Accouchement des grossesses gémellaires : enquête sur les politiques des maternités françaises

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

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.

[Active management of the second twin for vaginal delivery: ruptured versus intact membranes. Apropos a series of 182 patients]

AIM

The vaginal management of the second twin (T2) differs throughout our country. In 2009, the French National College of Gynecologists and Obstetricians released practice guidelines, with low-level evidence, encouraging active management of the second twin, using maneuvers with intact membrane.

PATIENTS AND METHODS

In our level III labour ward, these maneuvers are systematically performed when the second twin is in a breech or transverse presentation and after ruptured membranes in most cases. We studied 182 twin pregnancies with active management of the T2 at more than 28 weeks of gestation, from 1st January 1996 to 31st December 2010, by comparing the membrane status during delivery of T2.

RESULTS

The results did not show any significant differences between the two groups of patients concerning the neonatal or maternal results. The technique is feasible, even by residents. Our results show that total breech extraction of the second twin with ruptured membranes is feasible, which allows for reappraisal of the national recommendations.

CONCLUSION

In our practice, it is possible to actively deliver the T2 with ruptured membranes without altering maternal and fetal prognosis and thus simplifying learning for young doctors.

[Twin pregnancies: where should we manage them? Where should they deliver?]

OBJECTIVES

To define where should twin pregnancies be managed and delivered.

MATERIALS AND METHODS

A literature search was performed using the Pubmed and Cochrane database. Foreign societies guidelines were also consulted.

RESULTS

There is little or no evidence to answer the question. Risk of premature labor and chorionicity are the two main factors involved in twin management. When there is a risk of prematurity, in utero transfer is recommended. Twin care must be performed by a team trained in the specificity of management according to chorionicity. There is not enough evidence to support specialized clinics. Labor and delivery need permanent and immediate disponibility of a perinatal team including an OB-gyn, an anesthesiologist and a pediatrician.

CONCLUSION

Needs assessment and chorionicity are the best indicators to define the optimal place of care and delivery for twin pregnancies. More than a specific location, it seems more logical to define all necessary means to enforce an optimal management of these pregnancies.

[Twin delivery with the first twin in breech position. A study of 137 continuous cases]

AIM

The first twin (T1) in breech position is at risk of complications during vaginal delivery, making the choice of the appropriate delivery route highly important. Although British and American practice guidelines recommend the cesarean section, the French National College of Obstetricians and Gynecologists concluded that there was not enough data to choose one delivery route or the other. In this context, we set out to describe practices in our centre.

MATERIAL AND METHODS

Our retrospective study was conducted at a level III labor ward between January 1st, 1995 and December 31st, 2006. One hundred and thirty-seven twin pregnancies at more than 26 gestational weeks (GW), with T1 in breech and T2 in any position, were included.

RESULTS

A cesarean section was performed before labor in 60.6 % cases. Among the 54 (39.4 %) cases where a trial of labor was accepted, 29 patients (53.7 % success rate) delivered vaginally and 25 (46.3 %) had a cesarean section during labor. No statistical difference was observed between the neonatal outcomes after cesarean section as compared to vaginal birth. However, a significant relationship was found between delivery route and parity. Less than one-third of nulliparas versus two-third of patients with a history of at least one delivery, having trials of labor, ultimately gave birth vaginally. Thus, we observed a high rate of cesarean section during labor in nulliparas (68 % of the initially accepted trials of labor).

CONCLUSION

Our study is the first one that clearly shows that the success rate of the trial of labor is closely related to a history of vaginal birth. Following these results and because of more than two-third of cesarean section during labor in nulliparas, we subsequently plan an elective cesarean section at the 38th GW for nulliparas with twin pregnancies and T1 in breech position. Nevertheless, if any of these patients go in labor before the cesearean section, a careful trial of labor is offered.

Is a planned cesarean necessary in twin pregnancies?

OBJECTIVE

Evaluation of elective cesarean section for twin delivery as a standard of care.

DESIGN

Historical cohort in a national database (2 597 twin pregnancies).

SETTING

France.

SAMPLE

Twins with first child in cephalic presentation.

METHODS

Decision analysis.

