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.”
