Desenvolvimento de protocolo e manual para implantação da Classificação de Robson na admissão de gestantes para parto nas maternidades e casas de parto públicas do Distrito Federal, Brasil

Abstract

Introduction : The high rate of cesarean section delivery, contrary to the recommendations of the World Health Organization, persists as a global challenge in maternal and child health. The Robson Classification, proposed in 2001 and widely adopted, emerges as a standardized tool for monitoring and comparing cesarean section rates in different contexts, enabling the assessment of the impact of management adjustments. Despite the various advantages of this classification, it does not take into account other maternal or fetal factors that significantly influence cesarean section rates, such as high-risk pregnancies and fetal abnormalities. Objectives : Evaluate the Robson Classification in the context of a high-risk public maternity facility in the Federal District of Brasília, Brazil, analyzing pregnant women who gave birth on-site according to the Robson Classification, stratifying women based on the presence of low or high-risk situations. Present the protocol for using the Robson Classification upon admission of pregnant women for delivery in public maternity wards and birthing homes in the Federal District of Brasília, Brazil. Method : Cross-sectional observational study with data obtained from the health records of pregnant women undergoing delivery at the Maternal and Child Hospital of Brasília (Hmib), Brazil. All 1813 deliveries that occurred between January 1, 2019, and June 30, 2019, in the hospital's obstetric center were included. Electronic medical records of participants and procedure logs from the obstetric center were accessed for tracking and data collection. Data were analyzed concerning parity (nulliparous or multiparous with or without previous cesarean section), onset of labor (spontaneous, induced, or cesarean before the onset of labor), gestational age (premature or term), fetal presentation/situation (cephalic, breech, or transverse), and number of fetuses (single or multiple). Women were grouped into one of the 10 Robson Classification groups, stratifying the data according to obstetric and neonatal characteristics, including the presence of low or high-risk situations, type of delivery, and neonatal outcomes obtained. The significance probability used in hypothesis tests was 0.05, and comparisons of categorical variables were performed using Pearson's chi-square tests. The study was submitted to and approved by the Research Ethics Committee of the Foundation for Teaching and Research in Health Sciences, and data collection began after the committee's project approval, between December 2019 and January 2020. Confidentiality of participants and collected data was maintained. The study was funded with the researcher's own resources. All pregnant women who gave birth in the Obstetric Center of Hmib were included. The limit considered for defining delivery was gestational age greater than or equal to 22 weeks or weight greater than or equal to 500 grams. There were no exclusions of participants. Results : The conclusions of the tests were produced with p-values using the traditional cutoff of 5%. A total of 1813 records of pregnant women undergoing delivery from January to June 2019 at Hmib were analyzed. Regarding parity, 671 (37.1%) of the pregnant women were nulliparous, and 508 (28%) were multiparous with a previous cesarean section. Regarding the onset of labor, there was a predominance of the number of parturients who entered spontaneous labor - 1212 (66.8%). Meanwhile, 413 (22.8%) participants underwent cesareans before the onset of labor. Considering gestational age, 1426 (78.7%) deliveries were at term, and 253 (13.9%) were preterm. Concerning fetal presentation, 1676 (95%) fetuses were in cephalic position, while 85 (4.8%) were in breech position. As forthe number of fetuses, 1765 (97.4%) pregnant women had a singleton pregnancy. Regarding the size of the groups representing the population, Group 5 was the largest, with 21.8% of women admitted for delivery between January and June 2019 at Hmib. Groups 1 and 3 were the second and third largest, with 19.9% and 19.5% of pregnant women, respectively. The overall cesarean rate at Hmib during the analyzed period (N=1813) was 55.7%. The Robson groups with the highest cesarean rates were 9, 7, and 6, with rates of 100%, 98.3%, and 96%, respectively. Additionally, subgroups 2b and 4b had 100% cesarean rates due to being the only option in the group, and 5.2 had a 99% rate. However, when evaluating the group that contributed the most to the overall cesarean rate, Group 5 was the highest, with 33.3%, followed by Group 2, with 14.3%. Each Robson group was evaluated based on the type of delivery, cesarean or vaginal, and in relation to the early neonatal outcome of Apgar score (5th minute) and weight; if the pregnant woman was high-risk, if there was fetal pathology and what type of pathology, and among women with maternal comorbidity, the comorbidities presented. Based on the obtained data, it is concluded that there is an association with the type of delivery, newborn weight, and the presence of fetal pathology, regardless of the type. Newborns weighing over 4000g and the presence of fetal pathology determined the choice of cesarean delivery. Furthermore, it is concluded that there is an association with the type of delivery, whether the pregnant woman is considered high-risk, and whether there is fetal pathology, regardless of the type of pathology. The fact that the pregnant woman did not have high-risk monitoring and there was no fetal pathology was decisive in the conduct of vaginal delivery. Higher cesarean rates were observed in: high-risk pregnant women, the presence of fetal pathology, and among fetal pathologies, those with changes in Doppler flowmetry and amniotic fluid, and restricted intrauterine growth. Regarding the type of maternal comorbidity, there was an association only in the Robson 10 group. Presence of maternal infection, preeclampsia, gestational diabetes, and hypertension, whether gestational or chronic, were associated with higher cesarean rates in preterm births, Robson Group 10. Developed products : A protocol for the use of Robson's Classification on admission of pregnant women for delivery in public maternity hospitals and birthing centers in the Federal District of Brasília, Brazil, published as an e-book and submitted as a proposal for an care protocol by the Health Secretariat of the Federal District, Brasília, Brazil. Article submitted for publication in the Concilium Journal ISSN: 0010-5236 - CC BY-NC-SA, "Analysis of the appropriateness of the use of Robson's Classification in a high-risk maternity ward in Brasília, Brazil." Conclusions : The importance of using the Robson Classification as a tool for monitoring, planning, and decision-making by the healthcare team regarding cesarean section rates is emphasized. However, its limitations in the context of a high-risk maternity setting are acknowledged. Hmib exhibits a high cesarean section rate (55.7%), with 51.4% in preterm cesarean deliveries. The presence of fetal disease influenced the choice of cesarean section in various Robson groups in the studied population (1, 4, 4a, 5, 5.1, and 10). These findings could be explained by the fact that Hmib serves as a reference maternity facility for high-risk pregnancies. Nevertheless, it is evident that cesarean section rates can still be reduced in women with previous cesarean deliveries, term breech presentations, and term multiple pregnancies, except in cases with the first breech presentation. Based on this study, it is proposed to adopt a protocol for using the Robson Classification upon admission of pregnant women for delivery in maternity wards and birthing homes of the Health Department of the Federal District in Brasília, Brazil. This implementation is expected to lead to a reduction in cesarean section rates and the promotion of quality care, with minimal interventions for both mother and baby.