Understanding rising caesarean section trends: relevance of inductions and prelabour obstetric interventions at term

Aims: Single center 10-years audit on the relation between labour ward management and caesarean section rate, with special emphasis on the impact of reduced induction rate and the use of strict criteria for the diagnosis of onset of spontaneous labour and the indication for induction of labour. Methods: Retrospective classification of all deliveries between 1st January 2001 and 31st December 2010 in Ziekenhuis Oost Limburg, Genk Belgium, into the 10- group classification according to Robson. Numbers and rate of caesarean sections were defined for primiparous and multiparous women in spontaneous labour (groups 1 and 3 respectively), after induced labour (groups 2 and 4 respectively), with caesarean scar uterus (group 5) or with other gestational complications (groups 6 to 10). For these groups, a 10-years evolution was evaluated. Results: In a total of 19.675 deliveries, the overall caesarean section rate increased from 20% (380/1937) in 2001 to 25% (534/2121) in 2007 (p < 0.001), and decreased again to 20% in 2010 (415/2068) (p < 0.001). The increase of caesarean sections before 2007 was associated with an increase of inductions in singleton cephalic pregnancies at term from 28.5% (410/1437) in 2003 to 35.9% (551/1536) in 2006 (p < 0.001). The decrease of caesarean sections after 2007 occurred both in induced labours, as a direct consequence of rationalised reduction of induction rate, and in spontaneous labours, following introduction of strict criteria for diagnosis of labour. Despite a similar caesarean section rate of 20% in 2001 and 2010, the 6.6% (136/2068) repeat caesarean section rate in 2010 was higher than 4.2% (81/1937) in 2001 (p = 0.001). Conclusion: This single centre audit illustrates that increased induction rate is associated with increased caesarean section rate. This evolution can be reverted through a rationalised management aiming for reduction of induced labours and improved diagnosis of labour.