The worst of both worlds—combined deliveries in twin gestations: a subanalysis of the Twin Birth Study, a randomized, controlled, prospective study

Aviram, Amir; Lipworth, Hayley; Asztalos, Elizabeth; Mei‐Dan, Elad; Cao, Xingshan; Melamed, Nir; Zaltz, Arthur; Anastasio, Hannah; Berghella, Vincenzo; Barrett, Jon

doi:10.1016/j.ajog.2019.06.047

Cited by 19 publications

(18 citation statements)

References 13 publications

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“…Our rate of combined delivery is in agreement with previous retrospective data and recent sub-analyses of the TBS, concluding that non-cephalic presentation of the second twin is a strong risk factor for combined delivery. [24][25][26][27] Unlike the outlined studies, we also described that this adverse event was associated with an extended second stage of labor. Taken together, and acknowledging that the majority of women who crossed the 2 h point will ultimately experience a vaginal delivery, we suggest that 2 h into the second stage should be considered as a point in time that requires reassessment of labor progression, and as a consequence a shared decision about the recommended mode of delivery.…”

Section: Discussionmentioning

confidence: 69%

The impact of prolonged second stage in twins on perinatal outcomes

Zidan

Saad

Siegler

et al. 2021

Intl J Gynecology & Obste

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Objective To assess the duration of the second stage of labor in twin pregnancies in relation to maternal and neonatal outcomes. Methods A retrospective study between 2014 and 2020. Eligible cases were twin pregnancies that reached the second stage. The pre‐defined groups were based on the total time spent in the second stage of labor; Group 1 (<1 h), group 2 (1–2 h), and group 3 (>2 h), which was considered the prolonged second stage group. Results Among the 439 planned vaginal births, successful vaginal delivery of both twins was achieved in 63.8%. Prolonged second stage was observed in 25.8% (89/345). Nulliparity (odds ratio [OR] 7.72, 95% confidence interval [CI] 4.5–13.4) and use of epidural analgesia (OR 5.45, 95% CI 1.2–24.7), were the only independent variables significantly associated with prolonged second stage. Prolonged second stage was associated with a greater risk of intrapartum cesarean delivery (32.6%, P < 0.001), combined delivery (10.1%, P < 0.001), chorioamnionitis (8.3%, P = 0.006) and a admission to neonatal intensive care unit of at least one of the twins (30.3%, P = 0.02). Conclusion Prolonged second stage of labor affects maternal and fetal outcome in twin pregnancies.

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Section: Discussionmentioning

confidence: 69%

The impact of prolonged second stage in twins on perinatal outcomes

Zidan

Saad

Siegler

et al. 2021

Intl J Gynecology & Obste

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“…[35][36][37] A recent subanalysis of the Twin Birth Study had a conversion rate of 7%, similar to that of our institution which we used in our basecase scenario. 13 Very few cost-effectiveness analyses have been performed on twin VDs, especially analyzing delivery in the LDR versus OR. One prior study from Mauldin et al in 1998 analyzed delivery management of a nonvertex second twin and found that breech extraction of the second twin was more cost effective than external cephalic version or primary CD.…”

