Increased Cesarean Section Rates during the COVID-19 Pandemic: Looking for Reasons through the Robson Ten Group Classification System / Aumento das taxas de cesárea durante a pandemia de COVID-19: procurando explicações por meio da Classificação de Robson

Abstract Objective To compare cesarean section (CS) rates according to the Robson Ten Group Classification System (RTGCS) and its indications in pregnant women admitted for childbirth during the first wave of the coronavirus disease 2019 (COVID-19) pandemic with those of the previous year. Materials and Methods We conducted a cross-sectional study to compare women admitted for childbirth from April to October 2019 (before the pandemic) and from March to September 2020 (during the pandemic). The CSs and their indications were classified on admission according to the RTGCS, and we also collected data on the route of delivery (vaginal or CS). Both periods were compared using the Chi-squared (χ2) test or the Fisher exact test. Results In total, 2,493 women were included, 1,291 in the prepandemic and 1,202 in the pandemic period. There was a a significant increase in the CS rate (from 39.66% to 44.01%; p = 0.028), mostly due to maternal request (from 9.58% to 25.38%; p < 0.01). Overall, groups 5 and 2 contributed the most to the CS rates. The rates decreased among group 1 and increased among group 2 during the pandemic, with no changes in group 10. Conclusion There was an apparent change in the RTGSC comparing both periods, with a significant increase in CS rates, mainly by maternal request, most likely because of changes during the pandemic and uncertainties and fear concerning COVID-19.

Resumo Objetivo Comparar as taxas de cesárea segundo a Classificação de Robson, assim como suas indicações, em mulheres admitidas para parto durante a primeira onda de doença do coronavírus 2019 (coronavirus disease 2019, COVID-19, em inglês), com as do ano anterior. Materiais e Métodos Conduzimos um estudo transversal que comparou as mulheres admitidas para parto entre abril e outubro de 2019 (pré-pandemia) e entre março e setembro de 2020 (durante a pandemia). As cesarianas e as suas indicações foram classificadas conforme o sistema proposto por Robson, e obteve-se a via de parto (vaginal ou cesárea). Ambos os períodos foram comparados usando-se os testes do Qui quadrado ou o exato de Fisher. Resultados Ao todo, 2.943 mulheres foram incluídas, das quais 1.291 antes da pandemia e 1.202 durante a pandemia. A taxa de cesárea aumentou significativamente (de 39.66% para 44,01%; p = 0,028), principalmente devido a desejo materno (de 9,58% para 25,38%; p < 0,01). Os grupos 5 e 2 foram os que mais contribuíram para as taxas de cesárea. Durante a pandemia, o grupo 1 reduziu sua frequência, enquanto o grupo 2 a aumentou. Conclusão Houve uma aparente mudança nas características da população conforme a classificação de Robson. Observou-se significativo aumento nas taxas de cesárea, principalmente por desejo materno, o que reflete possíveis incertezas e medos relacionados à COVID-19.

Análise das indicações de cesáreas com base na classificação de Robson em uma maternidade brasileira de risco habitual / Cesarean section indication analysis in a habitual-risk maternity hospital in Brazil according to Robson classification system

Objetivo: Avaliar a taxa de cesáreas e suas principais indicações com base na classificação de Robson na Maternidade Municipal de São Vicente em 2020, um hospital público de risco habitual. Métodos: Trata-se de um estudo transversal observacional. Foram efetuadas revisão, correção e análise retrospectiva e documental da classificação de Robson na Maternidade Municipal de São Vicente. Foram analisados partos de janeiro a dezembro de 2020, dos quais foram coletadas e ordenadas as informações mais relevantes para a pesquisa. Resultados: Uma amostra de 1.627 partos foi encontrada. A taxa geral de cesáreas encontrada foi de 46,3%. A contribuição relativa dos grupos 1, 2 e 5 para a taxa de cesáreas foi de 16,8%, 13,3% e 46,8%, respectivamente, enquanto a contribuição relativa das indicações de cesáreas foi de 25,5% para parto cesáreo anterior e de 21,5% para sofrimento fetal agudo. Conclusão: Foi evidenciada alta taxa de cesáreas, e as principais indicações foram cesárea prévia e sofrimento fetal agudo. Os grupos 1, 2 e 5 da classificação de Robson foram os que mais contribuíram para essa taxa.

Objective: To evaluate the cesarean section rate and the cesarean indication rate based on Robson Classification during 2020 in Sã o Vicente's Municipal Maternity, a habitual-risk public hospital. Methods: This is a cross-sectional observational study. We have reviewed, corrected, analyzed retrospectively and documented Robson Classification in Sã o Vicente's Municipal Maternity. Births from January to December 2020 were analyzed, from which the main data for the research was collected and organized. Results: A sample of 1,627 births was found. The overall rate of cesarean section was 46.3%. The relative contribution of groups 1, 2 and 5 to the cesarean rate was 16.8%, 13.3% and 46.8%, respectively. While the cesarean indication relative contribution was 25.5% for previous cesarean and 21.5% for fetal distress. Conclusion: We found a high cesarean rate and the main indications were previous cesarean and fetal distress. Robson classification groups 1, 2 and 5 contributed the most to this rate.

