MISAMIS ORIENTAL INSTITUTE OF SCIENCE AND TECHNOLOGY

Cogon, Balingasag Misamis Oriental

SCHOOL OF MIDWIFERY

INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES

CASE MANAGEMENT PROCESS:

1. Assess the child or the young infant.

2. Classify the illness.
3. Identify treatment.
4. Treat the child.
5. Counsel the mother.
6. Give follow-up care.

TARGET AGE OF IMCI STRATEGY:

 Age 1 week up to 2 months.

 Age 2 months up to 5 years old.

METHODS USED IN MANAGING CHILDHOOD ILLNESSES:

1. ASSESS THE PATIENT/CHILD

 Taking the history of the patient is one way of getting information about the
disease condition. This can be done by asking and observing the patient’s
condition to explore the possible causes.
2. CLASSIFY THE DISEASE
 A thorough assessment supported with laboratory results is necessary for
classification of illnesses and confirmation of the disease.
(mild,moderate,severe)
3. TREAT THE PATIENT
 Treatment is a curative method of treating diseases. This varies on the
condition of the patient.
4. COUNSEL THE PATIENT
 Providing health education to clients promotes health and avoids risk of
infection. These are important for parents/caregivers especially who lacks
knowledge on health practices and risk factors that contribute to disease
ailments.

COLOR PRESENTATION CLASSIFICATION OF THE LEVEL OF MANAGEMENT

DISEASES
Green Mild Home Care
Yellow Moderate Manage at the RHU
Pink Severe Urgent referral in the
Hospital

1
 GENERAL DANGER SIGNS (GDS)

ASK for: LOOK for:

 Vomiting  Sleepy

 Convulsions

 Drink unable

*referred after first dose of antibiotic and other urgent treatment.

MAIN SYMPTOMS:

 Cough (difficulty breathing)

 Diarrhea
 Fever
 Ear Problem
 Malnutrition and Anemia

COUGH and DIFFICULT BREATHING:

SIGNS CLASSIFY AS TREATMENT

 Any general danger sign Severe Pneumonia or Very  1st dose antibiotics
 Chest indrawing Severe Disease  Vitamin A
 Stridor  Prevent low blood sugar
 Refer URGENTLY to Hospital
 Fast breathing Pneumonia  Antibiotics for 5 days
2-12 mos= 50bpm >12  Soothe throat and relieve
mos=40bpm cough
 Advise mother when to return
immediately
 Follow up 2 days
 No signs of pneumonia or No Pneumonia:  Refer, if coughing for >30days
very severe disease Cough or Cold  Soothe throat and relieve
cough
 Follow up 5 days

DIARRHEA: FOR DEHYDRATION

SIGNS CLASSIFY AS TREATMENT

Any TWO: Severe Dehydration  PLAN C ( if child has No other
 Sleepy ( difficult to severe classification)
awaken)  Refer URGENTLY ( if child has
 Sunken Eyes other severe classification)
 Sip- less (unable to drink)  Antibiotics for Cholera (if 2 years
 Skin Turgor very poor or old, with cholera in area)
skin pinch goes back
slowly
Any TWO: Some Dehydration  PLAN B
 Sunken Eyes  Refer URGENTLY (if has another

2
  Sip – full severe classification)
 Skin turgor poor or skin  Advise mother when to return
pinch goes back slowly immediately
 Restless  Follow up in 5 days

 Not enough signs No Dehydration  PLAN A

 Zinc SO4

If diarrhea of 14 days or more

SIGNS CLASSIFY AS TREATMENT

 Dehydration present Severe persistent Diarrhea  Treat dehydration
 Vitamin A
 Refer URGENTLY to Hospital
 No Dehydration Persistent Diarrhea  Advise on FEEDING
 Vitamin A
 Advise mother when to return
immediately
 Follow up in 5 days