MAIN OUTCOME MEASURES

All neonatal complications, i.e. death, whether intrapartum or in the delivery room or the immediate postpartum period, or neonatal transfer to intensive (or special) care, or trauma, of one or both twins.

RESULTS

When we focused on neonatal complications for either or both twins, the strategy of planned vaginal delivery was preferable; the weight of its decision tree branch was lower than that for planned cesarean (26.5 vs. 31.7). If only twin 2 was considered, vaginal delivery was also preferred (weight of vaginal delivery=27.6 vs. 32.7 for planned cesarean). As long as the morbidity and mortality of twin 1 or twin 2 or both during a cesarean for twin 2 in the case of planned vaginal delivery does not exceed 31.5%, all else being equal, vaginal delivery should be preferred to a planned cesarean for twin 1 and twin 2. The two-variable sensitivity analysis confirmed the robustness of the results.

CONCLUSIONS

The results of our study do not support a policy of planned cesarean delivery for twin pregnancies at and after 34 weeks of gestation.

LEVEL OF EVIDENCE

II.

[Modes of deliveries of twins as a function of their presentation. A study of 371 pregnancies]

OBJECTIVE

In France, global rate of caesarian section in twin pregnancies has been 50.2% in 2003. Modes of delivery according to different twin presentations remain controversial in the literature. The purpose of our study is to analyze our practice of twin deliveries in a 5-year period, with neonatal outcomes.

PATIENTS AND METHODS

Among 22,243 women having delivered in our maternity (22 weeks and over) during the study period, the study population consisted of 371 twin pregnancies, of which 305 after 33 weeks gestation.

RESULTS

Different presentations were relatively identical whatever the gestational age of pregnancies: the "cephalic-cephalic" presentation represented 60 to 70% of the total, the "cephalic-breech" presentation approximately 10% while the "breech-cephalic" or "breech-breech" presentations approximately 8% each. Mean terms of pregnancies were 35.2 ± 2.8 weeks, mean birthweight being 2243 ± 561 g. C-section rate was 53.5%. When the first twin was in cephalic presentation, C-section rate was 40% while it was almost 100% when the first twin was in breech or "other" presentations.

CONCLUSION

There were no significant differences in neonatal outcomes (mean birthweights, Apgar scores, transfers in neonatology, perinatal deaths) according to different mode of deliveries (vaginal or C-sections). Our policy of planned cesarean section may need to be revised.

Quelle place pour la radiopelvimétrie au XXIe siècle?

The purpose of this article was to perform a critical analysis of publications having estimated the utility of X-ray pelvimetry, in order to allow tangible and useful conclusions for the clinical practice. X-ray pelvimetry was proposed in 3 indications: trial of labour among patients with a history of caesarean section, breech presentation, suspicion of cephalopelvic disproportion. The large majority of these publications are retrospective studies, studying a low number of patients and especially without control groups or randomisation. Their contradictory results and their methodological weaknesses do not allow any conclusion. Published randomised trials are exceptional. Among patients with a history of caesarean section, there is only one randomised trial; it demonstrates that ante-partum X-ray pelvimetry is not necessary prior to a trial labour in women with one previous caesarean section. It increases the caesarean section rate and is a poor predictor of the outcome of labour. There is also only one randomised trial which evaluated the interest of X-ray pelvimetry in patients with a breech presentation: the use of pelvimetry in breech presentation at term does not significantly reduce the overall caesarean-section rate, and does not improve the neonatal issues. However, it allows better selection of the delivery route, with a significantly lower emergency Caesarean-section rate. Finally, the only one randomised trial having studied the utility of X-ray pelvimetry for the prediction of cephalopelvic disproportion shows that pelvimetry is a poor predictor of the outcome of labour, has no influence on the neonatal issues and increases the caesarean sections rate. Furthermore, although radiation exposure during a X-ray pelvimetry is very weak, diagnostic X-ray studies during any stage of gestation have been shown to increase the risk of childhood cancer in the irradiated fetus. In the rare cases where pelvimetry is useful (trial of labour with a breech presentation), it is thus careful to perform a MRI pelvimetry.