Cesarean Delivery Of Twins Research Articles

Risk factors for postpartum hemorrhage after elective cesarean deliveries for twin pregnancies.

To identify the high-risk factors associated with postpartum hemorrhage (PPH) after an elective cesarean delivery of twins. This retrospective cohort study included all women with twin gestations who chose to have an elective cesarean delivery after 28 weeks of gestation at at the Women's Hospital, School of Medicine, Zhejiang University between September 2014 and April 2019. Women with an intrauterine fetal demise of one or both twins were excluded. PPH was defined as an estimated blood loss of ≥ 1,000 mL within 24 h of birth. A total of 532 women were analyzed and classified into the PPH group (n = 70) and the no-PPH group (n = 462). Univariate and multivariate logistic regression analyses were performed to assess the independent risk factors. Among the 532 women pregnant with twins, PPH occurred in 13.2% women (n = 70). There were statistically significant differences in preeclampsia (p = 0.005), premature rupture of membrane (PROM, p < 0.001), placenta previa (p < 0.001), anemia [hemoglobin (Hb) < 100 g/L; p = 0.003], and antenatal magnesium sulfate (MgSO₄) use (p < 0.001) between the two groups. However, the following were the independent risk factors for PPH after an elective cesarean delivery for a twin pregnancy: preeclampsia [odds ratio (OR): 2.91; 95% confidence interval (CI): 1.33-6.36], PROM (OR: 8.57; 95% CI: 2.54-28.89), placenta previa (OR: 9.46; 95% CI: 3.59-24.89), antenatal MgSO₄ use (OR: 7.64; 95% CI; 3.18-18.41), and anemia (Hb < 100 g/L; OR: 2.68; 95% CI: 1.42-5.06). Preeclampsia, PROM, placenta previa,and antenatal MgSO₄ use were the risk factors for PPH after an elective cesarean delivery for twin pregnancies. Risk factor identification and prevention should be a priority.

Nomogram to predict postpartum hemorrhage in cesarean delivery for twin pregnancies: a retrospective cohort study in China.

Postpartum hemorrhage (PPH) is the most common cause of maternal morbidity and mortality worldwide. A reliable risk assessment tool for PPH could optimize available interventions to reduce adverse maternal outcomes. The objective of this study was to explore a nomogram predicting the risk of postpartum hemorrhage after cesarean delivery for twin pregnancies. This single-center retrospective cohort study conducted twin pregnancies who underwent cesarean delivery between January 2014 and July 2021. Propensity score matching at baseline was used to match PPH (blood loss ≥1000 mL) and non-PPH group (blood loss <1000 mL). A nomogram was developed to predict the risk of PPH in cesarean delivery for twin pregnancies. The receiver operating characteristic curve (ROC), calibration plot, and decision curve analysis (DCA) were, respectively, used to evaluate the discrimination, calibration, and clinical utility of the prediction models. After propensity score matching, 186 twin pregnancies in the PPH group were matched with 186 controls in the non-PPH group. Seven independent prognostic variables, including antepartum albumin, assisted reproductive technology, hypertensive disorders of pregnancy, placenta previa, placenta accrete spectrum, intrapartum cesarean delivered, and estimated weights of twins, were used to build the nomogram. Based on the performance of the model, it appears that a good calibration (Hosmer-Lemeshow χ2 = 4.84, P > 0.05), an excellent predictive ability (area under the curve: 0.778, 95% CI: 0.732-0.825), and a good positive net benefit in the predictive model have been achieved. The nomogram was first generated to predict PPH in cesarean delivery for twin pregnancies, which could help clinicians to provide a reference for the preoperative surgical plan, choose optimal treatments, optimize healthcare resources, and thereby reduce the associated adverse maternal outcomes.

