Cephalic Term Pregnancy Research Articles

Can the Day of the Week and the Time of Birth Predict the Mode of Delivery According to Robson Classification?

Worldwide, the cesarean section rate has steadily increased from 6.7% in 1990 to 21.1% in 2018 and is expected to rise even more. The World Health Organization propose the adoption of the Robson classification system as a global standard for monitoring, evaluating, and comparing delivery rates. The purpose of the current study is to use the Robson classification system to investigate how, independently of medical factors, the day of the week and time of delivery may be related to the mode of birth. In the sample analysis, we included the records of 8572 women giving birth in one private health facility in Greece. Over 60% of deliveries during the study period were performed by cesarean section, 30.6% by vaginal delivery, and 8.5% of deliveries were performed by operative vaginal delivery. The results of this study indicate that the lowest birth rates are observed on Monday, Saturday, and Sunday. Nulliparous women with no previous cesarean delivery, with a singleton in cephalic presentation ≥37 weeks with spontaneous labor (group 1) are 73% more likely to deliver by cesarean section between 08:00 A.M. and 03:59 P.M. compared to those who give birth between 12:00 A.M. and 07:59 A.M. Also, multiparous women with a single cephalic term pregnancy and one previous cesarean section (group 5.1) are 16.7 times more likely to deliver by cesarean section in the morning compared to overnight deliveries. These results point out two non-clinical variables that influences the CS rate. The Robson classification system was a useful tool for the above comparisons.

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.

Induction of Labor in Women with Previous Cesarean Section and Unfavorable Cervix: A Retrospective Cohort Study.

Background: The efficacy and safety of a cervical ripening balloon (CRB) in women with a previous cesarean section (CS) and unfavorable Bishop score are still controversial. Methods: A retrospective cohort study was performed across six tertiary hospitals from 2015 to 2019. Women with one previous transverse CS, singleton cephalic term pregnancy and BS < 6 were included if submitted to labor induction with a CRB. The main outcome was the rate of vaginal birth after cesarean (VBAC) after CRB ripening. Secondary outcomes were abnormal composite fetal and maternal outcomes. Results: Of the 265 women included, 57.3% had successful vaginal birth. Augmentation improved vaginal delivery (32.2% vs. 21.2%). Intrapartum analgesia was associated with an increased VBAC rate (58.6% vs. 34.5%). Maternal BMI ≥30 and age ≥40 years increased emergency CS rate (11.8% vs. 28.3% and 7.2 vs. 15.9%). Composite adverse maternal outcome occurred in 4.8% of CRB group women and increased to 17.6% when associated with oxytocin. Uterine rupture occurred in one case (0.4%) in the CRB-oxytocin group. Poorer fetal outcome occurred after emergency CS, if compared to successful VBAC (12.4% vs. 3.3%). Conclusions: In women with a previous CS and unfavorable Bishop score, induction of labor with a CRB can be considered safe and effective.

Investigating Caesarean Section Practice among Teenage Romanian Mothers Using Modified Robson Ten Group Classification System.

The Robson ten-group classification system is a recognized effective method of assessing caesarean rate. It is based on dividing patients into ten mutually exclusive groups, focusing on six maternal and newborn variables (parity, gestational age, plurality, foetal presentation, previous caesarean, and mode of labour onset). The aim of our analysis was twofold: first, to present the implementation of Robson classification in a pregnant teenage population; and second, to identify the indications for CS in the adolescent population. This study was designed as a one-year prospective analysis and considered all women younger than 20 years of age who delivered in a tertiary care hospital. Before discharge, women who had caesarean delivery responded to a questionnaire regarding their education, prenatal surveillance, and obstetrical history. Caesarean sections accounted for 47.01% of all births. A proportion of 24.57% of the participants had at least one previous caesarean section. Group 10 (all women with a single cephalic preterm pregnancy) was second most often identified among women in middle adolescence (14.03%); 32.20% of the participants in late adolescence were in group 5 (multiparas with a scarred uterus, single cephalic term pregnancy). Differences between the two age groups were not statistically different (p = 0.96). Abnormal cardiotocographic findings (38.23%), the arrest of descent (19.11%) and arrest of dilation (19.11%), were the most frequent indications for caesareans in Robson group 1. Neonates from mothers in Robson groups 8 (women with a multiple pregnancy) and 7 (multiparas single breech pregnancy) had the most unfavourable outcomes regarding gestational age at delivery and admission to the intensive care unit. We concluded that future focus on obstetrical management is mandatory in Robson groups 7 and 8. Adolescents in Robson group 1 (nulliparas, single cephalic term pregnancy, spontaneous labour) are the primary beneficiaries of strategies to reduce caesarean sections rates.

