Complications of Cesarean Delivery Based on Robson's Classification in Women Referred to Hospitals Affiliated to Shiraz University of Medical Sciences: A Cross-Sectional Study

Document Type : Original Research Article


1 MSc of Midwifery, Department of Midwifery, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran

2 Assistant Professor, Community Based Psychiatric Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

3 Lecturer, Noncommunicable Diseases Research Center, Bam University of Medical Sciences, Bam, Iran

4 Lecturer, Maternal –fetal Medicine Research Center, Shiraz University of medical sciences, Shiraz, Iran


Background & aim: WHO proposed using the Robson Ten Group Classification System (TGCS) for assessing, monitoring, and comparing cesarean section (CS) rates. This study aimed to identify which group of women have more complications after CS based on TGCS in Shiraz maternity teaching hospitals.
Methods: This cross-sectional study included a sample of 1787 pregnant women who underwent cesarean section. From September to November 2018, convenience sampling was carried out at selected maternity teaching hospitals affiliated with Shiraz University of Medical Sciences, Shiraz, Iran. Demographic, obstetric, and fertility-related data were collected through personal interviews and a review of CS records. This study employed the TGCS to classify the women based on their obstetric data. Descriptive statistical analysis was done using SPSS software (version 23).
Results:  Out of the 1787 patients, 455 (25.5%) had planned and 1332 (74.5%) had emergency CS. Complications of CSs included three causes: surgical, maternal, and neonatal. Surgical complications were the most prevalent in groups 5, 10, and 8; maternal complications were the most prevalent in groups 5, 2, and 10; and neonatal complications were the most prevalent in groups 5, 2, and 10. The most common CS complications were breastfeeding disorders (56.1%) and bladder adhesions to the uterus (27.5%). In total, 563 (25%) patients had surgical complications, 1077 (49.6%) had maternal complications, and 531 (24.4%) had neonatal complications.
Conclusion: Most complications occurred in cases where the women had a previous history of CS (group 5). It seems essential to develop more efficient strategies to prevent unnecessary CSs.


Main Subjects


Pregnancy and its termination form an important stage in women’s life requiring care and prevention of threatening factors (1). Cesarean section (CS) is a very prevalent surgery. While it was first developed for emergency cases, it has become drastically popular around the world in recent decades. Its optimized method and low mortality rate elevate indications (2, 3). Despite the life-saving nature of this intervention in cases where normal delivery is not possible or has complications for women or infants, research has indicated that the rise in CS rate over 15% does not significantly contribute to better maternal and neonatal health outcomes (4). Recent evidence suggests a ranging CS rate of 1.4% to 56.4% (18.6% on average) in 150 countries (5). Top CS rates in each region belong to the following countries: Brazil (55.6%), Dominican Republic (56.4%), Latin America and the Caribbean, Egypt (51.8%), and Italy (38.1%) in Europe; the United States (32.8%) in North America; and New Zealand (33.4%) in Oceania (5,6). Also, the rate of cesarean delivery in Chongqing, China was 36.01% and the rate of Cesarean Delivery on Maternal Request (CDMR) was 8.42% (7). However, according to studies, the cesarean birth rate in Iran is reported to be 3-4 times above the world standard. A 2014 systematic review suggested a CS prevalence of 48% based on the information recorded in university hospitals in Iran (8, 9). In the studies conducted, in cases where there is a mother's request for CS or delivery with healthy amniotic membranes, CS is used to prevent maternal or neonatal death. (10). In addition, CS rates vary significantly within and between countries. CS rate is higher among women living in urban areas, with higher education, and those visiting private hospitals (11, 12). The unexpected rise in the CS rate necessitates building a robust system to minimize unnecessary CS with no medical indications (13). Given the CS rate worldwide, obstetricians and gynecologists face some short-term and long-term complications that are particularly associated with multiparous women with one or more CS deliveries (14). A number of research studies have revealed the potential adverse effects that may arise from repeated CS for women and infants (14-16), from higher maternal risk of uterine rupture and abnormal placenta to stillbirth and iatrogenic preterm delivery. In addition, infants are at risk for allergic reactions and hormonal, physical, bacterial infection, and physiological effects over time (16). Taking into account midwifery records, labor stages, and gestational age, TGCS classifies women with CS into 10 exclusive and comprehensive groups (17). In 2015, the WHO recommended TGCS as an international CS classification system for hospitals to monitor how their operations are optimally utilizing CS. Additionally, this system would permit them to distinguish, inspect, and zero in on particular groups (18). Bracic et al. (2020) conducted a study entitled “10-year comparative study of cesarean births using the Robson” in a university hospital in Austria (2). Also, Geze et al. (2021) conducted a cross-sectional study to investigate the TGCS in identifying women contributing to CS rates in eastern Ethiopia (4). Additionally, this classification has been used in Australia (19) and South Asia to enhance outcomes for women, infants, and CS rates (20). In this classification, the overall cesarean rate is reported considering several groups (10 groups) with different risk levels, and this is the first important step for comparative analysis in groups. WHO has noted the effectiveness of Robeson's classification in aiding the reduction of the CS rate (21-22). Studies on Robeson's classification have been done in Iran, but they were different from the purpose of the present study. So it is not clear what the role of each Robson classification group is in the global rate of CS. This study aimed to identify which groups have more complications after CS based on TGCS in Shiraz maternity teaching hospitals.