Trial of labor of vertex-nonvertex twins following a previous cesarean delivery

Maternal and neonatal outcomes of trial of labor after cesarean delivery of twins are similar to those of singleton trials of labor after cesarean delivery. However, previous studies did not stratify outcomes by second-twin presentation on admission to labor. To examine maternal and neonatal outcomes following trial of labor after cesarean delivery in twins with vertex-nonvertex presentation. A retrospective multicenter study was conducted including data on deliveries occurring between the years 2005 and 2020. We included trials of labor after a previous cesarean delivery (at ≥320/7 weeks' gestation) of twin gestations with a vertex-presenting first twin on admission to labor. The exposed group was defined as deliveries with a nonvertex second twin at admission to labor, whereas the comparison group included deliveries with a vertex second twin at admission. Only parturients who attempted vaginal delivery were included. Cases of prelabor fetal death of either twin or major fetal anomalies were excluded. The primary outcome was uterine rupture. A total of 236 twin trials of labor after cesarean delivery were included, of which 128 involved nonvertex second twins and 108 a second vertex twin. Uterine rupture rates were comparable between the groups (1/128 [0.9%] vs 1/108 [0.8%]; P=1.000). Successful trial of labor after cesarean delivery of both twins occurred in 76.6% of the exposed group vs 81.5% of the comparison group, whereas cesarean delivery of both twins was performed in 21.9% of the exposed group vs 17.6% of the comparison group (P=.418; odds ratio, 1.32; confidence interval, 0.7-2.5). Two cases of cesarean delivery of the second twin occurred in the exposed group and 1 in the comparison group (1.6% vs 0.9%, respectively, P=1.000). There was no difference between the groups in maternal outcomes, including rates of postpartum hemorrhage, blood transfusion, placental abruption, thromboembolic events, and maternal fever. Neonatal outcomes were also comparable between the groups, including rates of intensive care admission and low (≤7) 5-minute Apgar scores. Our data show thattrial of labor after cesarean delivery of noncephalic second twins holds favorable maternal and neonatal outcomes, comparable with those of vertex-vertex trials of labor after cesarean delivery.Second-twin noncephalic presentation should not discourage parturients and caregivers from considering trial of labor after cesarean delivery if desired.

Opioid use after cesarean: a cohort study comparing combined versus separate oxycodone and acetaminophen regimens

Objective To determine whether an inpatient post-cesarean analgesic regimen which separated oxycodone and acetaminophen resulted in less inpatient opioid use, when compared to a regimen using combination medications containing both acetaminophen and oxycodone in a cohort including patients of all gestational ages, acuity levels, and modes of operative anesthesia. Methods This is a retrospective cohort study which was conducted at a single tertiary care center Labor and Delivery unit. Data were collected via retrospective chart review, and a total of 170 records were examined with a final N = 150. Inclusion criteria were all patients over the age of 18, and >23.0 weeks gestational age, who had a singleton or twin cesarean delivery regardless of their mode of operative anesthesia and whether or not they received intrathecal opioid at time of delivery. Exclusion criteria were pregnancies of higher-level multiples (triplets or greater), prolonged intensive care unit (ICU) stay, and patients who received both combination oxycodone-acetaminophen and separately administered oxycodone. For analysis patients were classified into two groups: the “Combined Medication” group representing patients who received combination oxycodone-acetaminophen medication only (n = 83) and the “Separate Medication” group representing patients who received oxycodone and acetaminophen separately (n = 67). Differences between the groups with respect to opioid use and acetaminophen use were assessed. Results The primary outcome was inpatient opioid medication use per 12-h period in intravenous morphine mg equivalents (MME). Patients received an average of 4.6 ± 3.5 MME IV morphine per 12 h in the Separate Medication group and 5.7 ± 3.7 MME IV morphine per 12 h in the Combined Medication group. When controlled for several covariates, the Separate Medication group took significantly fewer MME per 12-h period (mean difference = −1.2, 95% CI: (−2.3, −0.1), p = .04). There was no appreciable difference in acetaminophen utilization between groups. Conclusions An analgesic regimen where oxycodone is ordered separately from acetaminophen is associated with reduced inpatient opioid medication use in patients of all gestational ages, acuity levels, and modes of operative anesthesia.

