An analysis of the high cesarean section rates in Turkey by Robson classification

An Analysis of the Mode of Delivery, Risk Factors, and Subgroups with High Caesarean Birth Rates Using Robson Classification System

OBJECTIVE

We aimed to understand the utilization of the mode of delivery and related risk factors. Further aimed to apply the Robson classification system to evaluate the data quality and analyze the CS rates in subgroups.

METHODS

We conducted a retrospective descriptive study by reviewing the medical records of all women who delivered at the State Hospital in 2019. A proforma was developed for extracting data from patient records. All women with six obstetric parameters were categorized into Robson groups to determine the absolute and relative contributions of each group to the overall CS rate.

RESULTS

Of 797 deliveries, 401 (50.2%) were CSs. Being older, being Turkish Cypriot, having preterm births, previous CS, multiple fetuses, and having breech or transverse fetal presentations were related to having higher risks of CS. The most common medical indication for CSs (52.3%) was a history of previous CSs. Robson Group 5 contributed the most (50.7%) to the overall CS rate, with the highest absolute contribution of 21.8%. Group 10 and Group 8 were the second and third highest contributors to the overall CS rate, with relative contributions of 25.3% and 9.0%, respectively.

CONCLUSIONS

Findings revealed the substandard quality of obstetric data and a noticeably high overall CS rate. The top priority should be given to improving the quality of medical records. It underscored the necessity of implementing the Robson classification system as a standard clinical practice to enhance data quality, which helps to effectively evaluate and monitor the CS rates in obstetric populations.

A Randomized, Double-Blind, Graded Dose-Response Study of Norepinephrine Administration for Prevention of Post-Spinal Hypotension during Elective Cesarean Delivery

Norepinephrine has been recently introduced for prophylaxis against post-spinal hypotension during cesarean delivery; however, no data are available regarding its optimum dosing scheme. The primary objective of this study is to compare three different infusion and bolus dose combinations of norepinephrine for prophylaxis against post-spinal hypotension during cesarean delivery. This randomized, double-blind study was performed between February 2021 and May 2022. The study protocol was registered at Clinicaltrials.gov with the identification number NCT04701190. A total of 192 parturients were enrolled into this study. Patients were assigned to three groups-Zero-Bolus High-Infusion (Group ZBHI, 0 µg/0.1 µg kg-1 min-1, n = 61), Moderate-Bolus Moderate-Infusion (Group MBMI, 5 µg/0.075 µg kg-1 min-1, n = 61) and High-Bolus Low-Infusion (Group HBLI, 10 µg/0.05 µg kg-1 min-1, n = 61)-according to different combinations of norepinephrine infusion and bolus doses. All patients received spinal anesthesia with 10 mg hyperbaric bupivacaine plus 12.5 µg fentanyl. Immediately after cerebrospinal fluid was obtained, patients underwent a norepinephrine protocol corresponding to the randomized group. The primary outcome was the incidence of post-spinal hypotension. Secondary outcomes were post-delivery hypotension, frequency of post-spinal hypertension and bradycardia, and neonatal outcomes. The incidence of post-spinal hypotension was 11.7% in Group HBLI, 6.7% in Group ZBHI and 1.7% in Group MBMI (p = 0.1). The overall incidence of post-delivery hypotension in parturients was 41.1% (p = 0.797). The lowest frequency of post-spinal bradycardia (8.3%) and hypertension (11.7%) was seen in Group HBLI. The neonatal APGAR scores at 1st minute were higher in Group MBMI than in Group ZBHI (8.58 vs. 8.23, p = 0.001). All three infusion and bolus dose combinations of norepinephrine effectively reduced the incidence of post-spinal hypotension. However, high-dose bolus (10 µg) followed by low-dose infusion (0.05 µg kg-1 min-1) of norepinephrine can be preferred due to the reduced frequency of bradycardia and hypertension during cesarean delivery under spinal anesthesia.

