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Objectives: We analyzed the indications of cesarean section (CS) using Robson Ten-Group. Classification Systems (RTGCS) and comparison between private and public health facilities in Addis Abeba hospitals, Ethiopia, 2017. Methods: Facility-based retrospective cross-sectional study was carried out between January 1 and December 31, 2017, including 2411 mothers who delivered by CS were classified using the RTGCS. Data were entered into SPSS version 20 for cleaning and analyzing. Binary logistic regression and AOR with 95% CI were used to assess the determinants of the CS. Results: The overall CS rate was 41% (34.8% and 66.8% in public & private respectively, p < .0001). The leading contributors for CS rate in the private were Robson groups 5,1,2,3 whereas in the public 5,1,3,2 on descending order. Robson group 1 (nulliparous, cephalic, term, spontaneous labor) and group 3 [Multiparous (excluding previous cesarean section), singleton, cephalic, ≥ 37 weeks’ gestation& spontaneous labor], the CS rate was over two-fold higher in the private than the public sector. Women in Robson groups 1, 2, 5 & 9 are two and more times higher for the absolute contribution of CS in private than public. The top medical indications of CS were non-reassuring fetal status (NRFS, 39.1%) and repeat CS for previous CS scars (39.4%) in public and private respectively. Mothers who delivered by CS in private with history of previous CS scar (AOR 2.9, 95% CI 1.4-6.2), clinical indications of maternal request (AOR 7.7, 95% CI 2.1-27.98) and pregnancy-induced hypertension (AOR 4.2, 95% CI 1.6-10.7), induced labor (AOR 2.5, 95% CI 1.4-4.6) and pre-labored (AOR 2.2, 95% CI 1.6-3.0) were more likely to undergo CS than in public hospital. Conclusion: The prevalence of CS was found to be high, and was significantly higher in private hospitals than in a public hospital. Having CS scar [having previous CS scar, Robson group 5(Previous CS, singleton, cephalic, ≥ 37 weeks’ gestation) and an indication of repeat CS for previous CS scar] is the likely factor that increased the CS rate in private when compared within the public hospital. Recommendation: It is important that efforts to reduce the overall CS rate should focus on reducing the primary CS, encouraging vaginal birth after CS (VBAC). Policies should be directed at the private sector where CS indication seems not to be driven by medical reasons solely.

Objective Robson's Ten Group Classification System (TGCS) creates clinically relevant sub‐groups for monitoring caesarean birth rates. This study assesses whether this classification can be derived from routine data in Europe and uses it to analyse national caesarean rates. Design Observational study using routine data. Setting Twenty‐seven EU member states plus Iceland, Norway, Switzerland and the UK. Population All births at ≥22 weeks of gestational age in 2015. Methods National statistical offices and medical birth registers derived numbers of caesarean births in TGCS groups. Main outcome measures Overall caesarean rate, prevalence and caesarean rates in each of the TGCS groups. Results Of 31 countries, 18 were able to provide data on the TGCS groups, with UK data available only from Northern Ireland. Caesarean birth rates ranged from 16.1 to 56.9%. Countries providing TGCS data had lower caesarean rates than countries without data (25.8% versus 32.9%, P = 0.04). Countries with higher caesarean rates tended to have higher rates in all TGCS groups. Substantial heterogeneity was observed, however, especially for groups 5 (previous caesarean section), 6, 7 (nulliparous/multiparous breech) and 10 (singleton cephalic preterm). The differences in percentages of abnormal lies, group 9, illustrate potential misclassification arising from unstandardised definitions. Conclusions Although further validation of data quality is needed, using TGCS in Europe provides valuable comparator and baseline data for benchmarking and surveillance. Higher caesarean rates in countries unable to construct the TGCS suggest that effective routine information systems may be an indicator of a country's investment in implementing evidence‐based caesarean policies. Tweetable abstract Many European countries can provide Robson's Ten‐Group Classification to improve caesarean rate comparisons., Tweetable abstract Many European countries can provide Robson's Ten‐Group Classification to improve caesarean rate comparisons.

Objective: To analyze trends of CSs and evaluating them according to Robson’s Ten Groups Classification System (TGCS) at a leading government tertiary care hospital of South Punjab, Pakistan. Methods: This cross-sectional study was conducted at Department of Obstetrics and Gynaecology, Nishtar Medical University Hospital, Multan Pakistan, from October 2019 to March 2020.The study population included a total of 167 women who underwent CS in the hospital during the specified study period. For each case, we collected data regarding maternal characteristics and pregnancy-related information. The dependent variable was Robson classification group. Results: Overall, mean age was 26.53+5.1 years. Majority of the women, 116 (69.5%) belonged to urban areas of residence, 74 (44.3%) gestational aged between 37-42 years while 108 (64.7%) had history of cesarean section. Most of the patients, 85 (50.9%) turned out to be from TGCS Group-10. Group-5 and Group-1 were the 2nd and 3rd most common group, accounted for 24 (14.4%) and 19 (11.4%) cases respectively. Previous cesarean section (20.4%) and fetal distress (19.8%) were found to be most common indications leading to cesarean section. Conclusion: As per Robson’s Ten-Group Classification, Group-10 and Group-5 were found to be the most contributing among deliveries done. Previous cesarean section and fetal distress were the most common indications of cesarean section. doi: https://doi.org/10.12669/pjms.37.2.3823 How to cite this:Parveen R, Khakwani M, Naz A, Bhatti R. Analysis of Cesarean Sections using Robson’s Ten Group Classification System. Pak J Med Sci. 2021;37(2):567-571. doi: https://doi.org/10.12669/pjms.37.2.3823 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background Caesarean section (CS) rates have increased globally. The World Health Organization (WHO) recommends the use of the TenGroup Robson classification as the global standard for assessing appropriateness of CS. Nepal has higher-than-global average rates of CS requiring further investigation into appropriateness. Aim This study aims to investigate the caesarean section rates at tertiary care center in Nepal and make analysis based on the group-10 classification. Methods A retrospective cross-sectional study was carried out from 2016 April -2017 March in Lumbini Zonal Hospital, Butwal, Rupendehi, Nepal. 3,817 women who birth over a 12-month period were analyzed using this classification. The caesarean rate, its indications were calculated and categorized into groups according to Robson’s 10-group classification. Results Women with previous CS (Group 5) comprise the largest proportion (9.4%) of the overall 26.41% CS rate. The second largest contributor was a singleton nulliparous woman with cephalic presentation at term (6.6% of total 26.41%). Caesarean section rates in single breech pregnancies were very high (>65%). Robson’s Group 5 was the highest contributors to overall CS rate contributing 35% of all C-sections, followed by Group 2 (24%), and Group 1 (13%). Conclusion The ten-group classification helped to identify the main groups of the subjects who contribute the most to the overall caesarean section rate. This study results suggest that women with previous CS are at risk for having another CS delivery in subsequent pregnancies and therefore there is an urgent need for a dedicated vaginal birth after caesarean section (VBAC) clinic to support this such women to ensure CS are only done when indicated. Furthermore, reducing the CS rate for nulliparous i.e. Group 1 and 2 would, in the long-term, also reduce the size of Group 5 in the future.

