Does internal podalic version of the non-vertex second twin still have a place in obstetrics? A Danish national retrospective cohort study

Delivery Methods in Twin Gestations: Evaluating Outcomes, Risk Factors, and the Paradigm Shift Towards Elective Cesarean Deliveries

During the past decade, there has been a consistent rise in the number of twin births and the number of overall cesarean sections (CS) worldwide. This is owed to a variety of social, economic, educational, and scientific factors. More women are opting to advance their professional careers and gain financial stability before having children. Although this approach is understandable, a new set of challenges are faced as a result, the most important of which has been infertility due to advanced maternal age and the subsequent use of assisted fertility treatments, which have been noted to cause multiple gestations. Twin gestations are considered high-risk pregnancies and are associated with an amplitude of potential complications. Arguably, the biggest decision an obstetrician must make when dealing with this population is choosing the most appropriate mode of delivery. Given the lack of clear guidance pertaining to twin deliveries, CSs may often be perceived as safer and are often preferred over vaginal deliveries (VD). In this narrative review, we aimed to compare the outcomes of different delivery methods (CS versus VD) to investigate whether CS is truly superior to VD. Data were collected from the past two decades and analyzed based on the neonatal and maternal outcomes for each delivery mode. Our results indicate that planned VD is just as safe as CS, if not superior, in most uncomplicated twin pregnancies. Thus, it is best to advise and encourage healthy expecting twin carriers to undergo VD and explore any hesitations or fears they might have. Furthermore, a detailed guideline regarding twin delivery is essential to establish and better navigate twin deliveries, lower the rate of unnecessary CSs, and reduce overall twin gestation morbidity and mortality.

Guideline No. 428: Management of Dichorionic Twin Pregnancies

OBJECTIVE

To review evidence-based recommendations for the management of dichorionic twin pregnancies.

TARGET POPULATION

Pregnant women with a dichorionic twin pregnancy.

BENEFITS, HARMS, AND COSTS

Implementation of the recommendations in this guideline may improve the management of twin pregnancies and reduce neonatal and maternal morbidity and mortality.

EVIDENCE

Published literature was retrieved through searches of PubMed and the Cochrane Library using appropriate controlled vocabulary (e.g., twin, preterm birth). Results were restricted to systematic reviews, randomized controlled trials, controlled clinical trials, and observational studies. There were no date limits, but results were limited to English- or French-language materials.

VALIDATION METHODS

The content and recommendations were drafted and agreed upon by the principal authors. The Board of the SOGC approved the final draft for publication. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

Obstetricians, family physicians, nurses, midwives, maternal-fetal medicine specialists, radiologists, and other health care providers who care for women with twin pregnancies.

SUMMARY STATEMENTS

RECOMMENDATIONS.

[Factors associated with cesarean delivery of the second twin after vaginal delivery of the first twin: A case-control study]

OBJECTIVES

To identify risk factors for cesarean section of the second twin after vaginal delivery of the first twin.

METHODS

Case-control study conducted between 2004 and 2018 in a tertiary center, CHU Toulouse. Cases were women with twin pregnancy who had vaginal delivery of the first twin and emergency cesarean of the second twin. Controls were women with twin pregnancy who delivered both twins vaginally. Deliveries before 24 weeks of gestation, birth weight of less than 500 grams, fetal death in utero, terminations of pregnancy and delayed delivery were excluded. The association between potential risk factors and cesarean delivery of the second twin was analyzed using multivariable logistic regression.

RESULTS

Twenty-four patients who had vaginal delivery of the first twin and emergency cesarean of the second twin and 48 patients who delivered both twins vaginally were included. Neonatal morbidity was increased in the group of women who had an emergency cesarean of the second twin. In multivariable analysis, overweight (OR=10.5 [95% CI: 1.78-62.03] for women with body mass index above 25 compared to women with body mass index below 25), weight gain during pregnancy (OR=1.27 [95% CI: 1.01-1.48] for each kilogram) and preterm labor (OR=4,43 [IC 95%:1,10-17,80]) were associated with significantly increased risk of cesarean section of the second twin.

CONCLUSION

Overweight and weight gain during pregnancy are associated with increased risk for cesarean section of the second twin.

