Caesarean section for the birth of the second twin

Racial disparities in outcomes of twin pregnancies: elective cesarean or trial of labor?

OBJECTIVE

The objective of the study was to determine the relationships between maternal race and obstetric outcomes in twin gestations by planned mode of delivery.

STUDY DESIGN

We performed a secondary analysis of the Consortium on Safe Labor data. Patients with twin gestations in vertex-vertex presentation greater than 32 weeks' gestational age were grouped according to race. Demographic information and neonatal and maternal outcomes were analyzed according to planned mode of delivery: elective cesarean or trial of labor (with subsequent vaginal delivery, unplanned cesarean, or combined delivery). The primary outcome was unplanned cesarean. Secondary outcomes included maternal and neonatal outcomes.

RESULTS

One thousand nine vertex-vertex twin pregnancies were identified. There were no significant differences across ethnicities in the rate of unplanned cesarean delivery, which occurred in 233 of patients undergoing trial of labor (27%). Elective cesarean occurred in 151 patients (15%). African American women were less likely to have an elective cesarean compared with whites (odds ratio, 0.5; 95% confidence interval, 0.3-0.8), and Asian women were more likely to have an elective cesarean compared with whites (odds ratio, 2.0; 95% confidence interval, 1.2-3.4. Combined delivery occurred in 67 patients (8%) and did not differ among the groups. Subgroup analysis did not reveal any significant differences in neonatal outcomes. Adverse maternal outcomes were rare across ethnicities.

CONCLUSION

Unplanned cesarean delivery rates are similar in twin pregnancies, regardless of race. Maternal and neonatal outcomes in twin gestations are similar across ethnicities, regardless of mode of delivery.

[Rupture of membranes in case of internal podalic version: a risk for cesarean section on the second twin]

OBJECTIVES

To evaluate if internal version with ruptured membranes is a risk factor of cesarean section for the second twin.

PATIENTS AND METHODS

Two hundred and fifty-nine twins vaginal deliveries after 33 weeks of gestation from 1997 to 2009 in a level 3 maternity. A retrospective case-control study comparing two groups: cases of cesarean section on second twin and five twins vaginal deliveries following the case. Active management of the second twin delivery was performed with a short intertwin delivery.

RESULTS

Eleven cesarean sections on the second twin were performed (4.2%). The main indication was failure of internal version. The risk of cesarean section was significantly greater when the internal version was performed with ruptured membranes (OR: 25.4 IC 95% [2.3-275.7] P<0.003) and when intertwin time delivery interval was increased (8.1±5.1 vs 16.7±6.3, P<0.001).

DISCUSSION AND CONCLUSION

The rupture of amniotic membranes before or during the internal podalic version is associated with a risk of failure and cesarean for the second twin. We recommend to perform the internal podalic version with unruptured membranes according to the French recommendations.

Perinatal mortality in retained second twin

Retention of the second twin is diagnosed if the twin is still undelivered 30 minutes after the birth of the first baby and this condition constitutes an obstetric emergency often associated with a poor outcome. We report the causes of retention and the perinatal mortality rate in 30 retained second twins in a series of 128 sets of twin births recorded in Mansa General Hospital (Zambia) from 1 August 1993 to 31 July 1995. The study focused only on 125 available case notes. The incidence of twin birth is 4% of deliveries and 24% second twins were retained. The main causes of retention were uterine inertia (90%), malpresentation (60%) and home delivery of the first twin (23%). The perinatal mortality rate was higher in retained second twins (47%) than in those delivered normally (13%). The main factors associated with perinatal deaths were very low Apgar score (100%), cephalic presentation (64%) and very low birth weight (29%). Only good antenatal and intrapartum care can help reduce the incidence and poor outcome due to the retained second twin.

Twin pregnancies: incidence and outcome—Riyadh Armed Forces Hospital experience

A retrospective study of twin births at the Armed Forces Hospital, Riyadh, from January 1987 to December 1996 was carried out. There were 62 739 deliveries and 598 sets of twins. The incidence of twins was one in 105 maternities. The perinatal mortality rate was 46 per 1000 births compared with 12.3 per thousand for singletons. Premature delivery (<34 weeks) and very low birth weight infants (<1500 g) accounted for 12.5% and 8.7% of the twin deliveries respectively, but contributed to 60% and 63.6% of the total deaths respectively. Nineteen (3.2%) patients received no antenatal care, however, they contributed to 16.2% of the total deaths. This report represents our experience at the Armed Forces Hospital, Riyadh, Saudi Arabia on the management of twin pregnancies during a period of 10 years.

