Evaluation of Delivery Patterns Using the Robson Ten Group Classification System in a Tertiary Care Hospital

Krishna G et al | DOI: 10.65188/nurexus.1065

Page 34

Journal of MedVerse Research & Practice

ISSN: 3107-4278

Evaluation of Delivery Patterns Using the Robson Ten Group

Classification System in a Tertiary Care Hospital

Dr. Gopika Krishna, Dr. S Shakthi Selvi

Postgraduate, Professor

Department of OBG

Pondicherry Institute of Medical Sciences, Puducherry.

Email ID: gopika1993@gmail.com

Submission Date: 29.12.2025

Accepted Date: 27.01.2026

Published Date: 31.01.2026

DOI: 10.65188/nurexus.1065

article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted

use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

Abstract

Background: The rising rate of caesarean section (CS) has emerged as a major public health concern worldwide,

particularly in tertiary care hospitals managing a high proportion of high-risk pregnancies. The Robson Ten Group

Classification System offers a standardized and reproducible method to analyse delivery patterns and identify key

contributors to caesarean section rates.

Objectives: To categorize all deliveries using the Robson Ten Group Classification System and to evaluate the

overall and primary caesarean section rates along with their major contributing groups in a tertiary care hospital.

Methods: This prospective observational study was conducted in the labour unit of a tertiary care teaching hospital

over a period of two years. All pregnant women aged 18 years and above with a gestational age of 24 weeks or more

admitted for delivery were included. Deliveries were categorized into ten groups using the Robson Ten Group

Classification System. Data on maternal characteristics, labour onset, mode of delivery, and indications for caesarean

section were collected and analysed using descriptive statistics.

Results: A total of 600 deliveries were analysed. The overall caesarean section rate was 39.0%, with primary

caesarean sections accounting for 62.4% of all caesarean deliveries. Robson Group 1 was the largest group, while

Robson Group 5 was the single largest contributor to the overall caesarean section rate, accounting for 38.5% of

caesarean deliveries. Nulliparous women in Groups 1 and 2 together contributed significantly to primary caesarean

sections. Non-reassuring fetal heart rate pattern and failure to progress in labour were the most common indications

for primary caesarean section.

Conclusion: The Robson Ten Group Classification System proved to be an effective audit tool for analysing delivery

patterns and caesarean section practices in a tertiary care hospital. The high contribution of women with previous

caesarean sections and nulliparous women highlights the need for targeted interventions to reduce unnecessary

primary caesarean sections and promote evidence-based obstetric care.

Keywords: Robson Ten Group Classification System; Caesarean section; Delivery patterns; Tertiary care hospital;

Maternal health; Obstetric audit

Introduction

Delivery care is a fundamental component of maternal and newborn health services and has a direct

influence on obstetric outcomes. Over the past few decades, there has been a substantial global rise in

caesarean section (CS) rates, making it a major public health concern because of associated maternal

morbidity, neonatal complications, increased healthcare costs, and wide variations in obstetric practice

across institutions and regions [1]. While caesarean section is a life-saving intervention when medically

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indicated, unnecessary or excessive use does not confer additional benefits and may adversely affect

maternal and perinatal outcomes [1,2]. According to the World Health Organization, population-based

caesarean section rates above 10–15% are not associated with further reductions in maternal or neonatal

mortality [3]. Despite this recommendation, many tertiary care hospitals report caesarean section rates far

exceeding these thresholds [2,4]. The rise in caesarean deliveries is multifactorial and has been attributed

to increasing maternal age, higher prevalence of previous caesarean sections, greater use of labour

induction, changing obstetric practices, medico-legal concerns, and institutional policies [2,5]. In tertiary

care settings, the presence of high-risk pregnancies and referral bias further complicates interpretation of

overall caesarean section rates.

A major challenge in addressing rising caesarean section rates is the lack of a standardized, reproducible,

and clinically meaningful method to analyse delivery patterns. Earlier classification systems were

commonly based on indications for caesarean section, which are often subjective, overlapping, and

inconsistently documented, limiting meaningful comparisons between hospitals, regions, and time periods

[6]. To overcome these limitations, Robson proposed the Ten Group Classification System, a mutually

exclusive and totally inclusive framework that categorizes all women admitted for delivery into ten groups

based on five obstetric characteristics: parity, previous caesarean section, onset of labour, gestational age,

fetal presentation, and number of fetuses [6,7].

