ABSTRACTThe purpose of this article is to helpnurses understand how to quickly andeffectively manage the nursing care ofpatients with perinatal hemorrhage. Theetiology, symptoms, medical management,and nursing care of the patient experiencing aperinatal hemorrhage are discussed.

Hemorrhage during the antepartum, intrapartum, or post-partum period is a life-threatening emergency for the motherand/or fetus. Early antepartum hemorrhage (before 20 weeksgestation) can be related to abortion/miscarriage, ectopic preg-nancy, or gestational trophoblastic disease; late antepartumhemorrhage (after 20 weeks gestation) may result from placen-tal abruption and placenta previa. Intrapartum hemorrhage ismost commonly due to placental abruption, or to uterine rup-ture, uterine inversion, invasive conditions of the placenta, orcomplications of Cesarean birth. Postpartum hemorrhage isdefined as blood loss greater than 500 ml in a vaginal deliveryor 1000 ml in a Cesarean birth; early postpartum hemorrhageoccurs during the first 24 hours after delivery; late postpartumhemorrhage occurs after the first 24 hours after delivery. Themost common cause of postpartum hemorrhage is uterineatony; however, lacerations, hematomas, and subinvolution ofthe uterus can also cause postpartum hemorrhage. Nurseswho understand how to assess, plan, intervene, and evaluateoutcomes for perinatal hemorrhage are in the position to pre-vent the major tragedies that can accompany hemorrhage inpregnancy and shortly afterward.

Key Words: Hemorrhage; Labor complications; Pregnancycomplications; Puerperal disorders.

It is 7:25 A.M. on a busy moth-er/baby unit. You have just fin-ished collecting the report about

Mrs. Davis, a 25-year-old gravida 6,para 5015, who delivered at 2:34 A.M.

The night nurse’s report indicates an un-eventful postpartum course thus far. You

are about to begin your rounds when the emer-gency light in Mrs. Davis’ room goes on. As you walk

in the door, she screams, “I’m bleeding!” You see hergown, chux , and bedding saturated with blood.

Responding quickly to situations such as this is a neces-sary skill for the perinatal nurse. Management of hemor-rhage during the antepartum, intrapartum, and postpartumperiods is a complex process involving keen assessment andtimely intervention. This article presents a brief summaryof the etiology, symptoms, and medical and nursing man-agement of perinatal hemorrhage (Table 1).

Antepartum HemorrhageHemorrhage in the antepartum period can occur early (first20 weeks) or late (after 20 weeks) in gestation. Etiology ofhemorrhage during the first 20 weeks of pregnancy in-cludes elective, induced, or spontaneous abortion (threat-ened, incomplete, complete), ectopic pregnancy, and Gesta-tional Trophoblastic Disease (GTD), cervical polyps, cer-vicitis, or cervical cancer (Claydon & Pernoll, 2003;Gilbert & Harmon, 2003).

Early Pregnancy

In early pregnancy, in the case of threatened abortion, ex-pectant management of hemorrhage is employed if fetal

46 VOLUME 30 | NUMBER 1 January/February 2005

Nancy J. MacMullen, PhD, APN/cCNS, Laura A. Dulski, MSN, APN/cCNS, and Barbara Meagher, MSN, RN, CNM, PNNP, RDMS

cardiac activity is detected; evacuation of the uterus will beperformed for incomplete abortions (Yashar, 1998). If hem-orrhage is caused by an ectopic pregnancy, surgical orpharmaceutical management (Methotrexate, IM) is em-ployed, depending on the patient’s desires and the locationof the ectopic (Genovese, 2004). Patients with GTD musthave the trophoblastic tissue evacuated and have Beta hCGlevels measured frequently to assure that there is no occur-rence of choriocarcinoma (Dyne, 2004; Nimrod & Oppen-heimer, 1999). Cervical polyps, cervicitis, or cervical cancertreatment is specific to the type of lesion identified (Clay-don & Pernoll, 2003).

Late Pregnancy

In late pregnancy bleeding is generally caused by either pla-cental abruption or placenta previa. Placental abruption isthe premature separation of a normally implanted placenta(Heppard & Garite, 2002), and is classified as mild (Grade1, 10% detached), moderate (Grade 2, 20-50% detached),or severe (Grade 3, �50% detached). The amount ofblood loss is proportional to the grade of abruption, as isthe severity of the abdominal pain (Genovese, 2004). Pla-centa previa, abnormal implantation of the placenta eithercompletely or partially covering the cervical os, is classifiedas low lying, marginal, partial, or total, depending uponhow much of the internal os is covered (Miller, 2002).