This was a cross-sectional study conducted in 2018. According to previous studies (23), a number of 1787 CS samples in selected maternity teaching hospitals affiliated with Shiraz University of Medical Sciences have been sampled. The samples were selected for 3 months from September to November 2018 via convenience sampling according to the number of cases referred for childbirth in each hospital. Out of 2819 people in the sample group, 1032 underwent vaginal delivery and 1787 underwent CS within 3 months. In this survey, the majority of mothers referred to Hazrat Zainab (PBUH) Hospital with a sample number of 1016 and Hafez Hospital with a smaller sample number of 771. The study was approved by the Ethics Committee of Shiraz University of Medical Sciences (IR.SUMS.REC.1397.404).

. The inclusion criteria were undergoing CS, being literate in Persian, no smoking or drug abuse, no history or current medical condition (based on self-report and medical records), full consciousness of the mother after delivery (being able to breastfeed the baby), and a planned pregnancy. Incomplete medical records and withdrawal from participation were the exclusion criteria. Eligible women who were referred to maternity teaching hospitals for childbirth provided their informed consent to participate. The study objectives were explained to the participants, and they were asked to complete the sociodemographic and midwifery information parts of the questionnaire (with 38 questions). Other parts were completed using their medical records. Sociodemographic characteristics were collected through personal interviews during 30-60 minutes of sampling, and current pregnancy information (parity, gestational age, time of onset of labor, etc.) was collected from medical records. To record CS complications, patients' files were used, and statements and relevant specialists' reports were also collected and recorded. In addition, in some shifts, the help of a trained researcher assistant was taken because the researcher could not be present in the hospital 24 hours a day.

To ensure the scientific validity of the questionnaire, the content validity method was employed. This involved researching pertinent scholarly materials and recognizing intervening variables to design a proper survey. Afterward, five number of faculty members examined and validated the questionnaire. It was guaranteed to the participants that all their data would be kept confidential. The accuracy of the information recorded at the time of sampling was ensured as follows: the researcher was present at the time of sampling and completed parts of the questionnaire from the mothers present in the cesarean delivery groups based on the inclusion criteria. Also, since the information in the files was completed by the midwife in the researcher's presence, and the delivery room manager and the resident manager checked it again at the end of the shift, the researcher was confident about the accuracy of the information recorded in the file to record the rest of the information and birth complications. When there was uncertainty, the mother herself was helpful in some cases. Descriptive statistical analysis of the data was done by utilizing SPSS-23 software.


