Advertisement
JOGC

Decreasing Cesarean Delivery Rates Using a Trial of Labour After Cesarean (TOLAC) Bundle

      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

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Obstetrics and Gynaecology Canada
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      REFERENCES

        • Guise JM
        • Eden K
        • Emeis C
        • et al.
        Vaginal birth after cesarean: new insights.
        Evid Rep Technol Assess (Full Rep). 2010; : 1-397
        • Korb D
        • Goffinet F
        • Seco A
        • et al.
        Risk of severe maternal morbidity associated with cesarean delivery and the role of maternal age: a population-based propensity score analysis.
        CMAJ. 2019; 191: E352-EE60
        • Betrán AP
        • Temmerman M
        • Kingdon C
        • et al.
        Interventions to reduce unnecessary caesarean sections in healthy women and babies.
        Lancet. 2018; 392: 1358-1368
        • World Health Organization
        WHO recommendations: non-clinical interventions to reduce unnecessary caesarean sections.
        WHO, Geneva2018
        • Betran AP
        • Torloni MR
        • Zhang JJ
        • et al.
        WHO statement on caesarean section rates.
        BJOG. 2016; 123: 667-670
        • American College of Obstetricians and Gynecologists
        ACOG practice bulletin no. 184: vaginal birth after cesarean delivery.
        Obstet Gynecol. 2017; 130: e217-ee33
        • Public Health Agency of Canada
        Perinatal health indicators for Canada.
        Public Health Agency of Canada, Ottawa2017
        • Dy J
        • DeMeester S
        • Lipworth H
        • et al.
        No. 382—trial of labour after caesarean.
        J Obstet Gynaecol Can. 2019; 41: 992-1011
        • Canadian Institute for Health Information
        Childbirth indicators by place of residence.
        Canadian Institute for Health Information, Ottawa2019
        • Kelly S
        • Sprague A
        • Fell DB
        • et al.
        Examining caesarean section rates in Canada using the Robson classification system.
        J Obstet Gynaecol Can. 2013; 35: 206-214
        • Young CB
        • Liu S
        • Muraca GM
        • et al.
        Mode of delivery after a previous cesarean birth, and associated maternal and neonatal morbidity.
        CMAJ. 2018; 190: E556-EE64
        • Catling-Paull C
        • Johnston R
        • Ryan C
        • et al.
        Non-clinical interventions that increase the uptake and success of vaginal birth after caesarean section: a systematic review.
        J Adv Nurs. 2011; 67: 1662-1676
        • Chaillet N
        • Dumont A.
        Evidence-based strategies for reducing cesarean section rates: a meta-analysis.
        Birth. 2007; 34: 53-64
        • King V
        • Slaughter-Mason S
        • King A
        • et al.
        Improving maternal & neonatal outcomes: toolkit for reducing cesarean deliveries.
        Center for Evidence-Based Policy, Oregon Health & Science University, Portland, OR2013
        • Lundgren I
        • Smith V
        • Nilsson C
        • et al.
        Clinician-centred interventions to increase vaginal birth after caesarean section (VBAC): a systematic review.
        BMC Pregnancy Childbirth. 2015; 15: 16
        • Boatin AA
        • Cullinane F
        • Torloni MR
        • et al.
        Audit and feedback using the Robson classification to reduce caesarean section rates: a systematic review.
        BJOG. 2018; 125: 36-42
      1. Society of Obstetricians and Gynecologists of Canada. Vaginal birth after caesarean section. Available at: https://www.pregnancyinfo.ca/birth/delivery/vaginal-birth-after-caesarean/. Accessed on March 10, 2017.

        • Power to Push Campaign
        Vaginal birth after caesarean and planned repeat caesarean birth.
        2010 (Available at:) (Accessed on March 24, 2017)
        • Association of Ontario Midwives
        Thinking about VBAC: deciding what's right for me.
        2015 (Available at:) (Accessed on March 24, 2017)
        • Royal College of Obstetricians and Gynaecologists
        Birth options after previous caesarean section.
        2016 (Available at:) (Accessed on March 26, 2017)
        • Society of Obstetricians and Gynaecologists of Canada
        SOGC clinical practice guidelines. Guidelines for vaginal birth after previous caesarean birth. Number 155 (replaces guideline Number 147), February 2005.
        Int J Gynaecol Obstet. 2005; 89: 319-331
        • Bernstein SN
        • Matalon-Grazi S
        • Rosenn BM
        Trial of labor versus repeat cesarean: are patients making an informed decision?.
        Am J Obstet Gynecol. 2012; 207 (e1–6): 204
        • Cleary-Goldman J
        • Cornelisse K
        • Simpson LL
        • et al.
        Previous cesarean delivery: understanding and satisfaction with mode of delivery in a subsequent pregnancy in patients participating in a formal vaginal birth after cesarean counseling program.
        Am J Perinatol. 2005; 22: 217-221
        • Renner RM
        • Eden KB
        • Osterweil P
        • et al.
        Informational factors influencing patient's childbirth preferences after prior cesarean.
        Am J Obstet Gynecol. 2007; 196: e14-e16

      Linked Article