Nursing Care of the Patient With

Home , Amniotic sac, Rupture of membranes

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ABSTRACT Preterm premature rupture of the membranes (PPROM) is diagnosed when rupture of the amniotic membranes occurs prior to the completion of the 36th week of gestation. PPROM accounts for 25% of all cases of premature rupture of the membranes and is responsible for 30%-40% of all preterm deliveries. In mothers diagnosed with PPROM without evidence of infection, active labor, or fetal compromise, the current standard of care is expectant management. The goal of expectant management is the prolongation of the pregnancy to increase fetal gestational age thus potentially decreasing the effects of prematurity. Expectant management consists of ongoing observation for signs and symptoms of infection, active labor, and/or nonreassuring fetal status. This article provides clinical nursing guidelines for the mother diagnosed with PPROM who is managed expectantly. Eight targeted areas for nursing assessment and intervention are described: preterm labor, side effects of tocolytic therapy, maternal/fetal infection, fetal compro- he purpose of this article is to provide an overview of the management of PPROM (preterm premature rupture of the membranes), and to synthesize mise, side effects of extended bed Tthe available evidence and provide clinical nursing guidelines for the care of rest, maternal stress, educational the mother diagnosed with PPROM. Eight targeted areas for nursing assessment needs, and routine prenatal care. and intervention will be described: preterm labor, side effects of tocolytic therapy, maternal/fetal infection, fetal compromise, side effects of extended bed rest, ma- Key Words: Preterm premature rup- ternal stress, educational needs, and routine prenatal care. ture of membranes; Nursing care; The United States currently ranks 28th in infant mortality (7.0%) among indus- trialized countries, due largely to high rates of preterm birth and low birthweight. Bed rest; High-risk pregnancy. Preterm labor (Ͻ37 weeks gestation) accounts for 11.9% of births in the United States (National Center for Health Statistics, 2002). While the causes of preterm

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Marilyn Stringer, PhD, CRNP, RDMS, Susan R. Miesnik, MSN, RNC, CRNP, Linda Brown, PhD, RN, FAAN, Allison H. Martz, MSN, RNC, IBCLC, and George Macones, MD

labor remain unknown, preterm premature rupture of low to blue in the absence of blood) is considered a posi- membranes (membrane rupture before 37 weeks gestation) tive test for amniotic fluid. A microscopic examination of occurs in approximately 3% of all pregnancies, and 25% vaginal fluid for the presence of ferning is also considered of all cases of premature rupture of the membranes, and is a positive test for amniotic fluid (Iams, 2002a; McCartney, thought to be responsible for about one-third of all preterm 2002). Lastly, confirmation of oligohydramnios on ultra- births (Mercer, 2003). Although the etiology is frequently sound can be helpful in determining a definitive diagnosis obscure, the occurrence of PPROM may be associated with (Garite, 1999). Additional assessments should include ma- a preexisting infectious process or a physiologic abnormali- ternal vital signs, fetal status, and uterine activity. ty such as incompetent cervix or polyhydramnios that Depending on state and local practice regulations, dif- weakens the membrane making it susceptible to rupture ferent providers such as a nurse, physician, or physician (Garite, 1999). Regardless of etiology, PPROM