And if blood in STOOL

SIGNS CLASSIFY AS TREATMENT

 Blood in Stool Dysentery  Antibiotic for 5 days, for shigella
in your area
 Follow up in 2 days
 Advise mother when to return
immediately

PLAN A ( Treat Diarrhea at Home)

 Give extra fluids (as much as the child can)

 Breastfeed, ORS, food-based fluid
 Zinc supplement ( 10-14 days)
- 10mg per day for infant
- 20mg per day for children
 Continue feeding
 When to return ( ff up check up)

PLAN B ( treat some dehydration with ORS) oral rehydration salt

 Give in Health Center ORS over 4 hour period

 ORS in ml = kg wt. X 75, re assess after 4 hours
 Do PLAN A

PLAN C ( treat severe dehydration quickly)

 IVF 100mg/kg LRS or NSS

- INFANT =30ml/kg in 1 hour
= 70ml/kg in 5 hours
- CHILDREN = 30ml/kg in 30 minutes
= 70ml/kg in 2.5 hours

3
  Re assess q 1 to 2 hour
 Give ORS if can drink
 Re classify infant in 6 hours, children in 3 hours

FEVER

*MALARIA RISK -child lives in a malarious area or has travelled and stayed
overnight in a malaria area in the last 4 weeks.

SIGNS CLASSIFY AS TREATMENT

 Any General Danger  Very Severe  First dose QUININE, given IM
Signs Febrile Disease/  1st dose Antibiotics
 Stiff Neck Malaria  Prevent decreasing blood sugar
 Paracetamol for fever 38.5C
 Send blood smear with patient
 Refer URGENTLY

 (+) Blood smear  Malaria  Treat with Oral Antimalarial

 No runny nose and  Paracetamol for fever 38.5C or
measles and other above
causes of fever  Advise mother when to return
immediately
 Follow up in 2 days if fever
persists
 Refer for reassessment if fever
persist 7 days
 (-) Blood smear  Fever; Malaria  Paracetamol for fever 38.5C or
 (-) Runny nose unlikely above
 (-) Measles, or other  Advise mother when to return
cause of fever immediately
 Follow up in 2 days if fever
persists
 Refer for reassessment if fever
persist 7 days
 Treat other causes of fever

*No MALARIA RISK

SIGNS CLASSIFY AS TREATMENT

 Any General Danger  Very Severe  1st Dose antibiotics
Signs Febrile Disease  Prevent decreasing blood sugar
 Stiff Neck  Paracetamol for fever 38.5C
 Refer URGENTLY

 No signs of very severe  Fever : No Malaria  Paracetamol for fever 38.5C

febrile disease  Advise mother when to return
immediately
 Follow up in 2 days
 Refer for reassessment if fever
persist 7 days
 Treat other causes of fever

*If measles now or within last 3 months

4
SIGNS CLASSIFY AS TREATMENT
 Any General Danger  Severe  Give vitamin A
Signs Complicated  1st dose of antibiotic
 Clouding of cornea measles  Apply tetracycline eye ointment
 Deep or extensive (if clouding cornea or pus draining
mouth ulcers from the eye)
 Refer URGENTLY
 Pus draining from the  Measles with eye  Give vitamin A
eye or mouth  TETRACYCLINE (if pus draining
 Mouth ulcers complications from eyes)
 GENTIAN VIOLET (if mouth ulcers)
 Follow up in 2 days
 Advise mother when to return
immediately

 Measles now or within  Measles  Give vitamin A

last 3 months  Advise mother when to return
immediately.
*DENGUE risk;

SIGNS CLASSIFY AS TREATMENT

 Bleeding (nose, gums,  Severe Dengue  PLAN B, if there is persistent
stool, vomitus) Hemmorhagic vomiting, abdominal pain, (+)
 Petechiae Fever tourniquet test
 Cold clammy  PLAN C, if any signs of bleeding
extremeties  Prevent increasing blood sugar
 Capillary refill > 3  Refer URGENTLY; no ASPIRIN
seconds
 Abdominal pain
 Vomiting
 (+) Tourniquet test
 No signs of Severe  Fever; Dengue  Advise mother when to return
Dengue Hemmorhagic Hemorrhagic immediately
Fever Fever unlikely  Follow up in 2 days if fever
persists or bleeding
 No ASPIRIN

