At this moment, I am supporting and serving women in Okinawa, Japan. And, in the past couple months, I have encounter and met a great number of women who are currently pregnant with multiples. In fact, it is an honor and a joy to serve a sweet friend and very strong woman who is one of those mommies expecting twins. Likewise, I strongly consider that education, knowledge and research it is one of the greatest ways to advocate for ourselves and speak aloud about our rights. So, I wanted and dedicated time to research and to find evidence about pregnancy with multiples.
In the article, "An Evidence-Based Approach to Determining Route of Delivery for Twin Gestations," the Department of Obstetrics and Gynecology from Northwestern University and Feinberg School of Medicine, and the Department of Obstetrics and Gynecology from Indiana University School of Medicine, considered that "although delivery may take place due to iatrogenic or spontaneous etiologies -no matter what the indication- optimizing the route of delivery for twins is an important component of care that must be thoughtfully considered." Moreover, they acknowledged that "there is considerable controversy about the intrapartum management of twin pregnancies, which is due primarily to an absence of well-designed clinical trials and to conflicting recommendations in the literature."
METHOD OF DELIVERY: PLANNED CESAREAN VS. PLANNED VAGINAL DELIVERY
Consequently, they questioned "which route of delivery is preferred?" and in their review they found, "if the presenting twin is cephalic, the option of vaginal delivery must be contemplated." Likewise, they said, "if the second twin presents cephalic, one may allow the fetal head to descend into the pelvis." Moreover, they also emphasized that: "when choosing the vaginal route, one must be prepared for the second twin to change position after delivery of the first. [And,] the second twin experiences positional change in approximately 20% of twin planned vaginal deliveries."
Nevertheless, they considered that the evidence also suggests, "if the second twin’s presentation be breech or oblique -or should the obstetrician opt to deliver the fetus in a non-cephalic presentation in an attempt to expedite the remainder of the second stage- two additional options exist for vaginal delivery: external cephalic version (ECV) followed by vaginal delivery or internal podalic version followed by breech extraction." But, "if neither ECV followed by vaginal delivery nor internal podalic version followed by breech extraction is successful, then a cesarean delivery should be performed. [And,] when the first twin is delivered vaginally and the second by cesarean, it is called a combined delivery."
Note: According to the Farlex Partner Medical Dictionary, Internal Podalic Version is the"maneuver to deliver the fetus by inserting a hand
into the uterine cavity, grasping one or both feet, and drawing the through the cervix; rarely indicated today except for the delivery of a
second twin."
FINDINGS ON EXTERNAL CEPHALIC VERSION AND INTERNAL PODALIC VERSION
Although it is an old study, these group of researches mentioned it. In 1989, Stephen Gocke and colleagues, retrospectively evaluated 136 sets of vertex-nonvertex twin deliveries. This means they studied the presentation of any part of the fetal head, and they found that "when internal podalic version and breech extraction was performed as the first attempt, successful vaginal delivery occurred in 96% of patients."
On the other side, they also found that "when ECV was performed as the primary delivery attempt, successful vaginal delivery occurred in only 46% of patients. [And,] combined delivery occurred for 39% of the patients who underwent ECV first in contrast to a 4% combined delivery rate for those twins in which breech extraction was initially attempted"
WHAT IMPLICATIONS OF COMBINED DELIVERY DO THEY FOUND?
In this gynecology and obstetrics' review, they mentioned that "in 2008, the Maternal Fetal Medicine Unit (MFMU) compared twins delivered by combined delivery with twins delivered by cesarean. [And,] the review noted that, although endometritis was more common in the combined delivery group, the finding was not statistically significant (odds ratios) [... Moreover,] the article also evaluated neonatal outcomes and found no difference with respect to umbilical artery cord gas pH, Apgar scores, seizures, intraventricular hemorrhage, hypoxic ischemic encephalopathy, or neonatal death." Finally, it is mentioned that "the primary adverse outcome of a combined delivery in comparison with vaginal delivery may be limited to an increased risk of puerperal infection. [And other,] adverse outcomes related to combined delivery include the increased postoperative recuperation time and the impact on future pregnancies resulting from cesarean delivery."
SO, WHAT ARE THE GUIDELINES?
As it is mentioned in this review, "the American Congress of Obstetricians and Gynecologists (ACOG) suggests that individual obstetricians recommend the best route for their patients: “The route of delivery for twins should be determined by the position of the fetuses, the ease of fetal heart rate monitoring and the maternal and fetal status.”
