Background: With the rise of caesarean sections (CS) over the last five decades, World Health Organization (WHO) proposed that health care facilities to use the Robsons 10 group classification system to audit their caesarean sections rates. This classification would help understand internal structure of the CS rates at individual health facilities identify population groups, indication in each group and formulate strategies to reduce these rates.
Methods: This is a retrospective study for a period of 18 months at tertiary care hospital in rural area at department of obstetrics and gynaecology, Dr. PSIMS &amp; RF, Chinnoutpalli, Vijayawada, Andhra Pradesh. Women who delivered during this period were analysed and classified into Robsons group 10 classification and percentages were calculated for the overall rate, the representation of groups, contribution of groups and caesarean percentage in each group in rural territory centre during the period of January 2021 to June 2022.
Results: From January 2021 to June 2022 there were total of 547 deliveries. Out of which 224 had caesarean section accounting for a caesarean delivery rate of 40.9%. When data was analysed according to Robsons 10 group classification maximum contribution of caesarean section was with Robsons group 5.1 (36%), which comprised of patients with term cephalic multiparous with one previous scar. Followed by group 2A (21%), which comprised of patients with term cephalic nulliparous with labour induced. Breech pregnancies are completely undergoing caesarean section (groups 6 and 7).
Conclusions: We identified the contribution of each group to the overall CS rate as well as the CS rate within each group. Women with previous caesarean delivery contribute to the increasing proportion of caesarean deliveries. Use of Robson criteria allows standardized comparisons of data and identifies clinical scenarios in caesarean rates. All institutes to audit themselves to evaluate quality of caesarean section rates and to rationalize caesarean rates. Impact of interventions to reduce caesarean rates should be studied and documented. Evaluation of existing management protocols and further studies into indications of CS and outcomes in our setting will helps us to design strategies and improve outcomes

Gogineni, Sajana

Mahathi Panchumarthi

Santhi, Vege V.

Sunita, C.

International Journal of Reproduction Contraception Obstetrics and Gynecology

English

Background: With the rise of caesarean sections (CS) over the last five decades, World Health Organization (WHO) proposed that health care facilities to use the Robsons 10 group classification system to audit their caesarean sections rates. This classification would help understand internal structure of the CS rates at individual health facilities identify population groups, indication in each group and formulate strategies to reduce these rates.
Methods: This is a retrospective study for a period of 18 months at tertiary care hospital in rural area at department of obstetrics and gynaecology, Dr. PSIMS &amp; RF, Chinnoutpalli, Vijayawada, Andhra Pradesh. Women who delivered during this period were analysed and classified into Robsons group 10 classification and percentages were calculated for the overall rate, the representation of groups, contribution of groups and caesarean percentage in each group in rural territory centre during the period of January 2021 to June 2022.
Results: From January 2021 to June 2022 there were total of 547 deliveries. Out of which 224 had caesarean section accounting for a caesarean delivery rate of 40.9%. When data was analysed according to Robsons 10 group classification maximum contribution of caesarean section was with Robsons group 5.1 (36%), which comprised of patients with term cephalic multiparous with one previous scar. Followed by group 2A (21%), which comprised of patients with term cephalic nulliparous with labour induced. Breech pregnancies are completely undergoing caesarean section (groups 6 and 7).
Conclusions: We identified the contribution of each group to the overall CS rate as well as the CS rate within each group. Women with previous caesarean delivery contribute to the increasing proportion of caesarean deliveries. Use of Robson criteria allows standardized comparisons of data and identifies clinical scenarios in caesarean rates. All institutes to audit themselves to evaluate quality of caesarean section rates and to rationalize caesarean rates. Impact of interventions to reduce caesarean rates should be studied and documented. Evaluation of existing management protocols and further studies into indications of CS and outcomes in our setting will helps us to design strategies and improve outcomes.</jats:p

Vege V. Santhi

Sajana Gogineni

C. Sunita

null Mahathi Panchumarthi

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Incorporating Robsons classification in analysis of caesarean section at rural territory centre for 18 months