EAR PROBLEM

SIGNS CLASSIFY AS TREATMENT

 Tender swelling behind  Mastoiditis  1st dose of antibiotic
the ear  Paracetamol for PAIN
 Refer URGENTLY
 Pus draining from th ear  Acute Ear  Antibiotics for 5 days
for less than 14 days Infection  Paracetamol for PAIN
 (+) Ear pain  Wicking
 Follow up in 5 days
 Pus draining from th ear  Chronic Ear  Wicking
for less than 14 days or Infection  Follow up in 5 days
more
 No Ear pain, no Pus  No Ear Infection  No additional treatment

MALNUTRITION AND ANEMIA

SIGNS CLASSIFY AS TREATMENT

5
  Visible Severe Wasting  Severe  Give vitamin A
 (+) Edema of both feet Malnutrition and  Refer URGENTLY to hospital
 Severe Palmar Pallor Anemia
 Some palmar pallor  Anemia very low  Counsel mother on feeding
 Very low weight for age weight  Follow up in 5 days ( if feeding
problem)
 If some pallor:
- Give iron
- Mebendazole (if 1 year old; no
dose in the past 6 months
- Follow up 14 days
 If very low weight for age:
- Vitamin A
- Follow up in 30 days
 Advise mother when to return
immediately

 Not very low weight for  No anemia and  Counsel mother on feeding
age and no other signs not very low  Advise mother when to return
of malnutrition weight immediately
 Follow up in 5 days ( if feeding
problem)

SICK YOUNG INFANT (age 1 week up to 2 months)

POSSIBLE BACTERIAL INFECTION

SIGNS CLASSIFY AS TREATMENT

 Convulsions  Possible Serious  1st dose IM antibiotics
 Fast breathing ( more Bacterial Infection  Prevent decreasing blood sugar
than 60 cpm)  Advise mother how to keep infant
 Severe chest Indrawing warm on way
 Nasal Flaring  Refer URGENTLY
 Grunting
 Bulging Fontannels
 Pus from Ear
 Umbilical redness to
skin
 Severe skin pustules
 Abnormally sleepy or
difficult to awaken less
than normal movement
 Red umbilicus  Local Bacterial  Give oral antibiotics for 5 days
 Draining pus Infection  Treat Local infection in RHU and
 Skin pustule teach mother
 Advise mother about home care
 Follow up in 2 days

DIARRHEA

FOR DEHYDRATION

6
SIGNS CLASSIFY AS TREATMENT
 TWO OF ANY;  Severe  PLAN C, if child does not have
 Sleepy or difficulty to Dehydration possible bacterial infection nor
awaken dysentery
 Sunken eyes  Refer URGENTLY,if with possible
 Skin turgor very poor bacterial infection or dysentery

 TWO OF ANY;  Some  PLAN B

 Sunken eyes Dehydration  Refer URGENTLY,if with possible
 Skin turgor poor bacterial infection or dysentery
 Restless, irritable
 Not enough signs of  No Dehydration  PLAN A
dehydration

IF DIARRHEA 14 DAYS OR MORE

SIGNS CLASSIFY AS TREATMENT

 Diarrhea 14 days or  Severe persistent  If young infant has dehydration,
more diarrhea TREAT dehydration before referral
, unless the infant has possible
serious bacterial infection
 Refer URGENTLY

BLOOD IN THE STOOL

SIGNS CLASSIFY AS TREATMENT

 Blood in the Stool  Dysentery  Refer URGENTLY with mother
giving ORS on the way
 Advise mother to continue
Breastfeeding
FEEDING PROBLEM or LOW WEIGHT