The Robson Ten Group Classification System has been widely endorsed as the global standard for

monitoring, auditing, and comparing caesarean section rates. The World Health Organization formally

recommends its use at facility, regional, national, and international levels [3,7]. This system enables

identification of specific obstetric groups that contribute most to the overall caesarean section rate, such as

nulliparous women with induced labour or women with a previous caesarean section, thereby supporting

targeted clinical audits and evidence-based interventions [7,8].

In tertiary care hospitals, where obstetric populations are heterogeneous and referral loads are high,

systematic analysis using the Robson classification is particularly valuable. It helps differentiate between

unavoidable and potentially preventable caesarean sections, facilitates quality improvement initiatives, and

promotes rationalization of obstetric practices while ensuring maternal and fetal safety [4,8]. The present

study applies the Robson Ten Group Classification System to categorize deliveries in a tertiary care hospital

and analyse caesarean section patterns to inform institutional obstetric practice.

Materials and Methods

This prospective observational study was conducted in the Labour Unit of the Department of Obstetrics

and Gynaecology at Pondicherry Institute of Medical Sciences, Puducherry, a tertiary care teaching hospital

providing comprehensive obstetric services to both low-risk and high-risk pregnant women. The study was

carried out over a period of two years, from March 2024 to February 2026. All pregnant women aged 18

years and above with a gestational age of 24 weeks or more who were admitted for delivery during the

study period were included using a consecutive sampling technique, and no exclusion criteria were applied.

The minimum required sample size was calculated as 600 deliveries, assuming that 50% of deliveries would

fall under Robson Group 1, with an absolute precision of 4% and a 95% confidence interval, using the

standard formula n = Z²₁₋α⁄₂ × p × (1 − p) / d², where Z was 1.96, p was 0.5, and d was 0.04.

As this was an analytical observational study, no randomization or intervention was performed, and

participants were categorized solely based on the Robson Ten Group Classification System. Data were

collected using a structured case record form through detailed history taking, clinical examination, and

review of labour ward records, capturing maternal age, gestational age, parity, number of fetuses, fetal

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presentation, onset of labour, mode of delivery, Robson group classification, and indications for caesarean

section where applicable. Each delivery was assigned to one of the ten Robson groups based on predefined

criteria, and the assigned group was cross-verified during routine departmental audit meetings to ensure

accuracy and uniformity. The study was conducted after obtaining approval from the Institutional Ethics

Committee of Pondicherry Institute of Medical Sciences, and written informed consent was obtained from

all eligible participants prior to enrolment.

Results

Table 1. Baseline obstetric characteristics of the study population (n = 600)

Variable

Number (%)

Maternal age (years), mean ± SD

26.8 ± 4.3

Gestational age ≥ 37 weeks

512 (85.3%)

Nulliparous

278 (46.3%)

Multiparous

322 (53.7%)

Singleton pregnancy

574 (95.7%)

Multiple pregnancy

26 (4.3%)

Cephalic presentation

528 (88.0%)

Non-cephalic presentation

72 (12.0%)

Spontaneous onset of labour

402 (67.0%)

Induced labour / pre-labour CS

198 (33.0%)

Vaginal delivery

366 (61.0%)

Caesarean section

234 (39.0%)

Presents the baseline obstetric characteristics of the study population. The mean maternal age was 26.8 ±

4.3 years, with the majority of women delivering at term. More than half of the participants were

multiparous, and singleton, cephalic presentations predominated. Spontaneous onset of labour was

observed in two-thirds of women. The overall caesarean section rate was 39.0%, which is relatively high

and reflects the tertiary care setting with a substantial proportion of high-risk and referral cases.

Table 2. Distribution of deliveries according to Robson Ten Group Classification (n = 600)

Robson Group

Description

Total deliveries n

(%)

Group 1

Nulliparous, singleton, cephalic, ≥37 weeks, spontaneous

labour

192 (32.0%)

Group 2

Nulliparous, singleton, cephalic, ≥37 weeks, induced or CS

before labour

82 (13.7%)

Group 3

Multiparous (no previous CS), singleton, cephalic, ≥37

weeks, spontaneous labour

156 (26.0%)

Group 4

Multiparous (no previous CS), singleton, cephalic, ≥37

weeks, induced or CS before labour

46 (7.7%)

Group 5

Previous CS, singleton, cephalic, ≥37 weeks

102 (17.0%)

Group 6

Nulliparous, singleton breech

17 (2.8%)

Group 7

Multiparous, singleton breech

10 (1.7%)

Group 8

Multiple pregnancy

26 (4.3%)

Group 9

Singleton pregnancy with abnormal lie

5 (0.8%)

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Group 10

Singleton, cephalic, <37 weeks

14 (2.3%)

Shows the distribution of deliveries according to the Robson Ten Group Classification System. Robson

Group 1 constituted the largest group, followed by Group 3 and Group 5. Together, these three groups

accounted for nearly three-quarters of all deliveries. The sizeable proportion of women in Group 5 indicates

a high prevalence of previous caesarean section in the study population, which has important implications

for overall caesarean section rates in tertiary care institutions.

