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Delivering Twins Safely: Which Way Is Best?

October 2, 2013

Delivering Twins Safely: Which Way Is Best?

  1. Allison Bryant, MD, MPH

In a randomized trial, neonatal and maternal outcomes were similar regardless of planned mode of delivery.

  1. Allison Bryant, MD, MPH

Determining the safest delivery mode for twins has been controversial, particularly when the second twin is not in cephalic presentation. Previous retrospective cohort studies have suggested that planned cesarean delivery is associated with fewer adverse perinatal outcomes, fueling support for this approach. Now, Canadian investigators have conducted a multicenter, international study in which they randomized 1398 women with twin pregnancies (gestation, 32–39 weeks; first twin in cephalic presentation) to planned vaginal delivery or planned cesarean delivery. The primary outcome was a composite of fetal and neonatal mortality and serious neonatal morbidity; maternal outcomes also were assessed.

Among women in the planned-cesarean group, 90% underwent cesarean delivery of both twins, 1% had combined vaginal–cesarean deliveries, and 9% delivered both twins vaginally. In the planned-vaginal group, 40% of women underwent cesarean delivery of both twins, 4% had combined vaginal–cesarean deliveries, and 56% delivered both twins vaginally; 68% of cesarean deliveries in this group were performed during labor. Rates of fetal and neonatal adverse outcomes were similar in each group (2% of women). The nonpresenting twin was more likely to suffer an adverse outcome regardless of planned delivery mode. Maternal adverse outcomes were similar between groups (range, 7%–8%).

Comment

The results of this expertly conducted study are highly important. We can and should offer trial of labor to women with twin pregnancies and cephalic-presenting fetuses, assured of the relative safety of this approach. Nonetheless, the significant proportion of participants in the planned-vaginal group who underwent cesarean delivery for one or both twins is worth noting; these outcomes are important to convey. Women's preferences for vaginal or cesarean delivery should be assessed antenatally — and to reliably meet these preferences, we must train obstetric care providers to perform twin vaginal births with proficiency and confidence.

  • Disclosures for Allison Bryant, MD, MPH at time of publication Nothing to disclose

Citation(s):

Reader Comments (1)

MARTIN BRODER Physician, Cardiology, Baystate Medical Center

Very interesting - glad to see an important OB article in the NEJM

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