Fluid Volume Deficit r/t massive vaginal hemorrhage due to secondary to complete placental separation

Interventions:

1. Continuous evaluate maternal and fetal physiologic status, particularly on vital signs, bleeding,
electronic fetal and maternal monitoring tracing, signs of shock-pulse-rapid pulse, cold and moist skin,
decrease in blood pressure; Decreasing urine output; Never perform a vaginal or rectal examination or
take any action that would stimulate uterine activity.
R: Alteration in vital signs can call for prompt actions.

2. Asses the need for immediate delivery. R: If the client is in active labor and bleeding cannot be
stopped with bed rest, emergency cesarean delivery may be indicated
3. On admission, place the woman on bed rest in a lateral position. R: To prevent pressure on the vena
cava.
4. Insert a large gauge intravenous catheter into a large vein for fluid replacement. R: for fluid
replacement
5. Obtain a blood sample for fibrinogen level. R: To find out the extent of hemorrhage
for prompt intervention.
6. Monitor the FHR externally and measure maternal vital signs every 5 to 15 minutes. R: Allows prompt
intervention if fetal distress is detected.

7. Prepare for cesarean section. R: the method of choice for the birth
8. Provide client and family teaching. R: Allows them to understand the situation
9. Address emotional and psychosocial needs. R: Calms client and helps her to take in the stress.
10. Maintain accurate I/O and weigh daily. Measure urine specific gravity. Monitor blood pressure and
invasive hemodynamic parameters as indicated (e.g., CVP, PAP/PCWP). R: To evaluate effectiveness of
resuscitation measure

Impaired gas exchange: fetal r/t insufficient maternal-fetal oxygen transfer and supply secondary to
premature separation of the placenta

1. Auscultate mother’s abdomen to hear the fetal heart tone. Assess and monitor fetal heart tone, beat
and movement. R: To determine if there are any signs of life of the fetus inside the womb.
2. Assess level of consciousness of the mother. R: To determine what appropriateinterventions should
be given
3. Evaluate pulse oxymetry to determine oxygenation. R: To assess respiratory efficiency
4. Elevate head of bed or position the mother appropriately. R: To promote airway.
5. Provide supplemental oxygenation at lowest concentration as indicated by laboratory results.R:
Oxygen may transfer to the fetus, thus it provides oxygen and nutrients to the fetus.
6. Encourage or educate the mother to have adequate rest and limit activities to within client tolerance.
R: Helps limit oxygen needs or consumption of the mother
7. Promote/provide calm, restful, and free stimulant environment. R: Promotes comfort to the mother
8. Provide psychologic support such as listening to questions or concerns. R: To establish rapport and
trust
9. Administer medications as ordered by the physician. R: To treat underlying conditions
10. Assist with procedures as individually indicated like blood transfusion. R:
11. Position mother in left lateral position.

Helps limit oxygen needs or

consumption of the mother
Promotes comfort to the mother
To establish rapport and trust
To treat underlying conditions
Improves respiratory function or
oxygen carrying capacity