Analysis of cesarean section rates in two German hospitals applying the 10-Group Classification System.

OBJECTIVES: In Germany, cesarean section (CS) rates more than doubled within the past two decades. For analysis, auditing and inter-hospital comparison, the 10-Group Classification System (TGCS) is recommended. We used the TGCS to analyze CS rates in two German hospitals of different levels of care. METHODS: From October 2017 to September 2018, data were prospectively collected. Unit A is a level three university hospital, unit B a level one district hospital. The German birth registry was used for comparison with national data. We performed two-sample Z tests and bootstrapping to compare aggregated (unit A + B) with national data and unit A with unit B. RESULTS: In both datasets (national data and aggregated data unit A + B), Robson group (RG) 5 was the largest contributor to the overall CS rate. Compared to national data, group sizes in RG 1 and 3 were significantly smaller in the units under investigation, RG 8 and 10 significantly larger. Total CS rates between the two units differed (40.7 vs. 28.4%, p<0.001). The CS rate in RG 5 and RG 10 was different (p<0.01 for both). The most relative frequent RG in both units consisted of group 5, followed by group 10 and 2a. CONCLUSIONS: The analysis allowed us to explain different CS rates with differences in the study population and with differences in the clinical practice. These results serve as a starting point for audits, inter-hospital comparisons and for interventions aiming to reduce CS rates.

Rational dissection of a high institutional cesarean section rate: an analysis using the Robson Ten Group Classification System.

AIM: Cesarean section (CS) rates have risen far in excess of the optimal 15% recommended by the World Health Organization. The Robson Ten Group Classification System (TGCS) allows meaningful analysis of a CS rate. The aim of this study is to identify the leading patient categories contributing to our institution's CS rate. METHODS: Prospective study of all women who delivered at the Singapore General Hospital from January 2008 to December 2011. The following data was recorded: parity, singleton/multiple pregnancy, previous CS, mode of labor onset and gestational age at delivery. CS rates were computed for each group, as well as their relative contribution to the overall CS rate. RESULTS: There were 6074 deliveries, in which 2011 (33.1%) women had CS delivery. Group 5 was the largest contributor to the overall CS rate (25.9%). Of the patients in this group, 18.8% had a successful vaginal birth after cesarean (VBAC). Group 2 was the second largest contributor to the overall CS rate at 18.0%. Group 10 had a high contribution of 16.1%. CONCLUSION: The TGCS allows easy identification of the leading contributing patient groups. The surprisingly high contribution of group 10 suggests that our institution, a tertiary multidisciplinary teaching hospital, manages a sizeable group of high-risk patients in its obstetric case mix accounting for the high CS rate. Almost one in five term pregnancies with one previous CS had a successful vaginal delivery, suggesting that the institutional attempted VBAC rate is higher than 20%.

Leadership Driven Persistent Reduction in Cesarean Trends: An Interventional Study for Quality Improvement.

Background: This is a quality improvement study in North India undertaken to observe the efficacy and safety of a proposed set of interventions along Quality Improvement guidelines to reduce cesarean rates. Materials and Methods: It was a retrospective cross-sectional study conducted in New Delhi. Measures were iteratively introduced from 2017 and improved using multiple PDSA (Plan, Do, Study, Act) cycles to note the overall reduction in cesarean rates. Chi square tests were done with subanalysis based on the Robsons classification. Results: There was a significant reduction of annual cesarean rates from 36.35 to 22.87% over four years (p < 0.01) and in neonatal nursery admissions (p < 0.01). Covid outbreak saw a comparatively increased cesarean rate in 2020, for which it was excluded from the detailed study. The relative risk of cesarean delivery in the postintervention period was 0.62. Maximum reductions were seen in Robsons II, VI &VII. Conclusion: Devising multipronged interventions and their implementation through PDSA cycles are essential. Such measures in moderate resources are replicable elsewhere as well.

Detection of Math6-Expressing Cell Types in Murine Placenta.

The transcription factor Math6, mouse atonal homolog 6, belongs to the family of highly conserved basic helix-loop-helix transcription factors. It plays an important role in embryonic development and shows a wide expression pattern in murine tissues. The placenta, as a life-sustaining transient organ for the fetus, also depends on the expression of Math6. The adverse effects of deleting Math6 in mice, leading to deficient placental development and pregnancy loss, have already been demonstrated by us. Until now, detailed investigations regarding the specific mechanisms underlying the improper placental development in these murine mutants have failed, as the Math6 expression could not be confined to a specific cell type due to the lack of a highly specific Math6 antibody. To circumvent this problem, we used transgenic mice, where Math6 is marked with a Flag sequence that functions as a specific epitope. Tissues from these transgenic mice were used to establish immunohistochemical staining and fluorescence-activated cell sorting (FACS). The establishment of these methods yielded initial findings pertaining to the identification of Math6-expressing cell types and their localization. Our results reveal that Math6 shows a wide expression pattern in both maternal and fetal components of the murine placenta. It shows expression in various cell types, but predominantly in trophoblast giant cells, endothelial cells and macrophages. The largest subpopulation that we detected in the group of Math6-positive cells were identified as DBA+ uterine natural killer cells. These findings reveal information and a chance for further investigation on the involvement of Math6 in placental development and the molecular pathomechanisms of spontaneous abortion.

