Nursing Care of the Patient With

ABSTRACT

Preterm premature rupture of the

membranes (PPROM) is diagnosed

when rupture of the amniotic mem-

branes occurs prior to the completion

of the 36th week of gestation. PPROM

accounts for 25% of all cases of pre-

mature rupture of the membranes

and is responsible for 30%-40% of

all preterm deliveries. In mothers di-

agnosed with PPROM without evi-

dence of infection, active labor, or fe-

tal 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 po-

tentially decreasing the effects of pre-

maturity. Expectant management

consists of ongoing observation for

signs and symptoms of infection, ac-

tive labor, and/or nonreassuring fetal

status. This article provides clinical

nursing guidelines for the mother di-

agnosed with PPROM who is man-

aged expectantly. Eight targeted areas

for nursing assessment and interven-

tion are described: preterm labor,

side effects of tocolytic therapy, ma-

ternal/fetal infection, fetal compro-

mise, side effects of extended bed

rest, maternal stress, educational

needs, and routine prenatal care.

Key Words: Preterm premature rup-

ture of membranes; Nursing care;

Bed rest; High-risk pregnancy.

The purpose of this article is to provide an overview of the management ofPPROM (preterm premature rupture of the membranes), and to synthesizethe available evidence and provide clinical nursing guidelines for the care of

the mother diagnosed with PPROM. Eight targeted areas for nursing assessmentand intervention will be described: preterm labor, side effects of tocolytic therapy,maternal/fetal infection, fetal compromise, side effects of extended bed rest, ma-ternal stress, educational needs, and routine prenatal 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.Preterm labor (�37 weeks gestation) accounts for 11.9% of births in the UnitedStates (National Center for Health Statistics, 2002). While the causes of preterm

Nursing Care of the Patient With

144 VOLUME 29 | NUMBER 3 May/June 2004

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May/June 2004 MCN 145

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 ofmembranes (membrane rupture before 37 weeks gestation)occurs in approximately 3% of all pregnancies, and 25%of all cases of premature rupture of the membranes, and isthought to be responsible for about one-third of all pretermbirths (Mercer, 2003). Although the etiology is frequentlyobscure, the occurrence of PPROM may be associated witha preexisting infectious process or a physiologic abnormali-ty such as incompetent cervix or polyhydramnios thatweakens the membrane making it susceptible to rupture(Garite, 1999). Regardless of etiology, PPROM has a signif-icant impact on maternal and neonatal morbidity and mor-tality. Complications such as chorioamnionitis, pretermbirth, fetal stress associated with cord compression or pro-lapse, and fetal deformation syndrome, may all have delete-rious effects on outcomes (Garite).

Although a significant amount of outcome research hasbeen conducted to evaluate clinical interventions forPPROM such as hospitalization, bed rest, amnioinfusion,and administration of tocolytics, antibiotics, and corticos-teroids, debate regarding medical management remains(Garite, 1999). For mothers with PPROM who are not inlabor, and without evidence of fetal compromise orchorioamnionitis, interventions such as the use of tocolyt-ics and antibiotics still remain controversial (Garite). Al-though there is not consensus about medical managementregimens, there is agreement among providers concerningthe focus of that management: reducing the risk of mater-nal and neonatal morbidity and mortality.

Initial AssessmentTypically, when a woman whose gestation is �37 weekspresents with the complaint of a gush of fluid from thevagina, PPROM is suspected and a definitive diagnosis isneeded. A complete health history is indicated to assess forrisk factors such as gestational age, multiple gestation, pre-vious preterm labor/delivery, sexually transmitted diseases,and signs and symptoms of infection. The performance ofa sterile speculum exam is critical to establish a definitivediagnosis. Speculum exam assessment includes observationfor pooling of amniotic fluid in the posterior fornix and amother-elicited Valsalva maneuver to allow for observationof gross leaking from the cervical os. Next, nitrazine papertesting of vaginal fluid for alkaline pH (a change from yel-

low to blue in the absence of blood) is considered a posi-tive test for amniotic fluid. A microscopic examination ofvaginal fluid for the presence of ferning is also considereda positive test for amniotic fluid (Iams, 2002a; McCartney,2002). Lastly, confirmation of oligohydramnios on ultra-sound can be helpful in determining a definitive diagnosis(Garite, 1999). Additional assessments should include ma-ternal vital signs, fetal status, and uterine activity.

