Twin vaginal delivery: innovate or abdicate

Area of Science:

• Obstetrics and Gynecology
• Maternal-Fetal Medicine
• Neonatal Care

Background:

• Renewed interest in vaginal twin delivery, particularly for noncephalic second twins, driven by safety data and national guidelines.
• Rising cesarean delivery rates for twins and declining operative obstetrics skills raise concerns about provider competency in vaginal twin birth.
• Providers are identified as key stakeholders in increasing rates of vaginal twin delivery.

Purpose of the Study:

• To explore potential barriers among practicing obstetricians to the vaginal birth of twins, with a specific focus on delivering the noncephalic second twin.
• To assess provider familiarity with recent safety data and their alignment with current society guidelines regarding twin vaginal birth.
• To identify factors influencing provider preference for breech extraction and the perceived need for additional training.

Main Methods:

• A survey was conducted among practicing obstetricians to investigate barriers to vaginal twin delivery.
• The survey focused on the delivery of the noncephalic second twin and explored provider training, practice environment, and familiarity with recent trial data.
• Statistical analyses were performed to identify associations between provider characteristics, training, guideline adherence, and preference for breech extraction.

Main Results:

• Only 57% of 107 surveyed providers would perform a breech extraction for a noncephalic second twin.
• Providers preferring breech extraction were more likely to have maternal-fetal medicine training, be in academic practices, and work in high-volume twin delivery centers.
• Familiarity with the twin vaginal birth safety trial did not correlate with a preference for breech extraction, but agreement with guidelines did.
• A significant proportion of providers (46%) perceived a need for more training, and this was associated with a lower likelihood of preferring breech extraction.

Conclusions:

• Current scientific evidence and societal opinions alone are insufficient to reverse the national trend towards cesarean delivery for twins.
• Implementation of provider training and support programs is critical to enhance skills and confidence in performing vaginal twin births.
• Novel, provider-focused strategies are necessary to preserve and advance the skills required for vaginal twin delivery for current and future obstetricians.