has a signif- assistant may perform various levels of this assessment. Af- icant impact on maternal and neonatal morbidity and mor- ter a definitive diagnosis is established, the two most im- tality. Complications such as chorioamnionitis, preterm portant issues for determining clinical management are ac- birth, fetal stress associated with cord compression or pro- curate dating of the pregnancy and the presence/absence of lapse, and fetal deformation syndrome, may all have delete- chorioamnionitis. In the mother whose gestation is ,37 rious effects on outcomes (Garite). weeks, immediate delivery is reserved for cases of ad- Although a significant amount of outcome research has vanced labor, infection, and irreversible nonreassuring fetal been conducted to evaluate clinical interventions for heart tracing (Mercer, 2003). PPROM such as hospitalization, bed rest, amnioinfusion, In the presence of active labor, unrelieved nonreassuring and administration of tocolytics, antibiotics, and corticos- fetal heart tracing, or chorioamnionitis, an emergent deliv- teroids, debate regarding medical management remains ery plan may be vital. Nursing care should include ongo- (Garite, 1999). For mothers with PPROM who are not in ing assessment of maternal and fetal status, preparation labor, and without evidence of fetal compromise or for delivery including notification of neonatal personnel, chorioamnionitis, interventions such as the use of tocolyt- maternal education, and mother/family support through- ics and antibiotics still remain controversial (Garite). Al- out labor and during the birth. Additional emotional sup- though there is not consensus about medical management port and education may be necessary during the postpar- regimens, there is agreement among providers concerning tum period if the mother experiences further morbidity or the focus of that management: reducing the risk of mater- if the neonate has significant medical morbidity. nal and neonatal morbidity and mortality. Expectant Medical Management Initial Assessment In 1980, Mead established expectant management as the Typically, when a woman whose gestation is Յ37 weeks standard of care for PPROM when there was no evidence presents with the complaint of a gush of fluid from the of infection, labor, or fetal compromise. The goal of expec- vagina, PPROM is suspected and a definitive diagnosis is tant management is the prolongation of the pregnancy to needed. A complete health history is indicated to assess for increase gestational age, thereby potentially decreasing the risk factors such as gestational age, multiple gestation, pre- effects of prematurity. Expectant management consists of vious preterm labor/delivery, sexually transmitted diseases, ongoing observation for signs and symptoms of infection, and signs and symptoms of infection. The performance of active labor, and/or fetal compromise (ACOG, 1998). The a sterile speculum exam is critical to establish a definitive length of time from rupture of membranes until delivery of diagnosis. Speculum exam assessment includes observation the neonate is known as the latency period. Previously, for pooling of amniotic fluid in the posterior fornix and a clinicians believed that the earlier in gestation a woman mother-elicited Valsalva maneuver to allow for observation sustained ruptured membranes and the longer the latency of gross leaking from the cervical os. Next, nitrazine paper period, the more likely she was to develop an infection, testing of vaginal fluid for alkaline pH (a change from yel- placing both mother and neonate at risk (Garite, 1999).

