Assessment:

Assessment during the delivery process begins in the second stage of labor, encompassing full cervical dilation until the baby’s birth. This phase is critical, demanding the mother’s strength for an uncomplicated delivery and successful normal vaginal birth.

• Evaluate the mother’s responses to the intensity and duration of contractions.
• Assess the mother’s comfort with her chosen birthing position.
• Evaluate the effectiveness of the mother’s breathing techniques and whether they contribute to any difficulties.
• Assess the support person’s ability to assist the mother throughout labor and delivery.
• Monitor fetal heart sounds to ensure there is no cord occlusion affecting fetal circulation.
• Evaluate the overall comfort of the environment for both the mother and the baby.

Diagnosis:

The challenges a mother may face during delivery are diverse. Recognizing potential issues promptly is crucial for caregivers to establish an immediate diagnosis and care plan, guiding the mother toward a safe and meaningful delivery.

Nursing Diagnosis:

Pain related to the intensity of uterine contractions.

Planning:

Preparation for childbirth involves ensuring the birthing environment is ready well in advance. For multigravidas, room preparation can commence when the cervix has dilated to 9 to 10 cm, while for primiparas, it should begin when the head has crowned to the size of a quarter. The newborn care area within the same room must also be equipped with supplies for eye care, suction and resuscitation equipment, a radiant heat warmer, sterile towels, and proper identification for the newborn. The mother should be encouraged to choose a comfortable birthing position, with alternative positions including dorsal recumbent, lateral Sim’s, squatting, and semi-sitting. Healthcare providers should be positioned at the foot of the birthing table to prevent any risks if a precipitous birth occurs.

Implementation:

With the care plan in place, it’s time to put the interventions into action:

• Ensure awareness of the client’s birth plan among all healthcare providers.
• Encourage the mother to void before delivery to alleviate discomfort.
• Allow the client to consume ice chips or hard candies to relieve dry mouth.
• Create a comfortable environment for both the mother and the baby.
• Permit the client to choose a birthing position, ensuring it is not contraindicated.
• Assist the client in expressing any emotions related to her delivery experience.

Evaluation:

• A comprehensive care plan includes evaluating the effectiveness of the interventions:
• The client effectively manages discomfort using nonpharmacologic methods.
• The client can identify various pain relief measures.
• The client exhibits no signs of bladder distention and can void every 2 hours.
• The client reports reduced or no mouth discomfort.
• The client finds the environment comfortable.
• The client expresses that the delivery is a tolerable and highly meaningful part of her life.