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Objective To develop and implement a trial of labour after cesarean delivery (TOLAC) bundle—a group of interventions aimed at decreasing cesarean delivery (CD) for women who have had a prior CD (Robson group 5). Methods A TOLAC bundle was developed that included: (1) educational rounds for health care providers, (2) a physician–patient TOLAC discussion aid, and (3) patient-centred educational resources. A before-and-after study design was employed. A one-year chart review determined baseline CD rates in Robson group 5 patients at a tertiary care academic centre. Following this, from February 1, 2018 until May 31, 2019, each bundle intervention was sequentially introduced every four to six months and modified based on provider feedback. Obstetricians were provided with their individual CD rates using an audit-and-feedback approach prior to the introduction of the next intervention. Results The baseline CD rate for Robson group 5 patients was 71% (175/247 eligible patients). Following the introduction of the bundle, the CD rate decreased to 61% (131/214 eligible patients). This was a 10% decrease in the CD rate (P = 0.029). A significant increase in rate of induction was noted, from 5% pre-intervention to 11% post-intervention (p = 0.017). There were no significant decreases in the rate of vaginal birth after CD or increases in the rates of uterine rupture or NICU admission. Conclusions A TOLAC bundle, consisting of provider education, a TOLAC discussion aid, and patient resources, combined with audit and feedback, decreased CD for Robson group 5 patients.

Objective To examine rates of cesarean delivery (CD) and vaginal birth after cesarean delivery (VBAC) and the patient profile in a community-based obstetrical practice. Methods Retrospective data from 2012 to 2017 for the Sioux Lookout Meno Ya Win Health Centre (SLMHC) were compared to data from the 30 hospitals providing the same level of services (Maternity 1b: maternity care by family physicians/midwives with CD and VBAC capacity) and Ontario. SLMHC VBAC patients were then compared to the general SLMC obstetrical population. Data included maternal age, parity, comorbidities, CD, VBAC, neonatal birth weight, and Apgar scores. Results The SLMHC obstetrical population differed from comparable obstetrical programs, with significantly higher rates of alcohol, tobacco, and opioid use and a higher prevalence of diabetes. CD rates were significantly lower (25% vs. 28%), and women delivering at SLMHC chose a trial of labour after CD almost twice as often (46% vs. 27%), resulting in a significantly higher VBAC rate (31% vs. 16%). Patients in the VBAC population differed from the general SLMHC obstetrical population, being older (7 years) and of greater parity. The neonates of VBAC patients had equivalent Apgar scores but lower rates of macrosomia and lower birth weights, although the average VBAC birth weight at 3346 g was equivalent to the provincial average. Conclusion The SLMHC obstetrical program has lower CD and higher VBAC rates than expected, despite prevalent risk factors typically associated with CD. Our study demonstrates that VBAC can be safely performed in well-screened and monitored patients in a rural setting with emergency CD capacity.

To compare the demographic and clinical characteristics between women who chose elective repeat Caesarean section (ERCS) versus trial of labour after Caesarean section (TOLAC) in St. John's, Newfoundland and Labrador (NL).We conducted a retrospective case control study of women with live singleton gestations delivering at term in St. John's, NL between January 1, 2001 and December 31, 2014. Inclusion criteria were women who had a previous single lower segment Caesarean section (LSCS). TOLAC, successful TOLAC, and VBAC rates were calculated. Demographic and clinical characteristics were compared between women who chose ERCS versus TOLAC. Univariate analyses and multiple logistic regression analyses were performed, and adjusted odds ratios (aOR) and 95% CIs were calculated.A total of 1579 women were included, of whom 160 (10.1%) chose TOLAC, with 107 resulting in successful VBAC (67% successful TOLAC rate). The overall VBAC rate was 6.8%. Women who chose ERCS compared with those who chose TOLAC were more likely to be obese (aOR 3.20, 95% CI 1.85-5.54, P 0.001), less likely to have had GA at delivery greater than 40 weeks (aOR 0.13, 95% CI 0.08-0.21, P 0.001), less likely to have had a previous vaginal delivery (aOR 0.40, 95% CI 0.20-0.80, P 0.001), and less likely to have had the previous CS for breech presentation (aOR 0.51, 95% CI 0.33-0.80, P = 0.003).The overall TOLAC and VBAC rates in St. John's are low when compared with reported national rates. The successful TOLAC rate is within the expected range reported in the literature. Differences exist between women who chose ERCS compared with TOLAC.

