Decreasing caesarean delivery rates using a trial of labour after caesarean delivery (TOLAC) bundle: a multisite quality improvement initiative

Objectives To study the efficacy of a trial of labour after caesarean (TOLAC) bundle in decreasing caesarean delivery (CD) rates across five hospitals. Methods Five hospital sites participated, two tertiary-care centres and three community hospitals. Annual delivery rates ranged from 2500 to 7500 per site. A before and after study design was employed. The bundle consisted of three main interventions: (1) education for health care providers, (2) a TOLAC decision aid, and (3) patient educational tools. A one-year chart review determined baseline CD rates in eligible TOLAC patients, according to SOGC guidelines. The bundle interventions were then introduced every four to six months and CD rates were monitored. Obstetrics staff were provided their individual CD rates using an audit-and-feedback approach prior to introduction of the next intervention. Results Baseline CD rate was 77% (1730 out of 2244 eligible patients). Following the introduction of the bundle, the CD rate decreased to 71% (1497 out of 2096 eligible patients). This is a statistically significant 6% decrease in the CD rate, Χ²(1) = 18.29, p Conclusions This TOLAC bundle can decrease CD rates without negatively impacting uterine rupture or NICU admission rates. The interventions can be easily adapted for use in different hospitals and practice environments.