Rationalizing the use of caesarean section in Egypt through implementing 10 group Classification system

Traditionally, at facility level, monitoring of CS rates is done by using the overall percentage of deliveries by CS. Variations in this “overall CS rate” between different settings or over time are difficult to interpret and compare because of intrinsic differences in hospital factors and infrastructure (e.g. primary versus tertiary level), differences in the characteristics of the obstetric population (“case-mix”) served (e.g. percent of women with previous CS) and differences in clinical management protocols (e.g. conditions for induction or pre-labour CS). Ideally, there should be a classification

Will follow here the NICE guidelines (16)

1- Breech presentation

Cs should be offered to pregnant women with a singleton breech presentation at term, for whom external cephalic version is contraindicated or has been unsuccessful

On the other hand, Women who have an uncomplicated singleton breech pregnancy at 36 weeks' gestation should be offered external cephalic version Except ( women in labour and women with a uterine scar or abnormality, fetal compromise, ruptured membranes, vaginal bleeding or medical conditions.

2- Cs in multiple pregnancy

This include twin pregnancy (with all variants ) and triple pregnancy

A)    Twin pregnancy ( dichorionic diamniotic or monochorionic diamniotic )

1-     Discus and explain to women with an uncomplicated twin pregnancy planning their mode of birth that planned vaginal birth and planned caesarean section are both safe choices for them and their babies if all of the following apply:

·        the pregnancy remains uncomplicated and has progressed beyond 32 weeks

·        there are no obstetric contraindications to labor

·        the first baby is in a cephalic (head-first) presentation

·        there is no significant size discordance between the twins.

2-     Caesarean section is recommended to women if the first twin is not cephalic at the time of planned birth either full term or preterm between 26 and 32 weeks

3-     Offer an individualized assessment of mode of birth to women in suspected, diagnosed or established preterm labor before 26 weeks taking into account the complications of cs and neonatal standards.

B)      Twin pregnancy: monochorionic monoamniotic

Offer a caesarean section to women with a monochorionic monoamniotic twin pregnancy:

·        at the time of planned birth

·        after any complication is diagnosed in her pregnancy requiring earlier delivery

·        if she is in established preterm labour, and gestational age suggests there is a reasonable chance of survival of the babies (unless the first twin is close to vaginal birth and a senior obstetrician advises continuing to vaginal birth)

 C )       Triplet pregnancy  Cs should be done in cases of

·       At the time of planned birth

·         After any complication is diagnosed in her pregnancy requiring earlier delivery

·       If she is in established preterm labour, and gestational age suggests there is a reasonable chance of survival of the babies.

3- Placenta Previa

Women with a placenta that partly or completely covers the internal cervical os (minor or major placenta praevia) should be offered CS.

4- Morbidly adherent placenta Morbidly adherent placenta

Cs is the role here however obstetrician should ensure that:

•  A consultant obstetrician and a consultant anaesthetist are present

•  An experienced paediatrician is present

•  A senior haematologist is available for advice

•  A critical care bed is available

•  Sufficient cross-matched blood and blood products are readily available.

All hospitals should have a locally agreed protocol for managing morbidly adherent placenta that sets out how these elements of care should be provided and the decision with conservative surgery of hysterectomy should be balanced .

5- Predicting CS for cephalopelvic disproportion before labour

Is not accurate method for assessment and should not be considered indication of cs .

6- Mother-to-child transmission of maternal infection

-HIV/AIDS

-  Do not offer a CS in the following conditions( as the risk of transmission is the same with vaginal and cs delivery )

•  if Women on highly active anti-retroviral therapy (HAART) with a viral load of less than 400 copies per ml

•  Women on any anti-retroviral therapy with a viral load of less than 50 copies per ml.

-  Offer a CS to women with HIV who:

•  are not receiving any anti-retroviral therapy

•  are receiving any anti-retroviral therapy and have a viral load of 400 copies per ml or more.

- Hepatitis B virus

Not an indication for cs

- Hepatitis C virus

Alone is not indication for cs

Cs indicated if it is co-infected with HIV

-Herpes simplex virus Herpes simplex virus

Cs is indicated in primary genital infection in the third trimester

7-    Other emerging factor for conduct of cs

Legal aspects

Over the past decades, the mode of delivery has increasingly become a matter of risk- orientated, defensive obstetric practice. This must largely be seen as a consequence of the increase in guidelines and regulations. The costs of damage claims can at present can be very high in the whole world an in in Egypt in addition to legal responsibilities. (15)

Maternal request for CS

Cesarean delivery on maternal request that is defined as an elective cesarean in the absence of any medical or obstetric contraindication for attempting vaginal delivery (17,18)—is the most frequently cited reason for the increasing incidence of cesarean sections . C certainly, recent years have seen an increase in mothers expressing a wish for cesarean delivery on the basis of assumed advantages compared to vaginal delivery (15)

