European Journal of Cardiovascular Medicine

Caesarean section has classically been defined as an operative procedure performed for the delivery of the fetus through a surgical incision made on the abdominal wall and an intact uterine wall after the period of viability. [1] It can be classified based on the type of uterine incision as lower segment caesarean section (LSCS) or classical caesarean section (incision over the upper segment), based on the urgency, it can be classified as emergency or elective caesarean section. The rates of caesarean section vary widely by country, healthcare facility and delivering physician, partly because of differing perceptions by healthcare providers as well as by pregnant women of its benefits and risks. [2]

Analyzing the statement which WHO came up with in 2015, stating that there aren’t any significant reductions in maternal and newborn mortality rates with Caesarean Section rates higher than 10%, it can be concluded by saying that Caesarean Sections should be performed for women in need, rather than striving to achieve a particular rate. Statistics state that 82% of physicians performed Caesarean Sections to avoid negligence claims. Over the last 15 years, the increase has been substantial in many states with the southern states recording rates as high as in countries with the highest level of Caesarean Section in the world. Among the 28 states and union territories of India, the new state of Telangana has a distinction of having a rate higher than the global leader in Caesarean Section rate, Brazil.

In order to eliminate unnecessary and medically unindicated Caesarean Sections being done, a ten group classification system was proposed by Dr. Michael Robson, of the National Maternity Hospital, Dublin, in 2001. WHO proposes this Robson classification System as a global standard for assessing, monitoring and comparing Caesarean Section rates within the healthcare facilities over time, and also between facilities.

In cases where spontaneous vaginal delivery (SVD) is not possible or contraindicated, avoiding CS may endanger the lives of mother and the fetus. [3]

Analysis of leading groups contributing to the high caesarean section rates in a tertiary care hospital of West Bengal near Sundarbans area based on Modified Robson Ten Group Classification System (MRTGCS).

Study site: Diamond Harbour Government Medical College Hospital, West Bengal

Study Population: Women undergoing cesarean section deliveries including live births as well as stillbirths (weighing at least 500 grams), from 1st January 2023 to 31st December 2023.

Study design: A cross sectional observational study.

Study duration: The data collection for the study was done between 1st January 2023 to 31st December 2023 for a period of 1 year.

Sampling method: All the eligible subjects were recruited into the study consecutively by convenient sampling till the sample size is reached.

Inclusion criteria:

1. Booked pregnant females undergoing caesarean section
2. Consent for inclusion in the study

Exclusion criteria:

3. Unbooked pregnancy
4. Patients who have not given consent

Sample size: 6263

Statistical Analysis:

Data were entered into Excel and analyzed using SPSS and GraphPad Prism. Numerical variables were summarized using means and standard deviations, while categorical variables were described with counts and percentages. Two-sample t-tests were used to compare independent groups, while paired t-tests accounted for correlations in paired data. Chi-square tests (including Fisher’s exact test for small sample sizes) were used for categorical data comparisons. P-values ≤ 0.05 were considered statistically significant.

Table 1: Distribution of CS in Nullipara, singleton cephalic ≥37 weeks in spontaneous labour

Table 2: Association between CS in Nullipara, singleton cephalic, ≥37 weeks in Induced and before labour

Table 3: Distribution of CS in Multipara, singleton cephalic, ≥37 weeks, in spontaneous labour

Table 4: Association of CS between Multipara, singleton cephalic, ≥37 weeks in Induced and before labour

Table 5: Association of CS between patients with Previous Caesarean section, singleton cephalic ≥37 weeks in Spontaneous, and Induced labor and Caesarean section before labour

Figure 1: bar diagram showing relative size of group 6 A, group 6 B and group 6 C

