Vaginal delivery in twins increases risk of maternal morbidity as compared to elective C-section.

A 7-year assembled retrospective cohort study of women with vertex presenting twin who underwent vaginal delivery have higher incidence of maternal morbidity as compared to women delivered by C-section.

The findings of this study was published on-line on January 9,2017 in Obstetrics andGynecology Journal.[1]

Guidelines suggest an attempt at vaginal birth if first twin is vertex with no uterine scar or other contraindication exits. Many  studies have compared neonatal mortality and morbidity but not much information is available on maternal morbidities based on route of delivery in twins.

 Dr. Sarah Rae Easter of Brigham and Women's Hospital and Harvard Medical School in Boston is the lead author of the study. She and her colleagues carried out the study from 2007-2014. Out of 2,272 twin pregnancies beyond 32 weeks of gestation, 1,140 (50%) met inclusion criteria of no uterine scar and no other contraindication for vaginal birth.  571 (50%) women chose to have elective cesarean delivery and 569 (50%) underwent a trial of labor to attempt vaginal birth. 

In the trial of vaginal birth group, 74% had an uneventful vaginal delivery, while others required operative assistance or breech extraction.

After adjusting for confounders, trial of labor group  had higher rate of maternal morbidity (12.3%) as compared to elective C-section group (9.1%). The rates of Postpartum hemorrhage were nearly twice in women having vaginal births.3% of women had major lacerations of genital tract.

An earlier RCT published in BJOG by Hutton EK et al did not show any difference in maternal morbidities in elective C-section vs Vaginal delivery group. [2]

Dr. Easter did not advice against trial of labor in twins, but wanted the clinicians to be more cautious while counselling the patients. She quoted. "Though our findings suggest a trend towards increased maternal morbidity in those who labor, we do not see this as a deterrent to twin vaginal delivery, we feel the immediate increased risk of postpartum hemorrhage should be balanced with the benefits of a vaginal birth. We hope clinicians will thoughtfully incorporate our findings into counseling while keeping in mind the known long-term consequences of Cesarean delivery and its impact on future pregnancies."

“Delivery in hospitals equipped to manage postpartum hemorrhage is of equal importance for mothers attempting vaginal birth of twins” she further added.

The authors concluded “In pragmatic terms, the tradeoff for a 74% chance of vaginal delivery is a 4% absolute increase in the rate of serious postpartum hemorrhage.”

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[1] http://journals.lww.com/greenjournal/Abstract/publishahead/Association_of_Intended_Route_of_Delivery_and.98512.aspx

[2] https://www.ncbi.nlm.nih.gov/pubmed/26328526