How to reduce caesarean sections in first four Robson’s classess

How to reduce caesarean sections in first four Robson’s classess Svelato, A1 ; Meroni, MG2 ; Poli, M2 ; Perino, A1 ; Spinoso, R2 ; Ragusa, A2 1 Department of Obstetrics and Gynecology, University Hospital Paolo Giaccone, Palermo, Italy; 2 Department of Obstetrics and Gynecology, Niguarda Hospital, Milan, Italy Introduction Our aim was reduce cesarean sections (CS) in first four out of ten Robson’s classes, without increasing maternal and newborn morbidity. Methods This was a prospective health impact assessment study conducted at the Niguarda Hospital, Department of Obstetrics, in Milan, Italy. The study consists of three phases: (1) data capture and analysis of CS performed in the first four out of ten Robson’s classes between 1st January 2012 and 30th Jun 2012 (before intervention group, BI); (2) formulations and introductions of new clinical/assistance actions between 1st July 2012 and 31st December 2012: (a) Daily audit and collegial discussion of clinical cases; (b)Use of intrapartum ultrasound; (c) Consider the psychological wellbeing of women in labour; (d) Careful evaluation in the diagnosis of active labor and prolonged latent phase; (e) Use of a formal classification of abnormal CTG in labour; (f) Editing of a new protocol for the induction of labour and administration of oxytocin for augmentation; (g) Use of epidural analgesia in women who require it, but also in women with a medical indication; (3) data capture and analysis of CS performed in the first four out of ten Robson’s classes between 1st January 2013 and 30th Jun 2013 (after intervention group, AI). Cross-tabulations were checked by Fisher’s exact test. Results The total number of delivery, in the first four out of ten Robson’s classes, was 691 in BI group and 697 in AI group. There were no significant differences between the two groups of women in terms of demographic characteristics. In BI group, 119 (17%; 95% CI: 14.5–20.2) women delivered by ceasarean section, compared with 77 (11%; 95% CI: 8.8–13.6) in AI group (Fisher’s exact test: P = 0.001). We found improvements of CS rate in all classes except, in class III. In class II the improvement was particularly significant (Fisher’s exact test: P = 0.012). 5-min Apgar score <7 and umbilical cord arterial pH 7.00 did not show any difference. No one adverse perinatal event occurred in both groups. Conclusion The overall CS rate in first four out of ten Robson’s classes was reduced from 17% to 11%. This means a reduction of 35.8% in relative risk of CS in AI group compared to BI group. The lack of improvements found in III class is the consequence of poor number of women in this class and a low CS rate already present in this class. The best of our knowledge, it is the first study that after an audit phase using the Robson classification, shows an improvement in CS rate through an implementation of new clinical/assistance actions. In our opinion, the changes adopted are responsible for a new cultural attitude toward the management of patients during labor and childbirth. The study is still ongoing