212 Decreased procedure-related infection rates after implementation of ERAS protocol for cesarean section

The objective of this study was to determine if the implementation of an Enhanced Recovery After Surgery (ERAS) protocol for Cesarean section was associated with procedure-related infection rates in the post-partum period. This project was designed as part of a prospective cohort study which compared surgical outcomes for cesarean section patients prior to and following implementation of an ERAS protocol. Primary interventions aimed at reducing surgical site infections included standardization of vaginal preparation and the addition of azithromycin antibiotic prophylaxis for laboring patients. Inclusion criteria were patients over the age of 18 who had a singleton or twin cesarean delivery at a tertiary care center between February 2019 and January 2020. We included patients of all gestational ages and all acuity levels (scheduled, urgent and emergent). Exclusion criteria were pregnancies of higher-level multiples, prolonged intensive care unit (ICU) stay following delivery. Final number of patients after exclusion criteria applied N= 339 with n=170 pre-intervention and n=169 post-intervention. On analysis of descriptive variables there were no significant differences between groups for age, BMI, parity, number of prior cesarean deliveries and acuity of procedure. Among laboring patients, there was no significant difference between groups in the percentage of patients who received azithromycin with (87.95% pre-intervention and 87.65% post-intervention, p=1.00). Only 12.35% of patients received a vaginal preparation in the pre-intervention group versus 78.7% in the post-intervention group (p<.0001). The resulting cesarean procedure-related infection rate was significantly lower in the post-intervention group with rates of 5.3% versus 11.7% in the pre-intervention group (p=0.038). An ERAS protocol including vaginal preparation for all patients regardless of gestational age or acuity of procedure is associated with decreased procedure-related infection rates.

Neonatal outcomes according to actual delivery mode after planned vaginal delivery in women with a twin pregnancy

ObjectiveTo compare, in women with twin pregnancy with the first twin in cephalic position, neonatal morbidity and mortality rates after actual 1) Vaginal delivery (VD) both twins versus 2) unplanned Cesarean Delivery (CD) of both twins and 3) after VD of twin A and CD of twin B (combined delivery). Study DesignWe describe a nationwide cohort study of women pregnant with twins who planned to deliver vaginally between 32+0 - 41+6 weeks with the first twin in cephalic position, between 2000–2012 in the Netherlands.We used multivariate logistic regression analysis to compare neonatal morbidity and mortality according to actual mode of delivery, overall, and for preterm and term groups separately. ResultsWe included 19,723 women of whom 15,785 women (80.0 %) delivered both twins by VD, 2926 (14.6 %) delivered both twins by unplanned CD, and 1012 (5.1 %) women delivered by combined delivery.After unplanned CD of both twins compared to VD more perinatal mortality (1 or more twins affected) was seen (adjusted Odds Ratio (aOR) 2.23 (95 % CI 1.26–4.129)), as was ‘Asphyxia related morbidity’ (aOR 2.44 (95 % CI 1.80−3.31), ‘other morbidity’ (aOR 1.34 (95 %CI 1.17−1.54), and ‘any morbidity or mortality’ (aOR1.39 (95 % CI 1.22–1.58)). Less ‘Trauma- related morbidity’ after unplanned CD vs. VD (aOR 0.11 (95 % 0.02−0.79)) was seen.After combined delivery vs. VD, more perinatal mortality (aOR 7.75 (95 % CI 4.51−13.34)), more Asphyxia- related morbidity (aOR 6.67 (95 % CI4.91−9.06), ‘prematurity related morbidity’ (aOR 2.11 (95 % CI 1.59−2.79) ‘other morbidity’ (aOR 2.01 (95 % CI 1.65−2.46), and ‘any morbidity or mortality’ (aOR 2.44 (95 % CI 2.04−2.91)) were noted. All outcomes expect ‘trauma-associated morbidity’ were more increased for twin B as compared to twin A. ConclusionAfter unplanned CD of both twins vs. VD of both twins, a twofold increase in neonatal mortality is noted. Combined delivery vs. VD of both twins is associated with a sevenfold increase in perinatal mortality and a five-fold increase in asphyxia-related outcomes. Twin A is more affected after unplanned CD of both twins, while twin B is more affected after combined delivery.

