BACKGROUND AND PURPOSE:

• American and British guidelines recommend cesarean delivery for twin pregnancies with the first twin in breech presentation
• However, there is a paucity of evidence that planned vaginal delivery for a first twin in breech presentation is associated with a greater incidence of neonatal adverse outcomes
• Korb et al. (Obstetrics & Gynecology, 2020) compared neonatal mortality and morbidity based on the planned mode of delivery when the first twin is in breech presentation

METHODS:

• Secondary analysis of population-based study
  • JUmeaux MODe d’Accouchement (JUMODA) cohort
  • National prospective population-based study of twin deliveries conducted in 176 French hospitals
• Included data
  • Pregnancies with first twin in breech presentation and the following
    • Both fetuses alive
    • Birth weight between 1,500 g and 4,000 g
    • Pregnancies ≥32w0d
• Data analysis
  • Multivariate Poisson regression models and propensity score analyses to control for potential confounders
• Primary outcome: Composite of neonatal mortality and morbidity included ≥1 or more of the following
  • 5-minute Apgar score <4 | Birth trauma | Injury of the phrenic or facial nerve present | Subdural or intracerebral hemorrhage | Encephalopathy | Endotracheal ventilation | Sepsis | BPD | Need for supplemental oxygen | IVH (grade III and IV | NEC (stage II and III)
• Statistical analysis: Based on number of women available for each group
  • Power of 80% to show relative risk (RR) ≥ 2.65 for associations between the planned mode of delivery and the primary outcome

RESULTS:

• Data from 1,467 women
  • Planned cesarean delivery: 79.7%
  • Planned vaginal delivery: 20.3%
• Women who delivered both twins vaginally among the planned vaginal birth group: 62.1%
• Planned vaginal delivery was not associated with neonatal adverse outcomes
  • Planned vaginal: 1.7% (5 births)
  • Planned cesarean: 1.9% (22 births)
  • Crude RR: 0.90 (95% CI, 0.34 to 2.34)
  • Adjusted RR: 0.71 (95% CI, 0.27 to 1.86)
  • Using propensity score or other statistical analyses to account for confounders also did not demonstrate any association
• Neonatal mortality and morbidity rates were similar for second twins as well

CONCLUSION:

• Study limitations
  • The authors acknowledge comparatively small number of women who underwent a planned vaginal delivery
  • Study not powered to identify small differences in outcomes
• Planned vaginal delivery where the first twin is in breech presentation was not associated with an increased risk for significant neonatal mortality or morbidity

Learn More – Primary Sources:

First Twin in Breech Presentation and Neonatal Mortality and Morbidity According to Planned Mode of Delivery

Related ObG Topics:

Professional Recommendations: Delivery of Breech Presentation at Term

Vaginal Delivery of Twin A and Cesarean Delivery for Twin B: Risk Factors and Outcomes

Planned Cesarean or Planned Vaginal Delivery for Twins?

Trial of Labor After Cesarean for Twins and Risks for Adverse Outcomes