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Rahman RA, Mohammed Nawi A, Ishak S, Balaraman K, Abu MA, Abd Azman SH, Kalok AH, Mohamed Ismail NA, Mahdy ZA, Ahmad S. Second twin outcome at birth: retrospective analysis in a single tertiary centre in Malaysia. J Perinat Med 2024; 52:385-391. [PMID: 38511669 DOI: 10.1515/jpm-2023-0449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 01/15/2024] [Indexed: 03/22/2024]
Abstract
OBJECTIVES To investigate factors associated with outcome of second twin during labour. METHODS The study was a retrospective cohort study in a single tertiary centre in Malaysia from 2014 until 2018 involving all twin pregnancies delivered at or more than 24 weeks of gestation. RESULTS Total of 409 twin pregnancies were included. Dichorionic twin comprises of 54.5 % (n=223) and 45.5 % (n=186) are monochorionic. Women with dichorionic pregnancies are significantly older (p<0.001), have more pre-existing medical disorders (p=0.011) and fetal structural anomalies (p=0.009). Monochorionic pregnancies are significantly more amongst Malay (p=0.01) and conceived spontaneously (p<0.001). There are significantly more fetuses both in cephalic presentation (p=0.026), birthweight discrepancy more than 20 % (p=0.038) and shorter mean inter-twin delivery duration (p=0.048) in monochorionic pregnancies. Second twin delivered with Apgar score <7 is significantly more in dichorionic pregnancies (p=0.006). The second twin is associated with lower birthweight, small for gestational age and arterial cord pH<7.25. Within the group of women who delivered both fetuses vaginally, there was significantly more second twins with intertwin delivery duration less than 30 min who were delivered vaginally without instrumentation (p=0.018). There was significantly more second twin with intertwin delivery duration of 30 min and more with arterial cord pH<7.25 (p=0.045). Those who delivered spontaneously had inter-twin delivery duration within 15-29 min. The outcome of second twin is not influenced by type of twin, gestational age at delivery, inter-twin delivery duration, mode of delivery and presentation at birth. CONCLUSIONS The neonatal outcome for the second twin at birth is not influenced by type of twin, gestational age at delivery, inter-twin delivery duration, mode of delivery and presentation at birth in a cohort managed with non-active management of the second twin in Malaysia.
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Affiliation(s)
- Rahana Abd Rahman
- Department of Obstetrics & Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
| | - Azmawati Mohammed Nawi
- Hospital Canselor Tuanku Muhriz, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
| | - Shareena Ishak
- Hospital Canselor Tuanku Muhriz, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
- Department of Paediatrics, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
| | - Kartik Balaraman
- Department of Obstetrics & Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
| | - Mohamad Azrai Abu
- Department of Obstetrics & Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
| | - Siti Hajar Abd Azman
- Department of Obstetrics & Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
| | - Aida Hani Kalok
- Department of Obstetrics & Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
| | - Nor Azlin Mohamed Ismail
- Department of Obstetrics & Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
| | - Zaleha Abdullah Mahdy
- Department of Obstetrics & Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
| | - Shuhaila Ahmad
- Department of Obstetrics & Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Cheras, Kuala Lumpur, Malaysia
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Mahindra MP, Sampurna MTA, Mapindra MP, Putri AMS, Krisbiyantoro A, Aryananda RA. Factors affecting elective cesarean section in women with multiple pregnancy in Caruban, Indonesia. F1000Res 2023; 9:1481. [PMID: 38107345 PMCID: PMC10724646 DOI: 10.12688/f1000research.27292.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 12/19/2023] Open
Abstract
Background: Caesarean sections have become the most popular method for delivering twin babies because of the safety concerns associated with a natural birth. This study aims to identify the maternal characteristics and obstetric parameters that serve as risk factors influencing caesarean delivery in twin pregnancies by comparing women delivering via caesarean section and vaginal birth. Methods: A retrospective chart review design was used to analyse 47 women with multiple pregnancies from the medical records at a primary referral hospital in East Java, Indonesia. Women delivering vaginally were then compared with women who underwent a caesarean section to identify any differences between the groups. Results: In our study, more women delivered by caesarean section (n=35) than by vaginal birth (n=12). Women were more likely to undergo a caesarean section if they had a previous history of undergoing a caesarean section (OR 16.5; 95% CI 1.91-142.49; p=0.02). Similar to previous studies, we found that foetal malpresentation significantly increase the risk of caesarean delivery (OR 8.25; 95%CI 0.95-71.09; p=0.03), while labour augmentation decrease the likelihood of caesarean section (OR 0.20; 95% CI 0.49-0.81; p=0.03). There was also a significant older patients in the caesarean section groups (OR 1.26; 95% CI 1.09-1.45 ; p=0.00). Conclusions: The percentage of multiple pregnancies delivered via caesarean section is quite high. Other larger cohort study are warranted, since many factors were involved in the decision of caesarean section.