Study of Caesarean Section Births in a Tertiary Care Hospital in Mumbai Using Robson Classification System.

Introduction: Robson ten-group classification system is recommended by WHO (World health organization) as a global standard for assessment and monitoring caesarean section (CS) rates. This classification is simple and robust. It is prospective, easily reproducible and clinically relevant. Methodology: We conducted a prospective observational study of CS births at a tertiary care institute. Caesarean births in a tertiary care hospital were classified using Robson classification system as recommended by WHO. The study was conducted for period of 6 months duration. The ethics committee of the institute approved this study. We enrolled 4771 consecutive women who delivered during this study period. We included patients who had vaginal delivery as well as those who had delivery by CS. Both live births and stillbirths (of at least 500-g birth weight or at least 22 weeks gestation (according to WHO recommendations) were included in this study. Results: During this study period, we had 4771 deliveries, out of which 2231 pregnant women (46.76%) were delivered by CS as compared to 2540 vaginal deliveries. Women with previous CS (term with single cephalic pregnancy) were included in Robson group 5. Group 5 had the highest CS rate (13.41%). Robson group 5, 1 and 10 were the largest contributors to the high CS rates at our institute. Conclusion: In our study, 4771 deliveries were conducted during this study period (6 months). Out of 4771 deliveries, CS was done in 2231 pregnant women (46.76%). 2540 women had vaginal deliveries. Group 5 (13.41%) which comprised of women with previous CS had the highest CS rate followed by group 1 and group 10. The second largest contribution was from Group 1 with CS rate of 9.01%. Robson Group 1 included nulliparous term women with single cephalic pregnancy in spontaneous labour. Group 10 was the third largest contributor to the overall CS. Group 10 included women who delivered preterm (single cephalic presentation). Group 10 contributed to 8.09% of overall CS rate. We should make every effort to provide CS for women requiring this procedure, rather than work towards achieving a specific rate for CS.

Adgrg1 is a new transcriptional target of Hand1 during trophoblast giant cell differentiation.

The placenta, forming the maternal-fetal interface, is essential for the survival and development of the fetus. It has been shown that the basic helix-loop-helix (bHLH) transcription factor Hand1 plays an important role in trophoblast giant cells (TGCs) differentiation during placental development in mice. However, the underlying molecular mechanism remains elusive. We hereby report that Adgrg1 (GPR56), a G protein coupled receptor, was a new transcriptional target of Hand1. Hand1 activated the expression of Adgrg1 by binding to its promoter region during TGCs differentiation. Double in situ hybridization revealed co-expression of Hand1 and Adgrg1 in Prl2c2+ TGCs located in the junctional zone of the placenta. Knockdown of Adgrg1 not only led to increased Prl2c2 expression, but also the improvement of cell migration and invasion during TGC differentiation. Moreover, the ligand of Adgrg1, Tgm2, was expressed in Prl2c2+ TGCs located in the placental junctional zone and Tgm2 Knockdown increased cell migration and invasion, suggesting Tgm2 is a potential ligand involved in the functions of Adgrg1 during TGC differentiation in the manners of autocrine. Collectively, these results demonstrate that Adgrg1 is a new transcriptional target of Hand1, affecting Prl2c2 expression as well as cell migration and invasion during TGCs differentiation. As a transmembrane receptor, Adgrg1 perhaps could act as a potential therapeutic target for placental-associated diseases caused by abnormal trophoblast migration and invasion, providing new insights for the preventions and therapies of placenta-related diseases.

Examining Cesarean Delivery Rates by Race: a Population-Based Analysis Using the Robson Ten-Group Classification System.

The Robson Ten-Group Classification System is widely considered to be the gold standard for comparing cesarean section (CS) delivery rates, despite limited adoption in the United States (US). When reporting overall CS rates, Blacks and other minorities are typically reported to have high CS rates but comparing overall CS rates may be misleading as CS may be more common in some higher risk populations. Improved understanding of how CS rates differ by race among standardized groups could highlight differences in care and areas for improvement. The current study examines racial differences in cesarean section delivery rates using the Robson Ten-Group Classification System in a nationwide sample. Data from US vital statistics live birth certificates were used to identify 3,906,088 births which were each classified into one of the ten groups based on five obstetric characteristics identifiable on presentation for delivery including parity, onset of labor, gestational age, fetal presentation, and number of fetuses. Results indicated that Black and Asian mothers had the highest CS rates in groups 1-4 which all contain single, cephalic pregnancies at term with no prior CS and are only differentiated by parity and onset of labor. Black mothers also had the lowest CS rates for groups 6 and 7, containing women with nulliparous and multiparous breech births. Black and Asian mothers show differences in CS rates among groups that could indicate lack of appropriate care. Efforts should be made to prevent unnecessary primary CS among low-risk mothers.

