Process for decision-making, obstetrical risk management and mode of delivery after a prior caesarean delivery in Québec.

Since the 2000’s, the rate of caesarean section has increased steadily in Canada from 21% to over 26%. Prior caesarean section indication alone accounts for more than 30% of all caesarean sections. Each year, approximately 30,000 women in Canada will have to make a choice: plan another caesarean section or attempt a trial of labour after a caesarean (TOLAC) to achieve a vaginal birth after caesarean (VBAC).

The PRISMA trial is a multicenter study conducted in 40 Quebec hospitals to evaluate an intervention aiming to: 1) facilitate the decision-making process for a trial of labour or for a planned caesarean among women with a single previous caesarean section; and 2) to standardize clinical practices associated with trials of labour after a caesarean. The PRISMA program includes professional training to best practices and offers tools to facilitate decision-making process for a TOLAC or a planned caesarean. The key principles in the implementation of this strategy are: 1) the evaluation of women’s initial preferences; 2) the ultrasound assessment of the risk of uterine rupture; and 3) the evaluation of VBAC success chances.

The main objective of this study is to significantly reduce major perinatal morbidity by optimizing the management of women with a single previous caesarean. Secondary objectives of the trial are: the reduction of minor and major maternal morbidity, reduction of minor perinatal morbidity and increase of VBAC rates.

The results will contribute to mobilize professionals in the adoption of a risk assessment program, facilitate decision-making, standardize clinical practices and thus reduce the risk of complications by an optimal selection of women who want to attempt a TOLAC.