Ci a ion: Vila-Candel, R.;
Pique -Ma ín, N.; Pe domo-Uga e,
N.; Quesada, J.A.; Escu ie , R.;
Ma in-A ibas, A. Indica ions o
Induc ion and Caesa ean Sec ions
Pe o med Using he Robson
Classi ica ion in a Uni e si y
Hospi al in Spain om 2010 o 2021.
Heal hca e 2023,11, 1521. h ps://
doi.o g/10.3390/heal hca e11111521
Academic Edi o : Giuseppe Rizzo
Recei ed: 12 Ma ch 2023
Re ised: 13 May 2023
Accep ed: 22 May 2023
Published: 23 May 2023
Copy igh : © 2023 by he au ho s.
Licensee MDPI, Basel, Swi ze land.
This a icle is an open access a icle
dis ibu ed unde he e ms and
condi ions o he C ea i e Commons
A ibu ion (CC BY) license (h ps://
c ea i ecommons.o g/licenses/by/
4.0/).
heal hca e
A icle
Indica ions o Induc ion and Caesa ean Sec ions Pe o med
Using he Robson Classi ica ion in a Uni e si y Hospi al in
Spain om 2010 o 2021
Ra ael Vila-Candel 1,2,3,* , Nadia Pique -Ma ín2,3, Ne ea Pe domo-Uga e 2,3, JoséAn onio Quesada 4,5 ,
Ramón Escu ie 6and Anna Ma in-A ibas 6
1Depa men o Nu sing, Uni e si a de València, 46007 Valencia, Spain
2Depa men o Obs e ics and Gynaecology, Hospi al Uni e si a io de la Ribe a, 46600 Valencia, Spain
3Founda ion o he P omo ion o Heal h and Biomedical Resea ch in he Valencian Region (FISABIO-SP),
46020 Valencia, Spain
4Depa men o Clinical Medicine, Uni e sidad Miguel He nández, 03202 Elche, Spain
5Ne wo k o Resea ch on Ch onici y, P ima y Ca e and Heal h P omo ion (RICAPPS), 03550 Alican e, Spain
6School o Heal h Sciences Blanque na, Uni e si a Ramon Llull, C/Padilla 326, 08025 Ba celona, Spain
*Co espondence: [email p o ec ed]
Abs ac :
Backg ound: The Robson Ten G oup Classi ica ion Sys em (RTGCS) enables he assessmen ,
moni o ing, and compa ison o caesa ean sec ion a es bo h wi hin heal hca e acili ies and be ween
hem, and he indica ions o caesa ean sec ions (CS) pe o med in a ma e ni y wa d. The aims o
he p esen s udy we e o conduc an analysis o assess he le els and dis ibu ion o bi h om
a desc ip i e app oach by CS in La Ribe a Uni e si y Hospi al (Spain) be ween 2010–2021 using
he Robson classi ica ion; o desc ibe he indica ions o he induc ion o labou and he causes o
caesa ean sec ions pe o med; and o examine he associa ion be ween he induc ion o labou and
CS bi h. Me hods: A e ospec i e s udy be ween 1 Janua y 2010 and 31 Decembe 2021. All eligible
women we e classi ied acco ding o he RTGCS o de e mine he absolu e and ela i e con ibu ion
by each g oup o he o e all CS a e. The odds a io (OR) o he a iables o in e es was es ima ed by
logis ic eg ession. In an analysis o he subg oups, he le el o signi icance was adjus ed using he
Bon e oni me hod. Resul s: 20,578 women ga e bi h du ing he s udy pe iod, 19% o hem by CS. In
33% o bi hs, induc ion was pe o med, and he mos common cause was he p ema u e up u e
o memb anes. G oup 2 (nullipa ous wi h induced labou /elec i e CS be o e labou ) accoun ed o
he la ges con ibu ion o he o e all a e o CS (31.5%) and showed an upwa d end om 23.2% o
39.7% in he ime se ies, inc easing he CS a e by 6.7%. The leading cause o CS was suspec ed e al
dis ess, ollowed by induc ion ailu e. Conclusions: In ou s udy, Robson G oup 2 was iden i ied as
he main con ibu o o he hospi al’s o e all CS a e. De e mining he causes o induc ion and CS
in a popula ion sample classi ied using he RTGCS enables he iden i ica ion o he g oups wi h he
g ea es de ia ion om he op imal a e o CS and he es ablishmen o imp o emen plans o educe
he o e all a e o caesa ean sec ions in he ma e ni y uni .