Section: Discussionmentioning

confidence: 99%

Twin Vaginal Deliveries in Labor Rooms: A Cost-Effectiveness Analysis

et al. 2021

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Objective Twin vaginal deliveries (VDs) are often performed in the operating room (OR) given the theoretical risk of conversion to cesarean delivery (CD) for the aftercoming twin. We aim to evaluate the cost-effectiveness of performing VDs for twin gestations in the labor and delivery room (LDR) versus OR. Study Design We conducted a cost-effectiveness analysis using a decision-analysis model that compared the costs and effectiveness of two strategies of twin deliveries undergoing a trial of labor: (1) intended delivery in the LDR and 2) delivery in the OR. Sensitivity analyses were performed to assess strength and validity of the model. Primary outcome was incremental cost-effectiveness ratio (ICER) defined as cost needed to gain 1 quality-adjusted life year (QALY). Results In the base-case scenario, where 7% of deliveries resulted in conversion to CD for twin B, attempting to deliver twins in the LDR was the most cost-effective strategy. For every QALY gained by delivering in the OR, 243,335 USD would need to be spent (ICER). In univariate sensitivity analyses, the most cost-effective strategy shifted to delivering in the OR when the following was true: (1) probability of successful VD was less than 86%, (2) probability of neonatal morbidity after emergent CD exceeded 3.5%, (3) cost of VD in an LDR exceeded 10,500 USD, (4) cost of CD was less than 10,000 USD, or (5) probability of neonatal death from emergent CD exceeded 2.8%. Assuming a willingness to pay of 100,000 USD per neonatal QALY gained, attempted VD in the LDR was cost effective in 51% of simulations in the Monte Carlo analysis. Conclusion Twin VDs in the LDR are cost effective based on current neonatal outcome data, taking into account gestational age and associated morbidity. Further investigation is needed to elucidate impact of cost and outcomes on optimal utilization of resources. Key Points

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“…11 Aviram et al did report higher rates of morbidity in twin B as compared with twin A, though they warn that the overall prevalence of adverse outcome was low; thus, caution should be taken in drawing practical implications from these results. 12 Multifetal gestations have been shown to require significantly higher health care resources and cost as compared with singleton pregnancies. 5,23 With the consistent rise of twin pregnancies in recent years, one must consider the costs associated with twin deliveries.…”

Section: Discussionmentioning

confidence: 99%

Rates of Cesarean Conversion and Associated Predictors and Outcomes in Planned Vaginal Twin Deliveries

et al. 2020

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Objective Twin vaginal deliveries (VDs) are often performed in the operating room (OR) given the risk of conversion to cesarean delivery (CD) for the aftercoming twin. We aim to investigate the rates of conversion to CD for planned twin VDs and identify predictors and outcomes of conversion. Study Design A retrospective cohort study of all women who underwent a planned twin VD at two large academic medical centers over 4 years. Demographic and outcome data were chart abstracted. Various statistical tests were used to evaluate the influence of perinatal variables on mode of delivery and identify possible predictors of conversion. Results Eight hundred and eighty-five twin deliveries were identified, of which 725 (81.9%) were possible candidates for VD. Of those, 237 (32.7%) underwent successful VD of twin A. Ninety-five (40.1%) had a nonvertex second twin at time of delivery. Conversion to CD occurred in 10 planned VDs (4.2%). Conversions were higher with spontaneous labor (relative risk [RR]: 2.1; 95% confidence interval [CI] 1.6–2.7; p = 0.003), and having an intertwin delivery interval greater than 60 minutes (RR: 5.1; 95% CI: 2.5–10.8; p < 0.001). Nonvertex presentation of twin B, type of delivery provider, or years out in practice of delivery provider were not significantly different between groups. There were no significant differences in neonatal outcomes between VD and conversion groups. There was a significant association between use of forceps for twin B and successful VD (p = 0.02), with 84.6% in the setting of a nonvertex twin B. Conclusion Successful VD was achieved in planned VD of twins in 95.8% of cases, and there were no significant differences in maternal and fetal outcomes between successful VD and conversion to CD for twin B. With the optimal clinical scenario and shared decision-making, performing vaginal twin deliveries in labor and delivery rooms should be discussed. Key Points

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The worst of both worlds—combined deliveries in twin gestations: a subanalysis of the Twin Birth Study, a randomized, controlled, prospective study

Cited by 19 publications

References 13 publications

The impact of prolonged second stage in twins on perinatal outcomes

The impact of prolonged second stage in twins on perinatal outcomes

Twin Vaginal Deliveries in Labor Rooms: A Cost-Effectiveness Analysis

Rates of Cesarean Conversion and Associated Predictors and Outcomes in Planned Vaginal Twin Deliveries

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