Abstract
Objective
To develop and implement a trial of labour after cesarean delivery (TOLAC) bundle—a
group of interventions aimed at decreasing cesarean delivery (CD) for women who have
had a prior CD (Robson group 5).
Methods
A TOLAC bundle was developed that included: (1) educational rounds for health care
providers, (2) a physician–patient TOLAC discussion aid, and (3) patient-centred educational
resources. A before-and-after study design was employed. A one-year chart review determined
baseline CD rates in Robson group 5 patients at a tertiary care academic centre. Following
this, from February 1, 2018 until May 31, 2019, each bundle intervention was sequentially
introduced every four to six months and modified based on provider feedback. Obstetricians
were provided with their individual CD rates using an audit-and-feedback approach
prior to the introduction of the next intervention.
Results
The baseline CD rate for Robson group 5 patients was 71% (175/247 eligible patients).
Following the introduction of the bundle, the CD rate decreased to 61% (131/214 eligible
patients). This was a 10% decrease in the CD rate (P = 0.029). A significant increase in rate of induction was noted, from 5% pre-intervention
to 11% post-intervention (p = 0.017). There were no significant decreases in the rate of vaginal birth after
CD or increases in the rates of uterine rupture or NICU admission.
Conclusions
A TOLAC bundle, consisting of provider education, a TOLAC discussion aid, and patient
resources, combined with audit and feedback, decreased CD for Robson group 5 patients.
Résumé
Objectif
Les auteures avaient pour objectif de concevoir et de mettre en œuvre un programme
d’épreuve de travail après césarienne (EDTAC), soit un ensemble d'interventions visant
à réduire la fréquence des césariennes chez les femmes qui en ont déjà subi une (groupe 5
de Robson).
Méthodologie
Un programme EDTAC a été mis au point en intégrant les points suivants : (1) des visites
formatives pour les fournisseurs de soins de santé, (2) un outil d'aide à la discussion
sur l'EDTAC entre médecin et patiente, (3) des ressources de formation axées sur la
patiente. Une méthodologie d’étude avant-après a été employée. Une revue annuelle
des dossiers a permis de déterminer les taux de césariennes de référence pour les
patientes du groupe 5 de Robson dans un centre hospitalier universitaire de soins
tertiaires. Par la suite, entre le 1er février 2018 et le 31 mai 2019, l'ensemble des interventions du programme ont été
mises en œuvre de manière séquentielle tous les 4 à 6 mois et modifiées à la lumière
des commentaires des fournisseurs de soins. Les obstétriciens ont obtenu leurs taux
individuels de césariennes au moyen d'une méthode de vérification et de rétroaction
avant la mise en œuvre de l'intervention suivante.
Résultats
Le taux de césariennes de référence pour les patientes du groupe 5 de Robson s’élevait
à 71 % (175/247 patientes admissibles). À la suite de la mise en œuvre du programme,
le taux de césariennes est passé à 61 % (131/214 patientes admissibles), ce qui représente
une diminution de 10 % (p = 0,029). Une augmentation significative du taux de déclenchement artificiel du travail
a été observée, lequel est passé de 5 % avant l'intervention à 11 % après l'intervention
(p = 0,017). Il n'y a pas eu de diminution significative du taux d'accouchement vaginal
après césarienne ni d'augmentation des taux de rupture utérine ou d'admission à l'USIN.
Conclusions
La fréquence des césariennes chez les patientes du groupe 5 de Robson a été réduite
grâce au programme EDTAC, qui comprend la formation des fournisseurs, un outil d'aide
à la discussion sur l'EDTAC et des ressources pour les patientes, de pair avec la
vérification et la rétroaction.
Keywords
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Article info
Publication history
Published online: May 10, 2020
Footnotes
Disclosures: This work received support from the Sinai Health System Quality Improvement Project Competition Grant to create the patient educational videos.
All authors have indicated they meet the journal's requirements for authorship.
Identification
Copyright
© 2020 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
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- Corrigendum to ‘Decreasing Cesarean Delivery Rates Using a Trial of Labour After Cesarean (TOLAC) Bundle’ [Journal of Obstetrics and Gynaecology Canada 42 (2020) 1111–1115]Journal of Obstetrics and Gynaecology Canada Vol. 43Issue 9
