MID-Entrep MARIAM O.

BOCA, RM

PRELIM COVERAGE
Midwifery Entrepreneurship
(U.S. Department of State/Bureau of International Information
Programs)

Entrepreneurship as a discipline
What is meant by entrepreneurship? The concept of
entrepreneurship was first established in the 1700s, and the
meaning has evolved ever since. Many simply equate it with
starting one’s own business. Most economists believe it is
more than that.
To some economists, the entrepreneur is one who is willing to
bear the risk of a new venture if there is a significant
chance for profit. Others emphasize the entrepreneur’s role as
an innovator who markets his innovation. Still other
economists say that entrepreneurs develop new goods or
processes that the market demands and are not currently being
supplied.
In the 20th century, economist Joseph Schumpeter (1883-1950)
focused on how the entrepreneur’s drive for innovation and
improvement creates upheaval and change. Schumpeter viewed
entrepreneurship as a force of “creative destruction.” The
entrepreneur carries out “new combinations,” thereby helping
render old industries obsolete. Established ways of doing
business are destroyed by the creation of new and better ways
to do them.
Business expert Peter Drucker (1909-2005) took this idea
further, describing the entrepreneur as someone who actually
searches for change, responds to it, and exploits change as an
opportunity. A quick look at changes in communications—from
typewriters to personal computers to the Internet—illustrates
these ideas.
Most economists today agree that entrepreneurship is a
necessary ingredient for stimulating economic growth and
employment opportunities in all societies. In the developing
world, successful small businesses are the primary engines of
job creation, income growth, and poverty reduction. Therefore,
government support for entrepreneurship is a crucial strategy
for economic development.
As the Business and Industry Advisory Committee to the
Organization for Economic Cooperation and Development (OECD)
said in 2003, “Policies to foster entrepreneurship are
essential to job creation and economic growth.” Government
officials can provide incentives that encourage entrepreneurs
to risk attempting new ventures. Among these are laws to
enforce property rights and to encourage a competitive market
system.
The culture of a community also may influence how much
entrepreneurship there is within it. Different levels of
entrepreneurship may stem from cultural differences that make
entrepreneurship more or less rewarding personally. A
community that accords the highest status to those at the top
of hierarchical organizations or those with professional
expertise may discourage entrepreneurship. A culture or policy

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that accords high status to the “self-made” individual is more
likely to encourage entrepreneurship.

9. The Entrepreneur and the Internet

The Internet — a vast computer network linking smaller
computer networks — has revolutionized commerce by bringing
together people from all over the globe. Many of its features
can be used to shape a new business.
Communications: An entrepreneur must communicate with many
people—suppliers, distributors, and customers, for example. A
quick and relatively inexpensive way to send letters, reports,
photographs, etc. to other Internet users is with electronic
mail or “e-mail.” E-mail can be used even for marketing.
Various forms of computer software are available to protect
documents from unauthorized access or alteration so that they
can be securely shared and easily authenticated.
Research: Starting a business takes lots of research. An
entrepreneur can find information on almost any subject very
rapidly by using the Internet’s World Wide Web.. (The Web is a
collection of text and multimedia documents linked to create a
huge electronic library.) Many government agencies,
universities, organizations, and businesses provide
information on the Internet, usually at no cost.
The easiest way to find information on the Web is by using a
search engine—a data retrieval system. The user types key
words for a subject on the computer, clicks the enter button,
and receives a list of materials– often within seconds. The
items are linked electronically to the actual documents so
that Internet users can read them on their computer screens.
Among the most popular search engines are Yahoo!
([Link] and Google ([Link]
Promotion: Web sites, pages of print and visual information
that are linked together electronically, offer an opportunity
for entrepreneurs to introduce a new business and its products
and/or services to a huge audience. In general, Web sites can
be created and updated more quickly and inexpensively than
printed promotional materials. Moreover, they run
continuously!
To create a Web site for her business, the entrepreneur can
hire a firm to create one or purchase computer software to
create it on her own. Many universities offer courses that
teach how to build a Web site, also.
A Web site needs a name and an address. On the Internet, the
two are usually the same. Web site names and addresses must be
registered. Http://[Link] is a Web site that lists
registrars by country and language used. The address of the
online business is expressed as a Uniform Resource Locator
(URL). It usually ends in dot com (.com), which indicates a
“commercial” site. Dot net (.net), an alternate ending; is
often used when a specific Web site name ending in .com has
already been registered. Good business Web site names are easy
to remember and evoke the firm and its products or services.
The entrepreneur also needs a piece of property in cyberspace,
where her Web site will reside. Many commercial “hosting
services,” called Internet service providers (ISPs), rent
space on their large computers (called servers) for a small
monthly or annual fee.

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Web site promotion is critical. A Web site address can be put
on business cards, stationery, brochures— anything having to
do with the new firm. Or, an entrepreneur can pay to place a
colorful advertisement on non-competitive Web sites, such as
ones for complementary products. Advertising banners usually
link back to the advertised firm’s Web site.
Entrepreneurs also can provide information about their Web
sites to well-known Internet search engines. For a fee, most
search engines will promote a Web site when a selected set of
search terms is used. Online shoppers, for instance, often use
search engines to find businesses that provide specific
products and services.
Safe Use: Just as shopkeepers lock their storefronts,
entrepreneurs who use the Internet need to take steps to keep
their computer systems safe from the potential hazards of
security breaches and viruses. One of the most effective steps
is installing security software. Another is setting up an
Internet firewall to screen and block undesired traffic
between a computer network and the Internet. A technology
consultant on contract can install these and other computer
defenses. There is a lot of information about computer safety
available, and often for free. For example, the National Cyber
Security Alliance ([Link] an
organization devoted to raising Internet security awareness,
offers educational materials and other resources.
As Julian E. Lange, associate professor of entrepreneurship at
Babson College, has said, “For creative entrepreneurs with
limited resources, the Internet offers significant
opportunities to build new businesses and enhance existing
enterprises.” New businesses will develop solutions to enhance
the Internet user’s experience. Existing businesses will take
advantage of myriad Internet applications — from customer
service to order processing to investor relations. Lange
suggests that, for many entrepreneurs, the challenges posed by
the Internet are “opportunities to delight customers and
create exciting entrepreneurial ventures.”

10. Selling Online

Many entrepreneurs sell goods or services on the Internet.
Why? The Internet provides access to a large and growing
market. Approximately 627 million people were shopping online
worldwide in 2005, according to ACNielsen, a global
information-marketing company.
By selling on the Internet, a neighborhood shop or home-based
firm can reach a national or even international group of
potential customers. When entrepreneurs sell online, they are
on a more level playing field with larger competitors.
There are costs to Internet selling, certainly. But the price
of creating and managing a Web site has dropped, and the
number of Web site design and management companies has grown.
In fact, some entrepreneurs find it less costly to run an
Internet store than to hire a large sales force and maintain
one or more bricks and mortar — or actual — stores.
Some businesses — books, airline travel, and the stock market,
for example — have been transformed by their success in online
sales. Others, such as amusement parks, bowling alleys, or
utility companies, may not at first seem well suited to the

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Internet. But a Web site also can be used for selling tickets,
offering discounts, or letting customers make payments over
the Internet.
To start an online business, an entrepreneur must:
Register a domain name — an Internet name and • address.
Purchase a server or contract with an Internet service •
provider to host the Web site. Buy Internet software to create
a Web site or hire an expert to do so. Design an attractive
and easy-to-navigate online store.
Create an online catalog. Provide clearly written in•
formation, without technical language or jargon. Use lots of
photos to encourage potential customers to buy. Include clear
instructions to order by phone or online.
Establish a payment method. Some companies bill a • customer
before or after shipping merchandise. This may cause payment
delays, however. Another option is to have customers use
credit or debit cards online. A business can get a bank-
authorized transaction-processing account (merchant account)
for handling the revenue (and fees) from credit card
transactions from a bank or other institution that processes
credit cards online. Alternately, it is possible to hire an
online payment service, such as WorldPay ([Link]),
to handle these transactions.
Make the Web site secure, especially to protect cus• tomers’
financial information. Hiring a technology expert is time and
money well spent as compared to the potential risk of security
violations.
Establish a policy for shipping. Options include let• ting the
business absorb the cost (no charge), including costs in the
listed prices, or explicitly listing shipping charges.
Customers should never be surprised at the end of a
transaction with shipping costs. Customers may cancel the
sale.
Offer customers an e-mail address or phone number • for
complaints, suggestions, or compliments, and respond to them.
This can boost customer loyalty.
After creating an online store, there is still much to do. An
entrepreneur needs to attract potential customers. There are
many ways to advertise a Web site. One is to print a Web
address on business receipts, letterhead, newsletters, and
other materials. Another is to contact search engines like
Google and Yahoo, and to use key subject words in the Web site
design so that search-engine users are directed to the
entrepreneur’s Web site. For example, a restaurant
specializing in food from Afghanistan might include the key
words and phrases “Afghan cuisine,” “traditional recipes,”
“contemporary cooking,” “bulani,” “hummus,” “korma,” “kabobs,”
“kofta,” “lamb, “ashwak,” “steamed dumplings,” and others like
these.
Web site promotion is crucial. Getting noticed is the first
step to making online sales.

13. The Entrepreneur’s Need for Capital

New businesses rarely show a profit in the early months of
operation. Generating sales takes time, and receipts are not
usually sufficient to offset start-up costs and monthly
expenses. Therefore, entrepreneurs need to estimate how much

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money they need and then raise that amount to transform their
dream into a reality.
It doesn’t necessarily take a lot of cash to create a
successful business. In the mid-1970s, Steve Jobs and Steve
Wozniak started Apple Computer by selling a Volkswagen
microbus and a Hewlett-Packard scientific calculator to raise
$1,300 — enough for a makeshift production line. In 1997, Bill
Martin and Greg Wright used the free Internet connections in
their college dorm rooms and $175: $75 for a New Jersey
partnership fee, $70 to register their Web domain name, and
$30 for a month’s hosting fee — to start [Link],
which is now a successful financial Web site.
Many entrepreneurs start businesses with $5,000 or less, just
enough to establish the business, invest in some inventory,
and create some advertising materials. There are many ways to
reduce expenses: for instance, by initially working out of
one’s home rather than leasing an office or leasing office
equipment rather than buying it.
However, all entrepreneurs need to estimate how much cash they
need to cover expenses until the business begins to make a
profit. For this task, the best financial tools are the income
statement and cash flow statement. Cash flow refers to the
amount of money actually available to make purchases and pay
current bills and obligations. It is the difference between
cash receipts (money taken in) and cash disbursements (money
spent) over a specific time period.
It is important to attach notes to these forecasts to explain
any unusual expenses or assumptions used in the calculations.
An income statement sets out all of the entrepreneur’s pro•
jected revenues and expenses (including depreciation and
mortgages) to determine a venture’s profits per month and
year. Depreciation is a method to account for assets whose
value is considered to decrease over time.
A cash flow statement estimates anticipated cash • sales as
well as anticipated cash payments of bills. This estimate can
be done on a weekly, monthly, or quarterly basis, but experts
recommend that it be done at least once every month for the
first year or two of a new business. This forecast is used to
project the money required to finance the operation annually.
By calculating this forecast on a cumulative basis, the
entrepreneur can forecast his company’s overall capital needs
at start up.
The monthly net cash flow shows how much an entrepreneur’s
cash receipts exceed or fall short of monthly cash
expenditures. For most of the first year, the monthly
expenditures are likely to exceed the receipts. In many cases,
goods are shipped out before payment is received. Meanwhile,
the entrepreneur still has to pay his bills. Therefore, the
cumulative cash flow, which adds each month’s total to that of
previous months, will result in a growing negative amount.
A critical point for a new business occurs when monthly sales
receipts are enough to cover monthly expenses. At this point,
the negative cumulative cash flow will begin to decrease and
move toward a positive one. The cumulative cash flow amount
reached just before it reverses direction indicates
approximately how much capital the new business will need.

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Financial projections are inevitably somewhat inaccurate
simply because every contingency cannot be predicted. For this
reason, experts recommend that entrepreneurs add at least 20
percent to the financial needs calculated in the cash flow
statement to create a safety net for unforeseen events.
With these estimates, the entrepreneur can seek funding and
concentrate more clearly on launching the new business.

14. Sources of Financing

Many entrepreneurs struggle to find the capital to start a new
business. There are many sources to consider, so it is
important for an entrepreneur to fully explore all financing
options. He also should apply for funds from a wide variety of
sources.
Personal savings: Experts agree that the best source of
capital for any new business is the entrepreneur’s own money.
It is easy to use, quick to access, has no payback terms, and
requires no transfer of equity (ownership). Also, it
demonstrates to potential investors that the entrepreneur is
willing to risk his own funds and will persevere during hard
times.
Friends and family: These people believe in the entrepreneur,
and they are the second easiest source of funds to access.
They do not usually require the paperwork that other lenders
require. However, these funds should be documented and treated
like loans. Neither part ownership nor a decision-making
position should be given to these lenders, unless they have
expertise to provide. The main disadvantage of these funds is
that, if the business fails and money goes lost, a valuable
relationship may be jeopardized.
Credit cards: The entrepreneur’s personal credit cards are an
easy source of funds to access, especially for acquiring
business equipment such as photocopiers, personal computers,
and printers. These items can usually be obtained with little
or no money paid up front and with small monthly payments. The
main disadvantage is the high rate of interest charged on
credit card balances that are not paid off in full each month.
Banks: Banks are very conservative lenders. As successful
entrepreneur Phil Holland explains, “Many prospective business
owners are disappointed to learn that banks do not make loans
to start-up businesses unless there are outside assets to
pledge against borrowing.” Many entrepreneurs simply do not
have enough assets to get a secured loan from a lending
institution.
However, if an entrepreneur has money in a bank savings
account, she can usually borrow against that money. If an
entrepreneur has good credit, it is also relatively easy to
get a personal loan from a bank. These loans tend to be short-
term and not as large as business loans.
Venture investors: This is a major source of funding for
start-ups that have a strong potential for growth. However,
venture investors insist on retaining part ownership in new
businesses that they fund.
Formal institutional venture funds are usually limited •
partnerships in which passive limited partners, such as
retirement funds, supply most of the money. These funds have
large amounts of money to invest. However, the process of

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obtaining venture capital is very slow. Several books, such as
Galante’s Venture Capital & Private Equity Directory, give
detailed information on these funds.
Corporate venture funds are large corporations • with funds
for investing in new ventures. These often provide technical
and management expertise in addition to large monetary
investments. However, these funds are slow to access compared
to other sources of funds. Also, they often seek to gain
control of new businesses.
Angel investors tend to be successful entrepreneurs • who have
capital that they are willing to risk. They often insist on
being active advisers to businesses they support. Angel funds
are quicker to access than corporate venture funds, and they
are more likely to be invested in a start-up operation. But
they may make smaller individual investments and have fewer
contacts in the banking community.
Government programs: Many national and regional governments
offer programs to encourage small- and medium-sized
businesses. In the United States, the Small Business
Administration (SBA) assists small firms by acting as a
guarantor of loans made by private institutions for borrowers
who may not otherwise qualify for a commercial loan.

16. The Strengths of Small Business

Any entrepreneur who is contemplating a new venture should
examine the strengths of small businesses as compared to large
ones and make the most of those competitive advantages. With
careful planning, an entrepreneur can lessen the advantages of
the large business vis-à-vis his operation and thereby
increase his chances for success.
The strengths of large businesses are well documented. They
have greater financial resources than small firms and
therefore can offer a full product line and invest in product
development and marketing. They benefit from economies of
scale because they manufacture large quantities of products,
resulting in lower costs and potentially lower prices. Many
large firms have the credibility that a well-known name
provides and the support of a large organization.
How can a small firm possibly compete?
In general, small start-up firms have greater flexibility than
larger firms and the capacity to respond promptly to industry
or community developments. They are able to innovate and
create new products and services more rapidly and creatively
than larger companies that are mired in bureaucracy. Whether
reacting to changes in fashion, demographics, or a
competitor’s advertising, a small firm usually can make
decisions in days - not months or years.
A small firm has the ability to modify its products or
services in response to unique customer needs. The average
entrepreneur or manager of a small business knows his customer
base far better than one in a large company. If a modification
in the products or services offered — or even the business’s
hours of operation — would better serve the customers, it is
possible for a small firm to make changes. Customers can even
have a role in product development.
Another strength comes from the involvement of highly skilled
personnel in all aspects of a start-up business. In

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particular, start-ups benefit from having senior partners or
managers working on tasks below their highest skill level. For
example, when entrepreneur William J. Stolze helped start RF
Communications in 1961 in Rochester, New York, three of the
founders came from the huge corporation General Dynamics,
where they held senior marketing and engineering positions. In
the new venture, the marketing expert had the title
“president” but actually worked to get orders. The senior
engineers were no longer supervisors; instead, they were
designing products. As Stolze said in his book Start Up, “In
most start-ups that I know of, the key managers have stepped
back from much more responsible positions in larger companies,
and this gives the new company an immense competitive
advantage.”
Another strength of a start-up is that the people involved —
the entrepreneur, any partners, advisers, employees, or even
family members — have a passionate, almost compulsive, desire
to succeed. This makes them work harder and better.
Finally, many small businesses and start-up ventures have an
intangible quality that comes from people who are fully
engaged and doing what they want to do. This is “the
entrepreneurial spirit,” the atmosphere of fun and excitement
that is generated when people work together to create an
opportunity for greater success than is otherwise available.
This can attract workers and inspire them to do their best.

17. Entrepreneurship Aids the Economy

Most economists agree that entrepreneurship is essential to
the vitality of any economy, developed or developing.
Entrepreneurs create new businesses, generating jobs for
themselves and those they employ. In many cases,
entrepreneurial activity increases competition and, with
technological or operational changes, it can increase
productivity as well.
In the United States, for example, small businesses provide
approximately 75 percent of the net new jobs added to the
American economy each year and represent over 99 percent of
all U.S. employers. The small businesses in the United States
are often ones created by self-employed entrepreneurs.
“Entrepreneurs give security to other people; they are the
generators of social welfare,” Carl J. Schramm, president and
chief executive officer of Ewing Marion Kauffman Foundation,
said in February 2007. The foundation is dedicated to
fostering entrepreneurship, and Schramm is one of the world’s
leading experts in this field.
Others agree that the benefits of small businesses go beyond
income. Hector V. Baretto, administrator of the U.S. Small
Business Administration (SBA), explains, “Small businesses
broaden the base of participation in society, create jobs,
decentralize economic power, and give people a stake in the
future.”
Entrepreneurs innovate and innovation is a central ingredient
in economic growth. As Peter Drucker said, “The entrepreneur
always searches for change, responds to it, and exploits it as
an opportunity.” Entrepreneurs are responsible for the
commercial introduction of many new products and services, and
for opening new markets. A look at recent history shows that

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entrepreneurs were essential to many of the most significant
innovations, ones that revolutionized how people live and
work. From the automobile to the airplane to personal
computers – individuals with dreams and determination
developed these commercial advances.
Small firms also are more likely than large companies to
produce specialty goods and services and custom-demand items.
As Schramm has suggested, entrepreneurs provide consumers with
goods and services for needs they didn’t even know they had.
Innovations improve the quality of life by multiplying
consumers’ choices. They enrich people’s lives in numerous
ways – making life easier, improving communications, providing
new forms of entertainment, and improving health care, to name
a few.
Small firms in the United States, for instance, innovate far
more than large ones do. According to the Small Business
Administration, small technology companies produce nearly 13
times more patents per employee than large firms. They
represent one-third of all companies in possession of 15 or
more patents.
According to the 2006 Summary Results of the Global
Entrepreneurship Monitor (GEM) project, “Regardless of the
level of development and firm size, entrepreneurial behavior
remains a crucial engine of innovation and growth for the
economy and for individual companies since, by definition, it
implies attention and willingness to take advantage of
unexploited opportunities.” The GEM project is a multi-country
study of entrepreneurship and economic growth. Founded and
sponsored by Babson College (USA) and the London Business
School in 1999, the study included 42 countries by 2006.
International and regional institutions, such as the United
Nations and the Organization for Economic Cooperation and
Development, agree that entrepreneurs can play a crucial role
in mobilizing resources and promoting economic growth and
socio-economic development. This is particularly true in the
developing world, where successful small businesses are
primary engines of job creation and poverty reduction.
For all of these reasons, governments may wish to pursue
policies that encourage entrepreneurship.

