A 32-year-old woman at 34 weeks gestation presents to the emergency department with sudden onset of severe abdominal pain and vaginal bleeding. Assessment reveals a rigid, tender abdomen and fetal heart rate of 90 bpm. The nurse suspects abruptio placentae. What is the priority nursing intervention?

Scenario: A 32-year-old G3P2 at 34 weeks presents with acute severe abdominal pain, vaginal bleeding, a rigid uterus, and fetal bradycardia (FHR 90 bpm). Suspect grade 2-3 abruptio placentae with concealed hemorrhage.

• Activate Massive Transfusion Protocol: Notify the blood bank and prepare for massive transfusion. Abruptio placentae is a major risk factor for DIC and postpartum hemorrhage.
• Prepare for Emergency Cesarean Delivery: This is the definitive treatment. Fetal bradycardia necessitates a decision-to-delivery interval of less than 30 minutes. Notify the obstetrician, anesthesiologist, neonatologist, and surgical team simultaneously.
• Secure IV Access: Insert two large-bore (16-18 gauge) intravenous lines and initiate fluid resuscitation with warmed crystalloids (e.g., Lactated Ringer's) to maintain maternal blood pressure and urine output >30 mL/hr.
• Maternal-Fetal Monitoring: Apply continuous electronic fetal monitoring and maternal vital signs every 5 minutes. Assess for signs of shock (tachycardia, hypotension, pallor) and uterine hypertonus.

• No Vaginal Examination: Do not perform a digital cervical exam. It can disrupt a clot over the cervix and precipitate catastrophic hemorrhage, especially if an undiagnosed placenta previa is present.
• No Trendelenburg Positioning: Avoid this position as it can compromise maternal ventilation and does not improve uteroplacental perfusion. Keep the patient in a left lateral tilt to relieve aortocaval compression.

• Laboratory Studies: Send STAT labs: CBC, coagulation profile (PT, aPTT, fibrinogen), D-dimer, type and crossmatch for at least 4 units of packed red blood cells.
• Fibrinogen Monitoring: A fibrinogen level below 200 mg/dL is a strong predictor of severe postpartum hemorrhage and DIC progression. Prepare for cryoprecipitate or fibrinogen concentrate replacement.
• Uterine Assessment Post-Delivery: Inspect for a Couvelaire uterus (bluish, boggy discoloration). This may impair uterine contractility, requiring uterotonics (oxytocin, methylergonovine, carboprost) and intrauterine tamponade techniques.
• Neonatal Resuscitation: Ensure a neonatal resuscitation team is present at delivery. The newborn is at high risk for acidosis, hypovolemia, and anemia.

• Quantify Blood Loss: Use a calibrated drape and weigh all sponges to accurately measure blood loss, as visual estimation is often inaccurate.
• Emotional Support: Provide clear, calm explanations to the patient and family about the emergency and the need for immediate surgery. A perinatal loss or NICU admission is a high possibility.
• Documentation: Record the exact time of symptom onset, initial assessment findings, notifications made, interventions performed, and the decision-to-delivery interval.