Twin Births: Vaginal Delivery Safer Than

Caesarean
Norra MacReady
May 09, 2017

Vaginal delivery of twins is associated with less neonatal morbidity and mortality than
cesarean delivery, and should be the birth method of choice when the first twin has a
cephalic presentation, the authors of a large, population-based study report.

The findings "call for planned vaginal rather than cesarean delivery between 32 and
37 weeks of gestation and strongly support recent American College of Obstetricians
and Gynecologists recommendations," Thomas Schmitz, MD, PhD, from the
Gynecologic and Obstetric Service at the Hôpital Robert Debré, Paris, France, and
colleagues write in an article published in the June issue of Obstetrics & Gynecology.
This shows that "a lower rate of [caesarean] delivery in women carrying twins is not
only achievable, but that it is also safer for their neonates," Dwight J. Rouse, MD, adds
in an accompanying editorial.

At this time, 75% of twins in the United States are born through cesarean delivery, Dr
Rouse, associate editor (obstetrics) of Obstetrics & Gynecology, writes. Reducing that
even to 50% would help nearly 17,000 women each year avoid surgery that is both
unnecessary and potentially harmful to their newborns.

The additional risk associated with cesarean delivery was seen only when the infants
had a gestational age less than 35 or 37 weeks, depending on the risk level of the
pregnancy.

The data come from the Jumeaux Mode d'Accouchement (JUMODA) study, a
national, observational, prospective, population-based cohort study conducted in
France from February 10, 2014, through March 1, 2015. All maternity units that
handled more than 1500 pregnancies annually were invited to participate.
The analysis included women who gave birth to twins at or after 32 weeks' gestation,
with the first twin in a cephalic position. They were enrolled by their obstetricians
immediately after delivery and categorized according to planned mode of delivery:
cesarean or vaginal.

The study included 5915 women who delivered twins in 176 maternity units across
France. Of those patients, 1454 (24.6%) planned cesarean deliveries, and 4461
(75.4%) planned vaginal deliveries. Ultimately, 61% of the women in the entire cohort
delivered both twins vaginally, including 25 women (1.7%) in the planned cesarean
group.

Women who planned a cesarean delivery had a mean age of 32.8 ± 5.8 years
compared with a mean of 31.4 ± 5.1 years among women who planned a vaginal
delivery. Women planning a cesarean delivery also were heavier than women in the
planned vaginal delivery group, and also were more likely to have had previous
cesarean deliveries and complicated pregnancies and to deliver smaller neonates at
an earlier gestational age.

The primary study outcome was a composite of intrapartum mortality, neonatal

mortality during the first 28 days of life, and neonatal morbidity, defined as the
presence of one or more characteristics such as 5-minute Apgar score less than 4,
birth trauma, or respiratory or neurological complications. Overall, this outcome was
seen in 5.2% of infants born to mothers in the planned cesarean group and 2.2% of
infants in the planned vaginal delivery group (odds ratio [OR], 2.38; 95% confidence
interval [CI], 1.86 - 3.05).

To control for potential bias introduced by the differences in risk between

women planning cesarean or vaginal delivery, the authors conducted a
propensity-matched analysis comparing a subgroup of 2288 women (1144 in
each delivery category). The composite neonatal morbidity and mortality rate
among infants in the planned cesarean group was 5.3% compared with 3.0%
among infants in the planned vaginal delivery group (OR, 1.85; 95% CI, 1.29 -
2.67).
The most common cause of neonatal death in both groups was multiple
malformation or genetic syndromes.
In another subgroup analysis that excluded high-risk pregnancies, 564
(14.2%) of the women had planned cesarean deliveries and 3410 (85.8%) had
planned vaginal deliveries. "Analyses by gestational age in this subgroup
showed that planned cesarean delivery was associated with higher composite
neonatal mortality and morbidity only between 32 0/7 and 34 6/7 weeks of
gestation," the authors write.

"The propensity-matched and secondary analyses in the low-risk population

demonstrated no significant association between planned cesarean delivery
and the composite primary outcome."
Two main conclusions can be drawn from these findings, the authors say.
"First, high vaginal delivery rates with low neonatal mortality and morbidity are
possible for twin pregnancies with a cephalic first twin at or after 32 weeks of
gestation nationwide."

Second, planned cesarean delivery was associated with higher neonatal morbidity and
mortality, but only among twins born at less than 37 weeks' gestation in the overall
cohort, and at less than 35 weeks in the low-risk cohort. "Cesarean delivery before
labor is strongly associated with respiratory distress in term and late preterm
neonates."

The findings of this study are similar to those obtained in the Twin Birth Study
conducted in Canada, Dr Rouse adds. Both trials have shown that, when the first twin
has a cephalic presentation, and the appropriate equipment and personnel are
available, "at least from 32 weeks of gestation onward, an attempt at vaginal delivery
should be the default plan, regardless of the presentation of the second twin."
One study author reports having been a consultant for Procter & Gamble France, and
another reports having been a consultant and lecturer for Ferring Laboratories. The
other authors and Dr Rouse have disclosed no relevant financial relationships.
Obstet Gynecol. 2017;129:974-975, 986-995.