18. The Importance of Government Policies

Entrepreneurial activity leads to economic growth and helps to
reduce poverty, create a middle class, and foster stability.
It is in the interest of all h governments to implement
policies to foster entrepreneurship and reap the benefits of
its activity.
Thomas A. Garrett, a senior economist with the Federal Reserve
Bank of St. Louis, says that government policies can be
categorized as “active” or “passive” depending on whether they
involve the government in determining which types of
businesses are promoted. Active policies, such as targeted tax
breaks, help specific forms of businesses, while passive
policies help create an environment that is friendly to
entrepreneurs without regard to specific firms.
Both active and passive policies are effective in promoting
small business, Garrett says, but passive policies promote
entrepreneurship most broadly. “It is this entrepreneurial-

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friendly environment that will allow any individual or
business—regardless of size, location or mission—to expand and
to thrive,” he says.
Among the most successful strategies for encouraging
entrepreneurship and small business are changes in tax policy,
regulatory policy, access to capital, and the legal protection
of property rights.
Tax Policy: Governments use taxes to raise money. But taxes
increase the cost of the activity taxed, discouraging it
somewhat. Therefore, policymakers need to balance the goals of
raising revenue and promoting entrepreneurship. Corporate tax
rate reductions, tax credits for investment or education, and
tax deductions for businesses are all proven methods for
encouraging business growth.
Regulatory Policy: “The simpler and more expedited the
regulatory process, the greater the likelihood of small
business expansion,” says Steve Strauss, a lawyer and author,
who specializes in entrepreneurship. Reducing the cost of
compliance with government regulations is also helpful.
Governments can, for example, provide one-stop service centers
where entrepreneurs can find assistance and allow electronic
filing and storage of forms.
Access to Capital: Starting a business takes money. There are
required procedures and fees as well as the initial costs of
the new enterprise itself. Therefore, the most important
activity a government can undertake is to assist potential
entrepreneurs with finding money for start-ups.
In the United States, the Small Business Administration (SBA)
helps entrepreneurs get funds. The SBA is a federal agency
whose main function is guaranteeing loans. Banks and other
lenders that participate in SBA programs often relax strict
loan requirements because the government has promised
repayment if the borrower defaults. This policy makes many
loans available for risky new businesses.
Legal Protection of Property Rights: Small business can thrive
where there is respect for individual property rights and a
legal system to protect those rights. Without property rights,
there is little incentive to create or invest.
For entrepreneurship to flourish, the law needs to protect
intellectual property. If innovations are not legally
protected through patents, copyrights, and trademarks,
entrepreneurs are unlikely to engage in the risks necessary to
invent new products or new methods. According to the World
Bank report, “Doing Business 2007: How to Reform,” new
technologies are adopted more quickly when courts are
efficient. “The reason is that most innovations take place in
new businesses—which unlike large firms do not have the clout
to resolve disputes outside the courts.”
Creating a Business Culture: Governments can also show that
they value private enterprise by making it easier for
individuals to learn business skills and by honoring
entrepreneurs and small business owners. Policy makers can:
• Offer financial incentives for the creation of business
incubators. These usually provide new businesses with an
inexpensive space in which to get started and services – such
as a copier and a fax machine – which most new businesses
couldn’t otherwise afford. Often business incubators are

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associated with colleges, and professors offer their
expertise.
• Make information available. In the United States, for
example, the SBA has many offices, making publications widely
accessible. Its “Small Business Answer Desk” (telephone: 800-
827-5722) and its Web site ([Link]) answer general
business questions. Its online business tutorials are
available to anyone with Internet access
([Link]
• Enhance the status of entrepreneurs and businessmen in the
society. Governments might create local or national award
programs that honor entrepreneurs and call on business leaders
to serve on relevant commissions or panels.

20. Entrepreneurship: Glossary of Terms

Angel investors: Individuals who have capital that they are
willing to risk. Angels are often successful entrepreneurs who
invest in emerging entrepreneurial ventures, often as a bridge
from the self-funded stage to the point in which a business
can attract venture capital.
Assets: Items of value owned by a company and shown on the
balance sheet, including cash, equipment, inventory, etc.
Balance sheet: Summary statement of a company’s financial
position at a given point in time, listing assets as well as
liabilities.
Breakeven point: Dollar value of sales that will cover, but
not exceed, all of the company’s costs, both fixed and
variable.
Bridge finance: Short-term finance that is expected to be
repaid quickly.
Browser: A computer program that enables users to access and
navigate the World Wide Web.
Business incubator: This is a form of mentoring in which
workspace, coaching, and support services are provided to
entrepreneurs and early-stage businesses at a free or reduced
cost.
Business plan: A written document detailing a proposed
venture, covering current status, expected needs, and
projected results for the enterprise. It contains a thorough
analysis of the product or service being offered, the market
and competition, the marketing strategy, the operating plan,
and the management as well as profit, balance sheet, and cash
flow projections.
Capital: Cash or goods used to generate income. For
entrepreneurs, capital often refers to the funds and other
assets invested in the business venture.
Cash flow: The difference between the company’s cash receipts
and its cash payments in a given period. It refers to the
amount of money actually available to make purchases and pay
current bills and obligations.
Cash flow statement: A summary of a company’s cash flow over a
period of time.
Collateral: An asset pledged as security for a loan.
Copyright: Copyright is a form of legal protection for
published and unpublished literary, scientific, and artistic
works that have been fixed in a tangible or material form. It

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grants exclusive rights to the work’s creator for a specified
period of time.
Corporation: A business form that is an entity legally
separate from its owners. Its important features include
limited liability, easy transfer of ownership, and unlimited
life.
Depreciation: The decrease in the value of assets over their
expected life by an accepted accounting method, such as
allocating the cost of an asset over the years in which it is
used.
E-commerce: The sale of products and services over the
Internet.
Entrepreneur: A person who organizes, operates, and assumes
the risk for a business venture.
Equity: An ownership interest in a business.
Home-based business: A business, of any size or type, whose
primary office is in the owner’s home.
Income statement: Also known as a “profit and loss statement,”
it shows a firm’s income and expenses, and the resulting
profit or loss over a specified period of time.
Intangible assets: Items of value that have no tangible
physical properties, such as ideas.
Internet: The vast network of networks connecting millions of
individual and networked computers worldwide.
Inventory: Finished goods, work in process of manufacture, and
raw materials owned by a company.
Joint venture: A legal entity created by two or more
businesses joining together to conduct a specific business
enterprise with both parties sharing profits and losses.
Liabilities: Debts a business owes, including accounts
payable, taxes, bank loans, and other obligations. Short-term
liabilities are due within a year, while long-term liabilities
are due in a period of time greater than a year.

Qualities of entrepreneur
2. What Makes Someone an Entrepreneur?
Who can become an entrepreneur? There is no one definitive
profile. Successful entrepreneurs come in various ages, income
levels, gender, and race. They differ in education and
experience. But research indicates that most successful
entrepreneurs share certain personal attributes, including:
creativity, dedication, determination, flexibility,
leadership, passion, self-confidence, and “smarts.”
Creativity is the spark that drives the development • of new
products or services or ways to do business. It is the push
for innovation and improvement. It is continuous learning,
questioning, and thinking outside of prescribed formulas.
Dedication is what motivates the entrepreneur to • work hard,
12 hours a day or more, even seven days a week, especially in
the beginning, to get the endeavor off the ground. Planning
and ideas must be joined by hard work to succeed. Dedication
makes it happen.
Determination is the extremely strong desire to • achieve
success. It includes persistence and the ability to bounce
back after rough times. It persuades the entrepreneur to make
the 10th phone call, after nine have yielded nothing. For the

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true entrepreneur, money is not the motivation. Success is the
motivator; money is the reward.
Flexibility is the ability to move quickly in response • to
changing market needs. It is being true to a dream while also
being mindful of market realities. A story is told about an
entrepreneur who started a fancy shop selling only French
pastries. But customers wanted to buy muffins as well. Rather
than risking the loss of these customers, the entrepreneur
modified her vision to accommodate these needs.
Leadership is the ability to create rules and to set • goals.
It is the capacity to follow through to see that rules are
followed and goals are accomplished.
Passion is what gets entrepreneurs started and • keeps them
there. It gives entrepreneurs the ability to convince others
to believe in their vision. It can’t substitute for planning,
but it will help them to stay focused and to get others to
look at their plans.
Self-confidence comes from thorough planning, • which reduces
uncertainty and the level of risk. It also comes from
expertise. Self-confidence gives the entrepreneur the ability
to listen without being easily swayed or intimidated.
“Smarts” consists of common sense joined with • knowledge or
experience in a related business or endeavor. The former gives
a person good instincts, the latter, expertise. Many people
have smarts they don’t recognize. A person who successfully
keeps a household on a budget has organizational and financial
skills. Employment, education, and life experiences all
contribute to smarts.
.
Every entrepreneur has these qualities in different degrees.
But what if a person lacks one or more? Many skills can be
learned. Or, someone can be hired who has strengths that the
entrepreneur lacks. The most important strategy is to be aware
of strengths and to build on them.

3. Why Become an Entrepreneur?

What leads a person to strike out on his own and start a
business? Perhaps a person has been laid off once or more.
Sometimes a person is frustrated with his or her current job
and doesn’t see any better career prospects on the horizon.
Sometimes a person realizes that his or her job is in
jeopardy. A firm may be contemplating cutbacks that could end
a job or limit career or salary prospects. Perhaps a person
already has been passed over for promotion. Perhaps a person
sees no opportunities in existing businesses for someone with
his or her interests and skills.
Some people are actually repulsed by the idea of working for
someone else. They object to a system where reward is often
based on seniority rather than accomplishment, or where they
have to conform to a corporate culture.
Other people decide to become entrepreneurs because they are
disillusioned by the bureaucracy or politics involved in
getting ahead in an established business or profession. Some
are tired of trying to promote a product, service, or way of
doing business that is outside the mainstream operations of a
large company.

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In contrast, some people are attracted to entrepreneurship by
the advantages of starting a business. These include:
Entrepreneurs are their own bosses. They make • the decisions.
They choose whom to do business with and what work they will
do. They decide what hours to work, as well as what to pay and
whether to take vacations.
Entrepreneurship offers a greater possibility of • achieving
significant financial rewards than working for someone else.
It provides the ability to be involved in the total •
operation of the business, from concept to design and
creation, from sales to business operations and customer
response.
It offers the prestige of being the person in • charge.
It gives an individual the opportunity to build eq• uity,
which can be kept, sold, or passed on to the next generation.
Entrepreneurship creates an opportunity for a • person to make
a contribution. Most new entrepreneurs help the local economy.
A few—through their innovations—contribute to society as a
whole. One example is entrepreneur Steve Jobs, who co-founded
Apple in 1976, and the subsequent revolution in desktop
computers.
Some people evaluate the possibilities for jobs and careers
where they live and make a conscious decision to pursue
entrepreneurship.
No one reason is more valid than another; none guarantee
success. However, a strong desire to start a business,
combined with a good idea, careful planning, and hard work,
can lead to a very engaging and profitable endeavor.

4. Decisions and Downfalls

Entrepreneurship is an attractive career choice. But many
decisions have to be made before launching and managing a new
business, no matter its size. Among the questions that need to
be answered are:
Does the individual truly want to be responsible for • a
business?
What product or service should be the basis of the • business?
What is the market, and where should it be located?•
Is the potential of the business enough to provide a • living
wage for its employees and the owner?
How can a person raise the capital to get started?•
Should an individual work full or part time to start a • new
business? Should the person start alone or with partners?
Answers to these questions are not empirically right or wrong.
Rather, the answers will be based on each entrepreneur’s
judgment. An entrepreneur gathers as much information and
advice as possible before making these and other crucial
decisions.
The entrepreneur’s challenge is to balance decisiveness with
caution—to be a person of action who does not procrastinate
before seizing an opportunity—and at the same time, to be
ready for an opportunity by having done all the preparatory
work possible to reduce the risks of the new endeavor.
Preparatory work includes evaluating the market opportunity,
developing the product or service, preparing a good business
plan, figuring out how much capital is needed, and making
arrangements to obtain that capital.

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Through careful analysis of entrepreneurs’ successes and
failures, economists have identified key factors for up-and-
coming business owners to consider closely. Taking them into
account can reduce risk. In contrast, paying them no attention
can precipitate the downfall of a new enterprise.
Motivation:• What is the incentive for starting a business? Is
it money alone? True, many entrepreneurs achieve great wealth.
However, money is almost always tight in the startup and early
phases of a new business. Many entrepreneurs do not even take
a salary until they can do so and still leave the firm with a
positive cash flow.
Strategy:• What is the strategy for distinguishing the product
or service? Is the plan to compete solely on the basis of
selling price? Price is important, but most economists agree
that it is extremely risky to compete on price alone. Large
firms that produce huge quantities have the advantage in
lowering costs.
Realistic Vision:• Is there a realistic vision of the
enterprise’s potential? Insufficient operating funds are the
cause of many failed businesses. Entrepreneurs often
underestimate start-up costs and overestimate sales revenues
in their business plans. Some analysts advise adding 50
percent to final cost estimates and reducing sales
projections. Only then can the entrepreneur examine cash flow
projections and decide if he or she is ready to launch a new
business.

5. Go It Alone or Team Up?

One important choice that new entrepreneurs have to make is
whether to start a business alone or with other entrepreneurs.
They need to consider many factors, including each
entrepreneur’s personal qualities and skills and the nature of
the planned business.
In the United States, for instance, studies show that almost
half of all new businesses are created by teams of two or more
people. Often the people know each other well; in fact, it is
common for teams to be spouses.

There are many advantages to starting a firm with other

entrepreneurs. Team members share decision-making and
management responsibilities. They can also give each other
emotional support, which can help reduce individual stress.
Companies formed by teams have somewhat lower risks. If one of
the founders is unavailable to handle his or her duties,
another can step in.
Team interactions often generate creativity. Members of a team
can bounce ideas off each other and “brainstorm” solutions to
problems.
Studies show that investors and banks seem to prefer financing
new businesses started by more than one entrepreneur. This
alone may justify forming a team.
Other important benefits of teaming come from combining
monetary resources and expertise. In the best situations, team
members have complementary skills. One may be experienced in
engineering, for example, and the other may be an expert in
promotion.

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In general, strong teams have a better chance at success. In
Entrepreneurs in High Technology, Professor Edward Roberts of
the Massachusetts Institute of Technology (MIT) reported that
technology companies formed by entrepreneurial teams have a
lower rate of failure than those started by individuals. This
is particularly true when the team includes a marketing
expert.
Entrepreneurs of different ages can create complementary teams
also. Optimism and a “can-do” spirit characterize youth, while
age brings experience and realism. In 1994, for example, Marc
Andreessen was a talented, young computer scientist with an
innovative idea. James Clark, the founder and chairman of
Silicon Graphics, saw his vision. Together they created
Netscape Navigator, the Internet-browsing computer software
that transformed personal computing.
But entrepreneurial teams have potential disadvantages as
well. First, teams share ownership. In general, entrepreneurs
should not offer to share ownership unless the potential
partner can make a significant contribution to the venture.
Teams share control in making decisions. This may create a
problem if a team member has poor judgment or work habits.
Most teams eventually experience serious conflict. This may
involve management plans, operational procedures, or future
goals. It may stem from an unequal commitment of time or a
personality clash. Sometimes such conflicts can be resolved;
in others, a conflict can even lead to selling the company or,
worse, to its failure.
It is important for a new entrepreneur to be aware of
potential problems while considering the advantages of working
with other entrepreneurs. In general, the benefits of teaming
outweigh the risks.
Components of entrepreneurship
Intellectual
15. Intellectual Property: A Valuable Business Asset
Intellectual property is a valuable asset for an entrepreneur. It
consists of certain intellectual creations by entrepreneurs or
their staffs that have commercial value and are given legal
property rights. Examples of such creations are a new product and
its name, a new method, a new process, a new promotional scheme,
and a new design.
A fence or a lock cannot protect these intangible assets.
Instead, patents, copyrights, and trademarks are used to prevent
competitors from benefiting from an individual’s or firm’s ideas.
Protecting intellectual property is a practical business
decision. The time and money invested in perfecting an idea might
be wasted if others could copy it. Competitors could charge a
lower price because they did not incur the startup costs. The
purpose of intellectual property law is to encourage innovation
by giving creators time to profit from their new ideas and to
recover development costs.
Intellectual property rights can be bought, sold, licensed, or
given away freely. Some businesses have made millions of dollars
by licensing or selling their patents or trademarks.
Every entrepreneur should be aware of intellectual property
rights in order to protect these assets in a world of global
markets. An intellectual property lawyer can provide information
and advice.

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The main forms of intellectual property rights are:
Patents:• A patent grants an inventor the right to exclude others
from making, using, offering for sale, or selling an invention
for a fixed period of time - in most countries, for up to 20
years. When the time period ends, the patent goes into the public
domain and anyone may use it.
Copyright: • Copyrights protect original creative works of
authors, composers, and others. In general, a copyright does not
protect the idea itself, but only the form in which it appears -
from sound recordings to books, computer programs, or
architecture. The owner of copyrighted material has the exclusive
right to reproduce the work, prepare derivative works, distribute
copies of the work, or perform or display the work publicly.
Trade Secrets: • Trade secrets consist of knowledge that is kept
secret in order to gain an advantage in business. “Customer
lists, sources of supply of scarce materials, or sources of
supply with faster delivery or lower prices may be trade
secrets,” explains Joseph S. Iandiorio, the founding partner of
Iandiorio and Teska, an intellectual property law firm.
“Certainly, secret processes, formulas, techniques, manufacturing
know-how, advertising schemes, marketing programs, and business
plans are all protectable.”
Trade secrets are usually protected by contracts and non-
disclosure agreements. No other legal form of protection exists.
The most famous trade secret is the formula for Coca-Cola, which
is more than 100 years old.
Trade secrets are valid only if the information has not been
revealed. There is no protection against discovery by fair means
such as accidental disclosure, reverse engineering, or
independent invention.
Trademarks: A trademark protects a symbol, word, or design, used
individually or in combination, to indicate the source of goods
and to distinguish them from goods produced by others. For
example, Apple Computer uses a picture of an apple with a bite
out of it and the symbol (®) which means registered trademark. A
service mark similarly identifies the source of a service.
Trademarks and service marks give a business the right to prevent
others from using a confusingly similar mark.
In most countries, trademarks must be registered to be
enforceable and renewed to remain in force. However, they can be
renewed endlessly. Consumers use marks to find a specific firm’s
goods that they see as particularly desirable — for example,
Barbie dolls or Toyota automobiles. Unlike copyrights or patents,
which expire, many business’s trademarks become more valuable
over time.
Emotional
Concept of entrepreneurship
Risk taking
Stages of interventions
8. Marketing Is Selling
Marketing is often defined as all the activities involved in the
transfer of goods from the producer to the consumer, including
advertising, shipping, storing, and selling. For a new business,
however, marketing means selling. Without paying customers to buy
the goods or services, all the entrepreneur’s plans and
strategies will undoubtedly fail.

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How does a new business get orders? Before launching the
business, the entrepreneur should research the target market and
analyze competitive products. “Most business sectors have
specific marketing strategies that work best for them and have
already been put into practice,” entrepreneur Phil Holland said.
In 1970, Holland founded Yum Yum Donut Shops, Inc., which grew
into the largest chain of privately owned doughnut shops in the
United States. He suggests analyzing competitors’ successful
selling methods, pricing, and advertising.
An entrepreneur can also develop a file of potential customers,
for example, by collecting names or mailing lists from local
churches, schools, and community groups or other organizations.
This file can be used later for direct mailings—even for
invitations to the opening of the new business.
After the new firm is launched, its owners need to get
information about their product or service to as many potential
customers as possible—efficiently, effectively, and within the
constraints of a budget.
The most effective salesperson in a new venture is often the head
of the business. People will almost always take a call from the
“president” of a firm. This is the person with the vision, the
one who knows the advantages of the new venture and who can make
quick decisions. Many famous entrepreneurs, such as Bill Gates at
Microsoft, have been gifted at selling their products. Company-
employed sales people can be effective for a new venture,
particularly one aimed at a fairly narrow market. Direct sales
conducted by mail order or on the Internet are less expensive
options that can be equally successful.
External channels also can be used. Intermediaries, such as
agents or distributors, can be hired to market a product or
service. Such individuals must be treated fairly and paid
promptly. Some analysts advise treating external representatives
like insiders and offering them generous bonuses so that the
product or service stands out among the many they represent.
Advertising and promotion are essential marketing tools.
Newspaper, magazine, television, and radio advertisements are
effective for reaching large numbers of consumers. A less
expensive option is printing fliers, which can be mailed to
potential customers, handed out door to door, or displayed in
businesses that permit it. New companies can also compose new
product releases, which trade magazines usually publish without
charge.
It is important to be listed in local telephone directories that
group similar businesses under a single heading, such as the
Yellow Pages in the United States. It is also useful to be listed
on Internet search engines such as Google or Yahoo, which are
used by consumers for locating local businesses. These often link
to a company’s Web site, thereby communicating more information.
Publicity is also an extremely valuable way to promote a new
product or service. New firms should send press releases to media
outlets. A local newspaper might publish a feature about the
startup. A TV or radio station might interview its owners. This
can be very effective in generating sales, and it’s free!
Passion in entrepreneurship
Creating unique value proposition as an entrepreneur
12. Creating a Business Plan

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comprehensive business plan is crucial for a start-up
business. It defines the entrepreneur’s vision and serves as
the firm’s resume.
There are many reasons for writing a business plan:
To convince oneself that the new venture is • worthwhile
before making a significant financial and personal commitment.
To assist management in goal-setting and long-range •
planning.
To attract investors and get financing. •
To explain the business to other companies with which • it
would be useful to create an alliance or contract.
To attract employees. •
A business plan can help an entrepreneur to allocate resources
appropriately, handle unexpected problems, and make good
business decisions.
A well-organized plan is an essential part of any loan
application. It should specify how the business would repay
any borrowed money. The entrepreneur also should take into
account all startup expenses and potential risks so as not to
appear naive.
However, according to Andrew Zacharakis, a common
misperception is that a business plan is primarily used for
raising capital. Zacharakis, a professor of entrepreneurship
at Babson College, suggests that the primary purpose of a
business plan is to help entrepreneurs gain a deeper
understanding of the opportunity they envision. He explains:
“The business plan process helps the entrepreneur shape her
original vision into a better opportunity by raising critical
questions, researching answers for those questions, and then
answering them.”
Some entrepreneurs create two plans: a planning document for
internal use and a marketing document for attracting outside
investment. In this situation, the information in each plan is
essentially the same, but the emphasis is somewhat different.
For example, an internal document intended to guide the
business does not need detailed biographies of the management.
However, in a plan intended for marketing, the background and
experience of management may be the most important feature.
A standard business plan is usually about 40 pages in length.
It should use good visual formatting, such as bulleted lists
and short paragraphs. The language should be free of jargon
and easy to understand.
The tone should be business-like and enthusiastic. It should
be strong on facts in order to convince people to invest money
or time in the new venture.
The basic elements of a standard business plan include:
Title Page
Table of Contents
Executive Summary
Company Description
Product/Service
Market and Competition
Marketing and Selling Strategy
Operating Plan
Management/Organization
Financing
Supporting Documents