A rare cause of painless late-antepartum hemorrhage is

vasa previa. Vasa previa is the velamentous insertion ofumbilical vessels that cross in front of the fetal presentingpart (Heppard & Garite, 2002).

Management of hemorrhage after 20 weeks of gestationdepends upon several factors: the etiology, the severity ofthe bleeding, fetal gestational age, and whether the patientis in labor. Patients with significant blood loss are preparedfor emergency Cesarean birth regardless of gestational age.Minor bleeding episodes can be managed with bed rest in aside-lying position and fetal surveillance (Heppard &Garite, 2002).

Intrapartum HemorrhageHemorrhage during labor is most commonly caused byplacental abruption (Cunningham et al., 2001); however,other complications such as undiagnosed placenta previa,uterine rupture, uterine inversion, invasive placentas (acre-ta, increta, percreta), and hemorrhage during operative de-livery can cause bleeding (Gilbert & Harmon, 2003). Pa-tients experiencing these intrapartum complications areprepared for emergency surgery (Cesarean birth or hys-terectomy), while being stabilized with volume resuscita-tion, medication, and oxygen, if necessary. Once the uterusis empty, uterotonic drugs are given, if indicated (Kramer& Weiner, 2000) (Table 2).

While Cesarean births occur frequently, and are at timeseven encouraged as elective primary modes of giving birth

January/February 2005 MCN 47

(Minkoff & Chervenak, 2003), it is essential that nurses re-member that hemorrhage can occur at the time of Cesareanbirth. If uterine atony occurs, bimanual pressure and utero-tonic drugs are given via the appropriate routes (Dickinson,1999). If these methods fail to arrest the hemorrhage, uter-ine artery ligation/embolization and hypogastric artery bal-loon occlusion may be employed (Oei et al., 2001).

Postpartum HemorrhageExperienced perinatal nurses know that even with an uncom-plicated vaginal or Cesarean birth, hemorrhage can still occurafter delivery. A postpartum blood loss of �500 ml in a vagi-nal delivery or 1,000 ml in a Cesarean is designated as a he-morrhage. Early postpartum hemorrhage is that which oc-curs within the first 24 hours after delivery, and late postpar-tum hemorrhage occurs after the first 24 hours postpartum(Cohen, 2000; Dildy, 2002). The most common cause of ear-ly postpartum hemorrhage is uterine atony, but other etiolo-gies including placental anomalies, uterine inversion, retainedplacental tissue, obstetric lacerations, and coagulation defectsare also implicated (Cohen, 2000; Tropper, 2002).

Causes of late postpartum hemorrhage are atony, infec-tion, subinvolution (incomplete return of the uterus to its

prepregnant size and shape), and retained placenta (James,2001). Uterine atony is treated by fundal massage, express-ing clots, and administering medications to achieve uterinecontractility (Table 2). When these means of containingatony are unsuccessful, bimanual compression or surgical in-tervention may be necessary (uterine/hypogastric artery liga-tion/embolization, hysterectomy) (Cunningham et al.,2001).Suture techniques such as the B-Lynch procedure also mayprove effective (and may potentially preserve fertility) if oth-er efforts at reversing uterine atony fail (Dildy, 2002; Roman& Rebarber, 2003). If retained placental fragments are caus-ing the bleeding, they must be removed, perhaps necessitat-ing dilation and curettage (Gorrie, McKinney & Murray,1998). If uterine atony is not present, other causes of hemor-rhage must be explored. Careful inspection of the cervical,vaginal, and perineal area should be performed; lacerationsor hematomas should be repaired and coagulopathies man-aged appropriately (Bowes & Thorpe, 2004).

Medical interventions for late postpartum hemorrhagecaused by subinvolution of the uterus depend upon thecause. If the cause is retained placental fragments, they areremoved. If infection is the cause, it is treated with IV an-tibiotics (Chamberlin, 1999).