Introduction: Cesarean sectionis on the rising trend,so WHO proposes that health care facilities uses the Robson's 10 group classification system to audit their Cesarean section rates. This classification will helpto developstrategies to reduce these rates. Objective: The objective of this study was to classify the women coming for delivery into the 10 Robson’s group,to interpret the 10 group classification and to know the highest rate of cesarean section in the group. Methodology: This was a hospital basedcross sectional study carried out in the Department of Obstetrics and Gynaecology, for a period of 6months. All women undergoing deliverywere recruited for study .Based onthe patient’s obstetric parameters, women were assigned to one of 10 groups as per Robson’s 10-group classification system.The relative size of each group, the cesarean section rate in each group, and the absolute and relative contributions to the overall cesarean section rate was then reported. Results: During the study period, the overall Cesarean Section rate was 33.40%.Highest contribution was by Robson's Group 2(Nulliparous, single cephalic, ≥ 37 weeks, induced or CS before labor(9.84%) followed by Group 1(Nulliparous, single cephalic, ≥ 37 weeks, in spontaneous labor)(7.73%) and Group 5(Previous CS, single cephalic, ≥ 37 weeks) (5.75%). Least contribution was by Groups 8(All multiple pregnancies (including previous CS)and 9[All abnormal lies (including previous CS)]0.20% and 0.27% respectively. All women in group 9(all abnormal lies including previous CS)had 100% Cesarean rate. Conclusions: With reductions in the primary cesarean section rates and encouragingpatients forVBACcould reduce the contribution of Robson's groups towards the absolute Cesarean Section rates.

The aim of this study is to analyze the impact of the introduction of an internal clinical audit on the cesarean section (CS) rate, evaluated according to the Robson Ten Group Classification System (TGCS), and to identify the main contributors to the overall CS rate in order to plan further interventions.In 2014, an internal clinic audit committee was established in our center. Modifications of clinical management protocols were also implemented. A retrospective review of clinical records was conducted and pre-audit (2011-2014) results were compared against audit (2015-2018) results. Patients were clustered according to the Robson TGCS and the analyzed outcomes were CS rate and maternal and neonatal results.Between January 2011 and December 2018, 12,766 women gave birth at our institution among which 2,281 CS were analyzed. After the establishment of the clinical audit, the overall CS rate decreased from 20.27% to 14.82 % (p0.01). The major contribution to the overall CS rate in both periods were made by Group 2a (nulliparous with a single cephalic pregnancy at term who underwent labor induction: 4.86 % of all cases), followed by Group 5 (patients with a previous C-section: 3.26 %) and Group 1 (nulliparous with a single cephalic pregnancy at term with spontaneous labor: 2.39 %), representing 59.6 % of all CS. The group that showed the greatest reduction to the overall Cs rate was Group 2 (5.77 % vs 3.96 %, OR 1.48 (p0.01). No differences in perinatal and maternal results were found between preaudit and audit group.Audit, feedback, and modification of clinical management protocols may be effective in changing clinical practice and reducing CS rates without worsening maternal and neonatal morbimortality. Robson TGCS allowed us to identify which groups had the greatest impact on CS rate in order to establish new strategies that may lead us to optimize the use of this intervention. It seems that efforts to reduce the overall CS rate should be directed on increasing vaginal birth after CS and reducing CS rates in nulliparous women with single cephalic full-term pregnancy.

The Robson Ten-Group Classification System is widely considered to be the gold standard for comparing cesarean section (CS) delivery rates, despite limited adoption in the United States (US). When reporting overall CS rates, Blacks and other minorities are typically reported to have high CS rates but comparing overall CS rates may be misleading as CS may be more common in some higher risk populations. Improved understanding of how CS rates differ by race among standardized groups could highlight differences in care and areas for improvement. The current study examines racial differences in cesarean section delivery rates using the Robson Ten-Group Classification System in a nationwide sample. Data from US vital statistics live birth certificates were used to identify 3,906,088 births which were each classified into one of the ten groups based on five obstetric characteristics identifiable on presentation for delivery including parity, onset of labor, gestational age, fetal presentation, and number of fetuses. Results indicated that Black and Asian mothers had the highest CS rates in groups 1–4 which all contain single, cephalic pregnancies at term with no prior CS and are only differentiated by parity and onset of labor. Black mothers also had the lowest CS rates for groups 6 and 7, containing women with nulliparous and multiparous breech births. Black and Asian mothers show differences in CS rates among groups that could indicate lack of appropriate care. Efforts should be made to prevent unnecessary primary CS among low-risk mothers.