Clinical outcomes of prophylactic compression sutures for treatment of uterine atony during the cesarean delivery of twins

BackgroundTwin pregnancy has a high risk for developing uterine atony (UA). This study aimed to evaluate efficacy and clinical outcomes of prophylactic compression sutures to treat UA during twin cesarean section (CS).MethodsAll patient records of twin deliveries by CS after gestational age of 24 weeks in a large maternity hospital in South Korea between January 2013 and June 2018 were reviewed. Patients with monochorionic monoamniotic twins were excluded from data analysis. In total, 953 women were eligible for data analysis.ResultsOf the 953 patients, compression sutures were applied to 147 cases with postpartum bleeding that were refractory to uterine massage and uterotonics. Out of the 147, two patients (1.4%) proceeded to additional uterine artery ligation to achieve hemostasis, yielding a success rate of 98.6%. The rate of transfusion after the first 24 h of delivery in the suture group was not significantly different from that in the non-suture group, suggesting that both groups achieved hemostasis at an equal rate after the first 24 h of delivery. The difference in the operation time between the two groups was only 8.5 min. The rate of subsequent pregnancy among the patients who received compression sutures was 44.4%.ConclusionsOverall, our findings suggest that with early and fast implementation of compression sutures, UA can be treated in the setting of twin cesarean delivery without significantly increasing maternal morbidity.

Suspected pulmonary embolism postcesarean section in a patient with autosomal dominant polycystic kidney disease

Autosomal dominant polycystic kidney disease (ADPKD) is the most common genetically inherited kidney disease worldwide. It is however relatively underdiagnosed in Africans because its diagnosis is often incidental. During pregnancy, ADPKD is associated with increased risk of preeclampsia and venous thromboembolism. The case of a 33-year-old lady incidentally diagnosed with ADPKD during pregnancy is presented. She developed preeclampsia at term and had cesarean delivery of twins. She however suffered cardiopulmonary arrest postoperatively and this created a treatment dilemma because therapeutic anticoagulation which was the primary treatment for her suspected pulmonary embolism was absolutely contraindicated if the actual cause of her collapse was ruptured cerebral aneurysm which was also a feature of ADPKD. We decided to resuscitate aggressively and perform an urgent cranial computed tomography which ruled out intracranial hemorrhage. We then commenced anticoagulation and she made an excellent recovery. This case illustrates the importance of a timely multidisciplinary approach to patient management.

The worst of both worlds—combined deliveries in twin gestations: a subanalysis of the Twin Birth Study, a randomized, controlled, prospective study

The reported incidence of combined twin delivery (vaginal delivery of twin A followed by cesarean delivery for twin B) ranges between 5% and 10%. These estimates are based mostly on small studies or retrospective data. We aimed to evaluate to incidence and risk factors for and outcomes of combined twin deliveries, using a subanalysis of the Twin Birth Study, a randomized, controlled, prospective study. The Twin Birth Study included women with twin gestation between 32+0 and 38+6 weeks, with the first twin in vertex presentation at randomization. Women were randomized to planned cesarean delivery or planned vaginal delivery. For the purpose of this subanalysis, we included women who had a vaginal delivery of twin A. Women who had a combined delivery (cesarean delivery for twin B) were compared with women who had a vaginal delivery of both twins. Our primary objective was to identify risk factors for combined twin deliveries. Our secondary objective was to assess the rate of fetal/neonatal death or serious neonatal morbidity in combined deliveries. Of the 2786 women included in the original study, 842 women delivered twin A by a vaginal delivery and were included in the current analysis, of whom 59 (7%) had a combined delivery. Women in the combined delivery group had a lower rate of nulliparity (22.0% vs 34.7%, P= 0.047) and higher rates of noncephalic presentation of twin B at delivery (61.0% vs 27.3%, P < 0.001) and spontaneous version from presentation at randomization of twin B (72.9% vs 44.3%, P < 0.0001). In a multivariable model, the only risk factor significantly associated with a combined delivery was transverse/oblique lie of twin B following delivery of twin A (adjusted odds ratio, 47.7; 95% confidence interval, 15.4-124.5). Twins B in the combined delivery group had a higher rate of fetal/neonatal death or serious neonatal morbidity (13.6% vs 2.3%, P < 0.001), 5-minute Apgar score <7, neonatal intensive care unit admission, abnormal level of consciousness, and assisted ventilation. Transverse/oblique lie of twin B following vaginal delivery of twin A is a risk factor for combined delivery. Combined delivery is associated with higher risk of adverse neonatal outcomes of twin B. These data may be used to better counsel women with twin gestation who consider a trial of labor.