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Affiliation(s)
- Muhammad Pradhiki Mahindra
- Maternal-Fetal Medicine Department, Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, WC1E 6AU, UK
| | - Mahendra Tri Arif Sampurna
- Department of Pediatrics, Faculty of Medicine, Universitas Airlangga, Surbaya, East Java, 60115, Indonesia
| | - Muhammad Pradhika Mapindra
- Neonatology Department, Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, WC1E 6AU, UK
| | - Apriska Mega Sutowo Putri
- Faculty of Medicine, Sebelas Maret University, Surakarta, East Java, 57126, Indonesia
- Caruban General Hospital, Madiun, East Java, 63153, Indonesia
| | - Aries Krisbiyantoro
- Faculty of Medicine, Sebelas Maret University, Surakarta, East Java, 57126, Indonesia
- Caruban General Hospital, Madiun, East Java, 63153, Indonesia
| | - Rozi Aditya Aryananda
- Department of Obstetrics and Gynecology, Airlangga University, Subaya, East Java, 60115, Indonesia
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Rissanen AS, Loukovaara M, Gissler M, Nupponen IK, Nuutila ME, Jernman RM. Mode of delivery of Finnish dichorionic and monochorionic-diamniotic twins: A retrospective observational study including a risk score for intrapartum cesarean birth. Health Sci Rep 2023; 6:e1236. [PMID: 37181664 PMCID: PMC10167911 DOI: 10.1002/hsr2.1236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 04/06/2023] [Accepted: 04/18/2023] [Indexed: 05/16/2023] Open
Abstract
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%).
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Affiliation(s)
- Annu‐Riikka S. Rissanen
- Department of Obstetrics and GynecologyUniversity of HelsinkiHelsinkiFinland
- Department of Obstetrics and GynecologyWelfare District of Päijät‐HämeLahtiFinland
| | - Mikko Loukovaara
- Department of Obstetrics and GynecologyUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Mika Gissler
- Finnish Institute for Health and WelfareHelsinkiFinland
- Karolinska InstituteStockholm and Region StockholmSweden
| | - Irmeli K. Nupponen
- Children's HospitalUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Mika E. Nuutila
- Department of Obstetrics and GynecologyUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Riina M. Jernman
- Department of Obstetrics and GynecologyUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
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Large for gestational age presenting twin: risk factors, maternal and perinatal outcomes. Eur J Obstet Gynecol Reprod Biol 2022; 278:183-188. [DOI: 10.1016/j.ejogrb.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/11/2022] [Accepted: 09/26/2022] [Indexed: 11/19/2022]
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Loussert L, Laur J, Paret L, Parant O, Dupuis N, Guerby P. [Factors associated with cesarean delivery of the second twin after vaginal delivery of the first twin: A case-control study]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2022; 50:505-510. [PMID: 35288365 DOI: 10.1016/j.gofs.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 03/01/2022] [Accepted: 03/06/2022] [Indexed: 06/14/2023]
Abstract
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.
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Affiliation(s)
- L Loussert
- Service de gynécologie obstétrique, CHU de Toulouse, hôpital Paule-de-Viguier, 2, rue Charles-Viguerie, 31300 Toulouse, France.
