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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.