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The executive summary is the cornerstone of a good plan. This
is the section that people read in order to decide whether to
read the rest. It should concisely summarize the technical,
marketing, financial, and managerial details. More
importantly, it needs to convince the reader that the new
venture is a worthy investment.
The company description highlights the entrepreneur’s dream,
strategy, and goals.
The product/service section should stress the characteristics
and benefits of the new venture. What differentiates it from
its competition? Is it innovative?
The financial components of a new venture’s business plan
typically include three projections: a balance sheet, an
income statement, and a cash-flow analysis. These require
detailed estimates of expenses and sales. Expenses are
relatively easy to estimate. Sales projections are usually
based on market research, and often utilize sales data for
similar products and services produced by competitors.
Writing a business plan may seem overwhelming. However, there
are ways to make the process more manageable. First, there are
many computer software packages for producing a standard
business plan. Numerous books on entrepreneurship have
detailed instructions, and many universities sponsor programs
for new businesses.
Matching product with target market
6. Choosing a Product and a Market
prospective entrepreneur needs to come up with a good idea.
This will serve as the foundation of the new venture.
Sometimes an entrepreneur sees a market need and—Eureka!—has
an idea for a product or service to fill it. Other times an
entrepreneur gets an idea for a product or service and tries
to find a market for it. A Scottish engineer working at
General Electric created putty that bounces but had no use for
it. In the hands of a creative entrepreneur, it became a toy,
“Silly Putty,” with an enthusiastic market: children.
The idea doesn’t have to be revolutionary. Research, timing,
and a little luck transform commonplace ideas into successful
businesses. In 1971, Chuck Burkett launched a firm to make an
ordinary product, novelty key chains. But when he got a
contract with a new venture in Florida—Disney World —he
started making Mickey Mouse key chains, and achieved
tremendous success.
There are many ways to look for ideas. Read a lot, talk to
people, and consider such questions as: What limitations exist
in current products and services? What would you like that is
not available? Are there other uses for new technology?
What are innovative ways to use or to provide existing
products? In Australia in 1996, two entrepreneurs founded
Aussie Pet Mobile Inc. to bring pet bathing and grooming to
busy people’s homes. It is now a top U.S. franchise business.
Is society changing? What groups have unfulfilled needs? What
about people’s perceptions? Growing demand for healthy snacks
created many business opportunities in the United States, for
example.
Business ideas usually fit into one of four categories that
were described by H. Igor Ansoff in the Harvard Business
Review in 1957:

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An existing good or service for an existing mar• ket. This is
a difficult approach for a start-up operation. It means
winning over consumers through merchandising appeal,
advertising, etc. Entry costs are high, and profit is
uncertain.
A new good or service for a new market. This • is the riskiest
strategy for a new firm because both the product and the
market are unknown. It requires the most research and
planning. If successful, however, it has the most potential
for new business and can be extremely profitable.
A new good or service for an existing market. • (Often this is
expanded to include modified goods/services.) For example,
entrepreneurial greeting-card makers use edgy humor and types
of messages not produced by Hallmark or American Greetings—the
major greeting-card makers—to compete in an existing market.
An existing good or service for a new market. • The new market
could be a different country, region, or market niche.
Entrepreneurs who provide goods/services at customers’ homes
or offices, or who sell them on the Internet, are also
targeting a new market—people who don’t like shopping or are
too busy to do so.
The last two categories have moderate risk, but product and
market research can reduce it. They also offer opportunities
for utilizing effective start-up strategies—innovation,
differentiation, and market specification.
Entrepreneurship for midwives
Creating Kaizen spirit as midwife entrepreneur
Moving from midwife practitioner to midwife entrepreneur
7. Entry Strategies for New Ventures
It is easy to be captivated by the promise of entrepreneurship
and the lure of becoming one’s own boss. It can be difficult,
however, for a prospective entrepreneur to determine what
product or service to provide. Many factors need to be
considered, including: an idea’s market potential, the
competition, financial resources, and one’s skills and
interests. Then it is important to ask: Why would a consumer
choose to buy goods or services from this new firm?
One important factor is the uniqueness of the idea. By making
a venture stand out from its competitors, uniqueness can help
facilitate the entry of a new product or service into the
market.
It is best to avoid an entry strategy based on low cost alone.
New ventures tend to be small. Large firms usually have the
advantage of lowering costs by producing large quantities.
Successful entrepreneurs often distinguish their ventures
through differentiation, niche specification, and innovation.
Differentiation is an attempt to separate the new • company’s
product or service from that of its competitors. When
differentiation is successful, the new product or service is
relatively less sensitive to price fluctuations because
customers value the quality that makes the product unique.
A product can be functionally similar to its competitors’
product but have features that improve its operation, for
example. It may be smaller, lighter, easier to use or install,
etc. In 1982, Compaq Computer began competing with Apple and
IBM. Its first product was a single-unit personal computer

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with a handle. The concept of a portable computer was new and
extremely successful.
Niche specification is an attempt to provide a • product or
service that fulfills the needs of a specific subset of
consumers. By focusing on a fairly narrow market sector, a new
venture may satisfy customer needs better than larger
competitors can.
Changes in population characteristics may create opportunities
to serve niche markets. One growing market segment in
developed countries comprises people over 65 years old. Other
niches include groups defined by interests or lifestyle, such
as fitness enthusiasts, adventure-travel buffs, and working
parents. In fact, some entrepreneurs specialize in making
“homemade” dinners for working parents to heat and serve.
Innovation is perhaps the defining characteris• tic of
entrepreneurship. Visionary business expert Peter F. Drucker
explained innovation as “change that creates a new dimension
of performance.” There are two main types of product
innovation. Pioneering or radical innovation embodies a
technological breakthrough or new-to-the-world product.
Incremental innovations are modifications of existing
products.
But innovation occurs in all aspects of businesses, from
manufacturing processes to pricing policy. Tom Monaghan’s
decision in the late 1960s to create Domino’s Pizza based on
home delivery and Jeff Bezos’ decision in 1995 to launch
[Link] as a totally online bookstore are examples of
innovative distribution strategies that revolutionized the
marketplace.
Entrepreneurs in less-developed countries often innovate by
imitating and adapting products created in developed
countries. Drucker called this process “creative imitation.”
Creative imitation takes place whenever the imitators
understand how an innovation can be applied, used, or sold in
their particular market better than the original creators do.
Innovation, differentiation, and/or market specification are
effective strategies to help a new venture to attract
customers and start making sales.

11. Choosing a Form of Business

In many countries, entrepreneurs must select a form of
organization when they start a small business. The basic forms
of organization are sole proprietorships, partnerships, and
corporations. Each has advantages and disadvantages. Moreover,
the laws and regulations that apply to business owners vary
from country to country and by local jurisdiction.
Entrepreneurs should consult an attorney or other expert to
make sure that they have all the necessary licenses and
permits, and are aware of all their legal obligations. In many
countries, the local Chamber of Commerce or local business
council is also a good source of information.
Sole Proprietorship: In a sole proprietorship, the individual
entrepreneur owns the business and is fully responsible for
all its debts and legal liabilities. More than 75 percent of
all U.S. businesses are sole proprietorships. Examples include
writers and consultants, local restaurants and shops, and
home-based businesses.

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This is the easiest and least expensive form of business to
start. In general, an entrepreneur files all required
documents and opens a shop. The disadvantage is that there is
unlimited personal liability — all personal and business
assets owned by the entrepreneur may be at risk if the
business goes into debt.
Partnership: A partnership consists of two or more people who
share the assets, liabilities, and profits of a business. The
greatest advantage comes from shared responsibilities.
Partnerships also benefit by having more investors and a
greater range of knowledge and skills.
There are two main kinds of partnerships, general partnerships
and limited partnerships. In a general partnership, all
partners are liable for the acts of all other partners. All
also have unlimited personal liability for business debts. In
contrast, a limited partnership has at least one general
partner who is fully liable plus one or more limited partners
who are liable only for the amount of money they invest in the
partnership.
The largest disadvantage of any partnership is the potential
for disagreements, regardless of how well or how long the
partners have known each other.
Experts agree that a partnership agreement drawn up by an
experienced lawyer is essential to a successful partnership.
It is often used to:
create a mechanism for resolving disagreements; •
specify each partner’s contribution to the • partnership;
divide up management responsibilities; and •
specify what happens if a partner leaves or dies. •
Corporations: Corporations are recommended for entrepreneurs
who plan to conduct a large-scale enterprise. As a legal
entity that has a life separate from its owners, a corporation
can sue or be sued, acquire and sell property, and lend money.
Corporations are divided into shares or stocks, which are
owned by one, a few, or many people. Ownership is based on the
percentage of stock owned. Shareholders are not responsible
for the debts of the corporation, unless they have personally
guaranteed them. A shareholder’s investment is the limit of
her liability. Corporations can more easily obtain investment,
raise capital by selling stock, and survive a change of
ownership. They provide more protection from liability than
other forms of business. Their potential for growth is
unlimited.
However, corporations are more complex and expensive to set up
than other forms of business and are usually subject to a
higher level of government regulation.

Policies, standards requirements for licensing birthing clinic

and PhilHealth accreditation

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MID-Entrep MARIAM O. BOCA, RM

COMPLICATION OF PREGNANCY
A. First Trimester
1. Hyperemesis gravidarum: In about 2% of the pregnant women,
the nausea and vomiting that they experience persist beyond
the expected duration, even becoming worse. When nausea and
vomiting become lead to complication like dehydration,
weight loss, nutritional deficiencies and acidosis from
starvation, it becomes a disease condition called
Hyperemesis gravidarum.

Causes:
- Elevated HCG
- Thyroid dysfunction
- Psychological stress

Sign and Symptoms:

- Excessive nausea and vomiting persist beyond 12
weeks
- Sign of dehydration: thirst, dry skin, increased
pulse rate, weight loss, scanty urination.

Management:
- Differential Diagnosis: Liver and thyroid studies,
urinalysis, and white blood cell count

Conservative Management:
>Have dry, low fat, high Carbohydrate and bland diet.
>Avoid noxious stimuli that May precipitate nausea.
>Vitamin supplement.
>Enough relaxation and rest.
>Hospitalization: When pregnant woman suffers from
severe nausea and vomiting and shows sign
of dehydration.
> Parenteral/ Enteral Therapies
> Complementary
> Provide emotional support.

2. H-mole: A benign disorder of the placenta characterized by

degeneration of the chorion and death of the
embryo. The chorionic villi rapidly proliferate and
become grape like vesicles that produce large
amount of HCG.
Types:
- Complete Molar Pregnancy: Have only placenta parts
(there is no baby) and form when the sperm
fertilizes an empty egg.
- Partial Molar Pregnancy: The mother’s 23 chromosomes
remain, but there are two sets of chromosomes from
the father (the embryo has 69 chromosomes instead of
the normal 46.)

Risk Factors:

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- Related to geography: Higher occurrence in Asian
countries.
- Women below 18 and above 40 years old.
- Low socioeconomic status.
- Having a history of previous molar pregnancy.

Signs and Symptoms:

- Excessive Nausea and Vomiting
- Bleeding: from spotting to profuse hemorrhage.
- Passage of grape like vesicles around the 4th month
- Rapid increase in uterine size

- Signs of preeclampsia before 24 weeks’ gestation

- Absence of FHT and fetal skeleton
- Ultrasound reveals a mass of fluid filled vesicles
- Elevated plasma thyroxin levels
- Elevated serum gonadotropin level

Management:
- D and C to remove the mole
- Anticancer drug prescribed to the woman for one year
to prevent development of malignant or cancer cells
in the uterus.
- Monitored for HCG levels
- Advised not to get pregnant for one year
- Hysterectomy.

3. Abortion: Is the most common bleeding disorder of early

pregnancy. Abortion is the termination of pregnancy before
viability that is before 20 weeks gestation from LMP or
before the fetus weighs 500 grams.

Types:

a. Elective abortion or Therapeutic abortion: “the

deliberative termination of a pregnancy”.
Elective Abortion: Are those initiated by personal
choice.”
“Therapeutic abortion: are those recommended by the
health care provider to protect the mother’s physical
or mental health.
b. Spontaneous abortion: “the loss of a fetus during
pregnancy due to natural causes”.

Causes:
1. Fetal Factors:
a. Developmental anomalies and
b. Chromosomal Abnormalities.

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2. Maternal Factors:
a. Advancing maternal age.
b. Structural abnormalities of the reproductive
tract
c. Inadequate progesterone production
d. Maternal infections

e. Chronic and systemic maternal diseases

f. Exogenous factors: like tobacco, alcohol,
cocaine, caffeine, radiation.
Complications:

Hemorrhage: More common in late abortions. Continued heavy

bleeding indicates retained tissue (incomplete abortion)

Infection/Septic abortion: Is often a complication of criminally-

induced abortion.

Disseminated intravascular coagulation (DIC) may occur if a

missed abortion is retained beyond one month. This complication
is common in late abortion.

Types:

Threatened Abortion: Refers to the possible loss of the

products of conception. All vaginal bleeding in early pregnancy
without cervical changes is considered a threatened abortion.

Signs and Symptoms:

- Light vaginal bleeding
- None to mild uterine cramping. Severe cramps may
lead to an inevitable abortion.

Management:
- Assess for:
a. LMP (Last Menstrual Period)
b. Instruct client to save all pads for examination
c. Ask for presence of clots
d. Abdominal pain is the next common complaint of
women suffering from abortion next to vaginal
bleeding.
Conservative Management:
a. Instruct client to have bed rest until 3 days
after bleeding has stopped.
b. Advice the couple not to engage in coitus up to 2
weeks after bleeding has stopped.

Inevitable or Imminent Abortion: Refers to the loss of

the products of conception that cannot be prevented.

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Signs and Symptoms:
b. Moderate to profuse bleeding
c. Moderate to severe uterine cramping
d. Open cervix or dilatation of cervix
e. Rupture of membranes
f. No tissue has passed yet

Management:
g. Hospitalization
h. D and C
i. Oxytocin after D and C
j. Sympathetic understanding and emotional support

Complete Abortion: Refers to the spontaneous expulsion of the

products of conception after the fetus has died in the utero.
Signs and Symptoms:
a. Vaginal bleeding, abdominal pain and passage of
tissue. After the passage of tissue, the pain and
vaginal bleeding significantly diminished.
b. Upon examination, the following is noted: Light
bleeding, No tenderness in the cervix, uterus, and
abdomen. None to mild uterine cramping. Closed
cervix. Empty uterus on ultrasound.
Management:
- Needs no further medical or surgical treatment.
Usually the uterus contract well after expelling the
uterine contents so that there is no need for
metering or oxytocin.
- The patient must still be observed.
- Rest for a few days to 2 weeks.
- The woman must use family planning as pregnancy is
discouraged for the next 3 months after abortion
because of the likelihood of having repeat abortion.
- Advise the patient to return to the emergency
department if any of the following symptoms occur:
a. Profuse vaginal bleeding
b. Severe pelvic pain
c. Temperature greater than 100 F.

Incomplete Abortion: Expulsion of some parts and retention other

parts of concept us in utero.

Signs and Symptoms:

a. Heavy vaginal bleeding
b. Severe uterine cramping
c. Open cervix
d. Passage of tissue
e. Ultrasound shows that some of the products of
conception are still inside the uterus.
Management:
a. D and C
b. Monitor blood loss in patient who has inevitable
and incomplete abortion. Monitor VS particularly BP
and pulse rate. Monitor I and O.
c. Sympathetic understanding and emotional support.

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Missed Abortion: Retention of all products of conception after

the death of fetus in the uterus.

Signs and Symptoms:

a. Absence of FHT
b. Signs of pregnancy disappear. Missed abortion should
be suspected when the:
a. Uterus fails to enlarge
b. Fetal heart sounds are not heard.
c. Pregnancy test negative.
d. Ultrasound showing no cardiac activity provides the
earliest diagnosis
Management:
- The product of conception has to be removed from the
uterus to prevent DIC.
- Late missed abortion may be completed with a dilute
IV infusion of oxytocin.

[Link] Abortion: Abortion occurring in 3 or more successive

pregnancies.
Management:
[Link] the cause
[Link] cerelage
[Link] drugs
[Link] or Mini-Heparin
[Link] Phase Progesterone Support
Uterine abnormalities such as uterine septum.
[Link] of medical illness.

[Link] Abortion: Infection involving the products conception

and the maternal reproductive organs.

[Link] Abortion: Dissemination of bacteria (and/or their

toxins) into the maternal circulatory and organ system.

Causative Organisms:
a. Escherichia colli- Most common pathogenic agent
b. Enterobacteria aerogenes
c. Proteus vulgaris
d. Hemolytic streptococci
e. Staphylococci

Signs and Symptoms:

f. Foul smelling vaginal discharge
g. Utrerine cramping
h. Fever, chills, and peritonitis
i. Leukocytosis
j. Critically ill patients may evidence of septic or
endotoxic shock with vasomotor collapse, hypothermia,
hypotension, oliguria, or anuria, and respiratory
distress.

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Management:
k. Treat abortion
l. High dose IV antibiotic therapy
m. D and C
n. Infertility may occur after recovery.

Ectopic Pregnancy: Is implantation of the zygote outside the

uterine cavity or in an abnormal location inside the uterus.
It is the second leading cause of bleeding in early pregnancy.
Causes:
Mechanical Factors:
Salphingitis, Peritubal adhesion, kinking and narrowing,
developmental abnormalities such as diverticula, previous ectopic
pregnancy, previous operations on the tube, tumors that distort
the tube, past induced abortions.

Functional Factors:
External migrations of ovum, menstrual reflux, altered tubal
motility associated with the use of IUD.
Assisted Reproduction:
Ovulation induction associated with fertility drugs. In vitro
fertilization.

Failed Contraception:
IUD, Oral Contraception’s, Traditional Barrier Methods, Tubal
ligation, Hysterectomy.

Types:

> Tubal: More than 95% occurred in fallopian tube. Ampulla-

55%, Isthmic- 25%, Fimbrial- 17%, Interstitial- 2%,
Bilateral- very rare.
> Ovarian- 0.5 %
> Abdominal- Occurs 1/15, 000 pregnancies
> Cervical: Often due to In-vitro Fertilization and embryo
transfer.
> Heterotypic Pregnancy: A tubal pregnancy accompanied by
intrauterine pregnancy.
> Tubo-Uterine: Results from the gradual extension into
the uterine cavity of products of conception that
originally implanted in the interstitial portion of tube.
> Tubo-Abdominal: A zygote that originally implanted in the
fimbriated end of the fallopian tube gradually extends
into the peritoneal cavity.
> Tubo-Ovarian: A zygote that is partly implanted in the
tube and partly in the ovary.

Signs and Symptoms:

Normal pregnancies signs appear during the first week.
Before the rupture brief amenorrhea occurs, Pelvic and Abdominal
pain, “Arias-Stella reaction”- Uterus will not enlarge as in
normal pregnancy, deciduas will be formed but there is no
trophoblasts development because implantation is not within the
uterus.

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Ruptured ectopic pregnancy.

Pain: Sudden severe knife like pain is the most common symptom
when the tube ruptures. Pain radiating to the neck and shoulder
as blood accumulates in the abdominal cavity. Cervical pain
during IE. Spotting or Bleeding

Cullen’s sign or the bluish discoloration of the umbilicus due to

the presence of blood in the peritoneal cavity.
Signs of shock: cyanosis, pallor, cold clammy skin, rapid pulse,
hypotension, oliguria.

Diagnosis:
> Transvaginal ultrasound (TVUS) can reveal an extra uterine
pregnancy.
> Serial human chorionic gonadotropin (HCG).
> Pregnancy test
> Culdocentesis
> Serum progesterone levels.
> Uterine curettage
> Colpotomy
> Laparoscopy
> CBC
> Elevation in WBC.
Management:
For unruptured ectopic pregnancy, therapeutic abortion is
performed.
Ruptured ectopic pregnancy:
> Salphingectomy or surgical removal of the tube.
> Hyterectomy
> Oophorectomy
Depending on whether the tube will be removed or repaired, the
product of conception must be removed completely otherwise
secondary implantation and regrowth of throphoblastic tissue may
occur if it is incompletely removed.

Incompetent Cervix: A mechanical defect of the cervix wherein

there occurs painless cervical dilatation, in the second
trimester or early in the third trimester, followed by prolapsed
and ballooning of the membranes in the vagina that eventually
leads to membrane rupture and expulsion of the products of
conception.

