Vaginal Delivery Of Twins Research Articles

Delivery of the second twin: influence of presentation on neonatal outcome, a case controlled study

BackgroundSpontaneous vaginal twin delivery after 32nd week of gestation is safe when first twin presenting cephalic. Aim of this study is to identify obstetric factors influencing the condition of second twin and to verify whether non-cephalic presentation and vaginal breech delivery of the second twin is safe.MethodsThis is a retrospective case controlled cohort study of 717 uncomplicated twin deliveries ≥32 + 0 weeks of gestation from 2005 to 2014 in two tertiary perinatal centers. Obstetric parameters were evaluated in three groups with descriptive, univariate logistic regression analysis for perinatal outcome of second twins.ResultsThe three groups included twins delivered by elective cesarean section ECS (n = 277, 38.6%), by unplanned cesarean section UPC (n = 233, 32.5%) and vaginally (n = 207, 28.9%). Serious adverse fetal outcome is rare and we found no differences between the groups. Second twins after ECS had significant better umbilical artery UA pH (p < 0.001) and better Apgar compared to UPC (p = 0.002). Variables for a fetal population “at risk” for adverse neonatal outcome after vaginal delivery (UA pH < 7.20, Apgar 5´ < 9) were associated with higher gestational age (p = 0.001), longer twin-twin interval (p = 0.05) and vacuum extraction of twin A (p = 0.04). Non-cephalic presentation of second twins was not associated (UA pH < 7.20 OR 1.97, CI 95% 0.93–4.22, p = 0.07, Apgar 5´ < 9 OR 1.63, CI 95% 0.70–3.77, p = 0.25, Transfer to neonatal intermediate care unit p = 0.48). Twenty-one second twins (2,9%) were delivered by cesarean section following vaginal delivery of the first twin. Even though non-cephalic presentation was overrepresented in this subgroup, outcome variables were not significantly different compared to cephalic presentation.ConclusionsEven though elective cesarean means reduced stress for second twins this seems not to be clinically relevant. Non-cephalic presentation of the second twin does not significantly influence the perinatal outcome of the second twin but might be a risk factor for vaginal-cesarean birth.

Neonatal hypoxia of the second twin after vaginal delivery of the first twin: what matters?

Objective: Optimal management of twin deliveries is controversial. We aimed to assess potential risk factors correlated to the development of hypoxia in the second twin after vaginal delivery of the first twin.Study design: This is a retrospective observational study including diamniotic twin pregnancies delivering at our Institution at 35 weeks of gestational age or more, weighing ≥1800 g. Hypoxia was defined as at least one of the following: Apgar score <5 at 10 minute, neonatal resuscitation for >10 minutes, neonatal acidosis (pH ≤7 and/or BE ≥12 mmol/L).Results: A number of 275 diamniotic twin pregnancies met the inclusion criteria and were divided within the following groups: (1) second twin not developing neonatal hypoxia (n = 265); and (2) second twin developing neonatal hypoxia (n = 10). The rate of second twins with neonatal hypoxia during the study period was 3.6% (10/275). Abnormal cardiotocography during the intertwin delivery interval, defined as ACOG category III, was significantly correlated to second twin hypoxia. Of interest, there was no significant difference in the intertwin delivery interval between the study groups. In addition, breech presentation of the second twin did not show to be a risk factor for neonatal hypoxia. None of the second twins developing neonatal hypoxia was reported to have encephalopathy (follow up of at least 24 months). At multivariate analysis, only abnormal cardiotocography was an independent risk factor for second twin hypoxia (OR 17.8, 95% CI 4.1–77.2).Conclusions: In our study, neonatal hypoxia was significantly correlated to abnormal cardiotocography, while intertwin delivery interval was not correlated to the development of this adverse neonatal outcome.

Risk factors for cesarean delivery and adverse neonatal outcome in twin pregnancies attempting vaginal delivery.