Table 3. Caesarean section rate within each Robson group

Robson Group

Caesarean sections n

Group CS rate (%)

Group 1

41 / 192

21.4%

Group 2

40 / 82

48.8%

Group 3

22 / 156

14.1%

Group 4

18 / 46

39.1%

Group 5

88 / 102

86.3%

Group 6

16 / 17

94.1%

Group 7

9 / 10

90.0%

Group 8

15 / 26

57.7%

Group 9

5 / 5

100%

Group 10

10 / 14

71.4%

Demonstrates the caesarean section rate within each Robson group. As expected, Robson Group 9 had a

caesarean section rate of 100%, reflecting standard obstetric practice for abnormal lie. Very high caesarean

section rates were also observed in Groups 6 and 7, corresponding to breech presentations. In contrast, low-

risk groups such as Group 3 and Group 1 had comparatively lower caesarean section rates, indicating

appropriate use of caesarean delivery in these categories.

Table 4. Contribution of each Robson group to overall caesarean section rate (n = 234)

Robson Group

Caesarean sections n

Contribution to total CS (%)

Group 1

41

17.5%

Group 2

40

17.1%

Group 3

22

9.4%

Group 4

18

7.7%

Group 5

88

38.5%

Group 6

16

6.8%

Group 7

9

3.8%

Group 8

15

6.4%

Group 9

5

2.1%

Group 10

10

4.3%

Highlights the contribution of individual Robson groups to the overall caesarean section rate. Robson Group

5 emerged as the single largest contributor, accounting for more than one-third of all caesarean sections.

Groups 1 and 2 together contributed over one-third of caesarean sections, emphasizing the role of primary

caesarean deliveries in nulliparous women. These findings identify Groups 1, 2, and 5 as key targets for

focused clinical audit and intervention.

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Figure 1. Primary caesarean section indications (n = 146)

Summarizes the indications for primary caesarean section. Non-reassuring fetal heart rate pattern was the

most common indication, followed by failure to progress in labour and cephalopelvic disproportion. These

indications were predominantly observed among nulliparous women, underscoring the need for careful

intrapartum monitoring, appropriate use of labour augmentation, and adherence to evidence-based labour

management protocols to reduce potentially avoidable primary caesarean sections.

Discussion

In this prospective study of 600 deliveries classified by the Robson Ten Group system, the overall

caesarean section (CS) rate was 39.0% and Robson Group 5 (women with previous CS, singleton,

cephalic, ≥37 weeks) was the single largest contributor, accounting for 38.5% of all CS. Nulliparous

women (Groups 1 and 2) collectively contributed significantly to the primary CS burden. These patterns

are consistent with multiple recent facility-level Robson audits but also show important local differences

that merit discussion.

Several multicentre and single-centre Robson studies report overall CS rates that vary widely depending

on case-mix and referral patterns. Vogel et al. [9] reported broad international variation with higher rates

in tertiary referral settings, consistent with our elevated 39% rate. Similarly, Betrán et al. [10] and

Molina et al. [11] found that tertiary and referral hospitals frequently demonstrate CS rates well above

national averages because of higher-risk case-mix and referral bias. Our finding of a high overall CS

rate therefore, aligns with these previous observations.

Robson Group 5 being the leading contributor to CS is a finding that echoes many contemporary audits.

Souza et al. [12] and Torloni et al. [13] reported that women with prior CS often represent a substantial

and growing fraction of deliveries and account for a large share of institutional CS rates. In an Indian

tertiary setting, Patel et al. [14] similarly observed Group 5 contributions ranging from 25–40% of total

CS, comparable to our 38.5%. This convergence highlights two linked issues: rising primary CS in

earlier years and conservative approaches to vaginal birth after cesarean (VBAC) in many centres.

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The role of nulliparous women in driving primary CS is also well documented. Our analysis showed

Groups 1 and 2 together accounted for a substantial proportion of primary CS, with Group 2

(nulliparous, induced or pre-labour CS) demonstrating a particularly high group CS rate (48.8%). Vogel

et al. [9] and Robson [15] emphasize that reducing unnecessary primary CS in nulliparous women is

key to lowering overall institutional CS rates. Studies by Gómez et al. [16] and Singh et al. [17] found

similar high contributions from Groups 1–2 in tertiary hospitals and recommended targeted labour-

management protocols (e.g., careful induction policies, active management of labour, and standardised

criteria for labour dystocia) to reduce primary CS. Our results support prioritizing audit and intervention

in Groups 1 and 2.

