Study of cesarion section births using robson classification system and its outcome in tertiary health care centre This is my synopsis topic Give : aim , objectives, introduction, study material and methods, review of literature This is my non federation
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Synopsis: Study of Cesarean Section Births Using Robson Classification System and Its Outcome in a Tertiary Health Care Centre
(Non-Federation / Observational Study)
AIM
To study cesarean section (CS) births using the Robson Ten-Group Classification System (TGCS) and to evaluate maternal and neonatal outcomes at a tertiary health care centre.
OBJECTIVES
- To determine the overall cesarean section rate at the study institution.
- To classify all deliveries (both vaginal and cesarean) into the ten mutually exclusive Robson groups based on parity, previous uterine scar, fetal presentation, plurality, onset of labor, and gestational age.
- To identify which Robson group(s) contribute most to the overall CS rate.
- To analyze the indications for cesarean section within each Robson group.
- To assess immediate maternal outcomes - intraoperative complications (hemorrhage, bladder/bowel injury), need for blood transfusion, wound complications, febrile morbidity, ICU admission, and maternal mortality.
- To assess immediate neonatal outcomes - APGAR scores at 1 and 5 minutes, birth weight, NICU admission, neonatal morbidity, and perinatal mortality.
- To propose evidence-based institutional strategies to reduce unnecessary CS rates in the highest-contributing Robson groups.
INTRODUCTION
Cesarean section is one of the most common surgical procedures performed worldwide. While it is a life-saving intervention when medically indicated, rising rates have become a major global public health concern. The World Health Organization (WHO) recommends an optimal CS rate of 10-15% of all births; however, rates in many countries - particularly in tertiary care hospitals in India and South Asia - far exceed this threshold, commonly ranging between 30-50%.
Rising CS rates are associated with increased risks including surgical site infections, hemorrhage, blood transfusion, prolonged hospital stay, perioperative morbidity, and in future pregnancies, abnormal placentation and uterine rupture. Neonatal risks include respiratory morbidity, particularly transient tachypnea of the newborn and respiratory distress syndrome in elective pre-labor CS.
To standardize the audit and monitoring of CS rates, the WHO endorsed the Robson Ten-Group Classification System (TGCS), originally developed by Dr. Michael Robson in 2001. This system classifies every woman who delivers into one of ten mutually exclusive, totally inclusive, and clinically relevant groups based on five obstetric parameters:
| Parameter | Details |
|---|---|
| Parity | Nullipara / Multipara |
| Previous uterine scar | Yes / No |
| Onset of labor | Spontaneous / Induced / Pre-labor CS |
| Gestational age | Term / Preterm |
| Fetal presentation | Cephalic / Breech / Transverse/oblique |
| Number of fetuses | Singleton / Multiple |
The 10 Robson Groups are:
| Group | Description |
|---|---|
| 1 | Nulliparous, singleton, cephalic, ≥37 weeks, spontaneous labor |
| 2 | Nulliparous, singleton, cephalic, ≥37 weeks, induced or pre-labor CS |
| 3 | Multiparous (no previous scar), singleton, cephalic, ≥37 weeks, spontaneous labor |
| 4 | Multiparous (no previous scar), singleton, cephalic, ≥37 weeks, induced or pre-labor CS |
| 5 | Previous uterine scar, singleton, cephalic, ≥37 weeks |
| 6 | All nulliparous with breech |
| 7 | All multiparous with breech (including previous scar) |
| 8 | All multiple pregnancies (including previous scar) |
| 9 | All singleton transverse/oblique lie (including previous scar) |
| 10 | All singleton, cephalic, <37 weeks (including previous scar) |
For each group, the following are calculated: absolute number of CS, group CS rate, contribution to overall CS rate (relative size x group CS rate), and relative size (proportion of all deliveries).
This classification is recommended by WHO and the International Federation of Gynecology and Obstetrics (FIGO) as the global standard tool for auditing CS rates. It allows institutions to benchmark performance, identify targets for intervention, and monitor trends over time. Published data from Indian tertiary centres consistently show that Group 5 (previous uterine scar) is the single largest contributor to overall CS rates, followed by Groups 1, 2, and 10 - highlighting that reducing primary CS and promoting VBAC (vaginal birth after CS) are the most impactful interventions.
