Exploring Women's Preferences for the Mode of Delivery in Twin Gestations: Results of the Twin Birth Study

Comparison of perinatal outcome and mode of birth of twin and singleton pregnancies in migrant and refugee populations on the Thai Myanmar border: A population cohort

BACKGROUND

In low- and middle-income countries twin births have a high risk of complications partly due to barriers to accessing hospital care. This study compares pregnancy outcomes, maternal and neonatal morbidity and mortality of twin to singleton pregnancy in refugee and migrant clinics on the Thai Myanmar border.

METHODS

A retrospective review of medical records of all singleton and twin pregnancies delivered or followed at antenatal clinics of the Shoklo Malaria Research Unit from 1986 to 2020, with a known outcome and estimated gestational age. Logistic regression was done to compare the odds of maternal and neonatal outcomes between twin and singleton pregnancies.

RESULTS

Between 1986 and 2020 this unstable and migratory population had a recorded outcome of pregnancy of 28 weeks or more for 597 twin births and 59,005 singleton births. Twinning rate was low and stable (<9 per 1,000) over 30 years. Three-quarters (446/597) of the twin pregnancies and 96% (56,626/59,005) of singletons birthed vaginally. During pregnancy, a significantly higher proportion of twin pregnancies compared to singleton had pre-eclampsia (7.0% versus 1.7%), gestational hypertension (9.9% versus 3.9%) and eclampsia (1.0% versus 0.2%). The stillbirth rate of twin 1 and twin 2 was higher compared to singletons: twin 1 25 per 1,000 (15/595), twin 2 64 per 1,000 (38/595) and singletons 12 per 1,000 (680/58,781). The estimated odds ratio (95% confidence interval (CI)) for stillbirth of twin 1 and twin 2 compared to singletons was 2.2 (95% CI 1.3-3.6) and 5.8 (95% CI 4.1-8.1); and maternal death 2.0 (0.95-11.4), respectively, As expected most perinatal deaths were 28 to <32 week gestation.

CONCLUSION

In this fragile setting where access to hospital care is difficult, three in four twins birthed vaginally. Twin pregnancies have a higher maternal morbidity and perinatal mortality, especially the second twin, compared to singleton pregnancies.

The Association of Twin Chorionicity with Maternal Outcomes

OBJECTIVE

 Our objective was to investigate the association between maternal outcomes and twin chorionicity in a large, contemporary obstetric population.

STUDY DESIGN

 Retrospective cohort study was conducted at a single, large tertiary care center. Prenatal and inpatient records for all individuals with twin gestations were reviewed from 2000 to 2016. Patients with monoamniotic twins, higher-order multiples reduced to twins, multiple sets of twins in the study period, or undetermined chorionicity were excluded. Patients with monochorionic twins were compared with those with dichorionic twins. The co-primary outcomes were gestational diabetes mellitus and hypertensive disorders of pregnancy. Secondary outcomes included cesarean delivery, preterm delivery, postpartum hemorrhage, and other maternal outcomes. Bivariate and multivariate analyses were performed to assess associations of chorionicity with maternal outcomes.

RESULTS

 Of the 2,979 patients eligible for inclusion, 2,627 (88.2%) had dichorionic twin gestations and 352 (11.8%) had monochorionic twin gestations. Patients with monochorionic twins were less likely to self-identify as non-Hispanic White and to have conceived via assisted reproductive technology but were more likely to be publicly insured, multiparous and have prenatal care with a maternal-fetal medicine provider. Neither gestational diabetes mellitus (6.8% monochorionic vs. 6.2% dichorionic, p = 0.74; adjusted odds ratio [OR] 1.06, 95% confidence interval (CI) 0.60-1.86) nor hypertensive disorders of pregnancy (21.9% monochorionic vs. 26.3% dichorionic, p = 0.09; adjusted OR 0.99, 95% CI, 0.71-1.38) differed by chorionicity. Of the secondary maternal outcomes, patients with monochorionic twins experienced a lower frequency of cesarean delivery (46.0 vs. 61.8%, p < 0.001), which persisted after multivariate analyses (adjusted OR 0.60, 95% CI 0.46-0.80). There were no differences in preterm delivery, preterm premature rupture of membranes, hemorrhage, hysterectomy, or intrahepatic cholestasis of pregnancy.

CONCLUSION

 The odds of gestational diabetes mellitus and hypertensive disorders of pregnancy do not appear to differ by twin chorionicity.

KEY POINTS

· Hypertensive disorders of pregnancy do not differ by twin chorionicity.. · Gestational diabetes mellitus does not differ by twin chorionicity.. · Maternal outcomes are similar for individuals with monochorionic and dichorionic twin gestations..

Twin birth: The maternal experience

OBJECTIVE

Twin birth is a special setting for women giving birth, and the experience of childbirth can be different from singleton birth. The objective of this study was to evaluate and compare the childbirth experiences of twin mothers and singleton mothers. We also aimed to identify the risk factors of a negative childbirth experience in the whole study population.