Caesarean section for the second twin after vaginal delivery of first

Although caesarean section of a second twin after vaginal birth of the first twin is rare, it nevertheless has clinical importance as an acute emergency situation with high perinatal morbidity and mortality. We therefore found it appropriate to describe the obstetric management of such cases, including an overview of the literature and our own data. According to reports in the literature, 113 deliveries of second twins (3.4%) were carried out by section in 3342 twin births. At our department in Tubingen there were 497 twin births (1.9%) in 26 095 births. Of these the second twin was delivered by section in 11 cases (2.2%). This represents a statistical frequency of 0.04% of all births. As shown by case histories and our own study, the indications for abdominal delivery of the second twin were predominantly the prolapse of the umbilical cord or of small parts due to transverse or breech presentation, with simultaneous retraction of the cervix. Of our 11 births with emergency section, one child died postpartum. Because of above-mentioned risks the twin delivery must always be performed in a fully equipped facility, including facilities for intensive neonatal care.

Modes of delivery of first and second twins as a function of their presentation. Study of 614 consecutive patients from 1992 to 2000

OBJECTIVES

To study modes of delivery and neonatal morbidity of twins as a function of their presentation.

STUDY DESIGN

The study related to 614 consecutive patients who gave birth to twins in the maternity ward of the Hôpital Robert Debré from 1992 to 2000. Group A (n=529) included patients who gave birth after 33 weeks of gestation and group B (n=85) before 33 weeks. The parameters studied were the mode of delivery, the need for intubation at birth, 5-min Apgar score <9, transfer to intensive care, death in the neonatal period. The chi-square test was used for statistical analysis.

RESULTS

In group A, significantly more cesarean sections were performed for breech-breech (22.6%) and breech-vertex (16%) presentations than for vertex-vertex (10.3%) and vertex-breech (4.6%) presentations. In group B, there was no significant difference in the rate of vaginal delivery. Second vertex twins of group A had significantly higher frequencies of intubation (3%) at birth and transfer to intensive care (3%) than the vertex first twins born by vaginal delivery (p=0.01). These percentages were not significantly different from those observed for the second twins born by planned Cesarean section before the start of labor (2.8 and 5.6%, respectively). In group B, neonatal parameters did not differ significantly with the type of presentation at delivery.

CONCLUSIONS

The type of presentation should not influence the choice of mode of delivery of twin pregnancies, whatever the gestational age.

Mode of delivery for vertex-nonvertex twin gestations

OBJECTIVE

To compare the neonatal outcome of vaginally delivered (VD) to that of abdominally delivered (CS) vertex-nonvertex (Vx/NVx) twins.

METHODS

Vx/NVx live nonanomalous twin gestations >or=25 weeks delivered from 1984 to 2000 were divided into two groups: VD (N=138), and CS (N=79). The outcome of the second twin was compared.

RESULTS

The vaginal delivery rate for the Vx/NVx twins was 63.6%. The median Apgar scores at 1 and 5 min, respectively, were significantly lower in VD [7 (0-9) and 9 (1-10)] compared to CS [8 (2-10) and 9 (2-10)]. The neonatal mortality was also higher in VD (109/1000 vs. 38/1000, p=0.040). Differences in the 1-min Apgar scores persisted when infants <1500 g were excluded. All other neonatal outcome variables studied including respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage, trauma, seizures, and length of nursery stay were similar. On logistic regression analysis, vaginal delivery of Vx/NVx twins marginally increased low 5-min Apgar scores and neonatal deaths.

CONCLUSION

Vaginal delivery in vertex-nonvertex twins was achieved in 63.6% of cases at the expense of a higher incidence of low 1- and 5-min Apgar scores and neonatal death.

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.

Maternal and perinatal mortality and morbidity associated with transverse lie

OBJECTIVE

The aim of this study of transverse lie in labor of patients admitted to Korle Bu Hospital between 1 January 1996 and 30 June 1998, was to identify the methods of delivery, the perinatal and maternal morbidities and mortalities, and to provide recommendations to improve the outcome.

METHODS

This was a retrospective study of 152 patients who presented at the labor wards with transverse lie. The data sources of this study were the antenatal records, the labor wards delivery record books, the postnatal records and the admission books at the Neonatal Intensive Care Unit.

RESULTS

One hundred and forty-two cases (92.1%) had an emergency cesarean section. The rest had the external version followed by vaginal delivery. There were two maternal deaths resulting from hemorrhage, infections and difficult surgery. There were 25 stillbirths, and 37 of the neonates required hospital admission.

CONCLUSION

Transverse lie carries a high rate of complications in labor. Delivery should be carried out without delay in a hospital well-equipped for cesarean delivery and assisted vaginal delivery. The complications could be further reduced by early diagnosis during the antenatal period when associated risk factors, such as placenta previa could be diagnosed with the aid of the ultrasound scan. Elective deliveries could then be undertaken.

Delivery of the nonvertex second twin: a review of the literature

Twin gestations comprise approximately 1 percent of all pregnancies (1), and are associated with increased perinatal morbidity and mortality, mainly due to the increased incidence of prematurity and growth restriction (2). Hazards of twin delivery can be attributed to malpresentation, most often by the second twin. The vertex-nonvertex presentation occurs in approximately 40 percent of all twins (3, 4). Although there is consensus regarding the safety of vaginal delivery for twins when both are vertex (5), controversy exists over intrapartum management when the second twin is nonvertex. Some investigators advocate cesarean delivery, particularly when the second twin is nonvertex (6), or if the expected birth weight is < 2000 gm (6-8). This review aims to determine whether vaginal delivery of the nonvertex second twin, either by breech extraction or attempted external cephalic version, is associated with increased morbidity or mortality over cesarean delivery.