SIGNS CLASSIFY AS TREATMENT

 NOT ABLE TO;  Not able to feed;  1st dose IM antibiotics
 Feed Possible Bacterial  Advise how to keep warm
 Attach Infection  Refer URGENTLY
 Suck
 Not well attached to  Feeding Problems  Breastfeed as often as possible
breast or Low weight  Treat Thrush
 Not sucking effectively  Advise about home care
 Less than 8 breastfeeds  Follow up feeding problem or
in 24 hours thrush in 2 days
 Low weight for age  Follow up Low weight for age in
 Thrush 14 days
 Not very low weight for  No Feeding  Counsel mother on feeding
age and no other signs Problem
of inadequate feeding

FEVER

*MALARIA RISK -infant lives in a malarious area or has travelled and stayed
overnight in a malaria area in the last 4 weeks.

7
SIGNS CLASSIFY AS TREATMENT
 Any General Danger  Very Severe  First dose QUININE, given IM
Signs Febrile Disease/  1st dose Antibiotics
 Stiff Neck Malaria  Prevent decreasing blood sugar
 Paracetamol for fever 38.5C
 Send blood smear with patient
 Refer URGENTLY
 (+) Blood smear  Malaria  Treat with Oral Antimalarial
 No runny nose and  Paracetamol for fever 38.5C or
measles and other above
causes of fever  Advise mother when to return
immediately
 Follow up in 2 days if fever
persists
 Refer for reassessment if fever
persist 7 days
 (-) Blood smear  Fever; Malaria  Paracetamol for fever 38.5C or
 (-) Runny nose unlikely above
 (-) Measles, or other  Advise mother when to return
cause of fever immediately
 Follow up in 2 days if fever
persists
 Refer for reassessment if fever
persist 7 days
 Treat other causes of fever

*No MALARIA RISK

SIGNS CLASSIFY AS TREATMENT

 Any General Danger  Very Severe  1st Dose antibiotics
Signs Febrile Disease  Prevent decreasing blood sugar
 Stiff Neck  Paracetamol for fever 38.5C
 Refer URGENTLY

 No signs of very severe  Fever : No Malaria  Paracetamol for fever 38.5C

febrile disease  Advise mother when to return
immediately
 Follow up in 2 days
 Refer for reassessment if fever
persist 7 days
 Treat other causes of fever

*If measles now or within last 3 months

SIGNS CLASSIFY AS TREATMENT

 Any General Danger  Severe  Give vitamin A
Signs Complicated  1st dose of antibiotic

8
  Clouding of cornea measles  Apply tetracycline eye ointment
 Deep or extensive (if clouding cornea or pus draining
mouth ulcers from the eye)
 Refer URGENTLY

 Pus draining from the  Measles with eye  Give vitamin A

eye or mouth  TETRACYCLINE (if pus draining
 Mouth ulcers complications from eyes)
 GENTIAN VIOLET (if mouth ulcers)
 Follow up in 2 days
 Advise mother when to return
immediately

 Measles now or within  Measles  Give vitamin A

last 3 months  Advise mother when to return
immediately
*DENGUE risk;

SIGNS CLASSIFY AS TREATMENT

 Bleeding (nose, gums,  Severe Dengue  PLAN B, if there is persistent
stool, vomitus) Hemmorhagic vomiting, abdominal pain, (+)
 Petechiae Fever tourniquet test
 Cold clammy  PLAN C, if any signs of bleeding
extremeties  Prevent increasing blood sugar
 Capillary refill > 3  Refer URGENTLY; no ASPIRIN
seconds
 Abdominal pain
 Vomiting
 (+) Tourniquet test
 No signs of Severe  Fever; Dengue  Advise mother when to return
Dengue Hemmorhagic Hemorrhagic immediately
Fever Fever unlikely  Follow up in 2 days if fever
persists or bleeding
 No ASPIRIN
EAR PROBLEM