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Table 1. Care Guidelines: Expectant Management of the Mother Diagnosed With PPROM Targeted Risk Nursing Assessments Interventions Preterm labor Subjective: Report abnormal findings See Figure 1 Hydration, oral/intravenous Objective: Medications, as indicated Uterine activity; cervical status • Tocolytics/antimicrobial Vaginal discharge • Corticosteroids

Tocolytic therapy Subjective*: Report abnormal findings side effects Headache (1,2,3,4); vomiting (1,2,3,4); nausea (1,2,3); chest Decrease or discontinue drug pain (1,2); diarrhea (1); anxiety (1); palpitations (1); jitteriness Administer calcium gluconate for magnesium (1); itching (1); shortness of breath (1); constipation (2); sulfate toxicity lethargy (2); visual disturbances (2); weakness (2); flushing (2); nasal congestion (2); dizziness (3); GI bleeding (3); heartburn (3); depression (3) Objective (maternal)*: Blood pressure (1,3,4); breathe sounds (1,2); pulse rate (1,4); urine analysis/output (1,2); edema (1); skin rash (1); temperature (1); blood assays (1); respiratory rate (2); reflexes (2) Objective (fetal)*: ductus arteriousus (3); heart rate (1,2); amniotic fluid index (3) Maternal/fetal Subjective: Report abnormal findings infection Malaise, flulike symptoms, abdominal pain, foul-smelling Medications as indicated discharge, fetal movement Objective: Temperature, pulse, uterine tenderness, vaginal discharge, fetal well-being Fetal Subjective: Maternal repositioning compromise Decreased fetal movement Administer oxygen Objective: Increase hydration Fetal well-being Report abnormal findings Side effects of Subjective: Antiembolic devices extended bedrest Headache, indigestion, gastric reflux, constipation, hip/back Antacids, stool softeners soreness, leg pain, sleep/wake cycles, boredom, depression, Encourage increased hydration and fiber content anxiety, mood swings, Referrals: Objective: Homan’s sign, localized skin warmth and/or redness, weight Nutrition support, physical and occupational therapy, gain/loss, muscle strength, edema social service, pastoral care, community resources Active listening Encourage maternal verbalization Private, flexible visitation Structure daily activities Diversionary activities, i.e., books, crafts, educational and entertainment videos Bedrest support information Online support groups Reference material

Maternal stress Feeling of powerlessness Reassurance concerning maternal/fetal condition and Childcare issues, financial and employment concerns care plan Joint decision-making Involvement in self-care, i.e., uterine palpation, fetal activity monitoring, self-medication administration Relaxation exercises Open ended questions Support groups, social service, etc. referrals Educational Care of premature infant Neonatal consults; NICU tour, fetal development, labor, needs Pregnancy health teaching normal pregnancy, birth, lactation, postpartum care

*Dependent on agent used: 1 = betamimetic, 2 = magnesium sulfate, 3 = prostaglandin inhibitors, 4 = calcium channel blocker.