The impact of maternal morbidity on cesarean section rates: exploring a Latin American network of sentinel facilities using the Robson's Ten Group Classification System

Background: Latin America has the highest Cesarean Section Rates (CSR) in the world. Robson's Ten Group Classification System (RTGCS) was developed to enable understanding the CSR in different groups of women, classified according to obstetric characteristics into one of ten groups. The size of each CS group may provide helpful data on quality of care in a determined region or setting. Data can potentially be used to compare the impact of conditions such as maternal morbidity on CSR. The objective of this study is to understand the impact of Severe Maternal Morbidity (SMM) on CSR in ten different groups of RTGCS. Methods: Secondary analysis of childbirth information from 2018 to 2021, including 8 health facilities from 5 Latin American and Caribbean countries (Bolivia, Guatemala, Honduras, Nicaragua, and the Dominican Republic), using a surveillance database (SIP-Perinatal Information System, in Spanish) implemented in different settings across Latin America. Women were classified into one of RTGCS. The frequency of each group and its respective CSR were described. Furthermore, the sample was divided into two groups, according to maternal outcomes: women without SMM and those who experienced SMM, considering Potentially Life-threatening Conditions, Maternal Near Miss and Maternal Death as the continuum of morbidity. Results: Available data were obtained from 92,688 deliveries using the Robson Classification. Overall CSR was around 38%. Group 5 was responsible for almost one-third of cesarean sections. SMM occurred in 6.7% of cases. Among these cases, the overall CSR was almost 70% in this group. Group 10 had a major role (preterm deliveries). Group 5 (previous Cesarean section) had a very high CSR within the group, regardless of the occurrence of maternal morbidity (over 80%). Conclusion: Cesarean section rate was higher in women experiencing SMM than in those without SMM in Latin America. SMM was associated with higher Cesarean section rates, especially in groups 1 and 3. Nevertheless, group 5 was the major contributor to the overall CSR. (AU)

Uso da classificação de robson para avaliação das taxas de cesáreas em hospitais paranaenses vinculados ao sistema único de saúde / Use of the robson classification for the evaluation of cesarean section rates in hospitals in the state of paraná linked to the single health system / Uso de la clasificación de robson para evaluar las tasas de cesrea en hospitales paranaeses vinculados al sistema de salud único

Introdução: Os índices de parto cesariano vêm aumentando mundialmente e ultrapassando, em muitos locais, os índices de parto vaginal. No entanto, tais índices nem sempre refletem a indicação real do procedimento. Objetivo: analisar as taxas de cesáreas de hospitais vinculados à Secretaria Municipal do Estado do Paraná no ano de 2021, exceto universitários, através da Classificação de Robson. Métodos: Trata-se de um estudo descritivo, transversal e de abordagem quantitativa, foram avaliadas 356 instituições de saúde do estado do Paraná, os dados foram coletados no site do Departamento de Informática do Sistema Único de Saúde (DATASUS), através do Sistema de Informações sobre Nascidos Vivos (SINASC) via tabulador oficial do Ministério da Saúde- Tabwim, no ano de 2021. Resultados: Os maiores índices segundo Classificação de Robson, foram de mulheres entre 20 à 34 anos, com companheiro, escolaridade de oito anos ou mais de estudo, multíparas com filhos vivos anteriores a última gestação, sendo estas a termo, com gravidez única e sem anomalias congênitas, além da realização de sete consultas de pré-natal com seu início no primeiro trimestre de gestação. Conclusão: o parto cesariano ultrapassa os índices do parto vaginal. Podemos evidenciar a importância que os profissionais de saúde possuem para revertermos essa realidade através da educação em saúde, e no desenvolvimento de estratégias que minimizem esses números expressivos de cesarianas.

Introduction: The rate of cesarean delivery has been increasing worldwide and in many places surpassing the rate of vaginal delivery. However, such indexes do not always reflect the actual indication of the procedure. Objective: To analyze the rates of cesarean sections of hospitals linked to the Municipal Secretariat of the State of Paraná in the year 2021, except university, through the Robson Classification. Methods: It is a descriptive, cross-sectional and quantitative approach study, 356 health institutions of the state of Paraná were evaluated, the data were collected on the website of the Department of Informatics of the Unified Health System (DATASUS), through the Information System on Live Births (SINASC) via the official tabler of the Ministry of Health- Tabwim, in the year 2021. Results: The highest rates according to the Robson Classification were women between 20 and 34 years of age, with a partner, eight years of schooling or more of study, multiparous with living children prior to the last pregnancy, these being full-term, with single pregnancy and without congenital anomalies, in addition to having seven prenatal appointments with their start in the first trimester of gestation. Conclusion: cesarean delivery exceeds the rates of vaginal delivery. We can highlight the importance that health professionals have to reverse this reality through health education, and in the development of strategies that minimize these expressive numbers of cesareans.

Introducción: las tasas de natalidad cesárea han estado aumentando en todo el mundo y han superado las tasas de natalidad vaginal en muchos lugares. Sin embargo, esos índices no siempre reflejan la indicación real del procedimiento. Objetivo: analizar las tasas de cesárea hospitalaria vinculada a la Secretaría Municipal del Estado de Paraná en 2021, excepto los graduados universitarios, a través de la Clasificación de Robson. Métodos: Se trata de un estudio descriptivo, transversal y cuantitativo; se evaluaron 356 instituciones de salud del estado de Paraná; los datos se recogieron en el sitio web del Departamento de Información del Sistema de Salud Pública (DATASUS), a través del Sistema de Información sobre Aves Vivas (SINASC) a través del tabulador oficial del Ministerio de Salud ­ Tabwim, en 2021. Resultados: Los índices más altos según la Clasificación de Robson fueron las mujeres de 20 a 34 años de edad, con parejas, escolaridad durante ocho años o más de estudio, multiples con hijos vivos antes del último embarazo, con un solo embarazo y sin anomalías congénitas, y también se realizaron siete consultas prenatales con su inicio en el primer trimestre de gestación. Conclusión: el parto cesárea excede las tasas vaginales de nacimiento. Podemos destacar la importancia que tienen los profesionales de la salud para revertir esta realidad a través de la educación sanitaria, y en el desarrollo de estrategias que minimicen este número expresivo de cesáreas.

