Cost-effective delivery management of the vertex and nonvertex twin gestation

The aim of the study was to determine the most cost-effective delivery management of vertex and nonvertex twin pair gestations.

Two hundred sixty-six consecutive twin gestations were followed up prospectively in a special antepartum Twins Clinic directed by the Maternal-Fetal Medicine Division. Maternal demographic, obstetric, and neonatal data were compiled prospectively. Information regarding 84 vertex and nonvertex twin pair gestations was extracted for review. Comparison groups included 41 twin pairs managed by spontaneous vaginal delivery and breech extraction (group A), 19 twin pairs managed by spontaneous vaginal delivery and external cephalic version (group B), and 24 twin pairs managed by primary cesarean delivery (group C). In-hospital financial data were retrieved and adjusted for inflation to 1996 constant dollars (data from a single institution allow comparison of charges). The Kruskal-Wallis chi2 test, the Fisher exact test, and analysis of variance were used for statistical analysis.

The 3 groups did not differ with respect to maternal demographics, medical complications, gestational age, birth weight, fetal sex, or intrauterine growth restriction. Maternal and neonatal hospital charges were both significantly lower (P = .01 and P = .0001, respectively) in the breech extraction group A ($5890 +/- $2304 and $3526 +/- $5017, respectively) than in either group B ($8638 +/- $4175 and $11,754 +/- $15,457, respectively) or group C ($7,608 +/- $3,256 and $36,994 +/- $54,318, respectively). Although maternal morbidity was similar among the 3 groups, length of stay was shorter for mothers in group A. The infants delivered by spontaneous vaginal delivery and breech extraction (group A) had significantly lower rates of pulmonary disease (7% vs 24% vs 31% for groups A, B, and C, respectively; P = .002) and neonatal infectious disease (1% vs 0% vs 16%; P = .0005). These infants required the use of a ventilator less frequently (5% vs 12% vs 24%; P = .01), were more likely to be admitted to the normal newborn nursery (71% vs 51% vs 50%; P = .0001), and had a significantly shorter length of hospitalization (4.8 vs 12.4 vs 17.8 days; P = .0001).

There is no medical consensus regarding delivery management for vertex and nonvertex presenting twin pairs. When hospital charges are examined with clinical data, however, breech extraction of the nonvertex second twin is the most cost-effective delivery management strategy.