CS on maternal request is usually a result of anxiety about childbirth and it should be notice that the newly coined term “tocophobia” is mainly used in Scandinavia and the Anglo-American countries to describe strong fear of spontaneous childbirth.. The incidence of this unfortunately named condition is cited as between 6% and 10% (19,20

). every effort should be done including referral to a healthcare professional with expertise in providing perinatal mental health support to help her address her anxiety in a supportive manner however  if after discussion and perinatal mental  health

To answer this question which is a common one in practice nowadays? Two issues will be discussed (15)

A-      a cesarean section remains a surgical operation, and as such it also has side effects and complications

B- Comparison of complications of elective cesarean section and planned vaginal delivery

( A ) Complications of CS

Cesarean section remains a surgical operation, and as such it also has complications that can be intraoperative, post-operative or complications in subsequent pregnancies

Intraoperative complications

·       Infections

·       Organ injury (bladder, intestines, ureter, etc.)

·       Risks associated with anesthesia

·       Need for blood transfusions

·       Hysterectomy as a treatment for severe bleeding, e.g. from p lacenta praevia Postoperative complications

·       Thromboembolic complications (embolism, thrombosis)

·       Adhesions

·       Persistent pain

Complications in subsequent pregnancies

·       Intrauterine growth retardation and preterm delivery

·       Spontaneous abortion

·       Ectopic pregnancy

·       Stillbirth

·       Uterine rupture

·       Infertility

·       Placenta previa and Morbidly adherent Placenta

( B ) Comparison of complications of elective cesarean section and planned vaginal delivery

The data are based on the NICE guideline, in which the few prospective studies that exist were evaluated according to the criteria of evidence-based medicine (EBM).

i.  Risks reduced after elective cesarean:

–  Abdominal and perineal pain during the birth

–  Abdominal and perineal pain 3 days after the birth

–  Vaginal injuries

–  Anesthesia-related emergencies (shock, bleeding)

ii.  Risks reduced after vaginal delivery

–  Duration of hospital stay

–  Hysterectomy due to postpartum bleeding

–  Cardiac arrest

iii.   No differences

–  Abdominal and perineal pain 4 months after the birth

–  Injuries to nearby organs (bladder, ureter, or cervix)

–  Pulmonary embolism

Different authors have created and proposed several types of CS classification systems for use at facility level for different purposes, with the overall aim of providing a consistent and standardized framework to look at CS (27). In 2011 the World Health Organization (WHO) conducted a systematic review that identified 27 different systems to classify CS. These classifications looked at “who” (woman-based), “why” (indication- based), “when” (urgency-based), as well as “where”, “how” and “by whom” a CS was performed. This review concluded that women-based classifications in general, and the 10-Groups classification in particular, were in the best position to fulfill current international and local needs(28)

Unlike classifications based on indications for CS, the Robson Classification is for “all women” who deliver at a specific setting (e.g. a maternity or a region) and not only for the women who deliver by CS. It is a complete perinatal classification.

Since this system can be used prospectively and its categories are totally inclusive and mutually exclusive, every woman who is admitted for delivery can be immediately classified, based on a few basic characteristics which are usually routinely collected by obstetric care providers worldwide. The strength of this classification came from being simple, robust, reproducible, clinically relevant, and prospective.

Values of using Robson Classification

• Identify and analyze the groups of women which contribute most and least to overall

CS rates.

• Compare practice in these groups of women with other units who have more desirable

results and consider changes in practice.

• Assess the effectiveness of strategies or interventions targeted at optimizing the use of

CS.

• Assess the quality of care and of clinical management practices by analyzing outcomes

by groups of women.

According to these variables, 10 groups classification system was created known as Robson classification as shown in table 2 and figure 1

The Robson Classification should be considered as a common starting point for a perinatal classification system that can be further developed. Each of the 10 groups may need to be subdivided or some groups may need to be combined. In addition, more details such as indications for caesarean sections or neonatal morbidity can be added and analysed within the different groups. Other events and outcomes related to labour and delivery can also be analysed within the group (e.g. oxytocin or epidemiological variables such as age or body mass index). Moreover, there are several key obstetrical definitions, protocols or procedures which are not included in the classification but should be considered when interpreting the results.(29)

The definition of a “birth” may vary between countries and settings. While most high- income countries count births as infants weighing at least 500 g or with a gestational age at least 20 or 22 weeks, many countries use other cut-offs. For example, the threshold of viability in many countries is birth weight ≥ 1000 g and gestational age ≥ 28 weeks. In order to compare Robson Report Tables between countries and within countries over time, it is important that the users of the classification give a clear definition of what were the weight and gestational age cutoffs used in their population. This should be added as a footnote in their Robson Report Table.