Objective To determine the proportion of women in Robson group 5 (RG5) who were eligible for a trial of labour after Caesarean (TOLAC) and, among eligible candidates, identify determinants of having a TOLAC and subsequent vaginal delivery (VD). Methods This population-based cohort study used data derived from the Nova Scotia Atlee Perinatal Database. Deliveries from 1998–2014 to women in RG5 (≥1 previous CS with a singleton term cephalic fetus) were included. Eligibility for a TOLAC was based on SOGC criteria. Multivariable logistic regression was used to identify characteristics independently associated with TOLAC and VD. The characteristics associated with VD were used in a logistic model to predict the theoretical probability of VD in women who did not have a TOLAC. Results Of the 15 111 deliveries in RG5, 75.3% were by CS. Of the 14 763 eligible women, 5488 (37.2%) had a TOLAC, of which 3739 (68.1%) resulted in VD. Predictors of VD included high area–level income and either a CS without labour or a spontaneous VD in the preceding pregnancy. While mode of previous delivery also predicted TOLAC among eligible women, high area–level income was associated with reduced odds of TOLAC. The probability of VD in women who did not undergo TOLAC was estimated to be 47.1%, and the lowest CS rate attainable in RG5 was estimated at 46.3%. Conclusions Sociodemographic factors such as income and previous mode of delivery were associated with the rates of TOLAC and subsequent VD in eligible women, and suggest that the Caesarean section rate in RG5 could be safely reduced.

Objective To provide evidence-based guidelines for the provision of a trial of labour (TOL) after Caesarean section. Outcome Fetal and maternal morbidity and mortality associated with vaginal birth after Caesarean (VBAC) and repeat Caesarean section. Evidence MEDLINE database was searched for articles published from January 1, 1995, to February 28, 2004, using the key words "vaginal birth after Caesarean (Cesarean) section." The quality of evidence is described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on the Periodic Health Exam. Recommendations 1.Provided there are no contraindications, a woman with 1 previous transverse low-segment Caesarean section should be offered a trial of labour (TOL) with appropriate discussion of maternal and perinatal risks and benefits. The process of informed consent with appropriate documentation should be an important part of the birth plan in a woman with a previous Caesarean section (II-2B). 2.The intention of a woman undergoing a TOL after Caesarean section should be clearly stated, and documentation of the previous uterine scar should be clearly marked on the prenatal record (II-2B). 3.For a safe labour after Caesarean section, a woman should deliver in a hospital where a timely Caesarean section is available. The woman and her health care provider must be aware of the hospital resources and the availability of obstetric, anesthetic, pediatric, and operating-room staff (II-2A). 4.Each hospital should have a written policy in place regarding the notification and (or) consultation for the physicians responsible for a possible timely Caesarean section (III-B). 5.In the case of a TOL after Caesarean, an urgent laparotomy should be set-up immediately to facilitate delivery as quickly as possible (III-C). 6.Continuous electronic fetal monitoring of women attempting a TOL after Caesarean section is recommended (II-2A). 7.Suspected uterine rupture requires urgent attention and expedited laparotomy to attempt to decrease maternal and perinatal morbidity and mortality (II-2A). 8.Oxytocin augmentation is not contraindicated in women undergoing a TOL after Caesarean section (II-2A). 9.Medical induction of labour with oxytocin may be associated with an increased risk of uterine rupture and should be used carefully after appropriate counselling (II-2B). 10.Medical induction of labour with prostaglandin E2 (dinoprostone) is associated with an increased risk of uterine rupture and should not be used except in rare circumstances and after appropriate counselling (II-2B). 11.Prostaglandin E1 (misoprostol) is associated with a high risk of uterine rupture and should not be used as part of a TOL after Caesarean section (II-2A). 12.A Foley catheter may be safely used to ripen the cervix in a woman planning a TOL after Caesarean section (II-2A). 13.The available data suggest that a trial of labour in women with more than 1 previous Caesarean section is likely to be successful but is associated with a higher risk of uterine rupture (II-2B). 14.Multiple gestation is not a contraindication to TOL after Caesarean section (II-2B). 15.Diabetes mellitus is not a contraindication to TOL after Caesarean section (II-2B). 16.Suspected fetal macrosomia is not a contraindication to TOL after Caesarean section (II-2B). 17.Women delivering within 18 months of a Caesarean section should be counselled about an increased risk of uterine rupture in labour (II-2B). 18.Postdatism is not a contraindication to a TOL after Caesarean section (II-2B). 19.Every effort should be made to obtain the previous Caesarean section operative report to determine the type of uterine incision used. In situations where the scar is unknown, information concerning the circumstances of the previous delivery is helpful in determining the likelihood of a low transverse incision. If the likelihood of a lower transverse incision is high, a TOL after Caesarean section can be offered (II-2B). Validation These guidelines were approved by the Clinical Practice Obstetrics and Executive Committees of the Society of Obstetricians and Gynaecologists of Canada.