International Journal of Reproduction, Contraception, Obstetrics and Gynecology

                                                                                                                                   April 2023 · Volume 12 · Issue 4    Page 853 International Journal of Reproduction, Contraception, Obstetrics and Gynecology Santhi VV et al. Int J Reprod Contracept Obstet Gynecol. 2023 Apr;12(4):853-857 www.ijrcog.org pISSN 2320-1770 | eISSN 2320-1789 Original Research Article Incorporating Robsons classification in analysis of caesarean section at rural territory centre for 18 months  Vege V. Santhi*, Sajana Gogineni, C. Sunita, Mahathi Panchumarthi                    INTRODUCTION The caesarean delivery rates have been increasing in the last few decades throughout the world in both developed and developing countries upto 50 to 60% in many centers. There has been increased rate of 5% in 1940-1950s to 15% in 1970-1980s. There has been drastic increase in the caesarean rate globally. The rising rate of caesarean section is a matter of international public health concern as it increases maternal morbidity.1 In 2001 Robson proposed Robsons criteria for standardization of classification of caesarean section. The 10 group Robson classification of caesarean section has been accepted by World Health Organization (WHO) in 2014 and FIGO in 2016. Robsons DOI: https://dx.doi.org/10.18203/2320-1770.ijrcog20230676 Department of Obstetrics and Gynecology, Dr. PSIMS & RF, Gannavaram, Vijayawada, Andhra Pradesh, India  Received: 18 December 2022 Revised: 26 February 2023 Accepted: 06 March 2023  *Correspondence: Dr. Vege V. Santhi, E-mail: shanthikakumanu84@gmail.com Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ABSTRACT Background: With the rise of caesarean sections (CS) over the last five decades, World Health Organization (WHO) proposed that health care facilities to use the Robsons 10 group classification system to audit their caesarean sections rates. This classification would help understand internal structure of the CS rates at individual health facilities identify population groups, indication in each group and formulate strategies to reduce these rates. Methods: This is a retrospective study for a period of 18 months at tertiary care hospital in rural area at department of obstetrics and gynaecology, Dr. PSIMS & RF, Chinnoutpalli, Vijayawada, Andhra Pradesh. Women who delivered during this period were analysed and classified into Robsons group 10 classification and percentages were calculated for the overall rate, the representation of groups, contribution of groups and caesarean percentage in each group in rural territory centre during the period of January 2021 to June 2022.  Results: From January 2021 to June 2022 there were total of 547 deliveries. Out of which 224 had caesarean section accounting for a caesarean delivery rate of 40.9%. When data was analysed according to Robsons 10 group classification maximum contribution of caesarean section was with Robsons group 5.1 (36%), which comprised of patients with term cephalic multiparous with one previous scar. Followed by group 2A (21%), which comprised of patients with term cephalic nulliparous with labour induced. Breech pregnancies are completely undergoing caesarean section (groups 6 and 7). Conclusions: We identified the contribution of each group to the overall CS rate as well as the CS rate within each group. Women with previous caesarean delivery contribute to the increasing proportion of caesarean deliveries. Use of Robson criteria allows standardized comparisons of data and identifies clinical scenarios in caesarean rates. All institutes to audit themselves to evaluate quality of caesarean section rates and to rationalize caesarean rates. Impact of interventions to reduce caesarean rates should be studied and documented. Evaluation of existing management protocols and further studies into indications of CS and outcomes in our setting will helps us to design strategies and improve outcomes.  Keywords: Robsons 10 group classification, Caesarean section Santhi VV et al. Int J Reprod Contracept Obstet Gynecol. 2023 Apr;12(4):853-857 International Journal of Reproduction, Contraception, Obstetrics and Gynecology                                     Volume 12 · Issue 4    Page 854 classification will aid in optimization of caesarean section use, assessment of strategies aimed to decrease caesarean section rate, thus improving clinical practices and quality of care in health care centers.2  Aim This study was done to analyse caesarean sections using Robsons ten group classification system (TGCS) and to determine the groups of patients which contribute to caesarean sections in the study group over a period of 18 months. Objectives Objectives of the study were: to classify the caesarean section according to indications using Robsons ten group classification system (TGCS), and to audit the increasing causes of caesarean section in our territory care hospital.  