Causes:
>DES exposure in utero
> Cervical trauma from previous difficult deliveries
> Hormonal influences
> Congenitally short cervix
> Forced D and C
> Uterine anomalies

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Sign and Symptoms:

>Painless vaginal bleeding, or pinkish show accompanied by
cervical dilatation. Rupture of membranes and passage of
amniotic fluid follows with subsequent loss of the products
of conception.

Management:
Cervical cerclage or suturing of the cervix

Prerequisites of cervical cerclage:

> Cervix not dilated beyond 3 cm, intact membranes,
> No vaginal bleeding and uterine cramping.

After suturing the cervix:

Place woman on bedrest for 24 hours to several days after
the procedure. Observe for bleeding, uterine contractions and
rupture bag of waters.

Second Trimester
Abruptio Placenta:
Is the premature separation of a normally implanted placenta
after 20 weeks of gestation and before delivery of the fetus.
Also called ablation placenta, placental abruption, and
accidental hemorrhage.

Causes:
> Maternal hypertension
> Advanced maternal age
> Grand multiparity
> Trauma to the uterus
> Rapid decompression of an over-distended uterus
> Short umbilical cord
> Uterine leiomyoma or fibroids

Behavioral risk factors:

Cigarette smoking and Cocaine abuse spasm and vasoconstriction.
Maternal alcohol consumption.

Types:
Classification According to Placental Separation:
Covert/Central Abruptio Placenta: Separation begins at the center
of placental attachment resulting in a blood being trapped behind
the placenta, bleeding, then is internal and not obvious.

Overt/Marginal Abruptio Placenta: Separation begins at the edges

of the placenta allowing blood to escape from the uterine cavity.
Bleeding is external.

Classification According to signs and Symptoms:

Grade 0: No symptoms.
Grade 1: Some external bleeding, uterine tetany, and tenderness
may or may not be noted, absence of fetal distress and
shock.

Grade 2: External bleeding, uterine tetany, uterine tenderness,

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and fetal distress.
Grade 3: Internal and External bleeding (more than 1000 cc),
uterine tetany, maternal shock, probably fetal death
and DIC. Classification According to Extent Separation

Mild: Less than 1/6 of the placenta is separated from the uterus,
Bleeding may or may not be present (<250 cc). Some uterine
irritability with no fetal distress. There may be some uterine
tenderness and vague backache.

Moderate: Approximately 1/6 to 2/3 of the placenta is separated

from the uterus. Dark vaginal bleeding may be absent or present
(>1000 ml). Uterine tenderness and tetany are present. The fetus
will exhibit distress due to uteroplacental insufficiency.

Severe: More than 2/3 of the placenta is separated from the

uterus causing continuous uterine tenderness and rigidity along
with severe pain.

Sign and Symptoms:

> Vaginal bleeding
> Abdominal pain
> Board like abdomen caused by accumulation of blood
> behind the placenta with fetal parts hard to Palpate.
> Signs of shock and fetal distress if bleeding is Severe.

Management:
> Hospitalization
> If fetus is below 36 weeks:
[Link] bleeding episode. Monitor fetal condition
By daily nonstress test and kick counts.
Observe for signs of DIC
> Delivery:
a. Cesarean Section
b. Vaginal Delivery

> Postpartum
Placenta Previa: Is the abnormal implantation of placenta
near or over the internal os. It is the most common bleeding
disorder of the third trimester.

Types:
Complete or Total Placenta Previa: The placenta completely covers
the internal os when the cervix is fully dilated. Partial
Placenta Previa: The placenta partially covers the internal os.
Marginal Placenta Previa: The edge of the placenta is lying at
the margin of the internal os. Low Lying Placenta Previa: The
placenta implants near the internal os with its margin located
about 2 cm to 5 cm from the internal os. Its edges can be felt by
the examining finger on IE.

Causes:

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Multiparity, previous molar pregnancy, Endometritis, Previous
cesarean section, abortion, repeated D and C.
*Multiple pregnancy
*Advance of maternal age
*Decreased blood supply
*Short umbilical cord
*Abnormal placentas
*Large Placenta.
*Complications:
*Disseminated intravascular coagulation
*Infection
*Abnormal Adhesion of Placenta
*Renal failure may occur related to shock caused from hemorrhage
or DIC.
*Anemia
*Postpartum Hemorrhage
*More Lacerations
*Fetal Effects/ Neonatal Effects: Fetal death, Prematurity,
*Cesarean Delivery, Fetal hemorrhage, Neonatal Anemias, Infants
may be small for gestational age (SGA), Brain damage.

Signs and Symptoms:

> Sudden painless vaginal bleeding.
> Bright red bleeding may be intermittent or occur in gushes and
is rarely continuous.
> The placement of the placenta in the lower segment often
prevents the fetal head from entering the true pelvis.
> Decreased urinary output.

Management:
> Internal examination only under Double Set-up.
> Assess extent of blood loss.
> Watchful waiting/ Expectant Management/ Conservative
Management.

Out patient Management: Restricted activities at home, Inform the

patient and the family to be observant for danger signs and the
need to transport the woman to the hospital as soon as any of
these symptoms appear.

Post-partum nursing care:

> Watch out for Hemorrhage.
> Puerperal infection
> Anemia
> Toxemia of Pregnancy
> Hypertensive Vascular Disease

Third Trimester - Disease Affecting Pregnancy

Diabetes Mellitus: Is a hereditary endocrine disorder
characterized by inadequate or lack of insulin production that
results in impaired glucose absorption and metabolism resulting
in hyperglycemia.

Sign and Symptoms:

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Hyperglycemia: The islets of Langerhans of the pancreas are the
producer of insulin is to enable glucose to enter adipose and
muscle cells to be utilize as a source of energy.

Types:
Type 1 Diabetes Mellitus: Is characterized by the presence of
auto antibodies that destroy the insulin producer beta-cells of
the pancreas leading to absence of insulin production.

Type 2 diabetes: The onset of type 2 diabetes is more gradual,

and is estimated it is clinically diagnosed only after about 10
years and often only after a patient develops complications.
Other Specific Types: These are diabetes mellitus caused by known
etiologies or as a result of or as a result of or complication of
other diseases or conditions.

Gestational Diabetes: This is DM that develops during pregnancy

and spontaneously resolves after delivery.

Management:
- Pregnancy Planning: A diabetic woman who plans to get pregnant
must first achieve a stable disease state before conception.
- Prenatal clinic visits: Clinic visit every 2 weeks up to 36
weeks, then weekly.
- The goal of DM Management: Is to maintain maternal glycemic
control to reduce the risks associated with the disease and
promote optimum fetal development.
- Diabetic Diet: Nutritional counseling is the mainstay of
therapy for the gestational diabetic woman. Teach and Instruct
to:
> Reduce saturated fat
> Reduce cholesterol
> Increase dietary fibers
> Reduce concentrated sugars
> Avoid fasting and feasting
- Exercise
- Insulin Therapy
- Self-Monitoring of blood glucose (SMBG)
- Fetal wellbeing monitoring
- Continuing evaluation of diabetic complications.
The goal of DM: Is to maintain maternal glycemic control to
reduce the risks associated with the disease and promote optimum
fetal development.
Glycemic Goals: The glycemic goals recommended by the ADA are as
follows:
*Preprandial plasma glucose.
*Peak postprandial plasma glucose
*HbA 1c: Glycosylated hemoglobin (AIC)
*Heart Disease: The incidence of heart disease complicating
pregnancies is about 1/100. Approximately 75% of heart
disease in pregnancy is valvular, often the result of
rheumatic fever.

Effects of Pregnancy on Heart Disease:

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Increased blood volume and cardiac output.
Systemic vascular resistance drops significantly by 25% during
pregnancy lowering systolic and diastolic blood pressure
The gravid uterus can dramatically affect venous return to the
heart (preload) in some positions.
Normal cardiac findings in pregnancy:

Symptoms:
> Fatigue
>Dyspnea
>Light-headedness

Physical findings:
Displaced apical impulse
Prominent jugular venous pulsations
Widely split first and second heart sounds
Soft ejection systolic murmur

Electrocardiographic Findings:
sinus tachycardia
Premature atrial or ventricular ectopic beats
Right or left axis deviation
ST-segment depression
T-wave changes

Echocardiographic findings:
mild increase in left ventricular diastolic dimension with
preservation of ejection fraction
Functional tricuspid and mitral regurgitation
Small pericardial effusion

Classification of Heart Disease:

Group I: Mortality 1 %, includes corrected Tetralogy of Fallot,
pulmonic tricuspid disease, mitral stenosis (Classes I
and II), patent ductus, ventricular septal defect,
atrial septal defect, and porcine valve.

Group II: Mortality 5-15 %: Includes mitral stenosis with atrial

fibrillation, artificial heart valves, mitral stenosis
(Classes III and IV), uncorrected Tetralogy of Fallot,
uncomplicated aortic coarctation, and aortic stenosis.

Group III: Mortality 25-50%- Includes complicated aortic

coarctation, myocardial infarction, Marfans syndrome,
true cardiomyopathy, and pulmonary hypertension.

Signs and Symptoms:

>Difficulty of breathing

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> Palpitations
> Arrhythmias
> Chest pain
> Hemoptysis
> Syncope with exertion
> Cyanosis
> Clubbing of fingers
> Neck Vein distention
> Systolic and diastolic murmurs
> Cardiomegaly
> Persistent split second sound
> Pulmonary hypertension
* A pregnant woman with heart disease should avoid
infection, excessive weight gain, edema and
anemia because these conditions increase the
Workload of the heart.

Management:
>Prenatal Care
>Promotion of rest
>Diet: high in iron, protein minerals and vitamins

Complications During Labor and Delivery

Powers
Dystocia: Is abroad term referring to prolonged and difficult
labor (any labor that lasts more than 24 hours) caused by an
abnormality or a combination of abnormalities in the essential
factors of labor. Also known as difficult labor, abnormal labor,
difficult childbirth, abnormal childbirth, and dysfunctional
labor. The opposite of dystocia is eutocia, which is normal
labor.

Types:
Uterine dysfunction: Abnormalities of the powers
Abnormalities with passageway
Fetal dystocia

Abnormal Labor Patterns:

Prolonged Latent Phase: The period of time starting with the
onset of regular uterine contractions and ending with the onset
of the active phase. Prolonged latent phase is defined as
exceeding 20 hours in nulliparas and more than 14 hours in
multiparas.

Protraction Disorders- Occur during the active phase. It is the

most common abnormalities of labor.
Arrest Disorders: Active phase disorder characterized by lack of
fetal descent and dilatation.

Prolonged Second Stage: The median duration of the second stage

of labor in nullipara is 20 minutes, in multipara is 50 minutes.
One common cause of this second stage abnormality is persistent
occiput posterior position, another is epidural anesthesia.

Precipitate Labor:

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Ruptured Placenta
Dysfunctional Uterine Contraction: Caused by any or a combination
of the following conditions: pelvic contraction, fetal
malposition, over distention and excessive rigidity of the
cervix.

Types:
Hypotonic Uterine Contractions: Characterized by weak and
infrequent contractions which are insufficient to dilate the
cervix.

Causes:
Overdistention of the uterus.
Malpresentation and Malposition.
Pelvic bone contraction
Unripe or rigid cervix
Congenital abnormalities of the uterus
Unknown causes

Complications:
Maternal and Fetal Infection
Postpartum Hemorrhage
Fetal distress and Death
Maternal exhaustion

Management:
Reevaluate pelvic size to rule out fetopelvic disproportion.
Vaginal Delivery If contracted pelvis is present, caesarian
section is the method of delivery
Provide supportive nursing care.

Hypertonic Uterine Contractions: Usually encountered in the

lartent phase of labor. It is characterized by contractions that
are too frequent but uncoordinated, the uterus does not relax
completely in between contractions and tend to be more painful.

Management:
Evaluation of pelvic size
Maintenance of fluid and electrolyte
Therapeutic rest
Keep bladder empty
Encourage side lying position.
Watch for danger signals: fetal distress, passage of meconium
stained amniotic fluid.

Passageway
Cephalopelvic disproportion

Passenger
Prolapse cord
Cord coil

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Multiple Pregnancies: when two, three, four, or even five fetuses
are conceived, grow and develop in the uterus at the same time,
it is called multiple pregnancy or multifetal pregnancy.
Twins- 2 fetuses
Triplets- 3 fetuses
Quadruplets- 4 fetuses
Quintuplets- 5 fetuses
Sextuplets – 6 fetuses
Septuplets- 7 fetuses

Types:
Monozygotic or Identical twin: Identical twins develop from one
ovum and one sperm cell that undergo too rapid cell division
after fertilization resulting in the formation of two or more
fetuses. Since the fetuses came from the same sperm cell and egg
cell, they naturally possess the same genetic traits and are
always of the same sex.

Dizygotic or Fraternal Twin: Fraternal twins develop from two or

more ova and sperm cells that were fertilized at the same time.
They have different genetic traits; they may or may not be of the
same sex and always have separate placentas, chorions, and
amnions.

Complications:
Abortion
Preterm labor and birth
Pregnancy-Induced Hypertension
Anemia
Birth defects
Twin-to-twin transfusion syndrome
Cesarean delivery.
Postpartum Hemorrhage
Hydramnios
Low birth weight
Placenta previa
Intrauterine growth retardation
Cord entanglement, prolapse and compression.

Signs and Symptoms:

Uterus is large for gestational age
Auscultation of two or more fetal heart tone
History of twins in the family
Palpation of three or more large fetal parts
Ultrasound reveals two or more gestational sac
Higher levels of HCg, Estrogen, human placental lactogen,
estriol, pregnanediol hormones in blood or urine.

Responsible Parenthood and Family Planning Population Situation

of the:

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Philippines
Laws and Legislations Related to FP:
P.D. 965: A decree requiring applicants for marriage license to
receive instruction on Family Planning and Responsible
Parenthood. Such instruction or information may be in the form of
personal instruction and/or handbook, pamphlets or brochures.
Furthermore, such instructions and information shall be
consistent with the policies of the Commission on Population.
P.D. 79: The law that created the population Commission or
POPCOM. Amended by Presidential No. 16.

Duties and Functions of POPCOM:

To employ physicians, nurses, and midwives to provide, dispense
and administer all acceptable methods of contraception, provided
nurses and midwives have been trained and authorized by the
POPCOM.
To undertake projects, promote and publish information on the
Philippine Population Program.
To utilize clinics, pharmacies and other commercial channels for
the distribution of family planning information and
contraceptives.
P.D. 233:
P.D. 6365:
P.D. 69: Limits the number of children to four for tax Exemption
purposes.
P.D. 148: Woman and Child Labor Law. Provides for the privileges
of working women and states that no Child below 14 years old
shall be employed.
L.O.I 47: Directs all schools of midwifery, social work, nursing,
medicine and allied medical profession to include family planning
in their curricula.

Roles and Function of the Midwife

[Link] Counselor
2. Service Provider
3. FP Manager
[Link] of Family Planning in the Philippines
[Link] Parenthood
1. Human Sexuality
a. biophysical profile
b. psycho-physiological
c. socio cultural
2. Benefits of Family Planning
a. mother
b. father
c. children
[Link] Health Assessment
1. Importance
2. When to conduct Health Assessment
3. Components of Health Assessment

G. Counseling
1. Importance of Counseling

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2. Principles of Counseling
3. Components of Counseling
4. Steps in counseling
5. Skills in Counseling
6. Effective Counseling

[Link] Affecting Couples Acceptance and Non-Acceptance of

FP
I. Methods of Family Planning:
1. Natural Method: Natural Methods are based on sexual
abstinence at the time of ovulation to prevent
conception, also known as Fertility Awareness Methods
because the woman is taught to determine the days when
she is fertile and infertile.

Types of Natural Methods of Contraception:

a. Cervical Mucus Method: also known as Billing’s Method and
Wet Dry Method. It is based on the changes in cervical mucus
during the menstrual cycle. Before ovulation mucus discharge
becomes clear, abundant, slippery and stretchable due to
high estrogen level.
b. Symptothermal Method: Combines BBT, cervical mucus
method.
c. Coitus Interrupt us: or Withdrawal involves withdrawal of
penis from the vagina during coitus just before
ejaculation to prevent deposition of sperm cells in the
vagina.
d. Basal Body Temperature: The woman is fertile from the
day of the drop in temperature until the 3rd day of
elevated BBT.
c. Calendar or Rhythm Method: It is based on the number
of days of each menstrual cycle.

[Link] Method:
a. Contraceptive Pills: Are hormonal agents consisting of
estrogen and progesterone. The main action is to inhibit
ovulation.
b. DMPA( Depo-Medroxyprogesterone Acetate) are intramuscular
injections given every 12 weeks. They exert their
contraceptive effect by inhibiting ovulation, altering
cervical mucus and preventing endometrial growth.

[Link] Methods:
a. Chemical Barriers
> Spermicides: Exert their contraceptive effect by
killing spermatozoa before it reach the cervix and by
making the vaginal pH strongly acidic making it not
conducive for sperm survival. Its active ingredient
nonoxynol helps prevents STD’s
b. Mechanical Barriers:
> Male Condom: Is a thin rubber sheath placed over the
erect penis before intercourse. Can purchase without
prescription.

> Female Condom: A polyurethane sheath with one open

polyurethane ring and one closed. The closed ring is

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inserted into the vagina.
> Diaphragm: A circular rubber disc fitted over the cervix
to prevent the entrance of sperm cells into the uterus.
> Cervical Cap: Resembles a diaphragm but it is smaller
and has a taller dome. The cervical cap prevents
pregnancy in the same manner as the diaphragm.

[Link] Method: or Sterilization: A surgical

procedure intended to discontinue the capacity of a person to
have children. Passages of the ova and sperm cells are
occluded to render the person infertile.
a. Tubal ligation: or Bilateral tubal ligation (BTL) is the
most commonly used female sterilization, the fallopian
tubes are occluded by cauterization, blocking, crushing or
clamping.
b. Vasectomy: Male sterilization is achieved by ligation of
the vas deferens to block the passage of sperm cells.
d. Current Trends in Family Planning

V. Care of Infants
A. Principles of Growth and Development
B. Factors Influencing Growth and Development:
- Heredity: genetic characteristics passed down from parents
to offspring determine the rate of growth, height, weight,
hair and eye color and temperament.
- Environment: Although each person has a genetically
determined potential for growth and development, this can
be modified or hampered by environmental influences.
C. Theories of Growth and Development:

[Link] Freud- Psychosexual Stages

- 0 t0 12 months is Oral stage with the mouth as the most
pleasurable part of the body.
- Differentiates self from objects
- Primary concern is learning physical objects.
- Intellectual and Cognitive Development

2. Erik Erickson- Psychosocial Stages:

- 0-12 months is stage of trust and mistrust
- Significant person is the mother.
- Emotional Development

3. Piaget
D. Stages of Growth and Development
Prenatal Period: Conception to birth
> Germinal- Conception to 10 days gestation
> Embryonic- 10 days to 8 weeks gestation
> Fetal- 2 months gestation to birth

Infancy Period: Birth to one year

> Newborn/Neonatal period- Birth to one month
> Infancy- 1 month to 12 months

Childhood Period: One year to 12 years

> Toddler- 1 year to 3 years
> Preschool- 3 years to 6 years

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> School- 6years to 10 years
> Puberty- 10 years to 12 years

Adolescence- 12 years to 19 years

> Early adolescence- 12 years to 16 years
> Late adolescence- 16 years to 19 years.

Immediate Care of the Newborn:

[Link] Care: Before and during delivery, careful
consideration must be given to several determinants of
neonatal well- being that include:
1. Health status of the mother.
2. Prenatal complications, including any suspected fetal
Malformations.
3. Labor complications.
4. Gestational age.
5. Duration of labor and ruptured membranes.
6. Types, amounts, times, and routes of administration of
medications.
7. Type and duration of anesthesia.
8. Any difficulty with delivery.
9. EINC Protocol

New Born Care

The APGAR Scoring System

0 point 1 point 2 points

Color Generalized Body pink, Pink all over

(Appearance) pallor or extremities
bluish blue

Heartbeat Absent <100/min 100/min or

(Pulse) more

Reflexes None Grimace Cry

(Grimace)

Muscle tone Limp Some tone is Active flexion

(Activity) limbs of limbs

Breathing None Slow, Regular, with

(Respiration) irregular cry

[Link]. Many babies may be blue when they are delivered.

But they usually regain color and become pink soon. If the
newborn remains bluish, the baby may not be breathing well.
He may be cold, may have an infection or a congenital heart
problem. Refer the newborn to the doctor if the baby remains
bluish or pale.

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2. Heartbeat. The heartbeat of the newborn is between 120 to
160 beats every minute. Count the heartbeats of the baby for a
full minute. Heartbeats outside of the normal rate may mean
problems that referral to the doctor.

3. Reflexes. When you suction the baby’s mouth or nose, the baby
frowns or makes a grimace. This is the sign that the reflexes are
working well. Having good reflexes is an indication that the
baby’s brain and nerve are functioning well.

4. Muscle tone. A newborn with his arms and legs bent has good
muscle tone. A limp baby with his arms and legs loose has poor
muscle tone. A baby with poor or weak muscle tone may have
trouble breathing. Try rubbing his back so the baby will wake up.
Refer babies who are limp to the doctor or to the hospital.

5. Breathing. Babies who cry after birth are usually breathing

well. However, some newborns may have breathing problem.

