Twin birth - planned vaginal delivery still standard of care.

Abstract

Commentary on: Barrett JF, Hannah ME, Hutton EK, Willan AR, Allen AC, Armson BA, Gafni A, Joseph KS, Mason D, Ohlsson A, Ross S, Sanchez JJ, Asztalos EV. Twin Birth Study Collaborative Group. A randomized trial of planned cesarean or vaginal delivery for twin pregnancy. N Engl J Med 2013; 369: 1295–305. In this unique international effort to find evidence for the optimal mode of delivery for twins, planned Caesarean section did not reduce the risk for perinatal death or serious neonatal morbidity as compared to vaginal delivery 1. As pointed out by the authors, this finding may in part be explained by the high rate of Caesarean section (>40) in the planned-vaginal-delivery group, with most of these deliveries occurring during labour. Nevertheless, the design, the size of the study and high follow-up rate suggest that the findings are robust. Why is this knowledge important to neonatologists? Mainly, because the neonatologist is an important participant in counselling of women (and their partners) having twins, as well as in discussions with the obstetricians responsible for the delivery. With expectations of being the expert advisor acting in ‘the best interest of the baby’, the professional role of the neonatologist is to provide and discuss the safest mode of delivery. In this context, the study by Barrett et al. is central. The Twin Birth Study is also reassuring for those who try to challenge the ongoing increase in Caesarean section rates, not only for twin births 2 but also in general 3. Today, Caesarean section is the most common surgical procedure in women of reproductive ages and in many large countries and hospitals, Caesarean section rates exceed 50% by far. Besides the Twin Birth Study and the Term Breech Trial 4, there is a very weak evidence base for Caesarean section outside the emergency situation. For example, there is no randomized controlled trial testing Caesarean section for preterm birth; still, Caesarean section is often recommended for deliveries occurring before term. Given that half of the infants in the Twin Birth Study were born at 32–36 weeks of gestation, there seems to be little evidence for improved outcome after planned Caesarean section in moderately preterm infants. On the contrary, the opposite may be the case as suggested by observational data 5, 6. In this study, only short-term maternal and infant outcomes were compared. Epidemiological studies have reported associations between birth by Caesarean section and later health problems, such as increased risk for chronic immune disorders 7. While the underlying pathways for these associations are still obscure 8, it seems important that further long-term follow-up of participants in the Twin Birth Study will take place. https://ebneo.org/2015/04/twin-birth-planned-vaginal-delivery-still-standard-of-care/ None. None.