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| ORIGINAL ARTICLE |
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| Year : 2021 | Volume
: 8
| Issue : 2 | Page : 75-82 |
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Analysis of cesarean section using Robson's ten group classification system in a tertiary care center from Southern India: A cross-sectional study
Kanmani Murugesan, Sasirekha Rengaraj
Department of Obstetrics and Gynaecology, JIPMER, Puducherry, India
| Date of Submission | 07-Jul-2021 |
| Date of Decision | 27-Oct-2021 |
| Date of Acceptance | 31-Oct-2021 |
| Date of Web Publication | 30-Dec-2021 |
Correspondence Address:
Dr. Sasirekha Rengaraj
Department of Obstetrics and Gynaecology, JIPMER, Puducherry
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijamr.ijamr_152_21
Background: The rising cesarean section (CS) rate is a global concern and World Health Organization in 2015 has proposed the use of Robson-10 group classification system as a standard for assessing and monitoring CS both within and across the healthcare facilities. Objective: The objective is to analyze the CSs performed in a teaching hospital using Robson 10-group classification system. Methodology: The present cross-sectional study was done over a period of 1 year from May 2017 to April 2018. All eligible women delivered in JIPMER, a tertiary care referral center during the study period were classified as per Robson Ten-Group classification system. Caesarean delivery rates were reported. The relative and absolute contribution to CS rates in each groups were calculated. Epi data V.3.1 was used for data analysis. Results: Among 16,863 women delivered during the study, the CS rate was 21.4%. The three common indications for CS overall were fetal distress, nonprogress of labor, and cephalopelvic disproportion. Group 1 (nulliparous, singleton, term cephalic, spontaneous labor) was the largest size followed by group 2 (nulliparous, singleton, term cephalic, induced labor) with 25% and 16.9%, respectively. The maximum contribution of CS was by group 5 (multiparous women, singleton, term cephalic, previous uterine scar) followed by group 2 with 34.9% and 18.9%, respectively. Conclusion: Robson group 5, 2, and 1 were the major contributions to CS in our hospital. Further studies are needed to study the appropriateness of indications for CS especially in groups 2 and 1 as they are the future group 5. Keywords: Caesarean, delivery, Robson, Robson ten group classification system
How to cite this article:
Murugesan K, Rengaraj S. Analysis of cesarean section using Robson's ten group classification system in a tertiary care center from Southern India: A cross-sectional study. Int J Adv Med Health Res 2021;8:75-82 |
How to cite this URL:
Murugesan K, Rengaraj S. Analysis of cesarean section using Robson's ten group classification system in a tertiary care center from Southern India: A cross-sectional study. Int J Adv Med Health Res [serial online] 2021 [cited 2023 Mar 29];8:75-82. Available from: https://www.ijamhrjournal.org/text.asp?2021/8/2/75/334364 |
| Introduction | |  |
Caesarean section (CS) is a lifesaving procedure done either to save the mother or the fetus, sometimes both. Though it is a common surgical procedure, there are both short-term (hemorrhage, sepsis, blood transfusion, need for hysterectomy, and even death) and long-term risks (repeat CS, placenta accreta spectrum, and uterine rupture) associated with it.
