Grand Rounds

Is There a Role for Vaginal Delivery if First Twin is in Breech Presentation?

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

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

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

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

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