| | - J Laur
- Service de gynécologie obstétrique, CHU de Toulouse, hôpital Paule-de-Viguier, 2, rue Charles-Viguerie, 31300 Toulouse, France
| | - L Paret
- Service de gynécologie obstétrique, CHU de Toulouse, hôpital Paule-de-Viguier, 2, rue Charles-Viguerie, 31300 Toulouse, France
| | - O Parant
- Service de gynécologie obstétrique, CHU de Toulouse, hôpital Paule-de-Viguier, 2, rue Charles-Viguerie, 31300 Toulouse, France
| | - N Dupuis
- Service de gynécologie obstétrique, CHU de Toulouse, hôpital Paule-de-Viguier, 2, rue Charles-Viguerie, 31300 Toulouse, France
| | - P Guerby
- Service de gynécologie obstétrique, CHU de Toulouse, hôpital Paule-de-Viguier, 2, rue Charles-Viguerie, 31300 Toulouse, France; Inserm UMR 1048, I2MC, université de Toulouse, 1, avenue du Professeur Jean-Poulhès, 31432 Toulouse, France
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Ghesquière L, Rouilles J, Drumez E, Houfflin-Debarge V, Subtil D, Garabedian C. Is it reasonable to propose vaginal delivery with twin pregnancies, when the first twin is in breech presentation? J Gynecol Obstet Hum Reprod 2022; 51:102377. [DOI: 10.1016/j.jogoh.2022.102377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 04/03/2022] [Accepted: 04/07/2022] [Indexed: 11/28/2022]
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Aviram A, Barrett JFR, Melamed N, Mei-Dan E. Mode of delivery in multiple pregnancies. Am J Obstet Gynecol MFM 2021; 4:100470. [PMID: 34454159 DOI: 10.1016/j.ajogmf.2021.100470] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/25/2021] [Accepted: 08/18/2021] [Indexed: 11/25/2022]
Abstract
The mode of delivery in multiple pregnancies has been subject to vigorous debates during the last few decades. Although observational and retrospective data were accumulated, it was not until the publication of the Twin Birth Study that evidence-based recommendations could emerge. However, although some of the most pressing questions were answered by the Twin Birth Study, other questions were left outside the scope of the study. The questions were of great interest and included the following topics: the impact of gestational age, the influence of chorionicity, and the generalizability of the results for women with a previous uterine scar. The current evidence supported a trial of labor in dichorionic-diamniotic or monochorionic-diamniotic twin pregnancies in which the first twin is in cephalic presentation at ≥32 weeks' gestation. Dichorionic-diamniotic, monochorionic-diamniotic, and monochorionic-monoamniotic twins should be delivered at 37 0/7 to 38 0/7, 36 0/7 to 37 0/7, and 32 0/7 to 34 0/7 weeks' gestation, respectively. Breech extraction done by a competent healthcare provider seemed to offer a higher chance of successful vaginal delivery of the second twin than the external cephalic version. The current data did not allow for a clear recommendation regarding the mode of delivery in very preterm birth of low birthweight twins, but most studies did not demonstrate a clear benefit of cesarean delivery vs trial of labor. Furthermore, a trial of labor seemed safe in women with a previous cesarean delivery. Cesarean delivery is likely beneficial for twin pregnancies with the first twin in breech presentation, monochorionic-monoamniotic twins, and higher-order multiple pregnancies. In all multiple pregnancies, delivery should be performed by an experienced practitioner competent in multiple pregnancy deliveries.
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Affiliation(s)
- Amir Aviram
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (Drs Aviram and Melamed); Department of Obstetrics and Gynaecology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (Drs Aviram, Melamed, and Mei-Dan); Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada (Dr Barrett); Department of Obstetrics and Gynaecology, North York General Hospital, Toronto, Ontario, Canada (Dr Mei-Dan).
