# Application of a specific clinical pathway can affect the choice of trial of labor in patients with a history of cesarean delivery

## TL;DR

Changing hospital practices can safely increase vaginal births after cesarean delivery.

## Contribution

A set of quality improvement interventions successfully increased trial of labor and vaginal births after cesarean.

## Key findings

- Cesarean deliveries decreased from 89.94% to 64.47% after interventions.
- Trial of labor after cesarean increased from 13.18% to 42.12%.
- Successful vaginal birth after cesarean increased from 76.27% to 84.35%.

## Abstract

Mode of delivery in women with previous history of cesarean delivery (CD) is highly modifiable by the practices of the delivery unit. Vaginal birth after a cesarean (VBAC) delivery is a safe and preferred alternative in most cases. The aim of this study was to assess the impact of adopting a complex set of measures aimed at the mode of delivery in this group.

This was a retrospective observational study comparing two birth cohorts before and after the implementation of a series of quality improvement (QI) interventions. The study cohorts comprised women with a history of cesarean delivery who gave birth in the period before (January 2013 – December 2015) and after (January 2018 – December 2020) the adoption of the QI measures. The measures were focused on singleton term cephalic pregnancies with a low transverse incision in the uterus. Measures included approval of all planned CDs by a senior obstetrician, re-training staff on the use of the FIGO classification for intrapartum fetal cardiotocogram, establishing VBAC management guidelines, encouraging epidural analgesia during trial of labor after cesarean (TOLAC), establishing a labor ward team and introducing a monthly maternity audit.

Term singleton cephalic pregnancies with previous history of CD accounted for 12.55% of all births in the pre-intervention period and 12.01% in the post-intervention period. The frequency of cesarean deliveries decreased from 89.94% in the pre-intervention period to 64.47% in the post-intervention period (p < 0.0001). We observed a significant increase in TOLAC from 13.18 to 42.12% (p<0.0001) and also an increase in successful VBAC from 76.27 to 84.35% (p < 0.0001). All changes occurred without statistically significant change in overall perinatal mortality.

This study demonstrates the feasibility to safely increase trial of labor and vaginal birth after cesarean delivery by implementing a series of quality improvement interventions and clinical pathway changes.

The online version contains supplementary material available at 10.1186/s12884-024-06429-8.