CS rate has been increasing worldwide over the last 50 years and the rate has exceeded 30% in some regions.[1],[2],[3] The global increase in CS rate is of public concern for the last 30 years. The rate of CS varies greatly between different regions with lowest rate (4.1%) in African countries to highest (44.3%) in South American countries. India has also witnessed an unprecedented rise in the CS rate with a large disparity across the country.[1],[4],[5] The CS rate was found to be three times more common in private health facilities (odds ratio [OR] 3.79, 95% confidence interval [CI] 3.06–4.72) where only one-third of the total institutional deliveries occurred (37.9% in private and 13.7% in public setup).[5],[6],[7],[8],[9]
Ye et al. conducted the first systematic review in 2014 with data from 19 developed countries. It was hypothesized that increasing CS rate decreased the maternal and neonatal mortality rate up to a point after which no change in the mortality rates occurred even after increasing the CS rate.[6] The analysis showed that there was no change in the maternal mortality when CS rate exceeded 15% and no change in neonatal or infant mortality rate when the rate exceeded 10% after adjusting for the socioeconomic factors. Thus, it was concluded that having a CS rate higher than 10%–15% to improve perinatal outcome was not medically justified.[7]
The strategies to minimize unnecessary CS have not been shown to be beneficial in stabilizing the CS rate. Worldwide, no classification system is routinely followed to classify CS despite the recommendation by the World Health Organization (WHO) to use Robson ten group classification system (RTGCS) as it had been proven to be an action-oriented tool when compared with other classification systems. The utility of this systematic, standard tool for assessing, monitoring, comparing CS rates between countries and across healthcare facilities remains investigational, especially in developing countries.[8],[9],[10],[11],[12]
Improving the quality of care is an essential part of clinical care and CS is one of the important components of Comprehensive Emergency Obstetric and Neonatal Care. Hence auditing CS and assessing its rate is essential in improving the maternal and neonatal care especially where the maternal and neonatal mortality remain high. RTGCS does not explain why CS is done but it is a common point to investigate the reasons for CS. It is both robust and universal and the full potential of RTGCS will be understood when it is adopted as standard practice. We aimed to assess the pattern of CS in our teaching hospital using this RTGCS.
| Methodology | | |
The present cross-sectional study was done from a single tertiary care center from South India, JIPMER over a period of 1 year from May 2017 to April 2018. JIPMER is a teaching hospital located in southern part of India with annual delivery rate of 15,000–18,000. The data were retrieved from the hospital registers (maternity, operation) and case records of all women delivered in the institute during this period for the classification of RTGCS. All the data sources were compared and verified with data from medical record section for all the deliveries happened at JIPMER. The study was approved by institute ethics committee (IEC No. JIP/IEC/2016/1071).
The details were collected and entered in the predesigned proforma after obtaining written informed consent from the patient at admission. All the details including demographic, obstetric history, medical history, labor details, and details of CS including indication were entered in the prescribed format which was approved by department research committee. All the deliveries were classified as per RTGCS into ten groups with the help of Robson implementation manual by the WHO using the flow chart [Figure 1]. The variables which are necessary for classification include parity, gestational age, presentation, previous CS, onset of labor, and number of fetuses. Robson manual tool kit was used as a guide. A senior obstetrician periodically verified the entered data including its completeness. The deliveries that happened before 24 weeks of gestation or baby weight of < 500 g were excluded. If the gestational age was not known for an unbooked woman who was referred in later part of pregnancy the fetal weight was used as proxy for classifying; birth weight of 2500 g or more was considered as term gestation (37 weeks or more). The groups 2, 4 and 5 of RTGCS were sub-classified into a or b as per the flow chart [Figure 1]. | Figure 1: Flow chart used for classification based on Robson-1o group classification system. CS: caesarean section
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Statistical analysis
Data were entered into a Microsoft Excel datasheet and were analyzed using SPSS software version 19. (IBM SPSS Statistics for Windows IBM Corp., Armonk, NewYork, USA). Epi data V.3.1 was used for data analysis. Categorical data were expressed as frequencies and proportions. The mean and standard deviation was calculated for continuous data. The CS rate was calculated as percentage of deliveries by CS from total deliveries. The components of RTGCS were derived as follows: Group size (%) = No. of women in the group/Total No. of women delivered in the hospital x 100; Group CS rate (%) = No. of CS in group/Total No. of women in group x 100; Relative contribution to overall CS (%) = No. of CS in the group/Total No. of CS in the hospital x 100;Absolute contribution to overall CS (%) = No. of CS in the group/Total No. of women delivered in the hospital x 100. The results are presented according to Robson report table as recommended by WHO and multi-country survey (MCS).
| Results | | |
The total number of women delivered during the study period was 16,863. The CS rate was 21.4%. The SAMM (severe acute maternal morbidity) ratio during the study was 305 cases per 10000 live births (3.05%). The prevalence of SAMM in women who underwent CS during the study period was 3.99%. The maternal mortality ratio was 112 per 100,000 live births.
