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Delivery of the term twin

https://doi.org/10.1016/j.bpobgyn.2004.04.010Get rights and content

Abstract

The ever-increasing incidence of twin pregnancies world wide, together with the increasing trend to caesarean delivery, has resulted in intense scrutiny of the most appropriate method of twin delivery. The term twin has an increased risk of twin mortality compared to term singletons and this might be a result of the increase risk of labour and delivery compared to that of singletons. There are three ways to address this from the literature. The first is to compare outcome for the second twin versus the first twin, and to compare these outcomes in those twins delivered vaginally compared to those delivered by lower section caesarean section (LSCS). The second is to compare outcomes for twins delivered vaginally and for those delivered by caesarean section (CS). These data show higher rates of adverse perinatal outcome for the twin at or near term if delivery is vaginal versus CS. The third method is to compare outcomes for twins delivered by planned vaginal birth (VB; actual VB plus emergency CS) versus planned CS. This chapter will review this data thus outline an ongoing randomized controlled trial—the Twin Birth Study.

Section snippets

What is the risk of adverse perinatal outcome in twins at 32 weeks or more?

The risk of death for twins has decreased over time in Canada but still continues to be high.7 Table 1 shows not only that the risk is appreciable but that over the past 10 years this risk has not decreased at the same rate in more mature twins (34–37 weeks) as in aged 32–34 weeks. This implies that whereas our neonatal colleagues are improving the results of more premature infants, the obstetricians are not making similar inroads in fetal loss.

The next piece of sobering information for

The risk of stillbirth in term twins

There is now overwhelming cohort and epidemiological data demonstrating the increase risk of stillbirth in twins more than 37–38 weeks gestation compared to that of singletons.17., 18., 19., 20., 21., 22.

In the absence of a randomized controlled trial (RCT) but extrapolating from the RCT addressing the management of post-term singletons, many authorities, including the International Society for Twin Studies and the SOGC, now recommend delivery before the end of the 38th week of gestation.23

What is the evidence that a policy of planned CS might be beneficial for twins at or near term?

There are three ways of addressing this from the literature. The first is to compare the outcome for the second twin versus first twin and then to compare these outcomes in those twins delivered vaginally with those delivered by LSCS. In a recent study of 1305 twin pairs delivered between 1988 and 1999 in Nova Scotia, in which second-born twins were compared to the first-born twins at ≥1500 g birth weight, the risk of adverse perinatal outcome (intrapartum fetal death, neonatal death,

Where do we go from here?

It seems that many of physicians are in equipoise on this most fundamental of all aspects of twin research: What is the best way to deliver twins?

In 2001, Hutton undertook a survey of Canadian practitioners to determine their views toward different delivery options for twins.29 Most respondents indicated that for twins at 32 or more weeks gestation in which twin A was vertex, they would usually recommend a planned VB, with the recommendation of planned VB being as high as 100% for the

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    Copyright © 2004 Elsevier Ltd. All rights reserved.