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Garite has suggested that the risk of infection may correlate Figure 1. more closely with the timing of the first digital examination Common signs and symptoms of preterm labor. than the length of latency period. In PPROM, the incidence • Uterine cramping (menstrual-like cramp, constant or of chorioamnionitis and perinatal infections is not changed comes and goes) with increasing latency (Garite). The association of • Uterine contractions every 10 minutes or more often PPROM and escalated fetal lung maturity is controversial. (may be painless) Iams (2002b) suggests that confounding variables such as • Low dull backache (constant or comes and goes) sex of the fetus, PPROM onset, length of latency period, • Pelvic pressure, pushing (feels like the baby is pushing and wide gestational age range at delivery lead to difficulty down) in establishing the association of PPROM and fetal lung • Abdominal cramping, stomachache, gastrointestinal maturity. ACOG suggests that expectant management can disturbances (with or without diarrhea) potentially decrease the impact of neonatal prematurity • Bloating without increasing the risks associated with chorioamnioni- • Stretching, burning tis (ACOG, 1998). • Pain, tightness, soreness Expectant management of the mother diagnosed with • Increase or change in mucus/vaginal discharge PPROM frequently includes long-term hospitalization, bed • Fatigue rest, fetal surveillance, corticosteroid therapy, and other • Flu-like symptoms possible treatment modalities including antibiotic and to- • Difficulty walking colytic administration. Unfortunately, these treatment • Difficulty sleeping modalities are not without potential physiologic and psy- • “Just not feeling right” chosocial risks to the woman, her fetus/neonate, and her family. Additionally, the diagnosis of PPROM and its po- Reference: March of Dimes, 2002; Patterson, Douglas, Patterson, & Bradle,1992. tential risks may contribute to increased maternal stress levels. Women and their families experiencing PPROM of- may include maternal hydration, the short-term administra- ten find themselves in a family crisis when faced with the tion of tocolytic agents, corticosteroids and/or antimicrobial real concern of fetal demise. Maternal stress during preg- therapy, assembling of the obstetrical and neonatal teams, nancy has been shown to negatively effect maternal out- and preparation for impending delivery (Table 1). comes (ACOG, 1998). Therefore, clinical interventions that Uterine activity may be assessed by maternal self-report, help to decrease maternal stress may potentially improve palpation, and electronic fetal monitoring. Traditionally, maternal and/or neonatal outcomes. Nurses are optimally the early subjective signs and symptoms of preterm labor positioned to provide physiologic and psychosocial inter- requiring assessment have been identified as low backache, ventions that contribute to the well-being of the mother, changes in cervical mucous, pelvic pressure, and menstrual- her infant, and her family. like or intestinal cramping (Flynn, 1999). Weiss, Saks, & Harris (2002) list additional early symptoms that are sub- Eight Targeted Areas for Nursing tle, intermittent, and not always easily recognizable as preterm labor. These researchers identified maternal com- Assessment and Intervention plaints associated with preterm labor that included pains, Little or no nursing research is available on the care of the stomachache, bloating, soreness, stretching, burning, push- woman with PPROM who is expectantly managed. Al- ing, and difficulty walking. Furthermore, pains were de- though many aspects of nursing care are addressed in the scribed as sharp, ripping, pulling apart, and continuous literature under other antepartum complications such as (Weiss et al., 2002). In conjunction with the nurse’s assess- the side effects of bed rest or tocolytic management (Flynn, ment, mothers can be given a list of preterm labor signs 1999; Maloni, 1996), few of the studies are focused specifi- and symptoms for self-monitoring. cally on the mother with PPROM. Nursing research fo- Examinations to assess cervical status may be required cused on the care of the woman at risk for preterm birth based on maternal complaints or evidence of uterine activi- involves many of the same issues and interventions as that ty. Due to the risk of iatrogenic infection, sterile speculum of a woman experiencing PPROM. We propose that nurs- examinations and transvaginal ultrasound examinations for ing assessment and intervention focus on the following cervical length and funneling should be performed only as eight targeted areas. needed (Flynn, 1999). For women diagnosed with PPROM, serial digital and/or transvaginal ultrasound assessment of Preterm Labor cervical status may be contraindicated due to the risk of in- Because PPROM is the single most common diagnosis asso- fection. Therefore, certain providers may prohibit either ciated with preterm birth (Garite, 1999), frequent nursing type of examination whereas other providers may perform assessment for uterine activity and subjective signs and very limited examinations as clinically indicated. symptoms will assist in early identification of preterm labor (Figure 1). Early identification of a change in maternal status Side Effects of Tocolytic Therapy allows for reevaluation and modification of the plan of care Tocolytic agents, ordered prophylactically, have been focusing on more timely interventions. These modifications shown to prolong the latency period for approximately 24