Aplicación de la clasificación de Robson para el análisis de la tasa de cesárea en el Hospital Doctor Peset / Review of cesarean rate in Hospital Doctor Peset using the Robson classification

OBJECTIVE: To analyze the caesarean deliveries attended in our hospital, grouping them according to the Robson Classification System and to establish measures in order to reduce caesarean delivery rates. METHOD: Prospective study of all the deliveries attended at Hospital Doctor Peset in 2019 using the Robson classification. RESULTS: A total of 1113 births have been analyzed with a total cesarean section rate of 25.3%. The largest contribution to the total cesarean delivery rate with 34.4% was group 2A (nulliparous women with a single fetus in cephalic presentation, 37 weeks or more pregnant who started labor by induction). Secondly, group 5 (multiparous women with at least previous cesarean section, with single cephalic fetus, 37 weeks or more pregnant) which represents the 20.1% of the total. Inductions in nulliparas multiply the cesarean section rate by 3 compared to nulliparas that initiate labor spontaneously. CONCLUSIONS: Robsons classification is a tool that allows to easily classify and analyze the groups in which to implement measures to reduce the number of caesarean sections performed. Analyzing the induction indications and reviewing action protocols could suppose a substantial decrease in the caesarean section rate in our center.

OBJETIVO: Analizar las cesáreas realizadas en nuestro centro agrupándolas según la clasificación de Robson para establecer medidas que permitan reducir la tasa de cesáreas. MÉTODO: Auditoría prospectiva de los nacimientos asistidos en el Hospital Doctor Peset en el año 2019 mediante la clasificación de Robson. RESULTADOS: Se han analizado 1113 nacimientos con una tasa de cesárea del 25.3%. El grupo que más contribuyó al total de cesáreas realizadas, con un 34.4%, fue el 2A (nulíparas con feto único en presentación cefálica, de 37 semanas o más de embarazo, que iniciaron el parto mediante inducción). En segundo lugar, el grupo 5 (multíparas con al menos una cesárea previa, con un feto único en presentación cefálica, de 37 semanas o más de embarazo), con un 20.1%. Las inducciones en nulíparas multiplican por tres la tasa de cesárea respecto a las nulíparas que inician el trabajo de parto de manera espontánea. CONCLUSIONES: La clasificación de Robson es una herramienta que permite clasificar y analizar de manera sencilla los grupos en los que implantar medidas para reducir el número de cesáreas realizadas. Analizar las indicaciones de inducción y revisar los protocolos de actuación podría suponer una disminución sustancial en la tasa de cesáreas en nuestro centro.

Comparación de la tasa de cesáreas de dos maternidades públicas del Uruguay / Comparison of the caesarean section rate of two publics health maternity in Uruguay / Comparação da taxa de cesariana de duas maternidades públicas no Uruguai

Se realizó un analisis de la tasa de cesáreas en dos maternidades públicas de referencia de Uruguay (Hospital de Clínicas y Centro Hospitalario Pereira Rossell) utilizando la clasificación de Robson para compararlas entre sí, mediante un estudio observacional, descriptivo, retrospectivo y transversal en un periodo de 10 años y 10 meses (2009-2019). Se analizaron 85.526 nacimientos (7.685 (8,9%) en el Clínicas vs 77.841 (91.1%) Pereira Rossell). El porcentaje de cesáreas por año en el Clínicas fue 49,2% ± 5 vs 29,3% ± 3 en Pereira Rossell. Los grupos de Robson más prevalentes fueron 1, 5A y 10 en el Clínicas vs 3, 1 y 5A en Pereira Rossell. En ambos centros los grupos con mayor contribución relativa a la tasa global de cesáreas fueron: 5A, 10 y 1. Ambos centros presentan un aumento en la tasa de cesárea en la última década, pese a que se asisten poblaciones dispares entre cada uno de ellos. Se debe seguir buscando estrategias que ayuden a reducir la tasa de cesáreas principalmente en pacientes sin cesáreas anteriores o con una única cesárea previa, en caso de no presentan contraindicaciones para el parto vaginal.

An analysis of the caesarean section rate was carried out in two reference public maternity wards in Uruguay (Hospital de Clínicas and Centro Hospitalario Pereira Rossell) using Robson's classification to compare them with each other, through an observational, descriptive, retrospective and cross-sectional study in a period 10 years and 10 months (2009-2019). 85,526 births were analyzed (7,685 (8.9%) in the Clinics vs 77,841 (91.1%) Pereira Rossell). The percentage of caesarean sections per year in the Clinics was 49.2% ± 5 vs 29.3% ± 3 in Pereira Rossell. The most prevalent Robson groups were 1, 5A and 10 in the Clinicas vs 3, 1 and 5A in Pereira Rossell. In both centers, the groups with the highest relative contribution to the overall rate of cesarean sections were: 5A, 10 and 1. Both centers show an increase in the rate of cesarean section in the last decade, despite the fact that different populations are attended between each of them. Strategies should continue to be sought to help reduce the rate of cesarean sections, mainly in patients without previous cesarean sections or with a single previous cesarean section, if they do not present contraindications for vaginal delivery.

Foi realizada análise da taxa de cesárea em duas maternidades públicas de referência do Uruguai (Hospital de Clínicas e Centro Hospitalario Pereira Rossell), utilizando a classificação de Robson para compará-las, por meio de estudo observacional, descritivo, retrospectivo e transversal. em um período de 10 anos e 10 meses (2009-2019). Foram analisados 85.526 partos (7.685 (8,9%) nas Clínicas vs 77.841 (91,1%) Pereira Rossell). A porcentagem de cesarianas por ano nas Clínicas foi de 49,2% ± 5 vs 29,3% ± 3 em Pereira Rossell. Os grupos de Robson mais prevalentes foram 1, 5A e 10 nas Clínicas vs 3, 1 e 5A em Pereira Rossell. Em ambos os centros, os grupos com maior contribuição relativa para a taxa global de cesárea foram: 5A, 10 e 1. Ambos os centros apresentam aumento da taxa de cesárea na última década, apesar de diferentes populações serem atendidas entre cada um deles. Estratégias devem continuar a ser buscadas para ajudar a reduzir a taxa de cesárea, principalmente em pacientes sem cesárea anterior ou com cesárea única, se não apresentarem contra-indicações para parto normal.

