Intrapartum management of multiple gestation

Mode of delivery of twin gestation with very low birthweight: is vaginal delivery safe?

OBJECTIVE

The purpose of this study was to determine whether planned vaginal delivery is associated with increased risk of perinatal death and morbidity in twin pregnancies that are complicated by a very low birthweight of the second twin.

STUDY DESIGN

We conducted a retrospective cohort study of twin pregnancies in which the second twin's birthweight was ≤1500 g. One hundred ninety-three twin gestations met the study criteria; patients were classified into 2 groups according to the planned mode of delivery: (1) cesarean delivery (n = 142) and (2) vaginal delivery (n = 51). In the vaginal delivery group, 21 pairs were in cephalic-cephalic presentation at the time of delivery; 28 pairs were cephalic-noncephalic, and 2 pairs were noncephalic-noncephalic. Composite adverse neonatal outcome was defined as the presence of neonatal death, respiratory distress syndrome, sepsis, necrotizing enterocolitis, or intraventricular hemorrhage grade 3-4.

RESULTS

Trial of vaginal delivery was successful for both twins in 90.5% of cephalic-cephalic twins and 96.4% in cephalic-noncephalic twins. The rate of intraventricular hemorrhage was significantly higher in the vaginal delivery group (29.4% vs 8.5%, respectively; P = .013; adjusted odds ratio [OR], 3.65; 95% confidence interval [CI], 1.32-10.1). The increased risk of intraventricular hemorrhage in the vaginal delivery groups was evident in both twin A (17.6% vs 7.0%; P = .029) and twin B (15.7% vs 4.9%; P = .014); however, these differences were not significant after adjustment for possible confounders (twin A: adjusted OR, 1.79; 95% CI, 0.58-5.55; twin B: adjusted OR, 2.13; 95% CI, 0.63-7.25). In addition, subgroup analysis revealed that both cephalic-cephalic and cephalic-noncephalic twins who were delivered vaginally had increased risk for intraventricular hemorrhage. There were no significant differences between the cesarean and vaginal delivery groups in the rates of Apgar score <7 at 5 minutes, arterial cord pH <7.1, composite adverse neonatal outcome, and neonatal mortality rate. However, the rate of respiratory distress syndrome was significantly lower in the vaginal delivery group (66.7% vs 69%; P = .042; OR, 0.34; 95% CI, 0.12-0.96).

CONCLUSION

Vaginal delivery of very low birthweight twins is associated with an increased risk of intraventricular hemorrhage, regardless of presentation. Because of the small sample size and the retrospective cohort design, large prospective randomized studies are needed.

Intrapartum management of multifetal pregnancies

Over the past several decades advances in assisted-reproductive technologies have resulted in a dramatic increase in the number of multifetal gestations. Concomitant with this increase there has been a gradual rise in the overall preterm birth rate, as well as other pregnancy complications related to these pregnancies. Twin, triplet, and other high-order multifetal gestation pregnancies pose a number of important issues related to antepartum and intrapartum management. Antepartum issues include ultrasound determination of zygosity, management and prevention of preterm labor, maternal/fetal surveillance for complications, and specific interventions focused on prevention of adverse maternal and/or fetal outcomes. Intrapartum issues include those related to timing of delivery, labor management, anesthesia options, and determination of an optimal delivery modality. Clearly, these issues related to the management of multifetal pregnancies are of paramount importance to optimize pregnancy outcome. As many of the issues related to antepartum care for women with multifetal gestations have been reviewed elsewhere, we have restricted the focus of this article to intrapartum management. Thus, this article reviews salient issues related to the intrapartum management of multifetal gestations, including twins, triplets, and other high-order pregnancies.

Cesarean delivery for twins: a systematic review and meta-analysis

OBJECTIVE

We undertook a systematic review and meta-analysis to determine whether a policy of planned cesarean section or vaginal delivery is better for twins.

STUDY DESIGN

We searched MEDLINE and EMBASE from 1980 through May 2001 using combinations of the following terms: twin, delivery, cesarean section, vaginal birth, birth weight, and gestational age. Studies that compared planned cesarean section to planned vaginal birth for babies weighing at least 1500 g or reaching at least 32 weeks' gestation were included. We computed pooled odds ratios for perinatal or neonatal mortality, low 5-minute Apgar score, neonatal morbidity, and maternal morbidity. The infant was the unit of statistical analysis. Results were considered statistically significant if the 95% CI did not encompass 1.0.

RESULTS

We retrieved 67 articles, 63 of which were excluded. Four studies with a total of 1932 infants were included in the analysis. A low 5-minute Apgar score occurred less frequently in twins delivered by planned cesarean section (odds ratio, 0.47; 95% CI, 0.26-0.88) principally because of a reduction among twins if twin A was in breech position (odds ratio, 0.33; 95% CI, 0.17-0.65). Twins delivered by planned cesarean section spent significantly longer in the hospital (mean difference, 4.01 days; 95% CI, 0.73-7.28 days). There were no significant differences in perinatal or neonatal mortality, neonatal morbidity, or maternal morbidity.

CONCLUSION

Planned cesarean section may decrease the risk of a low 5-minute Apgar score, particularly if twin A is breech. Otherwise, there is no evidence to support planned cesarean section for twins.

Intra- and early postpartum ultrasonography: a review. Part II

Part II is a continuation of the preceding segment, which appeared in the previous issue (Survey 1998;53:000-000). This part presents data pertaining to ultrasound-guided procedures (invasive and noninvasive), physiology (fetal behavior), intrapartum hemorrhage, the third stage of labor, post-partum hemorrhage, and postcaesarean ultrasonography. In addition, this article includes data regarding nonobstetric ultrasound including anesthesiology, catheter placement, venous air embolism, effect of epidural anesthesia on uterine blood flow, and urinary retention. Finally, this part presents ultrasonographic data of the maternal cerebral circulation in preeclampsia/eclampsia and of the maternal deep venous system.