Trial of labor versus elective repeat cesarean delivery in twin pregnancies after a previous cesarean delivery—A systematic review and meta‐analysis

To perform a systematic review of success rates of trial of labor after cesarean (TOLAC) and maternal and neonatal outcomes in twin pregnancy versuselective repeat cesarean delivery (ERCD). We searched MEDLINE, EMBASE, and Web of Science from data inception to May 2018 with no language or regional restrictions, to identify all studies that compared twin TOLAC and ERCD for maternal and/or neonatal outcomes. The Newcastle-Ottawa Scale was used to assess the methodological quality of the included studies. We assessed the pooled relative risk and mean difference using a random-effects model. The pooled event rates for successful VBAC, cesarean deliveryfor twin B after vaginal delivery of twin A, and uterine rupture were determined. Of the 841 citations identified, 10 were eligible for analysis (2336 TOLAC cases and 5763 ERCD cases). The pooled event rates for successful VBAC and uterine rupture during TOLAC were 72.2% (95% CI 59.7%-83.2%) and 0.87% (95% CI 0.51%-1.31%), respectively. TOLAC was associated with a significantly higher risk of neonatal death (RR 3.02 [95% CI 1.07-8.54])with no significant differences in mean gestational age at birth, NICU admission rates, or 5-minute Apgar <7. Although the risk for maternal infectious morbidity was significantly lower with TOLAC(RR 0.48 [95% CI 0.25-0.90]), risks of uterine dehiscence, blood transfusions, and hysterectomy were comparable. Twin TOLAC is associated with a relatively high rate of successful vaginal delivery and a low risk of uterine rupture. The finding of higher neonatalmortality rates may be influenced by prematurity, but requires further investigation.

58: Association between twin vaginal delivery promotion and twin vaginal birth

Association between twin vaginal delivery promotion and twin vaginal birth. Using randomized trial data and society guidelines promoting twin vaginal birth as evidence, we implemented a program promoting twin vaginal delivery at an academic tertiary care center in 2013. The program included a provider needs assessment, provider didactics on and simulation of vaginal twin delivery, a hospital protocol for twin delivery, online patient education material, and the creation of a dedicated twin clinic for the highest risk twin pregnancies. The objective of the study is to investigate the impact of the program on vaginal delivery rates for twins. Out of 1,574 twins delivering between 2010 and 2015, 897 were eligible for inclusion. Rates of obstetric characteristics with the exception of intrauterine growth restriction were similar across the study. The rate of vaginal delivery nearly doubled by the last year of the study compared to the first year of the study (50.5% v. 27.8%, p<0.01 across years) with a lower number of patients electing cesarean delivery (59.8% v. 36.0%, p<0.01 across years) (Figure). After adjusting for fetal presentation, maternal age, and parity the adjusted odds of vaginal delivery increased across the study period with a stable decline in the adjusted odds of elective cesarean delivery (Table). The adjusted odds of vaginal delivery doubled comparing the time period before and after the intervention (aOR 2.12, 95% CI 1.54-2.91) and the adjusted odds of maternal and neonatal morbidity remained stable. Comparing the rates of twin vaginal birth before and after the intervention, 7.7 patients would need to be seen in a clinical environment promoting twin vaginal birth to prevent one cesarean delivery for twins. The promotion and support of attempted twin vaginal delivery is associated with an increase in rates of twin vaginal birth primarily due to decreased rates of elective cesarean delivery. Hospital-based implementation of similar programs may be a way to decrease rates of primary cesarean delivery for twins.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

The U.S. Twin Delivery Volume and Association with Cesarean Delivery Rates: A Hospital-Level Analysis.

