Cesarean Section Casestudy

Introduction: In this semester, at the maternity course, I chose this case with my instructor which it is about NSVD after C-section, I Believed that if a woman had delivered one baby by C-section, all other children had to be delivered the same way. But after taking this case and reading about it I realize that Today many women can have vaginal deliveries after a previous C-section delivery. This is referred to as a vaginal birth after cesarean ). Attempting to have a vaginal birth after a previous cesarean section is called a trial of labor after cesarean (TOLAC). I hope this case will be interesting case and help me to improve my knowledge, skills and practice, and to apply what I study at the university.

Demographic data: Patient name: A.S.M.S Date of admission: 1/11/2013 Hospital: AL-AHLI Hospital Address: Hebron Occupation : Engineering space

DX: Early labor previous c/s

Chief complain: Uterine contractions, “in labor” .labor pain ,

Date: 2/12/2013 Age: 28 years ‫ا‬

History of present pregnancy A28 year old woman admitted to AL-AHLI hospital as a case of Early labor previous c/s .her BP 100/60 .pulse 87,G.A 39week ,LMP 1/2/2013 and the EOD in8/11/2013 ,G2P2A0 .canula applied and lap test (CBC ,Crosshatch A+,HBsAAG the result was negative ,CTG)was taken .due to prolong 2nd stage of labor active management done at 3rd stage (Episiotomy extended RML and 30 unit sinto in 500cc R/L) ,a male baby was born at 9:05 AM his Wt 3,650 mg .ABGAR score was 8/9 . She is conscious .look very tired ,with poor pushing during the delivery, the . baby in good condition and his mother

Past medical history: .Medical history: no hypertension , no diabetes , and no tuberculosis .Surgical history: previous cesarean due to fetal distress . Allergic : unknown allergy to medication or food Medications: she didn't take any regular medication .No Gynecological disorder

Family History: Her father Have HTN and DM , other than this the family history is free; .there is no medical or surgical history, or congenital abnormalities

Obstetric history: She delivered before a baby girl , maturity at term and the mood of the . delivery was C/S due to fetal distress

Nutritional assessment habits: Pt is on regular diet. She eats 3 meals per day. Pt was taking Folic acid and iron supplement during pregnancy. Unknown allergy for any kind of food. Pt had nausea and vomiting in the first trimester . - she gained wt. during pregnancy was about 13 kg. Doesn’t smoke and doesn't drink alcohol

-

Allergies: -

Unknown allergy for any type of food or drug.

Labor & its stages FIRST STAGE OF LABOR--THREE PHASES In this phase, the mother feels slow, rhythmic contractions. The .(Early ) contractions last from 30 to 45 seconds with the intensity gradually increasing. The frequency of contractions is from 5 to 20 minutes. There is some cervical effacement. Dilation is from 2cm. "Bloody show" is ..present. The mother was able to walk, talk, laugh during this phase Active. In this phase, the contractions become stronger and last longer, for 45 to 60 seconds. The frequency is from 3 to 5 minutes. The cervix dilates 7 cm... She, then, becomes involved with bodily sensations and tends to withdraw from the surrounding environment. She is not able to .walk, but, desires companionship and encouragement Transient. In this phase, the contractions are sharp, more intensified, and last from 60 to 90 seconds. The frequency is from 2 to 3 minutes. The cervix dilates from 8 to 10 cm. The mother express feelings of frustration irritability. Her focus becomes internal. She has difficulty comprehending surroundings, events, and instructions. There is an increase in bloody show as a result of the rupture of capillary vessels in the cervix and the lower uterine segment. The mother feels an urge to push or to have a bowel movement. This is the most severe and difficult phase was for the .mother