Objective: To analyze cesarean section rates using Robsons 10 group classification system in a tertiary hospital over a period of five years (July 2014-Dec 2018). Main outcome: To analyze the main contributors of cesarean sections based on the ten groups under Robsons classification and to further analyze the main indications of cesareans in the relevant groups. Results and Discussion: All women with one or more previous cesareans with cephalic presentation (group V) contributed to the maximum number of cesareans, (32.5%), closely followed by group I (22.86%) and group IIA (10.25%). 31.65% of the total cesareans were elective cases, 17.23% were in women with inductions and 51.1% of the cesareans were in spontaneously laboring women. Robsons Ten Group Classification system (TGCS) found to be easy to understand, clear, mutually exclusive, reproducible system for classifying cesareans in all levels of Institutions. Among women who had elective cesareans, maximum were done in those in Group V who were not willing for TOLAC or those who has previous two cesareans. In spontaneously laboring women, 34% were due to meconium stained liquor and 32.9% were due to fetal distress, thus leaving a huge scope for reduction in cesarean rates. Conclusion: All institutions should routinely monitor cesareans based on Robsons TGCS to monitor time trends and for interinstitutional comparisons. Interventions should be targeted at maximizing normal deliveries, reducing primary cesareans and offering TOLAC where possible. There should be institutional protocols for defining indications like fetal distress, nonprogress of labour, failed induction and protocols for their managements Keywords: Cesarean rate reductions, Robsons classification, Ten Group classification system.

Objectives: To analyze the trends of cesarean sections, categorize them into Robson’s Ten Group Classification System (RTGCS), to identify the groups contributing the most to overall lower segment cesarean section (LSCS) rate and to formulate strategies for reducing these rates. Study Design: Cross sectional population based study. Setting: Gynecology and Obstetrics Department of Kahuta Research Laboratories (KRL) hospital, Islamabad. Period: From 1st Nov, 2017 to 30th April, 2018. Material & Methods: The births during this period were distributed into the RTGCS on the basis of past obstetric history and fetal characteristics along with mode of onset of labour. Overall LSCS rate was calculated and contribution of each group was analyzed separately by SPSS version 23. Results: Our study showed 617 LSCS out of 964 deliveries making a high LSCS rate of 64%. Group 5, 2 and 10 of RTGCS contributed to the majority of LSCS performed with the percentages of 47.5%, 18.5% and 12.8% respectively. Group 5 of RTGCS which contributed to the highest LSCS rate had 354 subjects which were previous scars out of which 199 had previous 1 scar making the percentage 56.21%. It contributed 32.3% to the overall LSCS rate. Conclusion: RTGCS is a very useful tool for auditing the LSCS rate at local, national and international levels. Once the LSCS are classified into specific RTGCS, analysis can be done about the reasons for the increasing rates of LSCS and then strategies can be devised to reduce them.

Oxytocin augmentation is essential in labor management, but how to optimize its use is still debated. Joint international guidelines regarding prolonged labor and the use of oxytocin augmentation are still not available. Due to its potential harmful side effects, a decreased use of oxytocin is encouraged. We aimed to implement a structured protocol on the use of oxytocin augmentation and to observe changes in labor outcomes.The protocol was implemented at the Obstetric Department of Sørlandet Hospital, Kristiansand, Norway on 1 January 2012; therefore, data from the hospital were collected prospectively and compared for two time-period cohorts: the historic control cohort (2009-2010) and the study period cohort (2012-2013). The structured protocol instructs, and restricts, the birth attendants to diagnose prolonged labor, by protocol definition only, before commencing oxytocin infusion for augmentation. Nulliparous women with singleton, term deliveries (≥37 weeks), cephalic presentation, and spontaneous onset of labor (Ten-Group Classification System (TGCS) group 1) were included in the analysis. The main outcome was use of oxytocin augmentation.The study cohort and control cohort comprised 1103 (26.2%) and 1399 (33.1%) of all laboring women, respectively (Implementation of a protocol of structured use of oxytocin augmentation reduced the frequency, dosage, and duration of oxytocin without increasing the cesarean section rate in TGCS group 1.

Background The increasing rates of cesarean sections (CS) in places with adequate access to health care is a global concern because they are related to higher rates of maternal and neonatal complications and do not provide a positive childbirth experience for women. The objective is to highlight the possibility of achieving CS rates acceptable by WHO standards, like Nordic countries, following evidence-based protocols in Brazil. Methods A cross-sectional study evaluated CS rates by Robson Groups for women who sought vaginal delivery in a private health practice in Brazil, comparing the rates with Swedish data. A collaborative practice with midwives and obstetrician, adopting evidence-based guidelines, was offered. The overall CS rate, CS rate by Robson group, contribution of each Robson group to the overall CS rate, clinical and non-clinical interventions and vaginal birth, pre-labor CS and intrapartum CS proportions were estimated. The expected CS rate for the population by the WHO c-model tool was calculated. The analysis used Microsoft EXCEL and the software "R Studio" (version 1.2.1335. 2009-2019). Results The overall CS rate was 15.1% (within the expected by the WHO c-model tool) in a population composed of 43.7% of women in Robson Group 1, 11.4% in Group 2 and 14.9% in Group 5, the greatest responsible for higher rates of CS, who altogether contributed to 75.4% of all cesarean sections. Conclusions Multidisciplinary care following evidence-based protocols, associated to a high motivation of both women and professionals of childbirth care for a vaginal route for delivery may lead to a significant and safe reduction of CS rates, obtaining better results even in contexts such as Brazil, where there is high medicalization of obstetric care and excess of CS.

