1. 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

2. 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 .

3. 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
(Early). In this phase, the mother feels slow, rhythmic contractions. The
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.

4. 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
5 U of oxytocin IM after delivery of anterior shoulder
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
Massage 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

5. 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,

6. 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,

7. 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
Serology /I mmun HBSAG
HBSAG/SCREEN
Meaning of
abnormal values
Normal
Normal
normal
normal
Negative
Urine analysis
Straw
Clear
Alkaline
Nill
Color
Appearance
Ph
Bacteria
Medication
Medication
ceftriaxone
Rocephin
I.V
N/S 150cc
uses
rational
is used to treat
Prophylactic
many kinds of
from
bacterial
infection
infections,
including severe
or lifethreatening
forms such as
Contraindicat side effect
ion
kidney
disease (or
if you are on
dialysis);
liver
disease;
diabetes;
gallbladder
diarrhea that is
watery or
bloody
fever, chills,
swollen glands,

8. meningitis
disease;
a stomach
or intestinal
disorder
such as
colitis;
if you are
allergic to
penicillin.
rash or itching,
joint pain, or
general ill
feeling
unusual
bleeding (nose,
mouth, vagina,
or rectum),
purple or red
pinpoint spots
under your
skin
Syntocinon
30unit with R/L
500ccc., I.V.
Induce and
augmentation
of labour,
stimulate
uterine
contractions,
for post
hemorrhage.
Syntocinon is
used to
Induce &
augmentation
of labour
Hypertonic
uterine action,
Mechanical
obstruction to
delivery, Fail
trial labour, Fetal
distress, placenta
preavia,.
Violent uterine
contraction
leads to rupture
& fetal
asphyxiation,
arrhythmias,
maternal
hypertension,.
Pithidinh
100mg IM
opioid
analgesic,
prescribed for
moderate to
severe pain, for
example labor
pain, before and
during a
surgical
operation. It
changes the
way the body
senses pain.
Labor pain ,
Episiotomy
procedure
patients with
history of severe
respiratory
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.
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.
4 hourly

9. 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.

10. 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
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
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 csection. 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.

11. 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:
DIAGNOSIS1-:
Pain re: RML episiotomy, puffy perineum manifested by client compalain.
NURSING GOALS:
1. Within 1 hour of receiving pain medication, client will state pain level has
been reduced to “0-2" on pain scale.
2. Throughout shift, client will state that perineal pain has lessened to a
tolerable level.
NURSING INTERVENTIONS:
1. Assess client’s pain level throughout shift (ask client to identify level

12. 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.
2. Offer analgesics per doctors order
Rationale: to maintain client’s comfort level by controlling pain and
preventing it to escalate.
3. Apply ice pack to perineum prn.
Rationale: to reduce swelling and numb perineum in order to relieve pain.
4. Offer sitz bath to client per doctor’s order.
Rationale: warm water cleansing the perineum is soothing and reduces
pain. The warm water will encourage blood flow to the area, encouraging
healing.
5. Visually assess the client’s perineal area qshift.
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

13. 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:
1)Checked the site of the episiotomy .
Rational: To observe for any bleeding or discharge which is media for
organisms growth
2-Teach client how to cleanse perineal area (cleanse from front to back
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
.
3)Checked the V/S (temp).
Rational: Because V/S indicate infection
.
4) Observe the CBC test (WBC) to discover if there is any kind of
infection
.
5)Teach the client about signs and symptoms of the wound infection like
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.

14. 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.
1))Nursing Diagnosis : risk for alteration in bowel elimination
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
Rational: to encourage the peristalsis movement.
Evaluation : bowel eliminations normal as pt states

15. 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 obgyns," 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,

16. 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.

17. 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.
There may be more blood loss.
The cut and the stitches may get infected.
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
If labor is stressful for the baby and the pushing phase needs to be shortened
to decrease problems for the baby
If the baby's head or shoulders are too big for the mother's vaginal opening
If the baby is in a breech position (feet or buttocks coming first) and there is a
problem during delivery
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.

18. 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 mediolateral.
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.
Perform perineal massage during the 4 - 6 weeks before birth.
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):21412148.
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.

19. Postpartum Discharge plan
Breastfeeding
Wash your breasts with water daily for cleanliness.
Air dry nipples after each feeding.
If nipples are sore, apply a few drops of breast milk after a feeding and let air
dry.
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.
Local agents, such as Tucks, Witch Hazel and Lanacaine, may be applied to
the stitches.
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.
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.

20. 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.
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.
Foul-smelling or irritating vaginal discharge.
Excessive vaginal bleeding.
Recurrence of bright red vaginal bleeding after it has changed to a rust color.
Swollen area, painful area on the leg that is red or hot to the touch.
Burning sensation during urination or an inability to urinate.
Pain in the vaginal or rectal area.
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

21. 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
book References
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.

22. 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