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TABLE 1. Types of Perinatal Hemorrhage Type of Hemorrhage Symptoms

Antepartum(Early) Abortion Dark spotting to frank, bright red bleeding; cramping,

cervical dilatationEctopic Vague pain/cramping; dark red discharge GTD Brownish vaginal bleeding; uterus small for dates; bright

red when molar tissue starts separating from uterus(Late)Abruption Dark vaginal bleeding; abdominal painPrevia Painless bright red bleeding IntrapartumUterine rupture Bright red vaginal bleeding; sharp abdominal painUterine inversion Bright red vaginal bleeding; atonyInvasive placentas Bright red vaginal bleedingOperative delivery Bright red bleeding from uterus or operative sitePostpartum(Early)Atony Bright red vaginal bleeding; clots; boggy (soft) uterusRetained placenta Bright red vaginal bleeding; clots; boggy uterus tissueLacerations Bright red vaginal bleeding; oozing; uterine fundus firmHematoma Exquisite pain at site of hematoma(Late)Atony Bright red bleeding, boggy uterusRetained placenta Bright red bleeding, tissue, clotsSubinvolution Irregular/prolonged/excessive bleeding; uterus larger

than normalInfection Pinkish brown vaginal drainage, foul smelling

Nursing Care for Perinatal HemorrhageClinical reasoning leading to diagnostic, ethical, and thera-peutic judgments by nurses in providing care for patientswith perinatal hemorrhage can be achieved through thenursing process: assessment, planning, intervention, andevaluation (Sherwin, Scolovino, & Weingarten, 1999).

Assessment

The first step in assessment is to review the patient’s historyfor data that may indicate the risk for perinatal hemor-rhage; particular attention should be paid to a history ofprevious obstetrical hemorrhages and their causative orprecipitating factors (Harkreader & Hogan, 2004).

Assessment includes monitoring vital signs, bleeding, in-take and output, pain experience, and emotional status. Con-tinuous fetal monitoring should be instituted if there is a vi-able fetus, in order to detect ominous patterns. Vital signs aretaken until bleeding is controlled and vital signs remain or re-turn to normal; they are taken more frequently (1-5 minutes)if the patient’s condition is unstable (Burke-Sosa, 2001). Thesite, color, odor, and the amount of bleeding are observed.

Perineal pads are counted and any tissue or clots are notedand saved for the physician to examine. The presence or ab-sence of tissue indicates the type of perinatal hemorrhage, asdoes the color of the blood (Sherwin et al., 1999) (Table 3).

Intake and output with specific gravity should be mea-sured every hour; urinary output should not fall below 30ml/hr; for �30 ml of urine/hr indicates decreased perfusionand the need for volume replacement (Heppard & Garity,2002). Current and previous lab data (including bloodtype) should be reviewed, and a Kleinhauer-Betke or APTtest done for women who are Rh negative to determine ifthe blood is of fetal origin and to calculate RhoGamdosage (Schnell, VanLeeuen, & Kranpitz, 2003).

The site, frequency, duration, and quality of pain need tobe observed. Intensity, duration, and frequency of contrac-tions are also monitored to establish that the patient is in la-bor, which will affect medical and nursing management.

The patient’s emotional state also must be assessed toevaluate the emotional response to the hemorrhage.Coping strategies and available support mechanisms are as-sessed for the purpose of assisting the patient and family todecrease anxiety and to realistically plan for future events(Doenges & Moorhouse, 1998).

January/February 2005 MCN 49

TABLE 2. Examples of Medications Used for Uterine AtonyMedication Dosage Route Frequency Contraindications Nursing Actions

Oxytocin 10-40 in 1 L ofnormal saline orlactated Ringer’ssolution

IV Infusion (continuous)

None for postpar-tum hemorrhage

Monitor fluids to avoidwater intoxication;monitor uterine bleeding

Methylergonovine 0.2 mg IM(IV not recommended)

Every 2-4 hr. upto 5 doses

Maternal hypertension/toxemia; knowndrug sensitivity

Monitor uterine bleeding

15-mPGF2alpha 0.25 mg IM, IMM* 15-90 min intervals not toexceed 8 doses

Hypertension, cardiac, pulmonaryrenal; hepatic(active) symptoms

Monitor VS, uterinetone/bleeding, renal,cardiac, pulmonarysymptoms

*IMM, intramyometrially by physician.