The Robson ten-group classification system is a recognized effective method of assessing caesarean rate. It is based on dividing patients into ten mutually exclusive groups, focusing on six maternal and newborn variables (parity, gestational age, plurality, foetal presentation, previous caesarean, and mode of labour onset). The aim of our analysis was twofold: first, to present the implementation of Robson classification in a pregnant teenage population, and second, to identify the indications for CS in the adolescent population. This study was designed as a one-year prospective analysis and considered all women younger than 20 years of age who delivered in a tertiary care hospital. Before discharge, women who had caesarean delivery responded to a questionnaire regarding their education, prenatal surveillance, and obstetrical history. Caesarean sections accounted for 47.01% of all births. A proportion of 24.57% of the participants had at least one previous caesarean section. Group 10 (all women with a single cephalic preterm pregnancy) was second most often identified among women in middle adolescence (14.03%), 32.20% of the participants in late adolescence were in group 5 (multiparas with a scarred uterus, single cephalic term pregnancy). Differences between the two age groups were not statistically different (p = 0.96). Abnormal cardiotocographic findings (38.23%), the arrest of descent (19.11%) and arrest of dilation (19.11%), were the most frequent indications for caesareans in Robson group 1. Neonates from mothers in Robson groups 8 (women with a multiple pregnancy) and 7 (multiparas single breech pregnancy) had the most unfavourable outcomes regarding gestational age at delivery and admission to the intensive care unit. We concluded that future focus on obstetrical management is mandatory in Robson groups 7 and 8. Adolescents in Robson group 1 (nulliparas, single cephalic term pregnancy, spontaneous labour) are the primary beneficiaries of strategies to reduce caesarean sections rates.

Background Cesarean section is an invasive surgical procedure in which a baby is delivered through an abdominal and uterine incision & carries with it many immediate and delayed morbidity and mortality risks. Objective To evaluate the feasibility of using the Robson Ten Group Classification System (TGCS) for cesarean delivery indications at Ain Shams Maternity hospital. Methods This is a retrospective study on women who delivered by cesarean delivery at Ain Shams Maternity hospital between July 1, 2016 and June 30, 2018. All patient files have been revised and data has been collected then categorized. The indications for this mode of delivery: suspected fetal growth impairment, fetal distress, preeclampsia/eclampsia, pregnancy duration in weeks or more pre-partum hemorrhage, cephalopelvic disproportion, dystocia, failure of progress, multiple pregnancy, suspected/imminent uterine rupture, breech or other malpresentations, previous cesarean delivery, failed induction of labor, tubal ligation, sterilization, maternal request genital herpes, extensive condyloma, any other obstetric complication, any other fetal indication or any other maternal medical complication. Results 15808 women delivered in the hospital during the study period, The CS rate was 58.04%. According to the Robson classification, Group5 and Group 10 were the most represented groups (31.72% and 29.91% of population, respectively). The major contributors to the CS rate were group 5 (27.10%), group10 (14.02%).The most commonly reported indications for CS included past CS, suspected fetal distress, preeclampsia, eclampsia.These suggested the need for further discussion on CS practices Conclusion This study provides an example on how the WHO manual for Robson classification can be used in an action-oriented manner for developing recommendations for improving the QoC, and the quality of data collected.

Background: Rate of cesarean section (CS) is one of the most frequently used indicators of healthcare quality at the national and international levels for clinical governance. Audit of indications of CS and to propose measures to reduce the rate of CS in our institution Methods: Prospective observational study was conducted at Department of Obstetrics and Gynaecology at Dr Rajendra Prasad Government Medical College Kangra at Tanda (HP) Results: In our study, previous CS (group 5) contributed the most (30.44%) of overall CS.Second largest contributor was nulliparous women with cephalic presentation at term (group 1 and 2).Induction of labor (group 2) was associated with higher CS (23.66%), as compare spontaneous labor (group1). Women with breech presentation (group 6 and 7) also showed high CS rate. Conclusion: In conclusion, RTGCS permits the easy identification of the leading contributing groups to CS increases. RTGCS is an internationally accepted classification that is much needed to scientifically study the effects of the rising CS rate. It identifies the contributors to differences in the CS rate but does not provide any explanation for these differences across various subgroups. Keywords: RTGCS, CS, NVD, Women.

Objective To examine postpartum haemorrhage (PPH) trends in Sweden using the Robson classification system. Design Population-based cohort study. Setting Sweden. Population Deliveries in 2000-2016, classified as Robson groups 1-5 (singleton pregnancies in vertex presentation, from gestational weeks 37+0; n = 1 590 178). Methods We examined temporal trends in PPH between 2000 and 2016 overall, and within each Robson group, and performed logistic regression to examine the influence of changes in risk factors (maternal, comorbidity, obstetric practice and infant factors) over time. Main outcome measures Postpartum haemorrhage, defined as an estimated blood loss of >1000 ml. Results The overall PPH rate increased from 5.4 to 7.3%, corresponding to a 37% (OR 1.37, 95% CI 1.32-1.42) increase over time. Rates varied between Robson groups, ranging from 4.5% in group 3 to 14.3% in group 4b. Increasing trends in PPH were found in all Robson groups except for groups 2b and 4b (prelabour caesarean deliveries). In the unstratified analysis, adjusting for maternal, comorbidity and obstetric practice factors slightly attenuated the risk of PPH in the later period (2013-2016), compared with the reference period (2000-2004; crude OR 1.26, 95% CI 1.24-1.29, adjusted OR 1.22, 95% CI 1.20-1.25). Within individual Robson groups, changes in risk factors did not explain increasing rates of PPH. Conclusions Postpartum haemorrhage rates varied between Robson groups. Changes in risk factors could not explain the 37% increase in PPH for women in Robson groups 1-5 in Sweden, 2000-2016. Tweetable abstract Changes in risk factors could not explain the increasing trend of PPH in Sweden, and rates of PPH varied widely between Robson groups.