SIGNS CLASSIFY AS TREATMENT

 Tender swelling behind  Mastoiditis  1st dose of antibiotic
the ear  Paracetamol for PAIN
 Refer URGENTLY
 Pus draining from th ear  Acute Ear  Antibiotics for 5 days
for less than 14 days Infection  Paracetamol for PAIN
 (+) Ear pain  Wicking
 Follow up in 5 days
 Pus draining from th ear  Chronic Ear  Wicking
for less than 14 days or Infection  Follow up in 5 days
more
 No Ear pain, no Pus  No Ear Infection  No additional treatment

MALNUTRITION AND ANEMIA

SIGNS CLASSIFY AS TREATMENT

 Visible Severe Wasting  Severe  Give vitamin A
 (+) Edema of both feet Malnutrition and  Refer URGENTLY to hospital
 Severe Palmar Pallor Anemia

9
  Some palmar pallor  Anemia very low  Counsel mother on feeding
 Very low weight for age weight  Follow up in 5 days ( if feeding
problem)
 If some pallor:
- Give iron
- Mebendazole (if 1 year old; no
dose in the past 6 months
- Follow up 14 days
 If very low weight for age:
- Vitamin A
- Follow up in 30 days
 Advise mother when to return
immediately
 Not very low weight for  No anemia and  Counsel mother on feeding
age and no other signs not very low  Advise mother when to return
of malnutrition weight immediately
 Follow up in 5 days ( if feeding
problem)

SICK YOUNG INFANT (age 1 week up to 2 months)

POSSIBLE BACTERIAL INFECTION

SIGNS CLASSIFY AS TREATMENT

 Convulsions  Possible Serious  1st dose IM antibiotics
 Fast breathing ( more Bacterial Infection  Prevent decreasing blood sugar
than 60 cpm)  Advise mother how to keep infant
 Severe chest Indrawing warm on way
 Nasal Flaring  Refer URGENTLY
 Grunting
 Bulging Fontannels
 Pus from Ear
 Umbilical redness to
skin
 Severe skin pustules
 Abnormally sleepy or
difficult to awaken less
than normal movement
 Red umbilicus  Local Bacterial  Give oral antibiotics for 5 days
 Draining pus Infection  Treat Local infection in RHU and
 Skin pustule teach mother
 Advise mother about home care
 Follow up in 2 days

DIARRHEA

FOR DEHYDRATION

SIGNS CLASSIFY AS TREATMENT

 TWO OF ANY;  Severe  PLAN C, if child does not have
 Sleepy or difficulty to Dehydration possible bacterial infection nor

10
 awaken dysentery
 Sunken eyes  Refer URGENTLY,if with possible
 Skin turgor very poor bacterial infection or dysentery

 TWO OF ANY;  Some  PLAN B

 Sunken eyes Dehydration  Refer URGENTLY,if with possible
 Skin turgor poor bacterial infection or dysentery
 Restless, irritable

 Not enough signs of  No Dehydration  PLAN A

dehydration

IF DIARRHEA 14 DAYS OR MORE

SIGNS CLASSIFY AS TREATMENT

 Diarrhea 14 days or  Severe persistent  If young infant has dehydration,
more diarrhea TREAT dehydration before referral
, unless the infant has possible
serious bacterial infection
 Refer URGENTLY

BLOOD IN THE STOOL

SIGNS CLASSIFY AS TREATMENT

 Blood in the Stool  Dysentery  Refer URGENTLY with mother
giving ORS on the way
 Advise mother to continue
Breastfeeding

FEEDING PROBLEM or LOW WEIGHT

SIGNS CLASSIFY AS TREATMENT

 NOT ABLE TO;  Not able to feed;  1st dose IM antibiotics
 Feed Possible Bacterial  Advise how to keep warm
 Attach Infection  Refer URGENTLY
 Suck
 Not well attached to  Feeding Problems  Breastfeed as often as possible
breast or Low weight  Treat Thrush
 Not sucking effectively  Advise about home care
 Less than 8 breastfeeds  Follow up feeding problem or
in 24 hours thrush in 2 days
 Low weight for age  Follow up Low weight for age in
 Thrush 14 days

