Twins with cephalic first is not a Per Se Indication for planned Cesarean Delivery.

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Vaginal delivery in twins more than 32 weeks is safer and associated with less neonatal morbidity and mortality as compared to cesarean section when the first twin is cephalic reports authors of large prospective population-based cohort study published ahead of print in Journal of Obstetrics and Gynecology.

Dwight J. Rouse, M.D writes in an accompanying editorial that in the year 2014, 75% of more than 135,000 twin deliveries were by cesarean section in USA. The results of the study show   "a lower rate of [caesarean] delivery in women carrying twins is not only achievable, but that it is also safer for their neonates."

This JUmeaux MODe d'Accouchement (JUMODA) study was multicentric, conducted across 176 maternity units in France and recruited patients from February 2014 to March 2015. All women with twin pregnancies and their neonates born at or after 32 weeks of gestation with a cephalic first twin were included in the study. (n= 5,915)  

Maternity units with more than 1500 annual deliveries were called to participate. The obstetrician completed an online survey after the twin delivery categorizing whether it was a planned vaginal or cesarean labor and what was the actual mode of delivery.

Of the total 5915 study participants, 1,454(25%) women were planned to be delivered by cesarean section and 4,461 (75%) were scheduled to undergo a trial of vaginal birth. Of the 4,461 (75%) planned for vaginal births, nearly (3,583 )80% delivered both twins vaginally.

Ultimately, 61% of twins in this large cohort delivered vaginally. The composite study outcome was intrapartum neonatal mortality, Apgar score at 5 minutes < 4, birth trauma or respiratory and neurological complications.

Overall the infants born by cesarean section had 2.38 times higher odds of suffering one or more of the study outcome as compared to infants born by vaginal route. (OR, 2.38; 95% confidence interval [CI], 1.86 - 3.05).

As the patients were not randomized, the researchers did a propensity score matching to eliminate this limitation. In this matched analysis also, infants born by planned cesarean section had 1.85 times higher odds of suffering one or more of the study outcome as compared to vaginal delivery (OR, 1.85; 95% confidence interval 1.29-2.67).

The researchers also did a subgroup analysis by excluding pregnancies who were high risks. The results showed that in these low risk group planned cesarean was associated with increased neonatal mortality and morbidity only between 32 0/7 and 34 6/7 weeks of gestation.

To conclude:  According to the study a planned vaginal delivery rather than a planned cesarean delivery between 32 to 37 weeks of twins’ gestation with cephalic first, can be attempted and it does not result in high neonatal morbidity and mortality, which is in accordance with the recent American College of Obstetricians and Gynecologists recommendations.

ACOG guidelines for twin delivery says “Perinatal outcomes for twin gestations in which the first twin is in cephalic presentation are not improved by cesarean delivery. Thus, women with either cephalic/cephalic-presenting twins or cephalic/noncephalic presenting twins should be counseled to attempt vaginal delivery.”

Planned cesarean delivery is associated with higher neonatal morbidity and mortality only in twins born before 37 weeks of gestation in overall study cohort and less than 35 weeks in low risk cohort.

In a hospital set up where appropriate facilities with skilled personnel are available, in twin pregnancy with cephalic first and gestational age > 32 weeks, the default plan should be an attempt at vaginal delivery, regardless of presentation of the second twin.