TABLE 3. Assessment of Vaginal BleedingColor Debris Amount* Flow*

Bright red Clots (red lumps, no tissue) Scant—-less than 1-inch stain Scant

Dark red Tissue (shiny gray material;may be interspersed with clots

Light—-less than 4-inch stain Trickle

Brown Heavy-saturated within 1 hour

Excessive-1 pad saturated within 1 hour

*Sources: Cashion (2004); Jacobsen (1985); James (2001).

Nursing Diagnoses

Nursing diagnoses related to perinatal hemorrhage (NAN-DA, 2003) are:• deficient fluid volume;• maternal/fetal injury, risk for;• ineffective tissue perfusion, maternal/fetal;• excess fluid volume;• risk for infection;• acute pain;• ineffective individual/family coping; and• deficient knowledge of hemorrhagic condition.

Expected OutcomesExpected outcomes for the client experiencing perinatal he-morrhage are:• resolve hemorrhage;• prevent shock, infection and DIC , and other complica-

tions;• avoid fetal injury/loss if fetus is viable; and• provide psycohological/spiritual support.

Planning

Planning includes being prepared to initiate nursing inter-ventions to manage any instance of hemorrhage. In anemergency situation such as perinatal hemorrhage, the abil-ity to rapidly revise the care plan as the patient’s conditionchanges is essential. Current knowledge of appropriatenursing strategies enables the nurse to collaborate and con-sult with other members of the perinatal team. Nursesworking in perinatal units must continually update theirknowledge by joining specialty organizations, attendingcontinuing education programs, subscribing to and readingappropriate nursing journals, and accessing informativeWeb sites.

Interventions

Timely, prioritized nursing interventions are necessary tocontain hemorrhage and prevent complications. Nursingactions common to all types of hemorrhage include the fol-lowing:1. Starting two large bore IVs and administering fluids,

blood/blood products, and drugs. Larger IV cathetersallow for rapid flow rates.

2. Using an intravenous crystalloid solution (normal saline

or Ringer’s Lactate) to restore circulation, because itsfluid and electrolytes are similar to plasma (Burke-Sosa,2001; Phillips, 2001).

3. Auscultating breath sounds before and after fluids aregiven to determine if fluid overload has occurred.

4. Initiating foley catheter insertion, pulse oximetry, EKG,and blood gases to monitor circulatory perfusion.

5. Preparing for the possible use of a CVP or Swan-Ganzdevice to monitor circulatory volume.

6. Teaching and counseling the patient throughout the ex-perience.

7. Documenting all care in the medical record clearly andconcisely.

8. Notifying the neonatal team that a maternal hemor-rhage is anticipated and there is a viable fetus.

Interventions Specific for the Early Antepartum Hemorrhage

Nursing management of early antepartum hemorrhage isdependent upon several factors: severity of bleeding, gesta-tional age of the fetus, and underlying cause of the hemor-rhage. Nursing interventions specific to managing early an-tepartum hemorrhage are (Melson et al., 1999):• instruct the patient about bed rest/supportive care;• prepare for surgery and recovery, if indicated;• administer RhoGam and medications specific to type of

hemorrhage;• provide information on the products of conception; and• administer pain medications cautiously (because of po-

tential for fetal effects).

Interventions Specific for Late Antepartum Hemorrhage• Provide fetal surveillance (continuous fetal monitoring,

ultrasound, and biophysical profile) • Administer tocolytics, RhoGam, fetal steroids as indicated• Instruct on bed rest (lateral position) with or without

bathroom privileges• Monitor contractions/pain• Prepare for emergency operative vaginal birth or cesare-

an birth • Summon neonatal team/perform neonatal resuscitation

Intrapartum Hemorrhage Interventions

Interventions specific for intrapartum hemorrhage are (Do-enges & Moorhouse, 1999):• monitor fetus continuously; intervene with positioning,

O2, IV bolus, if pattern nonreassuring;• assess contractions;• provide pain management and assess quality of relief;• prepare for emergency procedures; and• alert and assist neonatal team.

Postpartum Hemorrhage InterventionsInterventions specific for postpartum hemorrhage are (Mel-son et al., 1999):• assess fundus and gently massage uterus until firm, after

patient’s bladder is emptied (a full bladder can displace theuterus and prevent its contraction) (Lowdermilk, 2004);

50 VOLUME 30 | NUMBER 1 January/February 2005

Even with an uncomplicatedvaginal or Cesarean birth, hemorrhage can occur after delivery.