Objectives To understand the current attitudes and practice patterns of prenatal and intrapartum care providers regarding Trial of Labour After Cesarean Section (TOLAC) and to assess misconceptions regarding eligibility and risks of TOLAC. Methods A survey was developed based on published TOLAC literature, validated by a statistician, and piloted amongst university-affiliated faculty. French and English versions were distributed via the SOGC mailing list. Practicing obstetrical care providers with an office antenatal practice were eligible to participate. Data were analyzed using descriptive statistics, correlational and multiple regression analysis. Results The response rate was 33.7% (381/1130 eligible participants) with representation from every Canadian province and territory. Obstetricians/Gynecologists (239, 63%), Family Physicians (100, 26%) and Midwives (42, 11%) responded. Most participants (277, 78%) thought that TOLAC should be actively encouraged. Only 141 (40%) used a decision aid when counselling patients, although the majority of respondents (250, 71%) thought it would be useful. Providers were less comfortable offering oxytocin compared with cervical foley or amniotomy for induction and offering TOLAC to patients with an unknown uterine scar. Providers in Alberta and Saskatchewan reported more comfort offering TOLAC to patients with more than one previous cesarean section compared to other provinces. Two hundred and nine participants (62%) reported that they had at least one patient with a uterine rupture, with the minority (13, 6%) resulting in litigation. Conclusions This study offers new information on current national practice patterns and provider attitudes regarding TOLAC. These results can be used to guide future educational initiatives to increase TOLAC rates.

Objectives 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 ((1) = 9.80, p Conclusions 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.

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.

Objectives To develop and implement a Trial of Labour After Cesarean section (TOLAC) bundle—a group of interventions aimed to decrease the cesarean section (CS) rate in women with a prior CS (Robson 5). Methods A TOLAC bundle was developed including (1) educational rounds for health care providers, (2) a physician-patient TOLAC decision aid, and (3) patient-centered handouts and videos. A before-and-after study design was employed. A one-year chart review determined baseline CS rates in Robson 5 patients at a tertiary care academic center, according to SOGC guidelines. Following this, from February 1, 2018 until May 31, 2019, each bundle intervention was introduced every four to six months and modified based on provider feedback. Obstetrics staff physicians were provided with their individual CS rates using an audit-and-feedback approach prior to introduction of the next intervention. Results Baseline CS rate was 70.9% (175 out of 247 eligible patients). Following the introduction of the bundle, the CS rate decreased to 61.2% (131 out of 214 eligible patients). This is a 9.7% decrease in the CS rate, χ²(1) = 4.77, p = 0.029. Also, a significant increase in induction rate was noted, from 4.9% pre-intervention to 10.7% post-intervention, p = 0.017. There was no significant decrease in the vaginal birth after CS rate or increase in uterine rupture or NICU admission rates. Conclusions A TOLAC bundle consisting of provider education, a TOLAC decision aid, and patient resources, combined with audit and feedback, has the ability to decrease CS rates in Robson 5 patients.