Group-specific extremes observed in our cohort—100% CS in Group 9 (abnormal lie) and very high CS

rates in breech groups (Groups 6 and 7)—are expected and comparable with other reported series. Khan

et al. [18] and Lopez et al. [19] documented near-universal CS for abnormal lie and high CS rates for

breech presentation in settings where external cephalic version or vaginal breech delivery is rarely

practiced. These groups therefore represent appropriate and unavoidable contributors to the overall CS

rate.

When comparing the contribution of induced labours and pre-labour CS (Groups 2 and 4), our findings

mirror those reported by Ahmed et al. [20] and Rao et al. [21], who observed that induction practices

and pre-labour CS decisions can markedly influence institutional CS patterns. In particular, the elevated

CS rate in Group 2 suggests opportunities to review induction protocols, indications for elective pre-

labour CS, and intrapartum management to potentially reduce avoidable CS.

Several authors have also examined the impact of implementing Robson-based audits and quality

improvement interventions. Martínez et al. [22] and Fernandes et al. [23] demonstrated that repeated

feedback, standardized labour protocols, and VBAC-promoting strategies can reduce Group 1–2 CS

rates and, over time, the size and CS contribution of Group 5. These intervention studies provide a

roadmap for institutional changes in our setting: strengthening labour management, auditing primary

CS indications, and developing safe VBAC pathways.

Finally, benchmarking is important: while some centres report lower CS rates in low-risk groups

(Groups 1 and 3) than ours, others report similar or higher rates depending on referral load and

institutional policies. Olusanya et al. [24], Dutta et al. [25], and Ramirez et al. [26] all underscore that

Robson profiling is most useful when coupled with local audit, context-specific interventions, and

continuous monitoring. Our results, particularly the dominance of Groups 1, 2 and 5 in contributing to

CS, therefore identify clear targets for quality improvement within our tertiary setting.

Recommendations: Based on the findings of this study, routine implementation of the Robson Ten

Group Classification System is recommended for continuous audit of delivery practices in tertiary care

hospitals. Focused strategies should be directed toward reducing unnecessary primary caesarean

sections in nulliparous women through adherence to evidence-based labour management protocols,

standardized criteria for labour induction, and appropriate use of intrapartum monitoring. Development

and strengthening of institutional policies supporting vaginal birth after caesarean section in eligible

women may help reduce the contribution of Robson Group 5 to overall caesarean section rates. Regular

departmental audits, feedback to clinicians, and multidisciplinary review of caesarean section

indications are essential for sustaining quality improvement. Additionally, integration of Robson-based

analysis into institutional and regional maternal health surveillance systems may support benchmarking

and policy formulation.

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Strengths: A major strength of this study is its prospective design, which allowed complete and accurate

data collection for all deliveries during the study period. The use of the Robson Ten Group Classification

System ensured standardized, mutually exclusive, and totally inclusive categorization of all deliveries,

facilitating meaningful analysis and comparison with other studies. The large sample size and inclusion

of both low-risk and high-risk pregnancies enhance the reliability of the findings and reflect real-world

obstetric practice in a tertiary care setting.

Limitations: The study was conducted at a single tertiary care institution, which may limit the

generalizability of the findings to primary or secondary care settings. The high caesarean section rate

observed may partly reflect referral bias and the predominance of high-risk pregnancies inherent to

tertiary care hospitals. Additionally, neonatal and long-term maternal outcomes were not evaluated, and

the study did not assess the impact of specific interventions to reduce caesarean section rates. Future

multicentre studies incorporating outcome measures and intervention-based designs would provide

broader insights into optimizing delivery practices.

Conclusion

This prospective observational study applying the Robson Ten Group Classification System provides a

clear and structured overview of delivery patterns and caesarean section practices in a tertiary care

hospital. The overall caesarean section rate was high, with women in Robson Group 5 emerging as the

largest contributors, followed by nulliparous women in Groups 1 and 2. These findings highlight the

cumulative impact of primary caesarean sections on subsequent delivery patterns and underscore the

importance of judicious decision-making in nulliparous women. The Robson classification proved to be

a practical and effective audit tool, enabling identification of key obstetric groups contributing to the

caesarean section rate and offering actionable insights for improving intrapartum care and optimizing

obstetric outcomes in a tertiary care setting.

Conflict of interest: No Conflict of interest

Source Of Fund: No fund source

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