Additionally, they mentioned the Cochrane Database reviewed where the one randomized trial on mode of delivery for twins, "concluded that cesarean delivery should not be universally adopted as the route of delivery for twins. [And,] therefore, the question [should persist]: is there a preferred delivery method for twins?
WHAT ABOUT PRE-TERM AND LATE-TERM TWINS
This review also highlights that "perinatal outcome is perhaps the most important concern when choosing the preferred route of delivery for twin gestations." And they mentioned, "proponents of planned cesarean delivery of late preterm and term twins often cite the same four studies. However, they also said, "absolute numbers suggested that planned cesarean delivery may be beneficial, but the study was not adequately powered to show this benefit." In fact, they brought up "a study from Nova Scotia that examined perinatal outcomes in twins at 34 weeks of gestation or longer between vaginal delivery of both twins versus cesarean delivery with no labor found a relative risk of 2.57 (1.16–5.72) for a composite adverse outcome with vaginal delivery."
What other studies did they mention?
These group of scholars mentioned several other studies about pre-term and late-term twins.
A. They said that "Rabinovici and coworkers performed the only randomized, controlled trial addressing the question of perinatal outcome for twins based on route of delivery. The study included a total of 60 pregnancies at a gestational age of 35 weeks or longer. All women carried vertex-nonvertex twins. Thirty-three women were randomized to planned vaginal delivery, whereas 27 were randomized to cesarean delivery. The study found no statistically significant difference in any neonatal outcome including Apgar scores, birth trauma, neonatal death, or combined delivery. Maternal febrile morbidity was significantly higher in the cesarean delivery group (40% vs 11%)."
B. They mentioned Hogle and colleagues's meta-analysis of four trials: the Rabinovici trial and three retrospective, cohort studies. "The study goal was to determine if planned cesarean delivery was preferable to planned vaginal delivery and incorporated pooled ORs including perinatal, neonatal, and maternal outcomes. Although all analyses dealing with vertex-presenting first twins favored vaginal delivery, the ORs all crossed 1." So,"no statistically significant findings were uncovered."
C. They referenced the Mount Sinai Hospital in New York, where "287 mothers carrying twin gestations with breech second twins heavier than 1500 g were allowed to choose their route of delivery. Deliveries were performed by one of six attending obstetricians, and active management of the second stage was used. Results showed that 54.7% of patients chose cesarean delivery and 45.3% of patients chose vaginal delivery. No patients required a combined delivery."
D. They also indicated another study done at the Medical University of South Carolina, "84 vertex-nonvertex pregnancies greater than 35 weeks of gestation were analyzed with respect to method of delivery and cost. Three groups were evaluated: Group A, consisting of spontaneous vaginal delivery of the first twin and breech extraction of the second twin; Group B, consisting of spontaneous vaginal delivery of the first twin and external cephalic version of the second twin; and Group C, in which both twins underwent cesarean delivery. All patients in Group A delivered vaginally. Eleven of 19 patients in Group B delivered by combined delivery. When examining neonatal outcomes, researchers found that neonates in Group A had significantly fewer pulmonary complications than infants in Groups B or C."
So, after reviewing all these different studies they concluded that "there is an abundance of additional observational data with several hundreds of subjects that unanimously supports the safety of vaginal delivery of the non-vertex second twin by demonstrating improved or equal neonatal outcomes compared with cesarean delivery."
"For the delivery of term and late preterm twins, in situations where the presenting twin is vertex and the second twin is either vertex or non-vertex, there is a substantial body of evidence supporting planned vaginal delivery. It is important to note that almost every study lacked randomization. Nevertheless, when physicians with training in breech extractions are combined with an appropriate and willing patient, in most instances, a vaginal delivery can be performed successfully and safely for both mothers and infants."
WHAT ABOUT DISCORDANT TWINS?
Discordant Twins means that one twin shows a marked difference in size. However, according to this review and "based on the retrospective data available, twin discordance does not represent a contraindication to a vaginal trial of labor, even if the larger twin is the non-presenting twin. From the published data, weak evidence may support consideration of cesarean delivery in extremes of discordance. From a practical standpoint, this may apply when the second twin is approximately ≥40% larger than the presenting co-twin, although even in cases of extreme discordance, the overall contribution of discordant twins to the outcome of combined delivery is minimal."