Institutional-level data from tertiary teaching hospitals are essential to understand local drivers of CS rates, plan targeted interventions, and develop evidence-based obstetric policies aligned with national and WHO recommendations.
STUDY MATERIAL AND METHODS
1. Study Design
Hospital-based prospective/retrospective observational descriptive study.
(Prospective preferred for outcome data; retrospective acceptable if using existing records.)
2. Study Setting
Department of Obstetrics and Gynaecology, [Name of Tertiary Health Care Centre / Teaching Hospital].
3. Study Duration
[Specify: e.g., 2 years, from Month YYYY to Month YYYY]
4. Study Population
All women who delivered (both vaginally and by cesarean section) at the study institution during the study period at or beyond 28 weeks of gestation.
5. Sample Size
All deliveries during the study period will be included (census/universal sampling). No sample size formula is required, as the entire delivery population of the institution during the defined period will be enrolled.
6. Inclusion Criteria
- All women delivering at ≥28 weeks of gestation (or ≥1000 g birth weight) at the study centre.
- Both booked and unbooked cases.
- All modes of delivery: spontaneous vaginal, instrumental vaginal, and cesarean section.
7. Exclusion Criteria
- Deliveries with incomplete medical records.
- Gestational age < 28 weeks / birth weight < 1000 g.
- Cases of cesarean hysterectomy where the primary classification is unclear.
- Women transferred out before delivery outcome is recorded.
8. Data Collection
Data will be collected from:
- Labor room registers, operation theater records, discharge summaries, and case files.
- A predesigned, pretested, structured proforma capturing:
- Sociodemographic details (age, education, socioeconomic status, booking status)
- Obstetric history (gravida, para, previous CS, previous scar details)
- Current pregnancy details: gestational age, fetal presentation, plurality
- Mode of onset of labor (spontaneous, induced, pre-labor/elective CS)
- Indication(s) for CS
- Robson Group assignment
- Intraoperative details (type of anesthesia, intraoperative findings/complications)
- Maternal outcomes (hemorrhage, blood transfusion, ICU admission, wound infection, febrile morbidity, maternal mortality)
- Neonatal outcomes (sex, birth weight, APGAR at 1 & 5 min, NICU admission, neonatal morbidity, early neonatal mortality)
9. Robson Group Classification
Each delivery will be assigned to one of the ten Robson groups based on:
- Parity and previous uterine scar
- Onset of labor (spontaneous / induced / pre-labor CS)
- Gestational age (term ≥37 weeks / preterm <37 weeks)
- Fetal presentation (cephalic / breech / transverse/oblique)
- Number of fetuses (singleton / multiple)
For each Robson group, the following will be calculated:
- Absolute number of CS in the group
- Group size (% of all deliveries)
- Group CS rate (CS in group / all deliveries in group × 100)
- Contribution to overall CS rate (% CS from this group / total deliveries × 100)
10. Outcome Measures
Primary outcome:
- Overall institutional CS rate
- Distribution of deliveries across Robson groups
- CS rate within each Robson group
- Contribution of each Robson group to the overall CS rate
Secondary outcomes (Maternal):
- Intraoperative complications: hemorrhage (estimated blood loss >1000 mL), organ injury
- Requirement for blood transfusion
- Postoperative complications: wound infection, fever, endometritis
- ICU admission
- Length of hospital stay
- Maternal mortality
Secondary outcomes (Neonatal):
- APGAR score at 1 and 5 minutes (<7 = adverse)
- Birth weight (low birth weight <2500 g)
- NICU admission and duration
- Neonatal morbidity (respiratory distress, birth asphyxia, sepsis)
- Perinatal mortality (stillbirth + early neonatal death within 7 days)
11. Statistical Analysis
- Data will be entered in Microsoft Excel and analyzed using SPSS version __ / STATA / Epi Info.
- Descriptive statistics: frequency and percentage for categorical variables; mean ± SD or median (IQR) for continuous variables.
- Inferential statistics: Chi-square test / Fisher's exact test for categorical outcomes; Student's t-test / Mann-Whitney U test for continuous outcomes.
