Induction of Labor in Twin Compared With Singleton Pregnancies:

Risk of intrapartum cesarean delivery in twin pregnancies: A retrospective cohort study

OBJECTIVE

To compare the risk of intrapartum cesarean delivery (CD) between patients with twin and singleton pregnancies undergoing a trial of labor and identify risk factors for intrapartum CD in twin pregnancies.

METHODS

The present study was a retrospective cohort study of patients with a twin or singleton pregnancy who underwent a trial of labor at ≥340/7 weeks in a single center (2015-2022). The primary outcome was the rate of intrapartum CD. In twin pregnancies, this outcome was limited to CD of both twins. The association of plurality with intrapartum CD was estimated using multivariable Poisson regression.

RESULTS

A total of 20 754 patients met the study criteria, 669 of whom had a twin pregnancy. Patients with twins had a greater risk of intrapartum CD (of both twins) than those with singleton pregnancies (22.1% vs 15.9%, respectively; aRR 1.38 [95% CI: 1.15-1.66]), primarily due to a greater risk of failure to progress. In addition, 4.1% of the twin pregnancies had a CD for the second twin, resulting in an overall CD rate in twin pregnancies of 26.2%. Variables associated with intrapartum CD in twin pregnancies included nulliparity (aOR 3.50, 95% CI: 2.34-5.25), birthweight discordance >20% (aOR 2.47, 95% CI: 1.27-4.78), and labor induction (aOR 1.64, 95% CI: 1.07-2.53). The rate of intrapartum CD was highest when all three risk factors were present (67% [95% CI: 41%-87%]).

CONCLUSION

Twin pregnancies are associated with a greater risk of intrapartum CD than singleton pregnancies. Information on the individualized risk of intrapartum CD may be valuable when counseling patients with twins regarding mode of delivery.

Mode of delivery of Finnish dichorionic and monochorionic-diamniotic twins: A retrospective observational study including a risk score for intrapartum cesarean birth

Background and Aims

Trial of labor is considered safe also among twins, yet nearly 50% are born via cesarean section in Finland. While planned cesarean births have declined among twins, intrapartum cesarean deliveries have risen, postulating evaluation of criteria for trial of labor. The objective of this study was to create an outline of the mode of delivery of dichorionic and monochorionic-diamniotic Finnish twins. By evaluating risk factors for intrapartum cesarean delivery (CD), we aimed at creating a risk score for intrapartum cesarean birth for twins.

Methods

A retrospective observational study based on a cohort of dichorionic and monochorionic-diamniotic twin pregnancies considered as candidates for trial of labor in 2006, 2010, 2014, and 2018 (n = 720) was performed. Differences between parturients with vaginal delivery and intrapartum CD to identify potential risk factors for intrapartum CD were assessed. Logistic regression analysis (n = 707) was used to further define risk score points for recognized risk factors.

Results

A total of 23.8% (171/720, 95% confidence interval [CI] = 20.7-26.9) of parturients experienced intrapartum CD. Induction of labor, primiparity, fear of childbirth, artificial reproductive technology, higher maternal age, and other than cephalic/cephalic presentation independently associated with intrapartum CD. The achieved total risk score ranged from 0 to 13 points with significantly higher points among the CD group (6.61 vs. 4.42, p < 0.001). Using ≥8 points as a cut-off, 51.4% (56/109) were delivered by intrapartum CD (sensitivity = 33.73%, specificity = 90.20%, positive predictive value = 51.38%, negative predictive value = 81.61%). The total risk score had a fair predictive capability for intrapartum CD (area under the curve = 0.729, 95% CI = 0.685-0.773).

Conclusion

Fair-level risk stratification could be achieved with higher maternal age, primiparity, induction of labor, artificial reproductive technology, fear of childbirth, and other than cephalic/cephalic presentation increasing the risk. Parturients with low-risk score (0-7 points) appear to be the best candidates for trial of labor with acceptable CD rates in this group (18.4%).

Induction of Labor in Twins-Double Trouble?