Keywo ds:
Robson classi ica ion; caesa ean sec ion; labou induc ion; indica ions; onse o labou ;
mode o bi h
1. In oduc ion
The wo ldwide ise in caesa ean sec ion (CS) a es is a majo public heal h conce n
and a cause o conside able deba e due o hei s eady inc ease, he lack o consensus on
he app op ia e CS a e, he associa ed sho - and long- e m ma e nal and neona al isks
and cos s, and he inequi y in access [
1
,
2
]. In Eu ope, he a e o CS a ies conside ably
be ween coun ies om 15% o 45%, and he easons o his si ua ion appea o be mul iple,
complex, and, in many cases, coun y speci ic [3].
Heal hca e 2023,11, 1521. h ps://doi.o g/10.3390/heal hca e11111521 h ps://www.mdpi.com/jou nal/heal hca e
Heal hca e 2023,11, 1521 2 o 12
The Robson classi ica ion sys em is a ool used o classi y, moni o , and compa e
CS a es in a s anda dized, eliable, consis en , and ac ion-o ien ed manne , wi h he
aim o unde s anding he d i e s and con ibu o s o his end ac oss di e en se ings
and popula ions and iden i ying a eas whe e in e en ions may be needed o educe CS
a es [4–6].
In 2017, he Wo ld Heal h O ganiza ion (WHO) de eloped guidelines o i s use,
implemen a ion, and in e p e a ion, including he s anda diza ion o e ms and de ini ions,
in o de o help heal hca e acili ies adop and use he Robson classi ica ion [
7
]. In 2022,
he WHO has implemen ed ano he ool o acili a e he use o he Robson classi ica ion,
he “Robson Pla o m” [
8
]. This online pla o m allows he con inuous moni o ing o
caesa ean sec ions using he Robson Ten G oup Classi ica ion Sys em (RTGCS). Da a
is openly a ailable and is upda ed in eal ime as soon as new da a is uploaded by he
ma e ni y heal hca e acili ies. Gi en he cons an inc ease in CS use globally, he subs an ial
inequali ies in low- and middle-income coun ies, and he po en ial impac on pe ina al
heal h ou comes, con inuous moni o ing o caesa ean sec ions using such ools should be
es ablished as a global moni o ing p io i y [9,10].
Fu he mo e, o e he las decades, a es o induc ion o labou ha e also inc eased
om wo old o ou old in high-income coun ies, and he WHO es ima es ha 25%
o women unde go induced labou in his con ex [
11
]. P e ious s udies [
12
,
13
] ha e
associa ed he induc ion o labou wi h nega i e pe ina al ou comes, such as a g ea e
numbe o admissions o he neona al in ensi e ca e uni , cho ioamnioni is, pos pa um
haemo hage, o pe ineal inju ies, among o he ele an ou comes. In addi ion, acco ding
o he s udies [
14
,
15
], he isk o a CS in women ha unde go induced labou is be ween
wo and h ee imes highe when compa ed o women ha ha e a spon aneous onse o
labou , wi h ailed induc ion o labou being he mos equen cause o he indica ion o
a CS. In con as , o he au ho s ha e obse ed ha induc ions pe o med a week 39 in
nullipa ous p egnan women ha e educed he numbe o CS [16,17].
The aims o he p esen s udy we e o conduc an analysis o iden i y he g oups o
women ha con ibu e mos and leas o o e all CS a es, assess le els and dis ibu ion o
bi hs by CS om a desc ip i e app oach in La Ribe a Uni e si y Hospi al (Spain) be ween
2010–2021 using he Robson classi ica ion, desc ibe he indica ions o inducing labou and
he caesa ean sec ions pe o med, and examine he associa ion be ween induced labou
and CS bi h.
2. Ma e ials and Me hods
2.1. Design, Popula ion, and Sample
This is a e ospec i e obse a ional s udy o all bi hs a ended a Hospi al Uni e -
si a io de la Ribe a (HULR) be ween 1 Janua y 2010 and 31 Decembe 2021. Da a we e
ob ained by he esea ch eam om he e iew o he elec onic medical eco d o each o
he cases included.
Cu en ly, HULR a ends an a e age o 1300 bi hs pe yea and has a po en ial
e e ence popula ion o 250,000 inhabi an s. Misca iages a less han 22 weeks o ges a ion
o bi h weigh unde 500 g we e conside ed exclusion c i e ia.
We ob ained e hical clea ance om he Resea ch E hics Commi ee o Hospi al de la
Ribe a. Con iden ial da a and comple e in o ma ion conce ning pa icipan s we e secu ed
h oughou he e iew p ocess. Due o he na u e o he e ospec i e s udy, nei he he
pa ien in o ma ion shee no hei in o med consen we e necessa y, because only he
elec onic eco ds we e analysed, and he e was no con ac wi h any pa icipan .