Gestational risk as a determining factor for cesarean section according to the robson classification groups / Risco gestacional como fator determinante para cesariana de acordo com os grupos da Classificação Robson

Abstract Objective To analyze and compare the frequency of cesarean sections and vaginal deliveries through the Robson Classification in pregnant women attended at a tertiary hospital in two different periods. Methods Cross-sectional, retrospective study of birth records, comprising 4,010 women, conducted from January 2014 to December 2015 in the only public regional referral hospital for the care of high- risk pregnancies, located in Southern Brazil. Results The overall cesarean section rate reached 57.5% and the main indication was the existence of a previous uterine cesarean scar. Based on the Robson Classification, groups 5 (26.3%) and 10 (17.4%) were the most frequent ones. In 2015, there was a significant increase in the frequency of groups 1 and 3 (p < 0.001), when compared with the previous year, resulting in an increase in the number of vaginal deliveries (p < 0.0001) and a reduction in cesarean section rates. Conclusion The Robson Classification proved to be a useful tool to identify the profile of parturients and the groups with the highest risk of cesarean sections in different periods in the same service. Thus, it allowsmonitoring in a dynamic way the indications and delivery routes and developing actions to reduce cesarean rates according to the characteristics of the pregnant women attended.

Resumo Objetivo Analisar e comparar a frequência de partos cesáreos e vaginais através da classificação de Robson em gestantes atendidas em um hospital terciário em dois períodos distintos. Métodos Estudo transversal retrospectivo de registros de nascimento, compreendendo 4.010 mulheres, realizado de janeiro de 2014 a dezembro de 2015 no único hospital público de referência regional para atendimento de gestações de alto risco, localizado no sul do Brasil. A via de parto foi avaliada e as mulheres foram classificadas de acordo com a Classificação de Robson. Resultados A taxa geral de cesariana foi de 57,5% e a principal indicação foi a existência de cicatriz uterina por cesariana prévia. Quando aplicada a Classificação de Robson, os grupos mais frequentes foram o 5 (26,3%) e o 10 (17,4%). No ano de 2015, ocorreu um aumento significativo da frequência dos grupos 1 e 3 (p < 0,001), quando comparado ao ano anterior, resultando em aumento do número de partos vaginais (p < 0,0001) e redução das taxas de cesariana. Conclusão A Classificação de Robson mostra ser uma ferramenta útil para identificar o perfil das parturientes e os grupos com maior risco de cesariana em diferentes períodos em um mesmo serviço. Desta forma, permitemonitorar de forma dinâmica as indicações e vias de parto e desenvolver ações para redução das taxas de cesariana conforme as características das gestantes atendidas.

Análise da taxa de cesarianas: estudo comparativo entre duas maternidades públicas no estado do Rio de Janeiro / Cesarean section rate analysis: comparative study between two public maternity hospitals in the state of Rio de Janeiro

Objetivo: Comparar a taxa de cesarianas em duas maternidades públicas no estado do Rio de Janeiro, denominadas Maternidades A e B. Métodos: Foram extraídos das Declarações de Nascido Vivo (DNVs) dados sobre partos ocorridos no período de agosto a outubro de 2018, sendo realizada a classificação deles nos grupos de Robson. Foi possível identificar as características da população atendida e os grupos de maior representatividade que contribuíram para a taxa de cesarianas. Resultados: A idade média geral das puérperas em estudo foi de 25,7 anos. Verificou-se que ambas as maternidades apresentam taxas de cesarianas elevadas (a Maternidade A apresentou 46,4% e a Maternidade B, 34,4%), sendo a taxa geral do estudo de 40,1%. Analisando as características da população de ambas as maternidades, a maioria atendida na Maternidade A é representada por nulíparas com feto único e a termo (grupo 2 = 21,1%), e a Maternidade B é representada, em sua maioria, por multíparas, sem cesárea prévia, com feto único e a termo (grupo 3 = 22,9%). O grupo 2 foi o que mais contribuiu para a taxa geral de cesariana em ambas as maternidades, após o grupo de pacientes com pelo menos uma cesárea prévia (grupo 5), sendo 26% na Maternidade A e 33,1% na Maternidade B. Conclusão: Foi possível concluir que ambas as maternidades em estudo apresentaram taxas de cesarianas menores que a nacional, porém muito acima do recomendado pela Organização Mundial da Saúde (OMS). Ambas apresentaram valores consideráveis de preenchimento inadequado das DNVs.(AU)

Objective: To compare the cesarean section rate in two public maternity hospitals in the state of Rio de Janeiro, called maternity hospitals A and B. Methods: Data from Certificates of Live Births (DNVs) occurred during the period from August to October 2018 were extracted and their classification was performed in Robson's groups. Through this classification it was possible to identify the characteristics of the population served and the most representative groups that contributed to the cesarean section rate. Results: The overall average age of the puerperal women under study was 25.7 years. Both maternities showed higher caesarean section rates (Maternity A had a rate of 46.4% and Maternity B 34.4%), with the overall study rate of 40.1%. Analyzing the characteristics of the population of both maternities, the majority attended at Maternity A is represented by nulliparous women with single and full-term fetuses (group 2 = 21.1%), and Maternity B is mostly represented by multiparous women, without previous cesarean section, with single and full-term fetus (group 3 = 22.9%). It was group 2 that most contributed to the overall cesarean section rate after the group of patients with at least one previous cesarean section (group 5), being 26% in Maternity A and 33.1% in Maternity B. Conclusion: It was concluded that both maternity hospitals under study had caesarean section rates lower than the national rate, but much higher than recommended by World Health Organization (WHO). In addition, both presented considerable values of inadequate filling of DNVs.(AU)