OBJECTIVE

To determine and compare the safety and efficacy of different methods of induction of labor in twin gestations and their effect on maternal and neonatal outcomes.

METHODS

A retrospective observational cohort study was conducted at a single university-affiliated medical center. Patients with a twin gestation undergoing induction of labor at >32 + 0 weeks comprised the study group. Outcomes were compared to patients with a twin gestation at >32 + 0 weeks who went into labor spontaneously. The primary outcome was cesarean delivery. Secondary outcomes included operative vaginal delivery, postpartum hemorrhage, uterine rupture, 5 min APGAR < 7, and umbilical artery pH < 7.1. A subgroup analysis comparing outcomes for the induction of labor with oral prostaglandin E1 (PGE1), IV Oxytocin ± artificial rupture of membranes (AROM), and extra-amniotic balloon (EAB)+ IV Oxytocin was performed. Data were analyzed using Fisher's exact test, ANOVA, and chi-square tests.

RESULTS

268 patients who underwent induction of labor with a twin gestation comprised the study group. 450 patients with a twin gestation who went into labor spontaneously comprised the control group. There were no clinically significant differences between the groups for maternal age, gestational age, neonatal birthweight, birthweight discordancy, and non-vertex second twin. There were significantly more nulliparas in the study group compared to the control group (23.9% vs. 13.8% p < 0.001). The study group was significantly more likely to undergo a cesarean delivery of at least one twin (12.3% vs. 7.5% OR, 1.7 95% CI 1.04-2.85 p = 0.03). However, there was no significant difference in the rate of operative vaginal delivery (15.3% vs. 19.6% OR, 0.74, 95% CI 0.5-1.1 p = 0.16), PPH (5.2% vs. 6.9% OR, 0.75 95% CI 0.39-1.42 p = 0.37), 5-min APGAR scores < 7 (0% vs. 0.2% OR, 0.99 95%CI 0.99-1.00 p = 0.27), umbilical artery pH < 7.1 (1.5% vs. 1.3% OR, 1.12 95% CI 0.3-4.0), or combined adverse outcome (7.8% vs. 8.7% OR, 0.93 95% CI 0.6-1.4 p = 0.85). Furthermore, there were no significant differences in the rates of cesarean delivery or combined adverse outcomes in patients undergoing induction with oral PGE1 compared to IV Oxytocin ± AROM (13.3% vs. 12.5% OR, 1.1 95% CI 0.4-2.0 p = 1.0) (7% vs. 9.3% OR, 0.77 95% CI 0.5-3.5 p = 0.63 ) or EAB+ IV Oxytocin (13.3% vs. 6.9% OR, 2.1 95% CI 0.1-2.1 p = 0.53) (7% vs. 6.9% OR, 1.4 95% CI 0.15-3.5 p = 0.5) or between patients undergoing induction of labor with IV Oxytocin ± AROM and EAB+ IV Oxytocin (12.5% vs. 6.9% OR, 2.1 95% CI 0.1-2.4 p = 0.52) (9.3% vs. 6.9% OR, 0.98 95% CI 0.2-4.7 p = 0.54). There were no cases of uterine rupture in our study.

CONCLUSIONS

Induction of labor in twin gestations is associated with a two-fold increased risk of cesarean delivery, although this is not associated with adverse maternal or neonatal outcomes. Furthermore, the method of induction of labor used does not affect the chances of success nor the rate of adverse maternal or neonatal outcomes.

Twin Vaginal Deliveries in Labor Rooms: A Cost-Effectiveness Analysis

OBJECTIVE

Twin vaginal deliveries (VDs) are often performed in the operating room (OR) given the theoretical risk of conversion to cesarean delivery (CD) for the aftercoming twin. We aim to evaluate the cost-effectiveness of performing VDs for twin gestations in the labor and delivery room (LDR) versus OR.