 Not very low weight for  No Feeding  Counsel mother on feeding

age and no other signs Problem
of inadequate feeding

MATERNAL HEALTH PROGRAM OF DOH

The Maternal Health Program is a set of actions and services administered by

the Department of Health to aid women before, during and after pregnancy. The Philippines

11
is tasked to reduce the maternal mortality ratio (MMR) by three quarters by 2015 to achieve
its millennium development goal.

This means a MMR of 112/100,000 live births in 2010 and 80/100,000 live births by 2015.

Year Expected MMR

2010 112/100,000 live births
2015 80/100,000 live births

The maternal mortality ratio (MMR) has declined from an estimated 209 per 100,000 live
births in 1987-93 (NDHS 1993) to 172 in 1998. The Philippines found it hard to reduce
mortality. Similarly, perinatal mortality reduction has been minimal. It went down by 11% in
10 years from 27.1 to 24 per thousand live births.

Year Actual MMR

1987-1993 209/100,000 live births
1998 172/100,000 live births

The percentage of pregnant woman with at least four prenatal visits decreased from 77% in
1998 to 70.4 in 2003. In addition, pregnant women who received at least two doses of
tetanus toxoid also decreased from 38% in 1998 to 37.3% in 2003. Only about 76.8% of
pregnant women received iron supplementation during pregnancy.

The Philippine Health Statistics revealed that maternal deaths are due to:

Complication Percentage of total maternal deaths

Hypertension 25%
Postpartum Hemorrhage 20.3%
Pregnancy with abortive outcomes 9%

However births attended by health professionals increased from 56% in 1998 to 59.8% in
2003. There was also a notable increase to 51% in 2003 from 43% in 1998 in the percentage
of women with at least one prenatal visit. Only 44.6% of postpartum women received a dose
of Vitamin A.

The underlying causes of maternal deaths are delays in taking critical actions:

 delay in seeking care,

 delay in making referral and
 delay in providing of appropriate medical management.

12
Other factors that contribute to maternal deaths includes

 closely spaced births,

 frequent pregnancies,
 poor detection and management of high-risk pregnancies,
 poor access to health facilities brought about by geographic distance and
 cost of transportation, and
 as well as health care and health staff who lack competence in handling
obstetrical emergencies.
The overall goal of the Maternal Health Program is to improve the survival, health and well
being of mothers and unborn through a package of services all throughout the course of and
before pregnancy.

Basic Emergency Obstetric Care (BEMOC)

Launch and implement the Basic Emergency Obstetric Care or BEMOC strategy in
coordination with the DOH. The BEMOC strategy entails the establishment of facilities that
provide emergency obstetric care for every 125, 000 population and which are located
strategically. The strategy calls for families and communities to plan for childbirth and the
upgrading of technical capabilities of local health providers.

Improve the quality of Prenatal and Postnatal Care

Pregnant women should have at least four prenatal visits with time for adequate evaluation
and management of diseases and conditions that may put the pregnancy at
risk. Postpartum care should extend to more women after childbirth, after a miscarriage or
after an unsafe abortion.

Reduce women’s exposure to Health Risks

Through the institutionalization of responsible parenthood and provision of appropriate

health care package to all women of reproductive age especially those who are:

 less than 18 years old and over 35 years of age,

 women with low educational and financial resources,
 women with unmanaged chronic illness and
 women who had just given birth in the last 18 months.

13
Appropriate Allocation of Resources

LGUs, NGOs and other stakeholders must advocate for health through resource generation
and allocation for health services to be provided and are in place in the health system.

To address the problem, packages of health services are provided to the clients. These
essential health care packages are available and are in place in the health system.

Essential Health Service Package Available in the Health Care Facilities

These are the packages of services that every woman has to receive before and after
pregnancy and or delivery of a baby.

