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WAYS TO REDUCE THE FREQUENCY OF CESAREAN CANCER CONSIDERING
THE ROBSON CLASSIFICATION
VLADIMIR YURYEVICH TSVETKOV
Obstetrician-gynecologist, City Perinatal Center, Shymkent, Kazakstan
SEIDILLAEVA ULZHAN SEIDILLAEVNA
Obstetrician-gynecologist, City Perinatal Center, Shymkent, Kazakstan
OMAROVA ZHANAR ZULKAINAROVNA
Obstetrician-gynecologist, City Perinatal Center, Shymkent, Kazakstan
MAMYRBEKOVA SAULE UTIBEKOVNA
Assistant of the Department of Obstetrics and gynecology, SKMA JSC, Shymkent, Kazakstan
ALIEVA ELNARA NAZIMOVNA
Senior lecturer of the Department of Obstetrics and gynecology, Khoja Akhmet Yassawi International Kazakh-Turkish University, Shymkent, Kazakhstan
Abstract
Introduction. Caesarean section should be classified as a complex surgical procedure, with a high incidence of complications at all stages of operations and in the postoperative period. There is growing concern around the world about the increasing use of caesarean sections, especially in high-income countries. It is well known that caesarean section performed in the absence of justified indications does not reduce the level of maternal or infant mortality if carried out at a level above 10-15%.
According to many authors, an increase in the number of CS operations does not solve the entire complex of diverse problems of maternal and fetal health, but contributes to a decrease in obstetric professionalism. WHO recommends the use of the ten-group Robeson classification system as an effective monitoring and analysis tool for assessing the use of caesarean section (CS).
The purpose of the study was to analyze the birth history of women who delivered surgically, using the classification system of ten Robson groups in the urban perinatal center of Shymkent.
Materials and methods. A retrospective analysis of the birth histories of patients for 10 months of 2023 was carried out in the urban perinatal center of Shymkent using the 10-group Robson classification. According to the Robson system, upon admission to the hospital, each patient is assigned to only one specific group.
Results Absolute leadership in the structure of operative delivery for two years remains with women with a uterine scar - 35%. Every fourth abdominal delivery in the Perinatal Center was performed in the presence ofa scar on the uterus. The high frequency of CS in group No. 10 is justified by modern obstetric approaches, and it is possible to find reserves for reducing the number of delivery operations in this group only with adequate pre-conception preparation, especially in risk groups. Consequently, the main reserve for reducing the incidence of operative births are groups 1, 2, 3, 4.
Conclusion:
1. Preconception preparation in all risk groups for maternal and perinatal risk factors.
2. Personalized approach to labor induction methods in high-risk patients, especially in full-term pregnancies.
3. Rational management of childbirth, prevention of first cesarean section.
4. A differentiated approach when choosing methods of delivery for breech presentations.
5. Increased vaginal delivery in pregnant women with one scar on the uterus.
Keywords: Cesarean section; Robson classification; vaginal birth; Robson ten group classification; Continuous quality improvement.
INTRODUCTION:
There is growing concern around the world about the increasing incidence of operative delivery, especially in high-income countries [1]. Increasing the CS above the level of 10-15% does not lead to a decrease in maternal and perinatal mortality, and is often carried out in the absence of strict medical indications[2].
Unjustified, excessive use of clinical procedures can lead to an ever-increasing cascade of unnecessary therapeutic interventions [3] and become life-threatening during current or future pregnancies, both for the woman and the fetus [4]. The worldwide increase in abdominal delivery has become a growing public health problem. Concern and debate due to potential maternal and perinatal risks, cost issues and inequalities [5].
The highest rates of caesarean sections are observed in the Dominican Republic (56.4%), Brazil (55.6%) and Egypt (51.8%), with Africa (7.3%) having the lowest proportion [1]. In most European countries this figure ranges from 25% to 35% [5]. In Kazakhstan, according to the observation of the Ministry of Health of the Republic of Kazakhstan for 2022, every fifth woman undergoes a caesarean section.
One of the goals put forward by the World Health Organization (WHO) for 2030 is to reduce maternal and perinatal morbidity and mortality.
To achieve this goal, it is necessary to avoid unnecessary indications for cesarean section [6]. And the main challenge is to maintain a low rate of complications after CS while ensuring safe outcomes for the mother and newborn [9]. One of the main difficulties is the lack of a uniform classification that can be used internationally to provide feedback on audit results and to establish the optimal level of CS for countries.
To address this gap, in 2001 M. Robson et al proposed a general classification method to facilitate and analyze the rate of CS in obstetric hospitals. In addition, it allows us to identify the frequency of CS in each group, and all this in order to find solutions aimed at preventing unnecessary procedures [10,11,12].
WHO has proposed the use of the Robeson Ten Group Classification System (RTGCS) as a global standard because this classification method allows analysis of changing trends over time, provides the opportunity to compare differences between healthcare organizations and sheds light on how evolving clinical practice can optimize caesarean section rates , thereby ensuring a high level of maternal and perinatal care [13,14].
The deeper analysis offered by this method allows us to examine questions such as which women and obstetric groups are most likely to undergo caesarean sections. This may point us to the types of interventions that can help reduce caesarean section rates. Groups, when and what abbreviations are desirable [15].
The purpose of the study was to analyze the birth history of women who delivered surgically, using the classification system of ten Robson groups in the urban perinatal center of Shymkent.
MATERIAL AND METHODS OF RESEARCH
A retrospective analysis of the birth histories of patients for 10 months of 2023 was carried out in the urban perinatal center of Shymkent using the 10-group Robson classification. According to the Robson system, upon admission to the hospital, each patient was assigned to only one specific group. Robson's ten group classification system is shown in Table 1.
