Introduction
The increasing CS rate is a subject of debate within perinatal
care.1, 2 In order to monitor CS rates at national and
institutional levels WHO, FIGO and EBCOG in addition to many national
professional societies have endorsed the Ten-Group-Classification System
(TGCS) as the most appropriate tool for clinical
audit.3-6 The TGCS classifies all women into
clinically relevant groups each having a specific CS rate. It serves as
the initial structure within which epidemiological variables, processes,
perinatal events and outcomes can be analysed. The philosophy of the
TGCS is based on ‘an intention to treat’.4, 7, 8However although the TGCS tells you which women have a CS it does not
tell you why.
Internationally there is no consensus on classification of indications
for CS and none fulfill the criteria of simplicity, usefulness,
reproducibility and robustness.9 Indications for
pre-labour CS need to be considered differently from those performed
after spontaneous or induced labour and therefore deserve a separate
classification.10 Most indications used are very
detailed, often subjective and multiple and frequently overlap. This may
result in long lists of possible indications which has limited use on a
day-to-day basis to understand, change and improve care. Using a high
level classification system of CS initially prior to more detailed and
subjective indications both in prelabour CS and after spontaneous or
induced labour may provide the solution.
In 2014-15 a national quality improvement initiative, focusing on the
appropriate and safe use of oxytocin in labour took place at delivery
units in Norway. During this project, Norwegian maternity health
caregivers became aware of a new high level intrapartum CS
classification system (ICSCS) (Fig.1), incorporating information on the
fetal condition, the dynamic progress of labour, the use or not of
oxytocin to accelerate or induce labour and the frequency of
contractions. 10-12 This new ICSCS gives a unique
insight into the study and management of dystocia and the use of
oxytocin. The authors emphasize that the classification is designed to
be used irrespective of how you manage labour and must not be
misinterpreted as clinical guidance on how to manage labour.
Specifically the division of dystocic labours into those with efficient
(progress ≥1 cm/h) or inefficient (progress <1 cm/h) uterine
action is not an imperative for clinical management, but a pragmatic
cut-off to differentiate between the different dynamics of labour.
This classification has been used in The National Maternity Hospital,
Dublin since 2005 13 but had never been formally
tested outside that hospital. Following national discussion and
agreement, a prospective study was initiated in Norway to test the
practicalities and possible benefits of using this new ICSCS in
spontaneous and induced labour.