ANALYSIS OF CAESAREAN SECTION RATE ACCORDING TO MODIFIED ROBSON’S CLASSIFICATION AT TERTIARY CARE CENTRE IN JAIPUR, RAJASTHAN, INDIA

ANALYSIS OF CAESAREAN SECTION RATE ACCORDING TO MODIFIED ROBSON’S CLASSIFICATION AT TERTIARY CARE CENTRE IN JAIPUR, RAJASTHAN, INDIA

Seema Dhami, Bhanvi Bharadwaj, Nandani Singh and Himanshi Gangwal *

Department of Obstetrics & Gynecology, S. M. S. Medical College, Jaipur, Rajasthan, India.

ABSTRACT: According to WHO guidelines and US Healthy initiative 2000, the cesarean section rate should not be beyond 15 %. The aim of this study is to analyze caesarean section rate at tertiary care centre according to Modified Robson’s classification. Methods: The present study was carried out retrospectively at Department of Obstetrics & Gynecology, SMS Medical College, Jaipur, Rajasthan from May 2023 to Nov2023. All women delivered during this period were classified according to modified Robson’s classification. For each group, the caesarean section rate within the group and its contribution to overall caesarean section rate were calculated and results were noted as per Modified Robson’s criteria.  Results: Highest contribution to the total CS rate was made by Group 5 (previous cesarean, singleton, cephalic, > or equal to 37 weeks), accounting for 40.65% of all CSs, with CS rate of 95.83%. High CS rates were also observed in Group 6 (nulliparous breech) and Group 7 (multiparous breech) having a 100% CS rate. Group 2 (Nulliparous, singleton, cephalic, > or equal to 37 weeks) had a higher CS rate (48.33%) than Group1.Group 3 & 4 (Multiparous, singleton, cephalic, > or equal to 37 weeks) had relatively lower CS rates (19.53% & 30.56%, respectively). Conclusions: Modified Robson’s classification is easily implementable and effectively utilized in analyzing caesarean sections rate to guide us to form strategies to avoid unnecessary sections.

Keywords: Caesarean section, High caesarean, Modified Robson’s classification

INTRODUCTION: There has been a dramatic increase in the cesarean section rate globally. In some areas it has reached beyond 40%. In India CS rates is increasing steadily and there is wide variation in CS rates between private and public health sector ^{1, 2}. According to WHO guidelines and US Healthy initiative 2000, the cesarean section rate should not be beyond 15% ³.

However, there was an upward trend of cesarean section rate as there were no reliable and internationally standardized data enabling a global comparison for the indications of cesarean sections. There is need for an internationally accepted classification system for caesarean section that would allow meaningful and relevant comparison of CS rates.

The increasing rate of cesarean section is a matter of international public health concern as it increases the cesarean section related maternal morbidity ^{4, 5, 6}. The 10 group Modified Robson classification of caesarean section has been appreciated by WHO in 2014 and FIGO in 2016 ^{3, 5}. According to the Indian Council of Medical Research1 (ICMR) task force study, CS rate has increased from 21.8% in 1993-94 to 28.1% in 2005-06 ¹⁴. This classification system allows us to of cesarean section rate according to characteristics of pregnancy ⁷. According to WHO, this classification will aid in optimization of the cesarean section use and assess the strategies aimed to decrease the cesarean section rate and thus improve the clinical practices and quality of care in various health care facilities. This study was an attempt to classify the caesarean section based on this classification system to know and analyze the cause of rising caesarean section in our set up.

The Objectives of the Study were:

• To classify the cesarean section according to their causes.
• To identify and audit the rising causes of cesarean section in our scenario.
• To standardize the indications of cesarean section.

METHODS: The present study was carried out retrospectively at Department of Obstetrics & Gynecology, SMS Medical College, Jaipur, Rajasthan from May 2023 to Nov2023. All data was retrieved and statistically analyzed. The Relevant obstetric data was collected from labour room delivery register like gestational age, parity, number of fetuses, presentation of fetus, whether patient presented with spontaneous labour or was induced. Women were classified according to Modified Robson classification.