Depending on state and local practice regulations, dif-ferent providers such as a nurse, physician, or physicianassistant may perform various levels of this assessment. Af-ter a definitive diagnosis is established, the two most im-portant issues for determining clinical management are ac-curate dating of the pregnancy and the presence/absence ofchorioamnionitis. In the mother whose gestation is ,37weeks, immediate delivery is reserved for cases of ad-vanced labor, infection, and irreversible nonreassuring fetalheart tracing (Mercer, 2003).

In the presence of active labor, unrelieved nonreassuringfetal heart tracing, or chorioamnionitis, an emergent deliv-ery plan may be vital. Nursing care should include ongo-ing assessment of maternal and fetal status, preparationfor delivery including notification of neonatal personnel,maternal education, and mother/family support through-out labor and during the birth. Additional emotional sup-port and education may be necessary during the postpar-tum period if the mother experiences further morbidity orif the neonate has significant medical morbidity.

Expectant Medical ManagementIn 1980, Mead established expectant management as thestandard of care for PPROM when there was no evidenceof infection, labor, or fetal compromise. The goal of expec-tant management is the prolongation of the pregnancy toincrease gestational age, thereby potentially decreasing theeffects of prematurity. Expectant management consists ofongoing observation for signs and symptoms of infection,active labor, and/or fetal compromise (ACOG, 1998). Thelength of time from rupture of membranes until delivery ofthe neonate is known as the latency period. Previously,clinicians believed that the earlier in gestation a womansustained ruptured membranes and the longer the latencyperiod, the more likely she was to develop an infection,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:See Figure 1Objective:Uterine activity; cervical statusVaginal discharge

Report abnormal findingsHydration, oral/intravenousMedications, as indicated • Tocolytics/antimicrobial• Corticosteroids

Tocolytic therapyside effects

Subjective*:Headache (1,2,3,4); vomiting (1,2,3,4); nausea (1,2,3); chestpain (1,2); diarrhea (1); anxiety (1); palpitations (1); jitteriness(1); itching (1); shortness of breath (1); constipation (2);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); tempera-ture (1); blood assays (1); respiratory rate (2); reflexes (2)Objective (fetal)*:ductus arteriousus (3); heart rate (1,2); amniotic fluid index (3)

Report abnormal findingsDecrease or discontinue drugAdminister calcium gluconate for magnesium sulfate toxicity

Maternal/fetalinfection

Subjective:Malaise, flulike symptoms, abdominal pain, foul-smelling discharge, fetal movementObjective:Temperature, pulse, uterine tenderness, vaginal discharge,fetal well-being

Report abnormal findingsMedications as indicated

Fetal compromise

Subjective:Decreased fetal movement Objective:Fetal well-being

Maternal repositioningAdminister oxygenIncrease hydrationReport abnormal findings

Side effects ofextended bedrest

Subjective:Headache, indigestion, gastric reflux, constipation, hip/backsoreness, leg pain, sleep/wake cycles, boredom, depression,anxiety, mood swings, Objective:Homan’s sign, localized skin warmth and/or redness, weightgain/loss, muscle strength, edema

Antiembolic devicesAntacids, stool softenersEncourage increased hydration and fiber contentReferrals:Nutrition support, physical and occupational therapy,social service, pastoral care, community resourcesActive listening Encourage maternal verbalization Private, flexible visitationStructure daily activitiesDiversionary activities, i.e., books, crafts, educationaland entertainment videosBedrest support informationOnline support groupsReference material

Maternal stress Feeling of powerlessnessChildcare issues, financial and employment concerns

Reassurance concerning maternal/fetal condition andcare planJoint decision-making Involvement in self-care, i.e., uterine palpation, fetalactivity monitoring, self-medication administrationRelaxation exercisesOpen ended questionsSupport groups, social service, etc. referrals

