Outcome of Twins Delivery; Predictors for Successful Vaginal Delivery: A Single Center Experience

Abstract

The aim of this study was to compare maternal and neonatal outcome of twin births according to mode of delivery and to isolate the factors predicting a successful vaginal delivery and those predicting a failed trial of labor (TOL) leading to an emergent cesarean section. We reviewed all twin deliveries during the years 1995 to 2004. Parameters studied include maternal age, parity, gestational age, maternal antepartum complications and postpartum complications, fetal presentations, birthweight, mode of delivery of each twin, Apgar scores and cord pH. During the study period there were 40,710 deliveries of which 804 (1.9%) were twin deliveries. Of the 804 twins, 398 (49.5%) had planned cesarean sections (PCS) and 406 (50.5%) entered a TOL. Maternal age and parity were similar among the groups. Neonatal outcomes and postpartum complications did not differ between the groups. Of 406 women who had a TOL, 84.9% eventually delivered both twins vaginally. A significantly higher percentage of antepartum complications were noted among those who failed the TOL compared to those with successful TOL (8.2% vs. 1.7%, p = .01). The number of neonates with pH of less than 7.0 did not differ between the groups although more neonates (2.5% vs. 0.4%, p = .05) among the failed TOL had an Apgar score of less than 7.0 at 5 minutes compared to successful TOL. Vaginal delivery of both twins after TOL occurred in 91% of vertex/vertex compared with 71.8% of vertex/nonvertex presenting twins (p < .01). Neonatal outcomes did not differ between both groups. Our results indicate that both vaginal and PCS are comparable options for vertex presenting first twin regardless of second twin presentation.

Risk factors of unsuccessful vaginal twin delivery

“…After multivariate analysis, independent risk factors of CS were nulliparity and non‐cephalic presentation of the second twin. Of these, nulliparity showed the strongest relation to unsuccessful vaginal twin delivery, as has previously been reported 17‐22 …”

“…Of these, nulliparity showed the strongest relation to unsuccessful vaginal twin delivery, as has previously been reported. [17][18][19][20][21][22] Although a non-cephalic second twin was found to be an independent risk factor of CS, as many as 76.1% of the C/NC group cases achieved vaginal birth and perinatal outcomes were comparable in the C/C and C/NC groups. Therefore, in the light of these results, TOL can be a favorable option for twin pregnancies with a non-cephalic second twin if the parturient is oriented towards TOL.…”

“…Further, with cephalic‐presenting twin pairs, TOL was planned for 89.3% and VD was successful in 82.8% of these cases. Other studies have also searched for risk factors of failed TOL among twin pregnancies, but in those studies the TOL rate was much lower, ranging between 43.1% and 50.5% 17,19,20,22 …”

Cesarean Section for the Second Twin: A Population‐Based Study of Occurrence and Outcome

“…A randomized controlled trial conducted in the 1980s that investigated planned vaginal birth versus cesarean section for vertex‐nonvertex twins showed that the outcome of the second twin was not significantly affected by mode of delivery . These findings have been supported by others, concluding that morbidity and mortality are not significantly different when comparing vaginal and cesarean delivery of vertex‐nonvertex twins, except when the first twin is in breech position .…”

Outcome of planned vaginal delivery of twins

“…This study showed 67% of breech twins were delivery via emergency CS, a higher rate than that expressed in other studies 12. A larger randomized study is necessary to justify a policy of routine elective CS delivery of twins.…”