Rai SD et al. Classification of 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 into 10 groups based on five basic obstetric characteristics (parity, , 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 ,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-

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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

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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 induced or were delivered by CS before suggested. However, group 5 (women with previ- labour ous CS) has received the largest number of sugges- 5 5 All multiparous women with at least tions for sub-division.19 one previous CS, with a single cephalic The Society of and Gynaecologists of pregnancy, ≥37 weeks gestation Canada (SOGC) recommended the modified Rob- 6 All nulliparous women with a single son criteria, which can be used to enable compari- breech pregnancy son of CS rates and indications. This modified 7 All multiparous women with a single classification of CS allows evaluation and compar- breech pregnancy including women with ison of the contributors to the Caesarean section previous CS(s) rate and their impact. Group 2 and 4 each subdi- 8 All women with multiple vided into A (induced labour) and B (CS before including women with previous CS(s) labor); Group 5 to 10 each subdivided into A 9 All women with a single pregnancy with (induced labor), B (CS before labor) and C a transverse or oblique lie, including (spontaneous labor).23 women with previous CS(s) 10 All women with a single cephalic preg- nancy < 37 weeks gestation, including Use of the Robson Classification in South Asia women with previous CS(s) Use of Robson classification is growing in South Robson classification has been found to be easily Asia as witnessed by many hospital-based stud- applicable.18,21,22,24-51 The main weaknesses of the ies.24-45 Only a few studies have used modified Robson’s classification are: (1) missing data by Robson classification. Out of a total of 21 studies, which it cannot be classified in any 10 group as an 19 studies were retrospective and 2 were prospec- indicator of quality of data; some suggest to create a tive. Out of a total 19 studies24-43 conducted for group “99” and WHO recommends to report at foot- assessing CS rates, one study44 was conducted for note; (2) misclassification of women and; (3) lack of assessing trends and another45 for comparison of definition or consensus on core variables of the clas- protocols of foetal heart rate monitoring sification. (intermittent and continuous). However, there is paucity of large-scale studies comparing between WHO has developed and published a Robson classi- institutions, countries and multi-centre interven- 14 fication Implementation Manual in 2017 to sup- tions as well as further analysis of all perinatal port and guide healthcare facilities worldwide for events and outcomes adding significant epidemio- adopting and implementing this classification. The logical variables. WHO manual14 can improve common understand- ing to resolve the weakness of the Robson Classifi- Only one study, Mittal et al (2019)44 reported the cation, because it describes a standard approach in CS trend using Robson classification in North In- implementation and interpretation of the classifica- dia to assess the trend of CS rate for 3 years and it tion, including standardization of terms and defini- shows a static rate of CS in each group over the tions of core variables as well as the way of manag- years. [Figure-1]

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Rai SD et al. Classification of Caesarean Section NJOG. Jan-Jun. 2021;16(32):2-9 Review

Figure-1: Trends of CS rates in Robson Groups by Mittal et al (2019)44 Many hospital-based studies adapt the Robson Classification for monitoring CS rates.24-43 The group 5 is found to be the high risk group and the major contributor to overall CS rates by several studies.24-26,28- 34,38,40,41 Few studies found Robson groups 1 to be the greatest contributor to overall CS rate.27,37,42-44 The other major contributor to overall CS rate were group two,24,25,28,31-33,43,44 group three35,39,42,44 group four,27 and group ten.27,44 Kandhari et al conducted a hospital-based study in 2019 using Robson classification among low risk cases to compare intrapartum monitoring protocols (intermittent and continuous foetal monitoring) and found decreased operative intervention and a better neonatal outcome in continuous mon- itoring group.45 Neonatal outcome was improved in Robson group 2A, 4A, 7A and 10A and CS was de- creased in Robson group 2A.45 [Table-2] Table-2: Contribution of each group of Robson classification to the overall CS rates. Authors & year Contribution made by each Robson group to the overall CS rate % (Total delivery & CS) 1 2 3 4 5 6 7 8 9 10 Nazneen et al. 201124 14.4 5.06 15.65 4.33 22.15 1.60 1.34 1.18 2.42 2.32 (21149; 58.8%) 6 Dhodapker et al. 201525 (1123; 32.6%) 24.0 14.2 3.5 2.5 40.1 5.4 2.7 3.5 1.4 7.4 Das et al. 201626 (4392; 33.1%) 6.37 3.7 3.46 2.1 11.9 0.9 1.3 0.6 0.2 2.2 Yadav et al. 201627 (40986; 17%) 37.62 4.23 15.0 1.6 17.06 5.83 3.44 1.17 1.0 12.9 Ray et al. 201728 (162428.9%) 1.52 4.93 0.73 1.34 8.29 2.43 1.21 3.78 1.21 3.41 Kant et al. 201829 (531; 58.86%) 7.34 36.71 1.04 2.4 36.0 2.09 0.6 3.14 0.6 9.7 Mehta et al. 201830 (4785; 41.96%) 9.69 2.08 2.02 0.71 21.98 1.19 0.71 0.83 0.58 2.13 Jogia et al. 201931 (650; 28.3%) 7.61 21.20 0.54 4.35 36.96 8.15 7.61 2.17 3.26 8.15 Shenoy et al. 201932 18.7 15.60 24.33 0.26 2.26 27.24 3.70 1.32 4.23 1.85 (655; 27.24%) 8 Senanayake et al. 201933 (7504; 30.0%) 4.2 6.1 1.4 1.7 8.9 1.5 1.2 0.8 0.6 3.4 Gilani et al. 202034 (6155; 33.3%) 4.8 4.2 2.0 2.7 13.8 0.8 1.0 1.2 0.16 2.7 Das et al. 202035 (4394; 33.40%) 7.73 9.84 2.66 3.29 5.75 1.45 0.65 0.20 0.27 1.52 Mittal et al. 201944 (81784; 23.7%) 12.2 22.2 5.2 9.6 29.4 4.9 2.7 1.8 1.7 9.9 5