Educationalneeds

Care of premature infantPregnancy health teaching

Neonatal consults; NICU tour, fetal development, labor,normal pregnancy, birth, lactation, postpartum care

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


Garite has suggested that the risk of infection may correlatemore closely with the timing of the first digital examinationthan the length of latency period. In PPROM, the incidenceof chorioamnionitis and perinatal infections is not changedwith increasing latency (Garite). The association ofPPROM and escalated fetal lung maturity is controversial.Iams (2002b) suggests that confounding variables such assex of the fetus, PPROM onset, length of latency period,and wide gestational age range at delivery lead to difficultyin establishing the association of PPROM and fetal lungmaturity. ACOG suggests that expectant management canpotentially decrease the impact of neonatal prematuritywithout increasing the risks associated with chorioamnioni-tis (ACOG, 1998).

Expectant management of the mother diagnosed withPPROM frequently includes long-term hospitalization, bedrest, fetal surveillance, corticosteroid therapy, and otherpossible treatment modalities including antibiotic and to-colytic administration. Unfortunately, these treatmentmodalities are not without potential physiologic and psy-chosocial risks to the woman, her fetus/neonate, and herfamily. Additionally, the diagnosis of PPROM and its po-tential risks may contribute to increased maternal stresslevels. Women and their families experiencing PPROM of-ten find themselves in a family crisis when faced with thereal concern of fetal demise. Maternal stress during preg-nancy has been shown to negatively effect maternal out-comes (ACOG, 1998). Therefore, clinical interventions thathelp to decrease maternal stress may potentially improvematernal and/or neonatal outcomes. Nurses are optimallypositioned to provide physiologic and psychosocial inter-ventions that contribute to the well-being of the mother,her infant, and her family.

Eight Targeted Areas for Nursing Assessment and InterventionLittle or no nursing research is available on the care of thewoman with PPROM who is expectantly managed. Al-though many aspects of nursing care are addressed in theliterature under other antepartum complications such asthe side effects of bed rest or tocolytic management (Flynn,1999; Maloni, 1996), few of the studies are focused specifi-cally on the mother with PPROM. Nursing research fo-cused on the care of the woman at risk for preterm birthinvolves many of the same issues and interventions as thatof a woman experiencing PPROM. We propose that nurs-ing assessment and intervention focus on the followingeight targeted areas.

Preterm Labor

Because PPROM is the single most common diagnosis asso-ciated with preterm birth (Garite, 1999), frequent nursingassessment for uterine activity and subjective signs andsymptoms will assist in early identification of preterm labor(Figure 1). Early identification of a change in maternal statusallows for reevaluation and modification of the plan of carefocusing on more timely interventions. These modifications

may include maternal hydration, the short-term administra-tion of tocolytic agents, corticosteroids and/or antimicrobialtherapy, assembling of the obstetrical and neonatal teams,and preparation for impending delivery (Table 1).

Uterine activity may be assessed by maternal self-report,palpation, and electronic fetal monitoring. Traditionally,the early subjective signs and symptoms of preterm laborrequiring assessment have been identified as low backache,changes in cervical mucous, pelvic pressure, and menstrual-like or intestinal cramping (Flynn, 1999). Weiss, Saks, &Harris (2002) list additional early symptoms that are sub-tle, intermittent, and not always easily recognizable aspreterm labor. These researchers identified maternal com-plaints associated with preterm labor that included pains,stomachache, bloating, soreness, stretching, burning, push-ing, and difficulty walking. Furthermore, pains were de-scribed as sharp, ripping, pulling apart, and continuous(Weiss et al., 2002). In conjunction with the nurse’s assess-ment, mothers can be given a list of preterm labor signsand symptoms for self-monitoring.

Examinations to assess cervical status may be requiredbased on maternal complaints or evidence of uterine activi-ty. Due to the risk of iatrogenic infection, sterile speculumexaminations and transvaginal ultrasound examinations forcervical length and funneling should be performed only asneeded (Flynn, 1999). For women diagnosed with PPROM,serial digital and/or transvaginal ultrasound assessment ofcervical status may be contraindicated due to the risk of in-fection. Therefore, certain providers may prohibit eithertype of examination whereas other providers may performvery limited examinations as clinically indicated.