Out of 1787 cesarean births, 455 women (25.5%) had a planned cesarean birth, whereas 1332 women (74.5%) underwent an emergency cesarean. The majority of the women with cesarean section were multiparous with cesarean section (58.6%) and had term pregnancy (84.7%) (Table 1). In this study of the frequency of CS complications, the most common complications were breastfeeding disorders (56.1%) and bladder adhesion to the uterus (27.5%) (Table 2).

CS complications (surgical, maternal, and neonatal) and their frequencies in Shiraz maternity teaching hospitals are presented based on Robson's classification. Surgical complications (bladder adhesion to the uterus, bladder adhesion to the abdomen, omentum adhesion to the abdomen, and omentum adhesion to the uterus) were most common in groups 5 (86.9%), 10 (8.9%), and 8 (8.1%), respectively. Maternal complications (improper breastfeeding status, maternal infection, embolism, and uterine atony) were most common in group 5 (45.7%), group 2 (21.3%), and group 10 (13.7%), respectively. Neonatal complications (Apgar score < 7 in minute 1, Apgar score < 7 in minute 5, suspected sepsis, transient neonatal tachypnea, neonatal jaundice, and respiratory distress syndrome) were most common in group 5 (46.3%), group 2 (17.3%), and group 10 (15.6%), respectively. In total, among the 1787 subjects, 563 (31.5%) had surgical complications, 1077 (60.3%) had maternal complications, and 531 (29.7%) had neonatal complications (Table 3).


The aim of this study was to identify which groups have more complications after CS based on TGCS in Shiraz maternity teaching hospitals.

In the present study, the most common complications were breastfeeding disorders (56.1%) and bladder adhesion to the uterus.

Research results indicated that 27.5% of the bladder adhered to the uterus. This study supports Yaghmaei et al.'s (2018) findings, which state that the rate of pelvic adhesions in women who have undergone CS in Tehran was 32.02% (24). The rise in the CS rate has been ongoing, increasing in women who have Intra-abdominal adhesions were greater in women with a history of CS compared to those without a history. Also, with the increase in the number of CS, the rate of intra-abdominal adhesion increases (25), and the surgeons’ knowledge of the possibility of intra-abdominal adhesion in women with previous CS (groups 5 and 10) can be effective and help them deal with possible problems (24). Contrary to the present study, Moro et al. (2015) (26) reported 45.1% pelvic adhesions in London. This discrepancy can be due to their sample which included women with previous CS and other surgeries, while in our study only patients with previous CS were included.

According to our findings, 56.1% of participants were diagnosed with breastfeeding disorders. This is comparable to Boskabadi et al.'s (2014) report, which stated a prevalence rate of 55% in infants (27). According to the results, breastfeeding disorders in cesarean mothers were reported with a high prevalence of 56.1. As in other studies, cesarean delivery is associated with mother-infant separation, reduced breastfeeding ability, reduced acceptance of the baby, insufficient milk supply, and a delay in the initiation of breastfeeding, which predicts the shortening of breastfeeding duration and breastfeeding disorders (28-32). Although breastfeeding is physiological, it also requires skill and learning. Teaching the mother the correct principles and methods of



breastfeeding will reduce physical problems during feeding, improve latching on, and increase the transfer of milk to the baby (27). Gedefaw et al. (2020) reported that cesarean delivery has an adverse effect on the initiation of breastfeeding. Cesarean delivery, primipara, and unwanted pregnancy were correlated with a delay in the first breastfeeding (33). Adherence to a proper breastfeeding position and ways to stimulate the let-down reflex can lead to maximum milk intake by the baby with minimal problems for the mother (34). The results suggest that the uterine atony rate was 7.9%.