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hours but have not demonstrated improved neonatal out- evaluation or intervention. Vintzileos et al. (1995) suggest comes (ACOG, 1998). Occasionally tocolytic agents are that the presence of fetal breathing is a good predictor of ordered to allow time for achieving therapeutic levels of lack of infection in the newborn, whereas absence does not other medications such as corticosteroids or antibiotics. necessarily indicate impending infection. However, the use of tocolytic agents has associated mater- Additional nursing management includes continuing as- nal risks such as pulmonary edema and respiratory depres- sessment for other signs and symptoms of infection such as sion; therefore, appropriate nursing assessment and inter- maternal fever, maternal tachycardia, uterine tenderness, vention for the mother receiving tocolytic therapy should and foul-smelling or purulent vaginal discharge. The moth- be followed (Table 1). (For more detailed information relat- er needs to be educated to observe the color, odor, and ed to tocolytic therapies see Flynn 1999, and Freda 2001. amount of vaginal discharge to perform perineal care, to perform uterine self-palpation for tenderness and the presence of contractions, and to moni- tor fetal movement counts (Flynn, 1999). The If the woman diagnosed with PPROM has no evidence mother should be told to communicate this self-assessment data to the nurse on a daily of infection, active labor, or fetal compromise, the basis or immediately if a change is noted. current standard of care is expectant management. Fetal Compromise PPROM increases the risk of fetal deformation syndrome to 20%-50% depending on Maternal/Fetal Infection gestational age at PPROM, length of latency, and degree of The incidence of clinically evident chorioamnionitis is oligohydramnios (Garite, 1999). Additionally, PPROM 13%-60% in mothers with PPROM; postpartum infection coupled with oligohydramnios has an associated risk of is 2%-13% (ACOG, 1998). Major neonatal infections oc- umbilical cord prolapse (1.5%) and cord compression cur in 5% of all cases of PPROM and in 15%-20% of (8.5%) (Garite, 1999). The initial assessment of a woman those where chorioamnionitis develops prior to delivery with PPROM should include continuous electronic fetal (Garite, 1999). In addition, Vermillion et al. (2000) demon- monitoring to rule out a nonreassuring FHR tracing that strated an increased frequency of clinical chorioamnionitis may be indicative of umbilical cord compression or pro- in women with severe oligohydramnios (amniotic fluid in- lapse. The presence of variable decelerations may indicate dex [AFI] Ͼ5). umbilical cord compression and late decelerations may be Intrauterine infection results in changes in fetal behavior, evidence of uteroplacental insufficiency (Garite). Ongoing thought to be due to the presence of increased levels of assessment for fetal well being should include fetal move- prostaglandins. Other data suggest that the infectious ment counts and electronic fetal monitoring. The mother process may cause increased placental vascular resistance should be instructed to perform daily fetal movement secondary to the vasoconstriction of the chorionic and um- counts and to notify the nurse of any decrease in fetal ac- bilical vessels. These changes may affect fetal oxygenation tivity. Daily electronic fetal monitoring is suggested to eval- and lead to fetal circulatory, heart rate, and behavior uate fetal well-being (Mercer, 2003). In the event of fetal changes that can be detected using the biophysical profile compromise, appropriate nursing interventions are needed (BPP) test that provides fetal heart rate (FHR) and ultra- (e.g., maternal repositioning, administering oxygen, and in- sound evaluation (Greig, 1998). Fetal tachycardia of Ն160 creasing hydration). If umbilical cord compression is sus- bpm may be the first indication of infection (Lewis et al., pected, obtaining an amniotic fluid index may be useful in 1999). Nonstress tests (NST) that are nonreactive have validating severe oligohydramnios. Amnioinfusion, the in- been associated with perinatal infection (ACOG, 1998). stillation of fluid into the amniotic sac to relieve cord com- The BPP assesses five biophysical variables of the fetus pression, may be indicated with a mother experiencing se- including breathing, gross movement, tone, amniotic fluid vere oligohydramnios. Often, an unresolved nonreassuring volume, and the NST (Manning, Platt, & Sipos, 1980). A FHR tracing leads to emergent delivery. BPP score of 8-10 is reassuring of fetal well-being; a score of 6 or less is considered equivocal or nonreassuring. Lewis Side Effects of Extended Bed Rest and colleagues (1999) propose daily NST for PPROM Hospitalization for bed rest and pelvic rest is widely used mothers of Ͼ28 weeks gestation and daily biophysical pro- as a medical intervention after a diagnosis of PPROM files for all gestations Յ28 weeks. Although fetal surveil- (ACOG, 1998). However, the risks of antepartum bed lance techniques are often used with fetuses Յ28 weeks rest/activity restriction have been reported often, and in- gestation, established reliability and validity of these tech- clude significant deleterious physical and psychosocial ef- niques with these fetuses has not been determined. Fetal fects (Moore & Freda, 1998). Maloni et al. (1993) com- tachycardia Ն160 bpm, nonreactive NST, a biophysical pared hospitalized pregnant women on bed rest with preg- profile score of Յ6, absence of fetal breathing in associa- nant women who did not require bed rest, and found that tion with a nonreactive NST, or an AFI of Ͻ5 may be early women on bed rest suffered from leg muscle atrophy, loss indicators of infection and, therefore, necessitate further of weight, stress from separation from family, hostility,

