Total Breech Extraction Research Articles

Development and validation of a technical skill score for internal version and total breech extraction of the second twin: An interventional prospective study.

To develop and test an Objective Structured Assessment of Technical Skills (OSATS) score for the internal version and total breech extraction of the second twin if in a non-engaged cephalic position. This prospective interventional study took place in a tertiary obstetrics department in France. An objective scoring system was developed, and a standardized simulation scenario was set up. Score evaluation was blinded and analyzed according to group and number of past successful vaginal twin deliveries in real life. A satisfaction evaluation was performed, based on the "Student Design Scale" questionnaire. Simulation was performed on 33 participants in three groups: novice group (15 first- and second-year residents), intermediate group (11 third- to sixth-year residents), and expert group (seven senior obstetricians). The total score obtained by experts was higher than that of the intermediate group (P = 0.001), which was higher than that of the novice group (P < 0.001). In the intermediate group, no correlation was found between OSATS score and number of past successful vaginal twin deliveries. Participants' satisfaction was excellent. The OSATS score developed was reliable and valid to evaluate an internal version and a total breech extraction of the second twin, and to differentiate novice, intermediate, and expert practitioners.

L’accouchement des femmes enceintes de jumeaux : les enseignements de l’étude nationale observationnelle prospective comparative JUMODA

ObjectivesTo summerize the results of the JUMODA study (JUmeaux MODe d’Accouchement) on the planned mode of delivery of twin pregnancy and the management of second twin delivery. MethodsJUMODA was a national observational prospective comparative study that took place between february 2014 and march 2015 in 176 french maternity units performing more than 1500 deliveries per year. Its main objectives were the comparison of neonatal and maternal morbidity according to the planned mode of delivery and the determination of the managements of second twin delivery associated with the best neonatal outcomes. To control for potential confounding factors and indication biases, statistical analyses comprized multivariate logistic regressions and matching on propensity scores. ResultsThe JUMODA study recruited 8823 women with twin delivery at or beyond 22 weeks of gestation. For twin pregnancies with a cephalic first twin at 32 weeks of gestation and beyond, severe neonatal morbidity was higher in the planned cesarean (150/2908 (5.2 %) than in the planned vaginal delivery group (199/8922 (2.2 %), aOR 1.56, 95 % CI 1.19-2.04). Increased neonatal morbidity in the planned cesarean delivery group was explained by higher severe morbidity in neonates born preterm (aOR 1.64, 95 % CI 1.13-2.39, for deliveries between 32+0 and 34+6 weeks of gestation, aOR 2.04, 95 % CI 1.22-3.41, for deliveries between 35+0 SA and 36+6 weeks of gestation) but not in neonates born at term (aOR 1.19, 95 % CI 0.58-2.44). In comparison with planned cesarean delivery, planned vaginal delivery was not associated with increased severe neonatal morbidity in case of breech presenting first twin after 32 weeks of gestation or with decreased survival witout severe neonatal morbidity in case of delivery before 32 weeks of gestation whatever the first twin presentation. In comparison with planned vaginal delivery, planned cesarean delivery was associated with increased severe maternal morbidity only in women aged 35 and higher. Delivery of non cephalic second twin was associated with similar severe neonatal morbidity rate than delivery of cephalic second twin. Finally, in case of cephalic second twin, internal version followed by total breech extraction was associated with less cesarean for the second twin but with higher severe neonatal morbidity in case of preterm birth in comparison with pushing efforts, ocytocin perfusion and artificial rupture of membranes. ConclusionsPlanned vaginal delivery is the planned mode of delivery to encourage for the majority of pregnant women with twins, whatever first twin presentation and gestational age at delivery. No management of cephalic second twin appears better than an other, its choice will rest on obstetrician preferences.