Twin vaginal delivery presents a unique clinical challenge for obstetricians. The Twin Birth Study demonstrated the safety of planned vaginal delivery regarding neonatal outcomes. However, that study lacked a description of the risk factors associated with and the outcome of unplanned cesarean section. The aim of this study is to identify potential risk factors for cesarean section and delivery related neonatal morbidity and mortality in women with twin pregnancy attempting vaginal delivery. A retrospective cohort study including 1070 women with twin pregnancy that underwent a trial of labor between 2003 and 2015. The study population was divided according to the mode of delivery: vaginal delivery, combined vaginal-cesarean and intrapartum cesarean delivery of both twins. Several risk factors and neonatal outcomes were examined by both univariate analysis and multinomial logistic regression analysis. The rate of vaginal delivery of both twins was 88.3%, whereas the rates of combined vaginal cesarean and unplanned cesarean delivery were 4.6% and 7.1%, respectively. Nulliparity and nonvertex presentation of twin B were found to be independently associated with cesarean delivery for both twins. Additionally, nonvertex presentation of twin B was independently associated with combined vaginal-cesarean delivery. The proportion of neonates with Apgar score <7 at 5 min was increased for both twins in the combined vaginal-cesarean group compared with those delivered by the vaginal route alone. Nulliparity and nonvertex presentation of twin B were found to be associated with intrapartum cesarean delivery in twin pregnancies.

Clinical Factors Associated With Presentation Change of the Second Twin After Vaginal Delivery of the First Twin

(Obstet Gynecol. 2017;130(5):1104–1111) Although national guidelines recommend that women with vertex-presenting twins without contraindications attempt a vaginal delivery, clinical concerns regarding the unpredictability of the second twin’s presentation (11% of women may experience malpresentation) often lead women to elect for cesarean delivery. To promote evidence-based care decisions, the authors of the present study identified factors associated with intrapartum presentation change of the second twin after vaginal delivery of the first in a cohort of laboring women with vertex-vertex twins.

Induction of labor in twin gestation: can we predict success?

Abstract Objective: To identify factors associated with a successful induction of labor in twin pregnancies and associated maternal morbidity. Study design: This was a retrospective review of twin pregnancies ≥24 weeks’ gestation undergoing labor induction from 2011 to 2016. The primary outcome was a successful induction of labor. The secondary outcome was a composite of maternal morbidity, including ≥1 of the following: estimated blood loss (EBL) &gt;1500 ml, blood transfusion, hysterectomy, intensive care unit (ICU) admission or maternal death. Results: Of 104 twin pregnancies undergoing labor induction, 64 (61.5%) had a vaginal delivery of both twins. Multiparity [odds ratio (OR) 12.3, 95% confidence interval (CI) 3.9–38.8, P≤0.005] and maternal age &lt;35 years (OR 2.33, 95% CI 1.1–5.2, P=0.038) were independently associated with vaginal delivery. The overall rate of composite maternal morbidity was 7.7%. Cesarean delivery (CD) was associated with an increased rate of composite maternal morbidity compared to the successful induction group (17.5% vs. 1.6%, P≤0.005). An EBL &gt;1500 ml, uterine atony and the use of ≥1 uterotonic agent were more frequent in the CD group. Conclusions: Multiparous women and those &lt;35 years of age were more likely to have a vaginal delivery. Maternal morbidity is increased in women who required a CD after labor induction compared to those who achieved a vaginal delivery.

Neonatal morbidity associated with vaginal delivery of noncephalic second twins

Management of noncephalic second twin delivery rests on the results of population-based retrospective studies of twin births that have shown higher neonatal mortality and morbidity for second twins with noncephalic, compared with cephalic, presentations after vaginal delivery of the first twin. Because these studies are flawed by data of questionable validity, do not report the obstetrical practices at delivery, and do not allow collection of potential confounding variables, we performed a national prospective study specially designed to evaluate the management of twins' delivery. We sought to assess neonatal mortality and morbidity according to second twin presentation after vaginal birth of the first twin. The Jumeaux Mode d'Accouchement study was a nationwide prospective population-based cohort study of twin deliveries performed in 176 maternity units in France from February 2014 through March 2015. The primary outcome was a composite of intrapartum mortality and neonatal mortality and morbidity. Neonatal outcomes of second twins born ≥32 weeks of gestation after vaginal delivery of the first cephalic or breech twin were compared according to the noncephalic or cephalic second twin presentation. Multivariable logistic regression models controlled for potential confounders. Subgroup analyses were conducted according to the breech or transverse presentation of the noncephalic second twin, and gestational age at delivery, before or after 37 weeks of gestation. Among 3903 second twins enrolled in the study, 2384 (61.1%) were in cephalic and 1519 (38.9%) in noncephalic presentations, of whom 999 (25.6%) were in breech and 520 (13.3%) in transverse presentation. Composite neonatal mortality and morbidity did not differ between the noncephalic and cephalic group (47/1519 [3.1%] vs 59/2384 [2.5%]; adjusted odds ratio, 1.23; 95% confidence interval, 0.81-1.85). No significant difference between groups was shown for the primary outcome in subgroup analyses according to type of noncephalic second twin presentation or gestational age at delivery. Cesarean delivery rates for the second twin were lower in the breech than in the cephalic group (14/999 [1.4%] vs 75/2384 [3.1%], P= .003) and lower in the cephalic than in the transverse group (75/2384 [3.1%] vs 35/520 [6.7%], P < .001). Noncephalic and cephalic second twin presentations after vaginal delivery of the first twin ≥32 weeks of gestation are associated with similar low composite neonatal mortality and morbidity. Vaginal delivery of noncephalic second twin is a reasonable option.