Impact of clinical audits on cesarean section rate in a Spanish hospital: Analysis of 6 year data according to the Robson classification

ObjectivesThe aim of this study is to analyze the impact of the introduction of an internal clinical audit on the cesarean section (CS) rate, evaluated according to the Robson Ten Group Classification System (TGCS), and to identify the main contributors to the overall CS rate in order to plan further interventions. Study DesignIn 2014, an internal clinic audit committee was established in our center. Modifications of clinical management protocols were also implemented.A retrospective review of clinical records was conducted and pre-audit (2011−2014) results were compared against audit (2015−2018) results. Patients were clustered according to the Robson TGCS and the analyzed outcomes were CS rate and maternal and neonatal results. ResultsBetween January 2011 and December 2018, 12,766 women gave birth at our institution among which 2,281 CS were analyzed. After the establishment of the clinical audit, the overall CS rate decreased from 20.27% to 14.82 % (p < 0.01). The major contribution to the overall CS rate in both periods were made by Group 2a (nulliparous with a single cephalic pregnancy at term who underwent labor induction: 4.86 % of all cases), followed by Group 5 (patients with a previous C-section: 3.26 %) and Group 1 (nulliparous with a single cephalic pregnancy at term with spontaneous labor: 2.39 %), representing 59.6 % of all CS.The group that showed the greatest reduction to the overall Cs rate was Group 2 (5.77 % vs 3.96 %, OR 1.48 (p < 0.01).No differences in perinatal and maternal results were found between preaudit and audit group. ConclusionAudit, feedback, and modification of clinical management protocols may be effective in changing clinical practice and reducing CS rates without worsening maternal and neonatal morbimortality. Robson TGCS allowed us to identify which groups had the greatest impact on CS rate in order to establish new strategies that may lead us to optimize the use of this intervention. It seems that efforts to reduce the overall CS rate should be directed on increasing vaginal birth after CS and reducing CS rates in nulliparous women with single cephalic full-term pregnancy.

Trends in Cesarean Delivery Rate after Cessation of the One-Child Policy in China.

We aimed to describe changes in cesarean delivery (CD) rates after the change of the one-child policy in China by using the Robson classification in a large Chinese population. This retrospective cohort study included 91,015 women who delivered at ≥24 weeks of gestation at a large tertiary obstetric center in Shanghai, China from 2011 to 2016. We analyzed CD rate trend and CD contribution trend in each Robson group. Logistic regression was used to calculate the odds of CD while adjusting for confounding variables. The overall CD rate decreased from 49.0% in 2011 to 40.6% in 2016. In nulliparous women with singleton cephalic term pregnancy and planned CD, the CD contribution rate was reduced significantly from 29.3% in 2011 to 16.4% in 2016 (p < 0.001). In multiparous with a scarred uterus, the CD contribution rate began to increase from 3.8% in 2011 to 9.1% in 2016 (p < 0.001). Compared with delivery in 2011, delivery in 2016 was associated with a 37% (adjusted odds ratio [aOR]: 0.63; 95% confidence interval [CI]: 0.60-0.66) reduction in CD. This reduction was observed in both nulliparous women with singleton cephalic term pregnancy (aOR: 0.57; 95% CI: 0.54-0.60), and multiparous women with singleton cephalic term pregnancy without scar (aOR: 0.41; 95% CI: 0.30-0.55). The rate of cesarean delivery in our Chinese population has declined significantly in the past few years.