Implementation of the Robson Classification in Greece: A Retrospective Cross-Sectional Study

Cesarean sections have become the most commonly performed operations around the world. The World Health Organization recommended the use of the Robson classification system as a universal standard to establish a joint control system in healthcare facilities. The aim of this study was to implement the Robson classification for the first time in Greece to identify trends in cesarean births and examine the groups of women who are the main contributors to the increasing rates. Moreover, the indicators for cesarean sections will be evaluated as per the Robson classification. In the sample analysis, we included the records of 8572 women giving birth in one private health facility in Greece. A total of 8572 women gave birth during the study period, of which 5224 (60.9%) were cesarean section births and 3348 (39.1%) were vaginal births. In our study, according to the Robson classification, the largest contributors to the overall CS rate were as follows: (a) nulliparous women with a single cephalic term pregnancy, who were either labor induced or delivered by cesarean section before labor-Group 2 (34.6%); (b) multiparous women with a single cephalic term pregnancy and at least one previous cesarean section-Group 5 (30.7%); (c) women with a single cephalic preterm pregnancy-Group 10 (11.7%); (d) women with multiple pregnancies-Group 8 (7.0%). Our study is expected to assist policymakers in Greece in planning further interventions for each subgroup of women in order to reduce the overall CS rate and unnecessary CSs.

Women's Birth Beliefs During Pregnancy and Postpartum in the Netherlands: A Quantitative Cross-Sectional Study

INTRODUCTION

Women and care providers increasingly regard childbirth as a medical process, resulting in high use of medical interventions, which could negatively affect a woman's childbirth experience. Women's birth beliefs may be key to understanding the decisions they make and the acceptance of medical interventions in childbirth. In this study we explore women's beliefs about birth as a natural and medical process and the factors that are associated with women's birth beliefs.

METHODS

Data were obtained from a cross-sectional survey of women living in the Netherlands asking them about their experiences during pregnancy and childbirth, including their beliefs about birth as a natural and medical process.

RESULTS

A total of 3494 women were included in this study. Mean scores of natural birth beliefs ranged between 3.73 and 4.01 points, and medical birth belief scores ranged between 2.92 and 3.12 points. There were significant but very small changes between prenatal and postnatal birth beliefs. Regression analyses showed that (previous) childbirth experiences were the most consistent predictor of women's birth beliefs.

DISCUSSION

Women's high scores on natural birth beliefs and lower scores on medical birth beliefs correspond with the philosophy of Dutch perinatal care that considers pregnancy and childbirth to be natural processes. Perinatal care providers must be aware of women's birth beliefs and recognize that they as professionals influence women's birth beliefs. They make an important contribution to women's perinatal experiences, which affects both women's natural and medical birth beliefs.

Cesarean delivery rates based on time and indication using the Robson Ten-Group Classification System: Assessment at a Turkish tertiary center

OBJECTIVE

This study aimed to evaluate increasing cesarean delivery (CD) rates, their causes, and changes over the years in a Turkish tertiary center using the Robson Ten-Group Classification System (RTGCS).

METHODS

Data of deliveries involving birth weight of ≥500 g or ≥24 weeks of gestation period from 2013 to 2020 were retrospectively collected and classified from the hospital digital record system using obstetric concepts and parameters described in the RTGCS.

RESULTS

The overall CD rate for all births (69051) from 2013 to 2020 was 55.5%. Groups 3, 5, and 1 were the most represented groups (29.1%, 23.9%, and 19.4%, respectively). The major contributors to the overall CD rate were Groups 5, 2, and 10 (23.8%, 9.9%, and 5.6%, respectively). Groups 2 and 4 (nullipara, multipara, single cephalic at term) had high CD rates associated with high rates of pre-labor CD (88.9% and 73.3%, respectively). The CD rate was 99.7% in Group 5, which showed recurrent CD, and 67.2% in Group 10. The overall CD rate was 60.8% in 2020 owing to the significant increase in the contributions by Groups 5, 8, and 10. The most common indication for CD was previous CD (46.1%), fetal distress (13.2%), and cephalopelvic disproportion (CPD) (8%).