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)

Selective Termination of Pregnancy: About a Case of Anencephaly on a Bi-Chorial Twin Pregnancy

Background: The discovery of a lethal or disabling malformation requires a thoughtful decision in the event of a termination of pregnancy on medical grounds. The termination of pregnancy can be selective in the case of multiple pregnancies if a twin is suffering from a serious condition. Objective: To report a case of anencephaly on a twin pregnancy and conduct a review of literature. Case: This is a 30-year-old woman carrying a pregnancy obtained after the third attempt at in vitro fertilization (IVF) with transfer of two embryos. No risk factor was found on this pregnancy except for the twinning. The diagnosis was made at 14 weeks +1 day during first term ultrasound, which discovered an on-going bi-chorial bi-amniotic twin pregnancy, with twin B (TB) carrying a defect on his head. A selective interruption was performed on TB at 16 weeks by cordonal injection with potassium chloride. The pregnancy went on without incident and with spontaneous vaginal delivery of the second twin at 39 weeks of pregnancy. Despite the selective termination, the pregnancy went on without any complication. Conclusion: Anencephaly on twin pregnancy is a rare occurrence. In a bichorial pregnancy, a selective feticide can improve the gestational age at birth.

98: Neonatal outcomes according to second twin presentation after vaginal delivery of the first twin

98: Neonatal outcomes according to second twin presentation after vaginal delivery of the first twin

Effect of inter-twin delivery interval on umbilical artery pH and Apgar score in the second twin.

To examine the effect of inter-twin delivery interval on umbilical artery pH and Apgar score of the second twin after vaginal delivery of the first twin. Retrospective study conducted at a single teaching hospital. All pregnant women with twin gestation who delivered the first twin vaginally at more than 24weeks between 1995 and 2015 were included. Major malformations and intrauterine deaths of one or both twins were excluded. Women were divided into those who had an inter-twin delivery interval of less than 30 minutes (group 1) or 30 minutes or more (group 2). Primary outcome was umbilical artery pH less than 7.1 and/or Apgar score less than 7 at 5minutes of the second twin. Generalized linear regression with log was performed to evaluate the association with delivery interval. Of 88145 deliveries during this period, 1955 (2.2%) were twins. Overall, 713 twin pregnancies, 596 (83.6%) in group 1 and 117 (16.4%) in group 2, were eligible and included. Mean inter-delivery interval was 11.0±6.5 and 52.5±31.5minutes in groups 1 and 2, respectively. After adjusting for variables found significantly different between the groups in univariate analysis, inter-delivery interval of less than 30 minutes or 30 minutes or more was not a significant risk factor for pH less than 7.1 and/or Apgar less than 7 (P=.91). The cesarean rate for delivery of the second twin after vaginal delivery of the first twin was 4.3% overall, with a higher rate among group 2 compared with group 1 (18.2% and 3.2%, respectively; P=.001). The second twin's Apgar score and cord artery pH are probably not affected when the inter-twin delivery interval exceeds 30minutes.

Clinical Factors Associated With Presentation Change of the Second Twin After Vaginal Delivery of the First Twin.