The following are bad sign:

 The nostrils are flaring when the baby breathing

 The skin between the ribs retracts in breathing

 Very rapid breathing – more than 60 per minute

 Very slow breathing – less than 30 per minute

 The baby grunts when he breaths

Initial assessment and action to be taken

Initial assessment Action

Pink Dry and wrap baby
Heart rate >120 bpm Baby stays with mother
Breathing regularly
Blue Dry and wrap
Heart rate >100 bpm Clean the airway
Breathing inadequate
Blue or pale Dry and wrap
Heart rate <100 bpm Clear the airway /Ask for
Not breathing help
Refer to the doctor

SCORE:
- 7-10: Good adjustment, vigorous

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- 4-6 : Moderately depressed infant, needs airway Clearance.
- 0-3 : Severely depressed infant, in need of
Resuscitation.

- The total score, based on the sum of the five components

(heart rate, respiratory effort, muscle tone, reflex
irritability, and color.), is determined 1 and 5 minutes after
delivery.

- The 1-minute Apgar score reflects the need for immediate

resuscitation. The 5- minutes score, and particularly the change
in score between 1 and 5 minutes, is a useful index of the
effectiveness of resuscitative efforts.

2. Maintenance of Airway:
- Stimuli to Breathe Air- The newborn begins to breathe and cry
almost immediately after birth, indicating the establishment of
active respiration. Factors that appear to influence the first
breath of air include:
a. Physical stimulation, such as handling the infant during
delivery.
b. Deprivation of oxygen and accumulation of carbon dioxide.
c. Compression of the thorax during the second stage of
labor and vaginal birth.

3. Maintenance of Temperature:
- Newborns loss about 2-3 C of heat at birth because the
external environment is much cooler than the temperature inside
the mother’s womb. The average newborn temperature at birth is
around 37.2 C.

Nursing Interventions:
a. Dry head and body of amniotic fluid immediately after
birth.
b. Wrap the newborn with a dry and warm blanket. Subsequent
blankets should be changed as necessary.
c. Give the baby to the mother to hold. The warmth of her body
can be a source of heat for the newborn. Early skin-to-skin
contact for the first few hours after birth is more than
just a measure for preventing hypothermia. It also:
> provides warmth
> enables early breast-feeding
> prevents hypoglycemia
> encourage bonding
> expose the baby to the mother’s skin
Bacteria.

d. Ideally the newborn should be placed in an isolate or

droplight if his temperature is below 98 F rectally. Place
newborn under droplight without clothes for two hours after birth
or until temperature has stabilized and the baby can be placed in
an Open crib.

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e. Delay initial bath until temperature has Stabilized for a
least 2 hours.
f. Maintain ambient temperature of nursery at 24 C or 75 F.
g. Perform any extensive examination or procedure under radiant
heat to prevent Heat to prevent heat loss and expose only the
part of the body to be examined.
h. When taking temperature-only the first assessment is done
rectally to be able to check for the potency of the anus as well.
Subsequent temperature assessment is taking axillary.

Maturational Assessment of Gestational Age (New Ballard Score)

A. NEUROMUSCULAR MATURITY

Score
Neuromuscular -1 0 1 2 3 4 5 Record score
maturity sign here
Posture

Square
Window
Arm recoil

Popliteal angle

Scarf sign

Heel to ear

Total neuromuscular maturity score:

Physical Maturity rating

Score Weeks
- 10 20
-5 22
0 24
5 26
10 28
15 30
20 32
25 34
30 36
35 38
40 40
45 42
50 44

Physical maturity sign SCORE Record

score
here
-1 0 1 2 3 4 5

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Skin Sticky Gelati Smooth Superfici Cracking Parchment Leathery

Liuable nous pink, al pale deep cracked
Transpare red visible peeling & areas cracking wrinkled
nt transl veins or rash, rare no vessels
ucent few veins veins
Lanugo None Sparse Abundan Thinning Bald Mostly
t areas bald
Plantar Heel-toe >50mm Faint Anterior Creases Creases
surface 40-50 no red transvers ant. 2/3 over
mm:-1 crease marks e crease entire
<40mm:-2 only sole
Breast Impercept Barely Flat Stipped Raised Full
ible percep areola areola 1- areola 3- areola 5-
tible no bud 2 mm bud 4 mm bud 10 mm bud
Eye/ear Lids Lids [Link] Well Formed Thick
fused open ed curved and firm, cartilage
Loosely:- pinna pinna; pinna; instant ear soft
1 flat soft soft but recoil
Tightly:- Stays slow ready
2 folded recoll recoil
Genital Scrotum Scrotu Testes Testes Testes Testes
s flat,smoo m in descendin down good pendulous
(male) th empty, upper g few rugae deep rugae
Faint canal rugae
rugae rare t
rugae
Genital Clitoris Promin Promine Majora & Majora Majora
s prominent ent nt minoraequ large cover
(female And labia Clitor clitori ally minora clitoris &
) flat is and s znd prominent small minora
small small
labia labia
minora minora

Total physical maturity score:

Immediate care of the newborn
The umbilical cord is usually clamped after delivery of
the baby. However, others wait a while before clamping the cord.
By waiting, the baby receives some extra blood from the placenta.
When the baby has been dried, fix the cord with a cord clamp or a
sterile tie using the standard clean practice.

Infection prevention and other procedures

 Always wash hands before touching the baby. This is
very important in preventing infection because mot
infections are spread by hands. Use an antibacterial
soap to wash hands. You can also spray or rub your
hands with disinfectant like 70% isoprophyl alcohol.

 Skin to skin care and maintaining the baby close to the

mother decrease serious infections. It also keeps the
baby warm and dry. Keep the newborn’s body temperature
in the range of 36.6%-37.3% C. lower temperature
(hypothermia) in the newborn can cause acid-base
imbalance and can lead to death.

 Do not wash vernix routinely. Vernix can be

antibacterial. Besides, it is absorbed by the skin in a
day or two.

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 Breastfeed the baby. Breast milk contains antibodies
that protect the baby from infection aside from being
the best food for the baby.

 Apply 70% isoprophyl alcohol to the umbilical cord

stump three or four times daily. This will keep it dry
and clean. It will also help in making it fall off
early. Umbilical cord stumps usually fall off in 7-10
days. If it does not, refer to a doctor.

 Put tetracycline eye ointment on the baby’s eyes to

avoid conjunctivitis. The eyes frequently get infected
as the baby passes through the cervix and vagina during
childbirth.

 Inject the baby with 1 mg of vitamin K intramuscularly.

A newborn usually lacks vitamin K and is prone to
bleeding.

 Weigh the baby. Measure the birth length and head

circumference. These findings will tell you if the baby
is small or large for gestational age and what problems
to expect.

 Examine the newborn for anatomic abnormality and

recognize early the problems she may have.

 Start immunization with hepatitis B vaccine and BCG as

recommended.

 Avoid kissing the newborn because viruses carried in

the mouth by adults and older children may infect the
baby.

 Advise the mother to frequently observe the baby for

danger signs.

The following are the conditions of the newborn needing urgent

intervention:
a. Change in color from pink to paleness, blue or deep yellow

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b. Poor suck or weak cry or limpness
c. Irritability or nonstop crying
d. Preterm or very low birth weight
e. Gasping or not breathing (fast, slow breathing, grunting)
f. Convulsions
g. Frequent loose stools or difficulty of defecating
h. Fever or hypothermia (low temperature)
i. Pus in the umbilicus or redness around the umbilicus extending
to the skin
j. Bleeding
k. Pustules in the skin or swelling and redness
Bring the baby to the doctor or hospital immediately if she has
any of the above listed danger signs.

For the newborn, remember:

 An APGAR score of 7-10 indicates good condition.

 If the APGAR score after one minute is less than 7, the

baby needs resuscitation.

 In home births, it is better to bring the newborn

immediately to the hospital if the baby is depressed in
the first minute.

Emergencies in the newborn and the three delays

Many newborn deaths occur at home, often after childbirth.
The most important causes of newborn deaths are infections, birth
asphyxia (problem of oxygenation at birth), prematurity and
congenital birth defects. Just like the mother, the newborn can
also die because of the three delays that prevent their timely
access to emergency care.
Delay in seeking care. The woman and the family do not know the
danger signs in the newborn that need urgent referral to the
hospital or doctor.
Delay in reaching care. There is lack of money to pay for
transportation and not knowing where quality newborn care is
available.
Delay in receiving care. The hospital may lack trained personnel
to attend to newborn having complications. There is also the
common complaint of lack of supplies and equipment’s needed
during emergencies.

Causes of Neonatal Deaths

 Complications of prematurity 24%
 Birth asphyxia 29%
 Congenital anomalies 10%
 Infection (tetanus, sepsis, pneumonia, diarrhea) 32%
 Other 5%
Newborn babies needing referral
1. Small for gestational age babies. Small babies are those
born with birth weights of less than 2.5 kilograms. Small
babies may also be premature and may have trouble feeding.
They easily develop breathing problems, infection and
jaundice. They should be kept warm. Do not bath small babies

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because they can develop hypothermia. Refer these babies to
the doctor or hospital where they can receive better care.
2. Large for gestational age babies. Some babies may become
very big because of mothers who have diabetes. The increase
sugar in the blood of a diabetic mother stirs up the fetal
pancreas to give out extra insulin that acts as a fetal
growth hormone.
3. Congenital anomalies. About 2-3% of babies are born with
important birth defects. A birth defect may change a baby’s
appearance or affect his body’s functions or both. Worse, it
may cause death.
Examine the newborn for abnormalities as soon as possible
 Are all the body parts complete and in proportion?
 Is there cleft palate?
 Is the anus open and patent?
 Does the head seem bigger (hydrocephalus) or smaller
(microcephaly) than normal?
 Are there joined or extra parts such as extra fingers?
Is there clubbed feet?
4. Blood infection of the newborn (Sepsis neonatorum). Sepsis
neonatorum or septicemia is infection in the blood of the
newborn caused by bacteria that infected the baby before,
during or after birth.

Before birth. If the mother has infection (e.g. respiratory

or urinary) during pregnancy, she may pass this on the baby
resulting to intrauterine infection. The newborn usually
shows signs of the infection early or few hours after birth.

During birth. If the mother has genital infection, the

newborn may get it as he passes through the cervix and
vagina at birth. Another way is when the membranes rupture
long (12 hours or more) before delivery; bacteria from the
vagina may get through and infect the baby. The newborn may
show signs of infection several hours or days after birth.

After birth. The newborn gets the infection from unclean

surroundings and hygienic practices that can happen when
childbirth is not assisted by a skilled attendant. Signs of
the infection may show within the first month of life.

The signs of Sepsis are:

 Lethargy. The baby seems less active than before and

appears sick. He tends to sleep for longer periods, is
quite drowsy and reflexes are weak.
 Poor sucking or feeding. It is the refusal of the baby
to suck or feed. It may also mean reduced amount of
feeding or that this latch on to the nipple is weak.

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 Abnormal distention. A bloated abdomen with weak bowel
sounds may or may not be associated with vomiting.
 Pallor. It may be caused by anemia due to blood
infection.
 Jaundice. It is the yellowish discoloration of the skin
caused by the infection affecting the liver.
 Apnea. Stoppage of breathing that may occur in
intervals signifying that the infection is going up to
the brain and the brain center for breathing is getting
involved.
 Hypothermia. It is more common than fever in sepsis
indicating the breakdown of the newborn’s body defenses
against infection.
5. Conjunctivitis of the newborn (Ophthalmianeonatorum). There
is yellowish discharge (pus) from the eyes, redness of the
conjunctiva and swelling of the eyelids. This condition can
the result of infection caused by Chlamydia trachomatis or
gonococcus if the mother has a genital infection. Severe
conjunctivitis can lead the blindness if not treated. Refer
babies with this condition to the doctor or hospital for
appropriate treatment.
6. Infection of the umbilical stumps (Omphalitis). A healthy
umbilical cord stump is white and feels soft. In a few days
of good care, the cord stump becomes dry and dark brown.
Sometimes the umbilical stump may become infected. The
following are signs of infection:
 Smelly discharged on the surface of the umbilical stump
 The umbilical stump remains wet and soft.
 There is redness around the base of the umbilical.

7. Bleeding in the newborn. The fetus receives very little

amount of Vitamin K from the mother. Vitamin K is made by
bacteria in the gut. But because the gut is sterile in the
early days of life, the newborn is lacking of it. The liver
needs vitamin K to make other clotting factors. But since
the liver is immature at birth, it has no stores of vitamin
K. Therefore, a newborn baby is deficient in vitamin K. This
can cause a bleeding condition known as the “Hemorrhagic
Disease of the Newborn”. This condition usually occurs in
the first week of

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8. life. Blood maybe noted in the vomitus or in the stools of
the baby. The baby may even bleed from the vagina or from
the umbilical stump. Hemorrhagic disease of the newborn can
lead to permanent brain damage or even death.

9. Newborn with birth injury. Some newborn may get hurt by the
pressure of the birth canal during delivery. For example big
babies may have large shoulders and heads that would make
their deliveries hard and prone to injuries. Babies who
presents as breech or face presentations tend to get hurt as
a result of manipulation. Precipitate labor and delivery
wherein the baby is delivered very fast or even without
assistance may result in fall and trauma for the baby.

[Link]. Jaundice is the yellowish discoloration of the

skin and sclera caused by increased bilirubin levels in
the blood. Bilirubin is the yellow pigment that result from
the breakdown of hemoglobin.

Cord Care: EINC Protocol

Report any unusual sign and symptoms that indicate infection:

> Foul odor in the cord
> Presence of discharge
> Redness around the cord
> The cord remains wet and does not fall off within 7 to 10
days.
> Newborn fever
b. Characteristic of newborn:
c. Appearance of newborn

Infancy
a. Infant profile
b. Developmental task
c. Nutrition: “The study of food in relation to health”

Nutrient: Is a chemical component needed by the body to provide

energy, to build and repair body tissues and to regulate life
processes. The different nutrients needed by the body are water,
protein, carbohydrates, fats, minerals and vitamins.
Metabolism: Is the process by which the body utilizes food or the
different nutrients derived from food.

Nutritional Status: Is the condition or status of the body

resulting from utilization of nutrients. A person may have poor,
fair or good nutrition.
Fluids: Water is the second most important need of man next to
oxygen. In order to maintain fluid balance in the body, the
amount of water intake must be approximately equivalent to the
amount of water loss.
Why do infants need more water than adults:

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- Metabolism requires water. Infants have higher metabolic
rate than adult so they more water.
- Amount of insensible water loss depends on body surface
area. Infants have higher
- Checking Nutritional Status

Newborn screening
Newborn screening is a test to find out early if a new
born has any of following five inborn metabolic defects:
1. Congenital hypothyroidism
2. Congenital Adrenal Hyperplasia
3. Galactosemia
4. Phenylketonuria
5. Glocuse-6-Phosphate Dehydrogenase (G6PD) Deficiency

Newborn Screening of Five Inborn Metabolic Disorders

Disorder Screened Effect If NOT Effect If SCREENED

SCREENED and TREATED

Congenital Severe mental Normal

Hypothyroidism Retardation
(CH)

Congenital Adrenal Death Alive and

Hyperplasia (CAH) Normal

Galactosemia (GAL) Death or Alive and

Cataracts Normal

Phenylketonuria Severe mental Normal

(PKU) Retardation

G6PD Deficiency Severe Anemia, Normal

Kernicterus

FREQUENT – ASK QUESTION REGARDING

ESSENTIAL Intrapartum and Newborn Care

1. Preparing for the delivery

A- Companion of choice

Q- How do we address very anxious companion to the laboring

woman? Will this not lead to passible medic0-legal implications
if they see certain action? How do we ensure privacy?

A-It takes good patient rapport and appropriate and timely

counseling ( If possible, during the antenatal care) with regard
to the aspect. To begin with, it has to be explained to the

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companion why we would like them to be with the patient-to offer
verbal encouragement and support, to help them into a position
that’s comfortable for her, to hold her hand, to rub her back, to
coach her during the labor and delivery process, among other
things, If there is enough time, it also has to be explained
that, if there are physical arrangement constraints ( i.e. there
are other laboring woman in the unit.) we may ask them to just
intermittently come in if the husband is the one we are talking
to; If a female companion is available, then that may be
preferred, to ensure privacy of other women in the unit. The
presence of companion of choice also help keep every one else in
the labor and delivery unit on their toes.
B- Draft

Q-How do you check for drafts?

A-Pick up a piece of tissue by its corner and allow it to dangle.
If it moves then there is a draft.
C- Temperature

Q- How often should one check the room temperature?

A-Ideally, one should check the room temperature right before
every delivery.
D- Hand ashing

Q- Why teach the “1-2-3-4-5” and not the “Happy Birthday” method
of hand washing?
A-The “1,2,3,4,5” method is more systematic and ensures that all
hands surface are covered.
E- Double-Gloving

Q- In our center, we have two health workers attending to each

delivery- who should double gloves?
A-however handles (feel pulsations, clamps, cuts) the cord,
either after handling the perineum (the obstetrician or midwife)
or after drying the baby (the pediatric staff person) should
double gloves, Remove the first set before handling the cord,
double gloving is probably not necessary in cesarean section as
sterility is assumed.

Prepare delivery needs

Q-Why is the linear sequence being emphasized?

A-It is relatively easy to learn anew procedure, but more
difficult to “ unlearn” old familiar behaviors. The linear
sequence of instruments “forceps” the health worker into the new
behavior.

Linear Arrangement of instruments:

1. Sink or dipper
2. Soap
3. Towel to dry hand
4. 2 pairs of sterile gloves

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5. Baby bonnet
6. At least 2 towels to dry the baby
7. Oxytocin, (cotton balls, alcohol, syringe)
8. Plastic clamp, sterile
9. Instrument clamps ( forceps)
[Link], sterile
[Link] basin (* for placenta and for soiled gloves and
instruments)
[Link] care ointment or drops
[Link] K, (Cotton balls, Alcohol, syringe)
[Link] B Vaccine, (cotton balls, alcohol, syringe)
15. BCG vaccine, (cotton balls, alcohol, syringe)

Position of choice during labor

Q- Most hospital have laboring women strapped to a fetal monitor.

How will this allow for position of choice during labor?
A-It is possible to monitor the fetal heart tones as she walk
around the bed. If it becomes technically difficult to keep the
transducer in place (such that FHT pick-up is displaced) then
intermittent (Alternate) checking of the FHT is acceptable.

Semi-upright Position of the Mother During Delivery

Q-What if the labor/delivery bed cannot be raised?
A-The companion of choice become helpful at this point to raise
the woman’s upper body, to assist her into an upright position.
Alternatively, a edge-like apparatus or pillows or a bean bag may
be placed to assist the mother into a semi-upright position.

Doing an Enema

Q-Having women pass feces during delivery is very cumbersome,

some doctors prefer to do an enema to avoid this inconvenience.

A-It then becomes a physician centered to do an enema. Enemas

have not been proven to decrease infection rates nor dehiscence
of vaginal lacerations. The theoretical increase in bacterial
colonization in some studies has not been found to translate into
any significant clinical outcomes.

Doing an episiotomy

Q- The perineum of ASEAN women is usually shorter and will tend

to tear during vaginal delivery, Isn’t
An episiotomy indicated to prevent multiple tears?
A-In an observational study among Southeast Asian women, Dr. Ho
et al (IJGO) observed that severe perineal trauma/tears was
reduced to 1.9% from previous 3.9% among women in whom
restrictive (rather than routine.

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What is IMCI?
o This chapter provides key information on the IMCI
strategy, as well as its rationale, guiding principles
and objectives. It also gives an overview of the
components of the IMCI strategy
The IMCI strategy focuses on:
 improving case management skills of health-care providers
 improving overall health systems
 improving family and community health practices.

Main Symptoms. For older children include

A. cough or difficulty breathing,
B. diarrhea,

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C. fever,
D. ear infection.

Main Symptoms young infants,

A. local bacterial infection,
B. diarrhea,
C. jaundice.

In addition, all sick children are routinely assessed for

A. nutritional and immunization status,
and other potential problems

 color-coded triage system:

A. "pink" indicates urgent hospital referral or admission,
B. "yellow" indicates initiation of specific outpatient
treatment, and
C. "green" indicates supportive home care

 Measles is a highly infectious disease caused by a virus.

Measles kills more children than any other vaccine-
preventable disease. You wil find more information about
measles in the chapter on Fever.

 Diphtheria affects people of all ages, but most often it

strikes unimmunized children. In temperate climates,
diphtheria tends to occur during the colder months. In 2000
there were 30 000 cases and 3000 deaths of diphtheria
reported worldwide.

 Pertussis, or whooping cough, is a disease of the

respiratory tract caused by bacteria that live in the mouth,
nose and throat. Many children who contract pertussis have
coughing spells that last four to eight weeks. The disease
is most dangerous in infants. In 2000, an estimated 39
million cases and 297 000 deaths occurred worldwide, as a
result of pertussis.

 Poliomyelitis, or polio, is a crippling disease caused by

any one of three related viruses, poliovirus types 1, 2 or
3. All Member States of WHO agreed in 1988 to eradicate
polio. Since the global initiative to eradicate polio was
launched, the number of reported cases of polio has been
reduced from an estimated 350 000 in 1988 to 483 cases
associated with wild poliovirus in 2001.

 Tetanus is acquired through exposure to the spores of the

bacterium Clostridium tetani which are universally present
in the soil. The disease is caused by the action of a potent
neurotoxin produced during the growth of the bacteria in
dead tissues, e.g. in dirty wounds or in the umbilicus
following non-sterile delivery.
 People of all ages can get tetanus. But the disease is
particularly common and serious in newborn babies. This is
called neonatal tetanus. Most infants who get the disease

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die. Neonatal tetanus is particularly common in rural areas
where most deliveries are at home without adequate sterile
procedures. According to WHO estimates, neonatal tetanus
killed about 200 000 babies in 2000.