mother’s profile for (G2P2A0 ,first day in LMP1/2/2013 , EDD8/11/2013,GA39 .earlier and latest US ,and problem during pregnancy). Performed leopoled’s maneuver to determine fetal position, lie , and presentation.all were normal. Insert IV catheter , start hydration according to fetal and maternal condition (IV N/S 1500cc) .Oriented the patient to the surroundings (that is, room, call bell) In this phase opstractic history taken (previous C/S) mother’s At this stage V/S were taken ,position the mother in semi lateral ,encourage her to go to the bathroom and walk .the mid wife done abdominal examination Draw blood for (Hgb), (Hct), and type and X-matching were drawn , .clean urine sample for protein, glucose ,and bacteria were optained stage Second .Continues reassess the UCs, FHR, progress of labor Teach mother how to perform birthing exercise and how to make effective .bushing . Prepare the mother for labor (perennial care) Continuous assess the CTG and Pantograph Poor pushing Third stage episiotomy is Applied R.M.L U of oxytocin IM after delivery of anterior shoulder 5 cut umbilical cord Delivery of placenta Check placenta Evacuate the uterus from the clots Fourth stage Asses V/S every 15 m for one hour , then every 30 for one hour ,and then for 1 hour(V/S stable and within normal range)h Assess fundal height, position, and its tone hin the umbilical midline well contracted Monitor amount of lochia( mild lochia) Assess the perineum Palpate the bladder, encourage mother to void (‫ا‬Massage the fundus if boggy Encourage and assist with breast feeding as soon possible Monitor Hgb, Hct level Encourage the mother to void her bladder after the labor by 1 hour

:Post natal condition She looks fully conscious ,in good mood , tidy , has clean clothes and body ,she take care of himself , no bad odor , her Weight when she was pregnant is82kg, now her wt is 75kg Height: 165cm.Patient general condition stable, no headache, no epigastric pain, no visual disturbances. V/S taken and recorded, BP= 120/60mmhg,pulse90.Tem 36.5c. The second day the uterus well contracted. she has stable V/S, Pt out of bed , no dizziness and passed urine,lokia mild , episiotomy sutures no bleeding .,no hematoma ,good approximation .

Physical assessment Vital signs: Blood Pressure: 120/6o Pulse: 90 Temperature: 36.5 C Respiration: 19 breathe per m. Weight: Before delivery her wt was 82 kg , her wt now is 75kg. Height : 156 cm. Skin: Pink in color, smooth in texture, warm, no lesions, her skin is clear and free of spots. vertical linea niagra extend from pubic area to umbilicus, striae gravidanum after delivery is present Heart: Lub-dub heart sound, regular rhythm 90 beat/ min. Apex beat is chentrally placed, no murmur, no abnormal sounds, peripheral pulse is palpated. The Pt did not complain from heart problems , no hypertension during pregnancy. Palpation is clear in the apical area, Jugular veins are not visible. Peripheral pulses. Peripheral veins is normal, no tenderness on palpation of limbs, radial pulse palpable in both arteries in the both hands.

Breast: Both are symmetrical, soft, no redness or swelling, the nipple is small inverted. no congestion , Both are symmetrical, normal size ,soft,

no redness or swelling or masses, lactated, both nipples are normal, no abnormal discharge.

Abdomen: The uterus is in the mid line of umbilicus, uterus contracted, transverse incision from previous C/S , clean and dry, normal bowel habit, intact bowel sounds, central umbilicus, femoral pulses are palpated. Back: Has good postured shape, spinal vertebral is normal shape. no masses, or prominent curves, no pain Extremities: Both are symmetrical, have good reflexes, no edema, no varicose veins or DVT, she can walk alone. full range of motion, no varicose veins are present to the both legs, no deformities or scar tissue, will extension. Pelvic area: Dark skin, soft and firm, no lesion, no congenital anomalies, no UTI, there is moderate lochia ,no bleeding or tearing from episiotomy sutures,

Lap test Antenatal period: Blood CBC The CBC is used as a broad screening test to check for such disorders as anemia, infection, and many other diseases. It is actually a panel of tests that examines different parts of the blood. Prenatal test: 1/11/2013

