Decreasing cesarean section rates using a trial of labour after cesarean section (TOLAC) bundle

Objectives To develop and implement a Trial of Labour After Cesarean section (TOLAC) bundle—a group of interventions aimed to decrease the cesarean section (CS) rate in women with a prior CS (Robson 5). Methods A TOLAC bundle was developed including (1) educational rounds for health care providers, (2) a physician-patient TOLAC decision aid, and (3) patient-centered handouts and videos. A before-and-after study design was employed. A one-year chart review determined baseline CS rates in Robson 5 patients at a tertiary care academic center, according to SOGC guidelines. Following this, from February 1, 2018 until May 31, 2019, each bundle intervention was introduced every four to six months and modified based on provider feedback. Obstetrics staff physicians were provided with their individual CS rates using an audit-and-feedback approach prior to introduction of the next intervention. Results Baseline CS rate was 70.9% (175 out of 247 eligible patients). Following the introduction of the bundle, the CS rate decreased to 61.2% (131 out of 214 eligible patients). This is a 9.7% decrease in the CS rate, χ²(1) = 4.77, p = 0.029. Also, a significant increase in induction rate was noted, from 4.9% pre-intervention to 10.7% post-intervention, p = 0.017. There was no significant decrease in the vaginal birth after CS rate or increase in uterine rupture or NICU admission rates. Conclusions A TOLAC bundle consisting of provider education, a TOLAC decision aid, and patient resources, combined with audit and feedback, has the ability to decrease CS rates in Robson 5 patients.