Analysing the likelihood of caesarean birth after implementation of the two-childbirth policy in China, using the Ten Group Classification System

The aim of this study was to identify the main contributor to the high Caesarean section birth rate at a regional perinatal medical centre using the Robson Ten Group Classification System (TGCS). A total of 54,085 women were surveyed and were included in our study from 2015 to 2017 at the Women’s Hospital at Zhejiang University School of Medicine in Hangzhou, China. The Caesarean birth rate was similar among the three years; although, the new two-childbirth policy in China has been in implementation since 2016. According to the TGCS, Group 5 was the largest contributor to the overall Caesarean birth rate (40.79%), followed by Group 2 (21.36%). The Caesarean birth rate of Group 5 and Group 2 decreased significantly from 2015 to 2017 (p < .05). The proportion of Group 7 contributing to the overall Caesarean birth rate increased significantly (p < .05). Future efforts should focus on increasing vaginal birth after Caesarean in Group 5 and external cephalic version in Group 7 to decrease the overall Caesarean birth rate.Impact statementWhat is already known on this subject? The Ten Group Classification System (TGCS) proposed by World Health Organisation was used in some countries such as Queensland, Singapore and Japan to assess and compare Caesarean section rates. The main contributor to the high Caesarean birth rate varies in different counties. However, it is not widely used in China.What the results of this study add? It was the first study using the TGCS to analyse the Caesarean birth rate and the changes after implementation of the two-childbirth policy in China. It identified that Group 5 (multiparous mothers with a previous Caesarean birth in a singleton, cephalic full-term pregnancy) constituted the most important determinant of overall Caesarean birth rates, followed by Group 2 (nulliparous mothers with a singleton, cephalic full-term pregnancy undergoing an induction of labour or prelabour Caesarean birth). The contribution of Group 5 and Group 7 (multiparous women with a single breech pregnancy) to the overall Caesarean birth rate has increased significantly since the new childbirth policy was implemented.What the implications are of these findings for clinical practice and/or further research? Future efforts should focus on increasing vaginal birth after Caesarean in Group 5 and external cephalic version in Group 7 to decrease the overall Caesarean birth rate in China.

Caesarean section in Palestine using the Robson Ten Group Classification System: a population-based birth cohort study

ObjectiveTo analyse the current situation of caesarean section in Palestine using the Robson Ten Group Classification System (TGCS).DesignA population-based birth cohort study.SettingObstetrical departments in three governmental hospitals in Gaza.ParticipantsAll women...

Analysis of caesarean sections using Robson 10-group classification system in a university hospital in eastern Ethiopia: a cross-sectional study

ObjectiveTo analyse caesarean section (CS) using Robson 10-group classification system in an Ethiopian university hospital.DesignCross-sectional study.SettingA university hospital in eastern, Ethiopia.Participants980 women who underwent CS from January 2016 to April...

Caesarean section among immigrants with different obstetrical risks.

To determine the variation in caesarean section rates among immigrant populations. Australia is one of the most multicultural in the world and is also among those with the highest caesarean section rates. Secondary data analysis. Routinely collected data from a Local Heath District between 2011 and 2015 were analysed. Women were categorized into regional groups based on country of birth. Obstetrical risk was classified using the Robson classification. In total 48711 women gave birth, of whom 64.0% were born overseas; 13966 had a caesarean section (28.7%). South and Central Asia women had a high number of caesarean sections (n=4139; 29.6% of all caesarean sections), a high overall adjusted caesarean section rate (31.4%; 95% CI, 30.5%-32.3%), and consistently high caesarean section rates among women with single cephalic term pregnancy without a previous caesarean section. High adjusted caesarean section rates were seen among South East Asia women with nulliparous, single cephalic, term pregnancy, and spontaneous labour. Demographic and clinical characteristics explained 83.5% of the variation in overall caesarean section rates between country of birth and 21.8% to 100% depending on Robson group. Caesarean section rates varied by country of birth and within some Robson groups. The studied factors had various effects on the variation in caesarean section rates between country of birth and Robson groups.