| | - Jon F R Barrett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (Drs Aviram and Melamed); Department of Obstetrics and Gynaecology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (Drs Aviram, Melamed, and Mei-Dan); Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada (Dr Barrett); Department of Obstetrics and Gynaecology, North York General Hospital, Toronto, Ontario, Canada (Dr Mei-Dan)
| | - Nir Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (Drs Aviram and Melamed); Department of Obstetrics and Gynaecology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (Drs Aviram, Melamed, and Mei-Dan); Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada (Dr Barrett); Department of Obstetrics and Gynaecology, North York General Hospital, Toronto, Ontario, Canada (Dr Mei-Dan)
| | - Elad Mei-Dan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (Drs Aviram and Melamed); Department of Obstetrics and Gynaecology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (Drs Aviram, Melamed, and Mei-Dan); Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada (Dr Barrett); Department of Obstetrics and Gynaecology, North York General Hospital, Toronto, Ontario, Canada (Dr Mei-Dan)
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Pascalet M, Fourel M, Bourtembourg A, Toubin C, Coppola C, Becher P, Ramanah R, Riethmuller D, Mottet N. Mode of delivery of twin pregnancies with the first twin in breech position after the introduction of a policy of planned caesarean delivery for nulliparous women. Eur J Obstet Gynecol Reprod Biol 2019; 234:58-62. [PMID: 30660038 DOI: 10.1016/j.ejogrb.2018.11.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 11/26/2018] [Accepted: 11/27/2018] [Indexed: 11/17/2022]
Abstract
INTRODUCTION To evaluate the impact of the mode of delivery of twin pregnancies with the first twin in breech position for all parities combined after introduction of a policy of planned caesarean section in 38 weeks' gestation in nulliparas. MATERIAL AND METHODS A retrospective study of the mode of delivery of twin pregnancies with the first twin in breech position was conducted from January 2007 to December 2015 after the implementation of a planned caesarean section in 38 weeks' gestation in nulliparas. Maternal and neonatal outcomes were compared according to the decision of attempted vaginal or planned caesarean delivery. RESULTS Among the 134 women included, an attempted vaginal delivery was decided for 30.6% women (n = 41), with 95% (n = 39) who delivered vaginally and 5% (n = 2) by caesarean section during labour. Among the 69.4% women (n = 93) with a planned caesarean section, 64.5% (n = 60) and 11.8% (n = 11) delivered by caesarean before labour and during labour, respectively, and 23.7% (n = 22) delivered vaginally. The overall vaginal delivery rate was 45.5%, and the overall rate of caesarean section was 54.5% for all parities combined. In nulliparous women, the rate of caesarean section during labour was 33%. There were no significant differences in maternal mortality or morbidity between the two groups. CONCLUSION A selective policy of attempted vaginal delivery based on parity for twin pregnancies with the first twin in breech position can lead to a reduction in the overall rate of caesarean section in this population.
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Affiliation(s)
- Marion Pascalet
- Besançon University Medical Center, Department of Obstetrics and Gynaecology, Alexander Fleming Boulevard, 25000 Besançon, France.
| | - Marianne Fourel
- Besançon University Medical Center, Department of Obstetrics and Gynaecology, Alexander Fleming Boulevard, 25000 Besançon, France
| | - Aude Bourtembourg
- Besançon University Medical Center, Department of Obstetrics and Gynaecology, Alexander Fleming Boulevard, 25000 Besançon, France
| | - Claire Toubin
- Besançon University Medical Center, Department of Obstetrics and Gynaecology, Alexander Fleming Boulevard, 25000 Besançon, France
| | - Camille Coppola
- Besançon University Medical Center, Department of Obstetrics and Gynaecology, Alexander Fleming Boulevard, 25000 Besançon, France
| | - Patrick Becher
- Besançon University Medical Center, Department of Obstetrics and Gynaecology, Alexander Fleming Boulevard, 25000 Besançon, France
| | - Rajeev Ramanah
- Besançon University Medical Center, Department of Obstetrics and Gynaecology, Alexander Fleming Boulevard, 25000 Besançon, France
| | - Didier Riethmuller
- Besançon University Medical Center, Department of Obstetrics and Gynaecology, Alexander Fleming Boulevard, 25000 Besançon, France
| | - Nicolas Mottet
- Besançon University Medical Center, Department of Obstetrics and Gynaecology, Alexander Fleming Boulevard, 25000 Besançon, France.