METHODS This is a retrospective study carried out over a period of 18 months from January 2021 to June 2022 in the department of obstetrics and gynaecology, Dr. PSIMS & RF, Vijayawada, Andhra Pradesh. All data was entered in statistical package for the social sciences (SPSS) version 26.0 for analysis in structured proforma.  Table 1: Robsons ten group classification. Group Description Group 1 Nulliparous single cephalic more than 37 weeks in spontaneous labor Group 2 Nulliparous single cephalic more than 37 weeks induced or CS before labor 2A-induced labor, 2B-CS before labor Group 3 Multiparous (excluding previous CS) single cephalic more than 37 weeks in spontaneous labor Group 4 Multiparous without previous uterine scar, single cephalic more than 37 weeks induced or CS before labor 4A-induced labor, 4B-CS before labor Group 5 Multiparous with previous cesarean section single cephalic more than 37 weeks Group 6 All nulliparous with single breech Group 7 All multiparous with single breech including previous cesarean section Group 8 All multiple pregnancies including previous cesarean section Group 9 All women with single transverse or oblique lie including previous cesarean section Group 10 All single cephalic less than 37weeks pregnancies including previous cesarean section Inclusion criteria Retrospective observation study from parturition and case sheets, patients who delivered by caesarean section during the period (January 2021–June 2022) were recorded and classified according to Robsons 10 group classification system. Considered parameters are: parity, gestational age, fetal presentation, number of fetuses, and onset of labour. Exclusion criteria Term and preterm normal vaginal deliveries, and term and preterm instrumental vaginal deliveries were excluded from the study. Collected data was analysed using simple statistical measures like percentage and proportion. RESULTS From January 2021 to 2022 there were 547 deliveries. Out of which 224 had caesarean section and remaining were vaginal deliveries. Almost about 78.1% of women who underwent caesarean section were between 36+1 to 39+6 weeks (Table 2). Table 2: Period of gestation versus no of deliveries. Period of gestation (weeks) Total no. of cases Percentage  Less than 36  47 20.98 36+1 to 39+6  175 78.1 More than 40  2 0.89 Out of 224 caesarean deliveries 3% were twin pregnancies and 97% were singleton pregnancies (Table 3).  Table 3: No. of pregnancies with singleton and multiple. Parameters Total no. Percentage No. of twin pregnancies 6 3 No. of singleton pregnancies 218 97 49% of cases who underwent caesarean section belongs to second gravida (Table 4). Table 4: No. of patients who were primi and multigravida. Gravid status Total no. Percentage Primi 74 33 Gravida 2 107 49 Gravida 3 42 18 Santhi VV et al. Int J Reprod Contracept Obstet Gynecol. 2023 Apr;12(4):853-857 International Journal of Reproduction, Contraception, Obstetrics and Gynecology                                     Volume 12 · Issue 4    Page 855 75.8% of cases who underwent caesarean section was under 21 to 30 years age group (Table 5). Table 5: Age of patients versus who underwent CS. Age Total no. Percentage Less than 20 26 11.6 21-30 170 75.8 More than 31 28 12.5 Out of 230 new born, 152 comes under 2.6-3.5 kgs i.e., accounting for about 66% (Table 6). Table 6: Birth weights of new born. Birth weights No. of new born Percentage Less than 2.5 68 29.5 2.6-3.5 152 66 More than 3.6 10 4.5  Figure 1: Grouping of patients according to RTGCS. From January 2021 to June 2022 there were total of 547 deliveries. Out of which 224 had caesarean section accounting for a caesarean delivery rate of 40.9%. when data was analysed according to Robsons ten group classification, maximum contribution of caesarean section was with Robsons group 5.1 (36%), which comprised of patients with term cephalic multiparous with one previous scar (Figure 1). Followed by group 2A (21%), which comprised of patients with term cephalic nulliparous with labour induced. Breech pregnancies are completely undergoing caesarean section (groups 6 and 7).  Figure 2: Pie diagram of no. of patients versus Robsons group.  