CONCLUSION

Groups 1, 2, 5, and 10 were the major contributors to the overall CD rate at this tertiary center. To reduce overall CD rates, policies that reduce primary CD and support vaginal delivery after cesarean section should be established.

Labor Induction with Intravaginal Misoprostol versus Spontaneous Labor: Maternal and Neonatal Outcomes

Purpose. To compare the maternal and neonatal outcomes of pregnant women who had labor induction with intravaginal misoprostol or had spontaneous labor in our clinic. Material-Method. The records of 213 pregnant women, who were followed up in Acibadem Maslak University Hospital for vaginal delivery between June 2021 and December 2021, were retrospectively evaluated. The pregnant women, who gave birth, were divided into 3 groups as follows: spontaneous labor (SL), those induced by a single dose of misoprostol (SDM), and those induced by multiple doses of misoprostol (MDM). The groups were compared in terms of delivery type, the vaginal birth rate within 12 hours, need for intervention, duration of the second stage of labor, cesarean section ratio due to fetal distress, time from the last dose to delivery, and 1st and 5th minute APGAR scores. Results. Among the primiparous pregnant women, 84.7% of SL group, 65.2% of SDM group, and 37% MDM group delivered vaginally within 12 hours ( $p<0.05$ ). The time from the last misoprostol dose to delivery was also statistically significantly shorter in pregnant women, who received a single dose of misoprostol (483 vs. 720 min, respectively). When the hospitalization time was evaluated, in the SDM group, the MDM group, and the SL group, it was found to be 611, 831, and 379 min, respectively. In multiparous pregnant women, the hospitalization time was 735 min in the SDM group, 494 min in the MDM group, and 261.5 min in the SL group ( $p<0.05$ ). Other than the hospitalization time, when the aforementioned variables were studied in multiparous pregnant women, no statistically significant difference among groups was observed ( $p>0.05$ ). Conclusion. Intravaginal misoprostol seems to be a promising medical agent for labor induction due to its high delivery rates within 12 hours and the absence of negative fetal outcomes, its ease of storage, and affordable cost.

The role of personality traits on mode of delivery

PURPOSE

The aim of this study is to understand the motives behind CS requests in nulliparous women in their late pregnancy better and to investigate if specific personality traits affect the maternal decision on mode of delivery.

MATERIAL AND METHOD

This prospective study was conducted with 70 healthy, nulliparous parturient with singleton pregnancies. Women at their 28-32. weeks of gestation were asked to fill a socio-demographic data form and the questionnaires; Personality Belief Questionnaire - Short Form (PBQ-SF) and The Childbirth Attitudes Questionnaire (CAQ). After delivery, all the results of pre-filled questionnaires and women's mode of delivery were analyzed and compared.

RESULTS

There were significant differences in personality types; dependent (p = 0.033), passive-aggressive (p = 0.031), obsessive-compulsive (p = 0.001), antisocial (p = 0.014), narcissistic (p = 0.014) and borderline (p = 0.014) between vaginal delivery and CS groups. The CAQ scores of the mothers who requested CS were significantly higher (p:0.007). Weak but significant positive relation was found between total CAQ scores and avoidant (p = 0.022), dependent (p = 0.034), passive-aggressive (p = 0.040), narcissistic (p = 0,006), schizoid (p = 0.007), paranoid (p = 0.007) and borderline (p = 0.007) personality types.

CONCLUSION

This is the first study that investigates the relationship between mode of delivery and personality traits according to the Diagnostic and Statistical Manual of Mental Disorders (DSM) and cognitive behavioral perspective in the literature. These personality traits can be carried at a level that is not clinically significant to create an obvious pathology, yet they might play a role as the motives behind the apparent reasons for women who request CS. Understanding women's motives and attitudes for childbirth during their pregnancy may help healthcare providers to tailor women's approach to childbirth to avoid unnecessary CS.

