The following is a summary of “Application of a specific clinical pathway can affect the choice of trial of labor in patients with a history of cesarean delivery,” published in the April 2024 issue of Obstetrics and Gynecology by Psenkova et al.

The mode of delivery for women with a prior cesarean delivery (CD) history can be significantly influenced by the protocols established within the delivery unit. Vaginal birth after cesarean (VBAC) is widely recognized as a safe and preferable option for many individuals in this population. This study aimed to evaluate the impact of implementing a comprehensive set of interventions targeting delivery mode decisions in this patient cohort. Through a retrospective observational analysis, researchers compared two cohorts of births occurring before (January 2013 – December 2015) and after (January 2018 – December 2020) the implementation of quality improvement (QI) measures. 

These measures were specifically tailored for singleton-term cephalic pregnancies with a prior low transverse uterine incision. Interventions included senior obstetrician approval for planned CDs, staff re-training on intrapartum fetal cardiotocogram interpretation, establishment of VBAC management guidelines, promotion of epidural analgesia during trial of labor after cesarean (TOLAC), formation of a labor ward team, and introduction of monthly maternity audits. Results revealed that while term singleton cephalic pregnancies with a history of CD remained consistent across both periods, there was a substantial reduction in the frequency of cesarean deliveries from 89.94% pre-intervention to 64.47% post-intervention (p < 0.0001). 

Importantly, there was a notable increase in TOLAC rates from 13.18% to 42.12% (p < 0.0001) and successful VBAC rates from 76.27% to 84.35% (p < 0.0001). Remarkably, these changes occurred without statistically significant overall perinatal mortality alterations. These findings underscore the effectiveness and safety of implementing QI interventions and clinical pathway modifications to enhance the trial of labor and VBAC rates in women with prior CD history.

Source: bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-024-06429-8