Inconsistently, Rouse et al. (2005)  (35) and Butwick et al. (2014)  (36) reported 6% and 4% rates, respectively, which is due to the large sample size in the two studies. Multiparity, CS, and labor induction are risk factors for uterine atony. Therefore, the percentage of this complication has increased in groups 5 (multiparous with previous CS) and 2 (nulliparous with labor induction) as a more uterine cause Due to uterine causes, the percentage of this complication has increased in groups 5 (multiparous with a previous CS) and 2 (nulliparous with labor induction) (37). Similarly, studies by Hansen et al. and Smiths et al. (2008)  have shown more life-threatening complications, such as respiratory distress syndrome and transient tachypnea in the newborn in CS cases (38, 39). Respiratory dysfunction may be due to undetected pulmonary immaturity (40) and catecholamine deficiency in CS (41). Some researchers have reported that CS when performed at the start of labor, lowers neonatal respiratory complications. Accordingly, some researchers suggest that CS be postponed until labor pains begin (42) or postponed until after week 39 of pregnancy (43). In instances where the mother's or baby's life is at stake, CS is recommended to be incorporated as a delivery method.

On the other hand, comprehensive support, including cultural interventions for natural childbirth in order to modify women's beliefs and increase their knowledge, as well as planning a supportive and special care system for women with previous CS, will help them make a decision for VBAC (44). Also, the study of Mache et al. (2021) has suggested that to ensure the appropriate use of the delivery method, women with a previous cesarean delivery should be carefully checked for the possibility of vaginal delivery, and the hospital should regularly monitor the symptoms of cesarean delivery (45).

A strength of this study was that it was the first of its kind to be conducted in Iran to investigate CS complications based on TGCS in Shiraz maternity teaching hospitals. Another strength was the large sample size, which made it possible to determine the number of samples in each Robson stratum, making it possible to compare each stratum with the other stratum more clearly.

Suggestions for further research include the fact that repeated cesarean surgery has a direct effect on increasing maternal and newborn complications (48-46). Since the number of cases of vaginal delivery after cesarean section is still low due to the negative beliefs and attitudes of mothers and families and some legal considerations, it is suggested to train families and pregnant women to increase their awareness and change their attitudes about vaginal delivery, should it be performed after CS, which may be effective in reducing the complications of CS. Besides, legal support will increase the motivation and persuasion of specialist doctors who perform vaginal delivery after CS. On the other hand, conducting similar studies across the country and also comparing neonatal complications in normal delivery after CS with repeated CS and delivery without a history of CS, may be effective in reducing the prevalence of CS. The limitation of the present study included the inaccuracy of the complete registration of the mothers' hospital records, which did not allow a wider evaluation of some information.


In this study, the biggest group that played a role in the CS rate were multiparous women with a previous cesarean history (group 5). Complications such as breast-feeding disorders, adhesions to the uterus, respiratory distress syndrome, and transient tachypnea are caused. Consequently, it is necessary to devise more effective ways to motivate women who have previously undergone a CS to consider attempting a vaginal birth after cesarean (VBAC). In addition, the rate of cesarean delivery in premature births is increasing, which should be taken into consideration regarding the subsequent clinical consequences of this issue. On the other hand, considering the high rate of maternal and neonatal complications of CS, this is more important for Iran, which has changed its population policy to increase the population and should have appropriate strategies to prevent unnecessary CS and reduce maternal mortality and complications.


This article was extracted from a thesis (project number: 97-01-08-17097), approved and funded by Shiraz University of Medical Sciences, Shiraz, Iran. The authors would like to thank the authorities at Shiraz University of Medical Sciences.

Conflicts of interest

The authors declared no conflicts of interest.

