https://dx.doi.org/10.21608/zumj.2020.27925.

1812 Volume 28, Issue 6, November 2022(286-292) Supplement Issue

Manuscript ID ZUMJ-2004-1812 (R1)

DOI 10.21608/zumj.2020.27925.1812

ORIGINAL ARTICLE
Analysis of Caesarean Section Rate using the 10 Group Robson Classification in
Zagazig University Hospital.
Emad Mohammad Ahmed Hassan1, Abdul Magid Mahmoud Sarhan1, Ahmed Mahmoud
Abdou1, Ahmed Hassan El Maasrawy1
1)Obstetrics and Gynecology department, Faculty of medicine, Zagazig university, Zagazig , El sharkia, Egypt
Corresponding author ABSTRACT
Emad Mohammad Ahmed Background: Increase rate of unnecessary caesarean sections has been a
Hassan growing concern in the world. WHO proposed the Robson classification
E.mail : system as a global standard for assessing, monitoring and comparing
master.web1994@gmail.com caesarean section rates within healthcare facilities overtime and between
facilities. Aim: To assess and analyze Cesarean Section Rate (CSR) of
Zagazig university hospital over the period of six months using the 10
Submit Date 2020-04-14 Group Robson classification system.
Revise Date 2020-05-20 Patients & methods: A prospective cross-sectional study was carried out
Accept Date 2020-05-25 in the Department of Obstetrics & Gynecology at Zagazig University
Hospitals, Zagazig, Sharkia, Egypt, from January 2019 till June 2019. All
women admitted for delivery were classified using Robson classification.
Results: 2333 women were admitted for delivery. 854 (36.6%) gave birth
by vaginal delivery while 1479(63.4%) by CS. Robson Group 5
(multiparous, term, cephalic and previous cesarean section ) contributed
the most to the overall CS rate (53.2 % relative contribution). Group
10(cephalic preterm pregnancies) and group 2 (nulliparous
, single , term , cephalic pre labor) were the second and third
greatest contributors towards the overall CS rate , with
10.2% and 8.9 % respectively.
Conclusion: Robson Groups 5, 10, and 2 were identified as the main
contributors to the overall CS rate at our hospital. Robson classification
can be incorporated successfully into the routine maternal and perinatal
data collection system to improve the monitoring and evaluation of
caesarean section rate.
Keywords: Cesarean; Robson; Zagazig.
Determining the adequate Caesarean Sections rate
INTRODUCTION
at the population level is a challenging task due to
C S is the commonest and most important major
operation performed on women worldwide .
It is indicated when vaginal delivery might carry
intrinsic differences in hospital factors and
infrastructure (primary versus tertiary level ) ,
difference in characteristics of obstetric
a risk to the mother (mainly labor dystocia and
population and difference in management
previous cesarean) or to the fetus (mainly fetal
protocol(5) .
distress and malpresentations) or both(1,2).
Health organizations have suggested the need for
WHO estimates the rate of cesarean section to be
a classification system that can best monitor and
between 10-15% of all births in developed
compare CS rates in a standardized , reliable ,
countries. Nevertheless, the cesarean section rate
consistent and action oriented manner .WHO
in the UK was about 25% and in USA it was about
proposed the Robson classification system as a
32.1% in 2017. This increase in rate is partly due
global standard for assessing , monitoring and
to reasons other than medical necessity e.g., CS
comparing caesarean section rates within
on maternal request (3).
healthcare facilities overtime and between
Egypt has the highest rate of Caesarean section of
facilities .It classifies women in 10 groups based
54 % in the Eastern Mediterranean Region, with
on their obstetric characteristics( parity , previous
no furthermore improvement to maternal and
CS , gestational age , onset of labor , fetal
child mortality rates (4).
presentation , and number of fetuses ) without
needing the indication of CS (6) . It gives a good
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opportunity to evaluate the prevalence of CSs 4b Pre-labour CS Group (5) include all
among various groups of women , to compare data multiparous women with at least one previous CS,
between institutions , learn from each other .So, a with a single cephalic pregnancy, ≥37 weeks
better critical assessment can be provided to gestation
change the practice and create strategies for better Group (6) include all nulliparous women with a
results through audit and feedback cycle (7) . single breech pregnancy
PATIENTS AND METHODS Group (7) include all multiparous women with a
This prospective cross sectional study was carried single breech pregnancy including women with
out in the Department of Obstetrics & Gynecology previous CS(s)
at Zagazig University Hospitals, Zagazig, Sharkia, Group (8) include all women with multiple
Egypt, from 1st of January 2019 till 30 of June pregnancies including women with previous CS(s)
2019. The study population included all women Group (9) include all women with a single
who delivered and attended at Zagazig University pregnancy with a transverse or oblique lie,
hospital with live births or stillbirths of at least including women with previous CS(s)
500-gram birth weight or at least 28 weeks Group (10) include all women with a single
gestation for the six months . 2333 women were cephalic pregnancy < 37 weeks gestation,
included. All women delivering less than 28-week including women with previous CS(s)
gestation were excluded. All target population was as shown in table (1)
subjected to : Full history taking including Using these variables, women were placed into one
personal, present, past, family, contraceptive and of the 10 groups as shown in figure (1)
menstrual history and obstetric history that include The study was approved by the research ethical
( parity , previous CS , gestational age , onset of committee of Faculty of Medicine, Zagazig
labor , fetal presentation , and number of fetuses) University. The work has been carried out in
, general examination , abdominal examination , accordance with The Code of Ethics of the World
obstetric U/S , recording the events of labor and its Medical Association (Declaration of Helsinki) for
complications if present , neonatal resuscitation by studies involving humans.
neonatologist and assessment of the APGAR score Statistical analysis: All data were collected,
at 1 and 5 minute to diagnose the occurrence of tabulated and statistically analyzed using The
RDS in the neonates of both groups and EpiData V.3.1 software . Quantitative data were
classification of the women who give birth using expressed as mean ± SD while qualitative data
the 10 Group Robson classification as follows: were expressed as numbers and percentages (%)..
Group (1) include nulliparous women with a single RESULTS
cephalic pregnancy, ≥37 weeks gestation in 2333 women were admitted for delivery and
spontaneous labour classified using Robson classification. 854 (36.6 %
Group (2) include all nulliparous women with a ) had vaginal delivery and 1479 (63.4 % ) had CS.
single cephalic pregnancy, ≥37 weeks gestation Group 5 has the largest group size(33.9%) and is
who had labour induced or were delivered by CS the largest relative contributor for overall CSR
before labour 2a Labour induced 2b Pre-labour (33.7%). Group 6 and 9 have a 100% group CSR.
CS Group (3) include multiparous women without as shown in table (3)
a previous CS, with a single cephalic pregnancy, 275 women received induction of labor ; 119
≥37 weeks gestation in spontaneous labour Group women (43.2%) had CS as shown in table (4)
(4) include multiparous women without a previous Previous CS was the most common indication 940
CS, with a single cephalic pregnancy, ≥37 weeks women out of 1479(63.5 %) of performing CS,
gestation who had labour induced or were followed by fetal distress 180 women out of 1479
delivered by CS before labour 4a Labour induced (12.1%) as shown in table (5).

