TOLAC bundle empowers healthcare providers and patients with resources on alternatives to repeat caesarean delivery

Caesarean delivery rates are on the rise. After a primary caesarean birth, patients who become pregnant again must decide between undergoing a repeat caesarean or a trial of labor. While caesarean deliveries may be required to ensure a safe delivery, they are associated with increased maternal morbidity in addition to hospital expense. Trial of Labour After Caesarean (TOLAC) is when a patient with a previous caesarean section labours with the goal of having a vaginal delivery. For many patients, TOLAC is a safe alternative to repeat caesarean delivery.

The Trial of Labour After Caesarean (TOLAC) bundle was created and tested as a quality improvement initiative across five hospital sites in the greater Toronto area between 2018 and 2020. The TOLAC bundle aims to provide education to patients and clinicians in considering TOLAC as a possible safe alternative to repeat caesarean delivery. The project began at St. Michael's Hospital as a small single-site resident research project led by Dr. Elizabeth Miazga, focused on TOLAC delivery data. Now a MIGS fellow at St. Mike's, Miazga is continuing this work in collaboration with Dr. Eliane Shore, assistant professor and obstetrician-gynaecologist at St. Michael's Hospital, as well as received quality improvement advice from Dr. Amanda Cipolla, lecturer and obstetrician-gynaecologist at Trillium Health Partners.

The project expanded to four Greater Toronto Area hospitals with associated site leads: North York General Hospital (Dr. Modupe Tunde-Byass, assistant professor), Mount Sinai Hospital (Dr. Jodi Shapiro, assistant professor), and Trillium Health Partners (Dr. Amanda Cipolla, lecturer). As part of this project, the TOLAC bundle has three main interventions including healthcare provider education, a patient discussion aid, and patient education resources, all with the goal of equipping obstetrical care providers and patients with information about alternatives to repeat caesarean delivery and as a result, increasing the TOLAC rate.

“This project would not have been possible without our amazing team of staff physicians, residents and medical students who studied the bundle in 2097 patients across the GTA,” said Miazga. “We hope through this website, our resources can reach more people and be a useful tool to engage obstetrical care providers and patients in shared decision making on TOLAC.”

As part of providing healthcare provider education, each hospital hosted grand rounds on TOLAC delivery as an introduction to the bundle. The bundle was also combined with audit-and-feedback data for obstetrical staff including individual performance data on the rates of elective repeat caesarean delivery (ERCD) and vaginal birth after caesarean (VBAC).

The data revealed increased TOLAC rates at all sites and decreased caesarean delivery rates, both elective and in labour. All sites also showed an increased rate of induction of labour in patients with a previous caesarean section. The rate of successful TOLAC, or VBAC, remained stable at all sites. Throughout, there was no increase in the rate of uterine rupture or neonatal intensive care unit admissions, according to research on the bundle.

"Working on this bundle was a great opportunity to collaborate with colleagues and students across multiple U of T hospital sites,” said Shore. “It's inspiring to see the positive effects of our project on patients and providers.”

In response to the success of the project and site demand for resources and information, the TOLAC website was created to house all the resources for patients and clinicians. Initial findings from the pilot site have been published in the Journal of Obstetrics and Gynecology Canada and a summary of TOLAC for healthcare providers titled “5 Things to know about Trial of Labour After Caesarean” in the Canadian Medical Association Journal (CMAJ). The bundle has been presented at multiple conferences and selected as a top-rated abstract at the RCOG World Congress in 2021.