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

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)