Analysis of Caesarean section rate dynamics at Riga Maternity hospital between 2011 and 2015 according to Robson Ten Group Classification System

Introduction: The overall trend of increase in CS rate without clear evidence of decreases in maternal or neonatal morbidity or mortality raises significant concern that CS is overused. In 2001, Robson presented Ten Group Classification System (TGCS), which stratifies women according to their obstetric characteristics and in 2011 WHO stated that Robson would be the best to fulfill current international and local needs. In Latvia until now indication and urgency, based classifications were used. This is the first analysis of CS using TGCS. Aim. The purpose of the study was to carried out the audit of CS rate at Riga Maternity hospital using TGCS, and to see the dynamics of overall CS rate, the rate in each Robson group, and the contribution of each group to the overall CS rate, as well as to identify main indications for CS in the groups with major impact. Materials and methods: A descriptive retrospective study was conducted for 5 years from 2011 to 2015 at Riga Maternity hospital. Data were analyzed using TGCS, which stratifies all deliveries into 10 groups based on five routinely collected obstetric characteristics – parity, onset of labor, gestational age, fetal presentation, and number of fetuses. Statistical analysis and graphics were made by Matlab program. Results: A total 33,064 women gave birth from 2011 to 2015. Groups 1 (nulliparous with single cephalic full-term pregnancy with spontaneous labor), group 2 (nulliparous with single cephalic full-term pregnancy with induced labor (group 2a) or CS before labour (group 2b)), and group 3 (multiparous with single cephalic full-term pregnancy with spontaneous labor) are the largest groups representing in this study (Fig. 1A). Overall CS rate was decreasing from 2011 to 2014 (24.4%, 20.0%, 22.2% 19.9% respectively), and increased again in 2015–23.2% (Fig. 1B). Group 1 and 2 and group 5 (multiparous with previous caesarean section single cephalic full-term pregnancy) made the largest contribution to the overall CS rate. The main indications for CS are fetal distress, dystocia and cephalopelvic disproportion in group 1 and 2. In group 5 the main indication is previous CS. Comparing 2015 vs.2011, the largest increase in absolute contribution to the overall caesarean section rate are recorded in group 10 (women with single cephalic pre-term pregnancy) (+0.32%), group 5 (+0.21%), and group 1 (+0.19%), Fig. 1D. Although the CS rate has decreased within the group 5 (−5%), Fig. 1C, the size of the group 5 increased and also the contribution of this group to overall CS rate, Fig. 1D. Conclusion: Group 1, 2 and 5 are the largest contributors to the overall CS rate at Riga Maternity Hospital. To reduce the overall CS rate it is necessary to reduce CS rate in nulliparous women with single cephalic full-term pregnancy and increase vaginal birth after the first CS. A comparative analysis using the TGCS should be carried out in all institutions for childbirth in Latvian every year.

Comparison of delivery care provided by a midwife and by an obstetrician-gynaecologist in a low-risk pregnancy

Aim: The aim of the study was to compare delivery care provided by a midwife (group of midwifes) and an obstetrician-gynaecologist (group of physicians) in a low-risk pregnancy. Objectives: To evaluate the number of obstetrical interventions and operative deliveries in women who belonged to the group of midwifes or physicians. To evaluate newborn-related data in both groups. Methods: A retrospective analysis was performed at the Department of Obstetrics and Gynaecology of the Lithuanian University of Health Sciences. All the deliveries in 2012 were classified using the 10-group Robson classification. Data on nulliparous (Group 1) and multiparous (Group 3) with a single cephalic term pregnancy with spontaneous labour and low-risk pregnancy were analysed further. Demographic and delivery-related information was collected and evaluated. Results: Data on 1446 deliveries were analysed. Midwives provided care for 30% (439) and obstetricians-gynaecologists for 70% (1007) of women. Physicians were more frequently responsible for elder women (29.4 ± 4.7 years vs 28.0 ± 5.29 years, p = 0.013) and primiparous (p = 0.006). Other demographic data did not differ between the two groups. Women from the group of physicians were more likely to undergo amniotomy (36.2% vs 27.6%, p = 0.001), oxytocin augmentation (32.6% vs 27.1%, p = 0.039) and epidural analgesia (32.6% vs 22.6%, p < 0.001). More caesarean sections were performed in this group as well (10.4% vs 4.3%, p < 0.001), both for primiparous (15.9% vs 8%, p = 0.005) and for multiparous (4.5% vs 0.9%, p = 0.012). Other results relating to delivery (number of cervical, vaginal and perineal tears, episiotomies, postpartum haemorrhage) and newborns outcomes (Apgar scores, weight) did not differ between the two groups. Conclusion: Women with low-risk pregnancies underwent fewer obstetrical interventions and caesarean sections when their delivery care was provided by a midwife.

