Introduction Robson ten-group classification system is recommended by WHO (World health organization) as a global standard for assessment and monitoring caesarean section (CS) rates. This classification is simple and robust. It is prospective, easily reproducible and clinically relevant.
Methodology We conducted a prospective observational study of CS births at a tertiary care institute. Caesarean births in a tertiary care hospital were classified using Robson classification system as recommended by WHO. The study was conducted for period of 6 months duration. The ethics committee of the institute approved this study. We enrolled 4771 consecutive women who delivered during this study period. We included patients who had vaginal delivery as well as those who had delivery by CS. Both live births and stillbirths (of at least 500-g birth weight or at least 22 weeks gestation (according to WHO recommendations) were included in this study.
Results During this study period, we had 4771 deliveries, out of which 2231 pregnant women (46.76%) were delivered by CS as compared to 2540 vaginal deliveries. Women with previous CS (term with single cephalic pregnancy) were included in Robson group 5.Group 5 had the highest CS rate (13.41%). Robson group 5, 1 and 10 were the largest contributors to the high CS rates at our institute.
Conclusion In our study, 4771 deliveries were conducted during this study period (6 months). Out of 4771 deliveries, CS was done in 2231 pregnant women (46.76%). 2540 women had vaginal deliveries. Group 5 (13.41%) which comprised of women with previous CS had the highest CS rate followed by group 1 and group 10. The second largest contribution was from Group 1 with CS rate of 9.01%. Robson Group 1 included nulliparous term women with single cephalic pregnancy in spontaneous labour. Group 10 was the third largest contributor to the overall CS. Group 10 included women who delivered preterm (single cephalic presentation). Group 10 contributed to 8.09% of overall CS rate. We should make every effort to provide CS for women requiring this procedure, rather than work towards achieving a specific rate for CS.
Keywords : Robson Ten-group classification system (TGCS) · Caesarean section rate · Caesarean section (CS) births · Audit of caesarean births · Rising trends of caesarean births · Indications of caesarean section
Caesarean section is a very common surgical procedure carried out in Obstetrics. Over the recent years, the rate of caesarean sections has been increasing [1]. Absolute indication for caesarean section includes contracted pelvis, malpresentations (transverse lie and brow) and placenta previa. CS delivery poses more risks to the patient as compared to vaginal delivery if we compare these two modes of delivery [1]. Robson ten-group classification system (TGCS) is recommended by WHO (World health organization) as a global standard for assessing and monitoring caesarean section rates [2]. CS rates can be compared within healthcare facilities and between them using this classification. Robson classification is simple and robust. The ten-group Robson classification is simple, robust, reproducible and flexible [3, 4]. Robson classification has been now used to analyze rising trends of caesarean births and factors contributing to this increasing rate. The present study was done at our tertiary care centre to assess the frequency and indications for CS. CS births were analysed using Robson ten group classification. This study would help identify the group which has maximum caesarean section rate and possibly point out measures which can reduce rising CS rate.
This is a prospective observational study of caesarean section births. Caesarean births were analysed using Robson classification system as recommended by WHO. This study was conducted in a tertiary Care Hospital and Medical College for a period of 6 months duration in 2019 (1st July 2019 to 31st December 2019). The ethics committee of our institute approved this study.
4771 deliveries were conducted during this study period (6 months). Out of 4771 deliveries, CS was done in 2231 pregnant women (46.76%). 2540 women had vaginal deliveries. The ranking of contribution of CS of each group to total number of deliveries i.e., CS rate in each group is mentioned in Table 2, Fig. 1. Rate of C/S in each group is mentioned in Fig. 2. Ranking according to relative size of each group and rate of caesarean section in each group by Robson classification is stated in Table 3, Fig. 3. Contribution of CS of each group to total number of CS is mentioned in Fig. 4. Group 5 (13.41%) which comprised of women with previous CS had the highest CS rate followed by group 1 and group 10. The second largest contribution was from group 1 with CS rate of 9.01%. Robson group 1 included nulliparous term women with single cephalic pregnancy in spontaneous labour. Foetal distress, cephalopelvic disproportion and prolonged labour were the three most common reasons for doing CS in this group.
Group 10 was the third largest contributor to the overall CS. Group 10 included women who delivered preterm (single cephalic presentation). Group 10 contributed to 8.09% of overall CS rate. Group 2, 3 and 4 had CS rate of 4.63%, 3.43% and 2.01% respectively. Three groups who were the largest contributors to the CS rate were group 5, group 1 and group 10.