Mode of birth in twins: data and reflections

Our primary objective was to compare neonatal and maternal outcomes in women with twin pregnancies, beyond 32 weeks, having a planned vaginal birth or a planned caesarean section (CS). This was a retrospective cohort study from a single tertiary centre over nine years. 534 sets of twins ≥32 + 0 weeks of gestation were included. 401 sets were planned vaginally and 133 sets were planned by CS. We compared a composite adverse perinatal outcome (perinatal mortality or serious neonatal morbidity; five minute APGAR score ≤4, neurological abnormality and need for intubation) and a composite maternal adverse outcome (major haemorrhage, trauma or infection) between the groups. There were no significant differences. Given the similarity of these results with several other larger studies of twin birth, we sought to look at reasons why there is still a rising rate of CS for twin births. We further make suggestions for keeping this rate to a sensible minimum. Impact statement What is already known on this subject? The largest randomised controlled study comparing planned vaginal birth with planned CSs for lower risk twins between 32 and 39 weeks of gestation, showed no added safety from planned CS. However, in most of the Western countries this conclusion has failed to increase the number of planned vaginal births for lower risk twins. What do the results of this study add? This observational study from a single tertiary centre provides external validation of the twin trial results in a practical day-to-day setting. It also provides insights as to how planned vaginal birth can be developed and maintained, with a key focus on safety and maternal participation in decision making. It does focus on consent and providing accurate data. What are the implications of these findings for clinical practice and/or further research? There are good grounds to encourage vaginal birth for low-risk twin pregnancies. The trend of rising caesarean rates in low-risk twin pregnancies worldwide will erode important skills for the conduct of vaginal births without any clear benefit for mothers or babies. The current situation demands careful thought about implementing innovative training opportunities for younger obstetricians. Finally, we need intelligent responses to many non-evidence-based factors which can drive clinical practice.

The effect of twin-to-twin delivery time intervals on neonatal outcome for second twins

Background

The objective was to examine the effect of twin-to-twin delivery intervals on neonatal outcome for second twins.

Methods

This was a retrospective, hospital-based study, performed at a university teaching hospital in Western Sweden. Twin deliveries between 2008 and 2014 at ≥32 + 0 weeks of gestation, where the first twin was delivered vaginally, were included. Primary outcome was a composite outcome of metabolic acidosis, Apgar < 4 at 5 min or peri/neonatal mortality in the second twin. Secondary outcome was a composite outcome of neonatal morbidity.

Results

A total of 527 twin deliveries were included. The median twin-to-twin delivery interval time was 19 min (range 2–399 min) and 68% of all second twins were delivered within 30 min. Primary outcome occurred in 2.6% of the second twins. Median twin-to-twin delivery interval was 34 min (8–78 min) for the second twin with a primary outcome, and 19 min (2–399 min) for the second twin with no primary outcome (p = 0.028). Second twins delivered within a twin-to-twin interval of 0–30 min had a higher pH in umbilical artery blood gas than those delivered after 30 min (pH 7.23 and pH 7.20, p <  0.0001). Secondary outcome was not associated with twin-to-twin delivery interval time. The combined vaginal-cesarean delivery rate was 6.6% (n = 35) and the rate was higher with twin-to-twin delivery interval >  30 min (p <  0.0001).

Conclusions

An association, but not necessarily a causality, between twin-to-twin delivery interval and primary outcome was seen. An upper time limit on twin-to-twin delivery time intervals may be justified. However, the optimal time interval needs further studies.

Internal Podalic Version and Breech Extraction: Enhancing Realistic Sensations in a Simulation Model

BACKGROUND

Experience with internal podalic version and breech extraction is diminishing, especially in the younger generation of obstetricians. Simulation training is essential to teach and maintain these skills.

INSTRUMENT

We present a mannequin-based simulation method that enhances realistic sensations during training.

EXPERIENCE

By positioning the fetal mannequin into a thin plastic bag filled with water, the impression of palpating, grabbing, and pulling the fetal feet through the plastic bag is similar to reaching feet through intact membranes. The unique approach of this realistic simulation model makes the experience fun and memorable, which contributes to the didactic value and success of the model.

CONCLUSION

The simulation model we present mimics the situation and sensation obstetricians experience while performing internal podalic version and breech extraction.