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anxiety, boredom, and depression. In addition, postpartum Educational Needs and Routine Prenatal Care recovery was prolonged, and the ability to resume activities Maternal and family education must include information of daily living was delayed as a result of bed rest during on PPROM, treatment options, and consequences (such as pregnancy. Nursing care of the woman with PPROM on preterm birth). The most significant outcome of preterm bed rest/activity restriction must include a comprehensive birth is prematurity of the neonate. A member of the initial and ongoing assessment for side effects of bed rest neonatal team should meet with the mother and her family and appropriate interventions (Maloni, 1996) (Table 1). to discuss expected neonatal prognoses and treatment Referral to ancillary healthcare teams such as clinical nutri- modalities based on gestational age. In addition, maternal tion, physical therapy, and social services may be helpful in education should include information on normal pregnan- alleviating some of these side effects. ACOG (2003) has cy, growth and development of the fetus, breastfeeding, la- now stated in a Practice Bulletin that “Although bed bor and delivery (both vaginal and cesarean birth), and rest...is commonly recommended to women with symp- customary postpartum care (Table 1). toms of preterm labor, the effectiveness is not known...and When a pregnant woman has been diagnosed and hospi- the potential harm (thrombosis from stasis in the lower ex- talized with a complication such as PPROM, there is a dan- tremities) or negative impacts (loss of employment) should ger that healthcare providers will focus their assessments not be underestimated” (p. 7). and interventions on the specific complication and its impact on the mother and her fetus, and neglect various com- Maternal Stress ponents of basic prenatal care. For the mother being expec- Mothers experiencing PPROM are clearly at risk for tantly managed, routine prenatal assessments, interventions, preterm birth not only because of the ruptured membranes and maternal education must be continued (Table 1). but also because of the association between maternal stress and preterm birth (Wadwha et al., 2001). Nursing Conclusion interventions, therefore, should be targeted to reduce ma- The focus of nursing care for the woman diagnosed with ternal stress. Major stressors identified by women hospi- PPROM is dependent on the assessed needs of the mother talized for complications during pregnancy include the di- and her family, maternal preference, and the medical treat- agnosis of a high-risk pregnancy, separation from family ment plan to either emergently deliver or expectantly man- and friends, concern over the fetus’ status, change in their age the mother. For the mother being expectantly managed, own health status, and a feeling of powerlessness (Table 1) the nurse must assess for preterm labor, side effects of to- (Hatmaker & Kemp, 1998). To reduce maternal stress af- colytic therapy, maternal/fetal infection, fetal compromise, ter diagnosis, a mother experiencing PPROM may require side effects of extended bed rest, maternal stress, education- frequent reassurance that her actions did not result in the al needs, and routine prenatal care. Nurses who view the early membrane rupture. Providing the mother ongoing in- mother diagnosed with PPROM holistically are optimally formation regarding her current condition, plan of care positioned to both define and implement therapeutic inter- and status of the fetus may lead to a reduction in her concern over her diagnosis, health status, and the status of her fetus. Engaging the mother in active involve- For the mother being expectantly managed, the nurse ment in daily decision making can help must assess for preterm labor, side effects of tocolytic decrease her feelings of powerlessness and result in stress reduction. Listening to the therapy, maternal/fetal infection, fetal compromise, side woman as she talks about her feelings effects of extended bed rest, maternal stress, educational and daily experiences is a valuable com- ponent of nursing care and may signifi- needs, and routine prenatal care. cantly contribute to the alleviation of concerns and stress. Other potential stressors for the mother with PPROM at bed rest include child- ventions that contribute to the well-being of the woman, care issues, financial and employment concerns, and part- her fetus/neonate, and her family. ✜ ner/family difficulties (Table 1) (Maloni, Brezinski-Tomasi, & Johnson, 2001; Moore & Freda, 1998). In addition, Acknowledgments the mother’s partner may be experiencing increased stress This article was funded by the University Research Founda- secondary to additional responsibilities created by the tion, the University of Pennsylvania Center for Nursing Out- mother’s hospitalization and/or activity restriction. The comes Research, Sigma Theta Tau, Xi Chapter. nurse can advocate for the mother and assist the partner in managing multiple roles by encouraging the expression Marilyn Stringer is an Associate Professor, Clinician Educa- of feelings, helping in the development of positive coping tor, School of Nursing, University of Pennsylvania, Philadel- mechanisms, providing support and accurate information, phia. She can be reached at [email protected]. and providing referrals to resource people and agencies as Susan R. Miesnik is a Perinatal Nurse Practitioner, Chil- needed (Maloni, 1993). dren’s Hospital of Philadelphia, PA.