Figure 3: Pie diagram of percentage of patients versus Robsons group. Tabel 7: Robsons scoring in patients who underwent CS. Robsons score Description Number of sections % Contribution by EACG group to total CS 1 Nulliparous single cephalic term spontaneous labour 9 4 2A Nulliparous single cephalic term labour induced 47 21 2B Nulliparous single cephalic term prelabour CS 18 8 3 Multi single cephalic term spontaneous labour without prev uterine scar - - 4A Multi single cephalic term labour induced without prev uterine scar 5 2 4B Multi single cephalic term pre labour CS without prev uterine scar - - 5.1 Multi single cephalic term with one prev uterine scar 81 36 5.2 Multi single cephalic term with 2/more prev uterine scar 9 4 6 Nulliparous single breech including prev uterine scars 7 3 7 Multi single breech including prev uterine scars 6 3 9819 7 6 6 431471850204060801001 5.1 5.2 6 7 8 9 10 2A 2B 4ASeries19, 4%81, 36%9, 4%7, 3%6, 3%6, 3%4, 2%31, 14%47, 21%18, 8%5, 2% 15.15.26789102A2B4A14%5.136%5.24%63%73%83%92%1014%2A21%2B8%4A2%15.15.26789102A2B4AContinued. Santhi VV et al. Int J Reprod Contracept Obstet Gynecol. 2023 Apr;12(4):853-857 International Journal of Reproduction, Contraception, Obstetrics and Gynecology                                     Volume 12 · Issue 4    Page 856 Robsons score Description Number of sections % Contribution by EACG group to total CS 8 All women with multiple preg including prev uterine scars 6 3 9 All women with single preg with transverse/oblique lie including prev uterine scars 4 2 10 All women with single cephalic less than 37 weeks including prev uterine scars  31 14 DISCUSSION Increasing caesarean sections particularly in high income countries is a growing concern in most parts of the world.3 According to latest survey 29.7 million births occurred through CS in 2015, which was almost double the number of births by CS in 2000.1 WHO proposed the Robsons ten group classification system (TGCS) as a global standard for assessing, monitoring and comparing CS rates within healthcare facilities.4 Several international studies have analyzed the utility of this system to identify factors contributing to increasing CS rates which is a growing global concern.5 In my present study the rate of caesarean section in our hospital (40.9%) is higher than WHO (15%).6 The caesarean section rate in year 2013-2014 in India was 16.4%7. The rise to 18% in 2015-2016 is seen when survey conducts by nation family health survey. The average caesarean section rate in Asian countries was lower when compared with USA.8 In the present study the major contribution to overall CS is by group 5 (women with previous CS) followed by group 2A (term nulliparous induced labour).9 Almost same findings have been noted in various indian and international studies. Attempts to reduce repeat CS (by promoting trial of labour after caesarean section) for reducing overall CS rate should be under taken by full-fledged obstetric units with careful selection of cases.10 Labour induction protocols vary worldwide but increasing labour inductions as an upcoming contributor to caesarean deliveries.11 In my present study also group 2 and 4 had an increased caesarean section rate when compared with 1 and 3 respectively. So firstly, we have to limit induction of labour.12 Secondly, we should evaluate daily about the indication of primary caesarean section. Malpresentations especially breech presentations will also contribute to overall as well as primary CS rates in my present study.13 CS which are being done for breech presentation can be reduced by training residents in the art of breech delivery. The first step in the path to reduce caesarean rates is to classify under Robsons classification.14 Standardization of indication of caesarean deliveries, regular audits and protocols in hospital will reduce the caesarean rate.15,16 Limitations  Present study is the first study analyzing trends of CSs and evaluating them according to RTGCS in Dr. PSIMS&RF Hospital Gannavaram, Vijayawada. Main limitation of this study was we were unable to record perinatal and maternal outcomes among study participants. As this study was single center study with comparatively short sample size. CONCLUSION We used the RTGCS to identify specific groups that contributed the most to the overall CS in our setting. All deliveries and caesareans should be universally categorized by the Robson’s classification system. Groups contributing most to caesareans should be analysed regularly and interventions initiated. Those interventions should