The objective of this study was to test whether hospitals experienced in twin delivery have lower rates of cesarean delivery for twins. We divided obstetric hospitals in the 2011 National Inpatient Sample by quartile of annual twin deliveries and compared twin cesarean delivery rates between hospitals with weighted linear regression. We used Pearson's coefficients to correlate a hospital's twin cesarean delivery rate to its overall cesarean delivery and vaginal birth after cesarean (VBAC) rates. Annual twin delivery volume ranged from 1 to 506 across the 547 analyzed hospitals with a median of 10 and mode of 3. Adjusted rates of cesarean delivery were independent of delivery volume with a rate of 75.5 versus 74.8% in the lowest and highest volume hospitals (p = 0.09 across quartiles). A hospital's cesarean delivery rate for twins moderately correlated with the overall cesarean rate (r = 0.52, p < 0.01) and inversely correlated with VBAC rate (r = - 0.42, p < 0.01). Most U.S. obstetrical units perform a low volume of twin deliveries with no decrease in cesarean delivery rates at higher volume hospitals. Twin cesarean delivery rates correlate with other obstetric parameters such as singleton cesarean delivery and VBAC rates suggesting twin cesarean delivery rate is more closely related to a hospital's general obstetric practice than its twin delivery volume.

956: Cesarean delivery for twins: how have national rates changed over time?

956: Cesarean delivery for twins: how have national rates changed over time?

Simulation to Improve Trainee Knowledge and Comfort About Twin Vaginal Birth.

To describe a simulation-based curriculum on twin vaginal delivery and evaluate its effects on trainee knowledge and comfort about twin vaginal birth. Trainees participated in a three-part simulation consisting of a patient counseling session, a twin delivery scenario, and a breech extraction skills station. Consenting trainees completed a 21-item presimulation survey and a 22-item postsimulation survey assessing knowledge, experience, attitudes, and comfort surrounding twin vaginal birth. Presimulation and postsimulation results were compared using univariate analysis. Our primary outcomes were change in knowledge and comfort before and after the simulation. Twenty-four obstetrics and gynecology residents consented to participation with 18 postsimulation surveys available for comparison (75%). Trainees estimated their participation in 445 twin deliveries (median 19, range 0-52) with only 20.4% of these as vaginal births. Participants reported a need for more didactic or simulated training on this topic (64% and 88%, respectively). Knowledge about twin delivery improved after the simulation (33.3% compared with 58.3% questions correct, P<.01). Before training, 33.3% of participants reported they would strongly counsel a patient to attempt vaginal birth instead of elective cesarean delivery for twins compared with 50% after training (P=.52). Personal comfort with performing a breech extraction of a nonvertex second twin improved from 5.5% to 66.7% after the simulation (P<.01). Resident exposure to twin vaginal birth is infrequent and variable with a demonstrable need for more training. Our contemporary obstetric climate is prioritizing vaginal birth despite less frequent operative obstetric interventions. We describe a reproducible twin delivery simulation associated with a favorable effect on resident knowledge and comfort levels.

Twin vaginal delivery is associated with lower umbilical arterial blood pH of the second twin and less intrapartum blood loss

Objective: To clarify actual differences in the neonatal as well as maternal outcome between completed twin vaginal delivery and cesarean delivery.Methods: We collected the data from women with a twin pregnancy who delivered two live fetuses between 1 January and 31 December 2014 at 20 teaching hospitals11 Participants: Adachi Hospital, Hyogo Prefectural Amagasaki General Medical Center, Japan Baptist Hospital, Kitano Hospital, Kobe City Medical Center General Hospital, Kosaka Women’s Hospital, Kurashiki Central Hospital, Kyoto University Hospital, Mitsubishi Kyoto Hospital, Nagahama Red Cross Hospital, National Hospital Organization Kyoto Medical Center, National Hospital Organization Osaka National Hospital, Osaka Red Cross Hospital, Otsu Municipal Hospital, Otsu Red Cross Hospital, Red Cross Wakayama Medical Center, Saiseikai Noe Hospital, Shizuoka General Hospital, Takamatsu Red Cross Hospital and Tenri Hospital. in Japan. Only the cases that were retrospectively regarded as eligible for planned vaginal delivery were analyzed according to the actual mode of delivery.Results: Umbilical arterial blood pH (UmA-pH) of the second twin was slightly but significantly lower in the vaginal delivery group (7.26 ± 0.009) than in a cesarean delivery group (7.30 ± 0.006). Vaginal delivery was the only independent risk factor for second twin’s UmA-pH <7.20. Intrapartum blood loss was significantly larger in the cesarean delivery group (1444 ± 63 g) than in the vaginal delivery group (820 ± 109 g). Cesarean delivery was an independent risk factor for intrapartum blood loss ≥1500 g.Conclusion: Twin vaginal deliveries were associated with slightly but significantly lower UmA-pH of the second twin, whereas twin cesarean delivery was associated with significantly larger intrapartum blood loss. Not only the neonatal risk but also the maternal risk should be taken into account when an optimal delivery mode for the twin pregnancy is considered.

