Michael Robson

Comparative analysis of international cesarean delivery rates using 10-group classification identifies significant variation in spontaneous labor.

OBJECTIVE Cesarean section (CS) rates continue to rise throughout the developed world. The aim of this study was to highlight variations in obstetric populations and practices and to identify variations in CS rates in different institutions. STUDY DESIGN Data from 9 institutional cohorts (total, 47,402; range, 1962-7985) from 9 different countries were examined using a 10-group classification system based on 4 characteristics of every pregnancy, namely single/multiple, nulliparity/multiparity, multiparity with CS scar, spontaneous/induced labor onset and term (>or=37 weeks) gestation. RESULTS Overall CS rates correlated with CS rates in singleton cephalic nullipara (r = 0.992; P < .001). Whereas CS rates in induced labor were similar, greatest institutional variation were seen in spontaneously laboring multiparas (6.7-fold difference) and nulliparas (3.7-fold difference). CONCLUSION Ten-group analysis of international obstetric cesarean practice identifies wide variations in women in spontaneous cephalic term labor, a low-risk cohort amenable to effective intrapartum corrective intervention.

Using the medical audit cycle to reduce cesarean section rates

OBJECTIVE Our purpose was to determine whether completion of the medical audit cycle in labor ward practice could safely reduce cesarean section rates. STUDY DESIGN A retrospective medical audit of all deliveries from 1984 to 1988 was performed. The groups of women contributing most to the overall cesarean section rate were identified. Strategies for labor management directed at the primary indication for cesarean section (dystocia) were developed and introduced. The effect was monitored prospectively from 1989 through 1992. Data were analyzed with the chi 2 test. RESULTS A total of 21,125 deliveries were studied. After management change the overall cesarean section rate was decreased (9.5% vs 12%, p < 0.0001). In our population spontaneously laboring nulliparous women with a singleton, cephalic, term pregnancy contributed a significant number of cesarean sections 1982 to 1988 (19.7% of all cesarean sections). Applying principles of early diagnosis and treatment of dystocia in these women resulted in a decrease in the cesarean section rate (2.4% vs 7.5%, p < 0.0001). This was primarily responsible for the overall decrease in the cesarean section rate. CONCLUSION Effective medical audit of labor management can reduce cesarean section rates.

Methods of achieving and maintaining an appropriate caesarean section rate

Caesarean section rates continue to increase worldwide. The appropriate caesarean section rate remains a topic of debate among women and professionals. Evidence-based medicine has not provided an answer and depends on interpretation of the literature. Overall caesarean section rates are unhelpful, and caesarean section rates should not be judged in isolation from other outcomes and epidemiological characteristics. Better understanding of caesarean section rates, their consequences and their benefits will improve care, and enable learning between delivery units nationally and internationally. To achieve and maintain an appropriate caesarean section rate requires a Multidisciplinary Quality Assurance Programme in each delivery unit, recognising caesarean section rates as one of many factors that determine quality. Women will always choose the type of delivery that seems safest to them and their babies. Professionals need to monitor the quality of their practice continuously in a standardised way to ensure that women can make the right choice.

The Singleton, Cephalic, Nulliparous Woman After 36 Weeks of Gestation: Contribution to Overall Cesarean Delivery Rates

OBJECTIVE: To examine the contribution of singleton, cephalic, term (37 weeks or later) nulliparous cesarean rates to overall cesarean incidence in a single institution during a 35-year period. METHODS: Cesarean rates were examined for 1974, 1984, 1994, 1999, 2005, and 2008, applying a 10-group classification system. Groups 1 (spontaneously laboring, term nulliparous women) and 2 (prelabor cesarean and induced term nulliparous women) were combined as a composite variable—the term, singleton, cephalic nulliparous woman. RESULTS: Overall and term, singleton, cephalic nulliparous cesarean rates correlated throughout the 35-year period (r=0.93, P<.001). Between 1974 and 2008, overall cesarean rates increased from 5% to 19.1% and from 4.4% to 15.8% among term, singleton, cephalic nulliparous women. Term, singleton, cephalic nulliparous inductions increased from 19.7% to 32.7% (P<.001) and the intrapartum cesarean rate in term, singleton, cephalic nulliparous inductions rose from 4.1% to 27.3%. The cesarean rate in group 1 increased from 2.3% to 7.2%. CONCLUSION: The increase in term, singleton, cephalic nulliparous cesarean rates correlated with the increase in overall cesarean rates throughout 35 years in an institution with standard management of labor. This relationship was due to an increase in both the incidence and rate of cesarean delivery within term, singleton, cephalic nulliparous inductions. Examination of the different term, singleton, cephalic nullipara components (spontaneous labor, induction, or prelabor cesarean) can help to identify major variations in practice between institutions. LEVEL OF EVIDENCE: III