 Tuberculosis (TB) is caused by the bacterium Mycobacterium

tuberculosis which usually attacks the lungs, but can also
affect other parts of the body, including the bones, joints
and brain.
 Not everyone who is infected with tuberculosis bacteria
develops the disease. People who are infected may not feel
ill and may have no symptoms. The infection can last for a
lifetime, but the infected person may never develop the
disease itself. People who are infected but who do not
develop the disease do not spread the infection to others.
In 2001, approximately two million people worldwide died of
tuberculosis.

 Hepatitis B is caused by a virus that affects the liver.

Adults who get hepatitis B usually recover. However most
infants infected at birth become chronic carriers i.e. they
carry the virus for many years and can spread the infection
to others. In 2000, there were an estimated 5.7 million
cases of acute hepatitis B infection and more than 521 000
deaths from hepatitis B-related disease.

 Haemophilus influenzae type b (Hib) is one of six related

types of bacterium. In 2000, H. influenzae type b (Hib) was
estimated to have caused two to three million cases of
serious disease, notably pneumonia and meningitis, and 450
000 deaths in young children.

 The Hib bacterium is commonly present in the nose and

throat. Bacteria are transmitted from person to person in
droplets through sneezing and coughing. Infected children
may carry Hib bacteria without showing any signs or symptoms
of illness, but they can still infect others.

 The risk of disease is highest for children between 6 months

and 2 years of age.

 Pneumonia and meningitis are the most important diseases

caused by Hib bacteria. In developing countries, pneumonia
is more common than meningitis in children with Hib disease.
Hib disease should be suspected in the case of any child
with signs and symptoms of meningitis or pneumonia.

 Children who survive Hib meningitis may develop permanent

neurological disability, including brain damage, hearing
loss, and mental retardation. Between 15% and 30% of
children who survive Hib disease are at risk for these
disabilities. From 5% to 10% of people with Hib meningitis
are at risk of dying.

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Malnutrition is associated with many childhood illnesses and
deaths. There are several types of malnutrition.

One type of malnutrition is acute malnutrition. Acutely

malnourished children lack growth nutrients that are required to
build new tissues. These nutrients also aid weight gain after
illness, repair damaged tissues and help replace the rapid turn-
over of cells (intestine and immune cells). Correct replenishment
of nutrients is essential for recovery from malnutrition. A child
who has had frequent illnesses can also develop acute
malnutrition. The child's appetite decreases, and the food that
the child eats is not used efficiently.

Severe acute malnutrition (SAM) is a life threatening

condition requiring urgent treatment. Until recently, the
recommendation was to refer children suffering from SAM to
hospital to receive therapeutic diets along with medical care.
Treating severely malnourished children in hospitals however, is
not always desirable or practical especially in rural settings.
The situation has changed with the advent of ready to use
therapeutic foods (RUTF) which allows the management of a large
numbers of children who are severely malnourished above the age
of 6 months and without medical complications at home.

RUTF is made according to a standard, energy-rich composition

defined by the World Health Organization. Typically, RUTF is made
from full-fat milk powder, sugar, peanut butter, vegetable oil,
and vitamins and minerals. The benefits of RUTF include low
moisture content, a long shelf life without needing refrigeration
and that it requires no preparation.

A child whose diet lacks recommended amounts of essential

vitamins and minerals can also develop malnutrition.
Not eating foods rich in iron can lead to iron deficiency and
anemia. Anemia is a reduced number of red cells or a reduced
amount of hemoglobin in each red cell. A child can also develop
anemia as a result of:

 infection;
 parasites such as hookworm (Ancylostoma and Necator) or
whipworm (Trichuris), which can cause blood loss from the
gut;
 malaria, which can destroy red cells rapidly.
Children can develop anemia if they have had repeated episodes
of malaria or if the malaria was inadequately treated. The anemia
may develop slowly. Often, anemia in these children is a result
of both malnutrition and malaria.

Integrated Management of Childhood Illness

SICK CHILD AGE 2 MONTHS UP TO 5 YEARS:

Ask: Look: Danger Sign

1. Is the child able to drink or breastfeed?
2. Does the child vomit everything?

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3. Has the child had convulsions?
4. See if the child is lethargic or unconscious.
5. Is the child convulsing now?

Note:

A child with any general danger sign needs URGENT attention;

complete the assessment and any pre-referral treatment
immediately so referral is not delayed.

[Link]

A. Pink: SEVERE PNEUMONIA OR VERY SEVERE DISEASE

Sign: Any general danger signs or Stridor in calm

child.
 A child not able to drink or breastfeed
 Child vomit everything
 Child had convulsion
 Child is lethargic or unconscious
 Child convulsing now

B. Yellow: PNEUMONIA

Sign: Chest in drawing or Fast breathing.

the child is: Fast breathing is:

2 months up to 12 months 50 breaths per minute or More
12 Months up to 5 years 40 breaths per minute or More

C. Green: COUGH OR COLD

No signs of pneumonia or very severe disease.

* If referral is not possible, manage the child as described in

the pneumonia section of the national referral guidelines or as
in WHO Pocket Book for hospital care for children.

**Oral Amoxicillin for 3 days could be used in patients with fast

breathing but no chest in drawing in low HIV settings.

*** In settings where inhaled bronchodilator is not available,

oral salbutamol may be tried but not recommended for treatment of
severe acute wheeze.

If wheezing with either fast breathing or chest

in drawing:
* Give a trial of rapid acting inhaled bronchodilator for up to
three times 15-20 minutes apart. Count the breaths and look for
chest indrawing again, and then classify.

2. Diarrhea
Look and feel:

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 Look at the child's general condition. Is the child:
a. Lethargic or unconscious?
b. Restless and irritable?
c. Look for sunken eyes.
d. Offer the child fluid. Is the child:
1. Not able to drink or
2. Drinking poorly?
3. Drinking eagerly, thirsty?

* Pinch the skin of the abdomen.

1. Does it go back: Very slowly (longer than 2 seconds)?
Slowly?

Pink: SEVERE DEHYDRATION

Sign: Two of the following signs: Lethargic or unconscious

* Sunken eyes
* Not able to drink or drinking poorly
* Skin pinch goes back very slowly.
Yellow: SOME DEHYDRATION

Two of the following signs:

 Restless, irritable
 Sunken eyes
 Drinks eagerly, thirsty
 Skin pinch goes back slowly.

Green: NO DEHYDRATION
 Not enough signs to classify as some or severe dehydration.

3. Diarrhea 14 days or more

Pink: SEVERE PERSISTENT DIARRHEA
Sign: Dehydration present.

Yellow: PERSISTENT DIARRHEA

4. Blood in stool:
Yellow: DYSENTERY
Sign: Blood in the stool only

3. MALARIA
Decide Malaria Risk: Ask
> Does the child live in a malaria area?
> Has the child travelled during the past 3 weeks and, if so,
> where?

Then ask: Look and feel:

For how long?
 If more than 7 days, has fever been present every day?
 Has the child had measles within the last 3 months?
 Look or feel for stiff neck.
 Look for runny nose.
 Look for any bacterial cause of fever**.
 Look for signs of MEASLES. Generalized rash and

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 One of these: cough, runny nose, or red eyes.

Do a malaria test***: If NO severe classification

In all fever cases with malaria risk. If no obvious cause of
fever present.

Pink: VERY SEVERE FEBRILE DISEASE

 Any general danger sign or Stiff neck.
Yellow: MALARIA
Sign: Malaria test POSITIVE.

Green: FEVER: NO MALARIA

Sign: Malaria test NEGATIVE Other cause of fever
PRESENT.

Pink: VERY SEVERE FEBRILE DISEASE

Sign: Any general danger sign or Stiff neck.

Green: FEVER
Sign: No general danger signs, No stiff neck.

Do a malaria test***: If NO severe classification

In all fever cases with malaria risk. If no obvious cause of
fever present.

4. MEASLES

If the child has measles now or within the last 3 months:

 Look for mouth ulcers.
 Are they deep and extensive?
 Look for pus draining from the eye.
 Look for clouding of the cornea.

Pink: SEVERE COMPLICATED MEASLES****

Sign:
* Any general danger sign or
 Clouding of cornea or
 Deep or extensive mouth ulcers.

Assess Dengue Hemorrhagic Fever

ASK:
 Has the child had any bleeding from the nose or gums or in
the vomitus or stools?
 Has the child had black vomitus?
 Has the child had black stools?
 Has the child had persistent
 abdominal pain?
 Has the child had persistent vomiting

LOOK AND FEEL:

 Look for bleeding from nose or gums.
 Look for skin petechiae.
 Feel for cold and clammy extremities.
 Check for slow capillary refill.

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> if none of above ASK or LOOK and FEEL

signs are present and the child is 6 months or older and fever is
present for more than 3 days. Perform the tourniquet test.

Yellow: MEASLES WITH EYE OR MOUTH COMPLICATIONS

Sign: Pus draining from the eye or Mouth ulcers

Green: MEASLES
Sign: Measles now or within the last 3 months.

DENGUE HEMORRHAGIC FEVER

Pink: SEVERE DENGUE HEMORRHAGIC FEVER

Sign: * Bleeding from nose or gums or
 Bleeding in stools or vomitus or
 Black stools or vomitus or
 Skin petechiae or
 Cold and clammy extremities or
 Capillary refill more than 3 seconds or
 persistent abdominal pain
 Persistent vomiting or
 Tourniquet test positive

Green: FEVER: DENGUE HEMORRHAGIC FEVER UNLIKELY

Sign : No signs of severe dengue hemorrhagic fever

* These temperatures are based on axillary

temperature. Rectal temperature readings are approximately 0.5°C
higher.

**Look for local tenderness; oral sores; refusal to use a limb;

hot tender swelling; red tender skin or boils; lower abdominal
pain or pain on passing urine in older children.

*** If no malaria test available: If in malaria risk area -

classify as MALARIA; If NO obvious cause of fever - classify as
MALARIA.

**** Other important complications of measles - pneumonia,

stridor, diarrhea, ear infection, and acute malnutrition - are
classified in other tables.

[Link] Problems

If yes, ask: Look and feel:

 Is there ear pain?
 Is there ear discharge?
 If yes, for how long?
 Look for pus draining from the ear.
 Feel for tender swelling behind the ear

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Pink: MASTOIDITIS
Sign: Tender swelling behind the ear.

Yellow: ACUTE EAR INFECTION

Sign: *Pus is seen draining from the ear and
discharge is
 reported for less than 14 days, or
 Ear pain.

Yellow: CHRONIC EAR INFECTION

Sign: * Pus is seen draining from the ear and
discharge is
 reported for 14 days or more.

Green:
NO EAR INFECTION
Sign: * No ear pain and
 No pus seen draining from the ear.

7. NUTRITIONAL STATUS
CHECK FOR ACUTE MALNUTRITION
LOOK AND FEEL:
 Look for signs of acute malnutrition
 Look for edema of both feet.
 Determine WFH/L* ___ z-score.
 Measure MUAC**____ mm in a child 6 months or older.
 If WFH/L less than -3 z-scores or MUAC less than 115 mm,
then:

Check for any medical complication present:

 Any general danger sign
 Any severe classification
 Pneumonia with chest in drawing
 If no medical complications present:
 Child is 6 months or older, offer RUTF*** to eat.
Is the child:
 Not able to finish RUTF portion?
 Able to finish RUTF portion?
 Child is less than 6 months, assess
 Breastfeeding: (see page 45 of 77)
 Does the child have a breastfeeding problems

SEVERE ACUTE MALNUTRITION

Sign: WFH/L less than -3 zscores OR MUAC less
than 115 mm AND any

one of the following:

 Medical complication present or Not able to finish RUTF or
Breastfeeding problem.

Yellow: UNCOMPLICATEDSEVERE ACUTE MALNUTRITION

Sign:* WFH/L less than -3 zscores OR

 MUAC less than 115 mm AND
 Able to finish RUTF.

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Yellow: MODERATE ACUTE MALNUTRITION

Sign: * WFH/L between -3 and - 2 z-scores
 OR MUAC 115 up to 125 mm.

Green: NO ACUTE MALNUTRITION

Sign: * WFH/L - 2 z-scores or more

 OR MUAC 125 mm or more

*WFH/L is Weight-for-Height or Weight-for-Length determined by

using the WHO growth standards charts.

** MUAC is Mid-Upper Arm Circumference measured using MUAC tape

in all children 6 months or older.

***RUTF is Ready-to-Use Therapeutic Food for conducting the

appetite test and feeding children with severe acute
malnutrition.

8. ANEMIA
Pink: SEVERE ANEMIA
Sign: Severe palmar pallor

Yellow: ANEMIA
Sign: Some pallor

Green: NO ANEMIA
Sign: No palmar pallor

*If child has severe acute malnutrition and is receiving RUTF, DO

NOT give iron because there is already adequate amount of iron in
RUTF
ASK
Has the mother or child had an HIV test?
IF YES:
 Decide HIV status: Mother: POSITIVE or NEGATIVE Child:

= Virological test POSITIVE or NEGATIVE

= Serological test POSITIVE or NEGATIVE

If mother is HIV positive and child is negative or

unknown, ASK:

Was the child breastfeeding at the time or 6 weeks

before the test?
Is the child breastfeeding now?
If breastfeeding, ASK: Is the mother and child on
ARV prophylaxis?

IF NO, THEN TEST:

Mother and child status unknown: TEST mother.
Mother HIV positive and child status unknown: TEST child.

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Yellow: CONFIRMED HIV INFECTION
Sign: Positive virological test in child OR Positive serological
test in a child 18 months or older

Yellow: HIV EXPOSED

Sign:* Mother HIV-positive AND negative virological test in a
breastfeeding child or only stopped less than 6 weeks ago
 OR Mother HIV-positive, child not yet tested
 OR Positive serological test in a child less than 18 months’
old

Green: HIV INFECTION UNLIKELY

Sign: Negative HIV test in mother or child

* Give cotrimoxazole prophylaxis to all HIV infected and HIV-

exposed children until confirmed negative after cessation of
breastfeeding.

** If virological test is negative, repeat test 6 weeks after the

breastfeeding has stopped; if serological test is positive, do a
virological test as soon as possible.

IMMUNIZATION SCHEDULE: Follow national guidelines

AGE VACCINE VITAMIN A SUPPLEMENTATION

Give every child a dose of Vitamin A every six months from the
age of 6 months. Record the dose on the child's chart.

Birth BCG* Hep B0

ROUTINE DEWORMING
Give every child Mebendazole or Albendazole every 6 months from
the age of one year.

Record the dose on the child's card.

6 weeks Pentavalent 1** OPV1 RTV1**** PCV1*****
10 weeks Pentavalent 2 OPV2 RTV2 PCV2
14 weeks Pentavalent 3 OPV3 RTV3 PCV3

ORAL HEALTH
Advise mother to bring the child to a dentist every 6 months for
dental check-up from the age of 6 months

9 months Measles ***

12 months -
15 months MMR

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Children who are HIV positive or unknown HIV status with symptoms
consistent with HIV should not be vaccinated with BCG. Infant
born to mother with TB disease, do not give BCG first, instead
give Isoniazid Preventive therapy {IPT} for 3 months. If TST
negative after 3 months, give BCG.

**DPT+HIB+HepB is available as pentavalent vaccine

***Second dose of measles vaccine may be given at any

opportunistic moment during periodic supplementary immunization
activities as early as one month following the first dose.

***HIV-positive infants and pre-term neonates who have received 3

primary vaccine doses before 12 months of age may benefit from a
booster dose in the second year of life.

****Rotavirus Vaccine is given to children in selected areas due

to limited supplies; Rotavirus Vaccine is available as 2 dose or
3 dose schedule

*****Pneumococcal Conjugate Vaccine (PCV) is given to children in

selected areas only due to limited supplies.
ASSESS OTHER

MAKE SURE CHILD WITH ANY GENERAL DANGER SIGN IS REFERRED after
first dose of an appropriate antibiotic and other urgent
treatments. Treat all children with a general danger sign to
prevent blood sugar.

SEROLOGICAL TESTS (Including rapid tests)

What does the test detect?

=These tests detect antibodies made by immune cells in response
to HIV. They do not detect the HIV virus itself.

How to interpret the test?

HIV antibodies pass from the mother to the child. Most antibodies
have gone by 12 months of age, but in some instances they do not
disappear until the child is 18 months of age. This means that a
positive serological test in children less than 18 months in NOT
a reliable way to check for infection of the child.

VIROLOGICAL TESTS(Including DNAor RNA PCR)

What does the test detect?

These tests directly detect the presence of
the HIV virus or products of the virus in the
blood.
How to interpret the test?
Positive virulogical (PCR) tests reliably detect HIV infection at
any age, even before the child is 18 months old.
If the tests are negative and the child has been
breastfeeding, this does not rule out infection. The baby may
have just become infected.

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Tests should be done six weeks or more after breastfeeding has
completely stopped—only then do the tests reliably rule out
infection.

For HIV exposed children 18 months or older, a positive HIV

antibody test result means the child is infected. For HIV exposed
children less than 18 months of age:

If PCR or other virological test is available, test from 4 -

6 weeks of age.
A positive result means the child is infected.
A negative result means the child is not infected, but could
become infected if they are still breast feeding.

If PCR or other virological test is not available, use HIV

antibody test. A positive result is consistent with the fact that
the child has been exposed to HIV, but does not tell us if the
child is definitely infected.

Interpreting the HIV Antibody Test Results in a Child less than

18 Months of Age

Breastfeeding status =

1. NOT BREASTFEEDING, and has not in last 6 weeks

POSITIVE (+) test

HIV EXPOSED and/or HIV infected - Manage as if they could be
infected. Repeat test at 18 months.

NEGATIVE (-) test

HIV negative Child is not HIV infected

2. BREASTFEEDING

POSITIVE (+) test

HIV EXPOSED and/or HIV infected - Manage as if they could be
infected. Repeat test at 18 months or once breastfeeding has been
discontinued for more than 6 weeks.

NEGATIVE (-) test

Child can still be infected by breastfeeding. Repeat test once
breastfeeding has been discontinued for more than 6 weeks.

WHO PEDIATRIC STAGING FOR HIV INFECTION

This is used for monitoring children during follow up to
determine clinical response to ARV treatment. Determine the
clinical stage by assessing the child’s signs and symptoms. Look
at the classification for each stage. Decide what is the highest

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stage applicable to the child where one or more of the child’s
symptoms are represented.

How to interpret the test?

Positive virological (PCR) tests reliably detect HIV infection at
any age, even before the child is 18 months old.
If the tests are negative and the child has been
breastfeeding, this does not rule out infection. The baby may
have just become [Link] should be done six weeks or more
after breastfeeding has completely stopped—only then do the tests
reliably rule out infection.

For HIV exposed children 18 months or older, a positive HIV

antibody test result means the child is infected. For HIV exposed
children less than 18 months of age:

If PCR or other virological test is available, test from 4 -

6 weeks of age.
A positive result means the child is infected.
A negative result means the child is not infected, but could
become infected if they are still breast feeding.

If PCR or other virological test is not available, use HIV

antibody test. A positive result is consistent with the fact that
the child has been exposed to HIV, but does not tell us if the
child is definitely infected.

Interpreting the HIV Antibody Test Results in a Child less than

18 Months of Age

Breastfeeding status =

1. NOT BREASTFEEDING, and has not in last 6 weeks

POSITIVE (+) test

HIV EXPOSED and/or HIV infected - Manage as if they could be
infected. Repeat test at 18 months.

NEGATIVE (-) test

HIV negative Child is not HIV infected

2. BREASTFEEDING

POSITIVE (+) test

HIV EXPOSED and/or HIV infected - Manage as if they could be
infected. Repeat test at 18 months or once breastfeeding has been
discontinued for more than 6 weeks.

NEGATIVE (-) test

Child can still be infected by breastfeeding. Repeat test once
breastfeeding has been discontinued for more than 6 weeks.

WHO PEDIATRIC STAGING FOR HIV INFECTION

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This is used for monitoring children during follow up to
determine clinical response to ARV treatment. Determine the
clinical stage by assessing the child’s signs and symptoms. Look
at the classification for each stage. Decide what is the highest
stage applicable to the child where one or more of the child’s
symptoms are represented.
Stage 1 Asymptomatic

Symptoms/Signs
No symptoms, or only: Persistent generalized lymphadenopathy
(PGL).

Stage 2
Mild Disease
 Enlarged liver and/or spleen
 Enlarged parotid
 Skin conditions (prurigo, seborrheic dermatitis, extensive
 molluscum contagiosum or warts, fungal nail infection herpes
zoster)
 Mouth conditions recurrent mouth ulcerations, linea gingival
Erythema)
 Recurrent or chronic upper respiratory tract infections
(sinusitis, ear infection, tonsilitis, otorrhea)

Stage 3
Moderate Disease
Unexplained severe acute malnutrition not responding to standard
therapy

 Oral thrush (outside neonatal period).