Side Effects of Tocolytic Therapy

Tocolytic agents, ordered prophylactically, have beenshown to prolong the latency period for approximately 24


Figure 1.Common signs and symptoms of preterm labor.

• Uterine cramping (menstrual-like cramp, constant orcomes and goes)

• Uterine contractions every 10 minutes or more often(may be painless)

• Low dull backache (constant or comes and goes)• Pelvic pressure, pushing (feels like the baby is pushing

down)• Abdominal cramping, stomachache, gastrointestinal

disturbances (with or without diarrhea)• Bloating• Stretching, burning• Pain, tightness, soreness• Increase or change in mucus/vaginal discharge• Fatigue• Flu-like symptoms• Difficulty walking• Difficulty sleeping• “Just not feeling right”

Reference: March of Dimes, 2002; Patterson, Douglas, Patterson, & Bradle,1992.


hours but have not demonstrated improved neonatal out-comes (ACOG, 1998). Occasionally tocolytic agents areordered to allow time for achieving therapeutic levels ofother medications such as corticosteroids or antibiotics.However, the use of tocolytic agents has associated mater-nal risks such as pulmonary edema and respiratory depres-sion; therefore, appropriate nursing assessment and inter-vention for the mother receiving tocolytic therapy shouldbe followed (Table 1). (For more detailed information relat-ed to tocolytic therapies see Flynn 1999, and Freda 2001.

Maternal/Fetal Infection

The incidence of clinically evident chorioamnionitis is13%-60% in mothers with PPROM; postpartum infectionis 2%-13% (ACOG, 1998). Major neonatal infections oc-cur in 5% of all cases of PPROM and in 15%-20% ofthose where chorioamnionitis develops prior to delivery(Garite, 1999). In addition, Vermillion et al. (2000) demon-strated an increased frequency of clinical chorioamnionitisin women with severe oligohydramnios (amniotic fluid in-dex [AFI] �5).

Intrauterine infection results in changes in fetal behavior,thought to be due to the presence of increased levels ofprostaglandins. Other data suggest that the infectiousprocess may cause increased placental vascular resistancesecondary to the vasoconstriction of the chorionic and um-bilical vessels. These changes may affect fetal oxygenationand lead to fetal circulatory, heart rate, and behaviorchanges that can be detected using the biophysical profile(BPP) test that provides fetal heart rate (FHR) and ultra-sound evaluation (Greig, 1998). Fetal tachycardia of �160bpm may be the first indication of infection (Lewis et al.,1999). Nonstress tests (NST) that are nonreactive havebeen associated with perinatal infection (ACOG, 1998).

The BPP assesses five biophysical variables of the fetusincluding breathing, gross movement, tone, amniotic fluidvolume, and the NST (Manning, Platt, & Sipos, 1980). ABPP score of 8-10 is reassuring of fetal well-being; a scoreof 6 or less is considered equivocal or nonreassuring. Lewisand colleagues (1999) propose daily NST for PPROMmothers of �28 weeks gestation and daily biophysical pro-files for all gestations �28 weeks. Although fetal surveil-lance techniques are often used with fetuses �28 weeksgestation, established reliability and validity of these tech-niques with these fetuses has not been determined. Fetaltachycardia �160 bpm, nonreactive NST, a biophysicalprofile score of �6, absence of fetal breathing in associa-tion with a nonreactive NST, or an AFI of �5 may be earlyindicators of infection and, therefore, necessitate further

evaluation or intervention. Vintzileos et al. (1995) suggestthat the presence of fetal breathing is a good predictor oflack of infection in the newborn, whereas absence does notnecessarily indicate impending infection.

Additional nursing management includes continuing as-sessment for other signs and symptoms of infection such asmaternal fever, maternal tachycardia, uterine tenderness,and foul-smelling or purulent vaginal discharge. The moth-er needs to be educated to observe the color, odor, andamount of vaginal discharge to perform perineal care, to

perform uterine self-palpation for tendernessand the presence of contractions, and to moni-tor fetal movement counts (Flynn, 1999). Themother should be told to communicate thisself-assessment data to the nurse on a dailybasis or immediately if a change is noted.

