Mode Of Delivery In Twins Research Articles

Mode of delivery of twins at term.

Observational epidemiological analyses demonstrated a decreased risk of death and severe morbidity associated with caesarean delivery at term but an increased risk at preterm gestational age. A multicentre international randomized controlled compared planned caesarean section with vaginal birth and observed no difference in outcome; however, the trial included preterm and term births in approximately similar proportions. A subsequent re-analysis of the trial demonstrated that planned caesarean section was associated with an increased risk of adverse neonatal outcome at preterm gestational ages, but reduced the risk of perinatal complications at term, consistent with the epidemiological studies. Hence, decision-making around mode of delivery for twins should recommend against routine caesarean delivery preterm. At term, the balance of risks and benefits will vary according to the mother's prioritization of avoiding intervention, her attitude to managing the risks of uncommon but potentially severe adverse events, and her plans and potential for future pregnancies.

Survival Without Severe Neonatal Morbidity in Very Preterm Twins According to Planned Mode of Delivery.

To assess survival to discharge without severe neonatal morbidity by planned mode of delivery for twins born before 32 weeks of gestation. The JUMODA (JUmeaux MODe d'Accouchement) study was a French national prospective, population-based, cohort study of twin deliveries conducted from February 2014 to March 2015. This planned secondary analysis included diamniotic twin pregnancies from 26 0/7 through 31 6/7 weeks of gestation. Exclusion criteria included contraindications to vaginal delivery and situations for which planned cesarean delivery is favored, and neonatal prognosis depends largely on the underlying pathology rather than the planned mode of delivery. The primary outcome was survival to discharge without severe neonatal morbidity (bronchopulmonary dysplasia, grade 3 or grade 4 intraventricular hemorrhage, periventricular leukomalacia, stage 2 or stage 3 necrotizing enterocolitis). The association between planned mode of delivery and primary outcome was assessed by multivariate Poisson regression model. A propensity-score approach with inverse probability of treatment weighting also was performed to control for indication bias. Subgroup analyses according to birth order and sensitivity analyses limited to spontaneous preterm births only were performed. Among 424 very preterm twin pregnancies, 192 (45.3%) had a planned cesarean delivery and 232 (54.7%) had a planned vaginal delivery. Survival to discharge without severe morbidity did not differ in the two groups: 308 of 384 (80.2%) after planned cesarean and 375 of 464 (80.8%) after planned vaginal delivery (crude relative risk 0.99; 95% CI 0.91-1.15; adjusted relative risk 1.02; 95% CI 0.93-1.11). After applying inverse probability of treatment weighting, planned cesarean delivery still was not associated with higher survival to discharge without severe neonatal morbidity than planned vaginal birth (relative risk 1.11; 95% CI 0.84-1.46). Subgroup and sensitivity analyses showed similar results. Planned cesarean delivery for very preterm twins is not associated with higher survival to discharge without severe neonatal morbidity than planned vaginal delivery. These results suggest that very preterm delivery should not be considered a per se indication for planned cesarean in twin pregnancies.

Spotlight on… multiple pregnancy

Multiple pregnancy has received increasing attention over the last decade, with the National Institute for Health and Care Excellence (NICE) guideline on multiple pregnancy already in its second edition.1 The first review article about multiple pregnancy in The Obstetrician and Gynaecologist (TOG) was published in 2000 by Taylor and Fisk (TOG 2000;2:4–10). Looking again at this article and seeing the photograph of a young Myles Taylor (as all TOG articles featured the authors’ photos then!) brought back fond (…) memories of reading this for the MRCOG examination. It is interesting to compare the older article with a 2010 Review by Devaseelan and Ong (TOG 2010;12:179–85). Most aspects of care were largely unchanged, but the Eurofoetus trial2 had proven that endoscopic laser ablation of placental anastomoses was the treatment of choice for severe twin-to-twin transfusion syndrome (TTTS). Soon after the publication of the Eurofoetus study,2 Smith and Denbow wrote a comprehensive review on TTTS (TOG 2006;8:1–6) and its evolving management in light of the landmark trial. The complex management of TTTS has also been reviewed in the two Advances in fetal therapy articles published in 2005 (TOG 2005;7:183–9) by O’Brien and Kumar and in 2010 (TOG 2010;12:94–102) by Morris et al. Monoamniotic twin pregnancies are rare and challenging to manage. Dias et al. reviewed the pathophysiology, outcomes and management of these pregnancies in 2012 (TOG 2012;14:71–8). Even more challenging is the management of higher order multiple pregnancies and multiple pregnancies where one fetus has severe genetic or congenital abnormalities. Beriwal et al. summarised elegantly Multifetal pregnancy reduction and selective termination in 2020 (TOG 2020;22:284–92). Importantly, the authors highlighted the ethical, legal and psychological considerations for women, couples and doctors in these difficult cases. Beyond the rare multiple pregnancy cases that are mainly managed in fetal medicine units, the major challenge and source of neonatal mortality and morbidity in multiple pregnancies is preterm birth. Effective prevention strategies are still not available, but the most recent evidence was finely appraised by Murray et al. in 2018 (TOG 2018;20:57–63). For both preterm and term births, mode of delivery can be a difficult decision. Breeze and Smith reviewed the evidence for mode of delivery in twins in 2004 (TOG 2004;6:222–6). The Twin Birth Study has been published since then3 and has answered some questions about the safety of vaginal birth and caesarean section and actual mode of delivery depending on original intention. Overall, TOG has published a comprehensive selection of articles on the management of multiple pregnancy. As it is now 11 years since the last general multiple pregnancy review article (TOG 2010;12:179–85), perhaps it is time for another up-to-date review incorporating the latest evidence from the Twin Birth Study,3 the STOPPIT-2 trial4 and other relevant studies.