METHODS

All live diamniotic twin deliveries in the study hospital of at least 35⁺⁰ weeks of gestation with a plan of vaginal birth were included in this matched groups study from August 2015 to August 2019. For every twin birth, two singleton birth controls were selected and matched with parity, the actual mode of birth, and gestational weeks at birth. Six weeks after birth, a Childbirth Experience Questionnaire (CEQ) was sent to mothers, and 72 twin mothers and 126 singleton mothers returned the questionnaire.

RESULTS

The twin mothers' overall childbirth experience was positive. They reported a significantly lower opportunity to choose the birthing position (p < 0.001). Otherwise, there were no differences in the CEQ mean total scores between the study groups. Intrapartum cesarean section raised the risk of a negative childbirth experience and there was a high level of satisfaction with midwifery care among the whole study population.

CONCLUSION

The overall maternal experience in planned vaginal twin birth was positive. Twin mothers felt less often able to choose their birthing position, otherwise the childbirth experience did not differ from that of singleton mothers.

Feasibility of Conducting a Trial Assessing Benefits and Risks of Planned Caesarean Section Versus Planned Vaginal Birth: A Cross-Sectional Study

INTRODUCTION

Though interest is growing for trials comparing planned delivery mode (vaginal delivery [VD]; cesarean section [CS]) in low-risk nulliparous women, appropriate study design is unclear. Our objective was to assess feasibility of three designs (preference trial [PCT], randomized controlled trial [RCT], partially randomized patient preference trial [PRPPT]) for a trial comparing planned delivery mode in low-risk women.

METHODS

A cross-sectional survey of low-risk, nulliparous pregnant women (N = 416) and healthcare providers (N = 168) providing prenatal care and/or labor/delivery services was conducted in Argentina (2 public, 2 private hospitals). Proportion of pregnant women and providers willing to participate in each design and reasons for not participating were determined.

RESULTS

Few women (< 15%) or professionals (33.3%) would participate in an RCT, though more would participate in PCTs (88% women; 65.9% professionals) or PRPPTs (44.4% public, 63.4% private sector women; 44.0% professionals). However, most women would choose vaginal delivery in the PCT and PRPPT (> 85%). Believing randomization unacceptable (RCT, PRPPT) and desiring choice of delivery mode (RCT) were women's reasons for not participating. For providers, commonly cited reasons for not participating included unacceptability of performing CS without medical indication, difficulty obtaining informed consent, discomfort enrolling patients (all designs), and violating women's right to choose (RCT).

CONCLUSIONS FOR PRACTICE

Important limitations were found for each trial design evaluated. The necessity of stronger evidence regarding delivery mode in low-risk women suggests consideration of additional designs, such as a rigorously designed cohort study or an RCT within an obstetric population with equivocal CS indications.

Retrospective evaluation of attempted vaginal deliveries in dichorionic twin pregnancies

Purpose

Numbers of planned cesarean deliveries are increasing in twin pregnancies, despite the lack of evidence for this approach, and the second twin is thought to be at risk for a poorer outcome. The aim of this study was to examine whether twins have a poorer outcome if an attempted vaginal delivery is changed to a cesarean section or combined delivery.

Methods

This retrospective data analysis included all women with dichorionic twin pregnancies attempting vaginal delivery over a 10-year period. Outcome parameters for the first and second twins relative to their mode of birth were compared. A correlation model between the interdelivery time interval and Apgar scores was calculated. Subgroup analyses assessing the birth mode of the first and second twins were conducted.

Results

A total of 248 women were enrolled in the study. The second twins had significantly lower values for outcome parameters, such as umbilical artery cord pH and Apgar scores in comparison with the first twins (P < 0.01). The subgroup analysis of birth modes in first and second twins showed a significantly poorer outcome in the cesarean section and combined delivery group (P < 0.05). The interdelivery time interval was significantly longer in the second twin cesarean section group (P < 0.01). There was no significant correlation between the interdelivery time intervals and Apgar scores (P > 0.05).

Conclusion

Although outcome parameters were significantly lower in second twins and twins born via secondary cesarean section, the clinical relevance of this appears to be negligible.

Vaginal delivery of the second twin in unengaged cephalic presentation

In accordance with women's preferences guidelines, referring to population-based and randomized trials, which recommends counseling women with vertex-first twins to attempt a vaginal delivery. Yet, the rising rates of twin caesareans are associated with the decline in skills of senior and junior obstetricians. Although noncephalic second twins have been in the focus of interest, prompt delivery of cephalic second twins can be trickier when the head does not engage. We illustrate how to avoid complications during instrumental delivery or internal podalic version and breech extraction of the second twin encouraging to start when membranes are still intact.

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.