- P value <0.05 will be considered statistically significant.
- Robson analysis will be presented as a standardized Robson table with group size, CS rate, and contribution to overall CS rate per WHO-recommended format.
12. Ethical Considerations
- Ethical clearance from the Institutional Ethics Committee will be obtained before commencement.
- Patient confidentiality will be maintained; data will be anonymized.
- Informed consent will be obtained from all participants (for prospective design).
- The study will be conducted in accordance with the Declaration of Helsinki.
REVIEW OF LITERATURE
Global CS Rates
Global CS rates have risen from approximately 7% in 1990 to over 21% by 2020, with projections suggesting 29% by 2030 (Betran et al., BJOG 2016). The WHO recommends a CS rate of 10-15%, beyond which increasing CS rates are not associated with reductions in maternal or neonatal mortality.
WHO Endorsement of Robson Classification
The WHO endorsed the Robson TGCS in 2015 as the recommended global standard for classifying, reporting, and monitoring CS rates. The system was originally described by Dr. Michael Robson in Fetal and Maternal Medicine Review (2001). The WHO published a formal implementation manual in 2017 to facilitate institutional and national adoption.
Key Studies from India
- Janani L et al. (Indian J Public Health, 2022, PMID: 37039169) - A retrospective study from a tertiary care hospital in Manipur analyzing CS rates and indications using Robson's classification. Group 5 was the highest contributor.
- Nigam M et al. (Eur J Med Res, 2025, PMID: 41454415) - Retrospective analysis of patterns and indications of CS using Robson TGCS from a tertiary care centre in India, confirming Group 5 predominance.
- Studies from ASCOMS Jammu (IJMPR, 2025) found a CS rate of 35% with Group 5 as the maximum contributor, followed by Groups 1 and 2. Most common indication was previous CS, followed by fetal distress and failed induction.
Regional and International Studies
- Nazeer S et al. (JAMC, 2023, PMID: 37422820) - Cross-sectional study from a tertiary care hospital in Pakistan using Robson TGCS; Group 5 largest contributor.
- Baral G et al. (JNHRC, 2021, PMID: 33934140) - Robson TGCS analysis from Nepal; similar findings with Group 5 predominance.
- Rezaei Ghamsari S et al. (Cureus, 2023, PMID: 37736452) - Analysis in a public teaching hospital; CS rates were higher during non-teaching periods.
- El Radaf V et al. (Eur J Obstet Gynecol, 2025, PMID: 39705988) - A systematic review and meta-analysis of Robson TGCS across Europe confirmed Group 5 as the dominant contributor to CS rates across all settings.
- Jamshed S et al. (Front Med, 2021, PMID: 35096855) - Systematic review/meta-analysis demonstrating correlation between previous CS and adverse maternal outcomes stratified by Robson groups.
- Turkey (2025): A large retrospective study of 25,767 births found a CS rate of 46.4%, with Group 5 contributing 23.8% and Group 1 contributing 5.2%. The most common indication was previous uterine surgery (54.9%), followed by fetal distress (19.1%).
Significance of Group 5 in Driving CS Rates
Across virtually all published studies from low- and middle-income countries, Robson Group 5 (previous uterine scar, singleton, cephalic, term) is the single largest contributor to overall institutional CS rates. This underscores the self-perpetuating nature of CS - a primary CS increases the likelihood of all subsequent deliveries being by CS. Reducing the primary CS rate in nulliparous women (Groups 1 and 2) is therefore the most effective long-term strategy.
Targeted Interventions Identified Through Robson Analysis
- Careful assessment before induction of labor in Groups 1 and 2 (nulliparas)
- Promotion of VBAC (trial of labor after cesarean/TOLAC) in eligible Group 5 women
- External cephalic version (ECV) for breech presentation (Groups 6 and 7)
- Active management of labor and partograph monitoring in Groups 3 and 4
- Careful case selection and counseling to reduce elective/non-indicated CS
Note: Please fill in your institution's name, study duration, ethics committee details, and SPSS version as applicable. The reference list can be expanded by citing the PMID-linked papers above in Vancouver/APA format as required by your institution.
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