Analysis of caesarean sections at a tertiary care centre according to Robson’s criteria

Background: There has been a considerable increase in the rate of caesarean sections in the past few decades. Some demographers have argued that this increase is largely affected by the uprising trend of new medically indicated caesarean sections. M. S. Robson proposed a ten-group classification of caesarean sections in year 2001 which was appreciated by WHO in 2014 and FIGO in 2016. This classification is known as Robson’s classification which has ten groups.Methods: This is a retrospective study which was carried out at Civil Hospital, Karimnagar. The study group included all live births and still births of at least 500 gm birth weight or at least 28 weeks of gestation at Civil Hospital, Karimnagar during the period from October 2019 to December 2019. The data collected was analysed using simple statistical methods like percentage and proportion. The data was grouped according to the Robson’s 10 group classification system. The overall caesarean section rate, size of each group and the relative contribution of each group to the overall CS rate were calculated.Results: The total number of deliveries during the study period was 2493. Out of these, the number of caesarean deliveries was 1345. The caesarean section rate was calculated to be 53.95%. The group 5 (multiparous with at least one previous uterine scar with single cephalic pregnancy ≥37 weeks of gestation) contributed to 38.07% of the total caesarean section rate which is the highest.Conclusions: A regular audit into the number and indications of caesarean sections will definitely help in decreasing the primary and repeat caesarean sections.

Pattern of live births in Rio de Janeiro State, Brazil, according to Robson groups and the Kotelchuck index classification - 2015/2016 / Padrão de nascidos vivos no estado do Rio de Janeiro, Brasil, segundo os grupos Robson e a classificação do índice Kotelchuck - 2015/2016

Abstract Objective To investigate the patterns of hospital births in the state of Rio de Janeiro (RJ), Brazil, between 2015 and 2016; considering the classification of obstetric characteristics proposed by Robson and the prenatal care index proposed by Kotelchuck. Methods Data obtained from the Information System on Live Births of the Informatics Department of the Brazilian Unified Health System (SINASC/DATASUS, in the Portuguese acronym) databases were used to group pregnant women relatively to the Robson classification. A descriptive analysis was performed for each Robson group, considering the variables: maternal age, marital status, schooling, parity, Kotelchuck prenatal adequacy index and gestational age. A logistic model estimated odds ratios (ORs) for cesarean sections (C-sections), considering the aforementioned variables. Results Out of the 456,089 live births in Rio de Janeiro state between 2015 and 2016, 391,961 records were retained, 60.3% of which were C-sections. Most pregnant women (58.6%) were classified in groups 5, 2 or 3. The percentage of C-sections in the Robson groups 1, 2, 3, 4, 5 and 8 was much higher than expected. Prenatal care proved to be inadequate for women who subsequently had a vaginal delivery, had an unfavorable family structure and a lower socioeconomic status (mothers without partners and with lower schooling), compared with those undergoing cesarean delivery. For a sameRobson group, the chance of C-section increases when maternal age rises (OR = 3.33 for 41-45 years old), there is the presence of a partner (OR = 1.81) and prenatal care improves (OR = 3.19 for "adequate plus"). Conclusion There are indications that in the state of RJ, from 2015 to 2016, many cesarean deliveries were performed due to nonclinical factors.

Resumo Objetivo Investigar os padrões dos partos hospitalares no estado do Rio de Janeiro (RJ), Brasil, entre 2015 e 2016, considerando a classificação de características obstétricas de Robson e a dos cuidados pré-natais proposta por Kotelchuck. Métodos Dados sistema de informações sobre nascidos vivos (SINASC) do departamento de informática do sistema único de saúde (DATASUS) foram utilizados para agrupar gestantes relativamente à classificação de Robson. Foi efetuada uma análise descritiva para cada grupo de Robson, considerando-se as variáveis idade materna, estado civil, escolaridade, paridade, o índice de Kotelchuck de adequação do pré-natal e a idade gestacional. Também foi realizado o cálculo de razão de chances (RC) para parto cesáreo, considerando-se um modelo logístico. Resultados Dos 456.089 nascimentos vivos ocorridos no RJ de 2015 a 2016, foram incluídos 391.961 registros, sendo 60,3% cesáreas, com maioria de gestantes (58,6%) nos grupos 5, 2 ou 3. O percentual de cesáreas nos grupos 1, 2, 3, 4, 5 e 8 foi bem superior ao sugerido pela literatura. Para gestantes de um mesmo grupo (controladas as demais características), a chance de cesárea se eleva quando aumenta a idade materna (RC = 3,33 para 41-45 anos), existe a presença de um companheiro (RC = 1,81), o nível de escolaridade é maior (RC = 3,11 para ≥ 12 anos) e o pré-natal é mais cuidadoso (RC= 3,19 para "adequado plus"). Conclusão Há indícios que no RJ, de 2015 a 2016, muitos partos cesáreos foram realizados sob influência de fatores extraclínicos.

