By Will Boggs, MD
NEW YORK (Reuters Health) Feb 10 - Active management during second-stage labor facilitates vaginal delivery of twins, according to a report in the February Obstetrics & Gynecology.
"Vaginal delivery for twins is a safe and reasonable option, even in the setting of a noncephalic presenting second twin," lead author Dr. Nathan S. Fox from Mount Sinai School of Medicine, New York, told Reuters Health by email.
"Active management" included breech extraction of a noncephalic twin and internal version of a nonengaged cephalic twin followed by breech extraction. Dr. Fox and his colleagues note that in their group, the two senior obstetricians had formal training in internal version during their residencies, and these two trained the others.
Out of 287 twin pregnancies in their practice between 2005 and 2009, 157 were scheduled for cesarean section. The current article reports the outcomes of attempted vaginal delivery in the remaining 130 women and compares them to results in the cesarean group.
Rates of the primary outcome - 5-minute Apgar scores below 7 for twin B - were low overall and were not significantly different between the groups.
In addition, there were no significant differences in rates of arterial cord blood pH values below 7.20 for either twin.
Twenty women (15.4%) had a cesarean delivery in labor. The remaining 110 (84.6%) delivered both twins vaginally. No one who had vaginal delivery of twin A had a cesarean delivery for twin B, although twin B required breech extraction in 77 cases (70%).
Only one infant was injured during breech extraction. This baby had a fractured humerus during reduction of a nuchal arm, but without any permanent injury.
Compared to women who had cesarean section in labor, women with successful vaginal deliveries were younger and more likely to have had a prior vaginal delivery.
"Our high vaginal delivery rates are likely due to two factors: patient selection and active management of the second stage of labor," the investigators write.
"Like any medical or surgical procedure, the operator should have proficiency in performing the procedure before offering it to the patient," Dr. Fox told Reuters Health. "In the case of twin delivery, one variable is the presentation of the second twin. If it is breech or transverse, the operator should have skill in breech extraction, or should just probably recommend a cesarean delivery."
"It is important to emphasize, as we did in the article, that this management may not be appropriate in all settings, such as those without 24-hour anesthesia or NICU support," Dr. Fox added.
In an editorial, Dr. Mary E. D'Alton from Columbia Presbyterian Hospital, New York, points out that an international randomized trial, the Twin Birth Study, is underway and that until the results are known, "the mode of delivery of each twin gestation should be determined on an individual basis after objective evaluation of the case characteristics, clinical setting, and operator experience."
She concludes, "The data reported this month by Fox et al. add to existing evidence demonstrating that it is reasonable to recommend vaginal delivery and active management of the second stage for pregnancies with a cephalic-presenting twin and no other contraindication to labor."