For each group, the Caesarean Section rate within the group and its contribution to overall CS rate was calculated and analyzed using simple statistical measures & descriptive statistical analysis was done.

Inclusion Criteria: Patients delivered by caesarean section during the given period (May 2023 to Nov 2023) were recorded and classified according to Modified Robson’s 10 group classification system Table 3.

Exclusion Criteria: Term or Preterm normal or instrumental vaginally delivered patients.

The Parameters Considered were according to the classification system are-

• Parity (with/ without previous CS);
• Gestational age (>37/<36 weeks)
• Fetal presentation (CEPAHALIC, BREECH, ABNORMAL LIE)
• Number of fetus (Singleton, Multiple)
• Onset of labour (Spontaneous, Induced, prelabour cs)

This modified Robsons Classification includes sub classification of woman having caesarean section after spontaneous onset of labour, after induction of labour and before labour ⁸. Though there has been limitation to this modification also, still it is simple, easily implementable and important tool to monitor Caesarean Section rates Table 2.

TABLE 1: ROBSON’S CLASSIFICATION OF CESAREAN SECTION

TABLE 2: MODIFIED ROBSON’S CLASSIFICATION

TABLE 3: CESAREAN SECTION RATE AND CONTRIBUTION MADE BY EACH GROUP

TABLE 4: CESAREAN SECTION RATE AND CONTRIBUTION MADE BY EACH GROUP

RESULTS AND OBSERVATION: This retrospective analysis using Robson Ten Group Classification System (TGCS) provides a comprehensive overview of cesarean section (CS) rates and their distribution across different obstetric populations in our hospital. Data was analyzed as shown in Table 2 and Table 3. Out of a total of 5,312 deliveries, 2,145 cesarean sections were performed yielding an overall CS rate of 40.38%.

The highest contribution to the total CS rate was made by Group 5 (previous cesarean, singleton, cephalic, > or equal to 37 weeks), accounting for 40.65% of all CSs, with a striking CS rate of 95.83%, indicating limited success in VBAC (Vaginal Birth After Cesarean) attempts. Group 1 (nulliparous, singleton, cephalic, > or equal to 37 weeks, spontaneous labour) had the highest proportion of deliveries (39.53%), with a CS rate of 16.67%, contributing 16.31% to the total CS rate.

High CS rates were also observed in Group 6 (nulliparous breech) and Group 7 (multiparous breech), with both groups having a 100% CS rate, albeit with lower absolute contributions due to smaller group sizes. Group 10 (singleton cephalic, < or equal to 36 weeks, including previous CS) had a notable CS rate of 87.75%, reflecting the clinical complexity and cautious approach towards preterm deliveries. Group 2 (Nulliparous, singleton, cephalic, > or equal to 37 weeks, induced or CS before labour) had a higher CS rate (48.33%) than Group 1, particularly among induced labour and CS before labour subgroups. The induced subgroup had a 38% CS rate, whereas CS before labour was 100%, indicating that induction & elective CS in nulliparous women significantly increase surgical deliveries.

Group 3 & 4 (Multiparous, singleton, cephalic, more than or equal to 37 weeks) had relatively lower CS rates (19.53% & 30.56%, respectively) & moderate contributions to total CS (9.84% & 7.55%). Group 8 (All multiple pregnancies) & Group 9 (All abnormal lies) also had a100% CS rate. Group 8 contributed 6.71% to CS rate, while Group 9 accounted for 1.26%, showing that multiple gestation and abnormal presentations are predominantly managed by CS.

The dominance of Group 5 in CS contribution highlights the need for structured VBAC protocols and counseling. Interventions targeting primary cesarean prevention (Group 1 and 2) may help reduce the cascading effect into Group 5. High rates in breech and preterm groups reflect adherence to current obstetric guidelines favoring CS in such scenarios.

