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Classification of Caesarean Section NJOG Rai SD et al. Classification of Caesarean Section NJOG. Jan-Jun. 2021;16(32):2-9 Review Classification of Caesarean Section: A Scoping Re- view of the Robson classification Sulochana Dhakal-Rai1, Edwin van Teijlingen1, Pramod Regmi1, Juliet Wood1, Ganesh Dangal2, Keshar Bahadur Dhakal3 1 Bournemouth University, Bournemouth, UK 2 Kathmandu Model Hospital, Kathmandu, Nepal 3 Karnali Province Hospital, Nepal ABSTRACT CORRESPONDENCE Caesarean section (CS) rate is rising dramatically worldwide. WHO recom- mended CS rate of 10-15% at populational level would not be the ideal rate at Sulochana Dhakal-Rai, the hospitals level due to the differences on population they have been serving. Bournemouth Univer- At the hospital level, a perfectly effective system is necessary to understand the sity, Bournemouth, UK trends and causes of rising trends of CS as well as to implement effective measures where necessary to control the same. Hence, WHO recommended the Email:sdhakalrai@bourne Robson classification, which is also called the 10-group classification of CS mouth.ac.uk; (TGCS) as a global standard tool to assess, monitor and compare CS rates with- in healthcare facilities over time, and between health facilities. The Robson Received: January 21, 2021 classification, proposed by Dr Michael Robson in 2001, is a system that classi- Accepted: May 1, 2021 fies all women at admission at a specific health facility for childbirth into 10 groups based on five basic obstetric characteristics (parity, gestational age, on- Citation: set of labour, foetal presentation and number of foetuses). This classification is Rai SD, Teijlingen EV, easy and simple and mutually exclusive, highly reproducible, easily applicable, Regmi P, Wood J, Dangal and useful to change clinical practice. It has many strengths such as simplicity, G, Dhakal KB. Classifica- flexibility (further subdivisions can be made to increase homogeneity within tion of Caesarean Section: groups). This classification helps to identify and analyse the contribution of A Scoping Review of the each group to overall CS rates. It also allows distinguishing the main group of Robson classification. Nep women who contributes most and least to the overall CS rates; so that the CS J Obstet Gynecol. 2021;16 (32):2-9. DOI: https:// rates can be monitored in a meaningful, reliable, and action-oriented manner in doi.org/10.3126/njog.v16i1. each health facilities for optimal use of CS. 37409 Key words: Caesarean section, Classification system, Robson classification. INTRODUCTION needs to be done for stemming the The Caesarean section (CS) rate is rise. The World Health Organization 1,2 rising dramatically worldwide. The (WHO) recommended CS rate of 10 rising CS rate has been a major global -15% at population level in 1985.9 public health issue because of its as- Although, a debate is ongoing about sociation with potential health risks to 10 mother and baby,3,5 and adverse risks the optimal rate of CS, a CS rate in subsequent pregnancy,4 Additional- greater than 10% at population lev- ly, the rise of CS unnecessarily can el11 does not contribute to the preser- cause an financial burden in the vation of maternal and foetal .6 health system. health.12 The population-based rec- ommended CS rate 10 – 15% would CS rates are also rising in South not be realistic at the hospital level Asian city hospitals.7,8 Obstetricians due to the complexity of the popula- and hospitals need evidence-based tion they serve.13 Monitoring CS information regarding how or why rates at hospital level by using over- the CS rate has increased and what all CS rates is also difficult for inter- 2 Rai SD et al. Classification of Caesarean Section NJOG. Jan-Jun. 2021;16(32):2-9 Review pretation and comparison due to variations in sever- rater reproducibility, comparability, and interpreta- al factors such as differences in hospital practice, tion; and other bases like site and surgeon are lim- the characteristics of the local obstetric population ited by their utility.18 A systematic review conduct- they serve and clinical management protocols.13 The ed by WHO in 2011 determined that the Robson Robson classification system is a vital tool at the classification that is based on obstetric characteris- centre of the debate around defining the optimal rate tics at admission is the most appropriate classifica- of CS. In April 2015, WHO proposed the Robson tion system to achieve current international and classification to assess, monitor and compare the local needs.19 rates of CS rates within a health institution over- time, between different health institutions, countries ROBSON CLASSIFICATION and regions in a meaningful, reliable, and action- oriented manner.10,13-15 The objective of this article The Robson