Test

Value

WBC RBC HGb PLT

10.5 K/ul 4.93M/uL 13.3 g/dl 142K/UL

Normal value 4.1-10.9 K/ul 3.5-5.5M/uL 12-18g/dl 140440K/UL

Meaning of abnormal values Normal Normal normal normal

Serology /I mmun HBSAG Negative

HBSAG/SCREEN Urine analysis Color Appearance Ph Bacteria

Straw Clear Alkaline Nill

Medication Medication

uses

ceftriaxone Rocephin I.V N/S 150cc

is used to treat many kinds of bacterial infections, including severe or lifethreatening forms such as meningitis

rational Contraindicat ion Prophylactic from infection



kidney disease (or if you are on dialysis);



liver disease;

side effect diarrhea that is watery or ;bloody fever, chills, swollen glands, rash or itching,



diabetes;



gallbladder disease;



a stomach or intestinal disorder such as colitis;



if you are allergic to penicillin.

Syntocinon Induce and Syntocinon is Hypertonic 30unit with R/L augmentation used to uterine action, .500ccc., I.V of labour, Induce & Mechanical stimulate augmentation obstruction to uterine of labour delivery, Fail contractions, trial labour, Fetal for post distress, placenta .hemorrhage .,preavia Pithidinh opioid , Labor pain patients with analgesic, 100mg IM Episiotomy history of severe hourly 4 prescribed for procedure respiratory moderate to severe pain, for example labor pain, before and during a surgical operation. It changes the way the body senses pain.

problems, fits, head injuries, increased eye pressure, heart or liver problems, diabetes, depression, genetic disorder, any allergy, who are taking other medications, elderly and children.

joint pain, or general ill ;feeling unusual bleeding (nose, mouth, vagina, or rectum), purple or red pinpoint spots under your ;skin ; Violent uterine contraction leads to rupture & fetal asphyxiation, arrhythmias, maternal .,hypertension Nausea, vomiting, constipation, drowsiness, dizziness, dry mouth and sweating. Central Nervous SystemNervousness, headache, restlessness, uneasiness, fatigue, confusion, depression, hallucinations, tremors, muscle twitches, increased intracranial pressure and fits.

Pathophysiology: It is a vaginal birth after one or more cesareans. More than 80% of women will be able to have a VBAC. ACOG recently updated their opinion on VBAC and stated "VBAC is safer than repeat cesarean and VBAC with more than one previous cesarean does not pose any increased risk".

Vaginal Birth After C-Section (VBAC) The old phrase "once a C-section always" is no longer true. In the past, the belief was that if a woman had delivered one baby by C-section, all other children had to be delivered the same way. Today many women can have vaginal deliveries after a previous C-section delivery. This is referred to as a vaginal birth after cesarean (VBAC). Attempting to have a vaginal birth after a previous cesarean section is called .a trial of labor after cesarean (TOLAC)

Candidates For VBAC According to the American College of Obstetricians and Gynecologists (ACOG), the :following women are candidates for TOLAC

   The woman has had no more than one prior low-transverse Csection delivery. This refers to the cut on your uterus, not the one on your belly. If you’ve had a prior c-section, your health care provider may ask you to get a copy of the report from your first surgery to check what type of incision you had on the uterus. as my case. 

The woman has had no other uterine scars or ruptures, whether from previous C-sections or other surgeries.



The woman has a pelvis large enough to allow a vaginal delivery.



Delivery will be at an institution with a physician immediately available throughout active labor who can monitor the fetus and perform an emergent Csection if needed.



Delivery at an institution where anesthesia and staff is also immediately available if an emergent C-section needs to be performed.