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Table no. (1): Robson groups characteristics.

Table 2: the sociodemographic data of the studied poulation

Number
Age (years):
Mean ± SD 25 ± 3.4 years
Range 15- 39 years
Years of education:
Un-educated 3
1 – 6 years 14
7 – 9 years 52
10 – 12 years 1656 (70.9 %)
More than 12 years 608 (26%)
Employment state:
Un-employed 1794 (77%)
Employee 539 (23%)
The mean age was : 25 years
77 % of cases were un-employed

Table 3: Robson table for Zagazig university hospital

Group Tot. Tot. Tot. No. Group Group Absolute Relative group
No. No. of No. of delivered size CSR group contribution
CS in VD in in the contribution to overall CSR
each each group to overall CS
group group rate
1 53 203 256 10.90% 20.70% 2.20% 3.50%
2 132 69 201 8.60% 65.60% 5.60% 8.90%
3 42 329 371 15.90% 11.30% 2% 2.80%
4 126 87 213 9.10% 59.10% 5.40% 8.50%
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Group Tot. Tot. Tot. No. Group Group Absolute Relative group
No. No. of No. of delivered size CSR group contribution
CS in VD in in the contribution to overall CSR
each each group to overall CS
group group rate
5 787 5 792 33.90% 99.30% 33.70% 53.20%
6 54 Zero 54 2.30% 100% 2.30% 3.60%
7 63 3 66 3% 95.40% 2.70% 4.20%
8 58 51 109 4.70% 53% 2.40% 3.90%
9 12 Zero 12 0.50% 100% 0.50% 0.80%
10 152 107 259 11.10% 58.60% 6.50% 10.20%
Group size (%) = N. of women in the group/total N. women delivered in the hospital × 100.
Group CS rate (%) = N. of CS in the group/total N. of women in the group × 100.
Absolute contribution (%) = N. of CS in the group/total N. of women delivered in the hospital ×
100.
Relative contribution (%) = N. of CS in the group/total N. of CS in the hospital × 100.
CSR (caesarean section rate).
Group 5 has the largest group size(33.9%) and is the largest relative contributor for overall
CSR (33.7%)
Group 6 and 9 have a 100% group CSR

Table 4: women who were given induction of labor

Group Vaginal delivery Cesarean section Total
2. a 69 55 124
4. a 87 64 151
275 women received induction of labor ; 119 women (43.2%) had CS

Table 5 : most common Indications of CS

Indication of CS Number
Accidental hemorrhage 4
Breech 146
Cord prolapse 5
CPD 90
Eclampsia 7
Elderly PG 5
Fetal distress 180
HPV 3
Pelvic repair 1
Maternal request 16
CFMF 7
Severe PET 6
IUGR 12
Macrosomia 28
Previous CS 940
Precious baby 23
Triplet 1
Cardiac (A.S.) 1
Previous CS is the most common indication 940 women out of 1479(63.5 %) of performing CS, followed by
fetal distress 180 women out of 1479 (12.1%)