Identifying strategies to reduce cesarean section rates by using Robson ten-group classification.

OBJECTIVE: To assess the cesarean section (CS) rates using Robson ten-group classification system (RTGCS) and the interventions combined with RTGCS which may reduce the CS rates. METHODS: A total of 100,326 deliveries at Zekai Tahir Burak Research and Training Hospital in Ankara, Turkey between 2012 and 2018 were included in this study. Interventions including free mobilization of pregnant women, CS decision with the signature of three obstetricians, re-evaluate the CS decision, strictly obeying the failed induction algorithm to reduce the CS rates were started to be applied in 2017. The CS rates between 2012 and 2017 and in 2017 were compared to evaluate the effects of the interventions on CS rate regarding the Robson groups. RESULTS: The overall CS rates in between 2012 and 2017 significantly reduced from 37,703/84,279 (44.7%) to 6738/16,047 (42.0%) in 2017, p < .001. Cephalopelvic disproportion and suspected macrosomia rates reduced from 4992/37,703 (13.3%) to 683/6738 (10.0%), p < .001 and from 668/37,703 (1.8%) to 96/6738 (1.4%), p = .030, respectively. CONCLUSIONS: To the best of our knowledge, this study is the first that gives the birth data from Turkey using RTGCS and showed that some interventions combined with RTGCS to reduce CS rates should be properly used.

The Rates of Cesarean Section Deliveries According to Robson Classification System During the Year of 2018 Among Patients in King Abdul-Aziz Medical City, Jeddah, Saudi Arabia.

BACKGROUND: The rate of cesarean section (CS) births has been rapidly increasing in Saudi Arabia during the last two decades. Using the Robson Ten Group Classification System (TGCS) to classify and analyze the causes of the high CS rate. OBJECTIVE: To assess the increasing rates of CS by the implementation of the Robson TGCS on all CS births in our chosen population. STUDY DESIGN:  An observational, cross-sectional study conducted among all deliveries at the King Abdul-Aziz Medical City (KAMC), Jeddah, Saudi Arabia during most of 2018. Over the study period, 3168 births were enrolled in the study. RESULTS: The analysis of 3168 births, where 870 women gave birth through CS, resulted in a CS rate of 27.5%. The three major TGCS which contributed to the CS rate were group 5, 2 (divided into 2A and 2B), and 3. Class 5 (Previous CS, single cephalic, ≥37 weeks) contributed the most to the CS rate by 36.5%. Followed by Class 2 (divided into 2A; nulliparous, singleton, cephalic, ≥37 weeks, induced labor and 2B; nulliparous, singleton, ≥37, pre-labor CS) which contributed by 12.9%. Class 3 (multiparous (no previous CS), singleton, ≥37 weeks, spontaneous labor) was the third-highest contributing group by 9.2%. Women who gave birth spontaneously and vaginally were 1403 (44.3%) where women whose labor was induced were 1286 (40.6%). CONCLUSION:  The CS rate in KAMC was 27.5%. After classifying these patients according to the TGCS, Class 5 had the largest percentage of patients going for CS (36.2%). While they are individually low together, Robson classes from Class 1 to 4 (which are considered as low-risk classes) were responsible for 37.8% of the patients going for CS. Since the previously mentioned groups are considered low-risk they should be targeted by health institutions to reduce the CS rate. Improved education of nulliparous and multiparous women who never underwent a CS to prevent nonmedically indicated CS is in order, to preclude repeated CS births in the future and further increase the CS rate.

Is the Robson's classification system burdened by obstetric pathologies, maternal characteristics and assistential levels in comparing hospitals cesarean rates? A regional analysis of class 1 and 3.

OBJECTIVE: To assess if maternal risk profile and Hospital assistential levels were able to influence the inter-Hospitals comparison in the class 1 and 3 of the "The Ten Group Classification System" (TGCS). METHODS: A population-based analysis using data from Institutional data-base of an Italian Region was carried out. The 11 maternity wards were divided into two categories: second-level hospitals (SLH), and first-level hospitals (FLH). The recorded deliveries were classified according to the TGCS. To analyze if different maternal characteristics and the hospitals assistential level could influence the cesarean section (CS) risk, a multivariate analysis was done considering separately women in the TGCS class 1 and 3. RESULTS: From January 2011 to December 2013 were recorded 19,987 deliveries. Of those 7,693 were in the TGCS class 1 and 4,919 in the class 3. The CS rates were 20.8% and 14.7% in class 1 (p < 0.0001) and 6.9% and 5.3% (p < 0.0230) in class 3, respectively in the FLH and SLH. The multivariate logistic regression showed that the FLH, older maternal age and gestational diabetes were independent risk factors for CS in groups 1 and 3. Obesity and gestational hypertension were also independent risk factors for group 1. CONCLUSIONS: TGCS is a useful tool to analyze the incidence of CS in a single center but in comparing different Hospitals, maternal characteristics and different assistential levels should be considered as potential bias.