STUDY DESIGN

We conducted a cost-effectiveness analysis using a decision-analysis model that compared the costs and effectiveness of two strategies of twin deliveries undergoing a trial of labor: (1) intended delivery in the LDR and 2) delivery in the OR. Sensitivity analyses were performed to assess strength and validity of the model. Primary outcome was incremental cost-effectiveness ratio (ICER) defined as cost needed to gain 1 quality-adjusted life year (QALY).

RESULTS

In the base-case scenario, where 7% of deliveries resulted in conversion to CD for twin B, attempting to deliver twins in the LDR was the most cost-effective strategy. For every QALY gained by delivering in the OR, 243,335 USD would need to be spent (ICER). In univariate sensitivity analyses, the most cost-effective strategy shifted to delivering in the OR when the following was true: (1) probability of successful VD was less than 86%, (2) probability of neonatal morbidity after emergent CD exceeded 3.5%, (3) cost of VD in an LDR exceeded 10,500 USD, (4) cost of CD was less than 10,000 USD, or (5) probability of neonatal death from emergent CD exceeded 2.8%. Assuming a willingness to pay of 100,000 USD per neonatal QALY gained, attempted VD in the LDR was cost effective in 51% of simulations in the Monte Carlo analysis.

CONCLUSION

Twin VDs in the LDR are cost effective based on current neonatal outcome data, taking into account gestational age and associated morbidity. Further investigation is needed to elucidate impact of cost and outcomes on optimal utilization of resources.

KEY POINTS

· Cost effectiveness of twin VDs in the LDR versus OR was assessed.. · Twin VDs in the LDR are cost effective based on current neonatal outcome data.. · Attempted VD in the LDR was cost effective in 51% of simulations in the Monte Carlo analysis..

Induction of labor in twin pregnancies - A retrospective cohort study

OBJECTIVE

To investigate outcomes in spontaneous and induced twin deliveries. Secondary aims were to study impact of delivery interval and breech presentation of the first twin.

METHODS

This retrospective cohort study comprised 354 twin deliveries at a tertiary Norwegian hospital. Spontaneous labor onset and induction of labor were compared in women with planned vaginal delivery and gestational age ≥ 34 weeks. The main outcome was intrapartum cesarean section. Secondary outcomes were umbilical arterial pH and five-minute Apgar scores.

RESULTS

Among the induced labors, 63/229 (27.5%) women underwent intrapartum cesarean section, compared to 45/125 (36%) in spontaneous labors (P = 0.10). Odds ratio for intrapartum cesarean section in induced labors was 0.65 (95% CI 0.40-1.04) after adjusting for maternal age and parity. Median umbilical arterial pH was significantly lower in the second twins in both spontaneous and induced labors, 7.28 (6.94-7.43) vs. 7.32 (7.16-7.42), and 7.27 (6.90-7.48) vs. 7.29 (7.08-7.45), respectively. pH < 7.00 rarely occurred. Second twins born after a delivery interval > 30 min had a significantly higher frequency of pH < 7.10 than those with a shorter interval, P < 0.01. No significant difference was found in frequency of pH < 7.10 between breech-presenting and cephalic-presenting first twins (P = 0.65). One unexpected intrapartum fetal death occurred after labor induction.

CONCLUSION

Our results support spontaneous onset and induction of labor as safe. Intrapartum cesarean section rates did not differ significantly between spontaneous and induced labors. Delivery interval > 30 min was associated with a lower pH in the second twin.

Labour induction in twin pregnancies

Medically-indicated deliveries are common in twin pregnancies given the increased risk of various obstetric complications in twin compared to singleton pregnancies, mainly hypertensive disorders of pregnancy and foetal growth restriction. Due to the unique characteristics of twin pregnancies, the success rates and safety of labour induction may be different than in singleton pregnancies. However, while there are abundant data regarding induction of labour in singleton pregnancies, the efficacy and safety of labour induction in twin pregnancies have been far less studied. In the current manuscript we summarize available data on various aspects of labour induction in twin pregnancies including incidence, success rate, prognostic factors, safety and methods for labour induction in twins. This information may assist healthcare providers in counselling patients with twin pregnancies when labour induction is indicated.