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figure 1: flow chart for classification of women using Robson classification

DISCUSSION et al ., 2016(9) found that countries like, France

The study was designed as a prospective cross and Netherland and Brazil with better
sectional study at Zagazig university hospital. The socioeconomic status have also reported higher
mean age was : 25 years± 3.4 years .77% of cases contribution from this group i.e., 61% and 47%
were unemployed as shown in table (2). Women and 30.8% respectively towards overall CS rate.
classified into Group 5 (all multiparous women In our study only 5 women out of 792 from group
with at least one CS with a single cephalic 5 had VBAC . Cases were admitted in labor with
pregnancy, ≥ 37 weeks gestation) made the fully dilated cervix that was no time for
greatest contribution to the overall CS rate (53.2 performing a CS . The role of midwives in
% relative contribution). On further analysis, 33% reducing over medicalization of labor and
(263/787) of women had one previous CS and addressing women’s concerns in this respect
67% (524/787) had a history of previous two or should be well established. A well connected
more CS. Among those women who had previous midwifery system allowing them to conduct
history of only one CS in Group 5 ; 99 women normal vaginal deliveries will reduce the
were presented in spontaneous labour and 75 of workload for obstetricians, as many obstetricians
them had cervical dilatation of 2–5 cm on in Egypt do not offer VBAC due to their busy
admission. Women belonging to Group 5 are schedule.Clinicians and researchers have
increasingly important determinant of overall observed increases in the incidence of abnormal
CSR .Those presented with spontaneous labor placentation (placenta accrete and percreta ), and
were managed as an emergency CS even if they hemorrhage leading to higher maternal and
had only one previous CS and were eligible for neonatal mortality. The risk of abnormal
trial of labor. Tanaka and Mahomed 2017(8) found placentation is 40% with one CS, and 60% with
that the family pressure and existing culture of more than one CS. The effects of such
“once a CS is always a CS” among the studied complications are further intensified in low-
population played a major role in women not income settings, due to their increase fertility rate,
opting for vaginal birth after cesarean section lack of essential obstetric interventions and
(VBAC). Possible explanations for the lack of limited resources. During the period of study the
trial of labor include a lack of information incidence of hysterectomy was 41 cases, 40 of
concerning previous caesarean section among them had previous CS with placenta previa
women referred to our hospital . In addition, it is accreta . Among those 40 , one mortality case due
possible that clinicians’ fear of litigation and lack to massive bleeding.
of availability of resources necessary for the safe The second highest contributors were Women in
trial of labor, for example continuous EFM Group 10 (women with single cephalic pregnancy
(electronic fetal monitoring) during labor, and <37 weeks gestation, including women with
availability of one to one care are the factors previous CS) , (10.2% relative contribution) to the
identified for the high CS rate in this group. Zhang overall CS rate. Although preterm birth is the
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main determinant of neonatal morbidity and then group 1( nulliparous , single, term ,cephalic
mortality, prematurity itself with no other risk pregnancy with spontaneous labor ) by relative
factors is not an absolute indication for CS. contribution rate 3.5 % then group 3 (multiparous,
Women in group 2 (nulliparous with single , term single ,term ,cephalic pregnancy with
,cephalic either induced or planned CS )made the spontaneous labor ) by relative contribution rate
3rd largest contribution (8.9 % relative contribution 2.8 % and lastly group 9 (all women with a single
to the overall CS rate( .Among those women 41.6 oblique or transverse pregnancy including women
% (55/132)(group 2a) were given induction of labor with a scarred uterus) by relative contribution
by prostaglandin , while 58.4 % (77/132 )(group 2b) rate 0.8 %.
had a planned CS. CONCLUSION
Women in group 4 ) multiparous with single , term In our study, Robson Groups 5, 10, and 2 were
,cephalic either induced or planned CS )made the identified as the main contributors to the overall CS
4th largest contribution (8.5 % relative contribution rate at our university hospital. the most common
to the overall CS rate( .Among those women 50.7 indication of performing Cesarean Section was
% (64/126)(group 4a ) were given induction of previous CS. Group 5 was the largest contributor
labor by prostaglandin , while 49.3% (62/126 ) for CS by absolute group contribution 33.7 % and
(group 4b) had a planned CS. relative group contribution 53.2 %. We believe that
Group 2 , the 3rd largest contributor has a high Robson classification can be incorporated
group CS rate 65.6% . The common indications of successfully into the routine maternal and perinatal
CS in this group include precious baby and women data collection system to improve the monitoring
with unfavourable cervix and CS on maternal and evaluation of caesarean section rate.
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How to cite
Hassan, E., Sarhan, A., Abdou, A., elmaasrawy, A. Analysis of Caesarean Section Rate using The 10
Group Robson Classification in Zagazig University Hospital. Zagazig University Medical Journal,
2022; (286-292): -. doi: 10.21608/zumj.2020.27925.1812

Hassan, E., et al 292 | Page