The predicting factors and outcomes of caesarean section of the second twin

The aim of this study was to review the indications for caesarean delivery of second twins after vaginal delivery of a first twin (combined delivery) and the associated foetal outcomes of the second twin. Possible factors that could be employed to predict combined delivery were explored. This was a retrospective review of all twin pregnancies delivered in a tertiary maternity unit between 2000 and 2013. All twins (> =24 week gestation) with vaginal delivery of the first twin were reviewed. Of a total of 1039 pairs of twins, 441 pairs had vaginal delivery of the first twin, of which 47 (10.7%) needed combined delivery. Presentation of the second twin was found to be significantly associated with combined delivery (p < .001). The odds ratio for combined delivery for breech second twin was 2.4 compared with vertex second twins while the odds ratio for transverse lie second twin was 182.8. Second twins who were delivered by combined delivery had a higher incidence of 5 min Apgar score <7. The extremely high odds ratio for combined delivery for second twins in transverse lie would probably indicate that attempts at vaginal delivery of these vertex/transverse twin pregnancies would not be worthwhile. Impact statement It remains controversial in the literature whether non-vertex second twins are associated with a higher risk for combined delivery as compared to vertex second twins. Almost all previous studies have analysed the non-vertex second twins as a whole group rather than separating them into breech presentation and transverse lie. There is only one study analysing breech presentation and transverse lie of second twin separately but it has recruited only 14 patients. To our knowledge, the cohort is the largest available dataset comparing the odds ratio for combined delivery of breech and transverse lie of the second twin separately. We found that transverse lie of the second twin have extremely high rates of combined delivery with an odds ratio 182.8 and this may be ascribed to the lack of attempts to perform internal podalic version. Combined delivery is associated with higher maternal and neonatal morbidities. With such a high risk of transverse lie second twin in having combined delivery, it appears reasonable to advise women with vertex/transverse twins not to attempt vaginal delivery unless there are obstetricians who have experience in performing internal podalic version at the time of delivery. This is useful for patient counselling regarding the decision of the mode of delivery.

Safety of vaginal delivery among dichorionic diamniotic twins over 10 years in a UK teaching hospital

OBJECTIVE

To determine whether vaginal delivery among dichorionic diamniotic twins remains a safe option following full implementation of the European Working Time Directive in the UK.

METHODS

A retrospective study was conducted using data for women with dichorionic diamniotic twin pregnancies who attended a teaching hospital in London, UK, for delivery between January 4, 2000, and December 23, 2010.

RESULTS

Among 892 women, 474 (53.1%) attempted vaginal delivery, 220 (46.4%) of whom achieved spontaneous vaginal delivery of both twins. Instrumental vaginal delivery was performed among 89 women (18.8%), and 165 (34.8%) women underwent emergency cesarean delivery. Delivery of the second twin by emergency cesarean (n=31) was predominantly for fetal distress (13 [41.9%]) or abnormal lie (10 [32.3%]). A 5-minute Apgar score of 9 or 10 was recorded for 384 (83.7%) of 459 first twins and 369 (82.9%) of 445 second twins, irrespective of the mode of delivery.

CONCLUSION

Vaginal delivery among dichorionic diamniotic twins had a good success rate and a low intrapartum emergency cesarean delivery rate. Training in cardiotocography and intrapartum procedures might further reduce the need for emergency cesarean delivery.

[Training achieves an internal version and a total breech extraction at birth of second twin]

OBJECTIVES

To evaluate French residents in obstetrics and gynaecology's training to internal version and breech extraction during vaginal delivery of the second twin.

METHODS

A national descriptive survey conducted among 1064 residents between July and October 2014. Respondents were invited by email to specify the type of theoretical and practical training they had received, their university hospital obstetrical practices and the number of vaginal internal version and breech extraction of the second twin they had seen and performed.

RESULTS

Response rate was 38.7% (n=412). Regarding the type of theoretical training, 39.8% of residents (n=164) had received the obstetrical mechanics and techniques degree; 47.6% (n=196) had got a teaching during special education classes and 29.4% (n=121) a training on mannequin. There were important differences between regions. At the end of residency, 45.6% of residents (n=36) had practiced more than five vaginal internal version and breech extraction of the second twin.

CONCLUSION

Internal version and breech extraction are difficult but essential maneuvers for the management of twin delivery. The French residents in obstetrics and gynaecology's training for these maneuvers seems to be insufficient. It is necessary to improve their teaching, this teaching must also be equivalent between regions.