Objectives Classical cesarean section may be associated with increased short- and long-term risks. The objectives of this study were to review the following systematically: first, the short-term maternal and infant risks with preterm classical compared with low transverse cesarean sections; and second, the risk of spontaneous or early-labour uterine rupture. Data sources Medline, EMBASE, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov from January 1980 to July 2018. Study selection A total of 772 studies were independently screened by two reviewers, and 91 full texts were reviewed. The review included nine studies comparing outcomes after preterm classical versus low transverse cesarean section and 15 studies addressing subsequent pregnancy outcomes. Data synthesis Our primary short-term outcomes were maternal death and intensive care unit (ICU) admission. For subsequent pregnancies, our primary outcome was the risk of spontaneous or early-labour uterine rupture. The data were synthesized using random effects, and odds ratios (ORs) and 95% confidence intervals (CIs) were generated. There were no significant differences between preterm classical and low transverse cesarean sections in the odds of maternal death (OR 2.38; 95% CI 0.15–38.07) or ICU admission (adjusted OR 2.38; 95% CI 0.42–13.35). A subgroup from 28 to 31 weeks gestation had increased risks of endometritis, transfusion, and ICU admission with the classical incision. The low vertical incision was associated with a lower odds of organ injury than was the low transverse incision. The incidence of uterine rupture following the classical incision without a trial of labour was 1%. Conclusion Preterm classical cesarean section is not associated with significantly increased risks, but data are scarce. Subsequent uterine rupture risk when not planning a trial of labour is 1%.

Objective The purpose of this study was to evaluate pregnancy outcomes in a cohort of women with a placental edge between 11 and 20mm from the internal cervical os, and to determine the likelihood of a successful vaginal delivery when trial of labour is attempted in these women. Methods We carried out a prospective observational study of women with singleton pregnancies and a placental edge between 11 and 20mm from the internal cervical os (identified by transvaginal sonography) who underwent a trial of labour. Results Fourteen women with the above characteristics underwent a trial of labour during the study period. The mean interval (± SD) from ultrasound to delivery was 17.2±9.6 days. Thirteen women (92.9%) delivered vaginally with no complications, and only one woman (7.1%) required an emergency Caesarean section for intrapartum bleeding. The risks of antepartum and postpartum hemorrhage were 21.4% and 14.3%, respectively. Conclusion Having a placental edge more than 10mm from the internal os, measured by transvaginal sonography near term, justifies allowing a trial of labour and carries a low risk of subsequent obstetrical hemorrhage.

Pregnant women with a previous Caesarean section face making the decision to undergo an elective repeat Caesarean section or to attempt a trial of labour with the goal of achieving a vaginal birth after Caesarean (VBAC). One of the key factors in counselling these women is the probability of a successful VBAC. We aimed to validate a prediction model for VBAC success.We performed an analysis of women at term with one prior low-transverse Caesarean section and a live cephalic singleton pregnancy who attempted a trial of labour after Caesarean (TOLAC) at 32 hospitals in Quebec between 2008 and 2012. The individual TOLAC probabilities of success were calculated without regard to ethnicity, using a prediction model previously developed in the United States. The predictive ability of the model was assessed using receiver operating characteristic curves and the area under the curve (AUC). In addition, a calibration curve was generated by plotting the predicted and observed VBAC rates.Of 3113 eligible women who underwent TOLAC, we found an overall rate of VBAC of 75.3%. Beyond a predicted probability of 40%, both observed and predicted TOLAC success rates were similar. The accuracy of the model was high (AUC = 0.72; 95% CI 0.70 to 0.74, P0.001) as was the correlation between observed and predicted probabilities of TOLAC success (R² = 0.98). Finally, for women requiring induction of labour, observed and predicted probabilities were similar for a predicted probability ≥ 70%.It is possible to estimate VBAC success accurately in Quebec using a validated prediction model from the United States. This model may be used in practice without regard to ethnicity as a primary method to refine counselling during antepartum visits for women with a prior Caesarean section.