RESEARCH RESULTS AND THEIR DISCUSSION
Overall, the caesarean section rate for 2023 has not changed significantly compared to the previous one, which is 30.7% in 2022, and 26.6% in 2023. (Figure 1).
Figure 1. Caesarean section rate
Table 1. Robson's ten group classification system
group No Obstetric population
1 Primíparas with a singleton pregnancy in cephalic presentation, >37 weeks of gestation, with spontaneous onset of labor
2 Primíparas with a singleton pregnancy in cephalic presentation, >37 weeks of gestation, with induction of labor or delivery by caesarean section before the onset of labor
3 Multiparous women without a previous CS, with a singleton pregnancy in cephalic presentation, > 37 weeks of gestation, with spontaneous onset of labor u
4 Multiparous without previous CS, with a singleton pregnancy in cephalic presentation, > 37 weeks of gestation, with induction of labor or delivery by CS before the onset of labor
5 All multiparas with a history of one or more CS, with a singleton pregnancy in cephalic presentation, > 37 weeks of gestation
6 1. All primiparous women with a singleton pregnancy in breech presentation
7 All multiparous women with a singleton pregnancy in the breech presentation, including women with one or more previous CS
8 All women with multiple pregnancies, including women with a history of one or more CS
9 All women with a singleton pregnancy, transverse or oblique position of the fetus, including women with one or more previous CS
10 All women with a singleton pregnancy, cephalic presentation of the fetus
Table 2. Percentage of cesarean sections in each group
Groups Number of CS in Absolute contribution Relative contribution
group (%) of the group to the of the group to the
overall CS rate (%) overall CS rate
1 57 1,03 3,9
2 101 1,8 6,9
3 74 1,34 5,0
4 121 2,2 8,2
5 462 8,4 31,4
6 110 2,0 7,5
7 62 1,1 4,2
8 82 1,5 5,6
9 65 1,2 4,4
10 335 6,1 22,8
* Unclassified: number of cases and % (number of unclassified women / (total number of women who gave birth who were included in the classification + unclassified) x 100)
* Totals and percentages from table data
1. absolute contribution (%) = (number of CS in the group/total number of women giving birth)
x 100
2. relative contribution (%) = (number of CS in each group / total number of CS in institutions
100
Robson's criteria (Table 2) were used for the first time in our work. This helped us identify the most common reasons for indications for caesarean section and group them into groups. Our study showed that the caesarean section rate in our hospital over 10 months was 26.6%, which is significantly higher than the WHO criterion (15%). The most significant contribution to the frequency of CS for 10 months of 2023 was made by the 4th group, 5th and 10th groups. The study revealed that the main contribution was made by women from group 5 (All multiparous with one or more CS in history, with a singleton pregnancy in cephalic presentation, > 37 weeks of gestation), this indicates to us that we need to approach more differentiated when choosing indications for first operative delivery.
Absolute leadership in the structure of operative delivery for two years has been retained by the group of women with a uterine scar - 35%. Every fourth abdominal delivery in the Perinatal Center was performed in the presence of a scar on the uterus.
Undoubtedly, a personalized approach to patients in this group will reduce the percentage of abdominal births, but regardless of the difference in protocols, it should be noted that the main direction in preventing the increase in the frequency of CS is adequate management of labor and prevention of the first operation.
The high frequency of CS in group No. 10 is justified by modern obstetric approaches, and it is possible to find reserves for reducing the number of delivery operations in this group only with adequate pre-conception preparation, especially in risk groups.
We also noted a high rate of cesarean section in group 4. This is explained by the fact that the frequency of programmed births in the perinatal center increases every year due to the specifics of the institution. The main indications for induction of labor are hypertensive conditions and post-term pregnancy requiring delivery. The problem of delivery of pregnant women with several scars on the uterus creates a high risk for the mother and fetus during vaginal delivery, so it is not possible to influence the reduction of this indicator.
The next groups, which also contributed to the caesarean section rate - 6 and 7, are all women with a breech pregnancy. According to current protocols, the indications for CS have been expanded for breech delivery in order to reduce perinatal morbidity and mortality. We consider one of the ways to reduce abdominal birth in these groups to master and implement the practice of external assistance
ОФ "Международный научно-исследовательский центр "Endless Light in Science"
according to Tsovyanov and obstetric rotation of the fetus on its head, which was previously successfully performed in classical obstetrics, and today in obstetric hospitals of the 3rd level there is all necessary conditions for the implementation of this practice, including simulation training. In this situation, the work of a psychologist will also be justified.
Group 9 (singleton pregnancies with an oblique or transverse position of the fetus) makes up 1.2% of the total number of abdominal births, and due to the absolute validity of the indications, it is therefore not possible to influence the reduction of this indicator.
Thus, the main reserve for reducing the incidence of operative births are groups 1, 2, 3, 4. When trying to classify cases of emergency cesarean section in these groups, we determined that the main share of indications for surgery is the threatening condition of the fetus and labor anomalies. We consider these reasons to be manageable with an adequate assessment of perinatal risk factors and rational monitoring of the condition of the fetus.
CONCLUSION. Thus, the main reserves for reducing the frequency of cesarean sections in hospitals according to our study are:
1. Preconception preparation in all risk groups for maternal and perinatal risk factors.
2. Personalized approach to labor induction methods in high-risk patients, especially in full-term pregnancies.
3. Rational management of childbirth, prevention of first cesarean section.
4. A differentiated approach when choosing methods of delivery for breech presentations.
5. Increased vaginal delivery in pregnant women with one scar on the uterus.
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