Interventions to reduce caesarean section rates at government medical college and hospital Aurangabad, India

Background: Caesarean sections are effective in saving maternal and infant lives, but only when they are performed for medically indicated reasons, The Objective of this study was to reduce caesarean Section rate at GMCH, Aurangabad and to improve overall birthing experience with respectful maternity care.Methods: The caesarean sections done at GMCH Aurangabad were audited using Robson`s Ten Group classification system to identify the major contributors to the overall CS rate. The following clinical and non-clinical interventions were applied dynamically to control the caesarean section rates. Clinical Interventions were changes in protocols regarding induction of labour, Intermittent auscultation as opposed to continuous electronic foetal monitoring in low risk cases, use of a partogram, encouragement of different birthing positions, promoting TOLAC to reduce the secondary CS rate. Nonclinical interventions include encouragement of DOULA (birth companion), ante-natal counselling of the expectant mothers, training of healthcare staff for respectful maternity care and use of evidence based clinical practice guidelines with mandatory second opinion for every non recurrent indication of CS. Auditing of caesarean section using Robson classification.Results: In this study there has been steady decline in LSCS rates from 33% to 26.9%. On analysis with Robson classification, group 5 (previous LSCS) made largest contribution of 36.9% followed by Group 1, 2, 10 each contributed 18.01%,13.2% and 11.2% respectively. Group 6 to 10 account for 23%. Various birthing positions lowered use of oxytocics from 33 % to 19% as well lowered episiotomy rates with greater success in vaginal delivery.Conclusions: Modification of induction protocols have reduced the primary LSCS rates and successful VBAC using FLAMM score was helpful in reducing the repeat caesarean Sections. Various birthing positions, DOULA gave greater success in vaginal delivery. LSCS rates in mothers with breech, multiple or oblique/transverse lies were largely unmodifiable. Limiting the CS rate in low-risk pregnancies by individualizing every labour and not to set a time limit as long as mother and baby are closely monitored.

Are we operating unnecessarily?: caesarean audit in a single unit of a private tertiary care hospital in North India

Background: Caesarean section emerged as a lifesaving surgery in situations where vaginal delivery could put the mother and fetus at risk. Over the years global rise in caesarean delivery rate has been alarming and may be attributed to changes in medical practice and societal expectations, especially in urban areas and developing countries. Rising caesarean rate is worrisome as it increases maternal morbidity, exposes the mother to future obstetric risks, besides increasing financial burden on the health care system. Caesarean audits could be an effective tool to analyse, understand and propose solutions to reduce caesarean rates. Hence, this retrospective study was conducted to audit caesarean sections done over a period of 5 years (2011 to 2015) in a single unit of a tertiary care private hospital in North India.Methods: The case records of all caesarean deliveries from January 2011 to December 2015 were analysed retrospectively for demographic profile, clinical parameters and recorded indication of caesarean section on the basis of Robson’s classification.Results: The caesarean section rate in the study was 61.8%. According to Robson’s 10 system classification, Group 2, 5 and 10 were the largest contributors. The commonest indication was previous LSCS (18.7%) followed closely by fetal distress (15.4%) and prolonged labor/failed induction (13.3%). Maternal request contributed 10.6% of the Caesarean deliveries.Conclusions: The caesarean section rate in our study is way higher than the national average. We need to re-duce caesareans in primigravidae and consider VBAC where appropriate. Use of Electronic fetal monitoring during labor needs to be optimized. Appropriate use of oxytocics, proper monitoring and using robust criterion to infer non progress of labor are important. Appropriate counselling and assured pain management during labor may help reduce caesareans on maternal request.

Estudo da incidência de cesáreas de acordo com a Classificação de Robson em uma maternidade pública / Study of cesarean section incidence according to Robson Classification in a public maternity hospital

Objetivo: Analisar, na população obstétrica do Hospital Maternidade Leonor Mendes de Barros (HMLMB), os grupos que contribuem mais substancialmente para a taxa de cesariana, utilizando a Classificação de Robson. Métodos: Trata-se de uma análise secundária de dados provenientes de um estudo realizado no HMLMB que objetivou identificar a proporção de partos cesáreos e vaginais no ano de 2016. Assim, propusemos uma análise desses dados apoiada em uma revisão bibliográfica, identificando as principais contribuições da Classificação de Robson nesse hospital e comparando com serviços similares. Resultados: Os grupos de 1 a 5 representaram 87,4% das pacientes atendidas, com predomínio dos grupos 5 (21,7%), 3 (20,9%) e 2 (19,4%). A taxa geral de cesáreas foi de 41,8% no HMLMB em 2016, com maior contribuição dos grupos 5 (41,1%) e 2 (28,7%). Destacaram-se as baixas taxas de cesáreas nos grupos 1 (4,5%) e 3 (1,3%), quando comparadas com as taxas de instituições similares. Conclusão: É necessário investir em estratégias mais eficientes para reduzir as taxas de cesáreas. Com os resultados observados no HMLMB, é possível sugerir uma revisão de protocolos referentes ao preparo do colo do útero e indução eletiva do parto em nulíparas, bem como investir no implemento do parto vaginal após cesárea.(AU)

Objective: To analyze within the obstetric population of the Leonor Mendes de Barros Maternity Hospital (LMBMH), the groups that contribute most substantially to the cesarean section rate using the Robson Classification. Methods: This is a secondary analysis of data from a study conducted at the LMBMH that aimed to identify the proportion of cesarean and vaginal deliveries in 2016. Thus, we proposed an analysis of these data supported by a literature review, identifying the main contributions of the Robson Classification in this hospital and comparing with similar services. Results: Groups 1 to 5 represented 87.4% of the patients treated, with emphasis on groups 5 (21.7%), 3 (20.9%) and 2 (19.4%). The overall cesarean section rate at LMBMH in 2016 was 41.8%, with the largest contribution from groups 5 (41.1%) and 2 (28.7%). We highlight the low rate of cesarean sections in groups 1 (4.5%) and 3 (1.3%), when compared with the rates of similar institutions. Conclusion: It is necessary to invest in more efficient strategies to reduce cesarean rates. Looking at the results in the LMBMH, it is possible to suggest a review of protocols related to cervical preparation and elective induction of labor in nulliparas, as well as investing in the implementation of vaginal delivery after cesarean section.(AU)