Bishop score and cervical length at 33–35 weeks of gestation and the risk of intrapartum cesarean delivery of twins

The aim of this study is to determine the association between Bishop score and cervical length measured at 33-35 weeks of gestation and the intrapartum risk of cesarean delivery of twins. This prospective observational study recruited women with vertex/vertex twin gestations at 33-35 weeks of gestation. Determination of the Bishop score and ultrasound measurement of the cervical length were performed. A regression model was constructed with control for known intrapartum and postpartum confounders. One hundred and forty-six women were analyzed; 18 women (12.3%) had cesarean deliveries during labor. Based on univariate analysis, the Bishop score at 33-35 weeks was significantly associated with the risk of intrapartum cesarean delivery of twins, whereas cervical length, maternal age, height, and weight at 33-35 weeks were not associated. Multivariate logistic regression analysis identified induction of labor and birth weight of the first-born twin, but not Bishop score, as independent predictors of intrapartum cesarean delivery of twins. A low Bishop score at 33-35 weeks of gestation was associated with an increased risk of intrapartum cesarean delivery of twin gestations. However, this relationship disappeared after adjusting for relevant intrapartum or postpartum confounders. Only labor induction and high birth weight of the first-born twin were independently associated with an increased risk of cesarean delivery in labor.

Active Second-Stage Management in Twin Pregnancies Undergoing Planned Vaginal Delivery in a U.S. Population

To estimate neonatal morbidity and delivery outcomes according to planned mode of delivery in twin pregnancies with active second-stage management. This was an historic cohort of twin pregnancies delivered in one practice between June 2005 and September 2009 using a strict protocol of second-stage management, including breech extraction of a second noncephalic twin and internal version of a nonengaged cephalic second twin followed by breech extraction. Primary outcome was a 5-minute Apgar score less than 7 for twin B. Secondary outcomes were 5-minute Apgar score less than 7 for twin A and 1-minute Apgar score less than 7 and arterial cord pH below 7.20 for each twin. A total of 287 twin pregnancies were included. There were 157 patients (54.7%) in the planned cesarean group and 130 patients (45.3%) in the planned vaginal delivery group. There was no significant difference in the rates of twin B having a 5-minute Apgar score lower than 7 or an arterial cord pH below 7.20. Among the patients in the planned vaginal delivery group, the cesarean delivery rate was 15.4%. No patients had a vaginal delivery of twin A followed by cesarean delivery of twin B. Among the patients in the planned vaginal delivery group, patients who had a successful vaginal delivery were more likely to be younger (31.56+/-6.6 compared with 36.88+/-6.1 years, P=.001) and were more likely to have a prior vaginal delivery (47.3% compared with 15.0%, P=.007). Planned vaginal delivery of twin pregnancies seems to be associated with neonatal outcomes similar to those with planned cesarean delivery. Active second-stage management is associated with good neonatal outcomes and a low risk of combined vaginal-cesarean delivery. II.

Intravenous nitroglycerin: a potent uterine relaxant for internal podalic version: case