ACOG has specifically stated that whenever a woman is planning a TOLAC delivery, there should be an appropriate medical team available, including an anesthesiologist, throughout the active labor so that an emergency C-section may be done if necessary. Smaller hospitals may not have the resources to monitor a VBAC delivery or to

provide an emergency c-section for TOLAC situations, and VBAC delivery may not .be possible

Women Who Should NOT Have VBAC One of the main concerns with having a vaginal delivery after a C-section is the potential rupture of the uterus, which could be harmful to you and the baby. Therefore, ACOG has made recommendations for women who should not try a :VBAC delivery. These women include 

Women with a high vertical (or classical, T-shaped) incision on the uterus



Women with a history of extensive uterine surgery



Women with a small pelvis or delivering a large baby - it may not be safe for the baby to pass through the pelvis

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Those with a medical problem or obstetric condition, such as placenta previa or abruptio placenta



Women delivering in a hospital without an available medical team for VBAC monitoring and emergency C-section

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Prior uterine rupture



Women with more than two prior C-sections and no previous vaginal deliveries

The Benefits of VBAC Statistically, about 60-80% of women who try TOLAC are able to deliver vaginally. If you are considered a candidate for VBAC, there are some advantages to having a :vaginal delivery over a C-section. Some of these include 

Shorter hospitalization



No abdominal surgery



Lower risk for blood transfusion and infection



Overall faster recovery



May avoid multiple future c-sections if you are considering a large family (with three or more children)

Notably, however, some women who try to have a vaginal delivery end up with a c.section. They don’t get to experience these benefits

Risks The most serious risk with TOLAC is rupture of the uterus. The risk of rupture of the uterus after a prior low transverse c-section is about 1 percent, whereas the risk of

rupture of the uterus in previous classical C-section is 8 to 10 percent. In a recent large study, about 1 in 2,000 women who tried to TOLAC had a uterine rupture that caused permanent brain damage for the baby. Women in the group that tried to have a vaginal delivery were also more likely to need a blood transfusion and more likely to have an infection in their uterus that required antibiotics. On the other hand, about three quarters of the women who tried to have a vaginal delivery succeeded. These women avoided surgery and had a quicker recovery compared with the women who .chose to have a scheduled repeat c-section Reference: Irina Burd, MD, PhD, Maternal Fetal Medicine, Johns Hopkins University, Baltimore, MD. Review provided by VeriMed Healthcare Network.

Relegating to my patient

A28 year old woman admitted to AL-AHLI hospital as a case of Early labor previous c/s .her BP 100/60 .pulse 87,G.A 39week ,LMP 1/2/2013 and the EOD in8/11/2013 ,G2P2A0 .canula applied and lap test (CBC ,Crosshatch A+,HBsAAG the result was negative ,CTG)was taken .due to prolong 2nd stage of labor active management done at 3rd stage (Episiotomy extended RML and 30 unit sinto in 500cc R/L) (Roger W. Harms, M.D) ,a male baby was born at 9:05 AM his Wt 3,650 mg .ABGhR score was 8/9 . She is conscious .look very tired ,with poor pushing during the delivery, the baby in good condition and his mother.after the Vaginal birth She looks fully conscious ,in good mood , tidy , has clean clothes and body ,she take care of himself , no bad odor , her Weight when she was pregnant is82kg, now her wt is 75kg Height: 165cm.Patient general condition stable, no headache, no epigastric pain, no visual disturbances. V/S taken and recorded, BP= 120/60mmhg,pulse90.Tem 36.5c. The second day the uterus well contracted. she has stable V/S, Pt out of bed , no dizziness and passed urine,lokia mild , episiotomy sutures no bleeding ,no hematoma ,good approximation.