Total breech extraction of the second twin in trial of labor after cesarean

Maternal and neonatl outcomes in trial of labor after cesarean (TOLAC) deliveries of twins are similar to singleton TOLACs. We examined whether internal podalic version and total breech extraction of the second twin adversely impacts outcome. A retrospective multicenter study was conducted including data on deliveries occurring between 2005-2020. We included TOLACs only, at 320/7 gestational weeks and on, of twin gestations with a vertex presenting first twin upon labor admission. The exposed group was defined as deliveries with a non-vertex second twin at admission to labor, while the comparison group included deliveries with a vertex second twin at admission. Only parturients who attempted vaginal delivery were included. Cases of pre-labor fetal death of either twin or major fetal anomalies were excluded. The primary outcome was uterine rupture. Two hundred thirty-six twin TOLACs were included, of whom 128 presented with a non-vertex second twin, and 108 presented with a second vertex twin. There was no difference in the primary outcome of uterine rupture (1/128, 0.9% vs. 1/108, 0.8%, p=1.000) (Table 1). Successful TOLAC of both twins occurred in 76.6% of the exposed group vs. 81.5% in the comparison group, while cesarean delivery (CD) of both twins was performed in 21.9% of the exposed group vs. 17.6% of the comparison group (p=0.418, OR=1.32, CI 0.7-2.5). There were 2 cases of CD for the second twin in the exposed group and one case in the comparison group (1.6% vs. 0.9%, respectively, p=1.000) (Table 2). There was no difference between the groups in maternal outcomes, including rates of postpartum hemorrhage, blood transfusion, placental abruption, etc. (Table 1). Neonatal outcomes were also comparable between the groups. Non-cephalic second twin in TOLAC deliveries results in favorable maternal and neonatal outcomes, comparable with vertex-vertex TOLACs. Second twin non-cephalic presentation should not discourage parturients and caregivers from considering TOLAC if desired.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

387: Neonatal morbidity of cephalic second twins according to the obstetrical strategy adopted at delivery

To assess neonatal mortality and morbidity of cephalic second twins according to the obstetrical strategy adopted after vaginal birth of the first twin, either internal version followed by total breech extraction, as recommended by the French College of Gynecologists and Obstetricians, or pushing efforts. In this planned secondary analysis of the JUMODA cohort, a national prospective population-based study of twin deliveries conducted from 02/2014 to 03/2015 in 176 hospitals performing more than 1,500 annual deliveries in France, we included cephalic second twins after vaginal birth of the first twin at 32 weeks and more. Intrauterine fetal deaths, fetal malformations, twin-to-twin transfusion syndromes, monoamniotic pregnancies, and unknown presentations and managements of second twins were excluded. The primary outcome was a composite of neonatal mortality and morbidity. To control for potential confounders, we used multivariate Poisson regression models. Of 2261 cephalic second twins included in the study, 494 (21.8%) were born in breech presentation after internal version and total breech extraction and 1767 (78.2%) in cephalic presentation after pushing efforts. The mean inter-twin delivery interval was shorter in the internal version group compared to the pushing efforts group (6.6 ± 5.9 versus 10.0 ± 13.0, p<0.01). Neither rates of cesarean for the second twin (10/494 (2.0%) versus 61/1767 (3.2%), p=0.1) nor rates of composite neonatal mortality and morbidity (17/494 (3.4%) versus 36/1767 (2.2%); aRR 1.4, 95% CI 0.8-2.4) differed significantly between the two groups. Compared with pushing efforts after vaginal birth of the first twin, internal version followed by total breech extraction of cephalic second twins is associated with shorter inter-twin delivery intervals but not with improved neonatal outcomes.

Is the risk of obstetric anal sphincter injuries increased in vaginal twin deliveries?

Objective: Vaginal twin deliveries have a higher rate of intrapartum interventions. We aimed to determine whether these characteristics are associated with an increased rate of obstetric anal sphincter injuries compared with singleton.Study design: Retrospective study of all twin pregnancies undergoing vaginal delivery trial was conducted from January 2000–September 2014. Sphincter injury rate compared with all concurrent singleton vaginal deliveries. Multivariable analysis was used to determine twin delivery association with sphincter injuries while adjusting for confounders.Results: About 717 eligible twin deliveries. Outcome was compared with 33 886 singleton deliveries. Twin pregnancies characterized by a higher rate of nulliparity (54.8% versus 49.5%, p = 0.005), labor induction (42.7% versus 29.1%, p < 0.001), and instrumental deliveries (27.5% versus 16.7%, p < 0.001), lower gestational (34.6 ± 3.3 versus 38.8 ± 2.3, p < 0.001), and lower birth weight. Total breech extraction was performed in 29.0% (208/717) of twin deliveries. Overall obstetric sphincter injury rate was significantly lower in the twins group (2.8% versus 4.4%, p = 0.03, OR = 0.6, 95% CI 0.4–0.9), due to lower rate of 3rd degree tears in twins versus singletons (2.2% versus 4.0%, p = 0.02), rate of 4th degree tears similar among the groups (0.6% versus 0.4%, p = 0.5). In multivariable analysis, sphincter injuries were associated with nulliparity (OR = 3.9, 95% CI 3.4–4.5), forceps (OR = 6.8, 95% CI 5.8–7.8), vacuum (OR = 2.9, 95% CI 2.5–3.3), earlier gestational age (OR = 0.2, 95% CI 0.1–0.3), episiotomy (OR = 0.8, 95% CI 0.7–0.9), and birth weight over 3500 g (OR = 1.8, 95% CI 1.6–2.0). However, the association between twins (versus singletons) deliveries and sphincter injuries was lost after adjustment for delivery gestational age (OR = 0.7, 95% CI 0.4–1.2).Conclusion: Despite a higher rate of intrapartum interventions, the rate of sphincter injuries is lower in twins versus singleton deliveries, mainly due to a lower gestational age at delivery.

