Tuesday 25 October 2016

C-sections: Irish specialist comes up with internationally recognised 10-point-guide to Caesarean sections

WHO warned this week that global rates of C-sections are too high, hitting 39pc here. An Irish specialist has come up with an internationally recognised 10-point guide. Is it the answer...

Published 19/04/2015 | 02:30

Phoebe McVey from Galway (city) is expecting her second child at start of June.
Phoebe McVey from Galway (city) is expecting her second child at start of June.

The C-Word was back in the news this week after the World Health Organisation claimed Caesarean sections should only be done "when medically justified".

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Since 1985, the United Nations' public health agency has touted the ideal rate for Caesarean sections as being between 10 and 15pc of births.

As Ireland's C-section rate swelled to up to 39pc in some hospitals last year however, it expressed concern over the global surge in the surgical procedure: "When medically justified, a Caesarean section can effectively prevent maternal and perinatal mortality and morbidity.

"However, there is no evidence showing the benefits of Caesarean delivery for women or infants who do not require the procedure.

"As with any surgery, Caesarean sections are associated with short and long-term risk which can extend many years beyond the current delivery," it added, "and affect that health of the woman, her child, and future pregnancies."

Now an Irish doctor has found himself at the heart of the controversial 'too posh to push' debate after the WHO also backed his ground-breaking classification system for mums-to-be.

Read more: The 'too posh to push' slating of C-section mums: Irish mums share their thoughts

Dubbed the Robson Classification after Dublin-based obstetrician Dr Michael Robson, the new system essentially classifies women into 10 different groups based on their obstetric characteristics.

Speaking to Weekend Review this week, Dr Robson told of his pride and embarrassment at the endorsement: "Having my name on it is kind of the more embarrassing thing.

"[But] I will say it is something that I spent a lot of time doing. It took a while, and with a lot of input from different people."

Dr Robson - a consultant obstetrician and gynaecologist at the National Maternity Hospital - first proposed the fool-proof system for studying worldwide C-section rates back in 2001.

In its most recent report this week, the WHO accepted: "At the heart of the challenge in defining the optimal Caesarean section rate at any level is the lack of a reliable and internationally accepted classification system to produce standardised data, enabling comparisons across populations and providing a tool to investigate drivers of the upward trend in Caesarean section.

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"WHO proposes the Robson classification system as a global standard for assessing, monitoring and comparing Caesarean section rates within healthcare facilities over time, and between facilities."

Welcoming the news, Dr Sharon Cooley, consultant obstetrician/gynaecologist at the Rotunda and spokesperson for the Institute of Obstetricians and Gynaecologists, said: "It is great to see an Irish obstetrician leading the way in developing a classification system which could be used internationally to improve the quality of care for mothers and babies.

"The use of the Robson Classification allows us to understand the role played by each group of women in the increase in Caesarean section rates. It will also help healthcare professionals working in maternity units to identify the mothers that are more likely to require a Caesarean section, and the management of their labour would be informed by that."

Perinatal reports show that Ireland's C-section rate has risen steadily from 13pc in 1999 to 26pc 2007 and 30pc in 2013.

Last year however, a HSE report found that rate between hospitals varied by up to 19pc - from 19pc at Sligo General Hospital to 38pc at St Luke's Hospital in Kilkenny - leading the Association of Improvements in Maternity Services to describe the practice as a "geographic lottery".

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"Caesarean section rates are going up," said Dr Robson, "it might be good, and it may be bad. What my personal opinion is, what's right and wrong, that's maybe an irrelevance to the local situation.

"Everybody's trying to provide the best care. There are general issues - and local issues as well - why it might be high or low, but I think we should be able to study it and see what the significance is.

"The WHO statement, as I understand it, said they're worried about doing it for other things than medical indications," he added. "But I think it's also saying, 'Look, why don't we maybe stop the discussion in terms of what the ideal rate is … and learn from each other'.

"This isn't about Active Management [of] Labour. It's not to confront people and say, 'You should have a low Caesarean section rate or high Caesarean section rate'. It's just to say, 'Well look, let's standardise the data and make sense of it in different groups'.

"Those who have a low section rate may be surprised by those that have a higher [rate], and vice versa."

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Elsewhere in the US and UK, Caesarean section rates have also peaked at 33pc and 25pc, respectively, with the figures thought to reflect a combination of doctors believing surgery to be safer in certain births and women choosing not to undergo labour.

Writing in a medical journal the consultant professor Michael Turner of the UCD Centre for Human Reproduction at the Coombe said: "The main reasons for the rise in CS rates in developed countries are the safety of the procedure and the perceived risks of labour. It has been fuelled by the 'carpe diem' mentality of modern life where women and their doctors focus on the short-term outcomes of the current pregnancy without considering the long-term consequences for a woman's health."

"It is worrying to see the incidence of Caesarean section births increase worldwide over the last decade," said Laura Haugh of MummyPages.ie, Ireland's biggest online parenting community.

"Of course C-sections are a welcome intervention in emergency situations and when planned for medical reasons. However, our mums have commented on the lack of choice available to them when it comes to their birth plans.

Read more: 'I'm lucky I carried both girls to term': Why early detection of pre-eclampsia saves lives

"During labour a mother is at her most vulnerable and just wants to do what is best for her baby," she continued. "If she and her partner are advised that their natural delivery is not progressing, then they must trust in the medical staff caring for them."

Back at Holles Street, Dr Robson - whose eponymous classification has been adopted by hospitals throughout the globe including Africa and China - urged a shift in focus from Caesarean section rates to the outcomes for both mother and baby.

"The Caesarean section rate on its own is meaningless unless you can look at other parameters as a result of it," he argued. "You may look at the Caesarean section rate [and] say, 'Oh, well that's very low', [but] how are the babies? How long are the labours? How often do you use oxytocin? What's the haemorrhage rate? All of these other things are very important."

Despite spiralling C-section rates, he rubbished the notion of women here being 'too posh to push': "Most women choose the type of delivery they want for what is safest for them and their baby, I really do believe that.

"There are various situations, rare situations, where people either having had a very long labour before or having had a difficult experience, just don't want [that] next time.

Read more: 'I had the crisis pregnancy and despite pressure to have an abortion, I chose to have her.'

"I think that's why we've got to look after people physically well, but also emotionally well.

"We should know what our section rate is, why we're doing it and which groups of women," acknowledged Dr Robson. "At the end of the day though, outcome is the most important thing.

"You can have the best technology in the world, but a caring midwife - and, dare I say it, a caring doctor as well - is very crucial."

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