The mean age of women in the study population was 26.5 ± 4.4 years and the mean gestational age at CS was 38.3 ± 2.06 weeks. Of the total deliveries, 66.3% were spontaneous vaginal delivery and the rate of instrumental delivery during the study was 11.9%.
The largest group of women was group 1 (25%) followed by group 3 (22.1%) and group 2 (16.9%). The CS rate within group was highest in groups 6 (76.37%), 7 (72.01%), and 5 (63.02%) in descending order after group 9 (100%). The detailed classification of CS as per RTGCS is given in [Table 1]. | Table 1: Classification of cesarean sections as per Robson ten group classification system
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The most common indication in all four groups (1–4) was fetal distress (25%). The most common indication for CS in group 5 was doubtful scar integrity (38.2%) followed by fetal distress (16.4%). The interpretation of quality of data and population and assessment of CS rate of the present study as per Robson/multi-country survey (MCS) references are given in [Table 2]. There is no missing or misclassification of data. When compared to Robson/MCS reference standards, the proportion of women in group 6 and group 10 are more in our study and it is because of referral center. The ratio of group 1 vs. 2 and 3 vs. 4 in the present study indicates the high number of inductions in our population. The CS rates in each group are compared to Robson and MCS in [Table 3] and our rates are more than the reference standards in group 5, 7 and 10. | Table 2: Interpretation of quality of RTGCS data as per Robson/Multi country survey
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The three common indications were fetal distress (33.3%), malpresentation (18.7%), and doubtful scar integrity (14%). The indications in each group in detail are given in [Figure 2] (Groups 1–4) and 3 (Groups 5 and 10). Even among low risk groups (group 1–4) fetal distress constitute almost two-third of total CS s (67.3%) followed by labor abnormalities (13.7%) and failed induction (8.3%). A total of 12.6% of women in group 2 and 4 underwent prelabour CS. Doubtful scar integrity was the commonest indication in group 5 followed by fetal distress. Maternal indication, fetal distress, and failed induction were the common indications in group 10. The flow chart in [Figure 3] shows the management of women with one or more CS. Trial of labor after CS (TOLAC) was offered in 63.8% (n = 1165) of women and in 64% (n = 746) it was successful.
| Discussion | | |
The present study included 17,320 women from a single center over a period of 1 year, and the overall CS rate was 21.8% which is slightly above the national average; however this rate was less when compared to the CS rate in various other tertiary care centers and within in the country.[10],[11],[12] The CS rate in our center is lower than WHO MCS (31.2%) and global survey (26.4%) despite dealing with a multitude of high risk and referral patients.[13] However, there is a huge disparity between the public and private sectors within any country.[11],[14],[15] As reinforced in the WHO statement on CS, there is a need for universal classification of CS in all the hospitals for the meaningful analysis of CS in different groups. The accuracy of data collected in our study should encourage other teaching hospitals with similar volume of workload to adopt RTGCS. First, this will help us to understand CS rates in different groups in a particular center and secondly to compare CS across different hospitals. Furthermore, this will help us to identify the high risk groups in which quality improvement steps to be taken to optimize the CS rate.