Antenatal Registration

Pregnancy poses a risk to the life of every woman. Pregnant women may suffer complication
and die. Every woman has to visit the nearest facility for antenatal registration and to avail
prenatal care services. This is the only way to guide her in pregnancy care to make her
prepare for child birth. The standard prenatal visits that women have to receive during
pregnancy are as follows:

Prental Visits Period of Pregnancy

st
1 visit As early in pregnancy as possible before four months or during
the first trimester
2nd visit During the 2nd trimester
3rd visit During the 3rd trimester
Every 2 weeks After 8th month of pregnancy till delivery.

Tetanus Toxoid Immunization

Neonatal Tetanus is one of the public health concerns that we need to address among
newborns. To protect them from deadly disease, tetanus toxoid immunization is important
for pregnant women and child bearing age women. Both mother and child are protected
against tetanus and neonatal tetanus. A series of 2 doses of Tetanus Toxoid vaccination
must be received by a woman one month before delivery to protect baby from neonatal
tetanus. And the 3 booster dose shots to complete the five doses following the
recommended schedule provide full protection for both mother and child. The mother is then
called as a “fully immunized mother” (FIM).

14
Micronutrient Supplementation

Micronutrient supplementation is vital for pregnant women. These are necessary to prevent
anemia, vitamin A deficiency and other nutritional disorders. They are:

Nutrie Dose Schedule Remarks

nt
Vitamin 10,000 IU Twice a week starting Do not give Vitamin A supplementation
A on the 4thmonth of before the 4th month of pregnancy. It might
pregnancy cause congenital problems in the baby.
Iron 60 Daily To be given starting at 5th month of
mg/400 pregnancy and 2nd month post partum.
ug tablet

Treatment of Diseases and Other Conditions

There are other conditions that might occur among pregnant women. These conditions may
endanger her health and complication could occur. Follow first aid treatment:

Conditions/ What to do Do not give

Diseases
Difficulty of
 Clear airway
breathing/obstruction
of airway  Place in her best position
 Refer woman to hospital with EmOC
capabilities
Unconscious
 Keep on her back arms at the side
 Tilt head backward (unless trauma is
suspected)
 Lift chin to open airway
 Clear secretions from throat
 Give IVF to prevent or correct shock
 Monitor VS every 15 minutes
 Monitor fluid given. If difficulty of
breathing and puffiness develops,
stop infusion
 Monitor U.O.
 Do not give oral rehydration solution
to a woman who is unconscious or
has convulsions.
 Do not give IVF if you are not trained

15
 to do so
Post partum bleeding
 Massage uterus and expel clots
 If bleeding persists:
o Place cupped palm on
uterine fundus and feel for
state of contraction
o Massage fundus in a
circular motion
o Apply bimanual uterine
compression if ergometrine
treatment done and
p[ostpartum bleeding still
persists
o Give ergometrine 0.2. IM
and another dose after 15
minutes.
 Do not give ergometrine if woman
has eclampsia, pre-eclampsia
or hypertension.
Intestinal parasite Giver mebendazole 500mg tablet single dose Do not give
infection anytime from 4-9 months of pregnancy if none mebendazole in
was given in the past 6 months the first 1-3
months of
pregnancy. This
might cause
congential
problems in
baby.
Malaria Give sulfadoxin-pyrimethamine to women from
malaria endemic areas who are in 1st or
2nd pregnancy, 500mg-25 mg tab, 3tabs at the
beginning of 2nd to 3rd trimesters not less than
one month interval.

Clean and Safe Delivery

The presence of a skilled birth attendance will ensure hygiene during labor and delivery. It
may also provide safe and non traumatic care, recognize complications and also manage
and refer the women to a higher level of care when necessary. The necessary steps to follow
during labor, childbirth and immediate postpartum include the following:

Do a quick check upon admission for emergency signs:

16
  Unconscious/convulsion
 Vaginal bleeding
 Severe abdominal pain
 Looks very ill
 Severe headache with visual disturbance
 Severe breathing difficulty
 Fever
 Severe vomiting
Make woman comfortable

Establish rapport with the client by greeting and interviewing to make her comfortable.