In our study, Out of 6263 patients 298 (4.75%) patients had CS who were Nullipara, singleton cephalic, ≥37 weeks in spontaneous labour. It was not statistically significant (P=0.977). We found, 542 (8.65%) patients had CS after induction who were Nullipara, singleton cephalic, ≥37 weeks, and 1290 (20.59%) had Caesarean Section before labour, who were Nullipara, singleton cephalic, ≥37 weeks. Association of Nullipara, singleton cephalic, ≥37 weeks with Group was not statistically significant (p=0.987). In our study, 105 (1.67%) patients were Multipara, singleton cephalic, ≥37 weeks in spontaneous labour who had CS. It was not statistically significant (P=0.9679). In Induced, 123 (1.96%) patients CS who were Multipara, singleton cephalic ≥37 weeks, and 322 (5.14%) had Caesarean Section before labour, who were Multipara, singleton cephalic ≥37 weeks. Association of Multipara, singleton cephalic ≥37 weeks with Group was statistically significant (p<0.0001). In our study, 58 (0.92%) patients had CS who were Previous Caesarean section, singleton cephalic ≥37 weeks in spontaneous labour 8 (0.12%) patients had CS after induction who were Previous Caesarean section, singleton cephalic ≥37 weeks 1693 (27.03%) patients had Caesarean section before labour, who were Previous Caesarean section, singleton cephalic ≥37 weeks. Association of Previous Caesarean section, singleton cephalic, ≥37 weeks with Group was not statistically significant (p=0.889). In our study 31 (0.49%) patients in Spontaneous labour were all nulliparous breeches, 1 (0.01%) patient in Induced labour, were all nulliparous breeches 138 (2.20%) patients had Caesarean section before labour who were all nulliparous breeches Association of All nulliparous breeches with Group was not statistically significant (p=0.748).

Cesarean section is a key intervention to decrease maternal and neonatal morbidity and mortality. It is also one of the best indicators of the quality of maternal health services [4].

Thus, to optimize outcomes, facilities should initiate a detailed and rigorous assessment of their practice specifying the case mix of obstetric population they serve. The Robson ten group classification system enables institution-specific monitoring and auditing and can be a powerful tool to inform practice across different settings [5].

The overall CS rate in this study was 49.86 % i.e. out of 12560 total deliveries in the year 2023 between January 1^st and December 31^st 6263 caesarean sections were done with previous CS being the commonest indication. Robson groups 2,5 and 10 had the highest contribution to caesarean delivery in the health facility. The CS rate of 49.86% is considerably higher that the WHO recommended rate [6]

In Group 1, there were 298 (4.75%) patients who experienced spontaneous labour. This relatively low percentage might reflect the overall trend of increased medical interventions in childbirth. however the distribution was not statistically significant (P=0.977). Encouraging and supporting spontaneous labour in appropriate cases could be beneficial, given its association with lower complication rates compared to induced labour or Caesarean sections. Similar study by Christmann-Schmid C et al [7] (2016) found that Robson groups 1, 3 (nulliparous and multiparas, respectively, with a single cephalic term pregnancy in spontaneous labour), 5 (multiparas with a previous uterine scar with a single, cephalic, term pregnancy) and 7 (multiparas with a single breech pregnancy with or without previous scars) showed an increase in the caesarean section rates over time. Similar study by Tura AK et al [8] (2018) found that Robson group 3 (multiparous women with single cephalic full-term pregnancy in spontaneous labour with no history of CS), group 5 (multiparous women with single cephalic full-term pregnancy with history of CS) and group 1 (single cephalic nulliparous women full-term pregnancy in spontaneous labour) were the major contributors to the overall CS at 21.4%, 21.1% and 19.3%, respectively. Similar study by Janani L et al [9] (2022) this study The overall CS rate was 35.2%. Group 3 (multiparous women without previous CS in spontaneous labor) (27.6%) and Group 1 (nulliparous women in spontaneous labor) (23.7%) contributed to most of the obstetric populations.

Group 2 contributed maximum overall CS rate of 14.58 %, in which 542 (8.65%) patients underwent CS after induced labour, and 1290 (20.59%) patients had a Caesarean section before labour. However, this difference was not statistically significant (P=0.987). The high rate of pre- labour Caesarean sections in nulliparous women warrants further investigation. This trend could be due to several factors, including perceived risks, patient preference, or clinical recommendations. Reducing unnecessary C-sections in this group could be a focus for improving maternal and neonatal outcomes. A similar study by Crosby et al. [10] (2019) found out that major contributors were groups 2a consisting of labour-induced, 2b consisting of CS before labour, and 5.

Group 3 included 105 (1.67%) patients who experienced spontaneous labour.

However the distribution was not statistically significant (P=0.9679).The relatively small percentage highlights the need to explore factors that may be preventing spontaneous labour in multiparous women and identifying strategies to support it when safe and appropriate. Similar study by Akadri AA et al [11] (2023) showed that Interventions directed at reducing the first CS by improving management of spontaneous and induced labours; and strengthening clinical practice around encouraging vaginal birth after CS will have the most significant effect on reducing CS rate.