Inflammation Markers in Infants of Mothers with Gestational Diabetes

AimPentraxin-3, high sensitive CRP (HsCRP) and adropin were investigated in cord blood of infants of mothers with gestational diabetes mellitus (IDM) to evaluate the exposure of fetus to inflammation and whether there is any correlation with clinical findings.MethodsForty IDM and forty three infants whose mother did not have diabetes were included in this prospective study. Adropin, pentraxin-3 and HsCRP levels were measured in the cord blood samples. Echocardiographic measurements were performed in the first three days of life.ResultsAdropin and pentraxine-3 levels were significantly lower and HsCRP levels were significantly higher in IDM group. Echocardiographic measurements of myocardial hypertrophy were negatively correlated with adropin.ConclusionAlterations in these markers in IDM supports the hypothesis of in utero fetal exposure to inflammation caused by gestational diabetes mellitus. Potentially, cord blood adropin might be used as a predictor for complications of diabetes.

Immersive virtual reality on childbirth experience for women: a randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of immersive virtual reality (VR) on patient satisfaction as a distractive tool and pain relief among laboring women.

METHODS

This was a randomized, controlled clinical trial with 42 laboring women allocated to VR intervention and control groups. Among women in the VR group, patient satisfaction with the use of VR was assessed by a Virtual Reality Satisfaction Survey, measured by a Visual Analog Scale (VAS) score and evaluated by questioning them about whether they would choose VR in future labor. As a primary outcome, patient satisfaction scores regarding the overall childbirth experience were compared between women in the two groups. A secondary outcome was pain assessed by a visual pain rating scale in the early and active phases of labor in women in both groups. Psychometric information was also collected from participants in each group using the Beck Anxiety Inventory and Beck Depression Inventory.

RESULTS

We observed a high level of patient satisfaction with the use of immersive VR during labor. The VAS revealed a mean satisfaction score of 87.7 ± 12.9 out of a maximum of 100. Twenty out of 21 (95%) women in the VR group stated that they would like to use VR again in future labor. VR improved pain scores in early labor and contributed positively to the overall childbirth experience. The mean pain score pre-VR was 2.6 ± 1.2 compared to 2.0 ± 1.3 post-VR (p < 0.01). Anxiety and depression scores were similar in participants in the intervention and control groups (p = 0.103 and p = 0.13, respectively).

CONCLUSION

Immersive VR application during labor was associated with higher patient satisfaction based on our study findings. VR also improved participants' pain scores in early labor before epidural administration. Immersive VR may find a place as an adjunct in labor and delivery units to improve lengthy labor experiences for women. Studies with larger groups of participants are needed to confirm these observations.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05032456.

Cesarean delivery in Iran: a population-based analysis using the Robson classification system

Background

The rise of Cesarean Sections (CS) is a global concern. In Iran, the rate of CS increased from 40.7% in 2005 to 53% in 2014. This figure is even higher in the private sector.

Objective

To analyze the CS rates in the last 2 years using the Robson Classification System in Iran.

Methods

A retrospective analysis of all in-hospital electronically recorded deliveries in Iran was conducted using the Robson classification. Comparisons were made in terms of the type of hospital, CS rate, and obstetric population, and contributions of each group to the overall cesarean deliveries were reported.

Results

Two million three hundred twenty-two thousand five hundred women gave birth, 53.6% delivered through CS. Robson group 5 was the largest contributing group to the overall number of cesarean deliveries (47.1%) at a CS rate of 98.4%. Group 2 and 1 ranked the second and third largest contributing groups to overall CSs (20.6 and 10.8%, respectively). The latter groups had CS rates much higher than the WHO recommendation of 67.2 and 33.1%, respectively. “Fetal Distress” and “Undefined Indications” were the most common reasons for cesarean deliveries at CS rates of 13.6 and 13.4%, respectively. There was a significant variation in CS rate among the three types of hospitals for Robson groups 1, 2, 3, 4, and 10.

Conclusion

The study revealed significant variations in CS rate by hospital peer-group, especially for the private maternity units, suggesting the need for further attention and audit of the Robson groups that significantly influence the overall CS rate. The study results will help policymakers identify effective strategies to reduce the CS rate in Iran, providing appropriate benchmarking to compare obstetric care with other countries that have better maternal and perinatal outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04517-1.