Objectives To review the physiology of breech birth; to discern the risks and benefits of a trial of labour versus planned Caesarean section; and to recommend to obstetricians, family physicians, midwives, obstetrical nurses, anaesthesiologists, pediatricians, and other health care providers selection criteria, intrapartum management parameters, and delivery techniques for a trial of vaginal breech birth. Options Trial of labour in an appropriate setting or delivery by pre-emptive Caesarean section for women with a singleton breech fetus at term. Outcomes Reduced perinatal mortality, short-term neonatal morbidity, long-term infant morbidity, and short- and long-term maternal morbidity and mortality. Evidence Medline was searched for randomized trials, prospective cohort studies, and selected retrospective cohort studies comparing planned Caesarean section with a planned trial of labour; selected epidemiological studies comparing delivery by Caesarean section with vaginal breech delivery; and studies comparing long-term outcomes in breech infants born vaginally or by Caesarean section. Additional articles were identified through bibliography tracing up to June 1, 2008. Values The evidence collected was reviewed by the Maternal Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and quantified using the criteria and classifications of the Canadian Task Force on Preventive Health Care. Validation This guideline was compared with the 2006 American College of Obstetrician's Committee Opinion on the mode of term singleton breech delivery and with the 2006 Royal College of Obstetrician and Gynaecologists Green Top Guideline: The Management of Breech Presentation. The document was reviewed by Canadian and International clinicians with particular expertise in breech vaginal delivery. Sponsors The Society of Obstetricians and Gynaecologists of Canada. Summary Statements 1.Vaginal breech birth can be associated with a higher risk of perinatal mortality and short-term neonatal morbidity than elective Caesarean section. (I) 2.Careful case selection and labour management in a modern obstetrical setting may achieve a level of safety similar to elective Caesarean section. (II-1) 3.Planned vaginal delivery is reasonable in selected women with a term singleton breech fetus. (I) 4.With careful case selection and labour management, perinatal mortality occurs in approximately 2 per 1000 births and serious short-term neonatal morbidity in approximately 2% of breech infants. Many recent retrospective and prospective reports of vaginal breech delivery that follow specific protocols have noted excellent neonatal outcomes. (II-1) 5.Long-term neurological infant outcomes do not differ by planned mode of delivery even in the presence of serious short-term neonatal morbidity. (I) Recommendations Labour Selection Criteria 1.For a woman with suspected breech presentation, pre- or early labour ultrasound should be performed to assess type of breech presentation, fetal growth and estimated weight, and attitude of fetal head. If ultrasound is not available, Caesarean section is recommended. (II-1A) 2.Contraindications to labour include a.Cord presentation (II-3A) b.Fetal growth restriction or macrosomia (I-A) c.Any presentation other than a frank or complete breech with a flexed or neutral head attitude (III-B) d.d. Clinically inadequate maternal pelvis (III-B) e.Fetal anomaly incompatible with vaginal delivery (III-B) 3.Vaginal breech delivery can be offered when the estimated fetal weight is between 2500g and 4000g. (II-2B) Labour Management 4.Clinical pelvic examination should be performed to rule out pathological pelvic contraction. Radiologic pelvimetry is not necessary for a safe trial of labour; good progress in labour is the best indicator of adequate fetal-pelvic proportions. (III-B) 5.Continuous electronic fetal heart monitoring is preferable in the first stage and mandatory in the second stage of labour. (I-A) When membranes rupture, immediate vaginal examination is recommended to rule out prolapsed cord. (III-B) 6.In the absence of adequate progress in labour, Caesarean section is advised. (II-1A) 7.Induction of labour is not recommended for breech presentation. (II-3B) Oxytocin augmentation is acceptable in the presence of uterine dystocia. (II-1A) 8.A passive second stage without active pushing may last up to 90 minutes, allowing the breech to descend well into the pelvis. Once active pushing commences, if delivery is not imminent after 60 minutes, Caesarean section is recommended. (I-A) 9.The active second stage of labour should take place in or near an operating room with equipment and personnel available to perform a timely Caesarean section if necessary. (III-A) 10.A health care professional skilled in neonatal resuscitation should be in attendance at the time of delivery. (III-A) Delivery Technique 11.The health care provider for a planned vaginal breech delivery needs to possess the requisite skills and experience. (II-1A) 12.An experienced obstetrician-gynaecologist comfortable in the performance of vaginal breech delivery should be present at the delivery to supervise other health care providers, including a trainee. (I-A) 13.The requirements for emergency Caesarean section, including availability of the hospital operating room team and the approximate 30-minute timeline to commence a laparotomy, must be in accordance with the recommendations of the SOGC Policy Statement, "Attendance at Labour and Delivery" (CPG No. 89; update in press, 2009). (III-A) 14.The health care provider should have rehearsed a plan of action and should be prepared to act promptly in the rare circumstance of a trapped after-coming head or irreducible nuchal arms: symphysiotomy or emergency abdominal rescue can be life saving. (III-B) 15.Total breech extraction is inappropriate for term singleton breech delivery. (II-2A) 16.Effective maternal pushing efforts are essential to safe delivery and should be encouraged. (II-1A) 17.At the time of delivery of the after-coming head, an assistant should be present to apply suprapubic pressure to favour flexion and engagement of the fetal head. (II-3B) 18.Spontaneous or assisted breech delivery is acceptable. Fetal traction should be avoided, and fetal manipulation must be applied only after spontaneous delivery to the level of the umbilicus. (III-A) 19.Nuchal arms may be reduced by the Lovset or Bickenbach manoeuvres. (III-B) 20.The fetal head may deliver spontaneously, with the assistance of suprapubic pressure, by Mauriceau-Smellie-Veit manoeuvre, or with the assistance of Piper forceps. (III-B) Setting and Consent 21.In the absence of a contraindication to vaginal delivery, a woman with a breech presentation should be informed of the risks and benefits of a trial of labour and elective Caesarean section, and informed consent should be obtained. A woman's choice of delivery mode should be respected. (III-A) 22.The consent discussion and chosen plan should be well documented and communicated to labour-room staff. (III-B) 23.Hospitals offering a trial of labour should have a written protocol for eligibility and intrapartum management. (III-B) 24.Women with a contraindication to a trial of labour should be advised to have a Caesarean section. Women choosing to labour despite this recommendation have a right to do so and should not be abandoned. They should be provided the best possible in-hospital care. (III-A) 25.The Society of Obstetricians and Gynaecologists of Canada (SOGC), in collaboration with the Association of Professors of Obstetrics and Gynaecology (APOG), The College of Family Physicians of Canada (CFPC), and The Canadian Association of Midwives (CAM) should revise the training requirements at the undergraduate and postgraduate levels. SOGC will continue to promote training of current health care providers through the MOREOB, ALARM (Advances in Labour and Risk Management), and other courses. (III-A) 26.Theoretical and hands-on breech birth training simulation should be part of basic obstetrical skills training programs such as ALARM, ALSO (Advanced Life Support Training in Obstetrics), and MOREOB to prepare health care providers for unexpected vaginal breech births. (III-B)