DO WE HAVE THE RIGHT OF TRIAL OF LABOR AFTER CESAREAN DELIVERY (TOLAC)?
YES, women have the right to try! The article mentioned three independent studies that have evaluated a trial of labor after cesarean (TOLAC) in women carrying twins. They mentioned, "Data from the MFMU’s Cesarean Registry evaluated 412 women, of whom 186 chose a trial of labor; 64.5% successfully delivered vaginally, also known as a vaginal birth after cesarean (VBAC). Of women who failed a trial of labor, 45% underwent a combined delivery;" Now, as I am looking for more and recent studies, it is important to remember that this statistics are from 2005.
Furthermore, a similar study it is also mentioned where "33 6555 mothers with twin gestation were included, 1850 of whom opted for TOLAC. The rate of uterine rupture was 0.9% for women undergoing TOLAC. Successful VBAC occurred in 45.2%. The third study included data from 17 different centers in the northeastern United States. This study compared mothers undergoing TOLAC with twins to mothers undergoing TOLAC with singletons. Results showed women with twin gestation and previous cesarean delivery were less likely to choose a trial of labor. When TOLAC was chosen, VBAC occurred equally among women with twins and women with singletons."
WHAT DID THEY CONCLUDE?
As you might imagine this reviewed was long since it included several different studies, reviews and literature available at the time. And, after analyzing, reading and studying all of that information, the authors of "An Evidence-Based Approach to Determining Route of Delivery for Twin Gestations," concluded:
1. The best method by which to deliver pregnancies in which only the presenting twin is cephalic remains controversial.
2. Evidence supports a vaginal trial of labor in late preterm and term twins.
3. Routes of delivery for preterm twins lighter than 1500 g remains unclear, with compelling data for both planned cesarean and planned vaginal delivery.
4. No data support planned cesarean for birthweight discordance alone.
5. Risks of TOLAC for women with twins appear similar to risks for women with singletons particularly for those who successfully undergo VBAC.
Finally, this article gives two pieces of advice for our health care providers and community. First, "obstetricians need to be prepared for, and skilled in, breech extraction of the second twin." And second, "individualized patient counseling with regard to mode of delivery is important when offering a vaginal trial of labor to women with a twin gestation."
I truly hope this post can help and can provide good information for women who are currently pregnant with twins or for other doulas supporting twin pregnancies. Remember that you are your number one advocator, and the knowledge that you can acquire is your greatest tool.
Blessings,
Dayana Harrison Birth Services
Disclamer: All the information in this publication is strictly for informational purposes only and should not be taken as medical advice, therefore the information provided by this or another publication is not a substitute for a visit or consultation with your healthcare provider, and should not be interpreted as medical advice. All the information in this publication and on this page have the strict and only intention to clarify, share and offer information. At the same time, the content comes from different articles which can be found at the end of each publication in the respective list of references. Finally, I want to clarify that I have no commercial or personal relationship with the authors of the articles mentioned. And if in any case, you have other experiences, questions and so on, please leave a comment so I can help you with any questions you may have, or write me at dhbirthservices@gmail.com.
REFERENCES
Christopher, Diane, Barrett K Robinson, and Alan M Peaceman. “An Evidence-Based Approach to Determining Route of Delivery for Twin Gestations.” Reviews in Obstetrics and Gynecology 4.3-4 (2011): 109–116. Print.
Houlihan C, Knuppel RA. Intrapartum management of multiple gestations. Clin Perinatol. 1996;23:91–116.
Hogle KL, Hutton EK, McBrien KA, et al. Cesarean delivery for twins: a systemic review and meta-analysis. Am J Obstet Gynecol. 2003;188:220–227.
Fox NS, Silverstein M, Bender S, et al. Active second-stage management in twin pregnancies undergoing planned vaginal delivery in a U.S. population. Obstet Gynecol. 2010;115:229–233.
"internal podalic version." Farlex Partner Medical Dictionary. 2012. Farlex 15 Mar. 2018 https://medical-dictionary.thefreedictionary.com/internal+podalic+version
Varner MW, Leindecker S, Spong CY, et al. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network, authors. Maternal-Fetal Medicine Unit cesarean registry: trial of labor with a twin gestation. Am J Obstet Gynecol. 2005;193:135–140.