2.2. Da a Collec ion Tools
The Robson en g oup classi ica ion sys em (RTGCS) was used o ca ego ize caesa ean
sec ions in he selec ed sample. Table 1se s ou he de ini ions o each g oup.
Heal hca e 2023,11, 1521 3 o 12
Table 1. G oup desc ip ion o Robson’s classi ica ion sys em.
G oup Desc ip ion
1 Nullipa ous, single on cephalic, ≥37 weeks, spon aneous labou .
2a Nullipa ous, single on cephalic, ≥37 weeks, induced labou .
2b Nullipa ous, single on cephalic, ≥37 weeks, o caesa ean deli e y be o e labou .
3 Mul ipa ous, single on cephalic, ≥37 weeks, spon aneous labou .
4a Mul ipa ous, single on cephalic, ≥37 weeks, induced labou .
4b Mul ipa ous, single on cephalic, ≥37 weeks, caesa ean deli e y be o e labou .
5P e ious caesa ean deli e y, single on cephalic, ≥37 weeks, spon aneous labou , o induced labou o
caesa ean deli e y be o e labou (BVAC).
6
All nullipa ous single on b eeches, spon aneous labou , o induced labou o caesa ean deli e y be o e labou .
7All mul ipa ous single on b eeches (including p e ious caesa ean deli e y), spon aneous labou , o induced
labou o caesa ean deli e y be o e labou .
8 All mul iple p egnancies, spon aneous labou , o induced labou o caesa ean deli e y be o e labou .
9
All abno mal single on lies (including p e ious caesa ean deli e y bu excluding b eech), spon aneous labou ,
o induced labou o caesa ean deli e y be o e labou .
10 All single on cephalic, ≤36 weeks (including p e ious caesa ean deli e y), spon aneous labou , o induced
labou o caesa ean deli e y be o e labou .
The sys ems depa men p o ided us wi h he bi hs a ended in he s udy pe iod,
along wi h he a iables necessa y o he abula ion o he RTGCS. The i e a iables
o he RTGCS we e collec ed, which included obs e ic his o y (pa i y and p e ious CS),
ype o onse o labou (spon aneous, induced, o CS be o e labou ), e al p esen a ion
(cephalic, b eech, o ans e se), and numbe o newbo ns and ges a ional age (p e e m
o ull e m). In addi ion, sociodemog aphic a iables (coun y o o igin, age), obs e ic-
pe ina al a iables (sex o he newbo n, bi h weigh , indica ion o induc ion, and cause o
indica ion o CS) we e included. Finally, a ious a iables we e ca ego ized o ob ain an
analysis o pe ina al ou comes, such as low bi h weigh (bi h weigh < 2500 g), small o
ges a ional age (bi h weigh lowe han 10 h pe cen ile o ges a ional age) [
18
], suspec ed
in au e ine g ow h es ic ion (bi h weigh lowe han 5 h pe cen ile o ges a ional
age) [
18
], o mac osomia (bi h weigh > 4000 g) and p eeclampsia (yes/no). Nex , he
esea ch eam g ouped all eco ds in which he onse o labou was an induc ion o examine
he indica ions. Finally, all cases whe e bi h esul ed in caesa ean sec ion we e g ouped
oge he o de e mine he indica ions.
2.3. S a is ical Analysis
The basic desc ip i e me hods o calcula ion o mean and s anda d de ia ion we e
used o con inuous a iables, median and in e qua ile ange o nonno mal dis ibu ions,
and absolu e and ela i e equencies o ca ego ical a iables. The Kolmogo o –Smi no
goodness-o - i es was used o assess whe he he a iables complied wi h he p inciple
o no mali y. The associa ions be ween he quali a i e a iables we e analysed by means o
con ingency ables, applying he Chi-Squa e es . Fo quan i a i e a iables, mean alues
we e compa ed using S uden ’s - es o he ANOVA p ocedu e o he K uskal–Wallis es .
The odds a io (OR) and 95% CI o he a iables o in e es was es ima ed by simple logis ic
eg ession. In he analysis o he subg oups, he le el o signi icance was adjus ed using
he Bon e oni me hod. The le el o s a is ical signi icance de ined was p< 0.05. Da a we e
analysed using S a is ical Package o he Social Ve sion 28.0.1 Sciences (SPSS Inc., Chicago,
IL, USA).
Heal hca e 2023,11, 1521 4 o 12
3. Resul s
A o al o 20,578 bi hs a ended a HULR du ing he s udy pe iod we e analysed. The
women’s mean age was 30.85
±
5.77 yea s—79.4% we e o Spanish o igin and 54.9% we e
p imipa ous. A o al o 62% had spon aneous onse o labou , and 32.9% we e induced.