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Linda Brown is the Stirl Professor in Nutrition, School Maloni, J. A. (1993). Bed rest during pregnancy: Implications for nursing. Journal of Obstetric, Gynecologic and Neonatal Nursing, 22(5), 422- of Nursing, University of Pennsylvania, Philadelphia. 426. Allison H. Martz is a Division Officer, OB/GYN Clinic Maloni, J. A. (1996) Bed rest and high-risk pregnancy. Nursing Clinics of Naval Hospital, Camp Lejeune. North America, 31(2), 313-325. Maloni, J., Brezinski-Tomasi, J., & Johnson, L. (2001). Antepartum bed George Macones is a Director, Maternal Fetal Medicine rest. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 30(2), University of Pennsylvania Medical Center, Philadelphia, PA. 165-173. Maloni, J., Chance, B., Zhang, C., Cohen, A., Betts, D., & Gange, S. References (1993). Physical & psychosocial side effects of antepartum bed rest. American College of Obstetricians and Gynecologists (ACOG). (1998). Nursing Research, 42(4),197-203. ACOG practice bulletin: Premature rupture of membranes, 1. Wash- Manning, F., Platt, L., & Sipos, L. (1980). Antepartum fetal evaluation: De- ington, DC: Author. velopment of a fetal biophysical profile. American Journal of Obstet- American College of Obstetricians and Gynecologists (ACOG). (2003). rics and Gynecology, 136, 787-795. ACOG practice bulletin: Management of preterm labor, 43. Washing- Mead, P. (1980). Management of the mother with premature rupture of ton DC: Author. the membranes. Clinics in Perinatology, 7(2), 243-255. Flynn, K. (1999). Preterm labor & preterm premature rupture of mem- Mercer, B. (2003). Preterm premature rupture of the membranes. Obstet- branes. In L. Mandeville & N. Troiano (Eds.), High-Risk & Critical Care rics & Gynecology, 101(1), 178-193. Intrapartum Nursing, (pp. 102-122). Philadelphia, PA: Lippincott. Moore, M. L., & Freda, M. (1998). Reducing preterm & low birthweight Freda, M. C. (2001). High-risk pregnancy. In K. Simpson & P. Creehan births: Still a nursing challenge. MCN, The American Journal of Ma- (Eds.), Perinatal Nursing (pp. 207-219). Philadelphia, PA: Lippincott. ternal/Child Nursing, 23, 200-208. Garite, T. (1999). Premature rupture of the membranes. In R. Creasy & R. National Center for Health Statistics. (2002). Health, United States 2001. Resnik (Eds.), Maternal-Fetal Medicine (pp. 644-658). Philadelphia, PA: Hyattsville, MD: Department of Health and Human Services. WB Saunders. Patterson, E., Douglas, A., Patterson, P., & Bradle, J. (1992). Symptoms Greig, P. C. (1998). The diagnosis of intrauterine infection in women with of preterm labor and self diagnostic confusion. Nursing Research, PPROM. Clinical Obstetrics & Gynecology, 41, 849-863. 41(6), 367-372. Hatmaker, D., & Kemp, V. (1998). Perception of threat/subjective well-be- Vermillion, S., Kooba, A., & Soper, D. E. (2000). Amniotic fluid index val- ing in low & highrisk pregnant women. Journal of Perinatal &Neona- ues after preterm premature rupture of the membranes and subse- tal Nursing, 12, 1-10. quent perinatal infection. American Journal of Obstetrics and Gyne- Iams, J. (2002a). Preterm birth. In S. Gabbe, J. Niebyl, & J. Simpson cology, 183(2), 271-276. (Eds.), Obstetrics: Normal & Problem Pregnancies (pp. 743-820). Vintzileos, A. M., & Knuppel, R. A. (1995). Fetal biophysical assessment Philadelphia, PA: Churchill. in PROM. Clinical Obstetrics & Gynecology, 38(1), 45-58. Iams, J. (2002b). Preterm Birth. In S. Gabbe, J. Niebyl, & J. Simpson Wadwha, P. D., Culhane, J. F., Rauh, V., Barve, S. S., Hogan, V., Sand- (Eds.), Obstetrics: Normal & Problem Pregnancies (pp. 755-825). New man, V. A., et al. (2001). Stress, infection and preterm birth: A biobe- York, NY: Churchill Livingstone. havioral perspective. Pediatric and Perinatal Epidemiology, Lewis, D., Adain, C., Weeks, J., Barrilleaux, P., Edwards, M., & Garite, T. 15(S2),17-29. (1999). RCT of daily nonstress testing versus biophysical profile in Weiss, M. E., Saks, N. P., & Harris, S. (2002). Resolving the uncertainty of management of PPROM. American Journal of Obstetrics & Gynecolo- preterm symptoms: Women’s experiences with the onset of preterm gy, 181(6), 1495-1499. labor. Journal of Obstetric, Gynecologic and Neonatal Nursing, McCartney, P. (2002). Sterile speculum exams, nitrazine & ferning. MCN, 31(1), 66-76. The American Journal of Maternal Child Nursing, 27(2), 117. Weitz, B. (2001). Premature rupture of the fetal membranes: Update for March of Dimes. (2002). Health Library. Retrieved December 1, 2003, advance practice nurses. MCN, The American Journal of from http://www.marchofdimes.com/healthlibrary. Maternal/Child Nursing, 26(2), 86-92. March of Dimes Web site for Perinatal Nurses he March of Dimes has The site features three main areas: • About Nursing Education, which presents an overview of the launched an educational March of Dimes program for nurses TWeb site for perinatal nurses • Online Modules, which includes "Understanding the Behavior of Term Infants" at www.marchofdimes.com/nursing. • Modules in Print, which describes the organization's continu- The site includes the organization's ing education print products

first online nursing education module The March of Dimes has provided continuing education to peri- "Understanding the Behavior of Term natal nurses for 30 years. It publishes 29 continuing education modules for registered nurses and certified nurse midwives. The Infants" by Susan Blackburn and modules offer from 2.4 to 9.84 contact hours for nurses and Susan Bakewell-Sachs. from .2 to .5 CEUs for CNMS.

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