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Delivery of the second twin: influence of presentation on neonatal outcome, a case controlled study. BMC Pregnancy Childbirth 2018; 18:176. [PMID: 29776396 PMCID: PMC5960113 DOI: 10.1186/s12884-018-1815-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 05/01/2018] [Indexed: 12/15/2022] Open
Abstract
Background Spontaneous vaginal twin delivery after 32nd week of gestation is safe when first twin presenting cephalic. Aim of this study is to identify obstetric factors influencing the condition of second twin and to verify whether non-cephalic presentation and vaginal breech delivery of the second twin is safe. Methods This is a retrospective case controlled cohort study of 717 uncomplicated twin deliveries ≥32 + 0 weeks of gestation from 2005 to 2014 in two tertiary perinatal centers. Obstetric parameters were evaluated in three groups with descriptive, univariate logistic regression analysis for perinatal outcome of second twins. Results The three groups included twins delivered by elective cesarean section ECS (n = 277, 38.6%), by unplanned cesarean section UPC (n = 233, 32.5%) and vaginally (n = 207, 28.9%). Serious adverse fetal outcome is rare and we found no differences between the groups. Second twins after ECS had significant better umbilical artery UA pH (p < 0.001) and better Apgar compared to UPC (p = 0.002). Variables for a fetal population “at risk” for adverse neonatal outcome after vaginal delivery (UA pH < 7.20, Apgar 5´ < 9) were associated with higher gestational age (p = 0.001), longer twin-twin interval (p = 0.05) and vacuum extraction of twin A (p = 0.04). Non-cephalic presentation of second twins was not associated (UA pH < 7.20 OR 1.97, CI 95% 0.93–4.22, p = 0.07, Apgar 5´ < 9 OR 1.63, CI 95% 0.70–3.77, p = 0.25, Transfer to neonatal intermediate care unit p = 0.48). Twenty-one second twins (2,9%) were delivered by cesarean section following vaginal delivery of the first twin. Even though non-cephalic presentation was overrepresented in this subgroup, outcome variables were not significantly different compared to cephalic presentation. Conclusions Even though elective cesarean means reduced stress for second twins this seems not to be clinically relevant. Non-cephalic presentation of the second twin does not significantly influence the perinatal outcome of the second twin but might be a risk factor for vaginal-cesarean birth.
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Reitter A, Daviss BA, Krimphove MJ, Johnson KC, Schlößer R, Louwen F, Bisits A. Mode of birth in twins: data and reflections. J OBSTET GYNAECOL 2018; 38:502-510. [PMID: 29433366 DOI: 10.1080/01443615.2017.1393402] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- A Reitter
- a Department of Obstetrics and Gynaecology , University Hospital Frankfurt, Goethe-University , Frankfurt , Germany
| | - B A Daviss
- b Department of Obstetrics and Gynaecology, Midwifery Division , Montfort Hospital , Ottawa , Canada
| | - M J Krimphove
- a Department of Obstetrics and Gynaecology , University Hospital Frankfurt, Goethe-University , Frankfurt , Germany
| | - K C Johnson
- c Department of Epidemiology and Community Medicine , University of Ottawa , Ottawa , Canada
| | - R Schlößer
- d Department of Pediatrics, Division Neonatology , University Hospital Frankfurt, Goethe-University , Frankfurt , Germany
| | - F Louwen
- a Department of Obstetrics and Gynaecology , University Hospital Frankfurt, Goethe-University , Frankfurt , Germany
| | - A Bisits
- e Department of Obstetrics and Gynecology, Royal Hospital for Women , University of New South Wales , Randwick , Australia
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Dagenais C, Lewis-Mikhael AM, Grabovac M, Mukerji A, McDonald SD. What is the safest mode of delivery for extremely preterm cephalic/non-cephalic twin pairs? A systematic review and meta-analyses. BMC Pregnancy Childbirth 2017; 17:397. [PMID: 29187166 PMCID: PMC5707900 DOI: 10.1186/s12884-017-1554-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 10/31/2017] [Indexed: 12/21/2022] Open
Abstract