  1. Alipanahpour S , Tayebi N , Zarshenas M and Akbarzadeh M. Therapeutic Abortion Methods in Women Referring to Educational and Medical Centers in Shiraz. Current Women`s Health Reviews. 2022; 18(3): 59-65. Available at:
  2. Bracic T, Pfniß I, Taumberger N, Kutllovci-Hasani K, Ulrich D, Schöll W, Reif P. A 10 year comparative study of caesarean deliveries using the Robson 10 group classification system in a university hospital in Austria. PLoS One. 2020; 15(10): e0240475.
  3. Todman D. A history of caesarean section: from ancient world to the modern era. Australian & New Zealand Journal of Obstetrics & Gynaecology . 2007; 47(5): 357-361.
  4. Geze S, Tura AK, Fage SG, van den Akker T. Can the Robson 10 Group Classification System help identify which groups of women are driving the high caesarean section rate in major private hospitals in eastern Ethiopia? A cross-sectional study. BMJ Open. 2021; 11(8): e047206.
  5. Betrán AP, Ye J, Moller AB, Zhang J, Gülmezoglu AM, Torloni MR. The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: 1990-2014. PLoS One. 2016; 11(2): e0148343.
  6. Shirzad M, Shakibazadeh E, Hajimiri K, Betran AP, Jahanfar S, Bohren MA, Opiyo N, Long Q, Kingdon C, Colomar M, Abedini M. Prevalence of and reasons for women's, family members', and health professionals' preferences for cesarean section in Iran: a mixed-methods systematic review. Reproductive Health. 2021; 18(1): 3.
  7. Deng, R., Tang, X., Liu, J. et al. Cesarean delivery on maternal request and its influencing factors in Chongqing, China. BMC pregnancy and childbirth. 2021; 21(384): 1-12.
  8. Rafiei M, Saei Ghare M, Akbari M, Kiani F, Sayehmiri F, Sayehmiri K, Vafaee R. Prevalence, causes, and complications of cesarean delivery in Iran: A systematic review and meta-analysis. International Journal of Reproductive Biomedicine. 2018; 16(4): 221-234.
  9. Koohbor M A, Davati A, Garshasbi A. Evaluation of effective factors on the choice of delivery method by nulliparous pregnant women referring to shaheed mostafa khomeini hospital in tehran. Daneshvar Medicine. 2022; 29(6): 14-23.
  10. Rijken MJ, Meguid T, van den Akker T, van Roosmalen J, Stekelenburg J; Dutch Working Party for International Safe Motherhood & Reproductive Health. Global surgery and the dilemma for obstetricians. Lancet (London, England). 2015; 386(10007): 1941-1942.
  11. Fesseha N, Getachew A, Hiluf M, Gebrehiwot Y, Bailey P. A national review of cesarean delivery in Ethiopianternational. journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2011; 115(1): 106-111.
  12. Boatin AA, Schlotheuber A, Betran AP, Moller AB, Barros AJD, Boerma T, Torloni MR, Victora CG, Hosseinpoor AR. Within country inequalities in caesarean section rates: observational study of 72 low and middle income countries. BMJ. 2018; 360(24): k55.
  13. Betrán AP, Merialdi M, Lauer JA, Bing-Shun W, Thomas J, Van Look P, Wagner M. Rates of caesarean section: analysis of global, regional and national estimates. Paediatric and Perinatal Epidemiology. 2007; 21(2): 98-113.
  14. Keag OE, Norman JE, Stock SJ. Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis. PLoS medicine. 2018; 15(1): e1002494.
  15. Masukume G, McCarthy FP, Russell J, Baker PN, Kenny LC, Morton SM, Khashan AS. Caesarean section delivery and childhood obesity: evidence from the growing up in New Zealand cohort. Journal of Epidemiology and Community Health . 2019; 73(12): 1063-1070.
  16. Sandall J, Tribe RM, Avery L, Mola G, Visser GH, Homer CS, Gibbons D, Kelly NM, Kennedy HP, Kidanto H, Taylor P, Temmerman M. Short-term and long-term effects of caesarean section on the health of women and children. Lancet (London, England). 2018; 392(10155): 1349-1357.
