reduces evaporative heat loss, and provides tactile stimulation while the nurse simultaneously assesses breathing and tone. Drying is done on the mother's abdomen—not on a separate warmer—so that the baby remains with the mother from the very first moment.

Once the baby is dry and breathing well, the wet cloth is removed and the baby is placed prone on the mother's chest, skin-to-skin. This position supports thermoregulation through maternal heat transfer, promotes colonization with maternal flora, and facilitates early initiation of breastfeeding cues.

Cord clamping is deferred until pulsations have stopped, which typically occurs around 1 to 3 minutes after birth. This delayed cord clamping allows continued placental transfusion, improving neonatal iron stores and hemodynamic stability. The cord is clamped and cut only after this waiting period, not immediately after birth.

Eye ointment application is not part of the immediate newborn sequence. Under EINC, it is performed after the first full breastfeed, with mother and baby remaining together in uninterrupted skin-to-skin contact until that point. This preserves the early bonding window and avoids unnecessary separation or intervention before breastfeeding is established.

Order	EINC step	Rationale
1	Dry thoroughly on mother's abdomen	Prevents hypothermia; stimulates breathing; done within first 30 seconds
2	Remove wet cloth; place prone skin-to-skin on chest	Maintains warmth; promotes bonding and early breastfeeding cues
3	Clamp and cut cord after pulsations stop	Allows placental transfusion; supports iron stores and hemodynamic stability
4	Apply eye ointment after first full breastfeed	Routine prophylaxis delayed to protect early bonding and breastfeeding

Key point! The sequence is dry → skin-to-skin → delayed cord clamping → eye care after breastfeeding. Eye ointment is never done before skin-to-skin contact or before the first breastfeed in the EINC protocol.

Watch out! A common error is to clamp the cord immediately after drying. In EINC, cord clamping is intentionally delayed until pulsations cease, which takes about 1 to 3 minutes. Another error is placing eye ointment early in the sequence; this disrupts the uninterrupted skin-to-skin and breastfeeding initiation that EINC protects.

The correct order is therefore dry thoroughly (4), then skin-to-skin on the chest (1), then clamp and cut the cord after pulsations stop (3), and finally apply eye ointment after the first full breastfeed (2)—matching option 2.

While the provided evidence summaries do not directly describe the EINC step sequence, they reinforce the broader principle that contemporary obstetric and newborn care emphasizes minimizing unnecessary separation and supporting physiologic transition. The systematic review on contemporary obstetric interventions highlights that newborn care decisions are made within an integrated framework of maternal and neonatal outcomes, consistent with the EINC emphasis on keeping mother and baby together and timing interventions deliberately .