The mean bi h weigh was 3290.39
±
473.35 g, 48.6% emale, and 51.4% male. The CS a e
was 19.0%, wi h 14.5% co esponding o he a e o in apa um CS and 4.5% o elec i e
caesa ean sec ions, espec i ely. Table 2shows he dis ibu ion o he ype o onse o labou
and he mode o bi h o he sample analysed.
Table 2.
Dis ibu ion o he ype o onse o labou and mode o bi h o he sample om 2010 o 2021
a HULR (N= 20,578).
n%
Onse o labou
Spon aneous 12,770 62.1
Induced 6776 32.9
Elec i e caesa ean 916 4.5
Eme gency caesa ean 89 0.4
Eme gen caesa ean 27 0.1
Mode o bi h
Vaginal 16,676 81.0
Eme gency caesa ean 2986 14.5
Elec i e caesa ean 916 4.5
To de e mine whe he he e was a pe cen age change in he a iables analysed in
he ime se ies, we ca ego ized he dis ibu ion in o h ee di e en pe iods (2010–2013;
2014–2017 and 2018–2021). Table 3p esen s he dis ibu ion in socio-demog aphic and
obs e ic a iables among women a HULR, a hospi al in Spain, be ween 2010 and 2021.
The pe cen age o Spanish women dec eased om 83.0% in 2010-2013 o 70.9% in 2018–2021,
while he pe cen age o o eign women inc eased om 17.0% o 29.1% du ing he same
pe iod (p< 0.001). The p opo ion o male and emale babies emained s able ac oss he
h ee pe iods wi h no signi ican di e ence. Mos women had single on p egnancies, and
he p opo ion o mul iple e uses emained low and s able. The pe cen age o women wi h
one p e ious p egnancy inc eased om 55.6% in 2010–2013 o 61.0% in 2018–2021, while he
pe cen age o women wi h wo o mo e p e ious p egnancies dec eased om 44.4% o 36.1%
o e he same pe iod (p< 0.001). The mean ma e nal age inc eased om
30.4 ±5.5 yea s
in 2010–2013 o 31.2
±
6.1 yea s in 2018–2021, wi h a s a is ically signi ican di e ence
be ween he h ee pe iods (p< 0.001). The mean numbe o bi hs pe woman dec eased
om 0.6 in 2010–2013 o 0.5 in 2014–2017, bu hen inc eased back o 0.6 in
2018–2021
, wi h
a s a is ically signi ican di e ence be ween he h ee pe iods (p< 0.001). The mean bi h
weigh emained ela i ely s able o e he yea s, wi h a s a is ically signi ican di e ence
be ween he h ee pe iods (p= 0.022), al hough he di e ences we e small (23 g).
Simila ly, we examined socio-demog aphic ac o s such as coun y o o igin and
ma e nal age, as well as pe ina al a iables such as sex o newbo n and bi h weigh , o
each subg oup ac oss he ime se ies ( e e o Supplemen a y Table S1). Ou analysis
e ealed s a is ically signi ican di e ences in coun y o o igin o subg oups 1, 2, 3, 6,
8, and 10, wi h Spanish women being he mos p e alen (p< 0.001; p< 0.001; p< 0.001;
p< 0.001
;p= 0.013; p= 0.023, espec i ely). Ma e nal age inc eased o e he cou se o he
ime se ies, wi h signi ican di e ences obse ed in g oups 1, 2, 3, 4, 5, 7, and 10, pa icula ly
in g oups 5 and 7 (p= 0.005; p= 0.012; p< 0.001; p< 0.001; p< 0.001; p< 0.001; p= 0.041,
espec i ely), esul ing in an a e age ma e nal age inc ease om 31 o 35 yea s o hese
las wo g oups. Las ly, we obse ed ha s a is ically signi ican di e ences we e p esen
in bi h weigh o subg oup 3 (p< 0.001), wi h a di e ence o 51g be ween 2010–2013 and
2018–2021.
Heal hca e 2023,11, 1521 5 o 12
Table 3.
Dis ibu ion o socio-demog aphic and obs e ic a iables om 2010 o 2021 a HULR
(N= 20,578).