 Oral hairy leukoplakia.
 Unexplained and unresponsive to standard therapy:
= Diarrhea for over 14 days
= Fever for over 1 month
= Thrombocytopenia*(under 50,000/mm3 for 1month
= Neutropenia* (under 500/mm3 for 1 month)
= Anemia for over 1 month (hemoglobin under 8 gm)*
 Recurrent severe bacterial pneumonia
 Pulmonary TB
 Lymph node TB
 Symptomatic lymphoid interstitial pneumonitis (LIP)*
 Acute necrotising ulcerative gingivitis/periodontitis
 Chronic HIV associated lung Diseases including
bronchiectasis*

Stage 4
Severe Disease (AIDS)
Severe unexplained wasting/stunting/severe acute malnutrition not
responding to standard therapy

 Esophageal thrush
 More than one month of herpes simplex ulcerations.
 Severe multiple or recurrent bacterial infections > 2

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 episodes in a year (not including pneumonia) pneumocystis
pneumonia (PCP)*
 Kaposi's sarcoma.
 Extrapulmonary tuberculosis.
 Toxoplasma brain abscess*
 Cryptococcal meningitis*
 Acquired HIV-associated rectal fistula
 HIV encephalopathy*

*Conditions requiring diagnosis by a doctor or medical officer -

should be referred for appropriate diagnosis and treatment.

TREAT THE CHILD CARRY OUT THE TREATMENT STEPS IDENTIFIED ON THE
ASSESS AND CLASSIFY CHART

TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME Follow the

instructions below for every oral drug to be given at home.
Also follow the instructions listed with each drug's dosage
table.

 Determine the appropriate drugs and dosage for the child's

age or weight.
 Tell the mother the reason for giving the drug to the child.

 Demonstrate how to measure a dose.

 Watch the mother practice measuring a dose by herself.
 Ask the mother to give the first dose to her child.
 Explain carefully how to give the drug, then label and
package the drug.
 If more than one drug will be given, collect, count and
package each drug separately.
 Explain that all the oral drug tablets or syrups must be
used to finish the course of treatment, even if the child
gets better.
 Check the mother's understanding before she leaves the
clinic.

FOR PNEUMONIA, ACUTE EAR INFECTION:

FIRST-LINE ANTIBIOTIC: Oral Amoxicillin

* Amoxicillin is the recommended first-line drug of choice in the

treatment of pneumonia due to its efficacy and increasing high
resistance to cotrimoxazole.

FOR PROPHYLAXIS IN HIV CONFIRMED OR EXPOSED CHILD: ANTIBIOTIC FOR

PROPHYLAXIS: Oral Cotrimoxazole

FOR DYSENTERY give Ciprofloxacin

FIRST-LINE ANTIBIOTIC: Oral Ciprofloxacin

FOR CHOLERA:
FIRST-LINE ANTIBIOTIC FOR CHOLERA: COTRIMOXAZOLE

ALtERNATE DRUG FOR CHOLERA:

FURAZOLIDONE

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Give Inhaled Salbutamol for Wheezing USE OF A SPACER*

 A spacer is a way of delivering the
bronchodilator drugs effectively into the lungs. No child
under 5 years should be given an inhaler without a spacer. A
spacer works as well as a nebuliser if correctly used.

=From salbutamol metered dose inhaler (100 μg/puff) give 2

puffs.
=Repeat up to 3 times every 15 minutes before classifying
pneumonia.

Spacers can be made in the following way:

= Use a 500ml drink bottle or similar.
= Cut a hole in the bottle base in the same shape as the
mouthpiece of the inhaler. This can be done using a sharp
knife.
= Cut the bottle between the upper quarter and the lower 3/4 and
disregard the upper quarter of the bottle.
= Cut a small V in the border of the large open part of the
bottle to fit to the child's nose and be used as a mask.

= Flame the edge of the cut bottle with a candle or a lighter to

soften it.
= In a small baby, a mask can be made by making a similar hole
in a plastic (not polystyrene) cup.
= Alternatively commercial spacers can be used if available.

To use an inhaler with a spacer:

= Remove the inhaler cap. Shake the inhaler well.
= Insert mouthpiece of the inhaler through the hole in the
bottle or plastic cup.
= The child should put the opening of the bottle into his mouth
and breath in and out through the mouth.
= A career then presses down the inhaler and sprays into the
bottle while the child continues to breath normally.
= Wait for three to four breaths and repeat.
= For younger children place the cup over the child's mouth and
use as a spacer in the same way.

* If a spacer is being used for the first time, it should be

primed by 4-5 extra puffs from the inhaler.

Give Oral Antimalarial for P. falciparum MALARIA If Artemether-

Lumefantrine (AL)
 Give the first dose of artemether-lumefantrine in the clinic
and observe for one hour. If the childvomits within an hour
repeat the dose.
 Give second dose at home after 8 hours.
 Then twice daily for further two days as shown below.
 Artemether-lumefantrine should be taken with food.
 Advice patient to take AL with milk or fat containing food
("gata"or coconut milk, buko, or suman sa latik and
cookies)particularly on the 2nd and 3rd days of treatment.

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 Since lumefantrine is highly lipophilic, its absorption is
enhanced by co-administration of fat. low blood levels would
resultant treatment failure could potentially result from
inadequate fat intake.

1. Chloroquine remains highly effective against vivax malaria.

Hence, it remains the recommended drug ofchoice for P.
ovale.
However, in the absence of CQ and in case of treatment
failure, AL can be used.
2. Primaquine must not be given to infants <1 year old
3. Primaquine should be taken with meals {causes abdominal
discomfort taken on an empty stomach}
4. Primaquine can induce hemolysis in people with glucose-6-
phosphate dehydrogenase {G6PD}deficiency. Consider G6PD test
if available. If G6PD test is not available, observe a change
in urine color.

Stop Primaquine intake if urine turns dark {tea-colored}

Plasmodium malariae Malaria

Perform thick and thin blood film including parasite count
(for RHU, hospital and laboratory facilitiesonly) after
completing treatment on Day 3 then on Day 7, 14, 21 and 28. Refer
to the next level of health care if parasitemia is still present.

P. falciparum and P. vivax

* Treatment should be given after meals
* First day of treatment should be under the
supervision of the health worker

Give Paracetamol for High Fever (> 38.5°C) or Ear Pain

Give Iron*
Give one dose daily for 14 days.

* Children with severe acute malnutrition who are receiving

ready-to-use therapeutic food (RUTF) should not be given Iron.

Give Micronutrient Powder

 Give Micronutrient Powder Supplement or (MNP) daily to
children 6 - 23 months old
= Use this at 6 months of age during the
introduction of complementary feeding
= Mix MNP into complementary food
preferably soft or semi-solid before
feeding it to the child
= Do not add MNP to food before or during
Cooking
 for 6 - 11 months infant, give a total of 60 sachets over a
period of 6 months

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 for 12 - 23 months children, give 60 sachets every 6 months
for a total of 120 sachets in a
year

TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME

 Explain to the mother what the treatment is and why it
should be given.
 Describe the treatment steps listed in the appropriate box.
 Watch the mother as she does the first treatment in the
clinic (except for remedy for cough or sore throat).
 Tell her how often to do the treatment at home.
 If needed for treatment at home, give mother the tube of
tetracycline ointment or a small bottle of gentian violet.
 Check the mothers understanding before she leaves the
clinic.

Soothe the Throat, Relieve the Cough with a Safe Remedy

Safe remedies to recommend:

 Breast milk for a breastfed infant.
 Increase fluid intake.
 Give calamansi juice.

Harmful remedies to discourage:

 Don't give cough syrups or mucolytics.
 Don't give nasal decongestant like phenylpropanolamine.

Treat Eye Infection with Tetracycline Eye Ointment

 Clean both eyes 4 times daily.
 Wash hands.
 Use clean cloth and water to gently wipe away pus.

Then apply tetracycline eye ointment in both eyes 4 times daily.

 Squirt a small amount of ointment on the inside of the lower
lid.
 Wash hands again.
Treat until there is no pus discharge.
Do not put anything else in the eye.

Clear the Ear by Dry Wicking and Give

Eardrops*
Dry the ear at least 3 times daily.
 Roll clean absorbent cloth or soft, strong tissue paper into
a wick.
 Place the wick in the child's ear.
 Remove the wick when wet.
 Replace the wick with a clean one and repeat these steps
until the ear is dry.
Instill quinolone eardrops after dry wicking
three times daily for two weeks.
* Quinolone eardrops may include ciprofloxacin,
norfloxacin, or ofloxacin.
Treat for Mouth Ulcers with Gentian Violet (GV)

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 Treat for mouth ulcers twice daily.
= Wash hands.
= Wash the child's mouth with clean soft cloth
= wrapped around the finger and wet with salt water.
= Paint the mouth with half-strength gentian violet
(0.25% dilution).
= Wash hands again.
=Continue using GV for 48 hours after the ulcers have been cured.
= Give paracetamol for pain relief.

Treat Thrush with Nystatin Oral Suspension

Treat thrush four times daily for 7 days
 Wash hands
 Wet a clean soft cloth with salt water and use it to wash
the child’s mouth
 Give nystatin 1ml four times a day

 Avoid feeding for 20 minutes after medication

 If breastfed check mother’s breasts for thrush. If present
treat with nystatin
 Advise mother to wash breasts after feeds. If bottle fed
advise change to cup and spoon
 Give paracetamol if needed for pain

Give Vitamin A Supplementation and Treatment

VITAMIN A SUPPLEMENTATION:
 Give first dose any time after 6 months of age to ALL
CHILDREN
 Thereafter vitamin A every six months to ALL CHILDREN

VITAMIN A TREATMENT:
 Give an extra dose of Vitamin A (same dose as for
supplementation) for treatment if the child has MEASLES or
PERSISTENT DIARRHEA. If the child has had a dose of vitamin
A within the past month or is on RUTF for treatment of
severe acute malnutrition, DO NOT GIVE VITAMIN A.
 Always record the dose of Vitamin A given on the child's
card.

6 up to 12 months = 100 000 IU

One year and older = 200 000 IU

Give Mebendazole or Albendazole

 Give 500 mg Mebendazole as a single dose in the health
center if:
= hookworm/whipworm are a problem in children in your area, and
= the child is 1 years of age or older, and
= the child has not had a dose in the previous 6 months.
OR
=Give 400 mg Albendazole as single dose in the health center if:
= 12 to 23 months - 200 mg single dose every 6 months
= 24 months and above - 400 mg single dose every 6 months

Give Intramuscular Antibiotics GIVE TO CHILDREN BEING REFERRED

URGENTLY
 Give Ampicillin (50 mg/kg) and Gentamicin (7.5 mg/kg).

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 Alternate drug for Ampicillin is Benzyl Penicillin 500,000
units/ml
BENZYL PENICILLIN
 Add 8 ml sterile water to vial of 5 million units
AMPICILLIN
 Dilute 500mg vial with 2.1ml of sterile water (500mg/2.5ml).
 IF REFERRAL IS NOT POSSIBLE OR DELAYED, repeat the
ampicillin injection every 6 hours.
 Where there is a strong suspicion of meningitis, the dose of
ampicillin can be increased 4 times.

GENTAMICIN
1.5 mg/kg/day once daily

Give Diazepam to Stop Convulsions

 Turn the child to his/her side and clear the airway. Avoid
putting things in the mouth.
 Give 0.5mg/kg diazepam injection solution per rectum using a
small syringe without a needle (like a tuberculin syringe)
or using a catheter.
 Check for low blood sugar, then treat or prevent.
 Give oxygen and REFER
 If convulsions have not stopped after 10 minutes repeat
diazepam dose

Give Artesunate Suppositories or Oral Quinine for Severe Malaria

FOR CHILDREN BEING REFERRED WITH VERY SEVERE FEBRILE DISEASE:
 Check which pre-referral treatment is available in your
clinic (rectal artesunate suppositories, artesunate
injection or quinine).
 Artesunate suppository: Insert first dose of the suppository
and refer child urgently
 Oral quinine: Give first dose and refer child urgently to
hospital.

IF REFERRAL IS NOT POSSIBLE: For articulate suppository:

 Give first dose of suppository
 Repeat the same dose of suppository every 24 hours until the
child can take oral antimalarial.
 Give full dose of oral antimalarial as soon as the child is
able to take orally

For Quinine:
 Give first dose of oral Quinine.
 Pulverize tablet and give through NGT

Treat the Child to Prevent Low Blood Sugar

= If the child is able to breastfeed:
 Ask the mother to breastfeed the child.

= If the child is not able to breastfeed but is able

to swallow:
 Give expressed breast milk or a breast-milk substitute.
 If neither of these is available, give sugar water*.
 Give 30 - 50 ml of milk or sugar water* before departure.

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If the child is not able to swallow:

 Give 50 ml of milk or sugar water* by nasogastric tube.
 If no nasogastric tube available, give 1 teaspoon of sugar
moistened with 1-2 drops of water
* sublingually and repeat doses every 20 minutes to
prevent relapse.

* To make sugar water: Dissolve 4 level teaspoons of sugar (20

grams) in a 200-ml cup of clean water.

PLAN A: TREAT DIARRHEA AT HOME

Counsel the mother on the 4 Rules of Home Treatment:
1. Give Extra Fluid
2. Give Zinc Supplements (age 2 months up to 5 years)
3. Continue Feeding
4. When to Return.

1. GIVE EXTRA FLUID (as much as the child will

take) TELL THE MOTHER:
Breastfeed frequently and for longer at each feed. If the child
is exclusively breastfed, give ORS or clean water in addition to
breast milk. If the child is not exclusively breastfed, give one
or more of the following:

ORS solution, food-based fluids (such as soup, rice water, and

yoghurt drinks), or clean water.

It is especially important to give ORS at home when:

 the child has been treated with Plan B or Plan C during this
visit.
 the child cannot return to a clinic if the diarrhea gets
worse.

= TEACH THE MOTHER HOW TO MIX AND GIVE ORS. GIVE THE MOTHER 2
PACKETS OF ORS TO USE AT HOME.

= SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE

USUAL FLUID INTAKE

INTAKE:
Up to 2 years = 50 to 100 ml after each loose stool
2 years or more = 100 to 200 ml after each loose Stool

Tell the mother to:

 Give frequent small sips from a cup.
 If the child vomits, wait 10 minutes. Then continue, but
more slowly.
 Continue giving extra fluid until the diarrhea stops.

2. GIVE ZINC (age 2 months up to 5 years) TELL THE MOTHER HOW

MUCH ZINC TO GIVE:

2 months up to 6 months = ZINC SYRUP 20 mg / 5 ml = 1/2

tsp {2.5 ml} daily for 14days

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2 months up to 6 months = ZINC DROPS 10mg / ml = 1.0 ml daily
for 14 day
2 months up to 6 months = ZINC TABLET 20 mg tablet = 1/2 tablet
daily for 14days
6 months or more=ZINC SYRUP 20mg / 5 ml = 1 tsp {5 ml} daily for
14days
6 months or more =ZINC DROPS 10 mg / m = l 2.0 ml daily for 14
days
6 months or more =ZINC TABLET 20 mg tablet 1 = tablet daily for
14

SHOW THE MOTHER HOW TO GIVE ZINC SUPPLEMENTS

Infants - dissolve tablet in a small amount of expressed breast
milk, ORS or clean water in a cup.
Older children - tablets can be chewed or dissolved in a small
amount of water.

3. CONTINUE FEEDING (exclusive breastfeeding if age less than 6

months)

WHEN TO RETURN
PLAN B: TREAT SOME DEHYDRATION WITH ORS
In the clinic, give recommended amount of ORS over 4-hour period
DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS

 Use the child's age only when you do not know the weight.
The approximate amount of ORS required (in ml) can also be
calculated by multiplying the child's weight (in kg) times
75.
 If the child wants more ORS than shown, give more.
 For infants under 6 months who are not breastfed, also give
100 - 200 ml clean water during this period if you use
standard ORS. This is not needed if you use new low
osmolarity ORS.

SHOW THE MOTHER HOW TO GIVE ORS SOLUTION.

= Give frequent small sips from a cup.
= If the child vomits, wait 10 minutes. Then continue, but more
slowly.
= Continue breastfeeding whenever the child wants.

AFTER 4 HOURS:
= Reassess the child and classify the child for dehydration.
= Select the appropriate plan to continue treatment. Begin
feeding the child in clinic.

IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT:

= Show her how to prepare ORS solution at home.
= Show her how much ORS to give to finish 4-hour treatment at
home.
= Give her enough ORS packets to complete rehydration. Also give
her 2 packets as
= recommended in Plan A.

Explain the 4 Rules of Home Treatment:

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1. GIVE EXTRA FLUID
2. GIVE ZINC (age 2 months up to 5 years)
3. CONTINUE FEEDING (exclusive breastfeeding if age less than 6
months)
4. WHEN TO RETURN

Give Ready-to-Use Therapeutic Food for SEVERE ACUTE MALNUTRITION

 Wash hands before giving the ready-to-use therapeutic food
(RUTF).
 Sit with the child on the lap and gently offer the ready-to-
use therapeutic food.
 Encourage the child to eat the RUTF without forced feeding.
 Give small, regular meals of RUTF and encourage the child to
eat often 5–6 meals per day.
 If still breastfeeding, continue by offering breast milk
first before every RUTF feed.
 Give only the RUTF for at least two weeks, if breastfeeding
continues to breastfeed and gradually introduce foods
recommended for the age (See Feeding recommendations in
COUNSEL THE MOTHER chart).
 When introducing recommended foods, ensure that the child
completes his daily ration of RUTF before giving other food.
 Offer plenty of clean water, to drink from a cup, when the
child is eating the ready-to-use therapeutic food.

Steps when Initiating ART in Children

All children less than 5 years who are HIV infected should
be initiated on ART irrespective of CD4 count or clinical stage.

Remember that if a child has any general danger sign or a

severe classification, he or she needs URGENT REFERRAL. ART
initiation is not urgent, and the child should be stabilized
first.

STEP 1: DECIDE IF THE CHILD HAS CONFIRMED HIV INFECTION

Child is under 18 months:
 HIV infection is confirmed if virological test (PCR) is
positive

Child is over 18 months:
= Two different serological tests are positive
= Send any further confirmatory tests required If results are
discordant, refer If HIV infection is confirmed, and child is in
stable condition,

STEP 2: DECIDE IF CAREGIVER IS ABLE TO GIVE ART Check that the

caregiver is willing and able to give ART. The caregiver should
ideally have disclosed the child’s HIV status to another adult
who can assist with providing ART, or be part of a support group.

= Caregiver able to give ART: GO TO STEP 3

= Caregiver notable: classify as

CONFIRMED HIV INFECTION but NOT ON ART. Counsel and support the
caregiver. Follow-up regularly. Move to the step 3 once the
caregiver is willing and able to give ART.

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STEP 3: DECIDE IF ART CAN BE INITIATED IN YOUR FACILITY If child

is less than 3 kg or has TB, Refer for ART initiation. If child
weighs 3 kg or more and does not have TB, GO TO STEP 4

STEP 4: RECORD BASELINE INFORMATION ON THE CHILD'S HIV TREATMENT

CARD Record the following information:
= Weight and height
= Pallor if present
= Feeding problem if present

= Laboratory results (if available): Hb, viral load, = CD4 count

and percentage. Send for any
= laboratory tests that are required. Do not wait for results.
GO
TO STEP 5

STEP 5: START ON ART, COTRIMOXAZOLE PROPHYLAXIS AND ROUTINE

TREATMENTS
= Initiate ART treatment:
= Child up to 3 years: ABC or AZT +3TC+ LPV/R or recommended
first-
line regimen
= Child 3 years or older: ABC + 3TC + EFV, or recommended first-
line regimen.
= Give co-trimoxazole prophylaxis Give other routine treatments,
including Vitamin A and immunizations
= Follow-up regularly as per national guidelines

Advise the Mother When to Return to Health Worker

FOLLOW-UP VISIT: Advise the mother to come for follow-up at the

earliest time listed for the child's

A *PNEUMONIA
 DYSENTERY
 MALARIA, if fever persists
 FEVER: NO MALARIA, if fever persists 3
 MEASLES WITH EYE OR MOUTH D
 COMPLICATIONS A
 MOUTH OR GUM ULCERS OR THRUSH Y
 FEVER: DENGUE HEMORRHAGIC FEVER S
 UNLIKELY

B.
* PERSISTENT DIARRHEA 5
* ACUTE EAR INFECTION D
* CHRONIC EAR INFECTION A
* COUGH OR COLD, if not improving Y
* FEEDING PROBLEM S

UNCOMPLICATED SEVERE ACUTE MALNUTRITION 14 days

ANEMIA 14 days

MODERATE ACUTE MALNUTRITION 30 days

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CONFIRMED HIV INFECTION HIV EXPOSED According to national

recommendations

NEXT WELL-CHILD VISIT: Advise the mother to return for next

immunization according to immunization schedule.

WHEN TO RETURN IMMEDIATELY

Advise mother to return immediately if the child has any of these

signs:

Any sick child;

 Not able to drink or breastfeed
 Becomes sicker
 Develops a fever

If child has COUGH OR COLD, also return if:

 Fast breathing
 Difficult breathing

If child has diarrhea, also return if:

 Blood in stool
 Drinking poorly

SICK YOUNG INFANT AGE UP TO 2MONTHS

CHECK FOR VERY SEVERE DISEASE AND LOCAL BACTERIAL INFECTION

ASK: LOOK, LISTEN, FEEL:

> Is the infant having difficulty in feeding?
> Has the infant had convulsions (fits)?
> Count the breaths in one minute.
> Repeat the count if more than 60 breaths per minute
.
=Look for severe chest in drawing. YOUNG INFANT MUST BE CALM
=Measure axillary temperature.
=Look at the umbilicus. Is it red or draining pus?
= Look for skin pustules.
= Look at the young infant's movements.
If infant is sleeping, ask the mother to wake him/her.