Fetal Compromise

PPROM increases the risk of fetal deforma-tion syndrome to 20%-50% depending on

gestational age at PPROM, length of latency, and degree ofoligohydramnios (Garite, 1999). Additionally, PPROMcoupled with oligohydramnios has an associated risk ofumbilical cord prolapse (1.5%) and cord compression(8.5%) (Garite, 1999). The initial assessment of a womanwith PPROM should include continuous electronic fetalmonitoring to rule out a nonreassuring FHR tracing thatmay be indicative of umbilical cord compression or pro-lapse. The presence of variable decelerations may indicateumbilical cord compression and late decelerations may beevidence of uteroplacental insufficiency (Garite). Ongoingassessment for fetal well being should include fetal move-ment counts and electronic fetal monitoring. The mothershould be instructed to perform daily fetal movementcounts and to notify the nurse of any decrease in fetal ac-tivity. Daily electronic fetal monitoring is suggested to eval-uate fetal well-being (Mercer, 2003). In the event of fetalcompromise, appropriate nursing interventions are needed(e.g., maternal repositioning, administering oxygen, and in-creasing hydration). If umbilical cord compression is sus-pected, obtaining an amniotic fluid index may be useful invalidating severe oligohydramnios. Amnioinfusion, the in-stillation of fluid into the amniotic sac to relieve cord com-pression, may be indicated with a mother experiencing se-vere oligohydramnios. Often, an unresolved nonreassuringFHR tracing leads to emergent delivery.

Side Effects of Extended Bed Rest

Hospitalization for bed rest and pelvic rest is widely usedas a medical intervention after a diagnosis of PPROM(ACOG, 1998). However, the risks of antepartum bedrest/activity restriction have been reported often, and in-clude significant deleterious physical and psychosocial ef-fects (Moore & Freda, 1998). Maloni et al. (1993) com-pared hospitalized pregnant women on bed rest with preg-nant women who did not require bed rest, and found thatwomen on bed rest suffered from leg muscle atrophy, lossof weight, stress from separation from family, hostility,


If the woman diagnosed with PPROM has no evidenceof infection, active labor, or fetal compromise, the current standard of care is expectant management.


anxiety, boredom, and depression. In addition, postpartumrecovery was prolonged, and the ability to resume activitiesof daily living was delayed as a result of bed rest duringpregnancy. Nursing care of the woman with PPROM onbed rest/activity restriction must include a comprehensiveinitial and ongoing assessment for side effects of bed restand appropriate interventions (Maloni, 1996) (Table 1).Referral to ancillary healthcare teams such as clinical nutri-tion, physical therapy, and social services may be helpful inalleviating some of these side effects. ACOG (2003) hasnow stated in a Practice Bulletin that “Although bedrest...is commonly recommended to women with symp-toms of preterm labor, the effectiveness is not known...andthe potential harm (thrombosis from stasis in the lower ex-tremities) or negative impacts (loss of employment) shouldnot be underestimated” (p. 7).

Maternal Stress

Mothers experiencing PPROM are clearly at risk forpreterm birth not only because of the ruptured membranesbut also because of the association between maternalstress and preterm birth (Wadwha et al., 2001). Nursinginterventions, therefore, should be targeted to reduce ma-ternal stress. Major stressors identified by women hospi-talized for complications during pregnancy include the di-agnosis of a high-risk pregnancy, separation from familyand friends, concern over the fetus’ status, change in theirown health status, and a feeling of powerlessness (Table 1)(Hatmaker & Kemp, 1998). To reduce maternal stress af-ter diagnosis, a mother experiencing PPROM may requirefrequent reassurance that her actions did not result in theearly membrane rupture. Providing the mother ongoing in-formation regarding her current condition, plan of careand status of the fetus may lead to a re-duction in her concern over her diagnosis,health status, and the status of her fetus.Engaging the mother in active involve-ment in daily decision making can helpdecrease her feelings of powerlessness andresult in stress reduction. Listening to thewoman as she talks about her feelingsand daily experiences is a valuable com-ponent of nursing care and may signifi-cantly contribute to the alleviation ofconcerns and stress. Other potential stres-sors for the mother with PPROM at bed rest include child-care issues, financial and employment concerns, and part-ner/family difficulties (Table 1) (Maloni, Brezinski-Tomasi,& Johnson, 2001; Moore & Freda, 1998). In addition,the mother’s partner may be experiencing increased stresssecondary to additional responsibilities created by themother’s hospitalization and/or activity restriction. Thenurse can advocate for the mother and assist the partnerin managing multiple roles by encouraging the expressionof feelings, helping in the development of positive copingmechanisms, providing support and accurate information,and providing referrals to resource people and agencies asneeded (Maloni, 1993).