Cesarean section rates in Lithuania using Robson Ten Group Classification System

Background and objectiveThe aim of this study was to analyze cesarean section (CS) rates using Robson Ten Group Classification System (TGCS) and to identify the main contributors to the overall CS rate in Lithuania. Materials and methodsA prospective cross-sectional study was carried out. All women who delivered between January 1 and December 31, 2012, in Lithuania were classified using the TGCS. The CS rates overall and in each Robson group were calculated, as was the contribution of each group to the overall CS rate. ResultsThe CS rate was 26.4% (6697 among 25,373 deliveries) in 2012. Nulliparous women with single cephalic full-term pregnancy in spontaneous labor (Group 1) or who underwent induction of labor or prelabor CS (Group 2) and multiparous women with a previous CS (Group 5) were the greatest contributors (67.7%) to the overall CS rate. In addition, significant variation of CS rates between different institutions was observed, especially in women with single cephalic full-term pregnancy without previous CS (Groups 1–4), showing big differences in obstetric care across country. ConclusionsWomen in Groups 1, 2 and 5 were the largest contributions to the overall CS rate in Lithuania. It seems that efforts to reduce the overall CS rate should be directed on increasing vaginal birth after CS and reducing CS rates in nulliparous women with single cephalic full-term pregnancy (Groups 1 and 2).

Identification of obstetric targets for reducing cesarean section rate using the Robson Ten Group Classification in a tertiary level hospital

ObjectiveDue to continuous rise of cesarean section (CS) rate in recent decades to analyze this trend using Robson Ten Group Classification System (RTGCS) and identify the main contributor of the CS rate in an Italian tertiary level hospital. Study designA total of 17,886 deliveries in six (1998, 1999, 2004, 2005, 2010, 2011) of a 13-year period was analyzed using RTGCS. ResultsFrom 1998 to 2011 a rising CS birth rate from 38.7 to 43.7 per 100 births was calculated (p<0.001) in association with a significant reduction of vaginal delivery (VD) (59.7 vs. 53.7%; p<0.001). In multiparous women with a previous CS (Group 5) a repeat CS was performed routinely, resultant the most contributor of CS rate (15.4 vs. 16.2%; p<0.001). Nulliparous women with singleton cephalic full-term pregnancy in spontaneous or induced labor onset resulted the second contributor (Group 1, 3.3 vs. 4.7%; p<0.001; Group 2, 3.6 vs. 4.5%; p<0.001). ConclusionsThe RTGCS allows easy identification of the leading contributing patients groups. To propose and evaluate interventions for improving the labor management in nulliparous women and promote vaginal delivery after cesarean (VBAC) could help to mitigate further increases in the future.

Utility of the Robson Ten Group Classification System to determine appropriateness of caesarean section at a rural regional hospital in KwaZulu-Natal, South Africa.

High caesarean section (CS) rates are not only costly but associated with significant perinatal and maternal morbidity and mortality. It has recently been suggested that structured auditing of CSs may identify those groups in the obstetric population that contribute substantially to the high rates and for which focused interventions may bring about change. To evaluate the utility of the Robson Ten Group Classification System (RTGCS) in determining appropriateness of CS at a regional rural hospital in KwaZulu-Natal Province, South Africa. A retrospective review of the hospital records of women delivered by CS over a 3-month period was performed. The RTGCS was used to categorise women according to parity, age, past obstetric history, singleton or multiple pregnancy, fetal presentation, gestational age and mode of onset of labour/delivery. There were 2 553 hospital births over the 3-month study period. The CS rate was 42.4% (1 082/2 553). According to the RTGCS, groups 1 (n = 296, 27.4%), 5 (n = 186, 17.2%) and 10 (n = 253, 23.4%) were substantial contributors to the overall CS rate. The main indications for CS were fetal distress (36.5%) and cephalopelvic disproportion (26.8%). The RTGCS is a useful tool with which to identify patient groups warranting interventions to reduce high CS rates in a rural regional hospital setting. Group 1 (nullipara: single cephalic term pregnancy; spontaneous labour) warrants the most attention. Applying stricter criteria and due diligence in decision-making for primary CS may decrease the high CS rates.

