Analysis of high caesarean section rates: the second step after audits using the Ten Group Classification System

Objective: To identify possible methods of reducing high caesarean section rates in a tertiary care hospital.

Methods: Analysis of birth weight of neonates, maternal age and indications for caesarean section in the groups identified by a modification of Robson’s 10 Group Classification of caesarean section (TGCS), which contribute significantly to the high caesarean section rates in the University Obstetric Unit, Teaching Hospital Mahamodara, Galle Sri Lanka during 2010 - to 2014.

Results: Among nulliparous women, at term, having a singleton fetus, with a vertex presentation (NTSV) who underwent a caesarian section 25.6% delivered neonates weighing between 2500g and 2999g. Among multiparous women, at term, with no previous caesarean section, having a singleton fetes with a vertex presentation (MTSV) who underwent a caesarian section, those delivering neonates weighing between 2500g and 2999g ranged from 25.6% to 34.6%. Indications for ante part caesarean section included fetal distress, sub fertility, increased maternal age and cephalon-pelvic disproportion in NTSV, and fetal distress, vaginal varices, and a bad obstetric history in MTSV. Among multiparous women with one previous caesarean section undergoing repeat caesarean section, 29.8% delivered neonates weighing between 2500g and 2999g. Women >35 years had a higher risk of caesarean section, irrespective of whether they were nulliparous or multiparous, and whether they had a previous caesarean section or not.

Conclusions: A reduction in caesarean section rates in NTSV and MTSV, and women with one previous caesarean section, especially in those with foetuses weighing 2500g - 2999g, should be considered. Increased maternal age and subfertility per se should not be routine indications for antepartum caesarean section. Antepartum caesarean section for vaginal varices and cephalo-pelvic disproportion should be avoided. The diagnosis of fetal distress should be improved.