Orientador: Leandro Gustavo de Oliveira / Resumo: Introdução: A classificação de Robson tem sido utilizada para avaliação das taxas de cesáreas no mundo. Recomenda-se que cada localidade adapte a classificação original de acordo com suas necessidades. Objetivos: Analisar os casos de cesáreas realizadas na Maternidade do Hospital das Clínicas da Faculdade de Medicina de Botucatu utilizando uma classificação baseada nos 10 grupos de Robson, modificada a partir da inclusão de subgrupos e analisar os resultados a partir das recomendações estabelecidas pela Organização Mundial da Saúde. Métodos: Foi um estudo prospectivo com pacientes admitidas para assistência ao parto, no período de 01 de junho 2018 e 31 de maio de 2019. Uma planilha foi desenhada para a coleta dos dados e a classificação dos grupos foi elaborada a partir da classificação de Robson, modificada pela inclusão de subgrupos com métodos de indução e momento da indicação da cesárea. Resultados: Foram analisados 1823 partos, sendo 810 (44%) cesáreos. Houve 35,6% de primigestas, 19,5% de uma cesárea prévia e 15,4% de prematuros. O grupo 5, com maior número, teve 435 pacientes (23,8%), seguido do grupo 3, 422 (23,1%) e do grupo 1, 316 (17,3%). O grupo 5 teve maior número de cesáreas, 305 (37,6%). O grupo 2 teve 128 (15,8%). As iterativas totalizaram 19%. Indução do trabalho de parto teve 55,0% de sucesso. Entre pacientes com comorbidades, 60,5% tiveram cesárea. Comorbidades obstétricas mais frequentes foram: pré-eclâmpsia (12,7%), diabetes gestacional (8,4%) e restrição... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Introduction: Robson classification has been used to assess cesarean section rates worldwide. It is recommended that each location adapts the original classification according to their needs. Objectives: To analyze the cases of cesarean sections performed at the Maternity from the Clinics Hospital from Medical School of Botucatu using a classification based on Robson's 10 groups, modified from the inclusion of subgroups, and to analyze the results from the recommendations established by the World Health Organization. Methods: This was a prospective study with patients admitted for childbirth assistance from June 1, 2018 to May 31, 2019. A spreadsheet was designed for data collection and the classification of groups was elaborated from the classification of Robson, modified by the inclusion of subgroups with methods of induction and the moment of cesarean section indication. Results: 1,823 births were analyzed, 810 (44%) of which were cesarean. There were 35.6% of primiparous women, 19.5% of women with previous cesarean section and 15.4% of premature babies. Group 5, with the largest number, had 435 patients (23.8%), followed by group 3, 422 (23.1%) and group 1, 316 (17.3%). Group 5 had the highest number of cesarean sections, 305 (37.6%). Group 2 had 128 (15.8%). Women with two or more previous cesarean sections totaled 19%. Labor induction was 55.0% successful. Among patients with comorbidities, 60.5% had cesarean sections. Most frequent obstetric comorbidities were: pre-ecl... (Complete abstract click electronic access below) / Mestre

A sharp increase in caesarean section (CS) rates at the Muhimbili National Referral Hospital (MNH) – a tertiary referral hospital in Tanzania – by 50% in 2000–2011, was associated with concomitant increase in maternal complications and deaths and inconsistent improvement in newborn outcomes. The aims of this thesis were to explore care providers’ in-depth perspective of the reasons for these high rates of CS, and to evaluate and improve standards of care for the most common indica-tions of CS, obstructed labour and fetal distress, which are also major causes of adverse maternal and neonatal outcomes. This thesis reports an investigation performed at MNH, Tanzania. For Paper I, qualitative methods were employed and demonstrated how care providers dismissed their responsibility for the rising CS rate; and, instead, projected the causes onto factors beyond their control. Additionally, dysfunctinal teamwork, transparency, and previous poorly conducted clinical audits led to fear of blame among care providers in cases of poor outcome that subsequently encougared defensive practise by assigning unnecessary CS. Papers II and III evaluated stand-ards of care using a criteria-based audit (CBA) of obstructed labour and fetal dis-tress. After implementing audit-feedback recommendations, the standards of diag-nosis of fetal distress improved by 16% and obstructed labour by 7%. Similarly, the standards of management preceding CS improved tenfold for fetal distress and doubled for obstructed labour. The impact of the CBA process was evaluated by comparing the maternal and perinatal outcomes categorized into Robson groups (Paper IV) of all deliveries occurring before and after the audit process (n=27,960). After the CBA process, there was a 50% risk reduction of severe perinatal morbidi-ty/mortality for patients with obstructed labour. The overall CS rates increased by 10%, and this was attributed to an increase in the CS rate among breech, term preg-nancies (Robson group 6), and preterm pregnancies (Robson group 10) that specifi-cally had reduced risk of poor perinatal outcome. The overall neonatal distress rates were also reduced by 20%, and this was attributed to a decrease in the neonatal distress rate among low-risk, term pregnancies (Robson group 3). Importantly, the increased rates of poor perinatal outcomes were associated with referred patients that had higher risk of neonatal distress and PMR than non–referred patients, after CBA process.  In conclusion, the studies managed to educate the care providers to take on their roles as decision-makers and medical experts to minimize unnecessary CS, using the available resources. Care providers’ commitment to achieve the best practice should be sustained and effort for stepwise upgrading quality of obstetric care should be supported by the hospital management from the primary to tertiary referral level.