Normal labor curve in twin gestation

BACKGROUND

Failure to progress is one of the leading indications for cesarean delivery in trials of labor in twin gestations. However, assessment of labor progression in twin labors is managed according to singleton labor curves.

OBJECTIVE

This study aimed to establish a partogram for twin deliveries that reflects normal and abnormal labor progression and customized labor curves for different subgroups of twin labors.

STUDY DESIGN

This was a multicenter, retrospective cohort analysis of twin deliveries that were recorded in 3 tertiary medical centers between 2003 and 2017. Eligible parturients were those with twin gestations at ≥34 weeks' gestation with cephalic presentation of the presenting twin and ≥2 cervical examinations during labor. Exclusion criteria were elective cesarean delivery without a trial of labor, major fetal anomalies, and fetal demise. The study group comprised twin gestations, whereas singleton gestations comprised the control group. Statistical analysis was performed using Python 3.7.3 and SPSS, version 27. Categorical variables were analyzed using chi-square tests. Student t test and Mann-Whitney U test were applied to analyze the differences in continuous variables, as appropriate.

RESULTS

A total of 1375 twin deliveries and 142,659 singleton deliveries met the inclusion criteria. Duration of the active phase of labor was significantly longer in twin labors than in singleton labors in both nulliparous and multiparous parturients; the 95th percentile duration was 2 hours longer in nulliparous twin labors and >3.5 hours longer in multiparous twin labors than in singleton labors. The cervical dilation progression rate was significantly slower in twin deliveries than in singleton deliveries with a mean rate in twin deliveries of 1.89 cm/h (95th percentile, 0.51 cm/h) and a mean rate of 2.48 cm/h (95th percentile, 0.73 cm/h) in singleton deliveries (P<.001). In addition, epidural use further slowed labor progression in twin deliveries. The second stage of labor was also markedly longer in twin deliveries, both in nulliparous and multiparous women (95th percentile, 3.04 vs 2.83 hours, P=.002).

CONCLUSION

Twin labors are characterized by a slower progression of the active phase and second stage of labor compared with singleton labors in nulliparous and multiparous parturients. Epidural analgesia further slows labor progression in twin labors. Implementation of these findings in clinical management might lower cesarean delivery rates among cases with protracted labor in twin gestations.

Induction of Labor versus Cesarean Delivery in Twin Pregnancies

OBJECTIVE

This study was aimed to compare maternal and neonatal outcomes between women with twin pregnancies who underwent induction of labor with those women who had planned Cesarean delivery (CD).

STUDY DESIGN

This is a retrospective cohort study of women with twin pregnancies ≥ 24 weeks with an indication for delivery but not in labor. Two groups were examined, women who underwent induction and women who underwent planned CD. Maternal and neonatal outcomes were compared between groups both for deliveries at gestational age ≥ 37 weeks and < 37 weeks.

RESULTS

A total of 453 patients were included. Overall, 212 (46.8%) women underwent induction and 241 (53.2%) underwent planned CD. Women who underwent induction of labor had a high rate of VD, both in the term and preterm groups (69.8 and 73.6%, respectively). Women who underwent induction of labor had reduced maternal length of stay, neonatal length of stay, and blood loss, without any increase in adverse outcomes. Neonatal ventilation of either twin delivered < 37 weeks was higher in the CD compared with induction group (27.5 vs. 9.4%, p < 0.01), but this was not significant on adjusted odds ratio analysis (aOR = 0.71, 95% CI: 0.19-2.66).

CONCLUSION

Labor induction in twin gestations have improved maternal outcomes and similar neonatal outcomes compared with planned CD.