Maternal sepsis incidence, aetiology and outcome for mother and fetus: a prospective study

To determine the incidence of maternal bacteraemia during pregnancy and for 6 weeks postpartum, describe the gestation/stage at which sepsis occurs, the causative microorganisms, antibiotic resistance and review maternal, fetal and neonatal outcome.

Mode of delivery at term and adverse neonatal outcomes.

OBJECTIVE: To determine the relationship between mode of delivery and serious adverse neonatal outcomes in term, singleton, cephalic neonates. METHODS: A 10-year study of 64,555 term neonates reaching the second stage of labor in a single tertiary obstetric unit from 2000 to 2009. Multiple pregnancies, preterm deliveries (before 37 weeks of gestation), and lethal congenital anomalies were excluded. The primary outcome was the rate of peripartum death by mode of delivery. Secondary outcomes were rates of neonatal encephalopathy, intracranial hemorrhage-related mortality, and the relationship between instrument choice and adverse outcomes. Categorical data were compared using the &khgr;2 test, with odds ratios (ORs) and 95% confidence intervals included when appropriate. RESULTS: Compared with neonates delivered by second-stage cesarean, there were no differences in the rates of either peripartum neonatal death (OR 0.42; P=.37) or neonatal encephalopathy (OR 1.07; P>.99) after operative vaginal delivery. The rates of neonatal encephalopathy associated with operative vaginal and second-stage cesarean delivery were 4.2 and 3.9 per 1,000 term neonates, respectively. No significant differences in adverse neonatal outcomes were demonstrated between vacuum-assisted and forceps-assisted deliveries, although subanalysis is limited by the small numbers of serious adverse outcomes. The absolute risk of neonatal death secondary to intracranial hemorrhage is 3–4 per 10,000 operative vaginal deliveries for both instruments. CONCLUSIONS: Operative vaginal delivery is associated with similar rates of serious neonatal complications compared with cesarean delivery at full dilatation. LEVEL OF EVIDENCE: II

Quality assurance: The 10-Group Classification System (Robson classification), induction of labor, and cesarean delivery.

Quality assurance in labor and delivery is needed. The method must be simple and consistent, and be of universal value. It needs to be clinically relevant, robust, and prospective, and must incorporate epidemiological variables. The 10‐Group Classification System (TGCS) is a simple method providing a common starting point for further detailed analysis within which all perinatal events and outcomes can be measured and compared. The system is demonstrated in the present paper using data for 2013 from the National Maternity Hospital in Dublin, Ireland. Interpretation of the classification can be easily taught. The standard table can provide much insight into the philosophy of care in the population of women studied and also provide information on data quality. With standardization of audit of events and outcomes, any differences in either sizes of groups, events or outcomes can be explained only by poor data collection, significant epidemiological variables, or differences in practice. In April 2015, WHO proposed that the TGCS (also known as the Robson classification) is used as a global standard for assessing, monitoring, and comparing cesarean delivery rates within and between healthcare facilities.

Factors affecting mode of delivery in labour following a single previous birth by caesarean section

SummaryWe evaluated the course of labour and the mode of delivery in women delivered between 1 June 1992 and 31 May 1994 whose only previous delivery was by a transverse lower segment caesarean section in the National Maternity Hospital. The purpose of the study was to determine if routine measured clinical factors were associated with mode of delivery. During a 2 year period the details of labour and delivery were collected prospectively on a cohort of 239 patients and entered on to a computer data base. In a total of 12 387 deliveries 239 patients presented for delivery when their only other pregnancy had resulted in delivery by transverse lower segment caesarean section in the hospital (2 per cent). Of these cases 44 were delivered by repeat caesarean section before labour (18 per cent), 195 were allowed a trial of labour and of these cases 150 had a vaginal delivery (77 per cent). There was no case of uterine dehiscence. There was a 95 per cent chance of a vaginal delivery when the head was engaged on...

