Labour Management in Trial of Labour After C-Section (TOLAC): A Gap Analysis and Quality Improvement Initiative

Abstract Objective This quality improvement (QI) initiative was designed to identify gaps between evidence-based and/or hospital recommendations for TOLAC labour management, and clinical practice. Methods Viable, singleton pregnancies from January 1, 2016 to December 31, 2018 undergoing TOLAC were extracted from the electronic medical record. Sixty (60) randomly selected charts were reviewed for 1) consent 2) induction methods 3) oxytocin use 4) continuous fetal monitoring 5) admission indication 6) exam regularity 7) duration of dystocia prior to decision for cesarean section (CS) 8) maternal complications. Results Institutional VBAC rate was 71%. Documented consent to TOLAC on admission was present in 50% of cases. Oxytocin augmentation was used in 38% of cases and the median max dose was 4 [IQR 3-7.5] mU/min. Delays in initiating oxytocin were identified in 47% of those patients. Decisions to deliver by CS were made after a median time of 5h 40 min [IQR 3h 30m – 6h35m] of failure to progress despite adequate contractions. After this decision, median time to delivery was 1h 11m [IQR 57m – 2h 16m]. Complications included post-partum hemorrhage (5%) and chorioamnionitis (6.7%). Surgical injury occurred in 10% of intrapartum CS. Peri-partum complications were associated with delay in oxytocin implementation (χ2 (1) = 9.80, p Conclusion Areas for QI were identified in 1) consent, 2) duration of dystocia prior to decision for CS and delay to CS delivery, 3) peri-partum complications. We recognize the potential use of this as a tool to identify areas for QI and prospective study.