2010–2013 2014–2017 2018–2021
n % n % n % p-Value *
Coun y o o igin Spain 6897 83.0 5570 81.9 3877 70.9 <0.001
Fo eign 1411 17.0 1235 18.1 1588 29.1
Newbo n sex Male 4290 51.6 3486 51.2 2802 51.3 0.897
Female 4018 48.4 3319 48.8 2663 48.7
P e ious CS No 8077 97.2 6644 97.6 5313 97.2 0.216
Yes 231 2.8 161 2.4 152 2.8
Numbe o e us One 8216 98.9 6725 98.8 5402 98.8 0.928
Two o mo e 92 1.1 80 1.2 63 1.2
P e ious p egnancies
One 4321 55.6 3835 61.0 3121 63.9
<0.001
Two 3450 44.4 2448 39.0 1766 36.1
Th ee 466 86.8 438 83.9 431 74.6
Fou o mo e 71 13.2% 84 16.1 147 25.4
Pe iod nMean SD p- alue **
Ma e nal age
2010–2013 8308 30.4 5.5
<0.001
2014–2017 6805 31.1 5.7
2018–2021 5465 31.2 6.1
Numbe o bi hs
2010–2013 8308 0.6 0.7
<0.001
2014–2017 6805 0.5 0.7
2018–2021 5465 0.6 0.7
Bi h weigh
2010–2013 8308 3281.1 466.5
0.022
2014–2017 6805 3280.0 472.5
2018–2021 5465 3304.7 484.5
* Chi-squa e es ; ** K uskal–Wallis es ; HULR: Hospi al Uni e si a io de la Ribe a; CS: cesa ean sec ion.
Table 4shows he dis ibu ion o he bi hs ca ied ou in he s udy pe iod, aking he
RTGCS in o accoun . O e all, G oups 1 o 4 accoun o he la ges popula ion size.
Table 4.
Dis ibu ion o bi hs using he Robson classi ica ion sys em om 2010 o 2021 a HULR
(N= 20,578).
G oup C-Sec ion in
he G oup
No. o Women
in he G oup
G oup
Size
C-Sec ion Ra e
o he G oup
Absolu e
Con ibu ion by he
G oup o he O e all
C-Sec ion Ra e
Rela i e Con ibu ion
by he G oup o he
O e all C-Sec ion Ra e
1 784 6842 33.2% 11.5% 3.8% 20.1%
2 1228 3272 15.9% 37.5% 6.0% 31.5%
3 359 6427 31.2% 5.6% 1.7% 9.2%
4 377 1830 8.9% 20.6% 1.8% 9.7%
5 205 317 1.5% 64.7% 1.0% 5.3%
6 323 402 2.0% 80.3% 1.6% 8.3%
7 172 179 0.9% 96.1% 0.8% 4.4%
8 163 284 1.4% 57.4% 0.8% 4.2%
9 40 47 0.2% 85.1% 0.2% 1.0%
10 251 978 4.8% 25.7% 1.2% 6.4%
3902 20,578 100% 19.0% 19.0% 100%
Heal hca e 2023,11, 1521 6 o 12
We we e in e es ed in analysing he g oups wi h he g ea es ela i e con ibu ion
wi h espec o he global a e o caesa ean sec ions and obse ing hei a ia ion o e
ime (Figu e 1). The g oups ha educed hei ela i e con ibu ion o he o e all CS a e
we e G oup 1 (nullipa ous and spon aneous bi h), G oup 4 (mul ipa ous and induc ion),
and G oup 8 (mul iple p egnancies). G oup 1 wen om 22.1% in 2010 o 16.2% in 2021;
simila ly, i can be seen how he a e o caesa ean sec ions has dec eased (2.3%) du ing he
said pe iod. G oup 4 educed i s ela i e con ibu ion om 13.8% in 2010 o 11.7% in 2021,
accompanied by a dec ease in he CS a e om 4.5% du ing ha pe iod, and G oup 8 om
5.3% in 2010 o 2.8% in 2021, wi h a educ ion in i s ela i e con ibu ion o CS a e o 7.5%.
Heal hca e 2023, 11, x 6 o 12
We we e in e es ed in analysing he g oups wi h he g ea es ela i e con ibu ion
wi h espec o he global a e o caesa ean sec ions and obse ing hei a ia ion o e
ime (Figu e 1). The g oups ha educed hei ela i e con ibu ion o he o e all CS a e
we e G oup 1 (nullipa ous and spon aneous bi h), G oup 4 (mul ipa ous and induc ion),
and G oup 8 (mul iple p egnancies). G oup 1 wen om 22.1% in 2010 o 16.2% in 2021;
simila ly, i can be seen how he a e o caesa ean sec ions has dec eased (2.3%) du ing
he said pe iod. G oup 4 educed i s ela i e con ibu ion om 13.8% in 2010 o 11.7% in
2021, accompanied by a dec ease in he CS a e om 4.5% du ing ha pe iod, and G oup
8 om 5.3% in 2010 o 2.8% in 2021, wi h a educ ion in i s ela i e con ibu ion o CS a e
o 7.5%.