OBJECTIVE The objective of this study was to assess caesarean section (CS) rates before and after the implementation of the Project Appropriate Birth (PPA), based on the Robson ten group classification system. DESIGN A before-and-after study. SETTING Maternity hospital in South Brazil. POPULATION All pregnant women attending from April 2016 to April 2017 (period 1, pre-implementation of PPA) and from June 2017 to June 2018 (period 2, post-implementation of PPA). METHODS Maternal and obstetric characteristics were evaluated, including Robson's classification, based on the characteristics of pregnancy and childbirth. A chi-square test and crude and adjusted relative rates were used to analyse the study variables. The significance level was set at 5%. MAIN OUTCOME MEASURES The CS rate for each group, their contribution to the overall CS rate and the differences in these contributions before and after PPA implementation. RESULTS The CS rates decreased from 62.4 to 55.6%, which represented a 10.9% reduction after the implementation of the PPA. Pregnant women in Robson classification groups 1-4 had a 21.4% reduction in CS rates, ranging from 49.1 to 38.6%. The greatest contributors to the overall CS rates were group 5 and group 2, accounting for more than 60% of the CS deliveries. CONCLUSION The study results suggest that Project Appropriate Birth had an impact on the reduction of CS rates, especially in Robson classification groups 1 through 4, which indicates that providing mothers with evidence-based interventions for labour and childbirth assistance contributed to reduce CS rates. TWEETABLE ABSTRACT The Project Appropriate Birth is an innovative project that has demonstrated promising results, suggesting that interventions based on scientific evidence can lead to real changes in childbirth care, contributing to reduce CS rates. The aim of the PPA is to promote activities to improve childbirth care and encourage vaginal delivery. In this study, 6238 pregnant women admitted to the hospital for delivery were included and classified into one of the Robson 10-group classification. Findings revealed a 10.9% reduction in the overall CS rate and a 21.4% reduction for pregnant women in Robson classification groups 1 through 4, after the implementation of the PPA.

Objective The knowledge of a labour and birth unit’s rates of events and outcomes is essential to design any quality improvement initiative. It is in the same way important to have a system to analyse results of the ongoing changes within the unit. The Ten Group Classification System is the framework for doing this in a systematic and clinically relevant way. We aimed to use this classification system as a quality improvement tool. Study design All labours and births during four years at a secondary level Hospital were included in a continuous analysis and of events and outcomes based on the Ten Group Classification System. From the results of the audit, policies and guidelines were designed and updated to improve outcomes. Results The normal vaginal birth rate in Group 1 increased during the four-year-period and the Caesarean Section rate in Group 2 A dropped after the introduction of a new induction method. The overall Caesarean Section rate decreased. The experience of giving birth improved in Groups 1, 2 A and 3. Conclusion The use of a continuous audit of events and outcomes based on a clinically significant classification for all women makes it possible to improve quality. Other labour and birth units are encouraged to collect and present data in a way that allows comparisons between units and over time.

Introduction: Caesarean section rates have been slowly rising all over the world as the safety of operative deliveries has improved. An examination of a center's caesarean section incidence will reveal preventable causes of the growing issue. Caesarean section is usually performed to ensure safety of the mother and child under obstetric risks. Objective: This retrospective study used Robson's Ten Group Classification System to examine the indications for caesarean deliveries over a one-year period from June 18, 2017 to June 17, 2018, and to determine the preventable causes of caesarean section. Methods: The labour room delivery registry was used to track down all patients who gave birth during this time period. Age, parity, risk factors, mode of delivery, intrapartum incidents, and indication of caesarean section were all taken into consideration while reviewing their records. The information was entered into an Excel spreadsheet and categorised using Robson's Ten Group Classification System. Results: Caesarean section rate was 52.7% during the study period. Caesarean section was lowest in Group 3(10.31%) and highest in Group 6(92.68%).Group 2 made the highest contribution to overall Caesarean section rate(23.93%). Analysis of indications in Group 2 showed that Oligohydramnious and Post ART pregnancies were the two modifiable indications where decision towards Caesarean section was much liberal. Conclusion: Primigravida who are admitted to the hospital for safe containment, i.e. not in labour, should be the focus of strategies to reduce the caesarean section rate. The hospital's policy on interference in oligohydramniosis and post-ART pregnancies needs to be reviewed. Strict policy recommendations on labour induction procedures and labour trials in prior caesarean cases would strengthen the situation.

Background The rate of cesarean section (CS) births has been rapidly increasing in Saudi Arabia during the last two decades. Using the Robson Ten Group Classification System (TGCS) to classify and analyze the causes of the high CS rate. Objective To assess the increasing rates of CS by the implementation of the Robson TGCS on all CS births in our chosen population. Study design An observational, cross-sectional study conducted among all deliveries at the King Abdul-Aziz Medical City (KAMC), Jeddah, Saudi Arabia during most of 2018. Over the study period, 3168 births were enrolled in the study. Results The analysis of 3168 births, where 870 women gave birth through CS, resulted in a CS rate of 27.5%. The three major TGCS which contributed to the CS rate were group 5, 2 (divided into 2A and 2B), and 3. Class 5 (Previous CS, single cephalic, ≥37 weeks) contributed the most to the CS rate by 36.5%. Followed by Class 2 (divided into 2A; nulliparous, singleton, cephalic, ≥37 weeks, induced labor and 2B; nulliparous, singleton, ≥37, pre-labor CS) which contributed by 12.9%. Class 3 (multiparous (no previous CS), singleton, ≥37 weeks, spontaneous labor) was the third-highest contributing group by 9.2%. Women who gave birth spontaneously and vaginally were 1403 (44.3%) where women whose labor was induced were 1286 (40.6%). Conclusion The CS rate in KAMC was 27.5%. After classifying these patients according to the TGCS, Class 5 had the largest percentage of patients going for CS (36.2%). While they are individually low together, Robson classes from Class 1 to 4 (which are considered as low-risk classes) were responsible for 37.8% of the patients going for CS. Since the previously mentioned groups are considered low-risk they should be targeted by health institutions to reduce the CS rate. Improved education of nulliparous and multiparous women who never underwent a CS to prevent nonmedically indicated CS is in order, to preclude repeated CS births in the future and further increase the CS rate.