The Ten Group Classification System (TGCS) – a common starting point for more detailed analysis

No classification system has been formally introduced to study caesarean sections scientifically together with any ensuing consequences for mother or baby. In the future it will be this failure by clinicians that will be most vulnerable to criticism. The TGCS is a prospective, standardised structure of clinically relevant groups of women allowing for a more constructive debate on caesarean sections (Robson Fetal Matern Med Rev 2001;12:23–39). The TGCS serves as the initial structure within which additional epidemiological variables, processes, perinatal events and outcomes in addition to caesarean sections can be analysed. Often misunderstood and incompletely interpreted, the TGCS was never meant to be the endpoint of caesarean section audit, merely the starting point. Complicating a simple classification system at the outset with detailed subgroups and multiple variables discourages universal adoption and implementation. On its own, however, the TGCS of caesarean sections still provides a useful and easy tool for analysing the clinical activity and philosophy of care of an individual care group, organisation, region or country. The TGCS does not explain why caesarean sections are done but it does allow an objective, common starting point to investigate the reasons. Further classification of indications for caesarean sections within the groups is needed (Robson M. Best Pract Res Clin Obstet Gynaecol 2013;27:297–308). Any resultant changes in other perinatal outcomes as an effect of altering clinical practice can be monitored easily. The full potential of the TGCS will only be realised when it is adopted as standard practice, enabling clinicians to learn from each other. This may be sooner rather than later and it may be women and governments that request it rather than professional bodies. Its simplicity is such that the information needed to identify the group to which the woman belongs can be given by the woman herself, allowing the system to be both robust and universal. Despite this, many institutions and countries remain unable to publish their results because of poor quality data collection. Indeed one of many unexpected benefits of using the TGCS has been to assess data quality. This paper published in the BJOG is a national study of caesarean section rates over 1 week in three different epochs: 1995, 2003 and 2010. It uses the TGCS and shows a low overall caesarean section rate. It also highlights, as many others have previously, the importance of labour and delivery in the nulliparous women with a single cephalic term pregnancy. These data are useful references for other institutions to compare their own data with. However, more detailed data within each of the groups, their subgroups or amalgamation of some groups are needed to facilitate the debate on caesarean section. In particular, shortand long-term information on fetal but also maternal outcome is required. Efforts should be made to ensure that this data is collected routinely, validated locally and available in national databases.

Identification of a myometrial molecular profile for dystocic labor

BackgroundThe most common indication for cesarean section (CS) in nulliparous women is dystocia secondary to ineffective myometrial contractility. The aim of this study was to identify a molecular profile in myometrium associated with dystocic labor.MethodsMyometrial biopsies were obtained from the upper incisional margins of nulliparous women undergoing lower segment CS for dystocia (n = 4) and control women undergoing CS in the second stage who had demonstrated efficient uterine action during the first stage of labor (n = 4). All patients were in spontaneous (non-induced) labor and had received intrapartum oxytocin to accelerate labor. RNA was extracted from biopsies and hybridized to Affymetrix HuGene U133A Plus 2 microarrays. Internal validation was performed using quantitative SYBR Green Real-Time PCR.ResultsSeventy genes were differentially expressed between the two groups. 58 genes were down-regulated in the dystocia group. Gene ontology analysis revealed 12 of the 58 down-regulated genes were involved in the immune response. These included (ERAP2, (8.67 fold change (FC)) HLA-DQB1 (7.88 FC) CD28 (2.60 FC), LILRA3 (2.87 FC) and TGFBR3 (2.1 FC)) Hierarchical clustering demonstrated a difference in global gene expression patterns between the samples from dystocic and non-dystocic labours. RT-PCR validation was performed on 4 genes ERAP2, CD28, LILRA3 and TGFBR3ConclusionThese findings suggest an underlying molecular basis for dystocia in nulliparous women in spontaneous labor. Differentially expressed genes suggest an important role for the immune response in dystocic labor and may provide important indicators for new diagnostic assays and potential intrapartum therapeutic targets.