Educational Needs and Routine Prenatal Care

Maternal and family education must include informationon PPROM, treatment options, and consequences (such aspreterm birth). The most significant outcome of pretermbirth is prematurity of the neonate. A member of theneonatal team should meet with the mother and her familyto discuss expected neonatal prognoses and treatmentmodalities based on gestational age. In addition, maternaleducation should include information on normal pregnan-cy, growth and development of the fetus, breastfeeding, la-bor and delivery (both vaginal and cesarean birth), andcustomary postpartum care (Table 1).

When a pregnant woman has been diagnosed and hospi-talized with a complication such as PPROM, there is a dan-ger that healthcare providers will focus their assessmentsand interventions on the specific complication and its im-pact on the mother and her fetus, and neglect various com-ponents of basic prenatal care. For the mother being expec-tantly managed, routine prenatal assessments, interventions,and maternal education must be continued (Table 1).

ConclusionThe focus of nursing care for the woman diagnosed withPPROM is dependent on the assessed needs of the motherand her family, maternal preference, and the medical treat-ment plan to either emergently deliver or expectantly man-age the mother. For the mother being expectantly managed,the nurse must assess for preterm labor, side effects of to-colytic therapy, maternal/fetal infection, fetal compromise,side effects of extended bed rest, maternal stress, education-al needs, and routine prenatal care. Nurses who view themother diagnosed with PPROM holistically are optimallypositioned to both define and implement therapeutic inter-

ventions that contribute to the well-being of the woman,her fetus/neonate, and her family. ✜

Acknowledgments

This article was funded by the University Research Founda-tion, the University of Pennsylvania Center for Nursing Out-comes Research, Sigma Theta Tau, Xi Chapter.

Marilyn Stringer is an Associate Professor, Clinician Educa-tor, School of Nursing, University of Pennsylvania, Philadel-phia. She can be reached at [email protected].

Susan R. Miesnik is a Perinatal Nurse Practitioner, Chil-dren’s Hospital of Philadelphia, PA.


For the mother being expectantly managed, the nurse must assess for preterm labor, side effects of tocolytic therapy, maternal/fetal infection, fetal compromise, side effects of extended bed rest, maternal stress, educationalneeds, and routine prenatal care.


Linda Brown is the Stirl Professor in Nutrition, Schoolof Nursing, University of Pennsylvania, Philadelphia.

Allison H. Martz is a Division Officer, OB/GYN ClinicNaval Hospital, Camp Lejeune.

George Macones is a Director, Maternal Fetal MedicineUniversity of Pennsylvania Medical Center, Philadelphia, PA.

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The March of Dimes has

launched an educational

Web site for perinatal nurses

at www.marchofdimes.com/nursing.

The site includes the organization's

first online nursing education module

"Understanding the Behavior of Term

Infants" by Susan Blackburn and

Susan Bakewell-Sachs.

Web site for Perinatal Nurses

March of Dimes

TThhee ssiittee ffeeaattuurreess tthhrreeee mmaaiinn aarreeaass::• About Nursing Education, which presents an overview of the

March of Dimes program for nurses• Online Modules, which includes "Understanding the Behavior

of Term Infants"• Modules in Print, which describes the organization's continu-

ing education print products

The March of Dimes has provided continuing education to peri-natal nurses for 30 years. It publishes 29 continuing educationmodules for registered nurses and certified nurse midwives. Themodules offer from 2.4 to 9.84 contact hours for nurses andfrom .2 to .5 CEUs for CNMS.


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