Almost three-fourth of the women in our study belonged to groups 1–4 (75.4%) and the CS rate was 37.6% in those women. These are low risk women who had either spontaneous or induction of labor at term. The quite striking indication for CS in all these four groups was fetal distress [Figure 2] which was irrespective of method of labor. RTGCS does not lay down the guidelines for optimizing CS rates in each groups; however, it is a starting point to do so. These groups need to be studied in detail in future about the methods of oxytocin augmentation, labor induction methods; and the methods of intrapartum monitoring.[11],[12],[16] As trainees are the most important part of labor monitoring team in teaching hospitals, periodic training on intrapartum monitoring methods is essential. The CS rate in group 1–4 is in line with Robson and MCS standards. However, in group 2, 97.4% (2776/2849) of women had undergone induction of labor and 12.4% of CS was performed for failed induction. The indications, timing of induction of labor; and methods used varied between the units. Past dates and oligohydramnios were the common indications for induction of labor in those groups (Groups 1–4). There is no uniformity in assessing amniotic fluid volume and deep vertical pocket of <2 cm to be taken as cut off for labor induction in isolated oligohydramnios rather amniotic fluid volume (AFI) of <8.In addition, the timing of induction of labor varies between 37 and 39 weeks across units in small for gestational age fetuses (SGA) with normal fetal Doppler. The proportion of women in group 2 was 16.9% in the present study which is more than other studies.[13],[14] There is a possibility of misclassification in group 2: women who needed oxytocin augmentation would have been classified as labor induction in our study. However, the focus on group 1 and 2 to optimize the CS rates is very important as they are going to be the future group 5, which is a major contributor to overall CS rates as in many studies.
As shown in [Table 2], the proportion of women (group size) in various groups in our study is in line with Robson/MCS criteria except in group 10. The most represented groups were group 1 (25%) and groups 3 (23.1%) and similar findings have been observed in studies from various countries such as Srilanka, Brazil, South Africa, and Italy.[13],[17] However, the ratios of group 1 and 2, 3 and 4, 6 and 7 were lower compared to Robson and MCS reference levels [Table 2]. This is because ours is the common referral centrer for high-risk pregnancy who needs multidisciplinary care with level III neonatal care unit. The CS rate in group 10 (singleton, cephalic, preterm including previous CS) is 34.9% which is well above the reference rates of Robson and MCS [Table 3]. Almost a third of CS in this group was for fetal distress (28.8%) and 17.6% of women in this group underwent prelabor CS for maternal indications (17.6%). Of the total CS in this group, 58.8% of women had previous one or more CS; moreover, the induction rate in group 10 was 10.6% [Table 3]. Generally, the perinatal and maternal morbidity will be more in group 10 compared to other groups. Moreover, the induction of labor is less successful in achieving vaginal delivery hence careful and detailed analysis of this group including perinatal outcome is essential. Subclassifications like prelabour CS, women with previous CS, and with spontaneous/induction labor may help us to understand this group in detail before taking appropriate steps to optimize CS.[18],[19] This reiterates the stand by the WHO that there is no absolute standard CS rate and we should not strive to achieve particular number rather focus on improving maternal and neonatal outcome.
Group 5 was the major contributor to overall CS in our study (34.9%). A similar finding was observed in many studies across the world ranging from 15.4 to as high as 67.7%.[9],[12],[14] The most common indication for CS in group 5 was doubtful scar integrity followed by fetal distress. The TOLAC rate was 63.8% (n = 1165) of eligible women with previous CS and vaginal birth after CS was successful in 64% of women. The CS rate in group 5 (63%) is almost in line with Robson reference rate (60%) and lesser than MCS reference (74.4%). WHO MCS witnessed almost doubling of CS rate in this group. As it is mentioned, this group is heterogeneous with previous 1 or more CS and in some women the previous intraoperative findings or the current obstetric history may preclude the possibility of TOLAC. Hence, a detailed subgroup analysis will help us to focus on specific subtype of women with previous one CS.
The rate of vaginal breech delivery during the study was 25.3%. Almost 37.4% of women who underwent CS in groups 6 and 7 had an uncomplicated breech at the time of CS. More than improving the skill on vaginal delivery, increasing the performance of external cephalic version in appropriate cases could help in decreasing CS rate and size of these groups.