:NURSING DIAGNOSIS ‫ا‬:-DIAGNOSIS1

.Pain re: RML episiotomy, puffy perineum manifested by client compalain

:NURSING GOALS Within 1 hour of receiving pain medication, client will state pain level .1 .has been reduced to “0-2" on pain scale Throughout shift, client will state that perineal pain has lessened to a .2 .tolerable level :NURSING INTERVENTIONS Assess client’s pain level throughout shift (ask client to identify level .1 .using pain scale at least q2-3h) and when analgesic is due Rationale: to monitor client’s pain, preventing it from escalating and to .offer appropriate interventions as needed Offer analgesics per doctors order .2 Rationale: to maintain client’s comfort level by controlling pain and .preventing it to escalate .Apply ice pack to perineum prn .3 .Rationale: to reduce swelling and numb perineum in order to relieve pain .Offer sitz bath to client per doctor’s order .4 Rationale: warm water cleansing the perineum is soothing and reduces pain. The warm water will encourage blood flow to the area, encouraging .healing .Visually assess the client’s perineal area qshift .5 Rationale: to monitor level of swelling and redness and to identify any infection or worsening of skin breakdown. Allows for early interventions to .prevent complications if needed :EVALUATION Goal #1. Achieved. Thirty minutes after receiving Tylenol #3 tabs ii, the ."client stated that her perineal pain level was at “1 Goal #2. Achieved. Throughout the shift, the client took the Tylenol #3 q 4 hours and stated that it lessened her pain. When asked, client stated pain was at “0-1" throughout shift. Client stated that. She did not like the ice pack, so refused to have it repeated. She hsaid that applying a warm wet washcloth to the perineum after voiding stopped the stinging caused by .urine

:-NURSING DIAGNOSIS2

Risk for ineffective tissue perfusion related to hemorrhage

Goal After 8 hours of nursing interventions, the patient will demonstrate adequate perfusion and stable vital signs. Intervention 1-Monitor amount of bleeding by weighing all pads. To measure the amount of blood loss. 2-Frequently monitor vital signs. Early recognition of possible adverse effects allows for prompt intervention 3-Massage the uterus To help expel clots of blood and it is also used to check the tone of the uterus and ensure that it is clamping down to prevent excessive bleeding 4-Place the mother in Trendelenberg position to Encourages venous return to facilitate circulation, and prevent further bleeding 5-Administer medication as indicated To promote contraction and prevents further bleeding. Evaluation After 8 hours of nursing interventions ,the patient was able to demonstrated equate perfusion and stable vital signs NURSING DIAGNOSIS3:

.risk for wound infection related to the episiotomy incision Goals: maintain the wound clean and dry the wound and prevent . infection :Nursing action . Checked the site of the episiotomy (1 Rational: To observe for any bleeding or discharge which is media for organisms growth Teach client how to cleanse perineal area (cleanse from front to back -2 with warm wet & soapy washcloth). Advise client to do so when changing .perineal pad, after voiding and bowel movements Rationale: by keeping the perineum clean, there is less chance for infection of the area which could cause increased pain. Application of warm, wet, cloth soothes the perineum . .Checked the V/S (temp) (3 Rational: Because V/S indicate infection .

Observe the CBC test (WBC) to discover if there is any kind of (4 infection . Teach the client about signs and symptoms of the wound infection like (5 .redness or tenderness or any strange discharge from the wound area Rational: To be more familiar of early signs of wound infection and to go .to the most close health center and visit the doctor Evaluation: I saw her fine & hadn't any sign of infection or any change in WBC count :NURSING DIAGNOSIS4 .Risk for fatigue and muscle weakness related to bed rest .Goals: maintain the strength of muscle :Nursing Action * .Changing position .Rational: To prevent the stiff of muscle .Advice the pt to walking * .Rational: To strength the muscles * .Exercise .Rational: To strength the muscles and to prevent the stiff of muscles .Evaluation: goal is met, because pt walked

Nursing Diagnosis : risk for alteration in bowel elimination ((1 .constipation related to sluggish peristalsis movement Goal : short term pt will eliminate soft formed stool at aregular intervals during a hospitalization period, long term pt will verbalize an increased .in comfortable :Nursing action .encourage a high fibers diet specially vegetable Rational :Vegetable contains fibers which consider laxative that .facilitate deification . Asked pt for food intake .Rational : to determine the if she taking enough fluid Encourage pt to walk -‫ا‬ .Rational: to encourage the peristalsis movement Evaluation : bowel eliminations normal as pt states