Background Cesarean section (CS) is an important indicator of access to, and quality of maternal health services. The World Health Organization recommends the Robson ten group classification system as a global standard for assessing, monitoring and comparing CS rates at all levels. This study aimed to assess the rate of CS and perform an analysis based on Robson classification system. Methods A facility-based cross-sectional study was conducted at a tertiary hospital in Addis Ababa, Ethiopia. Data were collected from medical charts of all women who delivered from January-June 2018. The overall CS rate was calculated then women were categorized into one of the ten Robson groups. Relative size of each group, contribution of each group to the overall CS rate, and CS rate within each group were calculated. Results A total of 4,200 deliveries were analyzed. Of these 1,459 (34.7%) were CS. The largest contributors to the overall CS rate were Group 10 (19.1%), Group 2 (18.3%), Group 5 (17.1%), and Group 4 (15.8%). There was also a high rate of pre-labor CS in Group 2, Group 4, and Group 10. Conclusion Through implementation of the Robson ten group classification system, we identified the contribution of each group to the overall CS rate as well as the CS rate within each group. Group 10 was the leading contributor to the overall CS rate. This study also revealed a high rate of CS among low-risk groups. These target groups require more in-depth analysis to identify possible modifiable factors and to apply specific interventions to reduce the CS rate. Evaluation of existing management protocols and further studies into indications of CS and outcomes are needed to design tailored strategies and improve outcomes.

Objective The Robson 10 group classification system (RTGCS) is a reproducible, clinically relevant and prospective classification system proposed by the World Health Organization (WHO) as a global standard for assessing, monitoring and comparing cesarean section (CS) rates. The purpose of the present study is to analyze CS rates according to the RTGCS over a 3-year period and to identify the main contributors to this rate. Methods We reviewed data regarding deliveries performed from 2014 up to 2016 in a tertiary hospital in Portugal, and classified all women according to the RTGCS. We analyzed the CS rate in each group. Results We included data from 6,369 deliveries. Groups 1 (n = 1,703), 2 (n = 1,229) and 3 (n = 1,382) represented 67.7% of the obstetric population. The global CS rate was 25% (n = 1,594). Groups 1, 2, 5 and 10 were responsible for 74.2% of global CS deliveries. Conclusion As expected, Groups 1, 2, 5 and 10 were the greatest contributors to the overall CS rate. An attempt to increase the number of vaginal deliveries in these groups, especially in Groups 2 and 5, might contribute to the reduction of the CS rate. Resumo Objetivo A Classificação de Robson é um instrumento reprodutível, clinicamente relevante e prospectivo proposto pela Organização Mundial de Saúde (OMS) para avaliar, monitorar e comparar as taxas de cesarianas.Oobjetivo do presente estudo é analisar a taxa de cesarianas ao longo de 3 anos de acordo com a Classificação de Robson e identificar os grupos que contribuíram mais significativamente para essa taxa. Métodos Recolhemos dados relativos aos partos ocorridos entre 2014 e 2016 em um hospital terciário de Portugal e classificamos todas as grávidas de acordo com a Classificação de Robson. Analisamos a taxa de cesarianas em cada grupo. Resultados Incluímos dados relativos a 6,369 partos. Os grupos 1 (n = 1,703), 2 (n = 1,229) e 3 (n = 1,382) representaram 67.7% da população obstétrica. A taxa de cesarianas foi de 25% (n = 1,594). Os grupos 1, 2, 5 e 10 contribuíram para 74.2% da taxa de cesarianas. Conclusão Tal como esperado, os grupos 1, 2, 5 e 10 foram os quemais contribuíram para a taxa de cesarianas. Aumentar o número de partos vaginais nestes grupos, principalmente nos grupos 2 e 5, poderá contribuir para a redução da taxa de cesarianas.

Introduction Midwifery-led care is recognised as the best choice of maternity care for low-risk women. Robson’s Ten Group Classification System (TGCS) has been an internationally recognised audit tool, however there is no midwifery-led service presenting its statistics in this way. The objective of this study was to analyse caesarean section rates for the women attending midwifery-led care at the National Maternity Hospital Dublin, Ireland, using the Robson TGCS. Methods This is a retrospective study of electronic records for a total of 1097 women who were booked to attend the community midwife team in the National Maternity Hospital, during 2016 and 2017. Results The rate of caesarean section in low-risk nulliparous women (Robson Group 1) was under 6%, without affecting the perinatal outcome. The induction rate in nulliparous women (Group 2) was 36%, less than the national average but the cesarean rates were quadruple in this group. Conclusions Low-risk women who attend midwifery-led services, have a low caesarean section rate in this study. This was achieved with continuity of care, good antenatal preparation, and support throughout labour and birth by a dedicated team of midwives. Outcomes can only be truly compared if we use the same criteria to measure them. The TGCS demonstrates the effectiveness of midwifery-led care.