[Delivery of twin pregnancy and materno-fetal prognosis in a level 3 Tunisian University Center: a retrospective study about 399 cases]

En dépit des progrès obstétricaux et pédiatriques, les grossesses gémellaires représentent une situation à haut risque aussi bien pour le déroulement de la grossesse que pour l´accouchement et reste encore une situation angoissante pour l´équipe obstétricale. Le but de cette étude était de décrire la pratique des accouchements des grossesses gémellaires au service de gynécologie obstétrique de Sousse, de décrire le pronostic maternel et fœtal et d´analyser les facteurs pouvant l´influencer. Nous avons réalisé une étude descriptive, rétrospective portant sur les accouchements des grossesses gémellaires sur une période de deux ans. Ont été incluses dans l´étude les grossesses gémellaires ayant atteint au moins 28 semaines d´aménorrhée (SA) et les femmes ayants une grossesse gémellaire compliquée d'une mort fœtale in utéro. Ont été exclues les femmes ayant une grossesse gémellaire et ayant accouchés avant 28 SA. Les grossesses bi-choriales bi-amniotiques représentaient 67% des cas, contre seulement 11,5% de grossesses mono-choriales bi-amniotiques et 3% de grossesses mono-choriale mono-amniotique. Nous avons recensé 52 césariennes programmées. Le travail a été spontané dans 304 cas. Il a été déclenché dans 43 cas. Au total 178 parturientes ont accouché par voie basse (44,6%), contre 215 par voie haute (53,9%). Le taux de césarienne pour le deuxième jumeau était de 1,5%. Quand l'accouchement était par voie basse, 19 cas de complications ont été observés (10,7%). Nous avons analysé le score d'Apgar du premier jumeau et du deuxième jumeau en fonction du mode d'accouchement. Il n'y a pas eu de différence statistiquement significative du score d'Apgar entre les deux voies d'accouchement. La morbi-mortalité périnatale est plus importante pour le deuxième jumeau que pour le premier jumeau. La morbidité maternelle en cas d´accouchement par voie basse était supérieur à la morbidité en cas d´accouchement par césarienne. Il n´y a pas de différences significatives dans le score d´Apgar selon que les enfants sont nés par voie basse ou par césarienne.

Risk of cesarean after induction of labor in twin compared to singleton pregnancies

OBJECTIVE

To assess the risk of cesarean delivery after induction of labor in twin compared with singleton pregnancies.

STUDY DESIGN

This retrospective multicenter study compared data from two nationwide prospective cohorts: one of twin pregnancies established from February 2014 through March 2015 (JUMODA cohort), and the other of singleton pregnancies in November and December 2015 (MEDIP cohort). This study includes all women in both cohorts who had labor induced at ≥ 35 weeks of gestation, with a live fetus in cephalic presentation (Twin 1 for the twin pregnancies). Multivariate analyses with multilevel logistic regression models were used to study twin pregnancy as an independent risk factor for cesarean delivery, overall and stratified for parity and Bishop score.

RESULTS

The outcomes of 1995 twin births after induction of labor were compared to those of 2771 induced singleton births. The cesarean rate differed significantly between the two populations and was higher in twins (23% in twins vs 19.4% in singletons, P = 0.002). After adjustment for factors associated with cesareans, twin pregnancy was independently associated with it (aOR = 1.8, 95% CI 1.4-2.2).

CONCLUSION

Twin pregnancy appears to be an independent risk factor for cesarean births after induction of labor, but more than three-quarters of inductions culminated in vaginal delivery.

Induction of labor in twin gestation: can we predict success?

Objective:

To identify factors associated with a successful induction of labor in twin pregnancies and associated maternal morbidity.

Study design:

This was a retrospective review of twin pregnancies ≥24 weeks’ gestation undergoing labor induction from 2011 to 2016. The primary outcome was a successful induction of labor. The secondary outcome was a composite of maternal morbidity, including ≥1 of the following: estimated blood loss (EBL) >1500 ml, blood transfusion, hysterectomy, intensive care unit (ICU) admission or maternal death.