Ob Gyns Issue Less Restrictive VBAC Guidelines July 21, 2010 Washington, DC -- Attempting a vaginal birth after cesarean (VBAC) is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans, according to guidelines released today by The American College of Obstetricians and .Gynecologists The cesarean delivery rate in the US increased dramatically over the past four decades, from 5% in 1970 to over 31% in 2007. Before 1970, the standard practice was to perform a repeat cesarean after a prior cesarean birth. During the 1970s, as women achieved successful VBACs, it became viewed as a reasonable option for some women. Over time, the VBAC rate increased from just over 5% in 1985 to 28% by 1996, but then began a steady decline. By 2006, the VBAC rate fell to 8.5%, a decrease that reflects the restrictions that some hospitals and insurers placed on trial of labor after cesarean (TOLAC) as well as decisions by patients when presented with .the risks and benefits The current cesarean rate is undeniably high and absolutely concerns us as ob- " gyns," said Richard N. Waldman, MD, president of The College. "These VBAC guidelines emphasize the need for thorough counseling of benefits and risks, shared patient-doctor decision making, and the importance of patient autonomy. Moving forward, we need to work collaboratively with our patients and our colleagues, hospitals, and insurers to swing the pendulum back to fewer cesareans and a more ".reasonable VBAC rate In keeping with past recommendations, most women with one previous cesarean delivery with a low-transverse incision are candidates for and should be counseled about VBAC and offered a TOLAC. In addition, "The College guidelines now clearly say that women with two previous low-transverse cesarean incisions, women carrying twins, and women with an unknown type of uterine scar are considered appropriate candidates for a TOLAC," said Jeffrey L. Ecker, MD, from Massachusetts General Hospital in Boston and immediate past vice chair of the Committee on Practice Bulletins-Obstetrics who co-wrote the document with William A. Grobman, MD, from .Northwestern University in Chicago

VBAC Counseling on Benefits and Risks In making plans for delivery, physicians and patients should consider a woman's " chance of a successful VBAC as well as the risk of complications from a trial of labor, all viewed in the context of her future reproductive plans," said Dr. Ecker. Approximately 60-80% of appropriate candidates who attempt VBAC will be successful. A VBAC avoids major abdominal surgery, lowers a woman's risk of hemorrhage and infection, and shortens postpartum recovery. It may also help women avoid the possible future risks of having multiple cesareans such as hysterectomy, bowel and bladder injury, transfusion, infection, and abnormal placenta conditions .(placenta previa and placenta accreta) Both repeat cesarean and a TOLAC carry risks including maternal hemorrhage, infection, operative injury, blood clots, hysterectomy, and death. Most maternal injury that occurs during a TOLAC happens when a repeat cesarean becomes necessary after the TOLAC fails. A successful VBAC has fewer complications than an elective repeat cesarean while a failed TOLAC has more complications than an elective repeat .cesarean Uterine Rupture The risk of uterine rupture during a TOLAC is low—between 0.5% and 0.9%—but if it occurs, it is an emergency situation. A uterine rupture can cause serious injury to a mother and her baby. The College maintains that a TOLAC is most safely undertaken where staff can immediately provide an emergency cesarean, but recognizes that such .resources may not be universally available Given the onerous medical liability climate for ob-gyns, interpretation of The " College's earlier guidelines led many hospitals to refuse allowing VBACs altogether," said Dr. Waldman. "Our primary goal is to promote the safest environment for labor ".and delivery, not to restrict women's access to VBAC Women and their physicians may still make a plan for a TOLAC in situations where there may not be "immediately available" staff to handle emergencies, but it requires a thorough discussion of the local health care system, the available resources, and the potential for incremental risk. "It is absolutely critical that a woman and her physician discuss VBAC early in the prenatal care period so that logistical plans can be made well in advance," said Dr. Grobman. And those hospitals that lack "immediately available" staff should develop a clear process for gathering them quickly and all hospitals should have a plan in place for managing emergency uterine .ruptures, however rarely they may occur, Dr. Grobman added The College says that restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will if, for example, a woman in labor presents for care and declines a repeat cesarean delivery at a center that does not support TOLAC. On the other hand, if, during prenatal care, a physician is uncomfortable with a patient's desire to undergo VBAC, it is appropriate to refer her .to another physician or center