Assessment of a Novel Fixation Method of a Frameless Intrauterine Contraceptive Device Inserted during Cesarean Delivery as a Means of Preventing Displacements and Expulsions: A Prospective Observational Study

The primary objective of this study was to assess the novel fixation method of a frameless copper-releasing intrauterine device inserted following placental delivery during cesarean section and analyze its impact in reducing device displacement and expulsion during and after uterine involution. We hypothesized that the dual-anchoring technique could reduce the risk of intrauterine device displacement and expulsion during and after the uterine involution. The study was conducted at the Gazi University Medicine Faculty Hospital in Ankara, Turkey. Twenty-one pregnant women were enrolled. Insertion was performed following placental removal. To confirm the proper placement and good retention of the device, the distance between the fundal serosa (S) and device anchor knot (A) was measured (S–A) during follow-ups, by ultrasound. There were significant differences in the S–A, as observed by ultrasound at discharge and at 6 weeks post-delivery, which is consistent with the tissue contractions associated with uterine involution. Notwithstanding the uterine involution, no device displacements or expulsions occurred, which indicated a good retention of the frameless device. This innovative retention method of the frameless intrauterine device ensures a well-tolerated, long-term contraception, allowing for immediate contraception and proper pregnancy spacing for cesarean scar healing, and overcomes the issue of expulsion encountered with conventional intrauterine systems.

The use of immature granulocyte and other complete blood count parameters in the diagnosis of transient tachypnea of the newborn

Background

Although Transient tachypnea of the newborn (TTN) is one of the most common causes of respiratory distress in the newborn period, there is no laboratory parameter used to diagnose it. Immatur granulocyte (IG) measurement is accepted as a useful indicator that can be used in early detection of many infectious conditions, especially neonatal sepsis. In this study, it was aimed to determine if IG and other complete blood count (CBC) parameters could be used as laboratory findings supporting TTN diagnosis.

Materials and methods

This study, which was retrospectively planned, was conducted in the neonatal intensive care unit (NICU) a public hospital between January 1, 2019 and January 31, 2021. Randomly selected 50 infants, hospitalized with the diagnosis of TTN, constituted the patient group of the study. 50 infants hospitalized with the diagnosis of hyperbilirubinemia and did not have any additional problems accepted as the control group. IG and other CBC parameters of infants in the patient and control groups were compared in the study.

Results

There was no significant difference between the patient and control groups in terms of demographic data and types of delivery (p > 0.05). The rate of delivery by elective cesarean section (C/S) was significantly higher than the rate of normal spontaneous vaginal (NSV) delivery in the patient group (p < 0.001). The IG number and percentage, WBC (white blood cell) count, RDW (red cell distribution width), number and percentage of NRBC (nucleated red blood cell), neutrophil and lymphocyte ratio, count and percentage of basophil and PLR (platelet/lymphocyte ratio) of the patient group was significantly higher than the control group (p < 0.05).

Conclusion

According to the findings obtained in the study, it was concluded that IG and other CBC parameters may be used to support clinical and imaging findings to diagnose transient tachypnea of the newborn.

•

There was no significant difference between the patient and control groups in terms of demographic data and types of delivery.

•

The rate of elective cesarean section (C/S) was significantly higher than normal spontaneous vaginal (NSV) delivery in the patient group.

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The IG number and percentage, WBC count, RDW, number and percentage of NRBC, neutrophil and lymphocyte ratio, count and percentage of basophil and PLR of the patient group was significantly higher than the control group.

•

IG and other CBC parameters can be useful to support clinical and imaging findings to diagnose TTN.

Infants infected with SARS-CoV-2 and newborns born to mother diagnosed with COVID-19: clinical experience

Background

Almost every day, new information about the COVID-19 pandemic continues to emerge. COVID-19 presents a mild clinical picture in children. However, how it goes in newborns and pregnant is still entirely unclear.