Background Operative vaginal delivery (OVD), either vacuum or forceps, can be used to expedite vaginal delivery. While rates of OVD have been reducing worldwide, rates in Ireland remain high. The Robson Ten Group Classification System (TGCS) was originally created to compare rates of caesarean delivery between healthcare units, although no similar system exists for the analysis of OVD. Aims We sought to examine rates of OVD using the TGCS in an effort to understand which patient groups make significant contributions to the overall rate of OVD. Materials and methods This is a retrospective cohort study of all women delivering in a tertiary-level university institution in Dublin, Ireland, from 2007 to 2016. Mode of delivery for all patients was extracted from contemporaneously recorded hospital records. Rates of OVD were analysed according to the TGCS, and the contribution of each group to the overall hospital population was calculated. Results There were 86 191 deliveries of women in our institution, of which 19.3% (16 673/86 191) had an OVD. Women in Group 1 (singleton, cephalic, nulliparous women at term in spontaneous labour) contributed the most to the overall rate of OVD, accounting for almost half of all OVDs (46.1% (7679/16 673)). Nulliparous women with a singleton, cephalic fetus at term who were induced (Group 2) were more likely to have an OVD than similar patients who laboured spontaneously (Group 1). Conclusion OVD accounts for almost one in five deliveries in our population and is predominately performed in nulliparous women. These groups may be the subject of interventions to lower rates of OVD. The Robson TGCS is a freely available tool to hospitals and birthing centres to facilitate comparison of rates of OVD on local and national levels.

ObjectiveThe Robson ten group classification system is used as a global standard for assessing, monitoring and comparing caesarean delivery (CD) rates within and between maternity services. Our objective was to compare the changes of CD rates at our institution between the years 2008-2010 and 2017-2019 using the Robson ten group classification system.Study designData was collected retrospectively and all women were classified using the obstetric concepts and parameters described in the Robson ten group classification system.ResultsDuring 2008-2010 7,832 deliveries were performed, increasing to 9,490 in 2017-2019. The CD rate also increased from 29.1% to 32.2% (pConclusionThe biggest contributors to the CD rate in our hospital remain multiparous women at term with a previous CD. The CD rates, as well as the overall size of this group, keep rising, resulting in a need to establish more effective ways to motivate women with one previous CD towards vaginal birth after caesarean delivery (VBAC). Furthermore, the CD rate in preterm deliveries is increasing and approaching 50%. This illustrates the need to discuss whether CD is the appropriate mode of delivery in half of the preterm infants.

The problem of the increase in the frequency of Cesarean section delivery has not been resolved yet. Firstly, a large variation in the initial state of puerpera, secondly, a wide variety of indications to the operation fail to allow revealing main determinants. In order to develop and implement effective measures to reduce the rate of the abdominal delivery, an understandable, logical classification of patients is necessary. The World Health Organization recommends the use of Robson Ten-Group Classification System. This study executed with the use of the Robson scale reveals the contingent of patients in whom the decline in the frequency of abdominal deliveries is possible. The authors propose a set of measures aimed at reducing the rate of Cesarean section in institutions of the second level.

Objectives: Cesarean delivery rates have increased remarkably and cause a major public health concern. This study aims to evaluate the feasibility of using the Robson Ten Group Classification System (TGCS) for cesarean delivery (CD) indications at institutional level.Materials and Methods: Database of all women delivering at Cipto Mangunkusumo Hospital, Jakarta, Indonesia were analayzed. The CD rates overall and in each Robson group were calculated, as was the contribution of each group to the overall CD rate. In addition, the CD indications in each group were analyzed.Results: Approximately almost half (48.04%) of women delivered by CS in our study. Groups 10 was the largest groups representing 27.82% of the obstetric population. The second and third largest were group 3 and 1, which represents 18.00% and 17.34%, respectively. The highest relatively contribution of CS rate were group 10, 1, and 3 with the percentage of 28.24%, 17.59%, and 15.19%; contributively.Conclusion: The TGCS can be applied at institutional level. It helps in planning strategies for specific subgroups of women to reduce CS rate and improve outcomes.

The aim of this study was to identify the main contributor to the high Caesarean section birth rate at a regional perinatal medical centre using the Robson Ten Group Classification System (TGCS). A total of 54,085 women were surveyed and were included in our study from 2015 to 2017 at the Women's Hospital at Zhejiang University School of Medicine in Hangzhou, China. The Caesarean birth rate was similar among the three years; although, the new two-childbirth policy in China has been in implementation since 2016. According to the TGCS, Group 5 was the largest contributor to the overall Caesarean birth rate (40.79%), followed by Group 2 (21.36%). The Caesarean birth rate of Group 5 and Group 2 decreased significantly from 2015 to 2017 (

Background: The objective of this study was categorization and evaluation of the caesarean section rate at our institute as per Robson’s formula.Methods: This retrospective study was conducted at department of obstetrics and gynecology, RNT Medical college, Udaipur, a tertiary care teaching hospital in South Rajasthan. The data was collected retrospectively from December 2020 to February 2020 over a period of 2 months and percentage were calculated in various groups as per Robson’s ten group classification system.Results: Among a total of 1195 women delivered during study period, 420 (35.14%) delivered by CS. Women with previous CS (group 5) contributed maximum (35.95%) to the total number of CS followed by group 2 (27.14%).Conclusions: Standardization of indication of caesarean deliveries, regular audits and definite protocol in hospitals will aid in curbing the rate of caesarean deliveries in hospitals.