L’accouchement du deuxième jumeau en présentation céphalique. À propos d’une série de 127 patientes

In 2009, the French National College of Obstetricians and Gynaecologists (CNGOF) clinical practice guidelines encouraged the active management of the second twin (T2) in high and mobile cephalic presentation (CP) by performing systematic internal maneuvers. In our department, this type of management is less frequent as whenever T2 is not delivered spontaneously after a short time interval, an instrumental extraction is realized. We analyzed our practice for 5 years upon 127 twin pregnancies with a trial of vaginal delivery for T2 in CP. We compared the results following different modes of delivery which are: spontaneous delivery, instrumental extraction, and total breech extraction after manual internal version. No significant difference was found among the 3 groups in terms of maternal, fetal and neonatal well-being. Moreover, instrumental delivery was feasible, with a mean time interval for delivery between the 2 twins<15 minutes, even when performed by an obstetrician on training. The aim of our study was to evaluate our practice on T2 in CP, because this event can be quite tricky, thus discouraging less experienced obstetricians towards this practice and resulting in an increase in caesarean sections for T2. Instrumental delivery should be considered a possible option for any T2 in CP so as to ensure the continued existence of vaginal births for twin pregnancies.

Accouchement manœuvrier du deuxième jumeau : membranes rompues versus membranes intactes. À propos d’une série de 182 patientes

The vaginal management of the second twin (T2) differs throughout our country. In 2009, the French National College of Gynecologists and Obstetricians released practice guidelines, with low-level evidence, encouraging active management of the second twin, using maneuvers with intact membrane. In our level III labour ward, these maneuvers are systematically performed when the second twin is in a breech or transverse presentation and after ruptured membranes in most cases. We studied 182 twin pregnancies with active management of the T2 at more than 28 weeks of gestation, from 1st January 1996 to 31st December 2010, by comparing the membrane status during delivery of T2. The results did not show any significant differences between the two groups of patients concerning the neonatal or maternal results. The technique is feasible, even by residents. Our results show that total breech extraction of the second twin with ruptured membranes is feasible, which allows for reappraisal of the national recommendations. In our practice, it is possible to actively deliver the T2 with ruptured membranes without altering maternal and fetal prognosis and thus simplifying learning for young doctors.

90: Vaginal delivery of the second non-cephalic presenting twin by Total Breech Extraction versus Cesarean delivery: comparable for neonates, superior for mothers

90: Vaginal delivery of the second non-cephalic presenting twin by Total Breech Extraction versus Cesarean delivery: comparable for neonates, superior for mothers

Vaginal delivery of vertex–nonvertex twins: a fading skill?

Delivery of the second twin is one of the most challenging events for practicing obstetricians. Due to the increased incidence of twin gestations and lack of well-designed clinical trials, evidence-based recommendations are lagging behind clinical demand. The present review examines the practice of second nonvertex twin deliveries. A review of the literature was conducted using the term vertex-nonvertex; twin gestation; mode of delivery; and cesarean delivery. There is a lack of evidence supporting the appropriate approach to second nonvertex twin deliveries. Larger studies with increased power are needed to examine the variations regarding gestational period, birth weight, and institutional experience. In the mean time, unless otherwise contraindicated, it is reasonable to attempt vaginal delivery and total breech extraction and proceed to assisted delivery or cesarean delivery if unsuccessful. Preserving the art of obstetric maneuvering is important as well for twin deliveries. In cases of vertex-nonvertex presentation, vaginal delivery is preferred in certain conditions.

