Mode of birth in twins: data and reflections

Area of Science:

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

Background:

• The safety of planned vaginal birth versus planned caesarean section (CS) for twin pregnancies beyond 32 weeks gestation remains a topic of debate.
• Previous large randomized trials suggest no added safety benefit for planned CS in lower-risk twins, yet CS rates continue to rise globally.
• Understanding outcomes and identifying factors influencing delivery mode decisions are crucial for optimizing care in twin pregnancies.

Purpose of the Study:

• To compare neonatal and maternal outcomes between planned vaginal birth and planned caesarean section (CS) in twin pregnancies beyond 32 weeks gestation.
• To validate findings from previous studies in a real-world clinical setting and explore reasons for increasing CS rates in twin births.
• To provide insights and suggestions for maintaining a sensible minimum rate of CS for twin pregnancies.

Main Methods:

• Retrospective cohort study including 534 sets of twins delivered at ≥32 weeks gestation.
• Participants were divided into two groups: planned vaginal birth (n=401) and planned caesarean section (n=133).
• Comparison of composite adverse perinatal outcomes (perinatal mortality, neonatal morbidity) and composite maternal adverse outcomes (hemorrhage, trauma, infection).

Main Results:

• No significant differences were observed in composite adverse perinatal outcomes between the planned vaginal birth and planned CS groups.
• Similarly, no significant differences were found in composite adverse maternal outcomes between the two delivery groups.
• The study's findings align with larger studies, indicating no clear safety advantage for planned CS in this population.

Conclusions:

• This study provides external validation for encouraging planned vaginal birth in low-risk twin pregnancies beyond 32 weeks gestation.
• Rising caesarean section rates for twin births are not supported by evidence of improved maternal or neonatal outcomes and may erode essential clinical skills.
• There is a need for improved training for obstetricians in conducting vaginal twin births and for addressing non-evidence-based factors influencing delivery mode decisions.