Twin birth - planned vaginal delivery still standard of care.

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.

P19.03: Counselling regarding mode of delivery in twins at thirty‐two weeks gestation

P19.03: Counselling regarding mode of delivery in twins at thirty‐two weeks gestation

Neonatal Outcomes of Twins According to Birth Order, Presentation, and Mode of Delivery: A Systematic Review and Meta-Analysis

Please cite this paper as: Rossi A, Mullin P, Chmait R. Neonatal outcomes of twins according to birth order, presentation and mode of delivery: a systematic review and meta-analysis. BJOG 2011;118:523–532. Background The optimal mode of delivery for twins is undetermined. Objective To review literature regarding the neonatal outcomes following twin delivery. Data sources Searches were conducted in PubMed, Medline, Embase, Cochrane library and reference lists. Selection criteria Studies selection criteria were: both twins alive at labour, outcomes stratified for birth order, presentation, planned and actual delivery mode. Eighteen articles were included in the meta-analysis (39 571 twin sets). Data collection and analysis The Meta-analysis of Observational Studies in Epidemiology guidelines were followed. Interstudy heterogeneity (I2) was tested. A fixed model was generated whenever I2 < 25%. Pooled odds ratios (OR) with 95% CI were computed. Intergroup comparison was significant if 95% CI did not encompass 1. The first and second twins were indicated as Twin A (TA) and Twin B (TB), respectively. Main results Neonatal morbidity was lower in TA than TB (3.0 versus 4.6%; OR 0.53; 95% CI 0.39–0.70). TA experienced neonatal death less often than TB (0.3 versus 0.6%; OR 0.55; 95% CI 0.38–0.81). No differences were noted between vertex and non-vertex and attempted vaginal delivery versus planned caesarean section in either TA or TB. In TA, neonatal morbidity was lower after vaginal delivery (1.1%) than caesarean section (2.2%; OR 0.47; 95% CI 0.27–0.82). Neonatal death was not associated with actual delivery mode. In TB, morbidity following combined delivery (19.8%) was higher than after vaginal delivery (9.5%; OR 0.55; 95% CI 0.41–0.74) or caesarean section (9.8%; OR 0.47; 95% CI 0.43–0.53). When outcomes were stratified for both presentation and delivery mode, mortality rate was lower after vaginal delivery than caesarean section for both vertex and nonvertex TB. Author’s conclusion An attempt at vaginal delivery should be considered in twin pregnancies with vertex/vertex presentation.

Neonatal mortality and mode of delivery in spontaneous and induced twin labours: a population based cohort study

BackgroundThere is a continuing debate regarding optimal timing and mode of delivery in twins.AimTo describe neonatal mortality rates (NMR) and factors influencing mode of delivery in twins following induced or...

Neonatal outcomes of twins according to birth order, presentation and mode of delivery: a systematic review and meta-analysis*

The optimal mode of delivery for twins is undetermined. To review literature regarding the neonatal outcomes following twin delivery. Searches were conducted in PubMed, Medline, Embase, Cochrane library and reference lists. Studies selection criteria were: both twins alive at labour, outcomes stratified for birth order, presentation, planned and actual delivery mode. Eighteen articles were included in the meta-analysis (39, 571 twin sets). The Meta-analysis of Observational Studies in Epidemiology guidelines were followed. Interstudy heterogeneity (I(2) ) was tested. A fixed model was generated whenever I(2)<25%. Pooled odds ratios (OR) with 95% CI were computed. Intergroup comparison was significant if 95% CI did not encompass 1. The first and second twins were indicated as Twin A (TA) and Twin B (TB), respectively. Neonatal morbidity was lower in TA than TB (3.0 versus 4.6%; OR 0.53; 95% CI 0.39-0.70). TA experienced neonatal death less often than TB (0.3 versus 0.6%; OR 0.55; 95% CI 0.38-0.81). No differences were noted between vertex and non-vertex and attempted vaginal delivery versus planned caesarean section in either TA or TB. In TA, neonatal morbidity was lower after vaginal delivery (1.1%) than caesarean section (2.2%; OR 0.47; 95% CI 0.27-0.82). Neonatal death was not associated with actual delivery mode. In TB, morbidity following combined delivery (19.8%) was higher than after vaginal delivery (9.5%; OR 0.55; 95% CI 0.41-0.74) or caesarean section (9.8%; OR 0.47; 95% CI 0.43-0.53). When outcomes were stratified for both presentation and delivery mode, mortality rate was lower after vaginal delivery than caesarean section for both vertex and nonvertex TB. AUTHOR'S CONCLUSION: An attempt at vaginal delivery should be considered in twin pregnancies with vertex/vertex presentation.