To determine differences between family physicians and obstetricians in rates of trial of labour (TOL) attempt, vaginal birth after Caesarean section (VBAC) success, and maternal-fetal complications.We undertook a database evaluation study in an urban Quebec secondary care hospital centre that serves a multiethnic population. Study subjects were pregnant women with at least one previous Caesarean section (CS), who delivered singletons at St. Mary's Hospital Center between January 1995 and December 2003. Outcomes were rates of TOL attempt, of VBAC success and failure, and of uterine rupture or dehiscence.Of 32 500 singleton deliveries, 3694 (11.4%) women met study criteria. Of these, 3493 (94.6%) were patients of obstetricians, and 201 (5.4%) were patients of family physicians. The TOL attempt rate was 50.6% (1768) and 81.1% (163) for obstetricians and family physicians, respectively (P 0.001). For women having TOL, the VBAC success rate was 64.3% for obstetricians and 76.1% for family physicians (P = 0.002). Rates of uterine rupture or dehiscence in the combined failed and successful VBAC groups were 2.9% for obstetricians and 4.3% for family physicians (P = 0.33) whereas in the failed VBAC group the rates were 7.9% versus 17.9% for the family physicians (P = 0.04). Within delivery outcomes for successful and failed VBAC there were no differences in maternal characteristics and newborn outcomes by physician group.More patients of family physicians than of obstetricians attempted TOL and had successful VBAC. Newborn outcomes were similar in the two groups, except that in the failed VBAC group, the family doctors had slightly higher uterine rupture or dehiscence rates; given the low power of this study, further studies are needed to confirm and explain this result. Also, given the similarity in patient profiles, the differences in delivery outcomes may be attributable to differences in physician practice styles.