Although the size of group 8 (2.1%) was larger, the group-specific CS rate was less (42.09%) than other studies.[14],[15] Among the ten groups, this group had the highest group-specific CS rate after the group 9. CS was performed in women who conceived following assisted reproductive techniques (n = 13) because of coexisting maternal comorbidities and maternal request. Moreover, 80.5% of the CS in this group was performed for nonvertex presentation of first twin, twin gestation in women with prior CS, and IVF conception.
In general, when we analyze CS, the focus is on reducing primary CS. In our study, groups 1, 2 and 5 (65.6%) were the main contributors, whereas a teaching hospital from Srilanka and Ghana have recognized groups 5, 2, 4 (67%), and groups 2, 4, 5 (47.5%), respectively. Universal implementation of steps to reduce CS may not be successful at all levels and the actions have to be group specific.[17],[20] This highlights the importance of RTGCS in analyzing CS both at the institutional and national level.
The three common indications for CS in our study were fetal distress, malpresentation, and doubtful scar integrity. There is a scope for reducing CS rates in these groups by training the healthcare workers in recognizing hyperstimulation and to monitor labor through partogram. There are many studies that have shown a reduction in CS rate following implementation of this classification system and found a small reduction in the CS rates in group 1 and 2.[13],[18],[19],[21],[22],[23] Similarly, reducing CS rate at the cost of increased perinatal morbidity/mortality is not meaningful. Hence, analysis of CS by incorporating the details on perinatal outcome onto RTGCS system will make it as an appropriate auditing system.
This article concerns the rising incidence of CS rates in the present scenario and the usage of RTGCS as an auditing tool. The strength includes the study setting: JIPMER being an important tertiary care center in Southern part of India with an annual delivery rate of 15,000–18,000 is an ideal setting to explore the usefulness of RTGCS. The distribution of women in all the ten groups was as per WHO/MCS references and the missing data were negligible, hence the analysis of CS was meaningful and comparable. The major weakness was nonassessment of perinatal outcome while auditing CS. However, the detailed analysis of CS in this article helps us to understand the existing knowledge on the distribution of indications in various groups and plan future studies by incorporating perinatal outcome and details of labor characteristics onto existing RTGCS system.
The flexibility of RTGCS allows sub group classifications in certain groups like group 5 and 10 as mentioned earlier.[24] Maternal and fetal outcomes are to be incorporated into the RTGCS to establish optimal range of CS for better outcome.[19],[21],[22],[24],[25] This was highlighted in the systematic review on Robson classification for CS by Betrán et al.[18] Although simplicity, robustness, reliability, and flexibility are considered as positive aspects of RTGCS, problems such as misclassification, missing data and lack of definition on core variables have been identified as difficult areas. Training of health care workers in collecting the data and its systematic way of analysis are essential for successful implementation of RTGCS. As it is mentioned in the WHO manual, neither Robson nor MCS references should be taken into consideration for standardizing CS rates. Incorporating pattern of morbidity into RTGCS system may be useful to improve women's health as the knowledge on morbidity gives additional input on CS. RTGCS is a simple useful tool which not only is a starting point for meaningful analysis of CS but can also compare the trends over a period of time both at facility level and across different facilities by its virtue of analysis of different independent groups.
Limitations
The study is not without limitations. We did not include maternal and perinatal outcomes and analysis of CS by including them may be more meaningful as a quality improvement step. The detailed analysis on indications for CS in some subgroups among the ten main groups would have been possible if it was a longitudinal study.
| Conclusion | | |
From our study, we can conclude the groups 5, 2, and 1 were the three major groups that contributed to CS in our hospital. As endorsed in the WHO manual, RTGCS should be implemented in all the healthcare settings as it is a well-known base for analysis of CS. This may help us to analyze and compare the CS across institutes in a meaningful way. Further studies are needed to analyze the indications in detail in the most represented groups and include maternal/perinatal outcome as an action-oriented quality improvement tool.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]
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