Prise en charge de l’accouchement du deuxième jumeau

To determine the optimal mode of delivery of the second twin according to his presentation. The PubMed data base has been consulted. Considering longer intertwin intervals are correlated with poorer umbilical artery blood gas results and are associated with greater rates of cesareans for the second twin after vaginal birth of the first twin and increased neonatal morbidity of the second twin, second twin delivery should be actively managed for reducing this interval (EL3). In case of non cephalic presentation of the second twin, immediate total breech extraction, after internal version in case of transverse lie, could be associated with lower rates of cesareans for the second twin (EL3). In these situations, external version might be deleterious (EL3). In case of cephalic presentation above a 0 station, and if the obstetrical team is trained in obstetrical maneuvers, internal version followed by immediate total breech extraction could be preferred to the association of maternal pushing efforts, oxytocin infusion and artificial rupture of the membranes, because this first strategy might be associated with less cesareans for the second twin (EL4). In case of cephalic presentation at or below a 0 station, management of second twin delivery should consist in the association of maternal pushing efforts, oxytocin infusion and artificial rupture of the membranes (EL3). All the obstetrical maneuvers for second twin delivery should be performed in first intent with intact membranes (EL5). Second twin delivery should be actively managed and largely depends on the knowledge of specific obstetrical maneuvers. Training residents to these maneuvers remains a priority.

L’accouchement par voie basse des grossesses gémellaires est-il encore une option raisonnable ? Analyse des données de la littérature

The aim of this review was to analyze the nature of the data and practices reported in the literature in order to determine if vaginal delivery of twin gestations with a first twin in cephalic presentation after 34 weeks still remains an option. Compared to cesarean, large retrospective population-based studies demonstrated increased neonatal morbidity and mortality of the second twin associated with vaginal delivery. Some then suggested systematic planned cesarean could protect second twins from increased neonatal mortality and morbidity. These results have not been confirmed in hospital retrospective studies in which candidates for vaginal delivery were carefully selected, and second twin delivery actively managed, with internal version when the fetal head is above a 0 station in case of cephalic presentation and with systematic immediate total breech extraction in case of non cephalic presentation. Taking into account the poor external validity of the population-based studies, and the reassuring results of the hospital retrospective studies, attempted vaginal delivery after 34 weeks, when the first twin is in cephalic presentation, still appears as a safe option in low risk populations. Progress in the assessment of the risks associated with the mode of delivery could result from a large nationwide observational prospective study, a randomized trial being, even more than in the breech delivery issue, an inappropriate method for evaluating these risks.

Mode d’accouchement des grossesses gémellaires

The assessment of optimal delivery for twin gestations is complex due to the relatively high frequency of obstetrical complications and to the heterogeneity of delivery management in these conditions. The extern validity of the Anglo-Saxon studies is limited in particular because delivery management of the second twin (approach of external cephalic version) differs from the French one (approach of internal version and/or total breech extraction) in cases of non-vertex second twin. Anglo-Saxon studies suggest that a planned vaginal delivery is associated to an increased risk of neonatal morbidity for second twin compared to first twin at term, in particular in cases of combined vaginal-cesarean birth. To reduce the interval twin-to-twin delivery interval and the number of combined vaginal-cesarean births, in our opinion, one must stop to perform external cephalic version and recommend a routinely active management for the second non-vertex twin delivery. With this active management, there is no evidence to support planned cesarean section for twins. Nevertheless, active management requires training as internal version might be difficult to perform, and therefore it is essential to pursue to teach junior obstetrician these obstetric maneuvers. There is limited role for trial of labor after cesarean delivery in twin gestation with a policy of active management.

The use of ultrasound for the diagnosis of spinal hemorrhage in a newborn

We present a case of an unusually large spinal epidural hematoma in an infant after a total breech extraction, which was diagnosed by high-resolution ultrasonography. The lesion appeared unusually large, homogeneous, and isoechoic to the spinal cord. This case demonstrates the ability of ultrasound to diagnose the nature of the lesion, its exact location and full extent. Magnetic resonance imaging was used in this case only as a secondary modality to demonstrate the hemorrhagic nature of the lesion.

Twin pregnancies: Indications, techniques, and outcome after internal version and total breech extraction

Twin pregnancies: Indications, techniques, and outcome after internal version and total breech extraction

Delivery of the nonvortex second twin: Breech extraction versus external cephalic version

