Vaginal birth after caesarean section (VBAC)

-When advising about the mode of birth after a previous CS it is important to consider the maternal preferences and priorities, the risks and benefits of repeat CS and the risks and benefits of planned VBAC, including the risk of unplanned (i.e. emergency) CS.

women who have four caesarean sections there is risk of fever, bladder injuries and surgical injuries ,the risk of uterine rupture

Previous c.s increased length of stay in hospital risks of placenta praevia and accreta in future pregnancies.

Criteria for a successful VBAC: Adequate supervision continuous electronic fetal monitoring with CTG. assisted birth are readily available.

Progress of the labour is sufficient, observed both in the descent of the presenting part and by the dilatation of the cervix. The woman and her partner are fully informed about the risks and benefits.

Postoperative care airway control cardiorespiratory stability observations (respiratory rate, heart rate, blood pressure, pain and sedation) should be recorded every 15 minutes in the immediate recovery period (for the first 30 minutes) and there after every half-hour for 2 hours, and hourly

the wound and lochia must be inspected every 30 minutes to detect any ongoing blood loss. If the mother intends to breastfeed, the baby should be put to the breast as soon as possible,

-For women who have had intrathecal opioids, there should be a minimum hourly observation of respiratory rate, sedation and pain scores for at least 12 hours if diamorphine has been administered and for 24 hours in the case of morphine.

- For women who have had epidural opioids or patient-controlled analgesia (PCA) with opioids, there should be routine hourly monitoring of respiratory rate, sedation and pain scores throughout treatment and for at least 2 hours after discontinuation of treatment.

Postoperative analgesia -should be given on a regular basis and may be given in a variety of ways: Ongoing epidural anaesthesia/analgesia. Women should have diamorphine (3 mg) or fentanyl (100 µg) administered into the epidural space for intra- and postoperative

analgesia as it reduces the need for supplemental analgesia after a caesarean section. Intravenous or intramuscular administration of diamorphine (2.5–5 mg) is a suitable

intramuscular or intravenous analgesia should never be given in conjunction with epidural opioids for at least the first 4 hours after administration of the epidural dose because of the cumulative effects and risks of respiratory depression. PCA using opioid analgesics may be offered after caesarean section as an alternative pain relief regimen. Antiemetics (e.g. cyclizine; prochlorperazine) are usually prescribed when opioids are required

Analgesia, such as diclofenac (oral or rectal) or paracetamol (oral, intravenous or rectal) are the mainstays of postoperative analgesia. Oral drugs (e.g. dihydrocodeine, codydramol, ibuprofen or paracetamol).

there are no contraindications (history of kidney disease, sensitivity to nonsteroidal anti-inflammatory drugs [NSAIDs], peptic ulcer, severe brifle asthma), NSAIDs should be offered post-caesarean section as an adjunct to other analgesics, as they reduce the need for the administration of opioids

Care following regional block Following birth under epidural or spinal anaesthesia, the woman may sit up as soon as she wishes, provided her blood pressure is not low. -Women who are recovering well after CS and who do not have complications can eat and drink when they feel hungry or thirsty, at which point the intravenous fluid infusion can be discontinued.

-The baby should remain with the mother unless there is a medical reason for care (e.g. on a special care or neonatal intensive care unit) and indeed they should be transferred to the postnatal ward together once it is safe to do so. of benefit to a woman's psychological health and long-term wellbeing.

Care in the postnatal ward the blood pressure, temperature, respirations and pulse must be checked every 4 hours and recorded using a modified obstetric early warning score chart (MOEWS) -In addition, the wound and lochia should be inspected at the same time.

-Removal of the urinary bladder catheter should be carried out once a woman is mobile after a regional anaesthetic and not sooner than 12 hours after the last epidural ‘top up’ dose.

-urinary symptoms should consider the possible diagnosis of: urinary tract infection, stress incontinence (which occurs in about 4% of women after CS) or urinary tract injury

The mother should be encouraged to move her legs and to perform leg and breathing exercises, however routine respiratory physiotherapy does not need to be offered to women after a caesarean section under general or regional anaesthesia, as it does not improve respiratory outcomes such as coughing, phlegm, body temperature, chest palpation and auscultatory changes.

-get out of bed as soon as possible following a CS, and should also be encouraged to become fully mobile. -Prophylactic low molecular weight heparin and antiembolic or thromboembolic deterrent (‘TED’) stockings should be prescribed.

the first dose of low molecular weight heparin should be delayed until 4 hours after the intrathecal injection or removal of the epidural catheter. -Women who have had a general anaesthetic for CS may feel very tired and drowsy for some hours.

-A woman may complain of a feeling of detachment and unreality and may feel that she does not relate well to the baby. -The woman who is concerned should be reassured and be given the opportunity to talk freely.

The mother must be encouraged to rest as much as possible and tactful advice may need to be given to her visitors. If the mother becomes too tired, help is needed with care for the baby. This should, preferably, take place at the mother's bedside and should include support with breastfeeding. .

-Caesarean section wound care should include: removing the dressing 24 hours after the delivery, assessing the wound for signs of infection (such as increasing pain, redness or discharge) separation or dehiscence, encouraging the woman to wear loose comfortable clothes and cotton underwear,

gently cleaning and drying the wound daily if needed and planning the removal of sutures or clips if required. the obstetrician who undertook the CS to review the woman postpartum, not only in order to discuss the problems that necessitated the surgical intervention, but also to counsel about the options for any future pregnancy.

-heavy and/or irregular vaginal bleeding following CS should be aware that this is more likely to be due to endometritis than retained products of conception. treatment with broad spectrum antibiotics should be implemented rather than referral for ultrasound assessment.

-Whilst the length of hospital stay is likely to be longer after a caesarean section (an average of 3–4 days) than after a vaginal birth (average 1–2 days), stable case transfer to home (after 24 hours) from hospital