Robson Criteria for Cesarean Section-an Imperative and Emergent Necessity in Romanian Obstetrics

MIHAI DIMITRIU1,2, BOGDAN SOCEA1,2*, LIANA PLES1,3, DIANA-CLAUDIA GHEORGHIU2, NICOLAE GHEORGHIU1,4, ADRIAN NEACSU1, CATALIN-GABRIEL CIRSTOVEANU1,5, NICOLAE BACALBASA1,6, CRISTIAN GEORGE FURAU7,8, GHEORGHE OTO FURAU7,8, MIHAIL BANACU1,2, CRINGU ANTONIU IONESCU1,2 1Carol Davila University of Medicine and Pharmacy, Dionisie Lupu 37, 020021, Bucharest, Romania 2Sf. Pantelimon Emergency Clinical Hospital, 340-342 Pantelimon Road, 021661, Bucharest, Romania 3Sf. Ioan Clinical Emergency Hospital, Bucur Obstetrics Department, 10 Intre Garle Str., 040294, Bucharest, Romania 4Elias Emergency Hospital, 17 Marasti Str.,011461, Bucharest, Romania 5Maria Sklodowska Curie Emergency Clinical Pediatric Hospital, 20 Constantin Brancoveanu Str., 041434, Bucharest, Romania 6Dr. Ion Cantacuzino Clinical Hospital, 5-7 Ion Movila Str., 020475, Bucharest, Romania 7Vasile Goldis West University Arad, Faculty of Medicine, 94 Revolutiei Str., 310025, Arad, Romania 8Emergency Clinical Arad County Hospital, 2-4 Andreny Karoly Str., 310037, Arad, Romania

The cesarean section rate in Romania is among the top three in Europe and that it is among the top ranked in the world. Robson classification is a particularly useful tool for all factors involved in obstetrics. In our study, 840 cesarean births from 2018 were classified according to Robson Classification. Thus, the patients analyzed in the present study have in common an almost obvious trait: the indication for caesarean is, in mostly analyzed cases, not very clear. In fact, much of the cesareans studied are nothing but cesarean performed at the request of the patient. We believe that the urgent implementation of Robson Classification in maternity hospitals in Romania is not only necessary, but also extremely urgent, being a practical tool in determining the causes of certain obstetrical practices and customs.
Keywords: delivery, C-section, defensive C-section, Robson criteria, elective C-section, defensive medicine, C-section indications It is no longer a novelty that the cesarean section rate in Romania is among the top three in Europe and that it is among the top ranked in the world [1][2][3][4][5][6][7]. Some of the most recent statistical dates offered by World Health Organization (WHO) for Romania contained a caesarean rate of approximately 36% [1][2][3][4].
As in many other parts of the globe, the causes of this high cesarean rate are not fully elucidated, but they appear to be the result of a variety of factors such as on demand cesarean and defensive cesarean, attributes of an obstetric medicine and medicine in an accelerated expansion after a long period of prohibitions [1][2][3][4].
Another well-known fact is that countries do not constantly report data and that global reporting is not only discontinuous but also profoundly flawed by the absence of uniform reporting criteria to the WHO [1][2][3][4]. This makes it almost impossible to accurately and scientifically determine the causes and consequences of this variable percent of caesarean section [1], which is why there was more than a need for a language uniformization formula used by experts and professionals in the field, as well as uniformity of reporting rules.
This common language is Robson Classification of Caesareal Patients and was proposed as a WHO work tool as early as 2011-2012 but has become an almost mandatory recommendation of this international forum in 2017 [8][9][10][11][12][13].
Robson classification is a particularly useful tool for all factors involved in obstetrics, public health and scientific research on birth and caesareans, regardless of the fact that the people involved could be only practitioners, data providers or communicators, or end-users of these data.
Another great advantage of this data storage and reporting system is that it can be applied immediately, anywhere, whether it is a compartment, an obstetric department, a hospital, a city, a state or a continent. It is, in fact, a simple classification of the patients in one of the 10 obstetric categories imagined by Robson. It is very important to note that the Robson Classification in no way impairs the use of other data systems and can simply be added to any data generation, storage and usage system. It also does not have any effect on personal data or on the management of such data, according to EU regulations.
It does not produce any direct changes or consequences, nor does it impede the cesarean indication in any way. Moreover, the classification of Robson does not change the type or the nature of the cesarean indication at all. It does not classify the caesarean indication or pathology of the patient.
It is, in fact, a simple categorization of patients according to certain demographic criteria [8][9][10]. The reference criteria are 6: the parity, the existence (or inexistence) of the scarring uterus (C-section in the past), the way of obtaining the labor (spontaneous, induced, absence of labor during the cesarean operation), the number of fetuses (unique or twin pregnancy), gestational age (under 37 weeks or over 37 weeks), fetal position and presentation (cephalic flexed, pelvic, cephalic deflected, transverse).
Thus, regardless of the indication that led to the cesarean, the patient should be assigned to one of the 10 Categories or Groups Robson [8][9][10], groups shown in table 1.