• express clots (clots also can interfere with uterine con-traction);

• provide uterotonic drugs and drugs for pain manage-ment; and

• prepare for surgery if uterine atony is not resolved.

Evaluation

Evaluation assesses the quality of nursing care and linkspositive patient outcomes to quality care. It includes exam-ining reasons why interventions were effective or ineffec-tive. After evaluating the impact of nursing interventions,the nurse decides if the plan is to be continued or revised.Revision of the plan is necessary if outcomes were notreached (Harkreader & Hogan, 2004).

ConclusionBecause hemorrhage can unexpectedly occur during anystage of the perinatal period, planning for care of the peri-natal patient must include the potential of hemorrhage.The well-prepared perinatal nurse is knowledgeable aboutthe etiology, symptoms, and medical and nursing manage-ment of all types of perinatal hemorrhage. The nurse com-petent to initiate and implement an effective plan of carefor any perinatal emergency would respond to Mrs. Davis’hemorrhage by rapidly assessing and intervening with ap-propriate nursing actions. ✜

Nancy J. MacMullen is a University Professor, GovernorsState University, University Park, IL. She can be reachedvia e-mail at n-macmul@govst.edu.

Laura A. Dulski is a Nursing Instructor, West SuburbanCollege of Nursing, Oak Park, IL.

Barbara Meagher is a Midwife/Nurse Practitioner, TheUniversity of Chicago Hospitals, IL.

ReferencesBowes, W. A., & Thorpe, J. M. (2004). Clinical aspects of normal and ab-

normal labor. In R. Creasy, R. Resnick, & J. D. Iams (Eds.), Maternal-fetal Medicine (5th Ed., pp. 671-705). Philadelphia: W. B. Saunders.

Burke-Sosa, M. E. (2001). Bleeding: Significance and incidence. In K. R.Simpson & P. A. Creehan (Eds.), High Risk Pregnancy (2nd Ed., pp.173-291). Philadelphia: Lippincott.

Cashion, K. (2004). Nursing care of the postpartum woman. In D. L. Low-dermilk & S. E. Perry (Eds.), Maternity and Women’s Health Care (8thEd., pp. 616-646). St. Louis: Mosby.

Chamberlin, G. (1999). Obstetric emergencies. British Medical Journal,318(7194), 1342-1346.

Claydon, C. S., & Pernoll, M. L. (2003). Third trimester vaginal bleeding. InA. H. De Cherney & L. Nathan (Eds.), Current Obstetric and Gyneco-logic Diagnosis and Treatment (9th Ed., pp. 354-367). New York: LangMedical Books.

Cohen, W. R. (2000). Postpartum hemorrhage and hemorrhagic shock. InW. R. Cohen (Ed.), Cherry and Merkatz’s Complications of Pregnancy(5th Ed., pp. 803-813). Philadelphia: Lippincott, Williams & Wilkins.

Cunningham, F. G., Gant, N. F., Leveno, K. J., Gilstrap, L. C., Hauth, J. C., &Wenstrom K. D. (2001). William’s Obstetrics (21st Ed.), New York: Mc-Graw-Hill.

Dickinson, J. E. (1999). Cesarean section. In D. K. James, P. J. Stear, C. P.Weiner, & B. Gonik (Eds.), High Risk Pregnancy Management Options(2nd Ed., pp. 1217-1229). Philadelphia: W. B. Saunders.

Dildy, G. A. (2002). Postpartum hemorrhage: New management options.Clinical Obstetrics and Gynecology, 45(2), 330-344.

Doenges, M. E., & Moorhouse, M. (1999). Maternal/Newborn Plans ofCare (3rd Ed.). Philadelphia: F. A. Davis Company.

Dyne, P. (2004). Vaginal bleeding and other common complaints in earlypregnancy. In M. D. Pearlman, J. E., Tintinalli, & P. L. Dyne (Eds.), Ob-stetric and Gynecologic Emergencies (pp. 39-55). New York: McGraw-Hill.

Genovese, S. K. (2004). Antepartal hemorrhagic disorders. In D. L. Low-dermilk & S. E. Perry (Eds.) Maternity and Women’s Health Care (8thEd., pp. 860-880). Philadelphia: Lippincott.