Background Given the controversy around mode of delivery, our objective was to assess the evidence regarding the safest mode of delivery for actively resuscitated extremely preterm cephalic/non-cephalic twin pairs before 28 weeks of gestation. Methods We searched Cochrane CENTRAL, MEDLINE, EMBASE and http://clinicaltrials.gov from January 1994 to January 2017. Two reviewers independently screened titles, abstracts and full text articles, extracted data and assessed risk of bias. We included randomized controlled trials and observational studies. Our primary outcome was a composite of neonatal death (<28 days of life) and severe brain injury in survivors (intraventricular hemorrhage grade ≥ 3 or periventricular leukomalacia). We performed random-effects meta-analyses, generating odds ratios with 95% confidence intervals for the first and second twin separately, and for both twins together. We assessed the risk of bias using a modified Newcastle Ottawa Scale (NOS) for observational studies and used Grading of Recommendations Assessment, Development and Evaluation approach (GRADE). Results Our search generated 2695 articles, and after duplicate removal, we screened 2051 titles and abstracts, selecting 113 articles for full-text review. We contacted 36 authors, and ultimately, three observational studies met our inclusion criteria. In cephalic/non-cephalic twin pairs delivered by caesarean section compared to vaginal birth at 24+0–27+6 weeks the odds ratio for our composite outcome of neonatal death and severe brain injury for the cephalic first twin was 0.35 (95% CI 0.00–92.61, two studies, I2 = 76%), 1.69 for the non-cephalic second twin (95% CI 0.04–72.81, two studies, I2 = 55%) and 0.83 for both twins (95% CI 0.05–13.43, two studies, I2 = 56%). According to the modified Newcastle Ottawa Scale we assessed individual study quality as being at high risk of bias and according to GRADE the overall evidence for our primary outcomes was very low. Conclusion Our systematic review on the safest mode of delivery for extremely preterm cephalic/non-cephalic twin pairs found very limited existing evidence, without significant differences in neonatal death and severe brain injury by mode of delivery. Electronic supplementary material The online version of this article (10.1186/s12884-017-1554-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Catherine Dagenais
- Department of Obstetrics & Gynecology, McMaster University, 1280 Main St W, HSC 3N52B, Hamilton, ON, L8S 4K1, Canada
| | - Anne-Mary Lewis-Mikhael
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4K1, Canada
| | - Marinela Grabovac
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4K1, Canada
| | - Amit Mukerji
- Department of Pediatrics, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4K1, Canada
| | - Sarah D McDonald
- Department of Obstetrics & Gynecology, McMaster University, 1280 Main St W, HSC 3N52B, Hamilton, ON, L8S 4K1, Canada. .,Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4K1, Canada.
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Birth management and fetal outcome in multiple gestation: analysis of 1.444 births. Arch Gynecol Obstet 2017; 297:61-69. [PMID: 29018972 DOI: 10.1007/s00404-017-4559-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 09/28/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Since the late 1990s, controversies came up concerning the mode of delivery for multiples births. The twin birth study indicated no difference in maternal and fetal outcome between planned vaginal delivery and planned caesarean section, but did not analyze the influence of maternal and fetal characteristics or the obstetric management in vaginal birth. The purpose of this study is to analyze these parameters regarding fetal outcome. METHODS A large-scale retrospective analysis of twin births (n = 1.444) was performed at a university medical center. The analysis included pregnancy, delivery, and maternal and fetal parameters, including pH and base excess (BE) differences between the first- and second-born twin (delta pH, delta BE). RESULTS Delta pH correlated significantly with the birth interval for various positions of twins in the womb (p < 0.05). The longer the birth interval, the greater the delta pH with a lower pH of the second twin. Delta BE values were significantly correlated with the birth interval for a combination of twins in cephalic and breech presentation. Furthermore, it could be shown that higher differences in birth weight between the first/second twin are associated with higher delta pH, higher delta BE values (all p < 0.05). We found significantly decreasing delta pH values in vaginal deliveries over secondary and, finally, primary caesarean sections (p < 0.001). CONCLUSION We conclude a vaginal delivery of twin appears safe if experienced staff monitor birth weight discrepancies, birth interval, and blood values consequently. A good outcome also for the second twin delivered spontaneously is nevertheless feasible if experienced staff is available.