G oup 2 (nullipa ous and induced labou ) aised i s ela i e con ibu ion om 23.1%
o 39.7%, wi h he a e o caesa ean sec ions inc easing by 6.7%. G oup 5 (BVAC) inc eased
i s ela i e con ibu ion o he o e all CS a e by 2.7%, and in he ime se ies had an up-
wa d beha iou in e ms o CS a e, eaching 100% in 2021. G oups 6 (nullipa ous and
b eech), 7 (mul ipa ous and b eech), and 9 (abno mal p esen a ion) emained cons an .
G oup 10 (p e e m) unde wen a 0.6% inc ease in i s ela i e con ibu ion, al hough he
CS a e inc eased by 9.1%.
Figu e 1. Rela i e con ibu ion (%) by he g oup o he o e all C-sec ion a e om 2010 o 2021 a
HULR 2010–2021 (N = 20,578).
Induc ion was no ed in 33.0% o bi hs. Table 5 se s ou he dis ibu ion o he indi-
ca ions o induc ion acco ding o he mode o bi h ( aginal o CS). The ela i e con ibu-
ion o he o e all a e o caesa ean sec ions o G oups 2 and 4 oge he accoun s o 41.2%
o he o e all a e, and he main indica ions o induc ion we e p ema u e up u e o mem-
b anes (26.1%) and pos - e m p egnancy (16.3%).
Figu e 1.
Rela i e con ibu ion (%) by he g oup o he o e all C-sec ion a e om 2010 o 2021 a
HULR 2010–2021 (N= 20,578).
G oup 2 (nullipa ous and induced labou ) aised i s ela i e con ibu ion om 23.1%
o 39.7%, wi h he a e o caesa ean sec ions inc easing by 6.7%. G oup 5 (BVAC) inc eased
i s ela i e con ibu ion o he o e all CS a e by 2.7%, and in he ime se ies had an upwa d
beha iou in e ms o CS a e, eaching 100% in 2021. G oups 6 (nullipa ous and b eech),
7 (mul ipa ous and b eech), and 9 (abno mal p esen a ion) emained cons an . G oup
10 (p e e m) unde wen a 0.6% inc ease in i s ela i e con ibu ion, al hough he CS a e
inc eased by 9.1%.
Induc ion was no ed in 33.0% o bi hs. Table 5se s ou he dis ibu ion o he indica-
ions o induc ion acco ding o he mode o bi h ( aginal o CS). The ela i e con ibu ion
o he o e all a e o caesa ean sec ions o G oups 2 and 4 oge he accoun s o 41.2% o he
o e all a e, and he main indica ions o induc ion we e p ema u e up u e o memb anes
(26.1%) and pos - e m p egnancy (16.3%).
Heal hca e 2023,11, 1521 7 o 12
Table 5.
Dis ibu ion o indica ions o induc ion and mode o bi h om 2010 o 2021 a HULR
(N= 6776).
Vaginal
(n= 5265)
C-Sec ion
(n= 1511)
n%n%
In au e ine e al dea h 30 100 0 0
Unmoni o ed ges a ion 1 50.0 1 50.0
Indica ion o induc ion no documen ed 362 99.7 1 0.3
Placen a p e ia 0 0 1 100
Anhyd amnios 32 94.1 2 5.9
Poo obs e ic his o y 5 71.4 2 28.6
Reduced e al mo emen s 1 33.3 2 66.7
P io CS 9 81.8 2 18.2
Ad anced ma e nal age 2 40.0 3 60.0
Fe al pa hology 6 66.7 3 33.3
Fa ou able ce ix 628 99.4 4 0.6
3 d imes e me o hagia 33 86.8 5 13.2
Insidious p epa um wi h poo pain con ol 366 90.0 10 10.0
Dopple al e a ions 20 64.5 11 35.5
Twin p egnancy 26 60.5 17 39.5
Suspec ed mac osomia 70 74.5 24 25.5
Ma e nal disease 77 74.0 27 26.0
Polyhyd amnios 59 64.8 32 35.2
Small o ges a ional age 113 74.8 38 25.2
Ges a ional diabe es 90 61.2 57 38.8
Res ic ed in au e ine g ow h 189 73.3 69 26.7
Ca dio ocog aphic anomalies 203 68.1 95 31.9
Meconial amnio ic luid 363 76.9 109 23.1
Oligohyd amnios 283 70.6 117 29.4
P e-eclampsia 170 56.7 130 43.3
Pos - e m p egnancy 763 69.3 344 30.7
P ema u e up u e o memb anes 1364 79.0 405 21.0
We we e in e es ed in analysing he ela ionship be ween he onse o labou (spon a-
neous/induced) and he mode o bi h ( aginal/CS). We obse ed, in Table 6, ha he CS
a e was highe when labou was induced, and he di e ences a e s a is ically signi ican
(22.7% s. 11.3%; p< 0.001). The e is wice he isk o ending in CS a e labou is induced
compa ed o a spon aneous onse deli e y (p < 0.001).