Aims

To present the clinical course of SARS-CoV-2 positive newborns and outcomes of babies born to mothers diagnosed with COVID-19.

Methods

The present cohort-study examined two groups. The first group includes fourteen newborns born to mothers diagnosed with COVID-19. The second group evaluates twelve newborns infected with SARS-CoV-2.

Results

Fourteen infants born to mothers diagnosed with COVID-19 were not infected with SARS-CoV-2. They had no symptoms and pathological laboratory findings. Additionally, forty-one newborns suspected of COVID-19 were evaluated, and 12 of them were detected to be infected with SARS-CoV-2. The most common symptoms were feeding intolerance (vomiting or refusing to feed, 58%), cough (50%), elevated fever (42%), and respiratory distress (42%).

Conclusion

We did not come across any signs of vertical SARS-CoV-2 transmission. COVID-19 diagnosed newborns entirely healed with conservative treatment.

Perinatology clinic in the coronavirus disease-2019 pandemic: what harms, often teaches

BACKGROUND

Compartmental models simplify the mathematical modeling of infectious diseases based on reported cases. In the absence of precautions, personal protective equipment, quarantine and social distancing, a Susceptible-Exposed-Infectious-Recovered (SuEIR) model with Unscented Kalman Filter for coronavirus disease-19 (COVID-19) Forecasts in Turkey has revealed 174 641 infected people on August 15, 2020, whilst the reported case was 12 216. Through numerical experiments, the effects of quarantine, social distancing, and COVID-19 testing on the dynamics of the outbreak varies. We herein present the documentation of the work in a perinatology clinic during COVID-19 pandemic to find the reflection in a pandemic hospital as even in the pandemic, pregnancy complications and fetal diagnosis/therapy are time-sensitive and cannot be delayed. During the prevention of the horizontal transmission to the health-care workers (HCWs), testing all pregnant women with nasopharyngeal/oropharyngeal swabs for severe acute respiratory syndrome coronavirus (SARS-COV-2) undergoing birth, ultrasound examinations, invasive procedures appear to be the gold standard so that appropriate precautions can be taken if the screen is positive. Though it is logical, it may be incompatible with a busy obstetric practise as a pending polymerase chain reaction (PCR) result should never delay any emergent procedure.

OBJECTIVE

We aim to describe the development of COVID-19 disease of 408 HCW out of 1462 by the exposure to pregnant women while providing obstetric care in a single tertiary perinatology unit under strict clinical triage, recommended precautions and wearing personal protective equipment and compare the maternal and perinatal outcome with those of the preceding three months.

STUDY DESIGN

A prospective cohort study involving the pregnant women and the HCW with positive PCR for SARS-COV-2 were carried out to correlate with the horizontal transmission while documenting the perinatal work.

RESULTS

25 HCW, including nurses/midwives: 11, doctors: 7 and health technicians: 3 and support staff: 4 developed positive PCR for SARS-COV-2 while providing healthcare to 162 cases: mild-moderate (n = 146), severe (n = 12) and critical (n = 1) and asymptomatic (n = 3) in obstetric population. 22 out of 25 HCW were working in the perinatology unit. COVID-19 clinic was asymptomatic (n = 8), mild-moderate (13) or severe (n = 2) in HCW. However, "Exposed" group in the SuEIR model, both the pregnant women and the HCW that have already been infected and have not been tested, which have been also capable of infecting the "Susceptible" group could not be determined. Some of the HCW and the pregnant women in the "Exposed" group were tested and transferred to the "Infectious" group (which were reported to be PCR positive), while the rest of them who recovered, transitted to the so-called "Unreported Recovered" group. The ratio of the women with severe pre-eclampsia admitted to intensive care unit increased significantly during the lockdown (p = .01).

CONCLUSIONS

In a nonstop pandemic perinatology clinic, exposure to 162 PCR positive pregnant women may be correlated with a 5.4% (22/408) documented horizontal transmission in the frontline HCW despite clinical triage and personal protective equipment.

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.