Aim The aim of this study was to clarify the indication for cesarean section (CS) using the Robson Ten-Group Classification System (RTGCS) and to clarify the center variation using the Lorenz curve in the main institutions in Japan. Methods The records of 68 702 deliveries, which were performed in 125 institutions, were extracted from the Japanese perinatal database in 2013 and the cases were classified using the RTGCS, which classifies deliveries into one of 10 groups on the basis of five parameters. The equality of the CS rate of each hospital was evaluated by the Lorenz curve and the Gini coefficient. The standard error (SE) and 95% confidence intervals (95%CI) for the Gini coefficient were determined by the bootstrap method. The institutions were divided into three categories depending on their scale: comprehensive center (CC, Category I), regional center (RC, Category II) and others (Category III). Results The overall CS rate was 37.3%. The difference between Categories I (42.6%) and II (34.3%) was significant (P = 0.02). The CS rates that were classified as RTGCS group 3 (multiparous, single cephalic, ≥37 weeks, with spontaneous labor) were higher in Category I (4.0%) than in Category II (2.7%, P = 0.01). The Gini coefficient of Category I (0.119 ± 0.015; 95%CI, 0.092–0.152) was significantly lower than that of Category II (0.189 ± 0.013; 95%CI, 0.16–0.217). Conclusion We clarified the indication of CS and center variation. These two types of methods are useful for the evaluation of medical intervention in the perinatal field.

To audit the data of caesarean sections carried out in single-handed-run small private hospitals on the basis of the modified Robson criteria (Canada), to know the changing trends of caesarean sections over a considerable duration of time (15 years) in private sector, and to focus on a particular group out of the classification of caesarean section in the efforts to reduce the caesarean section rate. It is a retrospective observational study of 7342 caesarean section cases carried out in different small private maternity hospitals over a period of 15 years. The data analysed by applying the modified Robson criteria (Canada) and the changing trends were studied in the view of reducing caesarean section rate. Statistically significant increasing trend was observed in groups of both primary and repeat caesarean section cases done before the onset of labour in the last 5 years. Auditing the data of caesarean sections on the basis of the modified Robson criteria (Canada) is a better way of classification as compared to Ten Group Classification System (TGCS). The change in trends is seen only in the last 5 years, which suggests that there is shift in attitude of the obstetricians of small private hospitals in performing caesarean sections before onset of labour than performing it after the onset of labour. Our analysis suggests the obstetricians from small private hospitals to target groups 2B, 4B and 5C.

Aims and objectives To classify the cesarean section (CS) in different groups of Robson's ten-group classification system (TGCS) and comparing the rate and relative size of groups with that of previous year at the tertiary hospital. Materials and methods This retrospective study was conducted in Cheluvamba Hospital, which is a tertiary hospital attached to Mysore Medical College & Research Institute, Mysuru, between January 1, 2014 and December 31, 2014. The data collected was compared with the previous year data between January 1, 2013 and December 31, 2013. The data collected included parity, mode of previous delivery, gestational age, onset of labor-spontaneous or induced, delivery notes of labor ward, and operative notes of CS. This data was then applied to the Robson's TGCS for the year 2014 and compared with that of 2013. Results The total deliveries during 2014 were 12,930 and in 2013 were 15,182. The number of CSs during 2014 was 3,793 and in 2013 it was 3,917. Cesarean section rate in 2014 was 29.33% while in 2013 it was 25.8%. The CS rate has come down to half in group I (nulliparous, single, cephalic. 37 weeks, in spontaneous labor) and to onefourth in group III [multiparous (excluding previous CS) single, cephalic. 37 weeks, in spontaneous labor] in 2014. Conclusion Robson's TGCS is easy to classify. Clinical significance The study showed reduction in CS rate by half in group I and by one-third in group III in 2014 in our institution. This was probably due to the increased awareness among the staff of the institute by the previous year study about higher CS rate. How to cite this article Prameela RC, Shilpa G, Farha A, Prajwal S. Analysis of Cesarean Section Rate using Robson's Ten Group Classification System and comparing the Trend at a Tertiary Hospital for 2 Years. J South Asian Feder Obst Gynae 2016;8(3):175-180.

Introduction Cesarean section (CS) is the most common obstetric surgery and one of the most rewarding surgeries performed. The number of CSs has been growing rapidly, and concern has been expressed at the growing rate in some countries, with some referring to it as an emerging “global epidemic.” Aim The purpose of this study was to study the incidence and analyze different indications of CS in our institution and to compare the frequency of CS in Robson's ten group classification system (TGCS). Materials and methods A prospective hospital-based study for a duration of 3 months (January 2012 to March 2012) was conducted in the Department of Obstetrics and Gynecology, Umaid Hospital, Jodhpur. All patients admitted beyond 20 weeks gestation were included in the study, and record of all births during this period was evaluated. Each delivery was then classified into one of ten mutually exclusive categories according to obstetric characteristics. The information was used to identify the group that accounted for largest proportion of women or group that contributed most to CS and identify the areas for potential modification. Results We found cesarean rate of 28.6% during our study period, which is well above the World Health Organization guidelines. Group V (single, term, cephalic, previous CS) was the largest contributor to CS rates (30.4%). Groups I and II were the 2nd and 3rd largest contributors, i.e., 27.5 and 17.5% respectively. Maximum CS rate of 100% was found in group IX (abnormal lie), which was within the expected range. Group 2 had CS rate more than that of group I, and IV had a rate more than that of group I, which indicates that induction and cesarean before labor increases cesarean rate in both multiparous and nulliparous women. In our study, Robson's TGCS demonstrated the need to focus on groups I, II, III, and V because the contribution of these groups to overall cesarean rate was 82%. Clinical significance Ten group classification system was found to be a useful framework for auditing and analyzing different CS rates and their reasons. This will help in not only identifying the priority areas for the changes in clinical practice but also reducing cesarean rate. How to cite this article Bhati I, Jha A, Agarwal N. A New Way of Evaluating Cesarean Section Birth: The Robson's Ten Group Classification System. J South Asian Feder Obst Gynae 2016;8(3):212-216.