The Ten-Group Robson Classification: A Single Centre Approach Identifying Strategies to Optimise Caesarean Section Rates

Hindawi Obstetrics and Gynecology International Volume 2017, Article ID 5648938, 5 pages https://doi.org/10.1155/2017/5648938 Research Article The Ten-Group Robson Classification: A Single Centre Approach Identifying Strategies to Optimise Caesarean Section Rates Keisuke Tanaka1 and Kassam Mahomed2 1 Department of Obstetrics and Gynaecology, Ipswich Hospital, Ipswich, QLD, Australia Ipswich Hospital and University of Queensland, Ipswich, QLD, Australia 2 Correspondence should be addressed to Kassam Mahomed; kassam Received 26 July 2016; Revised 11 December 2016; Accepted 18 December 2016; Published 10 January 2017 Academic Editor: Robert Coleman Copyright © 2017 K. Tanaka and K. Mahomed. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Caesarean section (CS) rates have been increasing worldwide and have caused concerns. For meaningful comparisons to be made World Health Organization recommends the use of the Ten-Group Robson classification as the global standard for assessing CS rates. 2625 women who birthed over a 12-month period were analysed using this classification. Women with previous CS (group 5) comprised 10.9% of the overall 23.5% CS rate. Women with one previous CS who did not attempt VBAC contributed 5.3% of the overall 23.5% CS rate. Second largest contributor was singleton nulliparous women with cephalic presentation at term (5.1% of the total 23.5%). Induction of labour was associated with higher CS rate (groups 1 and 3) (24.5% versus 11.9% and 6.2% versus 2.6%, resp.). For postdates IOL we recommend a gatekeeper booking system to minimise these being performed <41 weeks. We suggest setting up dedicated VBAC clinic to support for women with one previous CS. Furthermore review of definition of failure to progress in labour not only may lower CS rates in groups 1 and 2a but also would reduce the size of group 5 in the future. 1. Introduction Rising caesarean section (CS) rate is of worldwide concern particularly in well-resourced countries [1]. The rate has increased from 23.3% in 2000 to 33% in 2013 in Australia [2, 3]. It has been reported that rates higher than 9–16% are not associated with decreases in maternal and neonatal mortality [4, 5]. There is growing concern about the higher incidence of long-term complications following one or more CS such as placenta accreta, retained placenta, and uterine rupture with possible need for peripartum hysterectomy [6– 8]. Another concern is the varying rates of CS among member hospitals of Women’s Healthcare Australasia (WHA), ranging from 18% to 37% [9]. This has been assumed to be due to a variation in the obstetric populations. A recent systematic review of 27 different classifications [10] suggested that the Ten-Group Robson classification of caesarean sections [11] might allow us to look at CS rates in specific groups to help identify possible reasons for this variation. Women who give birth are categorised into 10 groups based on their basic obstetric characteristics of parity, previous CS, gestational age, mode of onset of labour, fetal presentation, and number of fetuses. These groups are structured in such a way that they are mutually exclusive and totally inclusive. The Ten-Group Robson classification has been praised for its simplicity, robustness, reproducibility, and flexibility [12] and has been recommended for both the monitoring rates over time as well as between facilities by both WHO in 2014 and FIGO in 2016 [13, 14]. Various modifications or subdivisions to the original ten groups have been suggested such as having subdivisions based of the mode of onset of labour [15]. Prior to introducing interventions to address the rising CS rates we have classified all women who gave birth over a 12 months period from January to December 2015, using the Ten-Group Robson classification with subdivisions based on onset of labour. 2. Materials and Methods The study population included all live births and stillbirths of at least 400-gram birth weight or at least 20-week gestation at 2 Ipswich Hospital, Queensland, Australia, during the period January–December 2015. Ipswich Hospital is a secondary referral University teaching hospital, supported by 24-hour theatre, anaesthetic, and paediatric services with a special care nursery equipped to care for neonates from 32-week gestation. Data were extracted from the National Perinatal Data Collection (NPDC), an Australian population-based crosssectional data collection of pregnancy and childbirth and cross checked with the birth suite register to ensure that no CS were missed. Medical records were reviewed for missing or for verifying information. Overall CS rate, relative size of each group, CS rate, and relative contribution of each group to the overall CS rate were calculated. As this review conforms to the standards established by National Health and Medical Research Council for ethical quality review [16], ethics approval was not sought. 3. Results 2625 women gave birth to 2663 babies at Ipswich Hospital in 2015. CS was performed in 618 women resulting in an overall CS rate of 23.5%. Women in each of the ten groups are shown in Table 1. The table also shows the CS rate in each of these 10 groups as well as the contribution of each group to the overall CS rate of 23.5%. The largest contributor to the overall CS rate was women with previous CS (group 5), 10.9% of the overall 23.5%. CS rate in this group was 76.5% (287 out of 375 women). 224 out of 287 women (78.0%) had the CS performed prior to onset of labour (group 5c). Of the 250 women who had had one previous CS in group 5, altogether 110 (44%) attempted VBAC. A significant number of these would have been multiparous women with previous vaginal births. We do not have the number of women with CS in first pregnancy who attempted a VBAC in the second pregnancy. The second largest contributor was groups 1 and 2 combined, the singleton nulliparous women with cephalic presentation at term. This group that comprised 28.9% of the total population had an overall CS rate of 17.9% and accounted for 5.1% of the total CS rate of 23.5%. The prelabour CS rate in this group (group 2b/group 1 + group 2) was 1.7% (13 out of 759). 4. Discussion We present our data to encourage other obstetric units to adopt this classification that is simple to incorporate into the routine perinatal data collection system. CS rates for each of the 10 groups can then become more meaningful and rates for each group can then be compared with other obstetric units. Secondly, by identifying groups that contribute most to the CS rate in our unit, as we believe they would be similar in other units as well, quality improvement activity could be initiated to modify the CS rate in a particular group. The low CS rates, 11.9% in nulliparous women in spontaneous labour, 16.6% in mult (...truncated)