Results:

Of 104 twin pregnancies undergoing labor induction, 64 (61.5%) had a vaginal delivery of both twins. Multiparity [odds ratio (OR) 12.3, 95% confidence interval (CI) 3.9–38.8, P≤0.005] and maternal age <35 years (OR 2.33, 95% CI 1.1–5.2, P=0.038) were independently associated with vaginal delivery. The overall rate of composite maternal morbidity was 7.7%. Cesarean delivery (CD) was associated with an increased rate of composite maternal morbidity compared to the successful induction group (17.5% vs. 1.6%, P≤0.005). An EBL >1500 ml, uterine atony and the use of ≥1 uterotonic agent were more frequent in the CD group.

Conclusions:

Multiparous women and those <35 years of age were more likely to have a vaginal delivery. Maternal morbidity is increased in women who required a CD after labor induction compared to those who achieved a vaginal delivery.

INDUÇÃO DE PARTO EM UM HOSPITAL UNIVERSITÁRIO: MÉTODOS E DESFECHOS

RESUMO Objetivo: identificar as indicações de indução de trabalho de parto, as práticas utilizadas e os seus desfechos, em um Hospital Universitário do Sul do Brasil. Método: estudo transversal. A população-alvo deste estudo forem 137 mulheres que foram internadas para a indução de trabalho de parto no período de janeiro a outubro de 2014. A análise dos dados foi realizada por meio de análise estatística simples, exploratória, e teste não paramétrico, adotando nível de significância de p≤0,05. Resultados: a maioria (53%) das induções foi realizada por pós-datismo. Quanto aos métodos, destacou-se o uso do Misoprostol de 25mcg via vaginal em 46%, e também o uso do Misoprostol associado à Ocitocina em 28,4%. O Misoprostol foi mais associado a parto vaginal. Conclusão: a indução, caso seja utilizada da maneira correta, é uma importante estratégia para a redução dos altos índices de cesarianas.

The effect of induction method in twin pregnancies: a secondary analysis for the twin birth study

Background

This secondary analysis for the Twin Birth Study, an international, multicenter trial, aimed to compare the cesarean section rates and safety between methods of induction of labor in twin pregnancies.

Methods

Women with twin pregnancies where the first twin was in a cephalic presentation and who presented for labor induction, were non-randomly assigned to receive prostaglandin or amniotomy and/or oxytocin. Main outcome measures were the rates of unplanned cesarean section and neonatal and maternal mortality or serious morbidity.

Results

153 (41.5%) were induced by prostaglandin (prostaglandin group) and 215 (58.5%) were induced by amniotomy and/or oxytocin alone (no prostaglandin group). Induction using prostaglandin was more common in countries with a low perinatal mortality rate <10/1000 (45.7 versus 32.5%, p = 0.02). Cesarean section rates were similar in the two groups: 62/153 (40.5%) in the prostaglandin group and 87/215 (40.5%) in the no prostaglandin group (odds ratio 1, 95% CI 0.65-1.5). Nulliparity, late maternal age, non-cephalic presentation of twin B and high country’s perinatal mortality rate were found to be independently associated with the induction to end with an unplanned cesarean section. There were no significant differences between groups with respect to maternal or neonatal adverse outcomes.

Conclusions

The need for cervical ripening by prostaglandin had no effect on the incidence of cesarean delivery or an abnormal outcome. There is a significant risk of unplanned cesarean section independent of chosen induction method.

Trial registration

This trial was registered at the International Standard Randomized Controlled Trial Register (identifier ISRCTN74420086; December 9, 2003) and retrospectively registered at the www.clinicaltrials.gov (identifier NCT 00187369; September 12, 2005).

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-1201-8) contains supplementary material, which is available to authorized users.

Prediction of the risk of cesarean delivery after labor induction in twin gestations based on clinical and ultrasound parameters

AIMS

To develop a model based on clinical and ultrasound parameters to predict the risk of cesarean delivery after labor induction in near-term twin gestations.

METHODS

This retrospective cohort study included 189 consecutive women with twin gestations at ≥ 36.0 weeks scheduled for labor induction. The Bishop score and transvaginal ultrasonographic measurements of cervical length were obtained immediately before labor induction. Parameters studied included maternal age, height, weight, parity, gestational age, Bishop score, cervical length, epidural analgesia, method of conception, chorionicity and birth weight. Prostaglandin E2 (dinoprostone) and oxytocin were used for labor induction. Logistic regression analysis and receiver operating characteristic curve were used to generate a predictive model for cesarean delivery.

