Factors and Perinatal Outcomes Associated With Intrapartum Cesarean Delivery in Twin Gestations

To evaluate demographic, pregnancy, and labor characteristics and perinatal outcomes related to intrapartum cesarean delivery in twin gestations.

We conducted a population-based retrospective cohort study of twin pregnancies using natality data from the National Center for Health Statistics in the United States from 2018 to 2023. Women who attempted vaginal delivery for twin pregnancy after 35 weeks of gestation were included. The primary outcome was intrapartum cesarean delivery for one or both twins. Multinomial and binary logistic regression models were used to explore factors related to intrapartum cesarean delivery. In secondary analyses, we compared perinatal outcomes between twin pregnancies with intrapartum cesarean delivery and those with successful vaginal delivery.

A total of 69,172 participants with twin gestations were included. The rate of intrapartum cesarean delivery for one or both twins was 25.0% (95% CI, 24.6-25.3%), with 16.6% of participants undergoing intrapartum cesarean delivery for both twins and 8.4% for the second twin (combined delivery). The factors most strongly associated with intrapartum cesarean delivery for both twins and combined delivery included previous cesarean delivery (adjusted odds ratio [aOR] 3.27, 95% CI, 3.00-3.55) and nulliparity (aOR 2.55, 95% CI, 2.44-2.66) compared with vaginal delivery of both twins. In secondary analyses, compared with vaginal delivery of both twins, intrapartum cesarean delivery was most strongly associated with maternal transfusion (1.2% vs 2.9%, aOR 1.98, 95% CI, 1.71-2.30 with cesarean delivery of both twins; 1.2% vs 3.0%, aOR 2.53, 95% CI, 2.13-3.01 with combined delivery), maternal intensive care unit admission (0.1% vs 0.5%, aOR 2.96, 95% CI, 2.02-4.33 with cesarean delivery of both twins; 0.1% vs 0.5%, aOR 3.51, 95% CI, 2.28-5.41 with combined delivery), and Apgar score lower than 7 at 5 minutes (1.9% vs 5.1%, aOR 2.44, 95% CI, 2.20-2.71 with combined delivery).

Intrapartum cesarean delivery in twin gestations was more prevalent than previously reported and was associated with adverse perinatal outcomes. The factors associated with intrapartum cesarean delivery in twin pregnancies may assist in decision making regarding attempted vaginal delivery.