Does the infant move on his/her own?

If the young infant is not moving, gently stimulate
him/her. Does the infant not move at all?

1-VERY SEVERE DISEASE

Pink: VERY SEVERE DISEASE

Any one of the following signs

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 Not feeding well or
 Convulsions or
 Fast breathing (60 breaths per minute or more) or
 Severe chest indrawing or
 Fever (37.5°C* or above) or
 Low body temperature (less than 35.5°C*) or
 Movement only when stimulated or no movement AT ALL TIME

Yellow :LOCAL BACTERIAL INFECTION

Sign: Umbilicus red or draining pus Or Skin pustules
Green: SEVERE DISEASE OR LOCAL INFECTION UNLIKELY

Sign: None of the signs of very severe disease or local bacterial

infection

If jaundice present, ASK: LOOK AND FEEL:

> When did the jaundice appear first?
> Look for jaundice (yellow eyes or skin)
> Look at the young infant's palms and soles. Are they yellow?

2. JAUNDICE
Pink: SEVERE JAUNDIC
Any jaundice if age less than 24 hours or Yellow palms and soles
at any age

Yellow: JAUNDICE
Jaundice appearing after 24 hours of age and Palms and soles not
yellow

Green: NO JAUNDICE
infant have diarrhea*

IF YES, LOOK AND FEEL:

 Look at the young infant's general condition:
Infant's movements
= Does the infant move on his/her own?
= Does the infant not move even when stimulated but then stops?
= Does the infant not move at all?
= Is the infant restless and irritable?
= Look for sunken eyes.
= Pinch the skin of the abdomen. Does it go back:
= Very slowly (longer than 2 seconds)? or slowly?

Pink: SEVERE DEHYDRATION

Two of the following signs:
 Movement only when stimulated or no movement at all
 Sunken eyes
 Skin pinch goes back very slowly.

Yellow: SOME DEHYDRATION

Two of the following signs:
 Restless and irritable
 Sunken eyes
 Skin pinch goes back slowly.

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Green: NO DEHYDRATION
Not enough signs to classify as some or severe dehydration

* What is diarrhea in a young infant?

=A young infant has diarrhea if the stools have changed from
usual pattern and are many and watery (more water than fecal
matter).

=The normally frequent or semi-solid stools of a breastfed baby

are not diarrhea.

Advise the Mother When to Return to Health Worker

FOLLOW-UP VISIT: Advise the mother to come for follow-up at the
earliest time listed for the child's problems.

Follow-up visit of the following child problem will be 3 days.

=PNEUMONIA
= DYSENTERY
= MALARIA, if fever persists
= FEVER: NO MALARIA, if fever persists
= MEASLES WITH EYE OR MOUTH
= COMPLICATIONS
= MOUTH OR GUM ULCERS OR THRUSH
= FEVER: DENGUE HEMORRHAGIC FEVER
= UNLIKELY

Follow-up visit of the following child problem will be 5 days.

= PERSISTENT DIARRHEA
= ACUTE EAR INFECTION
= CHRONIC EAR INFECTION
= COUGH OR COLD, if not improving

14 days follow-up
= UNCOMPLICATED SEVERE ACUTE MALNUTRITION
= Anemia

30 days follow-up
=MODERATE ACUTE MALNUTRITION

WHEN TO RETURN IMMEDIATELY

Any sick child =
 Not able to drink or breastfeed
 Becomes sicker
 Develops a fever

If child has COUGH OR COLD, also return if:

 Fast breathing
 Difficult breathing

If child has diarrhea, also return if:

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 Blood in stool
 Drinking poorly

Give all missed doses on this visit.

 Include sick infants unless being referred.
 Advise the caretaker when to return for the next dose.

*Note: DPT-HIB-HEP B is available as Pentavalent vaccine

TREAT THE YOUNG INFANT:

GIVE FIRST DOSE OF INTRAMUSCULAR ANTIBIOTICS

Give first dose of both ampicillin and gentamicin
intramuscularly.

Avoid using undiluted 40 mg/ml gentamicin.

Referral is the best option for a young infant classified
with VERY SEVERE DISEASE. If referral is not possible, continue
to give ampicillin and gentamicin for at least 5 days. Give
ampicillin two times daily to infants less than one week of age
and 3 times daily to infants one week or older. Give gentamicin
once daily.

TREAT THE YOUNG INFANT TO PREVENT LOW BLOOD SUGAR

If the young infant is able to breastfeed:

 Ask the mother to breastfeed the young infant.
 If the young infant is not able to breastfeed but is able to
swallow:

= Give 20-50 ml (10 ml/kg) expressed breast milk before

departure.
= If not possible to give expressed breast milk, give 20-50 ml
(10 ml/kg) sugar water (To make sugar water: Dissolve 4 level
easpoons of sugar (20 grams) in a 200-ml cup of clean water). If
the young infant is not able to swallow:

= Give 20-50 ml (10 ml/kg) of expressed breast milk

or sugar water by nasogastric tube.

GIVE AN APPROPRIATE ORAL ANTIBIOTIC FOR LOCAL BACTERIAL INFECTION

= First-line antibiotic: Amoxicillin drops or

suspension Second-line antibiotic:
To Treat Skin Pustules or Umbilical Infection
 The mother should do the treatment twice daily for 5 days:
 Wash hands
 Gently wash off pus and crusts with soap and water
 Dry the area
 Paint the skin or umbilicus/cord with full strength gentian
violet (0.5%) OR
 Mupirocin cream 2x a day until dry (usually in 3 days)
 Wash hands

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To Treat Thrush (ulcers or white patches in

mouth)
 The mother should do the treatment four times daily for 7
days:
 Wash hands
 Paint the mouth with half-strength gentian violet (0.25%)
using a soft cloth wrapped around the finger
 An alternative treatment to gentian violet is Nystatin oral
suspension 100,000 units/ml. Give 1-2 ml into the mouth for
7 days
 Wash hands

GIVE ARV FOR PMTCT PROPHYLAXIS

 Initiate triple ART for all pregnant and lactating women
with HIV infection, and put their infants on ART
prophylaxis*:
 Nevirapine or zidovudine are provided to young infant
classified as HIV EXPOSED to minimize the risk of mother-to-
child HIV transmission (PMTCT).

=If breast feeding: Give NVP for 6 weeks beginning

at birth or when HIV exposure is recognized.
=If not breast feeding: Give NVP or ZDV for 4-6
weeks beginning at birth or when HIV exposure is
recognized.

PREVENTION OF MATERNAL-TO-CHILD-TRANSMISSION (PMTCT) ART

PROPHYLAXIS:
OPTION B+: MOTHER ON LIFELONG TRIPLE ART REGIMEN, YOUNG INFANT ON
NVP PROPHYLAXIS FROM BIRTH FOR 6 WEEKS IF BREASTFEEDING OR NVP OR
AZT FOR 4-6 WEEKS IF ON REPLACEMENT FEEDING.

OPTION B: MOTHER ON TRIPLE ART REGIMEN TO BE DISCONTINUED

ONE WEEK AFTER CESSATION OF BREASTFEEDING, YOUNG INFANT ON NVP
PROPHYLAXIS FROM BIRTH FOR 6 WEEKS OR NVP OR AZT FOR 4-6 WEEKS IF
ON REPLACEMENT FEEDING.

TEACH CORRECT POSITIONING AND ATTACHMENT FOR BREASTFEEDING

Show the mother how to hold her infant.
 with the infant's head and body in line.
 with the infant approaching breast with nose opposite to the
nipple.
 with the infant held close to the mother's body.
 with the infant's whole body supported, not just neck and
shoulders.

Show her how to help the infant to attach. She should:

 touch her infant's lips with her nipple
 wait until her infant's mouth is opening wide
 move her infant quickly onto her breast, aiming the infant's
lower lip well below the nipple.

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=Look for signs of good attachment and effective
suckling. If the attachment or suckling is not good,
try again.

TEACH THE MOTHER HOW TO EXPRESS

BREAST MILK
 Ask the mother to:
 Wash her hands thoroughly.
 Make herself comfortable.
 Hold a wide necked container under her nipple and areola.
 Place her thumb on top of the breast and the first finger on
the underside of the breast so they are opposite each other
(at least 4 cm from the tip of the nipple).
 Compress and release the breast tissue between her finger
and thumb a few times.
 If the milk does not appear she should re-position her thumb
and finger closer to the nipple and
 compress and release the breast as before.
 Compress and release all the way around the breast, keeping
her fingers the same distance from the nipple. Be careful
not to squeeze the nipple or to rub the skin or move her
thumb or finger on the skin.
 Express one breast until the milk just drips, then express
the other breast until the milk just drips.
 Alternate between breasts 5 or 6 times, for at least 20 to
30 minutes.
 Stop expressing when the milk no longer flows but drips from
the start.

TEACH THE MOTHER HOW TO KEEP THE LOW WEIGHT INFANT WARM AT HOME
 Keep the young infant in the same bed with the mother.
 Keep the room warm (at least 25°C) with home heating device
and make sure that there is no draught of cold air.
 Avoid bathing the low weight infant. When washing or
bathing, do it in a very warm room with warm water, dry
immediately and thoroughly after bathing and clothe the
young infant immediately.
 Change clothes (e.g. nappies) whenever they are wet.
 Provide skin to skin contact as much as possible, day and
night. For skin to skin contact:
 Dress the infant in a warm shirt open at the front, a nappy,
hat and socks.
 Place the infant in skin to skin contact on the mother's
chest between her breasts. Keep the infat's head turned to
one side.
Cover the infant with mother's clothes (and an additional warm
blanket in cold weather).
When not in skin to skin contact, keep the young infant clothed
or covered as much as possible at all
times. Dress the young infant with extra clothing including hat
and socks, loosely wrap the young

infant in a soft dry cloth and cover with a blanket.

Check frequently if the hands and feet are warm. If cold, re-warm
the baby using skin to skin contact.

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Breastfeed the infant frequently (or give expressed breast milk
by cup).

Note: important matter

 Respiratory infections can occur in any part of the
respiratory tract: the nose, throat, larynx, trachea, air
passages or lungs

child who has had a cough or difficulty breathing for more

than 2 weeks has a chronic cough. This may be a sign of
tuberculosis, asthma, whooping cough or another problem.
Child's age: Fast breathing:
50 or more breaths per minute
2 months up to 12
months

12 months up to 5 40 or more breaths per minute

years
Note: A child who is exactly 12 months old has fast breathing
if you count 40 or more breaths per minute.
Not another single clinical sign has a better combination of
sensitivity and specificity to detect pneumonia in children
under 5 years of age than respiratory rate, specifically fast
breathing. Even auscultation by expert pediatricians is less
sensitive as a single sign.
CHEST INDRAWING= Lower chest wall indrawing (the inward
movement of the bony structure of the chest wall when the
child breathes in) is an indicator of pneumonia. It is more
specific than intercostal indrawing, which concerns the soft
tissue between the ribs without involvement of the bony
structure of the chest wall.
 you did not lift the child's shirt when you counted the
child's breaths, ask the mother to lift it now.
 Before you look for chest indrawing watch the child to
determine when the child is breathing in and when the
child is breathing out.
 Look for chest indrawing when the child breathes in.
 Look at the lower chest wall (lower ribs). The child has
chest in drawing if the lower chest wall goes in when
the child breathes in.

Chest indrawing occurs when the effort the child needs to

breathe in is much greater than normal. In normal breathing,
the whole chest wall(upper and lower) and the abdomen move
out when the child breathes in. When chest indrawing is
present, the lower chest wall goes in when the child breathes
in.

Note: For chest indrawing to be present, it must be clearly

visible and present all the time. If you only see chest
indrawing when the child is crying or feeding, the child does
not have chest indrawing.

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If only the soft tissue between the ribs goes in when the
child breathes in (intercostal indrawing or intercostal
retraction), the child does not have chest indrawing. In this
assessment, chest indrawing means lower chest wall indrawing.
It does not include intercostal indrawing.

LOOK and LISTEN for stridor

Stridor is a harsh noise made when the child
breathes in. Stridor happens when there is a swelling of the
larynx, trachea or epiglottis. These conditions are often
called croup. This swelling interferes with air entering the
lungs. It can be life-threatening when the swelling causes
the child's airway to be blocked. A child who has stridor
when calm has a dangerous condition.
 To look and listen for stridor, look to see when the
child breathes in.
 Listen for stridor when the child breathes in. Put your
ear near the child's mouth because stridor can be
difficult to hear.
 Sometimes you will hear a wet noise if the child's nose
is blocked. Clear the nose, and listen again. A child
who is not very ill may have stridor only when crying or
upset. Be sure to look and listen for stridor when the
child is calm.
LOOK and LISTEN for wheezing
Wheezing is a soft musical noise made when the child is
breathing out. Wheezing is caused by a narrowing of the air
passages in the lungs. Breathing out takes longer than normal
and requires effort.
 Look and listen for wheezing when the child breathes
out.
Hold your ear near the child's mouth because the wheezing
noise can be difficult to hear. Sometimes so little air moves
that there is no noise. Look to see if the breathing out
phase requires great effort and is longer than normal.

If wheezing and either fast breathing or chest indrawing:

 Give a trial of rapid acting inhaled bronchodilator for
up to three times 15-20 minutes apart. Count the breaths
and look for chest indrawing again, and then classify.
There are three classification tables for classifying diarrhea.
1, All children with diarrhea are classified for
dehydration.
2. If the child has had diarrhea for 14 days or more, the child
should be classified for persistent diarrhea.

3. If the child has blood in the stool, the child should be

classified for dysentery
A child with diarrhea may have three conditions that may lead to
death:

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 Acute watery diarrhea, including cholera, causes dehydration
and contributes to malnutrition.
 Persistent diarrhea which lasts more than 14 days causes
nutritional problems that contribute to deaths in children
who have diarrhea.
 Dysentery or bloody diarrhea causes dehydration and
contributes to malnutrition. The most common cause of
dysentery is Shigella bacteria. Amoebic dysentery is not
common in young children. A child may have both watery
diarrhea and dysentery.
 What is IMCI?
o This chapter provides key information on the IMCI
strategy, as well as its rationale, guiding principles
and objectives. It also gives an overview of the
components of the IMCI strategy
The IMCI strategy focuses on:
 improving case management skills of health-care providers
 improving overall health systems
 improving family and community health practices.

Main Symptoms. For older children include

A. cough or difficulty breathing,
B. diarrhea,
C. fever,
D. ear infection.
Main Symptoms young infants,
A. local bacterial infection,
B. diarrhea,
C. jaundice.

In addition, all sick children are routinely assessed for

A. nutritional and immunization status, and other potential
problems

 color-coded triage system:

A. "pink" indicates urgent hospital referral or
admission,
B. "yellow" indicates initiation of specific outpatient
treatment, and
C. "green" indicates supportive home care

 Measles is a highly infectious disease caused by a virus.

Measles kills more children than any other vaccine-
preventable disease. You wil find more information about
measles in the chapter on Fever.

 Diphtheria affects people of all ages, but most often it

strikes unimmunized children. In temperate climates,
diphtheria tends to occur during the colder months. In 2000
there were 30 000 cases and 3000 deaths of diphtheria
reported worldwide.

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
 Pertussis, or whooping cough, is a disease of the
respiratory tract caused by bacteria that live in the mouth,
nose and throat. Many children who contract pertussis have
coughing spells that last four to eight weeks. The disease
is most dangerous in infants. In 2000, an estimated 39
million cases and 297 000 deaths occurred worldwide, as a
result of pertussis.

 Poliomyelitis, or polio, is a crippling disease caused by

any one of three related viruses, poliovirus types 1, 2 or
3. All Member States of WHO agreed in 1988 to eradicate
polio. Since the global initiative to eradicate polio was
launched, the number of reported cases of polio has been
reduced from an estimated 350 000 in 1988 to 483 cases
associated with wild poliovirus in 2001.

 Tetanus is acquired through exposure to the spores of the

bacterium Clostridium tetani which are universally present
in the soil. The disease is caused by the action of a potent
neurotoxin produced during the growth of the bacteria in
dead tissues, e.g. in dirty wounds or in the umbilicus
following non-sterile delivery.
 People of all ages can get tetanus. But the disease is
particularly common and serious in newborn babies. This is
called neonatal tetanus. Most infants who get the disease
die. Neonatal tetanus is particularly common in rural areas
where most deliveries are at home without adequate sterile
procedures. According to WHO estimates, neonatal tetanus
killed about 200 000 babies in 2000.

 Tuberculosis (TB) is caused by the bacterium Mycobacterium

tuberculosis which usually attacks the lungs, but can also
affect other parts of the body, including the bones, joints
and brain.

 Not everyone who is infected with tuberculosis bacteria

develops the disease. People who are infected may not feel
ill and may have no symptoms. The infection can last for a
lifetime, but the infected person may never develop the
disease itself. People who are infected but who do not
develop the disease do not spread the infection to others.
In 2001, approximately two million people worldwide died of
tuberculosis.
 Hepatitis B is caused by a virus that affects the liver.
Adults who get hepatitis B usually recover. However most
infants infected at birth become chronic carriers i.e. they
carry the virus for many years and can spread the infection
to others. In 2000, there were an estimated 5.7 million
cases of acute hepatitis B infection and more than 521 000
deaths from hepatitis B-related disease.

 Haemophilus influenzae type b (Hib) is one of six related

types of bacterium. In 2000, H. influenzae type b (Hib) was
estimated to have caused two to three million cases of
serious disease, notably pneumonia and meningitis, and 450
000 deaths in young children.

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 The Hib bacterium is commonly present in the nose and
throat. Bacteria are transmitted from person to person in
droplets through sneezing and coughing. Infected children
may carry Hib bacteria without showing any signs or symptoms
of illness, but they can still infect others. The risk of
disease is highest for children between 6 months and 2 years
of age.
 Pneumonia and meningitis are the most important diseases
caused by Hib bacteria. In developing countries, pneumonia
is more common than meningitis in children with Hib disease.
Hib disease should be suspected in the case of any child
with signs and symptoms of meningitis or pneumonia.
 Children who survive Hib meningitis may develop permanent
neurological disability, including brain damage, hearing
loss, and mental retardation. Between 15% and 30% of
children who survive Hib disease are at risk for these
disabilities. From 5% to 10% of people with Hib meningitis
are at risk of dying.
Malnutrition is associated with many childhood illnesses and
deaths. There are several types of malnutrition.

One type of malnutrition is acute malnutrition. Acutely

malnourished children lack growth nutrients that are required to
build new tissues. These nutrients also aid weight gain after
illness, repair damaged tissues and help replace the rapid turn-
over of cells (intestine and immune cells). Correct replenishment
of nutrients is essential for recovery from malnutrition. A child
who has had frequent illnesses can also develop acute
malnutrition. The child's appetite decreases, and the food that
the child eats is not used efficiently.

Severe acute malnutrition (SAM) is a life threatening

condition requiring urgent treatment. Until recently, the
recommendation was to refer children suffering from SAM to
hospital to receive therapeutic diets along with medical care.
Treating severely malnourished children in hospitals however, is
not always desirable or practical especially in rural settings.

The situation has changed with the advent of ready to use

therapeutic foods (RUTF) which allows the management of a large
numbers of children who are severely malnourished above the age
of 6 months and without medical complications at home.
RUTF is made according to a standard, energy-rich composition
defined by the World Health Organization. Typically, RUTF is made
from full-fat milk powder, sugar, peanut butter, vegetable oil,
and vitamins and minerals. The benefits of RUTF include low
moisture content, a long shelf life without needing refrigeration
and that it requires no preparation.

A child whose diet lacks recommended amounts of essential

vitamins and minerals can also develop malnutrition.

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Not eating foods rich in iron can lead to iron deficiency and
anemia. Anemia is a reduced number of red cells or a reduced
amount of hemoglobin in each red cell. A child can also develop
anemia as a result of:
 infection;
 parasites such as hookworm (Ancylostoma and Necator) or
whipworm (Trichuris), which can cause blood loss from the
gut;
 malaria, which can destroy red cells rapidly.
Children can develop anemia if they have had repeated episodes
of malaria or if the malaria was inadequately treated. The anemia
may develop slowly. Often, anemia in these children is a result
of both malnutrition and malaria.

*****************************End********************************

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GRADING SYSTEM:
Quizzes / Class standing 50%

Prelim Grade = 50% CS + 50% Prelim Exam

Partial Midterm Grade = 50% CS + 50% Midterm Exam
Midterm Grade = 1/3 Prelim Grade + 2/3 Partial Midterm Grade
Semi-Final Grade = 50% CS + 50% Semi-Final Exam
Partial Final Grade = 50% CS + 50% Final Exam
Tentative Final Grade = 1/3 Semi Final Grade + 2/3 Partial Final
Grade
Final Grade = ½ Midterm Grade + ½ Tentative Final Grade

Learning Resources:

: Myles textbook for midwives

: family Planning (APSOM-JHPIEGO)
: IMCI Manual (WHO)
: Dr. RPS Maternal & Newborn Care

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Instructor’s Data:

Name : Mariam O. Boca, RM

Office Location : Midwifery Department
Office Phone : N-O-N-E
Contact Number : 09364428267
E-mail Address : yammj.71@[Link]

Prepare
d by:

Mariam O. Boca, RM
Instructor’s

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