Objective: To compare maternal and neonatal outcomes in twin gestations with a vertex presenting first twin undergoing either an elective repeat Caesarean section or a trial of labour subsequent to having had a Caesarean delivery in a prior pregnancy. Methods: Maternal and newborn data from 1980 to 1999 in twin gestations, having I or more previous lower-segment Caesarean section(s) and a vertex presentation of the first twin, were analyzed from the Nova Scotia Atlee Perinatal Database. Categorical data were compared using chi-square or Fisher exact tests and continuous data by the Student t test. Logistic regression was used to control for covariates. Results: Of the 121 women eligible for the data analysis, 38 chose to have a trial of labour, and 28 delivered vaginally with no uterine ruptures, scar dehiscences, maternal deaths, or increase in neonatal morbidity or mortality reported. Two Caesareans in the trial-of-labour group were for the delivery of the second twin. Women choosing elective Caesarean section had a higher incidence of infectious morbidity (p = 0.04). Conclusion: In twin pregnancies with twin A presenting as a vertex, a cautious trial of labour may be an effective and safe alternative to elective repeat Caesarean section. Further research on a trial of labour after previous Caesarean section in twin gestations is warranted, as the studies published to date do not have sufficiently large numbers to detect adverse maternal and neonatal outcomes.

Objective: To determine antenatal factors that may predict successful vaginal birth after Caesarean (VBAC). Data Sources: The MEDLINE database was searched for all English-language articles describing the impact of various factors on outcomes when VBAC is attempted. Articles reviewed included published abstracts, retrospective and prospective studies, and meta-analyses. Criteria for Study Selection: Studies were included if they reported both a control group of pregnant women without the factor under evaluation and a study group with this factor, both undergoing a trial of labour (TOL). Other criteria included accountability for all individuals enrolled at study outset, and vaginal delivery rates in both study and control groups stated or easily calculated. Results: A nonrecurrent indication for previous Caesarean section (CS), such as breech presentation or fetal distress, is associated with a much higher successful VBAC rate than recurrent indications, such as cephalopelvic disproportion (CPD). Even with a history of CPD, two-thirds of women will have successful VBAC, though rates decrease with increasing numbers of prior CS. Prior vaginal deliveries are excellent prognostic indicators of successful VBAC, especially if the vaginal delivery follows the prior CS. A low vertical uterine incision does not seem to adversely affect VBAC success rates as compared to a low transverse incision. Maternal obesity and diabetes mellitus adversely affect VBAC outcomes. Fetal macrosomia does not appear to be a contraindication to VBAC, as success rates exceeding 50% are achieved and uterine rupture rates are not increased. Twin gestation does not preclude VBAC. Post-dates pregnancies may deliver successfully by VBAC in greater than two-thirds of cases. Conclusion: There are few absolute contraindications to attempted VBAC. Attempted VBAC will be successful in the majority of attempted cases.