Improving the management of high-risk pregnancies with the use of the Robson classification / Melhorando a gestão da gravidez de alto risco com o uso da classificação de Robson

Abstract Objective To analyze the rates of cesarean delivery longitudinally in a university hospital using the Robson classification. Methods Data related to births performed between 2014 and 2018 and recorded in the Maternal and Neonatal Health Information System (Sistema de Informações em Saúde Materna e Neonatal, SISMATER, in Portuguese) were analyzed using the Robson classification. As an aid, we used articles published in the last five years that approach the same topic in other Brazilian maternity hospitals; they were retrieved from the LILACS, MEDLINE, CINAHL, Scopus, Web of Science and Cochrane Library databases. Results There was little variation in the total rate of cesarean sections in the period; however, the profile of each group changed over the years. It was possible to verify a significant reduction in the participation of groups of pregnant women with lower risk and an increase in high-risk pregnancies, attributable to the decrease in beds in the institution, with a greater transfer of patients. In addition, there was a reduction in cesarean sections among the lower-risk groups,while the rate among the higher-risk groups remained stable. Conclusion The use of the Robson classification to stratify cesarean deliveries contributes to a better analysis of the indications for cesarean delivery, enabling the establishment of strategies to reduce the rates, generating a positive impact on hospital management and quality of care.

Resumo Objetivo Analisar longitudinalmente as taxas de parto cesáreo em um hospital universitário usando a classificação de Robson. Métodos Foram analisados, por meio da classificação de Robson, dados relacionados a partos realizados entre 2014 e 2018 e armazenados no Sistema de Informações em Saúde Materna e Neonatal (Sismater). Para auxílio, foram utilizados artigos publicados nos últimos cinco anos que abordavam o mesmo tema em outras maternidades Resultados A taxa total de cesárea variou pouco no período; no entanto, alterou-se o perfil de cada grupo ao longo dos anos. Foi possível constatar redução significativa da participação de grupos de contendo gestantes de risco habitual e aumento das gestações de alto risco, atribuíveis à diminuição de leitos na instituição, com maior transferência de pacientes. Além disso, houve uma redução na taxa de cesáreas nos grupos de mais baixo risco, enquanto a taxa dos grupos de risco mais elevado se manteve estável. Conclusão A utilização da classificação de Robson para estratificar os partos cesáreos contribui para uma análise melhor das indicações do parto cesáreo, o que permite o estabelecimento de estratégias para a redução das taxas, gerando um impacto positivo na gestão hospitalar e na qualidade assistencial.

Evaluation of caesarean section practices according to Robson's 10-group classification at a level two maternity ward in Conakry, Guinea

Background: The frequency of caesarean sections (CS) increased dramatically in the world over the last twenty years. The objective of this study was to evaluate caesarean section practices based on Robson classification in an urban referral hospital in Conakry, GuineaMethods: We conducted a cross-sectional study of 2,266 birthing records collected at the maternity ward of the Coronthie Communal Medical Center in Conakry, from January 1st to December 31st 2016. We included in the study all women who had a caesarean section and whose medical records were complete. Robson's classification was used to classify women into 10 groups based on maternal and fetal characteristics. The relative size of each group, its gross caesarean section rate as well as its contribution to overall caesarean section rate and the main caesarean section indications were calculated.Results: In 2016, 769 caesarean sections were performed out of 2,266 deliveries, corresponding to a hospital section rate of 33.9%. Groups 5 (11.0%), 1 (4.8%), and 3 (4.3%) of the Robson classification were the most contributors to registered hospital caesarean section rate. The main indications for caesarean section were uterine scar in group 5 and acute fetal distress in groups 1 and 3.Conclusions: The systematic reference to the Robson classification could help to identify and avoid the relative indications of the caesarean section in urban Guinea. Besides, increasing induction of labor and strengthening providers’ capacities in emergency obstetric and newborn care services could contribute to reduce caesarean section rates in Guinea.

Classification of births according to Robson 10 group classification: an emerging concept to audit the increasing caesarean section rate

Background: High caesarean birth rates are an issue of international public health concern. Worries over such increases have led the WHO to advice that caesarean section rate should not be more than 15%. WHO proposes that the health care facilities to use the Robson’s 10 group classification system to audit their CS rates. Our aim was to investigate the CS rates in a period of 6 months using Robso’s 10 group classification.Methods: This was a cross sectional study conducted for a period of 6 months from July 2018 to December 2018 in Department of Obstetrics and Gynecology, Siddhartha medical college which is a tertiary care center .All women delivered during this period in labour ward were included. All relevant obstetric information (parity, mode of previous deliveries, previous CS and indications, gestational age, onset of labor) was entered on a questionnaire and classified into Robson’s 10 classes and percentages were calculated.Results: Total number of deliveries in 6 months is 4719 out of which C-sections are 1816 which accounts for 38.48%. Highest contribution was by group 5 and group 2. Together these two groups contribute to 62.4% of the total caesarean sections. Group 6 and group 9 by themselves did not contribute much but within their groups had 100% C-section rates.Conclusions: Robson’s 10 group classification provides easy way in collecting information about caesarean section rate which obtains good insight into certain birth groups. Number of women who attempt VBAC has declined over recent years due to fear of uterine rupture. Reducing primary C-section rates, adequate counseling and changing norms for non-reassuring fetal status could reduce contribution of Robson’s groups towards absolute C-section rates.