  17. Robson M. The Ten Group Classification System (TGCS) - a common starting point for more detailed analysis.BJOG : an international journal of obstetrics and gynaecology. 2015; 122(5): 701.
  18. WHO. Robson classification: implementation manual. 2017. Available at: https:// apps. who. int/iris/bitstream/handle/10665/259512/9789241513197-ita.pdf
  19. Mayne L, Liu C, Tanaka K, Amoako A. Caesarean section rates: applying the modified ten-group Robson classification in an Australian tertiary hospital. Journal of obstetrics and gynaecology : the journal of the Institute of Obstetrics and Gynaecology. 2022; 42(1): 61-66.
  20. 2 Hassan L, Woodbury L, Jamal N, et al. Examining the Efficacy of the Robson Classification System for Optimizing Cesarean Section Rates in South Asia. Journal of South Asian Federation of Obstetrics and Gynaecology .2020; 12(6): 366–371.
  21. 2 Alonso BD, Silva FMBD, Latorre MDRDO, Diniz CSG, Bick D. Caesarean birth rates in public and privately funded hospitals: a cross-sectional study.  Revista de Saude Publica. 2017; 51: 101.
  22. 2 Rookesh Z, Zarshenas M, Tayebi N and Akbarzadeh M, Analysis of Cesarean Section Causes Using Robson’s Ten Group Classification System in Selected Hospitals Affiliated to Shiraz University of Medical Sciences: A Cross-sectional Study, Current Women`s Health Reviews 2024; 20(3) : e270423216272
  23. 2 Dadipour S, Madani AH, Alvai A, Rozbeh N, Safari‑Moradabadi A. Survey of the growing trend of cesarean section in Iran and the world. The Iranian Journal of Obstetrics, Gynecology and Infertility. 2016; 19: 8‑17.
  24. 24. Yaghmaee M, Darvish S, Farmanbar M. Characteristics of previous cesarean section in patients with and without intra-abdominal adhesions in Ayatollah Taleghani hospital in Tehran in 2016. Iranian Journal of Obstetrics, Gynecology and Infertility. 2018;21(10):1-6.
  25. 2 Sinha P, Gupta U, Singh J, Srivastava A, Chauhan S. Per operative findings in repeat cesarean section. International Journal of Reproduction, Contraception, Obstetrics and Gynecology. 2016; 5(4): 1904-1909.
  26. Moro F, Mavrelos D, Pateman K, Holland T, Hoo WL, Jurkovic D. Prevalence of pelvic adhesions on ultrasound examination in women with a history of Cesarean section.Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology. 2015; 45(2): 223-228.
  27. Boskabadi H, Zakeri-Hamidi M, Bagheri F. Outcomes of vaginal delivery and cesarean in Mashhad Ghaem University Hospital. Tehran University Medical Journal. 2014; 71(12): 807-815.
  28. Regan J, Thompson A, DeFranco E. The influence of mode of delivery on breastfeeding initiation in women with a prior cesarean delivery: a population-based study. Breastfeeding medicine : the official journal of the Academy of Breastfeeding Medicine . 2013; 8(2): 181-186.
  29. Watt S, Sword W, Sheehan D, Foster G, Thabane L, Krueger P, Landy CK. The effect of delivery method on breastfeeding initiation from the The Ontario Mother and Infant Study (TOMIS) III. Journal of Obstetric, Gynecologic, and Neonatal Nursing. 2012; 41(6): 728-737.
  30. Zanardo V, Pigozzo A, Wainer G, Marchesoni D, Gasparoni A, Di Fabio S, Cavallin F, Giustardi A, Trevisanuto D. Early lactation failure and formula adoption after elective caesarean delivery: cohort study. Archives of disease in childhood. Fetal and neonatal edition. 2013; 98(1): F37-F41.
  31. Chalmers B, Kaczorowski J, Darling E, Heaman M, Fell DB, O'Brien B, Lee L. Maternity Experiences Study Group of the Canadian Perinatal Surveillance System. Cesarean and vaginal birth in canadian women: a comparison of experiences. Birth. 2010; 37(1): 44-49.
  32. 32. Dejbakht M, Montaseri Z, Saem J, Rezaei M, Akbarzadeh M. Effect of Maternal Pethidine on Breast Feeding Behavior of Infants in Cesarean Section by Spinal Anesthesia: A Randomized Controlled Trial. Archives of Iranian Medicine. 2021; 24(8): 591-598.