Study Methods: A retrospective chart review was conducted on patients who underwent a hysterectomy subsequent to a NovaSure ablation over a four year time frame in one community based hospital. Detailed analysis was performed on 203 charts. Results: Of the 1994 women who underwent NovaSure ablation 226 (11%) subsequently had a hysterectomy. The Novasure procedure was unable to be performed in 23 patients and those charts were excluded. The primary indication for hysterectomy was bleeding in 117 (58%). Other indications include pain in 31 (15%), pain and bleeding in 45 (22%), and other, prolapse, and cancer 10 (5%). New onset pain was reported in 45 (22%) patients following NovaSure and 16 (8%) underwent a hysterectomy solely due to new onset pain. Of the 164 pathology reports that commented on the endometrium, 88 (54%) showed active endometrium, 10 (6%) inactive or atrophic, 52(32%) fibrosis, scarring, or “postablative changes”. 14 (9%) had both scarring and residual active endometrium. Conclusion: Bleeding is the most common reason for Novasure failure. However, new onset pain following the NovaSure procedure is a significant burden for 22% of patients. The finding of post ablative scarring and fibrosis was not found universally in those with new onset pain, nor was it consistently noted in those patients with a bleeding component, making it difficult to attribute it as a consistent or common cause of the pain. O-OBS-PhD-108 FACTORS OBSTETRICIANS, FAMILY PHYSICIANS AND MIDWIVES CONSIDER WHEN COUNSELLING PREGNANT WOMENWITH A PREVIOUS CESAREAN SECTION (CS) ON DELIVERY METHOD C. Kurtz Landy York University, 4700 Keele St., HNES 312A, Toronto, Ontario, M3J 1P3, Canada W. Sword, S. McDonald, A. Biringer, J. Cramp, J. Dawdy, P. Angle, C. Cunningham, M. Heaman, M. Morris, H. McDonald, H. Shannon, J. Blake Objectives: Repeat CSs are major contributors to the high rate of CS in Canada. Maternity care providers have a strong influence on women’s decision to have a planned repeat CS or trial of labour (TOL), yet little is known about factors providers consider when counselling women. This study examined factors maternity care providers consider when counselling pregnant women with a previous CS, eligible for a TOL, on delivery method. Study Methods: We used a qualitative descriptive approach and conducted in-depth telephone interviews with 39 maternity care providers in Ontario. A semi-structured interview schedule guided the interviews. Data was analyzed using qualitative content analysis. Results: Maternity care providers considered systems, clinical, and personal factors when counselling women. System factors of concern to obstetricians included the availability of anesthesiologists and time needed to mount emergency CSs; and oncall providers’ support for TOL. All providers identified clinical factors, i.e. women’s characteristics that increased or decreased the likelihood of successful TOL(e.g., BMI); as well as women’s risk tolerance related to both modes of delivery. All providers considered women’s preferences. Women’s preferences were particularly important to the midwives. Midwives described that some women sought their care for a TOL believing midwives could make vaginal delivery possible when physicians couldn’t, or when obstetricians refused to support a TOL. Providers’ negative clinical experiences 490 l MAY JOGC MAI 2016 also influenced their counselling. Convenience of delivery method was considered by some. Conclusion: Effectively addressing systems, clinical and personal factors providers consider when counselling women on delivery methods may assist in decreasing non medically indicated elective repeat CS rates. O-OBS-MFM-MD-113 CORRELATION OF ESTIMATED FETAL WEIGHT WITH NEONATAL BIRTH WEIGHT AT BORDERLINE VIABILITY N. Ladhani Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada S. Hughes, J. Nguyen, J. Barrett Objectives:We sought to determine the correlation between estimated fetal weight and neonatal birth weight in live-birth deliveries between 23+0 and 25+6 weeks gestational age at a major Canadian tertiary care centre. Predicting the likelihood of morbidity and mortality in neonates delivered at the extreme of prematurity, namely 23+0 to 25+6 weeks gestational age, is an important part of counseling in this population. Physicians rely on a number of sonographic markers to establish an estimated fetal weight (EFW) composite which they use as a surrogate marker to predict true birth weight. Study Methods: A retrospective cohort study was conducted at Sunnybrook Health Sciences Centre. We sampled patients retrospectively through records of all patients delivering singleton pregnancies at gestational ages of 23+0 to 25+6 weeks between January 2003 and December 2013 inclusive, who had an ultrasound scan less than 2 weeks prior to delivery. We collected information regarding maternal demographics, ultrasound parameters, and neonatal characteristics. Results: Two hundred and forty-seven deliveries, with an average birth weight of 679g, were includded. Median maternal age was 32 years (16-46years); median gravidity was 2. The mean interval between ultrasound (measuring fetal biometry) and birth was 3.24 days. Estimated fetal weight was moderately correlated with live birth weight (r1⁄40.63). Conclusion: Estimates of fetal weight correlate moderately with live birth weight in neonates born at 23+0 to 25+6 weeks. Developing a better understanding of the utility of EFW in assessing extremely premature neonates will help guide physicians’ and families’ decision-making during this difficult periviable period W-GYN-JM-094 THE MIND-BODY CONNECTION AFTER SURGERY FOR PELVIC FLOOR DISORDERS: FACT OR FICTION? M. Larouche Providence Health St. Paul’s Hospital, 1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada L. Brotto, N.A. Koenig, T. Lee, G.W. Cundiff, R. Geoffrion Objectives: To determine the association between depression and anxiety symptoms, and patient-centered outcomes after surgical treatment for pelvic floor disorders (PFD). Study Methods: Prospective cohort of 50 women undergoing inpatient surgery for PFDs at a single tertiary care center. Preoperative validated questionnaires included Beck’s Depression Inventory-II (BDI-II), Beck’s Anxiety Inventory (BAI), Pelvic Floor Impact Questionnaire (PFIQ-7), and Pelvic Floor Distress Inventory (PFDI20). Women were asked about their post-surgical goals at baseline. All questionnaires were readministered at 6 weeks postoperatively