Age of medicolegal viability. Not well documented in Egypt however it is used in the majority of the units to be 28 weeks of gestation

SPONTANIOUS LABOUR start of labor without any artificial initiation

Induction of labour is defined as the process of artificially stimulating the uterus to start labour. It is usually performed by administering oxytocin or prostaglandins to the pregnant woman or by manually rupturing the amniotic membranes (30)

The latent first stage is a period of time characterized by painful uterine contractions and variable changes of the cervix, including some degree of effacement and slower progression of dilatation up to 5 cm for first and subsequent labours.(30)

The active first stage is a period of time characterized by regular painful uterine contractions, a substantial degree of cervical effacement and more rapid cervical dilatation from 5 cm until full dilatation for first and subsequent labours (31)

Augmentation of labour .acceleration of already started uterine contraction and hence delivery (31)

Subdivision of Robson Groups

Many suggestions for Robson Classification groups subdivisions have been recoded

(12). Subdivisions of certain groups (e.g. Groups 2, 4 or 5) may prove to be more meaningful than others. The objective of the subdivisions is to further increase the uniformity and homogeneity of the groups by stratifying women within that group according to certain relevant characteristics. This can be especially useful when planning the implementation of clinical interventions in specific subgroups. The importance and potential usefulness of these subdivisions will depend on the size of the groups within the specific setting where the classification will be used. However, it is important to remember that the analyses of any subdivision by itself may be misleading if no attention is given to what has been left out. For this reason it is recommended that before looking at subgroups users become accustomed to first analyse the 10 groups. Otherwise, the data may be misinterpreted. Table 3

Subdivion of group 2 and 4

Refer to nulliparous and multiparous women without previous CS, respectively, with a singleton, term fetus in cephalic presentation who did not enter labour spontaneously and this can be subdivided either their have labour induction or prelabour planned cs .

Since Groups 2 and 4 may represent a large proportion of the obstetric population in many hospitals, these subcategories are important to understand how differences in clinical practice (rates of induced labouror pre-labourCS) contribute to the rates of CS in nulliparous and multiparous women without a previous CS, as well as the overall CS rates in different hospitals. Additionally, the rate of CS in Subgroups 2a and 4a can also be used to assess and compare the success of induction guidelines in different hospitals or in the same hospital over time

Group 5 includes all multiparous women with at least one previous CS carrying a singleton, term fetus in cephalic presentation. In current obstetric practice, Group 5 can be very important in many settings because there is a growing number of women with previous CS and therefore the size of this group may be quite significant. Since the rate of CS in this group is usually high, Group 5 may be an important contributor to the total number of CS in these settings. However, Group 5 includes two distinct and mutually exclusive subcategories, namely

Group 5 (1) with only one previous CS section And a group (2) with two or more CS .

Given the differences in clinical management of these two types of women, these common subcategories should be reported separately in the classification, as 5.1 and 5.2. The usefulness of these subcategories will depend on the actual size of Group 5 in a specific setting. In many high-and middle-income countries where the size of Group 5 is becoming substantial, the proposed subcategories will be more useful and appreciated than in places where Group 5 represents only a small proportion of the obstetric population. This subgrouping will give a potentiality of VBAC 9 vaginal birth after caesarean section) trial in cases of 5 (1) subgroup which will be much difficult to be conducted with group 5 (2)

1.Group size (%) = n of women in the group / total N women delivered in the hospital x 100

2. Group CS rate (%) = n of CS in the group / total N of women in the group x 100

3. Absolute contribution (%) = n of CS in the group/ total N of womendelivered in the hospital x 100

4.  Relative contribution (%) = n of CS in the group / total N of CS in the hospital x 100

Interpretation of the Robson Classification Report Table

Benefits of interrelation

Useful insights into the quality of data collection

- the type of population served by the hospital

-   the CS rates of each group

-   how each of the individual 10 groups contributes to the overall rate of CS in your setting

-    The overall philosophy of care of in a maternity unit.

-   Can guide the necessary training and advocacy at each units as well as country level for decreasing cs rate.

-   can be used to analyze changes over time

-   compare differences between hospitals and to help modify clinical practice to optimize CS rates in specificgroupswhileensuringgood maternalandperinataloutcomes.

GENERAL PRINCIPLES and tips of Interpretation of Robson Report Tables

-   In settings with low volumes of delivery, the interpretation should take into account the effect of small changes in numbers on the percentages.

-   It is important to assess the sizes of all the 10 groups to ascertain the balance and makeup of the whole obstetric population so it should be clear that No individual group should be interpreted unless the whole 10 groups are analysed first.

-   The main three reasons for differences in sizes of groups or events and outcomes within groups are the following:

1-     Poor data quality (incorrect information in the patient records or errors in retrieving information from the records)

2-     Differences in significant epidemiological characteristics of the populations (age, BMI, etc...)

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