To identify clinical factors associated with a change from vertex to nonvertex presentation in the second twin after vaginal birth of the first. We assembled a retrospective cohort of women with viable vertex-vertex twin pregnancies who delivered the presenting twin vaginally. Women whose second twin changed from vertex to nonvertex after vaginal birth of the first were classified as experiencing an intrapartum change in presentation. Characteristics associated with intrapartum presentation change in a univariate analysis with a P value ≤.10 were then evaluated in a multivariate logistic regression model. Four-hundred fifty women met inclusion criteria, of whom 55 (12%) had intrapartum presentation change of the second twin. Women experiencing intrapartum presentation change were more likely to be multiparous (69% compared with 47%, P<.01) and to have had a change in the presentation of the second twin between the most recent antepartum ultrasonogram and the ultrasonogram done on admission to labor and delivery (11% compared with 4%, P=.04). In an adjusted analysis, multiparity and gestational age less than 34 weeks were significantly associated with presentation change (adjusted odds ratio [OR] 2.9, 95% CI 1.5-5.6 and adjusted OR 2.6, 95% CI 1.1-5.9, respectively). Women with intrapartum presentation change were more likely to undergo cesarean delivery for their second twin (44% compared with 7%, P<.01) with an adjusted OR of 10.50 (95% CI 5.20-21.20) compared with those with stable intrapartum presentation. Twenty of the 24 (83%) cesarean deliveries performed in the intrapartum presentation change group were done for issues related to malpresentation. Multiparity and gestational age less than 34 weeks are associated with intrapartum presentation change of the second twin.

Birth management and fetal outcome in multiple gestation: analysis of 1.444 births

Since the late 1990s, controversies came up concerning the mode of delivery for multiples births. The twin birth study indicated no difference in maternal and fetal outcome between planned vaginal delivery and planned caesarean section, but did not analyze the influence of maternal and fetal characteristics or the obstetric management in vaginal birth. The purpose of this study is to analyze these parameters regarding fetal outcome. A large-scale retrospective analysis of twin births (n=1.444) was performed at a university medical center. The analysis included pregnancy, delivery, and maternal and fetal parameters, including pH and base excess (BE) differences between the first- and second-born twin (delta pH, delta BE). Delta pH correlated significantly with the birth interval for various positions of twins in the womb (p<0.05). The longer the birth interval, the greater the delta pH with a lower pH of the second twin. Delta BE values were significantly correlated with the birth interval for a combination of twins in cephalic and breech presentation. Furthermore, it could be shown that higher differences in birth weight between the first/second twin are associated with higher delta pH, higher delta BE values (all p<0.05). We found significantly decreasing delta pH values in vaginal deliveries over secondary and, finally, primary caesarean sections (p<0.001). We conclude a vaginal delivery of twin appears safe if experienced staff monitor birth weight discrepancies, birth interval, and blood values consequently. A good outcome also for the second twin delivered spontaneously is nevertheless feasible if experienced staff is available.

Evaluation of vaginal delivery for twin pregnancy

Careful management of twin pregnancy is needed because of the high risk for mother and babies, and it is uncertain if vaginal delivery or cesarean delivery is favorable. The purpose of this study was to examine the effect of the mode of delivery on maternal complications and short-term neonatal outcomes in twin pregnancy. Of the 50 cases, vaginal deliveries were attempted in 25 cases, with 17 achieving successful vaginal delivery of both twins and eight requiring emergency cesarean delivery. The other 25 cases underwent planned cesarean delivery. There were no differences in the neonatal outcome including birth weight, Apgar scores, and umbilical artery pH between cases with successful and failed vaginal delivery, or between failed vaginal delivery and planned cesarean delivery, even though vaginal delivery failed in some cases. These findings suggest that vaginal delivery can be attempted safely in twin pregnancy.