Table 6.
Rela ionship be ween induc ion and mode o bi h om 2010 o 2021 a HULR (N= 19,662).
Vaginal C-Sec ion
n % n % p-Value * OR CI 95% p-Value **
Onse o labou Spon aneous 11,427 88.8 1448 11.3 <0.001 1<0.001
Induced 5249 77.2 1538 22.7 2.3 2.1–2.5
* Chi-squa e es ; ** Simple logis ic eg ession.
Table 7shows he di e ences be ween he indica ions o pe o ming CS be ween
in apa um and elec i e caesa ean sec ions. The main indica ions o in apa um CS we e
suspec ed e al dis ess (29.3%), ailed induc ion (22.2%), and obs uc ed labou (17.9%),
while non-cephalic p esen a ion (53.8%) was he mos equen o elec i e CS.
Heal hca e 2023,11, 1521 8 o 12
Table 7. Dis ibu ion o he indica ion o caesa ean sec ion om 2010 o 2021 a HULR (N= 3902).
In apa um C-Sec ion
(n= 2986)
Elec i e C-Sec ion
(n= 916)
n%n%
Res ic ed in au e ine g ow h 4 14.3 24 85.7
T iple s 0 0.0 1 100
Fe al pa hology 1 14.3 6 85.7
P ema u i y 1 100 0 0
P io u e ine su ge y 2 7.4 25 92.6
U e ine up u e 2 100 0 0
Cho ioamnioni is 3 100 0 0
Fa ou able ce ix 6 33.3 12 66.7
Ma e nal pa hology 22 33.3 44 66.7
Co d p olapse 16 100 0 0
Suspec ed mac osomia 17 14.5 117 85.5
I e a i e caesa ean sec ion 19 12.8 149 87.2
Placen a p e ia 20 41.7 28 58.3
Poo ly con olled p eeclampsia 33 60.0 22 40.0
Placen al ab up ion 56 100 0 0
Fe al malposi ion 59 100 0 0
Non-cephalic p esen a ion 254 36.3 487 63.7
Cephalopel ic disp opo ion 396 99.7 1 0.3
Obs uc ed labou 534 100 0 0
Failed induc ion 664 100 0 0
Suspec ed e al dis ess 877 100 0 0
Rega ding he ela ionship be ween he main indica ions o CS and he mode o bi h
(Table 8), we obse ed how ailed induc ion has inc eased in he ime se ies, ising om
25.6% (2010–2013) o 40.1% (2018–2021), wi h hese di e ences being s a is ically signi ican
(p< 0.001).
Table 8.
Indica ion o in apa um caesa ean sec ion and mode o bi h in ime se ies om 2010 o
2021 a HULR (N= 1949).
2010–2013 2014–2017 2018–2021
n%n%n%p-Value *
Indica ion o
C-sec ion CPD 200 24.3 100 16.9 96 18.2
<0.001
Failed
induc ion 200 25.6 250 42.3 214 40.1
SFD 413 50.1 241 40.8 223 41.7
* Chi-squa e es ; CPD: cephalopel ic disp opo ion; SFD: suspec ed e al dis ess.
4. Discussion
This s udy includes he analysis o he indica ions o induc ion o labou and CS o
a 12-yea ime se ies in a uni e si y hospi al in eas e n Spain, whe e a o al sample o
20,578 bi hs has p e iously been classi ied using he RTGCS. An inc ease in he num-
be o caesa ean sec ions [
14
,
15
] has been obse ed in he g oups in which induc ion
was pe o med.
Al hough he analysis using he RTGCS cons i u es a i s s ep owa ds in es iga ing
di e ences in CS a es [
3
,
19
], he unde lying easons o such di e ences emain unclea .
One o he d i ing ac o s behind ou adop ion o his me hodology is ou aim o dec ease
he o e all a e o caesa ean sec ions pe o med in ou hospi al. In o de o es ablish a
a ge , i is essen ial o ha e a clea unde s anding o he cu en si ua ion. The upwa d
end in cesa ean sec ions o e he pas ew decades has highligh ed he need o audi s
ha u ilize a s anda dized classi ica ion sys em, such as he en-g oup sys em p e iously
Heal hca e 2023,11, 1521 9 o 12
desc ibed, which enables compa ison o caesa ean a es wi h hose o o he hospi als. By
iden i ying po en ial in e en ions ha can help educe he numbe o caesa ean sec ions,
we hope o make a meaning ul con ibu ion owa ds achie ing ou goal. Th ough ou
seconda y analysis o indica ions o induced deli e y and causes o caesa ean sec ions, we
ha e been able o ca y ou an in es iga ion in o he g oups ha mos con ibu e o he
o e all a e o caesa ean sec ions. In ou s udy, he p e alence o induc ion eached 33%, in
line wi h o he s udies conduc ed in de eloped coun ies anging om 20% o 40% [
20
].