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Arsene E, Langlois C, Garabedian C, Clouqueur E, Deruelle P, Subtil D. Prenatal factors related to face presentation: a case–control study. Arch Gynecol Obstet 2015; 294:279-84. [DOI: 10.1007/s00404-015-3992-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 12/10/2015] [Indexed: 10/22/2022]
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15
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Clinical indicators associated with the mode of twin delivery: an analysis of 22,712 twin pairs. Eur J Obstet Gynecol Reprod Biol 2015; 195:133-140. [DOI: 10.1016/j.ejogrb.2015.09.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Revised: 09/13/2015] [Accepted: 09/17/2015] [Indexed: 11/18/2022]
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Sato Y, Emoto I, Maruyama S, Taga A, Fujii T. Twin vaginal delivery is associated with lower umbilical arterial blood pH of the second twin and less intrapartum blood loss. J Matern Fetal Neonatal Med 2015; 29:3067-71. [PMID: 26553843 DOI: 10.3109/14767058.2015.1118039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To clarify actual differences in the neonatal as well as maternal outcome between completed twin vaginal delivery and cesarean delivery. METHODS We collected the data from women with a twin pregnancy who delivered two live fetuses between 1 January and 31 December 2014 at 20 teaching hospitals (1) (1) PARTICIPANTS: Adachi Hospital, Hyogo Prefectural Amagasaki General Medical Center, Japan Baptist Hospital, Kitano Hospital, Kobe City Medical Center General Hospital, Kosaka Women's Hospital, Kurashiki Central Hospital, Kyoto University Hospital, Mitsubishi Kyoto Hospital, Nagahama Red Cross Hospital, National Hospital Organization Kyoto Medical Center, National Hospital Organization Osaka National Hospital, Osaka Red Cross Hospital, Otsu Municipal Hospital, Otsu Red Cross Hospital, Red Cross Wakayama Medical Center, Saiseikai Noe Hospital, Shizuoka General Hospital, Takamatsu Red Cross Hospital and Tenri Hospital. in Japan. Only the cases that were retrospectively regarded as eligible for planned vaginal delivery were analyzed according to the actual mode of delivery. RESULTS Umbilical arterial blood pH (UmA-pH) of the second twin was slightly but significantly lower in the vaginal delivery group (7.26 ± 0.009) than in a cesarean delivery group (7.30 ± 0.006). Vaginal delivery was the only independent risk factor for second twin's UmA-pH <7.20. Intrapartum blood loss was significantly larger in the cesarean delivery group (1444 ± 63 g) than in the vaginal delivery group (820 ± 109 g). Cesarean delivery was an independent risk factor for intrapartum blood loss ≥1500 g. CONCLUSION Twin vaginal deliveries were associated with slightly but significantly lower UmA-pH of the second twin, whereas twin cesarean delivery was associated with significantly larger intrapartum blood loss. Not only the neonatal risk but also the maternal risk should be taken into account when an optimal delivery mode for the twin pregnancy is considered.
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Affiliation(s)
- Yukiyasu Sato
- a Department of Obstetrics and Gynecology , Otsu Red Cross Hospital , Otsu , Japan and
| | - Ikuko Emoto
- a Department of Obstetrics and Gynecology , Otsu Red Cross Hospital , Otsu , Japan and
| | - Shunsuke Maruyama
- a Department of Obstetrics and Gynecology , Otsu Red Cross Hospital , Otsu , Japan and
| | - Atsuko Taga
- a Department of Obstetrics and Gynecology , Otsu Red Cross Hospital , Otsu , Japan and
| | - Tsuyoshi Fujii
- b Department of Obstetrics and Gynecology , Kyoto Katsura Hospital , Kyoto , Japan
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Garabedian C, Poulain C, Duhamel A, Subtil D, Houfflin-Debarge V, Deruelle P. Intrapartum management of twin pregnancies: are uncomplicated monochorionic pregnancies more at risk of complications than dichorionic pregnancies? Acta Obstet Gynecol Scand 2015; 94:301-7. [PMID: 25494703 DOI: 10.1111/aogs.12558] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Accepted: 12/03/2014] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To analyze mode of delivery and neonatal morbidity according to chorionicity in a hospital birth center with a policy of vaginal delivery for twins. STUDY DESIGN Retrospective analysis over a 13-year period. SETTING Department of Obstetrics, University Hospital, Lille, France. POPULATION In all, 1009 twin pregnancies were included, divided into 171 uncomplicated monochorionic pregnancies (17%) and 838 dichorionic pregnancies (83%). METHODS We compared the monochorionic and the dichorionic populations. MAIN OUTCOME MEASURES Rate of cesarean section and neonatal outcome (umbilical artery pH, Apgar score and neonatal complications). RESULTS The rate of cesarean sections was 45.7% with no difference found based on chorionicity. The reasons for elective cesarean section were mainly noncephalic presentation, which was more frequent in dichorionic than in monochorionic (48.8% vs. 37.2%, p = 0.025) pregnancies. Birthweight was lower in monochorionic twins (2249 ± 469 g vs. 2329 ± 478 g, p = 0.045). The rate of umbilical artery cord blood values with a pH < 7.10 was similar in monochorionic and dichorionic pregnancies. There was no difference in neonatal complications between the two groups. CONCLUSION Monochorionic and dichorionic twin pregnancies had similar delivery outcomes. The neonatal outcome for twin 2 was not different between monochorionic and dichorionic pregnancies. Vaginal birth could be offered to women with twin pregnancies regardless of chorionicity.
