Hila Hochler1, Aharon Tevet2, Moshe Barg3, Yael Suissa-Cohen4, Michal Lipschuetz4, Simcha Yagel4, Amir Aviram5, Elad Mei-Dan6, Nir Melamed5, Jon F R Barrett7, Nathan S Fox8, Asnat Walfisch4. 1. Department of Obstetrics and Gynecology, Hadassah Hebrew University Medical Center, Mount-Scopus, Jerusalem, Israel (Drs Hochler, Suissa-Cohen, Lipschuetz, Yagel, and Walfisch). Electronic address: hilahochler@gmail.com. 2. Department of Obstetrics and Gynecology, Hadassah Hebrew University Medical Center, Ein-Kerem, Jerusalem, Israel (Dr Tevet); Department of Obstetrics and Gynecology, Shaare-Zedek Medical Center, Jerusalem, Israel (Drs Tevet and Barg). 3. Department of Obstetrics and Gynecology, Shaare-Zedek Medical Center, Jerusalem, Israel (Drs Tevet and Barg). 4. Department of Obstetrics and Gynecology, Hadassah Hebrew University Medical Center, Mount-Scopus, Jerusalem, Israel (Drs Hochler, Suissa-Cohen, Lipschuetz, Yagel, and Walfisch). 5. Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (Drs Aviram, Mei-Dan, and Melamed). 6. Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (Drs Aviram, Mei-Dan, and Melamed); Department of Obstetrics and Gynecology, North York General Hospital, University of Toronto, Toronto, Ontario, Canada (Dr Mei-Dan). 7. Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada (Dr Barrett). 8. Maternal Fetal Medicine Associates PLLC, New York, NY (Dr Fox); Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY (Dr Fox).
Abstract
BACKGROUND: Maternal and neonatal outcomes of trial of labor after cesarean delivery of twins are similar to those of singleton trials of labor after cesarean delivery. However, previous studies did not stratify outcomes by second-twin presentation on admission to labor. OBJECTIVE: To examine maternal and neonatal outcomes following trial of labor after cesarean delivery in twins with vertex-nonvertex presentation. STUDY DESIGN: A retrospective multicenter study was conducted including data on deliveries occurring between the years 2005 and 2020. We included trials of labor after a previous cesarean delivery (at ≥320/7 weeks' gestation) of twin gestations with a vertex-presenting first twin on admission to labor. The exposed group was defined as deliveries with a nonvertex second twin at admission to labor, whereas the comparison group included deliveries with a vertex second twin at admission. Only parturients who attempted vaginal delivery were included. Cases of prelabor fetal death of either twin or major fetal anomalies were excluded. The primary outcome was uterine rupture. RESULTS: A total of 236 twin trials of labor after cesarean delivery were included, of which 128 involved nonvertex second twins and 108 a second vertex twin. Uterine rupture rates were comparable between the groups (1/128 [0.9%] vs 1/108 [0.8%]; P=1.000). Successful trial of labor after cesarean delivery of both twins occurred in 76.6% of the exposed group vs 81.5% of the comparison group, whereas cesarean delivery of both twins was performed in 21.9% of the exposed group vs 17.6% of the comparison group (P=.418; odds ratio, 1.32; confidence interval, 0.7-2.5). Two cases of cesarean delivery of the second twin occurred in the exposed group and 1 in the comparison group (1.6% vs 0.9%, respectively, P=1.000). There was no difference between the groups in maternal outcomes, including rates of postpartum hemorrhage, blood transfusion, placental abruption, thromboembolic events, and maternal fever. Neonatal outcomes were also comparable between the groups, including rates of intensive care admission and low (≤7) 5-minute Apgar scores. CONCLUSION: Our data show that trial of labor after cesarean delivery of noncephalic second twins holds favorable maternal and neonatal outcomes, comparable with those of vertex-vertex trials of labor after cesarean delivery. Second-twin noncephalic presentation should not discourage parturients and caregivers from considering trial of labor after cesarean delivery if desired.
BACKGROUND: Maternal and neonatal outcomes of trial of labor after cesarean delivery of twins are similar to those of singleton trials of labor after cesarean delivery. However, previous studies did not stratify outcomes by second-twin presentation on admission to labor. OBJECTIVE: To examine maternal and neonatal outcomes following trial of labor after cesarean delivery in twins with vertex-nonvertex presentation. STUDY DESIGN: A retrospective multicenter study was conducted including data on deliveries occurring between the years 2005 and 2020. We included trials of labor after a previous cesarean delivery (at ≥320/7 weeks' gestation) of twin gestations with a vertex-presenting first twin on admission to labor. The exposed group was defined as deliveries with a nonvertex second twin at admission to labor, whereas the comparison group included deliveries with a vertex second twin at admission. Only parturients who attempted vaginal delivery were included. Cases of prelabor fetal death of either twin or major fetal anomalies were excluded. The primary outcome was uterine rupture. RESULTS: A total of 236 twin trials of labor after cesarean delivery were included, of which 128 involved nonvertex second twins and 108 a second vertex twin. Uterine rupture rates were comparable between the groups (1/128 [0.9%] vs 1/108 [0.8%]; P=1.000). Successful trial of labor after cesarean delivery of both twins occurred in 76.6% of the exposed group vs 81.5% of the comparison group, whereas cesarean delivery of both twins was performed in 21.9% of the exposed group vs 17.6% of the comparison group (P=.418; odds ratio, 1.32; confidence interval, 0.7-2.5). Two cases of cesarean delivery of the second twin occurred in the exposed group and 1 in the comparison group (1.6% vs 0.9%, respectively, P=1.000). There was no difference between the groups in maternal outcomes, including rates of postpartum hemorrhage, blood transfusion, placental abruption, thromboembolic events, and maternal fever. Neonatal outcomes were also comparable between the groups, including rates of intensive care admission and low (≤7) 5-minute Apgar scores. CONCLUSION: Our data show that trial of labor after cesarean delivery of noncephalic second twins holds favorable maternal and neonatal outcomes, comparable with those of vertex-vertex trials of labor after cesarean delivery. Second-twin noncephalic presentation should not discourage parturients and caregivers from considering trial of labor after cesarean delivery if desired.