be targeted at reducing primary caesareans and convincing patients for trial of labour after caesarean section where possible. Inductions should be done only when necessary. All institutes to audit themselves to evaluate quality of caesarean section rates and to rationalize caesarean rates. Impact of interventions to reduce caesarean rates should be studied and documented. Evaluation of existing management protocols and further studies into indications of CS and outcomes in our setting will helps us to design strategies and improve outcomes. Funding: No funding sources Conflict of interest: None declared Ethical approval: The study was approved by the Institutional Ethics Committee REFERENCES 1. Ye J, Zhang J, Mikolajczyk R, Rorloni MR, Gulmezoglu Am, Betran AP. Association between rates of caesarean section and maternal and neonatal mortality in the 21st century: a worldwide population-based ecological study with longitudinal data. BJOG. 2016;123(5):745-53.  2. Torloni MR, Betran AP, Souza JP, Widmer M, Allen T, Gulmezoglu M, et al. Classifications for cesarean section:a systematic review. PloS One. 2011;6:e14566.  3. Mumtaz S, Bahk J, Khang YH. Rising trends and inequalities in cesarean section rates in Pakistan: Evidence from Pakistan Demographic and Health Surveys 1990-2013. PLoS One. 2017;12(10):e0186563. Santhi VV et al. Int J Reprod Contracept Obstet Gynecol. 2023 Apr;12(4):853-857 International Journal of Reproduction, Contraception, Obstetrics and Gynecology                                     Volume 12 · Issue 4    Page 857 4. Khan MA, Sohail I, Habib M. Auditing the cesarean section rate by Robson's ten group classification system at tertiary care hospital. Professional Med J. 2021;37(2):567-71. 5. Naeem M, Khan MZ, Abbas SH, Khan A, Adil M, Khan MU. Rate and Indication of elective and emergency cesarean section:A study in a Tertiary Care Hospital of Peshawar. J Ayub Med Coll Abbottabad. 2015;27(1):151-4. 6. Amin N, Malik NJ. Role of antenatal checkup on caesarean section rate –study at CMH Attock. Pak Armed Forces Med J. 2017;67(4). 7. Jabeen J, Mansoor MH, Mansoor A. Analysis of indications of caesarean sections. J Rawalpindi Med Coll (JRMC) 2013;17(1):101-3. 8. Stavrou EP, Ford JB, Shand AW, Morris JM, Roberts CL. Epidemiology and trends for Caesarean section births in New South Wales, Australia: A population-based study. BMC Pregnancy Childbirth. 2011;11:8. 9. MacDorman MF, Menacker F, Declercq E. Cesarean birth in the United States: epidemiology trends, and outcomes. Clin Perinatol. 2008;35(2):293-307.  10. World Health Organization. Appropriate technology for birth. Lancet. 1985;2:436-7. 11. World Health Organization, United Nations Population Fund, Mailman School of Public Health. Averting Maternal Death and Disability & United Nations Children's Fund (UNICEF). Monitoring emergency obstetric care: a handbook. World Health Organization. Available at: https://apps.who.int/iris/ handle/10665/44121. Accessed on 12 December 2022. 12. Robson M, Hartigan L, Murphy M. Methods of achieving and maintaining an appropriate caesarean section rate. Best Pract Res Clin Obstet Gynaecol. 2013;27(2):297-308. 13. Robson MS. Classification of caesarean sections. Fetal Matern Med Rev. 2001;12(1):23-39. 14. FIGO Working Group on Challenges in Care of Mothers and Infants during Labour and Delivery. Best practice advice on the 10-Group Classification System for cesarean deliveries. Int J Gynecol Obstet. 2016;135(2):232-3. 15. WHO Expert Committee on Physical Status: the Use and Interpretation of Anthropometry (1993: Geneva, Switzerland) & World Health Organization. (1995). Physical status: the use of and interpretation of anthropometry, report of a WHO expert committee. World Health Organization. Available at: https://apps.who.int/iris/handle/10665/37003. Accessed on 12 December 2022. 16. World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience: World Health Organization. 2016. Available at: https://www.who.int/publications/i/item/9789241549912. Accessed on 12 December 2022.        Cite this article as: Santhi VV, Gogineni S, Sunita C, Panchumarthi M. Incorporating Robsons classification in analysis of caesarean section at rural territory centre for 18 months. Int J Reprod Contracept Obstet Gynecol 2023;12:853-7. 

http://dx.doi.org/10.18203/2320-1770.ijrcog20230676

Incorporating Robsons classification in analysis of caesarean section at rural territory centre for 18 months

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International Journal of Reproduction, Contraception, Obstetrics and Gynecology