DISCUSSION: Standardization and classification of cesarean deliveries was done in our department according to the Modified Robson’s criteria. This was an attempt to see which clinically relevant groups contributed most to the cesarean deliveries. As we observed in present study, the rate of cesarean section in our hospital (40.38%) is quite higher than what has been considered by WHO (15%). The cesarean section rate depicted in year 2013-2014 in India was 16.4% ⁷. This rose to 18% in 2015-16 when a health survey was conducted by Nation Family Health Survey. The average cesarean rate in Asian countries (27.3%) was much lower when compared with USA (31.1%) ^{2, 8} Vogel et al analyzed the contributions of specific groups through Robson’s 10 group classification system in 2 WHO multi- country surveys and concluded the proportion of women with previous caesarean section has increased along with the caesarean section rate in these women as we see in present study⁹.Similarly, the use of induction and pre-labour caesarean caesarean section and caesarean section after induction in multiparous has also increased according to them.

In our study the highest contribution to the total CS rate was made by Group 5 (previous cesarean, singleton, cephalic, > or equal to 37 weeks), accounting for 40.65% of all CSs this was much lower than study done by Pratima mittal et al study done in 2017 in north India ¹⁵.

In present study also group 2 and 4 had an increased caesarean section rate when compared with 1 and 3 respectively same findings were seen in study done by prtimamittal et al.¹⁵ Hence, the need of the hour is to firstly limit induction of labour. It should be strictly evidence based. Secondly, we should critically evaluate on daily basis the indication of primary caesarean section. This will not only decrease the caesarean section in nulliparous but will also eventually decrease caesarean section in multiparous with previous caesarean section. The hospital where this study was conducted was a tertiary care centre where there is large number of referred high risk cases. There is an increase in trend of cesarean section on maternal request.

Main advantage of Modified Robson’s classification is its simplicity, robustness, reproducibility and flexibility. It is clinically relevant and suitable even for low resource settings. Indication based CS classification are variable, subjective, lack clarity, deficient of relevant obstetric history and thus does not allow valid comparisons. Limitation of this study were that it does not allow analysis of CS by demand and those for specific indication like placenta previa. It does not account for preexisting medical, surgical condition or fetal distress, indication and methods used for IOL and degree of prematurity, all of which may influence the rate of CS.

However, we need to reduce the number of cesarean sections in primiparas and make judicious use of vaginal birth after cesarean deliveries but not at the cost of health of mother and baby. ACOG recently recommended clinical guidelines to restrict the number of cesarean deliveries which are nonmedically indicated and induction of labour before 39 weeks of gestation ¹⁰.

Efforts to reduce such births should include awareness to public, reducing unindicated induction before 39 weeks certain changes and standardization in the departmental policies. Increasingly sedentary lifestyle and poor tolerance to pain are adding to CSMR ratio. Authors should judiciously make use of vaginal birth after cesarean deliveries but not at the cost of maternal or fetal health. Standardization of indication of cesarean deliveries, regular audits and definite protocols in hospital will aid in curbing the cesarean section rate in hospital. This will definitely aid in decreased maternal morbidity associated with cesarean delivery rates, reduce the hospital stay and in turn improve the economy. At the same time, one should make every effort to provide the cesarean delivery to the woman in clinically indicated.

CONCLUSION: Modified Robson’s classification is easily implementable, can be effectively utilized in analyzing delivering women and determinate contributors to caesarean sections to guide the health care providers to form strategies to avoid unnecessary sections. At the same time, one should make every effort to provide the cesarean delivery to the woman in clinically indicated need rather than to achieve a specific rate.

ACKNOWLEDGMENT: We would like to thank the staff of Department of Obstetrics and Gynecology, SMS Medical College for their support during study.

Funding: No funding sources

Ethical Approval: Not Required

Contribution from Authors: Research concept, Research design Data analysis and interpretation, Critical review, Supervision, Critical review -Dr Himanshi Gangwal Materials, Data collection, Literature search, Critical review- Dr Seema Dhami, Dr Bhanvi Bharadwaj, Dr Nandani Singh.

CONFLICTS OF INTEREST: None declared

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    How to cite this article:

    Dhami S, Bharadwaj B, Singh N and Gangwal H: Analysis of caesarean section rate according to modified robson’s classification at tertiary care centre in Jaipur, Rajasthan, India. Int J Pharm Sci & Res 2025; 16(11): 3021-36. doi: 10.13040/IJPSR.0975-8232.16(11).3021-36.

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