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

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.