Analysis of cesarean delivery at Assiut University Hospital using the Ten Group Classification System

ObjectiveTo evaluate the feasibility of using the Robson Ten Group Classification System (TGCS) for cesarean delivery (CD) indications at institutional level. MethodsProspective clinical audits of women delivering by CD at Women’s Health Hospital, Assiut, Egypt, were conducted in 2008 and 2011. The CD rates overall and in each Robson group were calculated, as was the contribution of each group to the overall CD rate. In addition, the CD indications in each group were analyzed. ResultsThe CD rate was 32% (443/1357) in 2008 and 38% (626/1628) in 2011. The most common CD indication at both time intervals was a previous CD. Multiparas without uterine scar, a single cephalic term pregnancy, and spontaneous labor (Robson Group 3) comprised the largest group of women undergoing CD, followed by nulliparas with a single cephalic term pregnancy and spontaneous labor (Group 1), and multiparas with a scarred uterus and a single cephalic term pregnancy (Group 5). Group 5 was the largest contributor (30%) to the overall CD rate, followed by Groups 1 and 4 (10% each). ConclusionThe TGCS can be applied at institutional level. It helps in planning strategies for specific subgroups of women to reduce CD rates and improve outcomes.

The rate of obstetric anal sphincter injuries in Finnish obstetric units as a patient safety indicator

ObjectiveTo study whether there are significant differences in the rate of obstetric anal sphincter injuries (OASIS) between the different sized delivery units in Finland. Study designThe study was performed as a population based registry study in Finland, including all births (294725) between 2006 and 2010. All the Finnish delivery units (34) were categorized by the number of annual deliveries and the OASIS rate was then compared between the different sized delivery units using a logistic regression analysis adjusting for maternal age and parity. The Robson ten group classification was used for more accurate comparison. ResultsThe OASIS rate was significantly elevated, both in the largest units with 5000 annual deliveries or more (OR 1.46, 95% CI 1.11–1.92) and in the smallest units with less than 500 annual deliveries (OR 1.33, 95% CI 1.22–1.45). In the Robson's group 1 (primiparous, single cephalic term pregnancy, spontaneous labour) the risk for OASIS was the highest in the largest units (OR 1.44, 95% CI 1.28–1.61) while in the Robson's group 3 (multiparous, single cephalic term pregnancy, spontaneous labour) the highest risk was found in the smallest units (OR 2.90, 95% CI 1.68–5.02). ConclusionsThere is significant inter-hospital variation in OASIS rates suggesting significant differences in obstetric practices. Robson's ten group classification should be used to enhance the inter-hospital comparison.

Changing trends of cesarean section births by the Robson Ten Group Classification in a tertiary teaching hospital

To analyse changing trends of cesarean section (CS) birth rates over an 11 year period (2000-2010) using the Robson Ten Group Classification System (RTGCS) to identify the main contributors to the rising CS birth rates at a tertiary teaching hospital in Singapore. Retrospective study. National University Hospital, Singapore. All women who delivered between 1 January 2000 and 31 December 2010 (hospital maternity database). The RTGCS was used to classify these women according to parity, past obstetric history, singleton or multiple pregnancy, fetal presentation, gestational age and mode of onset of labor/delivery. The RTGCS results. From 2000 to 2010 the CS rate increased from 19.9 to 29.6 per 100 births. Multiparous women with a previous cesarean birth (Group 5) were the greatest contributor to the CS rate, followed by nulliparous women with singleton cephalic full-term pregnancy in spontaneous labor (Group 1). These two groups contributed to 75% of the rise in the CS rate from 2000 to 2010. The increase in CS rate is attributed largely to the rising CS rate in Group 5, followed by Group 1. We propose that future efforts to reduce overall CS rate should be focused on increasing vaginal birth after cesarean and reduce CS rates in nulliparous women with singleton cephalic full-term pregnancy (Groups 1 and 2), which in turn will reduce the number of pregnant women with a previous CS.