Dear Editor, The uterine-muscle relaxation required for complicated obstetric situations traditionally has been achieved by use of a potent inhalation anesthetic. However, this procedure exposes the obstetric patient with full stomach to unnecessary general anesthesia, with the attendant risk and potentially lethal complications. Emergent uterine relaxation may be required for conditions such as retained placenta, uterine inversion, internal podalic version (IPV), and breech extraction. EVective on smooth muscle tissue and a venodilator, nitroglycerin is a short-acting and a potent uterine relaxant [1, 2]. Safety, predictability, and ease of intravenous (IV) administration of this drug have been established, and it has attracted the attention of obstetricians. Nitroglycerin is primarily indicated for the treatment or prevention of angina pectoris. Nitroglycerin has been used during manual extraction of retained placenta without clinically signiWcant hemodynamic eVects [1] and during replacement of a contracted, completely prolapsed uterus [1, 2]. Its use as a tocolytic has been reported in cesarean delivery of twins performed under spinal anesthesia: two cases of intrapartum external cephalic version, internal intrapartum podalic version of the second twin, and for the fetal head entrapment during vaginal breech delivery [1]. We report a case of IPV of intrauterine fetal demise (IUFD) in which relaxation of the uterus was accomplished quickly and safely with the use of IV nitroglycerin. A 30-year-old gravida 4 para 3 at 38 weeks gestation presented in active labor with antepartum hemorrhage since 2 h. Ultrasound conWrmed transverse lie, abruption placentae and IUFD; and examination revealed 4 cm dilated cervix. Her vitals were stable, hematocrit was 28% and coagulation proWle was normal. She made good progress, reaching 8 cm cervical dilatation over the next 4 h after which she started having hematuria so the decision was taken immediately to deliver the fetus by IPV. Uterine relaxation was achieved by direct IV nitroglycerin bolus 50 mcg along with ketamine hydrochloride 30 mg IV for sedation. Infusion of nitroglycerin at the rate of 50 mcg/min was started after 1 min of loading dose. When the uterus was relaxed (conWrmed with manual palpation), approximately 45 s after bolus, the obstetrician performed IPV and breech extraction. The procedure was completed in 4 min and 30 s. The total dose of nitroglycerin was 250 mcg. The placenta delivered spontaneously with no unusual cord traction. Transabdominal massage of the uterus and oxytocin infusion improved uterine tone. The hematocrit had decreased from 28 to 22%. One unit blood transfusion was given and she remained stable in the postpartum period. Hematuria was cleared in 2 h postpartum. Monitoring consisted of electrocardiogram, SpO2 and non-invasive blood pressure measurement. Hypotension occurred 1 min after nitroglycerin injection, which was normalized within 50 s with rapid infusion of crystalloids. The heart rate increased at the same time to 130 bpm. Side M. N. Gandhi · H. R. Iyer Department of Anaesthesiology, B. Y. L. Nair Charitable Hospital, T. N. Medical College, Dr. A. L. Nair road, Bombay 400008, Maharashtra, India

Cesarean Delivery for the Second Twin

To examine maternal and infant outcomes after a vaginal delivery of twin A and a cesarean delivery of twin B, and to identify whether the second twin experienced increased short-term morbidity as part of a combined route of delivery. Between January 1, 1999, and December 31, 2000, a prospective cohort study of all cesarean deliveries was conducted at 13 university centers. This secondary analysis was limited to women with twin gestations who experienced labor and underwent cesarean delivery. We compared outcomes of the second twin in women who had vaginal delivery of the first twin and a cesarean delivery of the second twin to those who had cesarean delivery of both twins. One thousand twenty-eight twin pregnancies experienced labor and underwent cesarean delivery; 179 (17%) had a combined vaginal/cesarean delivery. Gestational age at delivery was 34.6 weeks in both groups (P=.97). The rupture of membranes to delivery interval was longer in the combined group (3.2 compared with 2.3 hours, P<.001). Endometritis and culture-proven sepsis in the second twin were more common in the combined group, respectively (n=24, odds ratio 1.6, 95% confidence interval, 1.0-2.7; n=15, odds ratio 1.8, 95% confidence interval, 1.0-3.4). These differences were not significant after logistic regression analysis. There were no statistically significant differences in an arterial cord pH of less than 7.0, Apgar score less than or equal to 3 at 5 minutes, seizures, grade III or IV intraventricular hemorrhage, hypoxic ischemic encephalopathy, or neonatal death. Combined twin delivery may be associated with endometritis and neonatal sepsis when compared with a twin delivery where both are delivered by cesarean in twin pregnancies experiencing labor. More serious neonatal sequelae, including hypoxic ischemic encephalopathy and death, were not affected by the route of delivery of the second twin.

Optimal timing of elective cesarean delivery for twins

Optimal timing of elective cesarean delivery for twins