RESULTS

Fifty (26.5%) of the 189 women had cesarean deliveries. According to logistic regression analysis, maternal height (P = 0.004), parity (P = 0.005) and cervical length (P = 0.016), but not Bishop score (P = 0.920), were identified as independent predictors of cesarean delivery. A risk score based on a model of these three parameters was calculated for each patient. The model was shown to have an adequate goodness of fit (P = 0.201) and the area under the curve was 0.722, indicating fairly good discrimination.

CONCLUSIONS

Maternal height, parity and cervical length were independent parameters for predicting the risk of cesarean delivery after labor induction in twin gestations. A predictive model using these parameters may provide useful information for deciding whether or not to induce labor.

Induction of labor in twin gestation: lessons from a population based study

INTRODUCTION

The route of delivery and the role of induction of labor in twin gestations are controversial. The aim of this study was to determine the efficacy of induction of labor in twin gestations.

METHODS

This retrospective population based cohort study included 4605 twin gestations divided into following groups: 1) spontaneous parturition (n = 2937, 63.78%); 2) induction of labor (n = 653, 14.2%) and 3) elective cesarean delivery (n = 1015, 22.04%).

RESULTS

The rate of vaginal delivery in the labor induction group was 81% (529/653). In comparison to the other study groups, induction of labor in twins was independently associated with a 77% reduction in the risk of cesarean delivery (OR 0.23; 95% CI 0.18-0.31) and a 78% reduction in the risk of postpartum death for the second twin (OR 0.22; 95% CI 0.05-0.94). The rate of nulliparity, term delivery and labor dystocia was higher in the induction of labor group (p < 0.001 in all comparisons).

CONCLUSIONS

Our results suggest that induction of labor in twin gestation is successful and is independently associated with substantial reduction in the risk of cesarean delivery and postpartum death of the second twin.

Timing of induction of labor

Determining the optimal timing for induction of labor is critical in minimizing the risks to maternal and fetal health. While data are available to guide us in some clinical situations, such as hypertension and diabetes, many gaps in knowledge still exist in others, including cholestasis of pregnancy, fetal anomalies, and placental abruption. This review of the currently available literature assesses the risks and benefits of preterm and early term induction in a wide variety of maternal and fetal conditions.

Risk factors for cesarean delivery in twin pregnancies attempting vaginal delivery

OBJECTIVE

The purpose of this study was to estimate independent risk factors for cesarean delivery in patients with twin pregnancies who attempt vaginal delivery.

STUDY DESIGN

This was an historic cohort of twin pregnancies that were delivered in 1 practice from June 2005 to February 2014. Baseline characteristics were compared between women who delivered vaginally and women who underwent cesarean delivery in labor. Logistic regression analysis was performed to estimate independent risk factors for cesarean delivery.

RESULTS

Two hundred eighty-six women with twin pregnancies who had attempted vaginal delivery were included in the study. The overall modes of delivery were vaginal delivery (82.2%), cesarean delivery (17.8%), and combined vaginal-cesarean delivery (0%). The most common indication for cesarean delivery in labor was an arrest disorder (82.4%). The risk factors that were associated independently with cesarean delivery were nulliparity (adjusted odds ratio, 5.78; 95% confidence interval, 2.24-14.88) and advanced maternal age of ≥35 years (adjusted odds ratio, 2.36; 95% confidence interval, 1.16-4.80). The patients at highest risk for cesarean delivery (nulliparous, advanced maternal age, induced labor) still had a 48.6% likelihood of vaginal delivery.

CONCLUSION

In patients with twin pregnancies who attempt labor, nulliparity and advanced maternal age are associated independently with cesarean delivery in labor. However, even the patients at highest risk for cesarean delivery have nearly a 50% likelihood of successful vaginal delivery and therefore should be allowed to attempt vaginal delivery if it is desired and not otherwise contraindicated.