Rai SD et al. Classification of Caesarean Section NJOG. Jan-Jun. 2021;16(32):2-9 Review

DISCUSSION oxytocin usage, postpartum haemorrhage, neonatal The Robson classification/TGCS is an international- outcomes, and duration of labour ) along with out- ly accepted classification system for monitoring CS comes (stillbirth rate, low birth weight rate, inci- rates. The review found that use of Robson classifi- dence of preeclampsia, and maternal mortality ) by cation is rising in South Asia. It reported that Rob- incorporating significant epidemiological variables 57 son group 5 (All multiparous women with at least (age, body mass index). This classification would one previous CS, with a single cephalic pregnancy, be useful for auditing all perinatal events world- ≥37 weeks gestation) is the most vulnerable group wide and it could provide an opportunity for obste- 57 and greatest contributor to overall CS rate. Similar tricians to learn from each other. findings are reported in Turkey,15 Australia,46 Cana- The review noted that there is a deficit of large- da47 and Brazil.48 Trend analysis showed Robson scale studies in South Asia (as in other countries) group 5 is expanding because of performing CS for such as comparison across health institutions or group 1 – 4 which may then require repeat CS.15 regions using the Robson classification including Although, the Robson group 1 (Nulliparous women CS trend analysis,15,47,48,51,53,54 multi-centre inter- with a single cephalic pregnancy, ≥37 weeks gesta- ventional studies54 and perinatal auditing using the tion in spontaneous labour) is low risk pregnancy Robson classification. group, this group was also reported as the main con- CONCLUSIONS tributor to overall CS rate by some studies in South The use of the Robson classification of CS is in- Asia. A similar finding is reported by other stud- creasing in South Asia and Robson group 5 is 49,50,51 ies. Robson group 2 (Nulliparous women with found to be the main contributor to overall CS rate a single cephalic pregnancy, ≥37 weeks gestation followed by group 1 and 2. The clinical strategies/ who had labour induced or were delivered by CS practice could be modified to optimize CSs in 48,50,51 before labour), group 3 (Multiparous women health facilities. without a previous CS, with a single cephalic preg- nancy, ≥37 weeks gestation in spontaneous labour), REFERENCES 48,50 group 4 (Multiparous women without a previ- 1. Betran AP, Ye J, Moller AB, Zhang J, Gulme- ous CS, with a single cephalic pregnancy, ≥37 zoglu AM, Torloni MR. The increasing trend in weeks gestation who had labour induced or were caesarean section rates: Global, Regional and delivered by CS before labour) and group10 (All National estimates: 1990-2014. PLOS ONE. women with a single cephalic pregnancy < 37 2016;5;11(2): e0148343. Published February 5, weeks gestation, including women with previous CS 2016.|DOI |Google Scholar |PubMed |Full text | (s))52 also are major contributor to overall CS rate. 2. Boerma T, Ronsmans C, Melesse DY, Barros These groups are those which are most likely to AJD, Barros FC, Juan L, et al. Global epidemi- contribute to the high CS rate and therefore need ology of use of and disparities in caesarean sec- close monitoring and could be targeted for reduc- tions. Lancet. 2018;392(10155):1341-8. | DOI | tion of CS rates. For example, unnecessary primary PubMed | Google Scholar | Full text | Weblink and elective CS should be avoided in low risk preg- | nancy such as group 1 and provision of evidence- 3. Sandall J, Tribe RM, Avery L, Mola G, Visser based practice for vaginal birth after CS (VBAC). GHA, Homer CSE, et al. Short-term and long- The Robson classification itself does not show the term effects of caesarean section on the health reasons of CS but can be the common starting plat- of women and children. Lancet. 2018;392 form to identify the reasons of performing CS by (10155):1349-57. | DOI | PubMed | Google performing further analysis of indications for CS in Scholar | Full text | Robson group as required.55 Likewise, this classifi- 4. Keag OE, Norman JE, Stock SJ. Long-term cation can be the starting point for further detailed risks and benefits associated with cesarean de- analysis and comparison of all perinatal events and livery for mother, baby, and subsequent preg- 56 nancies: systematic review and meta-analysis. outcomes and adding epidemiological variables. PLoS Medicine.1002494. Published January 23, A study conducted by Robson et al in Dublin (2015) 2018.| DOI | Google Scholar | Full text showed that the Robson Classification can be used |PubMed | as the common starting point to analyse all labour 5. Souza JP, Gülmezoglu AM, Lumbiganon P, events processes (for example: rates of oxy- Laopaiboon M, Carroli G, Fawole B, et al.

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Rai SD et al. Classification of Caesarean Section NJOG. Jan-Jun. 2021;16(32):2-9 Review

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