A new study concludes that planned cesarean section (SC) delivery is no better than with planned vaginal birth (VB) for twins, when the first baby is in a good position.

Researchers at Sunnybrook Health Sciences Centre (Toronto, Canada) and other institutions conducted a trial involving 2,804 women from 26 countries randomized to planned induced VB or planned CS of twins at 32-38 weeks' gestation; only those with the first twin situated head first, and both weighing 1,500–4,000 gram by ultrasound within a week of randomization were included. Centers had to have emergency cesarean available and participating practitioners had to be vouched as skilled at vaginal twin delivery. The primary composite endpoint was perinatal or neonatal mortality or serious neonatal morbidity.

The results showed that death or serious neonatal morbidity occurred in 2% of cases, irrespective of how the birth was planned. The second twin to be delivered had a poorer outcome than the first, but there was no interaction with treatment group. The planned CS group had some crossover to VB (9%), while 40% of the planned VB ended up as CS delivery for both twins, and 4% got vaginal delivery of one and cesarean for the other. None of the components showed a significant difference, but there tended to be more bone fractures in the planned VB group. The study was presented at the Society for Maternal-Fetal Medicine (SMFM) annual meeting, held during February 2013 in San Francisco (CA, USA).

“Skill at operational vaginal birth is considered a fading art, as many of the newer generation of obstetricians haven't been trained in it, but vaginal twin delivery is still common enough a skill that it shouldn't be a barrier to applicability of the results in the community,” concluded lead author Jon Barrett, MBBch, MD, and colleagues. “The data I think will preserve the art and skill of operative vaginal delivery and will serve all of us as a warning lesson that before we trend to what is seemingly an easier and safer option, cesarean section, we should think twice.”

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Sunnybrook Health Sciences Center