Induction of labor in twin pregnancies with oral misoprostol versus vaginal dinoprostone--is it effective and safe?

OBJECTIVE

To compare the effectiveness and safety of oral misoprostol versus vaginal dinoprostone for the induction of labor in twin pregnancies.

METHODS

All twin pregnancies ≥ 34 weeks 0 days that were induced with either misoprostol or dinoprostone in St. Hedwig Hospital between 2002 and 2013 were included in this retrospective study. Length of induction, mode of delivery, maternal and neonatal outcomes were compared between the two groups.

RESULTS

After identifying 186 twin mothers matching the inclusion criteria, 154 women were induced with misoprostol (group A) and 32 with dinoprostone (group B). There were no differences in demographic data between the groups. Rates of successful vaginal delivery (53.9% versus 56.3%) and length of induction to delivery (30.2 h versus 26.9 h) were also similar. There were slightly higher rates of postpartum hemorrhage in group B (16.6% versus 10.8%), but without reaching statistical significance. Neonatal outcomes regarding umbilical artery pH <7.20 and one minute Apgar also were without significant differences.

CONCLUSIONS

Study data indicate that oral misoprostol and vaginal dinoprostone are similarly effective and safe for the induction of labor in twin gestations. Further trials with larger series are needed to confirm these results.

[Induction of labor in twin pregnancies compared to singleton pregnancies; risk factors for failure]

OBJECTIVES

The aim of this study was to evaluate the modalities of induction of labour in twin pregnancies compared with singleton pregnancies and to identify risk factors for failure.

MATERIALS ET METHODS

A retrospective population-based study was conducted at the Toulouse University Hospital to compare a cohort of diamniotic twin gestations (Twin A in vertex presentation), with induction of labour ≥36 weeks of gestation, between January 2007 and December 2012, to a singleton's cohort that were induced ≥36 weeks of gestation during the 2007 year. One singleton pregnancy was matched for each twin pregnancy with parity and gestational age.

RESULTS

One hundred and fifty-six twins pregnancies met the inclusion criteria for an induction of labor and were compared to 156 single pregnancies. The same and standard protocol of induction of labor was used for the two cohorts (intrauterine balloon catheter±dinoprostone/ocytocine). The cesarean section rate for failed labor induction (cesarean in latent phase) was similar in the 2 populations (14.7% for twin vs 13.5% for single; P=0.66). The factors associated to failed induction of labor in the total population were nulliparity (OR=1.49) and Bishop score<6 at the beginning of the induction (OR=2.83).

CONCLUSION

Twin did not appear as risk of failed induction. The protocol for induction of labor in singletons may be safely proposed to twin gestations.

Is induction of labor risky for twins compare to singleton pregnancies?

OBJECTIVE

The aim of this study was to investigate whether induction of labor in twin pregnancies is associated with higher rates of maternal complications as compared to singletons.

METHOD

A retrospective population-based study was conducted to compare maternal complications following induction of labor in twin pregnancies and singletons at Soroka University Medical Center, Be'er-Sheva, Israel, between 1988 and 2010. Stratified analysis using a multiple logistic regression model was performed to control for confounders.

RESULTS

The study population included 25 913 patients following induction of labor, of these 191 (0.73%) were in twin pregnancies. Induction of labor in twin pregnancies was not associated with adverse maternal outcomes such as cervical tears, third degree perineal tears, uterine rupture, peripartum hysterectomy, post-partum hemorrhage or retained placenta. However, labor induction in twins was significantly associated with cesarean deliveries (31.2% versus 17.1%; p < 0.001). Using a multivariable analysis controlling for confounders, induction at twins was an independent risk factor for cesarean delivery (CD; adjusted OR = 2.2, 95% CI 1.7-2.7, p < 0.001).

CONCLUSION

Induction of labor in twin pregnancies does not increase the risk for maternal complications. However, it is an independent risk factor for CD.