O&G Forum

OBSTETRICS & GYNAECOLOGY FORUM 2021 | ISSUE 3 | 14 and health system factors. Maternal indications for CS include: maternal request, fear of labour pains, convenience and previous bad experiences with normal vaginal delivery. 5 Increasing maternal age was also found to be associated with higher rates of CS with women over 40 years having rates of 43.1%. 6 Risk factors for CS reported by Yale Academic Hospital include none reassuring fetal status, preeclampsia, suspected macrosomia and other maternal and fetal conditions such as placental attachment disorders and congenital anomalies. 7 Health professional reported factors such as fear of litigation and work convenience were cited as causes for increased CS rates. 5 Optimising the use of CS is of global interest. One of the methods adopted to reduce the epidemic worldwide is the use of Robson’s 10-group classification. This is a system where women who deliver are stratified into 10 groups based on various categories: gestational age, parity, fetal number, fetal presentation, onset of labour and prior caesarean section.8 The Robson’s 10-group classification monitors rates of caesarean sections in healthcare facilities over time. From this classification, the most common indications may be identified thus allowing one to direct efforts to reduce CS rates at specific groups. 9 This system of analysis also allows one to consider the obstetric management of an individual. A population-based study in Australia found that Robson’s class 5 (all multiparous women with at least one previous uterine scar, with a single cephalic pregnancy, ≥37 weeks gestation) was the most common indication for CS (76.3 %).10 This group was followed by Robson’s class 2 (nulliparous women with a single cephalic pregnancy ≥37 weeks gestation who either had labour induced or were delivered by caesarean section before labour) with a rate of 39.7 %. 10 In a systematic review on optimising CS rates, the Robson groups that made the largest contribution to overall CS frequency in China and Brazil were group 1 (39·9% in China and 35·4% in Brazil) and group 5 (33·9% in China and 32·7% in Brazil). 3 An increase in CS rates for group 5 (29% to 61%) was observed from 1996 to 2014. The aim of this study was to establish the rate, indications, and immediate outcome of women delivered by caesarean section. Methods This was a retrospective study conducted at Steve Biko Academic Hospital (SBAH), a tertiary level hospital in Pretoria, South Africa. SBAH is the primary referral hospital for a district and regional hospitals in the Tshwane District. Mamelodi Regional Hospital refers all tertiary cases to SBAH while Tshwane District Hospital does not perform any caesarean sections after hours or on weekends. In addition, these two hospitals do not offer vaginal birth after caesarean sections. Delivery data from 1 January 2014 to 31 December 2018 was analysed. An existing database used for reporting maternity statistics at Steve Biko Academic hospital was used in this study. This database has been in existence since the 1990s as part of the obstetric unit records and as required by the Department of Health for maternal morbidity and mortality statistics. Information obtained from data sheets include maternal obstetric information: maternal demographics, gravidity and parity, gestational age, fetal number and presentation, previous caesarean sections as well as onset of labour. Any inaccurately entered information was taken as missing data and the entry excluded from data analysis. There was no contact with patients. For the caesarean section rate, the following formula was used: (Number of caesarean sections ÷ total number of deliveries) X 100. The result was expressed as a percentage. The caesarean section rate per year was also analysed. The Robson’s 10 group classification was used to classify each delivery. This system classifies caesarean sections into ten mutually exclusive and exhaustive groups and consists of 10 groups based obstetric characteristics: parity, previous caesarean section, gestational age, onset of labour, fetal presentation and the number of fetuses. From this allocation, the most common groups were established. The Robson’s 10 group classification is shown below: 1. Nulliparous, single cephalic, ≥37weeks in spontaneous labour. 2. Nulliparous, single cephalic, ≥37weeks, induced or CS before labour. 3. Multiparous, no previous scar, single cephalic, ≥37 weeks in spontaneous labour. 4. Multiparous, no previous scar, single cephalic, ≥37 weeks, induced or CS before labour. 5. All multiparous, ≥1 previous CS, ≥ 37 weeks, single cephalic pregnancy. 6. All nulliparous with single breech pregnancy. 7. All multiparous with single breech pregnancy including women with previous scars. 8. All multiple pregnancies, including women with previous scars. 9. All women with transvers or oblique lies, including women with previous scars. 10. All women with single cephalic pregnancy < 37 weeks gestation, including women with previous scars. Indications and immediate outcomes of CS were assessed using multivariable logistic regression. These included: i. Maternal demographics. ii. Presence or Absence Postpartum haemorrhage associated with the caesarean section. This study was approved by the University of Pretoria Health Sciences Research Ethics Committee (Protocol 696/2019). Results The total number of deliveries over the 5-year study period was 15295; 6883 women delivered vaginally and 8412 by caesarean section. The overall caesarean section rate over the 5 years was 55%. The trend along the 5 years was 56.3% for 2014, 56.6% for 2015, 52.8% for 2016, 53.0% for 2017 and 55.8% for 2018. The age group of women with the highest caesarean section rate was 20-35 years (n= 6616, 78.7%). This was followed by the age group > 35years (n=1508, 17.9%) and lastly < 20 years (n=280, 3.3%). e largest contributor to the Robson-10 classi cation was group 5 - multiparous women with at least one previous uterine scar, with a single cephalic pregnancy, ≥37 weeks gestation (n=2432, 29%). is was followed by group 10, women with a single cephalic pregnancy <37 weeks gestation including women with previous scars (n=1841, 22%). Table 1 shows the contributions to caesarean sections according to Robson’s 10 group classi cation. ere were 34 inaccurately entered data which were taken as missing values. Table 1: Robson’s 10 group classification among women who delivered by caesarean section at Steve Biko Academic Hospital 2014-2018. Robson’s 10 Group Total Caesarean sections (n) Robson’s 10 group contribution to overall caesarean section number (%) 1 823 9.8 2 671 8.0 3 864 10.3 4 849 10.1 5 2432 29.0 6 83 0.9 7 317 3.7 8 426 5.1 9 72 0.9 10 1841 22 Total CS 8412 100 The contribution of underlying medical disease to the CS number was determined. Eighty-one percent (n=6809) of caesarean deliveries were performed for obstetric indications while 1592 (19%) of caesarean deliveries were performed for maternal medical disease. O&G Forum 2021; 31: 13 - 16 ORIGINAL RESEARCH