Factors predicting primary cesarean delivery and successful vaginal delivery in twin pregnancies: Does structured obstetric management play a role in the delivery mode and neonatal outcome?

Abstract

Purpose While the optimal delivery method of twin pregnancies is heavily debated, the rate of cesarean deliveries is increasing. This retrospective study evaluates delivery methods and neonatal outcome of twin pregnancies during two time-periods and aims to identify predictive factors for the delivery outcome. Methods 553 twin pregnancies were identified in the institutional database of the University Women’s Hospital Freiburg, Germany. 230 and 323 deliveries occurred in period I (2009–2014) and period II (2015–2021) respectively. Cesarean births due to non-vertex position of the first fetus were excluded. In period II, the management of twin pregnancies was reviewed and adjusted and systematic training and standardized procedures were implemented. Results Period II showed significantly lower rates of planned cesarean deliveries (44.0% vs. 63.5%, p < 0.0001) and higher rates of vaginal deliveries (68% vs. 52.4%, p = 0.02). Independent risk factors for primary cesarean delivery were period, maternal age > 40 years, nullipara, previous cesarean birth (HR:11.3, p < 0.001), gestational age < 37 + 0th weeks, monochorionicity and higher fetal weight difference. Predictive factors for successful vaginal delivery were previous vaginal delivery, gestational age between 34–36 weeks and vertex/vertex presentation of the fetuses. The neonatal outcome in period I and period II were comparable. Planned cesarean delivery showed significantly higher rates of NICU transfer. Conclusion Vaginal labor in twin pregnancies is safe. Structured and regular updates of obstetrical concepts and procedures in obstetric departments are key to increase vaginal deliveries without impairing its safety. To reduce elective cesarean deliveries, prevention of the first cesarean birth seems to be most promising.