Experimental part
Although Romanian obstetricians are obviously fierce opponents of the rules [1][2][3][4], we succeeded in implementing in 2018 (without any national or local level legislative norm that would oblige us to do so) Robson's classification in Obstetrics and Gynecology Clinic of the Emergency Clinical Hospital Sf. Pantelimon in Bucharest.
Practically, from 1 st of January 2018, the Robson Classification became mandatory in this clinic (by an administrative disposition of the head of the clinic) and applied to all caesarean cases, thus supplementing the documents in the patient observation sheet with a form dedicated to this purpose.
In addition to the birth registry of the clinic, since the same date, the Robson category has been computed with an acronym of the type R followed by the number 1 to 10 and the subcategory letter (A, B or C), where is the case (eg: R1 or R6B). None of these measures has in any way influenced the collection, storage or use of patients' personal data.
Obstetricians were previously instructed to complete these data and how the Robson Classification is done, but none of the purposes of introducing this classification into the current practice of the clinic was presented to them, precisely because they should not be influenced by changing practices and personal obstetrical indications.

Results and discussions
Analysis of the data obtained by us showed that of the total of 1223 births (N = 1223) performed at the Obstetrics and Gynecology Clinic of St. Pantelimon in Bucharest, in 2018, a number of 840 (68.68%) were births by caesarean section (a slight decrease from previous years) [1][2][3][4] and 383 (31.31%) were vaginal deliveries conducted and / or completed in the clinic. It should be noted from the beginning that we included in the study all the births completed in the clinic in 2018 (January 1 st -December 31 st inclusive), regardless of the method of birth, and the criterion of the gestational age that defined the birth was that legally considered in Romania, of 24 gestational weeks.
In our study, 840 cesarean births (N=840) were classified according to Robson Classification as shown in table 2. We had 8 caesarean cases for which we did not have enough data to classify them correctly, that was why we excluded them from the study (eg. exact age of Table 1 ROBSON'S CRITERIA gestation, presence or absence of labor during cesarean, and so on ).
If we carefully analyze the data in table 2 we can obviously observe with some surprise the following, at least paradoxical, realities: the most common category was Robson 1 (226 cases with a single fetus in cranial presentation and spontaneously triggered labor); 2 nd place as frequency was Robson 5 (213 cases of cicatriceal uterus after multiple cesarean previously operations, with single fetus in term in cranial presentation); 3 rd place as frequency was Robson 9 (95 causes of distocic or oblique presentation other than pelvic -that was, cephalic deflected or transverse); the fourth place as frequency was occupied by the Robson 3 criterion (70 cases of single fetus in term, cranial presentation and spontaneous labor at women with multiple previous gestations).
The Robson 8 criterion (multiple pregnancy) was the most rarely assigned (only 15 cases = 1.78% of the total Csections).
The most controversial results were summed up by the criteria that totalize the distocic presentations (Robson 9 = 95 cases = 11.30% of the cesareans performed) and the potentially distocic (pelvian) (Robson 6 and 7, ie another 7.61% of cesareans performed in the clinic in 2018). In other words, almost one in five cases of caesarean section was indicated for a non-cephalic presentation (159 out of 840 cases, ie 18.91% of caesarean cases). Another very important remark is that over 255 cases of caesarean section have been done to women with cicatriceal uterus after previous C-sections, so the indication was mainly due to previous cesarean operations.

Conclusions
Thus classified, the patients analyzed by us in the present study have in common an almost obvious trait: the indication for caesarean is, in mostly analyzed cases, at least questionable.
The results clearly show an incredible incidence of distocic presentation, even if the St. Pantelimon Obstetrics Department is classified as a Grade III (highest) center (resolves the most complicated cases).
In fact, much of the cesareans studied are nothing but cesarean performed at the request of the patient (even if this is not legalized in Romania) or defensive C-section" practices by obstetricians to avoid possible litigation.
There is also a good conclusion, that a preventive obstetrics was certainly practiced, avoiding as much as possible distocic presentations of any kind and cause.
However, the St. Pantelimon Obstetrical Department is one that reflects quite well the obstetric practices of Romania [1][2][3][4], and the mandatory introduction of the Robson Classification in all maternities in the country will generate statistical results very similar to ours. This is also the reason why we consider it more honest and safer (both for patients and for obstetricians) to legalize cesarean at the patient's explicit request and to avoid "production of indications more or less close to reality (and therefore more or less verifiable).
We believe that, at least nowadays, we all sail (equally patients and obstetricians) into extremely troubled waters" and, implicitly, dangerous ...
We also believe that the urgent implementation of Robson Classification in maternity hospitals in Romania is not only necessary, but also extremely urgent, being a very practical tool in determining the causes of certain contemporary obstetrical practices and customs.