OBJECTIVE: Our purpose was to compare the maternal and perinatal outcomes of twin gestations in which the nonvortex second twin was delivered by total breech extraction versus those delivered by external cephalic version. STUDY DESIGN: The intrapartum courses of 284 consecutive twin gestations were analyzed retrospectively. Once those with actual birth weight <600 gm, unrecognized multifetal pregnancy, multiple congenital anomalies, cesarean delivery, and/or antepartum intrauterine fetal death were excluded, 23 mothers were delivered by total breech extraction and 21 underwent external cephalic version. RESULTS: The two groups were similar for mean (±SD) maternal age, gravidity, parity, gestational age at delivery, ultrasonographic estimate of birth weight for twin B, incidence of breech or transverse presentation for the second fetus, and actual birth weight of the first or second newborn. Suspected fetal distress that led to cesarean delivery occurred significantly more often in parturients who underwent attempted external version ( 4 21 ) than total breech extraction ( 0 23 , p = 0.04 ). The incidence of eventual abdominal delivery was also significantly higher in patients who underwent attempted external cephalic version ( 10 21 ) rather than breech extraction ( 1 23 , p = 0.001 ). For twin B the occurrence of low Apgar scores at 1 minute was significantly higher for infants after attempted external version ( 7 21 ) rather than breech extraction ( 1 23 , p = 0.02 ), but the mean pH, number with Apgar scores <7 at 5 minutes, and number of neonatal intensive care unit admissions were similar. No perinatal traumatic injury occurred in either group. CONCLUSION: On the basis of our experience, total breech extraction of the nonvertex second twin is preferable to external cephalic version because it appears to be associated with a significantly lower incidence of fetal distress and abdominal delivery with comparable neonatal outcome.

Breech presentation in Spain, 1992: a collaborative study

Objectives: The goals of the present work were to study the incidence of breech deliveries in Spain, the causes for breech presentation and its management and the incidence of cesarean sections and its correlation with the perinatal mortality rates among different centers. Study design: Data from 102 038 deliveries, 3829 of which were singleton breech deliveries attended in 1992, were obtained from 40 hospital centers located in different autonomic communities of Spain and analyzed using a computer statistical package (R-sigma, Horus Hardware). Results: The incidence of breech deliveries was 3.8%, although this proportion varied between different centers and regions. Up to 18% of the cases occurred in preterm. The most frequent causes were prematurity and uterine malformations. In its management, an increase in the tendency to perform elective cesarean section was noticed. The incidence of cesarean sections reached 14.9% of the total and 67.9% in breech deliveries. Perinatal mortality rate in breech deliveries was more than four times that of all deliveries, according to national standards, and more than three times according to international standards (47.8 versus 11.8 × 1000, and 24.7 versus 8 × 1000, respectively). The intrapartum and neonatal mortality in breech deliveries was 13 × 1000. No correlation between incidence of cesarean sections and perinatal mortality rates was found. Primiparity, deflexed head, macrosomia and prematurity were the most decisive parameters to indicate a cesarean section. Neither the external cephalic version nor the total breech extraction were common procedures. Conclusions: The incidence of breech deliveries is variable between different centers (1.7%–5.1%) and Spanish regions (3.3%–4.3%), with a mean of 3.8% in overall and 11.4% in preterm deliveries. There is a tendency to perform cesarean sections, especially in primiparae. There is no correlation between the percentage of cesarean sections in each center and the perinatal mortality rate. External cephalic version and total breech extraction were uncommon procedures.

Vaginal delivery of the nonvertex second twin

The purpose of our study was to test the hypothesis that there is no increased morbidity or mortality associated with vaginal delivery of the nonvertex second twin. The medical records of 781 consecutive twin gestations achieving a gestational age > or = 20 weeks and delivering between Jan. 1, 1985, and Dec. 31, 1988, were reviewed. All live-born, vaginally delivered second twins were identified, grouped by presentation, and compared with respect to 5-minute Apgar scores, length of neonatal hospital stay, neonatal intensive care unit admissions, and neonatal deaths. Of the 390 live-born, vaginally delivered second twins, 207 were delivered as vertex and 183 were delivered as breech. Ninety-five percent of the breech deliveries were total breech extractions. There were no statistically significant differences between the vaginal breech and vaginal vertex deliveries in any of the neonatal outcome measures studied even when stratified by birth weight. These results support the null hypothesis and suggest that vaginal delivery of the nonvertex second twin is a safe intrapartum management option, although no conclusion can be reached in infants weighing < 1500 gm. We found no evidence of excessive morbidity or mortality associated with total breech extraction of the second twin.

The second twin

Two hundred and seven deliveries producing 414 infants during the years 1965 through 1969 are included in this study. Apgar scores, birth weights, and methods of delivery were reviewed. At 1 minute second twins had a higher incidence of fair and poor Apgar scores when compared to those of the first twins. Total breech extraction or version and extraction were associated with 23 of 42 second infants weighing 2,000 grams of more and given fair or poor 1 minute scores.