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Affiliation(s)
- Charles Garabedian
- Department of Obstetrics, Jeanne de Flandre Hospital, Lille, France; Unit EA 4489 Perinatal Environment and Growth, Faculty of Medicine, Henri-Warembourg, University of Lille, Lille, France
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Seelbach-Goebel B. Twin Birth Considering the Current Results of the "Twin Birth Study". Geburtshilfe Frauenheilkd 2014; 74:838-844. [PMID: 25278625 PMCID: PMC4175125 DOI: 10.1055/s-0034-1383064] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Revised: 08/20/2014] [Accepted: 08/20/2014] [Indexed: 01/26/2023] Open
Abstract
The rate of caesarean sections in multiple births has grown sharply worldwide. The reason for this may be the results of large retrospective cohort studies from the 1990s, which displayed an increased risk of mortality and morbidity, especially for the second twin, in the case of vaginal births. Multiple monocentric analyses have not been able to confirm this. As a prospective, multi-centre randomised study, the Twin Birth Study published in 2013, in which 105 clinics in 25 countries took part, showed that, under optimum conditions, there was no difference in neonatal and maternal mortality and morbidity if the birth was planned to be vaginal or via caesarean. Detailed analyses, which would be helpful in choosing the type of birth method and obstetric management in the event of vaginal birth, have not previously been published. Retrospective studies must be referred to for this.
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Affiliation(s)
- B. Seelbach-Goebel
- Hospital of the Merciful Brothers – St. Hedwig Clinic, Department of Obstetrics and Gynaecology of the University , of Regensburg, Regensburg
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Vogel JP, Holloway E, Cuesta C, Carroli G, Souza JP, Barrett J. Outcomes of non-vertex second twins, following vertex vaginal delivery of first twin: a secondary analysis of the WHO Global Survey on maternal and perinatal health. BMC Pregnancy Childbirth 2014; 14:55. [PMID: 24484695 PMCID: PMC3916070 DOI: 10.1186/1471-2393-14-55] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 01/24/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mode of delivery remains a topic of debate in vertex/non-vertex twin pregnancies. We used the WHO Global Survey dataset to determine the risk of adverse maternal/perinatal outcomes associated with presentation of the second twin, following vaginal delivery of a vertex first twin. METHODS We analysed a derived dataset of twin pregnancies ≥ 32 weeks gestation where the first twin was vertex and delivered vaginally. Maternal, delivery and neonatal characteristics and adverse outcomes were reported by presentation of the second twin. Logistic regression models (adjusted for maternal and perinatal confounders, mode of delivery and region) were developed to determine odds of adverse outcomes associated with presentation. RESULTS 1,424 twin pregnancies were included, 25.9% of these had a non-vertex second twin and Caesarean was more common in non-vertex presentations (6.2% vs 0.9%, p < 0.001). While the odds of Apgar < 7 at 5 minutes were higher in non-vertex presenting second twins (16.0% vs 11.4%, AOR 1.42 95% CI 1.01-2.00), the odds of maternal ICU admission (4.6% vs 1.7%, AOR 1.30, 95% CI 0.88-1.94), blood transfusion (6.0% vs 3.4%, AOR 1.23, 95% CI 0.67-2.25), stillbirth (7.6% vs 4.7%, AOR 1.15, 95% CI 0.72-1.73), early neonatal death (3.8% vs 2.1%, AOR 1.68, 95% CI 0.96-2.94), and NICU admission (26.6% vs 23.2%, AOR 0.93, 95% CI 0.62-1.39) were not. CONCLUSION After a vaginal delivery of a vertex first twin, non-vertex presentation of the second twin is associated with increased odds of Apgar <7 at 5 minutes, but not of other maternal/perinatal outcomes. Presentation of the second twin is not as important a consideration in planning twin vaginal birth as previously considered.
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Affiliation(s)
- Joshua P Vogel
- School of Population Health, Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, 35 Stirling Highway, Crawley, WA 6009, Australia
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva CH-1211, Switzerland
| | - Erica Holloway
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON, Canada
| | - Cristina Cuesta
- Centro Rosarino de Estudios Perinatales, Rosario, Santa Fe, Argentina
| | - Guillermo Carroli
- Centro Rosarino de Estudios Perinatales, Rosario, Santa Fe, Argentina
| | - João Paulo Souza
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva CH-1211, Switzerland
| | - Jon Barrett
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON, Canada
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