Periventricular leukomalacia and mode of delivery in twins under 1500 g

Background: The optimal mode of delivery in twin gestations remains undefined, particularly for twins weighing less than 1500 g. Objective: To evaluate the impact of the mode of delivery on neonatal outcome in twins below 1500 g. Materials and methods: In this multicenter cohort study during 1999, 66 sets of twins born in hospital and weighing below 1500 g formed our study group. Antenatal and neonatal parameters and their relationship to mode of delivery were studied, based on a factor analysis. Analysis of covariance was used to assess the effect of the mode of delivery on postnatal factors, with antenatal parameters used as covariates. Results: Statistical analysis showed that infants delivered vaginally had significantly more periventricular leukomalacia than those children delivered by Cesarean section (p = 0.03). The estimated odds for leukomalacia were higher in the vaginal than in the Cesarean group when adjusted for covariates (OR = 4.7; 95% CI = 1.0, 25.15). Conclusion: Routine Cesarean section should be recommended in twin gestations with infants weighing less than 1500 g, regardless of gestational age or fetal presentation.

Periventricular leukomalacia and mode of delivery in twins under 1500 g

Background: The optimal mode of delivery in twin gestations remains undefined, particularly for twins weighing less than 1500 g.Objective: To evaluate the impact of the mode of deliveryon neonatal outcome in twins below 1500 g.Materials and methods: In this multicenter cohort study during 1999, 66 sets of twins born in hospital and weighing below 1500 g formed our study group.Antenatal and neonatal parameters and their relationship to mode of delivery were studied, based on a factor analysis. Analysis of covariance was used to assess the effect of the mode of delivery on postnatalfactors, with antenatal parameters used as covariates.Results: Statistical analysis showed that infants delivered vaginally had significantly more periventricular leukomalacia than those childrendelivered by Cesarean section (p = 0.03). The estimated odds for leukomalacia were higher in the vaginal than in the Cesarean group when adjusted for covariates (OR = 4.7; 95% CI = 1.0, 25.15).Conclusion:Routine Cesarean section should be recommended in twin gestations with infants weighing less than 1500 g, regardless of gestational age or fetal presentation.

Should all twins be delivered by caesarean section? A preliminary report.

The aim was to analyse the neonatal mortality related to mode of delivery for twins using a population-based registry. In all, 18,125 twins delivered in Sweden between 1991 and 1997, after excluding those with unknown gestational duration, were used to analyse the differences between groups of twins. Results showed the OR for neonatal death, breech vaginal delivery versus caesarean section (all indications) was 1.47 (95% CI 0.99-2.17). The OR at vaginal delivery for neonatal death, twin I in breech versus cephalic presentation was 5.60 (2.62-11.94) and for twin II the corresponding figures were 1.85 (1.03-3.32). Analyses using population-based registries from other countries are needed to confirm or reject the present findings of an increased neonatal mortality for twins in breech presentation delivered vaginally.

Should all Twins be Delivered by Caesarean Section? A Preliminary Report

AbstractThe aim was to analyse the neonatal mortality related to mode of delivery for twins using a population-based registry. In all, 18,125 twins delivered in Sweden between 1991 and 1997, after excluding those with unknown gestational duration, were used to analyse the differences between groups of twins. Results showed the OR for neonatal death, breech vaginal delivery versus caesarean section (all indications) was 1.47 (95% CI 0.99-2.17). The OR at vaginal delivery for neonatal death, twin I in breech versus cephalic presentation was 5.60 (2.62-11.94) and for twin II the corresponding figures were 1.85 (1.03-3.32). Analyses using population-based registries from other countries are needed to confirm or reject the present findings of an increased neonatal mortality for twins in breech presentation delivered vaginally.

The controversy of mode of delivery in twins: the intrapartum management of twin gestation (Part I).

The controversy of mode of delivery in twins: the intrapartum management of twin gestation (Part I).

The controversy of mode of delivery in twins: the intrapartum management of twin gestation (Part II).

The controversy of mode of delivery in twins: the intrapartum management of twin gestation (Part II).