Practice Bulletin #115, "Vaginal Birth after Previous Cesarean Delivery," is .published in the August 2010 issue of Obstetrics & Gynecology

Roger W. Harms, M.D. Episiotomy An episiotomy is minor surgery that widens the opening of the vagina during childbirth. It is a cut to the perineum -- the skin and muscles between the vaginal .opening and anus What Are The Risks? There are some risks to having an episiotomy. Because of the risks, episiotomies are :not as common as they used to be. The risks include 

The cut may tear and become larger during the delivery. The tear may reach into the muscle around the rectum, or even into the rectum itself.

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There may be more blood loss.

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The cut and the stitches may get infected.

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Sex may be painful for the first few months after birth.

.Sometimes, an episiotomy can be helpful even with the risks Will I Need An Episiotomy? :Times when an episiotomy is often performed include 

If you are pushing as the baby’s head is close to coming out, and you tear up toward the urethral area

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If labor is stressful for the baby and the pushing phase needs to be shortened to decrease problems for the baby

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If the baby's head or shoulders are too big for the mother's vaginal opening

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If the baby is in a breech position (feet or buttocks coming first) and there is a problem during delivery

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If instruments (forceps or vacuum extractor) are needed to help get the baby out

Not every woman will need an episiotomy during childbirth. Many women get .through childbirth without tearing on their own, and without needing a cut

Episiotomies don't heal better than tears. They often take longer to heal since the cut is usually deeper than a natural tear. In both cases, the cut or tear must be stitched .and properly cared for after childbirth What Happens if I Need an Episiotomy? Just before your baby is born, and as the head is about to crown, your doctor or midwife will give you a shot to numb the area (if you haven’t already had an .epidural) Next, a small incision (cut) is made. There are two types of cuts: median and medio.lateral 

The median incision is the most common type. It is a straight cut in the middle of the perineum.



The medio-lateral incision is made at an angle. It is less likely to tear through to the anus, but it takes longer to heal than the median cut.

.Your doctor will then deliver the baby through the enlarged opening 

Next, your doctor will deliver the placenta (afterbirth).



The cut will be stitched closed.

How Can I Avoid an Episiotomy? You can do things to strengthen your body for labor that may lower your chances of .needing an episiotomy 

Practice Kegel exercises.

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Perform perineal massage during the 4 - 6 weeks before birth.

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Practice the techniques you learned in childbirth class to control your breathing and your urge to push.

Keep in mind, even if you do these things, you may still need an episiotomy. Your doctor or midwife will decide if you should have one based on what happens during .your labor References Hartmann K, Viswanathan M, Palmieri R, Gartlehner G, Thorp J Jr, Lohr KN. Outcomes of routine episiotomy: a systematic review. JAMA. 2005;293(17):2141.2148 American College of Obstetricians-Gynecologists. Episiotomy. Clinical Management .Guidelines for Obstetrician-Gynecologists. ACOG Practice Bulletin. 2006;71 Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database of Systematic .Reviews. 2009;1:CD000081

Cunningham FG, Leveno KJ, Bloom SL, et al. Normal labor and delivery. In: Cunnigham FG, Leveno KL, Bloom SL, et al, eds. Williams Obstetrics. 23rd ed. New .York, NY: McGraw-Hill; 2010:chap 17

Postpartum Discharge plan Breastfeeding 

Wash your breasts with water daily for cleanliness.