In Group 4, 123 (1.96%) patients had induced labour, and 322 (5.14%) patients had a Caesarean section before labour. The association was statistically significant (P<0.0001). The higher rate of pre-labour C-sections in multiparous women suggests that past experiences, health

Complications or medical advice play significant roles. Understanding these influences can help tail or interventions to reduce unnecessary C-sections.

Group 5 displayed significant variation: 58 (0.92%) patients had spontaneous labour, 8 (0.12%) had induced labour, and 1693 (27.03%) had a Caesarean section before labour. This association was not statistically significant (P=0.889).The very high rate of elective C-sections among women with a previous C-section underscores the challenges and decisions surrounding vaginal birth after Caesarean (VBAC). Promoting VBAC where safe and feasible could help reduce repeat C-sections. A similar study by Pravina et al. [12] (2022) found out the average CS rate was 38.16%, with group 5 contributing the most (34.97%), subsequent to groups 2 (26.35%), 1 (15.51%), and 10 (7.14%). VBAC is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies, as well as a decrease in the overall CS rate. Hence, for promoting VBAC, the Royal College of Obstetricians and Gynaecologists [13] recommends the routine use of VBAC checklists during antenatal counseling as they would ensure informed consent and shared decision-making in women undergoing VBAC. Naik er al. [14] (2022) found out group 5 followed by group 2 and 1 contributed majority of CS with total CS rate of 61.2%

For Group 6, 31 (0.49%) patients had CS in spontaneous labour, 1 (0.01%) had induced labour, and 138 (2.20%) underwent a pre-labour Caesarean section. This association was not statistically significant (P=0.748). The preference for C-sections in breech presentations reflects current clinical guidelines aimed at minimizing complications associated with breech vaginal deliveries.

In Group 7, 23 (0.36%) patients had CS in spontaneous labour, 1 (0.01%) had induced labour, and 97 (1.54%) had a Caesarean section before labour. This association was statistically significant (P<0.0001). Similar to nulliparous breech cases, the preference for C-sections in this group aligns with efforts to reduce risks associated with breech deliveries.

Group 8 saw 13 (0.20%) patients with spontaneous labour, 5 (0.07%) with induced labour, and 136 (2.17%) with a pre-labour Caesarean section. This association was statistically significant (P<0.0001). The higher rate of C-sections in multiple pregnancies is consistent with clinical practices aimed at minimizing complications in these higher-risk pregnancies.

In Group 9, 8 (0.12%) patients had CS in spontaneous labour, 3 (0.04%) had induced labour, and 14 (0.22%) had a Caesarean section before labour. This association was statistically significant (P<0.0001). The management of abnormal lies often necessitates C-sections to prevent complications during delivery, explaining the higher surgical intervention rate.

Finally, in Group 10, 79 (1.26%) patients had CS in spontaneous labour, 94 (1.50%) had induced labour, and 1181 (18.85%) had a pre-labour Caesarean section. This association was statistically significant (P<0.0001). The significant number of pre-labour C-sections in preterm singleton pregnancies highlights the complexities of managing preterm deliveries and the need for tailored approaches to optimize outcomes for both mother and baby. Similar study by Akadri AA et al [11] (2023) showed that Multiparous women with previous CS, single, cephalic, term (group 5); nulliparous women, single cephalic, term, with induced labour or pre-labour CS (group 2); women with preterm single cephalic, term (group 10); and single cephalic term multiparous women in spontaneous labour (group 3) were the largest contributors to CS rate accounting for 34.5%, 14.0%, 12.6%, and 10.0% respectively.

This analytical study of caesarean sections using the Modified Robson Ten Group Classification System in a tertiary care centre near the Sundarban area of West Bengal highlights the groups contributing most significantly to the rising caesarean rates. Group 5 (previous CS, term, singleton, cephalic) emerged as the predominant contributor, indicating a need to promote vaginal birth after caesarean (VBAC) where feasible. Enhanced antenatal counseling, standardized labor management, and adherence to clinical guidelines can help optimize caesarean delivery rates. This classification system proves to be a valuable tool in monitoring, auditing, and guiding clinical practices to improve maternal and neonatal outcomes.

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