While twins account for approximately 3% of all deliveries, the evidence remains inconclusive as to the ideal mode of delivery
Delivery of twins by C-section has substantially increased, particularly in the US
This study by Schmitz et al. (Obstetrics & Gynecology, 2017) sought to determine the impact of planned mode of delivery on neonatal risk in twin pregnancies in an unselected population
Prospective Population-Based Cohort Study
5,915 women with twin pregnancies who delivered at ≥32 weeks’ gestation, with a cephalic first twin, were included in the study
1,454 (24.6%) women had planned C-sections
Women with planned C-sections were more likely to be older, obese and have additional maternal and fetal complications
4,461 (75.4%) women had planned vaginal deliveries
3,583 (80.3%) delivered both twins vaginally
Composite neonatal mortality and morbidity was 5.2% in the planned C-section group and 2.2% in the vaginal delivery group (odds ratio 2.38, 95% CI 1.86-3.05)
After matching to limit bias due to indication and adjusting for previous C-section, infants born via planned C-section had higher composite neonatal mortality and morbidity rates than infants born vaginally (5.3% compared with 3.0%; odds ratio 1.85, 95% confidence interval 1.29-2.67)
Differences were only seen at gestational ages < 37 weeks
Exclusion of high risk pregnancies (14.2%) showed increased composite neonatal mortality and morbidity between 32 weeks 0 days and 34 weeks and 6 days
Main neonatal complication was respiratory morbidity
Other complications were also more common in the C-section group such as bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis, and neonatal sepsis
The authors recognize the main limitation, as with all observational studies, is that of uncontrolled confounders
Multiple statistical approaches were used to reduce bias
Planned vaginal deliver after 32 weeks is associated with low neonatal risk if the first twin is cephalic
The data strongly supports ACOG recommendations for planned vaginal delivery between 32 and 37 weeks for a twin pregnancy with a cephalic first twin
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