We had 230 breech presentations (in both primigravida and multigravida) during this study period. 53 of these breech presentations were delivered vaginally and the remaining were delivered by CS. Group 6 and group 7 thus accounted for 3.7% CS. Group 9 included patients with transverse or oblique lie. This group contributed to 0.64% of total number of deliveries. CS was done for all women in group 9 (transverse lie or oblique lie). The caesarean section rate of this group was 100%. Patients with multifetal gestations were included in group 8. This group contributed to 1.80% of all CS.
After analysis of this study by Robson classification we noted that group 5 which included women with previous CS had the highest contribution to the total CS rate. This group contributed to 13.41% of total CS rate. Groups who had significant contribution to the caesarean section rate were Group 1, Group 10 and Group 2 with each contributing to 9.01%, 8.09% and 4.63% CS rate respectively. Women in group 5 women were delivered by CS, mainly due to the fear of life threatening complication such as uterine rupture. Repeat CS was thus responsible for increased CS rate. Study conducted by D. Leno et al. reported similar findings [5]. It has been noted that reducing primary CS and successful VBAC (vaginal birth after caesarean) will help reduce CS in this group [6–8]. Patients can be given TOLAC (trial of labor after caesarean) after proper selection of cases. FLAMM scoring system can also be used to reduce the rate of CS [6]. Continuous monitoring of both mother and fetus can ensure successful VBAC. High CS rate in group 5 was also seen in study done by S. Gadappa et al., V. Das et al. and A. Ray et al. [4, 6, 7, 9, 10]. Increase in incidence of CS in primigravida patients can be avoided by avoiding unnecessary induction of labor in primigravida patients [10]. Treating obstetricians need to proficient in conducting vaginal examinations, pelvic assessments and giving trial of labor to patients with borderline pelvis. In our study CS rate was 46.76%. WHO recommends caesarean rate of 10–15%, it may be difficult to achieve this rate in a tertiary institute like LTMMC & GH Sion, Mumbai, catering to a large population of high risk referred cases. Our hospital is located near Asia’s largest slum Dharavi. Caesarean section rates were higher than other studies which could be explained by referral of high risk cases requiring emergency CS. Lack of facilities for emergency caesarean section and transfusion of blood and blood products, unavailability of NICU, patients requiring tertiary care (ICU) were some other reasons for referral of cases requiring CS to our institute. Similar high rates were observed in study done by Varija T et al. and Patel RV et al. [11, 12].
As per WHO relative size (B/total number of deliveries × 100) of group 1 and 2 combined should represent 35–42% of obstetric population. In our study the relative size of group 1 and 2 combined was 32.04%. This contribution is less than WHO expectation as most of our population included multiparous women [3]. Relative size of group 3 and 4 combined usually represents about 30% of women but in our study we found relative size of group 3 and 4 combined is 28.88%. The reason for reduced size of groups 3 and 4 could be that the size of group 5 (repeat CS) is very high [3]. Increase in number of patients in group 5 contributes to overall high CS rate.
Main reason behind rising rates of CS among group 1, 2, 3 and 4 are fetal distress which is one of the most common indication of CS [5, 6, 13]. Studies have shown that increasing number of unnecessary CS are carried out on the basis of non-reassuring fetal heart rate detected by continuous electronic fetal heart monitoring. Many cases of fetal hypoxia and acidosis are predicted on the basis of continuous electronic fetal monitoring [2, 6]. In low risk pregnancies intermittent auscultation with electronic fetal Doppler as opposed to continuous electronic fetal monitoring may be done. It is important to correctly identify cases of fetal distress requiring prompt delivery.
WHO recommends that relative size of groups 6 and 7 which included women with breech presentation should be 3–4%. In our study we found out it to be 4.81%. We should reduce CS in this group by doing external cephalic version in women with breech presentation eligible for this procedure. Vaginal breech delivery can be conducted in suitable women with the help of Z score assessment. Similar rates of CS among breech presentation are also found in study done by A. Yerra et al. and M. Patel et al. [14, 15]. As per WHO, relative size of Group 8 should be 1.5–2% but in our study, we found it to be 2.87%, this higher rate is explained by the fact that our hospital is a tertiary care center where patients with high risk pregnancy (including women with multiple pregnancy) get registered for antenatal care. Moreover, patients requiring LSCS are referred from peripheral center’s due to lack of adequate facilities for LSCS and NICU at these centers. As per WHO implementation manual relative size of group 9 (women with transverse lie or oblique lie) should be less than 1%. In our study group 9 contributed to 0.64% CS. Robson group 10 included all women with single cephalic pregnancy who underwent a CS before term gestation (< 37 weeks). In our study group 10 stood at 3rd position for CS. Fetal distress was the primary cause of rising CS in this group. Early delivery in preterm babies may be required if fetus is at risk of hypoxia leading to fetal distress due to high risk maternal and fetal factors [14]. Fear of scar rupture was the primary reason for repeat caesarean deliveries and rising CS rates.
