Long-Term Cesarean Delivery Patterns Using Classification

Jun 08, 2025

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The following is a summary of “An Intrapartum Cesarean Delivery Classification System – a prospective eighteen year longitudinal cohort study,” published in the May 2025 issue of American Journal of Obstetrics & Gynecology by Robson et al.

There was no universally accepted system to classify indications for cesarean delivery (CD), underscoring the need for distinct standardized frameworks for intrapartum and prelabor procedures.

Researchers conducted a retrospective study to describe the value of a standardized Intrapartum Cesarean Delivery Classification System (ICDCS) and its relationship with labor, delivery events, and outcomes within the Ten Group Classification System
(TGCS).

They performed a longitudinal analysis at an Irish tertiary maternity center with single cephalic pregnancies at ≥ 37 weeks’ gestation with either spontaneous or induced labor, delivered between January 1, 2005, and December 31, 2022. The population included nulliparous women in spontaneous labor (Group 1) or induced labor (Group 2a); multiparous women without a prior cesarean in spontaneous labor (Group 3) or induced labor (Group 4a); and women with a previous cesarean in spontaneous labor (Group 5a) or induced labor (Group 5b). Each cesarean performed after labor onset was classified using the ICDCS. Labor and delivery data were recorded in the National Maternity Hospital (NMH) Annual Clinical Report and used chi-square tests to compare proportions, with a P value of < .05 indicating statistical significance.

The results showed that over 18 years, 151,284 deliveries occurred at the NMH, with a CD rate of 24.5% (37,131/151,284). In Groups 1, 2a, 3, 4a, 5a, and 5b, 13,124 intrapartum cesarean deliveries were performed and classified using the ICDCS. The cesarean rate increased in Group 1 from 7.4% to 11.9% (P<.001) and in Group 2a from 27.9% to 38.3% (P<.001) over the study period, while rates in Groups 3, 4a, 5a, and 5b remained stable. Classification patterns within and between these groups were generally consistent, allowing clear identification of variations. Comparing Group 1 cohorts from 2010–2012 and 2020–2022 revealed rises in overall cesarean rates from 8.0% to 10.2% (P<.001), cesareans for fetal reasons without oxytocin from 1.3% to 2.6% (P<.001), dystocia due to inefficient uterine action and poor response from 0.9% to 2.1% (P<.001), and dystocia with efficient uterine action related to persistent malposition and cephalopelvic disproportion from 0.8% to 1.5% (P<.001). Conversely, cesareans for dystocia with inefficient uterine action and inability to treat over contracting decreased from 1.2% to 0.4% (P<.001). Postpartum hemorrhage ≥1000 mL increased from 0.6% to 4.1% (P<.001), vaginal operative delivery rates rose from 24.9% to 29.0% (P<.001), while oxytocin use declined from 52.6% to 48.0% (P<.001).