Assess the woman in labor

Assessing the client is a reference guide for a health worker to determine its status
during laborstage. This can be done by taking the history of the ff:

 Last menstrual period (LMP)

 Number of pregnancy
 Start of labor pains
 Age/height
 Danger signs of pregnancy
Taking the history through interview will help determine the client’s condition
during delivery of a baby.

Determine the stage of labor

Labor can be determined when woman’s response to contraction is observed pushing down
and vulva is bulging, with leaking amniotic fluid, and vaginal bleeding. A vaginal
examination can be performed to determine the degree of contraction.

Decide if the woman can safely deliver

By assessing the condition of the client and not finding any indication that could harm
the delivery of a baby, a trained health worker can decide a safe delivery of a mother.

Give supportive care throughout labor

17
There are many things that a woman needs to do during labor. This will help her deliver
clean, safe and free from fatigue. These are:

 Encourage to take a bath at the onset of labor

 Encourage to drink but not to eat as this may interfere surgery in case needed.
 Encourage to empty bladder and bowels to facilitate delivery of the baby. Remind
to empty bladder every 2 hours
 Encourage to do breathing technique to help energy in pushing baby out the
vagina. Panting can be done by breathing with open mouth with 2 short breaths
followed by long breath. This prevent pushing at the end of the first stage.
Monitor and manage labor

These are different stages of labor to watch out any danger signs

Stage What to do Not to do

First Stage Not yet Do not do vaginal
 Check every hour for
in active labor, examination more
cervix is dilated 0- emergency signs, frequency frequently than every 4
3cm and hours.
contractions are and duration of
weak, less than 2 to contractions, fetal heart rate,
10 minutes.
etc.
 Check every 4 hours for fever,
pulse, BP and cervical dilatation
 Record time of rupture of
membranes and color
of amniotic fluid.
 Assess progress of labor
o Refer woman
immediately to
hospital facility with
comprehensive
emergency
obstetrical care
capabilities if after 8
hours, contractions
are stronger and
more frequent but no
progress in cervical

18
 dilatation, with or
without membranes
ruptured.
First Stage In
 Check every 30 minutes for
active labor, cervix
is dilated 4 cm or emergency signs
more
 Check every 4 hours for fever,
pulse, BP and cervical dilation
 Record time of rupture of
membranes and color
of amniotic fluid
 Record findings in
partograph/patient record.
 Do not allow woman to push
unless delivery is imminent. It
will just exhaust the woman.
 Do not give medications to
speed up labor. It may
endanger and cause trauma to
mother and the baby.
Second Stage:
 Check every 5 minutes for
Cervix dilated 10
cm or bulging thin perineum thinning and bulging,
perineum and head
visible visible descend of the head
during contraction, emergency
signs, fetal heart rate and mood
and behavior.
 Continued recording in the
partograph.
 Do not apply fundal pressure to
help delivery the baby.
Third Stage
 Deliver the placenta
Between birth of
the baby  Check the completeness
and delivery of
the placenta of placenta and membranes
 Do not squeeze or massage the
abdomen to deliver
the placenta

19
Others

 Monitor closely within one hour after delivery and give supportive care
 Continue care after one hour postpartum. Keep watch closely for at least 2 hours.
 Educate and counsel on FP and provide FP method if available and decision was
made by a woman.
 Birth registration
 Importance of BF
 Newborn Screening for babies delivered in RHU or at home within 48 hours up to 2
weeks after birth
 Schedule when to return for consultation for postpartum partum visits

Inform, teach and counsel the woman on important MCH messages:

1st Visit 1st week post partum preferable 3-5 days

2nd Visit 6 weeks post partum

20