Perinatal and maternal mortality associated with retained second twins

OBJECTIVES

The aim of this study of retained second twins admitted to Korle-Bu Hospital between 1988 and 1993 was to identify the factors contributing to the mode of delivery, perinatal and maternal mortalities, and draw up recommendations to improve outcome.

METHODS

The study consisted of a review of record cards, outpatient admission and discharge books, delivery books, and inpatient case notes of women admitted with retained second twins of 28 weeks' or more gestation during the study period.

RESULTS

Of the 65 cases fully reviewed, 33 (approximately 50%) were delivered by cesarean section due mainly to abnormal lie with or without shoulder impaction. The rest were assisted deliveries, mainly vertex deliveries or breech extractions. The perinatal mortality of the retained second twins was 38.5% compared with 12.3% for the first twins. Although in general the longer the interdelivery interval, the greater the second twin perinatal mortality risk, no clear direct correlation could be established. There was one perioperative maternal mortality due to anaphylactic reaction to intramuscular morphine injection.

CONCLUSION

Irrespective of the antenatal course and early labor findings, twin delivery should be undertaken in a unit equipped for cesarean section and assisted delivery. The unacceptably high perinatal mortality of retained second twins could thus be significantly reduced.

Caesarean section in Britain and the United States 12% or 24%: is either the right rate?

The rate of caesarean section (CSR) in Great Britain (GB) and the U.S.A., 12% in England in 1989 ascertained from a survey performed by the authors, and 24% according to official U.S. figures, is higher than warranted by the known and agreed obstetric indications for this operation, which suggest a rate of 6-8% would be adequate. It is argued that the fall in perinatal mortality which has occurred over the period during which the CS rate has risen is not the main reason for this fall. The training of obstetricians to deal with anxiety, provision of primary maternity care by appropriately trained midwives and general or family practitioners, and changes in management protocols could cut the CSR. The number of women undergoing surgery every year in the U.K. could be reduced by 20,000 and in the U.S.A. by 470,000 if the rate of 6% were achieved. In studies of midwifery care the CSR is even lower and it is possible that labour proceeds more efficiently if the woman knows her caregivers and labours at home, as in The Netherlands. Although CS is much safer than in the past it is still more likely to result in the death of the woman and has significant morbidity for the woman and economic costs for society.

The influence of presentation and method of delivery on neonatal mortality and infant neurodevelopmental outcome in nondiscordant low-birthweight ( < 2500 g) twin gestations

The effects of birth order, presentation and method of delivery on neonatal mortality and neurodevelopmental outcome in nondiscordant low birthweight ( < 2500 g) twin gestations were evaluated. Sixty-four sets of twins were included in the study; 29 sets were in vertex/vertex presentation (Group I), 25 sets in vertex/breech (Group II) and in 10 pregnancies the first twin was nonvertex (Group III). The rate of favorable neonatal outcome (survival and normal neurodevelopmental outcome after a 2-year follow-up) was lower in pregnancies in which at least one twin was in nonvertex presentation (50/70 vs. 52/58 P = 0.02). However, after adjustment by multiple logistic regression analysis for the effects of gestational age, birthweight, birth order and educational level of the mother, this difference was not statistically significant (odds ratio = 0.6; 95% confidence interval 0.44 to 5.9; P = 0.5). In pregnancies in which at least one of the twins was in nonvertex presentation, delivery by cesarean section did not affect the rate of favorable neonatal outcome (odds ratio = 1.8; 95% confidence interval 0.48 to 12.9; P = 0.8). The results of this study suggest that in low birthweight twin gestations, method of delivery in relation to fetal presentation has little or no effect on neonatal mortality and subsequent neonatal neurodevelopmental outcome.

Cesarean delivery of the second twin after the vaginal birth of the first twin: misfortune or mismanagement?

The perinatal characteristics of 16 vaginal-abdominal deliveries of twins were evaluated. The primary indication for the cesarean delivery was compound vertex presentation (n = 4), prolapsed umbilical cord (n = 4), transverse lie (n = 7), and mentoposterior face presentation (n = 1). Ther outcome of Twin A was not different from that of Twin B. About 90% of the twins were eventually discharged on time. A significant correlation (R = 0.9722, p less than 0.0003) was found between the reported rates of combined deliveries and cesareans in twins. The data suggest that a higher rate of combined deliveries is expected in practices where abdominal deliveries are performed more often in twin gestations, while in obstetric services with low cesarean rates in twins, combined deliveries seem to be unfortunate occurrences dictated by unexpected intrapartum events.