  33. 33. Gedefaw G, Goedert MH, Abebe E, Demis A. Effect of cesarean section on initiation of breast feeding: Findings from 2016 Ethiopian Demographic and Health Survey. PLoS One. 2020; 15(12):
  34. 3 Boskabadi H, Maamouri G, Ebrahimi M, Ghayour-Mobarhan M, Esmaeily H, Sahebkar A, Ferns GA. Neonatal hypernatremia and dehydration in infants receiving inadequate breastfeeding. Asia Pacific Journal of Clinical Nutrition. 2010; 19(3): 301-630.
  35. 3 Rouse DJ, Leindecker S, Landon M, Bloom SL, Varner MW, Moawad AH, et al. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. The MFMU Cesarean Registry: uterine atony after primary cesarean delivery. American Journal of Obstetrics and Gynecology. 2005; 193(3Pt 2): 1056-1060.
  36. Butwick AJ, Carvalho B, El-Sayed YY. Risk factors for obstetric morbidity in patients with uterine atony undergoing caesarean delivery. British Journal of Anaesthesia. 2014; 113(4): 661-668.
  37. Ferreira EC, Costa ML, Cecatti JG, Haddad SM, Parpinelli MA, Robson MS; Brazilian Network for Surveillance of Severe Maternal Morbidity Study Group. Robson Ten Group Classification System applied to women with severe maternal morbidity. Birth. 2015; 42(1): 38-47.
  38. Hansen AK, Wisborg K, Uldbjerg N, Henriksen TB. Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study. British Medical Journal. 2008; 336(7635): 85-87.
  39. Schmitz T, Carnavalet Cde C, Azria E, Lopez E, Cabrol D, Goffinet F. Neonatal outcomes of twin pregnancy according to the planned mode of delivery. Obstetrics and Gynecology. 2008; 111(3): 695-703.
  40. Liu X, Landon MB, Cheng W, Chen Y. Cesarean delivery on maternal request in China: what are the risks and benefits. American journal of Obstetrics and Gynecology. 2015; 212(6): 817.e1-819.e1.
  41. Falconer AD, Lake DM. Circumstances influencing umbilical-cord plasma catecholamines at delivery. British Journal of Obstetrics and Gynaecology. 1982; 89(1): 44-49.
  42. Cohen M, Carson BS. Respiratory morbidity benefit of awaiting onset of labor after elective cesarean section. Obstetrics and Gynecology. 1985; 65(6): 818-824.
  43. 4 Glavind J, Kindberg SF, Uldbjerg N, Khalil M, Møller AM, Mortensen BB, Rasmussen OB, Christensen JT, Jørgensen JS, Henriksen TB. Elective caesarean section at 38 weeks versus 39 weeks: neonatal and maternal outcomes in a randomised controlled trial. An International Journal of Obstetrics and Gynaecology. 2013; 120(9): 1123-1132.
  44. Firoozi M, Tara F, Mazloum S. R, Latifnejad Roudsari, R. A Qualitative Inquiry to Explore Why Women with Previous Cesarean-Section Do Not Choose Vaginal Birth after Cesarean. Journal of Midwifery and Reproductive Health. 2021; 9(2): 2753-2762.
  45. Mache GA, Halil HM, Abdo RA. The Rate, Indications and Contributing Factors of Cesarean Delivery in Southern Nation Nationalities and People’s Region, Ethiopia. Journal of Midwifery & Reproductive Health. 2021; 9(1): 2541-2547.
  46. Gilbert SA, Grobman WA, Landon MB, Spong CY, Rouse DJ, Leveno KJ, et al. Elective repeat cesarean delivery compared with spontaneous trial of labor after a prior cesarean delivery: a propensity score analysis. American Journal of Obstetrics and Gynecology . 2012; 206(4): 311.e1-319.e1.
  47. Sabol B, Denman MA, Guise JM. Vaginal birth after cesarean: an effective method to reduce cesarean. Clinical Obstetrics and Gynecology. 2015; 58(2): 309-319.
  48. Dodd JM, Crowther CA, Huertas E, Guise JM, Horey D. Planned elective repeat caesarean section versus planned vaginal birth for women with a previous caesarean birth. The Cochrane Database of Systematic Reviews. 2013; (12): CD004224.