classification, which is also called the is to explore basic information on the Robson Clas- 10-group classification of CS (TGCS), proposed 20 sification and its use in South Asia. by Dr Michael Robson in 2001 is a system that classifies all women admitted at a specific health METHODS facility for childbirth into 10 groups based on five 16 basic obstetric characteristics which are mutually A short scoping review of articles highlighting the exclusive and absolutely comprehensive. The sys- issues around Robson’s Classification were tem does not include the indications for CS. The searched using several bibliographic electronic data- maternal obstetric characteristics are: parity bases such as PubMed, MEDLINE, EMBASE, (nulliparous, multiparous with and without previ- SCOPUS, CINAHL and Web of Science as well as ous caesarean section); gestational age (preterm or open access journals. Articles on Robson’s Classifi- term); onset of labour (spontaneous, induced or pre cation were searched using Medical Subject Head- -labour caesarean section); foetal presentation ings (MeSH) heading such as caesarean, cesarean, c (cephalic, breech or transverse); and number of -section was combined with the specific key words foetuses (single or multiple). The 10 groups with such as Robson Classification using Boolean opera- specific obstetric characters as Robson Classifica- tors (and/or). Additional articles were searched from tion16 are tabulated. [Table-1] the reference list of the selected articles and organi- zational websites such as WHO, and open access The Robson Classification categorizes all women journal databases such as Nepal journals on-line who give birth in any health institution irrespective (NepJOL) and Bangladesh journals on-line of route of delivery. It can be applied prospectively (BanglaJOL) were also searched. Titles and ab- on admission. Every woman who gets admitted to stracts of the identified articles were initially the hospital for childbirth can be directly classified scanned and then, eligible full-text articles were ap- based on maternal obstetric characteristics as de- praised, and relevant data was extracted, then simple scribed above. These characteristics are usually 17 content analysis performed. Quantitative studies collected routinely in maternity wards every- conducted in South Asia using the Robson classifi- where.13-15,19-22 This classification provides com- cation from January 2010 to December 2020 and mon initial platform for further detailed analysis written in English language were included in this within perinatal events, so that outcomes can be review. A total of 1,170 articles were found and on measured and compared. 13-15 appraisal 26 were used in this scoping review. STRENGTHS AND WEAKNESSES OF THE CLASSIFICATIONS OF CS ROBSON CLASSIFICATION There are mainly four types of classification sys- In 2014, WHO conducted a second systematic re- tems commonly used to classify CS. Classification view and explored several strengths and weakness- based on indications lacks of uniform definition of es of Robson classification from the users of this 19 indications of CS, low reproducibility and insuffi- classification. The main strengths of the Robson cient comparison; based on degree of urgency has classification are: simple to implement, robust, many weaknesses such as the lack of clear and un- reliable, flexible and directness of initial interpre- ambiguous definitions that could compromise inter- tation. Other many studies also reported that the 3 Rai SD et al. Classification of Caesarean Section NJOG. Jan-Jun. 2021;16(32):2-9 Review Table-1: The Robson Classification ing missing data.14 Misclassification and missing Group Obstetric population data can be minimised by providing training/ guidelines, educational inputs and regular audit.10 1 Nulliparous women with a single ce- phalic pregnancy, ≥37 weeks gestation MODIFICATIONS OF ROBSON CLASSIFI- in spontaneous labour CATION 2 Nulliparous women with a single ce- phalic pregnancy, ≥37 weeks gestation WHO (Robson Classification Implementation who had labour induced or were deliv- Manual) has introduced the sub-classifications in ered by CS before labour Robson group 2 (2a: Labour induced and 2b: Pre- 3 Multiparous women without a previous labour CS), group 4 (4a: Labour induced and 4b: CS, with a single cephalic pregnancy, Pre-labour CS) and group 5 (5a: With one previous ≥37 weeks gestation in spontaneous la- CS and 5b: With two or more previous CSs) to bour bring common point on classification.14 For the 4 Multiparous women without a previous improvement of the classification for local use and CS, with a single cephalic pregnancy, to increase homogeneity within the groups, several ≥37 weeks gestation who had labour subdivisions in each of the 10 groups have been
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