Caesarean section audit in a tertiary hospital of North India using Robson’s classification

Background: In view of upsurging Caesarean section (CS) rate worldwide WHO conducted two multicountry surveys to diagnose the driving determinants. In two WHO surveys increased overall CS rate was observed from 26.4% to 31.2% worldwide except Japan. Both WHO 2014 and FIGO 2016 recommend Robson ten- group classification for monitoring caesarean rate over time because of its clarity, tenacity, resilience and pliability. Our Aim is to classify women delivered in our Hospital as per Robson ten –group classification and access the factor driving caesarean rate in each group.Methods: This is a retrospective study 1671 caesarean section conducted in tertiary hospital over 6 months (July- December) 2018. All the delivering women were classified according to Robson ten-group classification and data was analyzed using Microsoft excel and SPSS 23 software.Results: During the study period there were 5917 deliveries. Of these 1671 deliveries were CS accounting for CS rate of 28.24% . The major contributor to CS rate were women in group 5 followed by primigravida’s in group 1 and 2. Increasing  CS rate was observed in group 1 ,2, 3 and 5. Most common indication for caesarean section was fetal distress , failed induction , previous caesarean , breech and Antepartum hemorrhage.Conclusions: Increasing trend in CS rate is observed in group 1,2 ,3 and 5. In order to reduce CS rate among group 2 better patient selection is required for induction of labour based on Bishop score. In order to reduce CS rate in group 5 promotion of  VBAC deliveries should be encouraged. By classifying women according to Robson group 10 classification  helps in identification of women likely to deliver by caesarean  and to identify effective strategies to optimize the CS rate.

Audit of caesarian deliveries in a tertiary care center, in rural Bangalore, India

Background: The Robson’s Ten-Group Classification System allows critical analysis of caesarean deliveries according to characteristics of pregnancy. The objective was to analyze caesarean section rates in a rural tertiary care teaching hospital in Bangalore, using Robson’s ten groups classification.Methods: This study was done in MVJ Medical College and Research Hospital, a rural tertiary care teaching hospital. All patients who underwent caesarean delivery, between November 2017 and October 2018, were included in the study. Women were classified in 10 groups according to Robson’s classification. For each group, authors calculated its relative contribution to the overall caesarean rate.Results: The overall caesarean section rate was 46.7%. The main contributors to this high caesarean rate were primiparous women in spontaneous labour (group 1) and women with previous caesarean section (group 5).  52.1% of CS were conducted on women who were unbooked or booked at a peripheral health facility and referred to present institution due to complications in labor. Strategies to lower CS rates would include encouraging women with previous CS, to undergo trial of labor to reduce CS rates for group 5C. Sensitization of staff in peripheral medical facilities for early referral of high-risk pregnancies to a tertiary care center for better control of medical complications like hypertensive disorders of diabetes mellitus. Other strategies include offering external cephalic version to eligible women with breech presentation and consider offering vaginal breech delivery to suitable women in groups 6 and 7.Conclusions: The Robson’s classification is easy to use. It is time to implement obstetric audit to lower the overall CS rates.

Analysis of caesarean section rate according to modified Robson’s classification at tertiary care centre in Uttarakhand, India

Background: High caesarean section rate worldwide including India is matter of concern. The aim of this study is to analyse caesarean section rate at tertiary care centre according to Modified Robson’s classification.Methods: This retrospective study was conducted at Shri Guru Ram Rai Institute of Medical and Health Sciences (SGRRIMHS) and Shri Mahant Indiresh Hospital at Dehradun from April 2018 to September 2018. All women delivered during this period were classified according to modified Robson’s classification using their maternal characteristics and obstetric history. For each group, authors calculated the caesarean section rate within the group and its contribution to overall caesarean section rate.Results: Out of total 1302 women delivered, 395 underwent CS (30.3%).The major contribution to overall caesarean section rate was 33.4% by group 5 (Previous CS, singleton, cephalic, >37weeks) followed by 16.7% by group 1 (nullipara, singleton, cephalic, >37 weeks, spontaneous labour), 12.4% by group 3 ( multipara, singleton, cephalic, >37 weeks, spontaneous labour ).CS rates among various group ranges from 100% among women with abnormal lie (group 9) to 77.5% in nulliparous breech (group 6), 73.7% in previous CS (group 5) and least 11.2%  in multipara induced or pre labour CS (group 4).Conclusions: Modified Robson classification is simple, systematic, reproducible and can be effectively utilized in analyzing delivering women. Major contribution to overall caesarean section is made by previous CS.

Exploring obstetrical interventions and stratified cesarean section rates using the Robson classification in tertiary Care hospitals in the united arab emirates

Abstract Objective The objective of the present study was to explore obstetric management in relation to clinical, maternal and child health outcomes by using the Robson classification system. Methods Data was collected from obstetrics registries in tertiary care hospitals in Dubai, United Arab Emirates (UAE). Results The analysis of > 5,400 deliveries (60% of all the deliveries in 2016) in major maternity hospitals in Dubai showed that groups 5, 8 and 9 of Robson's classification were the largest contributors to the overall cesarean section (CS) rate and accounted for 30% of the total CS rate. The results indicate that labor was spontaneous in 2,221 (45%) of the women and was augmented or induced in almost 1,634 cases (33%). The birth indication rate was of 64% for normal vaginal delivery, of 24% for emergency CS, and of 9% for elective CS.The rate of vaginal birth after cesarean was 261(6%), the rate of external cephalic version was 28 (0.7%), and the rate of induction was 1,168 (21.4%). The prevalence of the overall Cesarean section was 33%; with majority (53.5%) of it being repeated Cesarean section. Conclusion The CS rate in the United Arab Emirates (UAE) is higher than the global average rate and than the average rate in Asia, which highlights the need for more education of pregnant women and of their physicians in order to promote vaginal birth. A proper planning is needed to reduce the number of CSs in nulliparous women in order to prevent repeated CSs in the future. Monitoring both CS rates and outcomes is essential to ensure that policies, practices, and actions for the optimization of the utilization of CS lead to improved maternal and infant outcomes.