The g oups wi h he highes induc ion a e we e 2a (nullipa ous induced), 4a (mul ipa ous
induced), 5 ( aginal bi h a e caesa ean), 8 (mul iple p egnancies), and 10 (p e e m bi h).
Al hough he dis ibu ion o hese g oups ha e no inc eased in all cases in e ms o he
ela i e con ibu ion o caesa ean sec ions, he inc ease in G oups 2a, 5 and 10 s ands ou ,
wi h G oup 5 being especially ele an , compa ed o he his o ical end and coinciding
wi h he esul s epo ed by he Eu o–Pe is a P ojec [
3
]. The caesa ean sec ion a e in
G oup 5 should no be highe han 60% [
1
], and we should poin ou , as in ou case, ha
his may be due o he ac ha his g oup con ains a highe numbe o women wi h wo o
mo e p e ious caesa ean sec ions.
Acco ding o a sys ema ic e iew and me a-analysis published in he Coch ane
Da abase o Sys ema ic Re iews [
21
], induc ion o labou was no associa ed wi h an
inc eased isk o caesa ean deli e y. On he o he hand, o he s udies concluded ha induc-
ion o labou inc eased he isk o CS, pa icula ly in nullipa ous women ha ha e been
classi ied by he RTGCS as G oup 2a, in line wi h ou esul s [
14
,
15
]. In consonance wi h
di e en au ho s [
6
,
22
], ou esul s show ha he e is wice he isk o labou ending in a CS
when an induc ion is pe o med, compa ed o a spon aneous onse o labou . In addi ion,
we obse e ha p ema u e memb ane up u e and ailed induc ion we e, espec i ely,
he mos equen causes o induc ion and CS, as obse ed in o he s udies [
12
–
14
,
23
]. In
o de o educe he o e use o caesa ean sec ions in his g oup, e o s should be made o
dec ease bo h induc ions and elec i e cesa ean sec ions. Elec i e cesa ean sec ions should
be p esen ed in a clinical session and each speci ic case should be e alua ed, as well as
on-demand cesa ean sec ions, which pose a challenge ha we mus equen ly con on . I
is impo an o e lec on whe he a caesa ean bi h p e en s an ad e se pe ina al ou come
o , con e sely, an unnecessa y indica ion is gi en in he ligh o a pe cei ed isk [
16
]. The e
is no doub ha in ecen yea s in de eloped coun ies, he induc ion o childbi h has dou-
bled o ipled, while he a e o caesa ean sec ions has been inc easing ala mingly [
17
,
24
].
This high a e o induc ion and o CS has ailed o educe ad e se pe ina al ou comes, and
we belie e we should be conce ned abou he sho - and long- e m e ec s on ma e nal
mo bidi y and mo ali y.
The mean CS a e o ou s udy was 19% (4.5% elec i e CS a e), which is lowe han
he a e age o Spain o a ound 25% [
3
]. The main indica ions o elec i e CS include non-
cephalic p esen a ions ( e al c i e ion ha allows aginal bi h in b eech p esen a ion: ank
b eech o comple e b eech p esen a ion, es ima ed e al weigh be ween 1,500 and 4,000 g,
and cephalic a i ude in lexion o indi e en , assessed by ul asound), placen a p e ia,
asa p e ia, e al mac osomia (es ima ed e al weigh g ea e han o equal o 4,500 g in
diabe ic p egnan women and g ea e han o equal o 5,000 g in non-diabe ic p egnan
women), p esence o u e ine sca ing, seconda y o i e a i e caesa ean, e al pa hology
ha ad ises agains aginal bi h, and ma e nal pa hology ha ad ises agains aginal
bi h [
25
]. In ou case, we obse ed ha non-cephalic p esen a ion was he mos equen
indica ion (53.2%), whe e G oups 6 (nullipa ous single on b eeches) and 7 (mul ipa ous
single on b eeches) can be included, mainly, oge he wi h G oups 8 (mul iple p egnancies)
and 9 (abno mal lies). G oups 6 and 7 ha e also shown a g ea e endency in CS a es o
Eu opean coun ies, in acco dance wi h ou esul s [3].
Fu he mo e, conside ing ha induc ion o labou (IOL) is a medical in e en ion ha
may a ec women’s bi h op ions and hei expe ience o he bi h p ocess, his should only
be ecommended when he e a e clea indica ions ha con inuing wi h p egnancy poses a
g ea e isk o he mo he o baby han he isk o inducing labou [
11
]. The e o e, in line