Trial of vaginal delivery for twins – is it safe? a single center experience

Purpose: This study assessed our hospital protocol of vaginal delivery for twins and evaluated whether trial of vaginal delivery (unless contraindicated) was as safe as elective cesarean. Risk factors leading to failed trial of labor (TOL) were characterized to improve our ability to advise patients and select cases for TOL.Methods: This retrospective, cohort study included women >32 weeks gestation, with twin A in cephalic presentation and no contraindications for vaginal delivery. Controls were women with twin pregnancy and planned cesarean delivery (PCD). Maternal and neonatal morbidity between TOL and PCD were compared. TOL group was subcategorized by vaginal or cesarean delivery to characterize pre-labor risk factors for failed TOL.Results: Of the 411 twins, 215 had TOL and 196 had PCD. Among TOL, 196/215 (91%) delivered vaginally. TOL was more likely to have spontaneous pregnancy, pregnancy complications and tended to deliver earlier. More TOL had postpartum hemorrhage (p < .05), although transfusion rates in each group were similar. Neonatal outcomes between groups did not differ. Induction and gestational age at delivery were risk factors for failed TOL.Conclusions: The results support the contemporary practice of TOL for twins at term when the first is in cephalic presentation with no other contraindications.

Naproxen Sodium for Pain Control With Intrauterine Device Insertion: A Randomized Controlled Trial.

Naproxen Sodium for Pain Control With Intrauterine Device Insertion: A Randomized Controlled Trial.

The predicting factors and outcomes of caesarean section of the second twin

The aim of this study was to review the indications for caesarean delivery of second twins after vaginal delivery of a first twin (combined delivery) and the associated foetal outcomes of the second twin. Possible factors that could be employed to predict combined delivery were explored.This was a retrospective review of all twin pregnancies delivered in a tertiary maternity unit between 2000 and 2013. All twins (> =24 week gestation) with vaginal delivery of the first twin were reviewed. Of a total of 1039 pairs of twins, 441 pairs had vaginal delivery of the first twin, of which 47 (10.7%) needed combined delivery. Presentation of the second twin was found to be significantly associated with combined delivery (p < .001). The odds ratio for combined delivery for breech second twin was 2.4 compared with vertex second twins while the odds ratio for transverse lie second twin was 182.8. Second twins who were delivered by combined delivery had a higher incidence of 5 min Apgar score <7.The extremely high odds ratio for combined delivery for second twins in transverse lie would probably indicate that attempts at vaginal delivery of these vertex/transverse twin pregnancies would not be worthwhile.Impact statementIt remains controversial in the literature whether non-vertex second twins are associated with a higher risk for combined delivery as compared to vertex second twins. Almost all previous studies have analysed the non-vertex second twins as a whole group rather than separating them into breech presentation and transverse lie. There is only one study analysing breech presentation and transverse lie of second twin separately but it has recruited only 14 patients.To our knowledge, the cohort is the largest available dataset comparing the odds ratio for combined delivery of breech and transverse lie of the second twin separately. We found that transverse lie of the second twin have extremely high rates of combined delivery with an odds ratio 182.8 and this may be ascribed to the lack of attempts to perform internal podalic version.Combined delivery is associated with higher maternal and neonatal morbidities. With such a high risk of transverse lie second twin in having combined delivery, it appears reasonable to advise women with vertex/transverse twins not to attempt vaginal delivery unless there are obstetricians who have experience in performing internal podalic version at the time of delivery. This is useful for patient counselling regarding the decision of the mode of delivery.

Twin vaginal delivery: innovate or abdicate

Neonatal safety data along with national guidelines have prompted renewed interest in vaginal delivery of twins, particularly in the case of the noncephalic second twin. Yet, the rising rate of twin cesarean deliveries, coupled with the national decline in operative obstetrics, raises concerns about the availability of providers who are skilled in twin vaginal birth. Providers are key stakeholders for increasing rates of twin vaginal delivery. We surveyed a group of practicing obstetricians to explore potential barriers to the vaginal birth of twins with a focus on delivery of the noncephalic second twin. Among 107 responding providers, only 57% would deliver a noncephalic second twin by breech extraction. Providers who preferred breech extraction had a higher rate of maternal-fetal medicine subspecialty training (26.2% vs 4.3%; P<.01) and were more likely to be in an academic practice environment (36.1% vs 10.9%; P<.01) and to practice in high-volume centers that deliver >30 sets of twins annually (57.4% vs 34.8%; P=.02). Most providers (54.2%) were familiar with the findings from the recent randomized trial that demonstrated the safety of twin vaginal birth. However, knowledge of the trial was not associated statistically with a preference for breech extraction (62.3% vs 43.5%; P=.05). Providers who preferred breech extraction were more likely to agree with recent society guidelines that encourage the vaginal birth of twins (86.9% vs 63.0%; P<.01). In an adjusted analysis, the 46% of providers with a perceived need for more training were far less likely to prefer breech extraction for delivery of a noncephalic second twin (adjusted odds ratio, 0.38; 95% confidence interval, 0.16-0.95). Furthermore, 57% of providers who would not offer their patient breech extraction would be willing to consult a colleague for support with a noncephalic twin delivery. These results suggest that scientific evidence and society opinion are likely insufficient to reverse the national trends that favor cesarean delivery for twins. Instead, implementation of provider training and support programs is critical for increasing the rates of twin vaginal birth. Changing our national landscape of vaginal twin delivery may require innovation. Without novel provider-focused strategies, we may relinquish passively the requisite skills for not only our patients but also for future generations of obstetricians.