Gilbert, E. S., & Harmon, J. S. (2003). High Risk Pregnancy and Delivery(3rd Ed.). St. Louis: Mosby.

Gorrie, T. M., McKinney, E. S., & Murray, S. S. (1998). Foundations of Ma-ternal-Newborn Nursing. (2nd Ed.). Philadelphia: W. B. Saunders.

Harkreader, H., & Hogan, M. A. (2004). Fundamentals of Nursing (2ndEd.). St. Louis: Saunders.

Heppard, M. C. S., & Garity, T. J. (2002). Acute Obstetrics: A PracticalGuide (3rd Ed.). St. Louis: Mosby.

Jacobsen, H. (1985). A standard for assessing lochia volume. MCN, TheAmerican Journal of Maternal/Child Nursing, 10(3), 174-177.

James, D. C. (2001). Postpartum care. In K. R. Simpson & P. A. Creehan(Eds.) Perinatal Nursing (2nd Ed., pp. 446-472). Philadelphia: Lippincott.

Lowdermilk, D. L. (2004). Postpartum complications. In D. L. Lowdermilk& S. E. Perry (Eds.), Maternity and Women’s Health Care (8th Ed., pp.1036-1050). St. Louis: Mosby.

Kramer, W. B., & Weiner, C. P. (2000). Disorders of hemostasis. In W. R.Cohen (Ed.). Cherry and Merkatz’ Complications Of Pregnancy (5thEd., pp. 337-359). Philadelphia: Lippincott, Williams & Wilkins.

Melson, K. A., Jaffe, M. S., Kenner, C., & Amlung, S. (1999). Maternal-In-fant Care Planning (3rd Ed.). Springhouse, PA: Springhouse.

Miller, D. A. (2002). Placenta previa. In D. R. Mishell Jr., T. Murphy Good-winn, & P. F. Brenner (Eds.), Management of Common Problems inObstetrics and Gynecology (4th Ed., pp. 134-146). Malden, MA: Black-well Sciences, Inc.

Minkoff, H. & Chervenak, F. A. (2003). Elective primary Cesarean delivery.New England Journal of Medicine, 348(10), 946.

North American Nursing Diagnosis Association (NANDA). (2003). NANDANursing Diagnosis: Definitions and Classifications 2003-2004.Philadelphia: Author.

Nimrod, C. A., & Oppenheimer, L. W. (1999). Third trimester bleeding. In E.A. Reece & J. C. Hobbins (Eds.), Medicine of the Fetus and Mother(2nd Ed., pp. 1497-1505). Philadelphia: Lippincott-Raven.

Oei, G. S., Kho, S. N., tenBroeke, E. D., & Brolman, H. A. (2001). Arterialballoon occlusion of the hypogastric arteries: A lifesaving procedurefor severe obstetric hemorrhage. American Journal of Obstetrics andGynecology, 48(3), 34-53.

Phillips, L. D. (2001). Manual of IV Therapeutics (3rd Ed.). Philadelphia: F.A. Davis.

Roman, A. S., & Rebarber, A. (2003).Seven ways to control postpartum he-morrhage. Controversies in Obstetrics and Gynecology, 48(3), 34-53.

Schnell, Z. B., Vanleuwen, A. M., L., & Kranpitz, J. R. (2003). Davis’s Com-prehensive Handbook of Laboratory and Diagnostic Tests With Nurs-ing Implications. Philadelphia: F. A. Davis.

Sherwen, L. N., Scoloveno, M. A., & Weingarten, C. T. (1999). MaternityNursing: Care of the Childbearing Family (3rd Ed.). Stamford, CT: Ap-pleton and Lange.

Tropper, P. (2000). Postpartum hemorrhage. In H. N. Winn & J. C. Hobbins(Eds.), Clinical Maternal-Fetal Medicine (pp. 167-170). New York:Parthenon Publishing Group.

Yashar, C. M. (1998). Bleeding in the first twenty weeks of pregnancy. InM. D. Pearlman & J. E. Tintinalli (Eds.), Emergency Care of theWoman (pp. 29-35). New York: McGraw-Hill.

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March of Dimeswww.marchofdimes.com AWHONN (nursing standards and carelinks to other sources)www.awhonn.org

Medscape (research and clinical nursing and medical articles)www.medscape.com ACOG (Standards of care, technical bulletins, press releases)www.acog.org

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