Air dry nipples after each feeding.

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If nipples are sore, apply a few drops of breast milk after a feeding and let air dry.

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If breasts are engorged, apply warm packs and express milk.

Uterine Changes 

After pains, or cramping, are normal. This cramping means that the uterus is contracting to return to its non-pregnant size. The uterus takes 5-6 weeks to return to its non-pregnant size.

Vaginal Discharge 

Usually lasts about 10 days to 4 weeks. The color will change from bright red to brownish to tan and will become less in amount and finally disappear.



Menstruation: your period will resume in approximately 6-8 weeks, unless breastfeeding.

Care of Episiotomy 

Sitz Bath: sitting in a tub of warm water for 15 minutes, 2-3 times per day, will help relieve the discomfort.

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Local agents, such as Tucks, Witch Hazel and Lanacaine, may be applied to the stitches.

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Stitches will dissolve in 1-3 weeks.

Pain Relief 

Use a mild analgesic (Tylenol or Advil) for breast engorgement, uterine cramping and episiotomy discomfort.

Diet & Nutrition



Continue taking your prenatal iron and vitamin pills until your postpartum visit.

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It is important to eat a well-balanced diet and drink plenty of fluids. Drink two quarts of fluid per day if you are breastfeeding.

Emotional Changes 

You may get “baby blues” after delivery. You may feel let down, anxious and cry easily. This is normal. These feelings can begin 2-3 days after delivery and usually disappear in about a week or two. Prolonged sadness may indicate Postpartum Depression.

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Rest! Do not do heavy housework or heavy exercise for two weeks. Avoid driving for 1-2 weeks. Check with your doctor for limitations on activities if you have had a C-Section.

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Avoid sexual activity, douching or tampons until your postpartum visit.

Birth Control 

Is advisable as soon as you resume sexual intercourse. Foam and condoms are safe and easy to use. Birth control methods will be discussed further at your postpartum visit.

Postpartum Visit Call your obstetrician's office 2-3 days after discharge to make an .appointment for 6 weeks :When to call your Doctor/Midwife 

Fever greater than 101, with or without chills.

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Foul-smelling or irritating vaginal discharge.

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Excessive vaginal bleeding.

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Recurrence of bright red vaginal bleeding after it has changed to a rust color.

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Swollen area, painful area on the leg that is red or hot to the touch.

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Burning sensation during urination or an inability to urinate.

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Pain in the vaginal or rectal area.

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Crying and periods of sadness beyond the two weeks.

Source: Vaginal Birth After C-Section (VBAC) | University of Maryland Medical Center http://umm.edu/health/medical/pregnancy/labor-and-delivery/vaginal-birthafter-csection-vbac#ixzz2h7rvOuNr University of Maryland Medical Center

References From my observation. Patient chart. Health team members (nurses and doctor). From patient.

Internet references VBAC.com http://www.webmd.com/baby/vaginal-birth-after-section-vbac-directory Vaginal Birth After Cesarean FAQ - Childbirth.org Cesarean: Beyond the Wound - by Ana Alvarez-Errecalde Vaginal birth after caesarean - Wikipedia, the free encyclopedia Home Birth After Caesarean Vaginal Birth After Cesarean (VBAC) | International Cesarean Awareness Network

References book Lenin (1995) pharmacology, Philadelphia, Lippincoot Company, fourth edition. Pillitter, Adel, maternal and child health nursing, fourth edition. Gil Bert and human, manual of high risk pregnancy and delivery, third edition 2003.

BETHLEHEM UNIVERSITY FACULTY OF NURSING AND HEALTH SCIENCE DEPARTMENT OF NURSING MATERNITY 335 CASE STUDY: NSVD AFTER C-SECTION (VBAC) DONE BY: MUANA MOHAMMAD AL-HEEH PRESENTED TO : WAFA AL KARABLIEH

FALL 2013