Association of Intended Route of Delivery and Maternal Morbidity in Twin Pregnancy.

To evaluate maternal morbidity in twin pregnancies according to intended mode of delivery. We assembled a 7-year retrospective cohort (2007-2014) of women delivering viable, vertex-presenting twins at or beyond 32 weeks of gestation without contraindication to labor or uterine scar. We classified women as undergoing a trial of labor to attempt vaginal birth or choosing an elective cesarean delivery. Our primary outcome was a measure of composite maternal morbidity including death, postpartum hemorrhage, infection, major procedure, readmission for infection or reoperation, need for dilation and evacuation for hemorrhage or infection, venous thromboembolism, small bowel obstruction or ileus, or intensive care unit admission. Postpartum hemorrhage was defined as estimated blood loss greater than or equal to 1,500 mL or need for transfusion. The rate of lacerations in each group was also determined. Using logistic regression to control for confounders, we examined the odds of maternal morbidity according to intended mode of delivery. Of 2,272 twin pregnancies at or beyond 32 weeks of gestation, 1,140 (50%) met inclusion criteria with 571 (50%) electing cesarean delivery and 569 (50%) undergoing a trial of labor to attempt vaginal birth. Vaginal delivery of both twins was achieved in 74% (n=418) of women choosing a trial of labor. The rate of maternal morbidity was 12.3% in the trial of labor group compared with 9.1% in the elective cesarean delivery group (P=.08, adjusted odds ratio [OR] 1.6, 95% confidence interval [CI] 1.1-2.4). Postpartum hemorrhage was more common among women who attempted vaginal delivery (n=52) compared with those electing cesarean delivery (n=28) with rates of 9.1% compared with 4.9%, respectively (P<.01, adjusted OR 2.2, 95% CI 1.4-3.6) and was responsible for the difference in the composite morbidity rate between groups. When adjustment is made for potential confounders, women undergoing a trial of labor with twins experience a higher odds of maternal morbidity than those electing cesarean delivery, primarily as a result of hemorrhage. In pragmatic terms, the tradeoff for a 74% chance of vaginal delivery is a 4% absolute increase in the rate of serious postpartum hemorrhage.

Safety of vaginal delivery among dichorionic diamniotic twins over 10years in a UK teaching hospital.

To determine whether vaginal delivery among dichorionic diamniotic twins remains a safe option following full implementation of the European Working Time Directive in the UK. A retrospective study was conducted using data for women with dichorionic diamniotic twin pregnancies who attended a teaching hospital in London, UK, for delivery between January 4, 2000, and December 23, 2010. Among 892 women, 474 (53.1%) attempted vaginal delivery, 220 (46.4%) of whom achieved spontaneous vaginal delivery of both twins. Instrumental vaginal delivery was performed among 89 women (18.8%), and 165 (34.8%) women underwent emergency cesarean delivery. Delivery of the second twin by emergency cesarean (n=31) was predominantly for fetal distress (13 [41.9%]) or abnormal lie (10 [32.3%]). A 5-minute Apgar score of 9 or 10 was recorded for 384 (83.7%) of 459 first twins and 369 (82.9%) of 445second twins, irrespective of the mode of delivery. Vaginal delivery among dichorionic diamniotic twins had a good success rate and a low intrapartum emergency cesarean delivery rate. Training in cardiotocography and intrapartum procedures might further reduce the need for emergency cesarean delivery.

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.