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J Matern Fetal Neonatal Med, Early Online: 17

! 2015 Informa UK Ltd. DOI: 10.3109/14767058.2015.1035640

ORIGINAL ARTICLE

Twin pregnancy outcomes after increasing rate of vaginal twin delivery:

retrospective cohort study in a Hong Kong regional obstetric unit
Hiu Tung Tang, Ah Lai Liu, Sum Yee Chan, Chin Ho Lau, Wai Kuen Yung, Wai Lam Lau, and Wing Cheong Leung

Department of Obstetrics and Gynaecology, Kwong Wah Hospital, Hong Kong

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Abstract Keywords
Objective: To determine any change in adverse neonatal/maternal outcomes after increasing Caesarean delivery, maternal outcome,
the rate of vaginal twin delivery by comparing vaginal twin delivery and caesarean delivery with neonatal outcome, twins, vaginal delivery
our previous cohort study.
Methods: In a retrospective cohort study, all twins booked at a Hong Kong regional obstetrics History
unit were evaluated during a 3-year period from 1 April 2009 to 31 March 2012.
Results: Out of the 269 sets of twins who eventually delivered in our unit, 68 (25.3%) of them Received 1 November 2014
were delivered vaginally, compared to 15.8% in our previous cohort study (p 0.02). For those Revised 8 March 2015
who were suitable for vaginal delivery, significantly more women attempted vaginal delivery: Accepted 26 March 2015
93/133 (69.9%) versus 47/100 (47%) (p 0.0005). The success rate for vaginal delivery and rate Published online 20 April 2015
of requiring caesarean delivery for the 2nd twin were similar between these two periods. There
were significantly more 2nd twins with cord blood pH57.2 when both twins were delivered by
For personal use only.

vaginal delivery. Otherwise, there was no significant difference between other neonatal/
maternal morbidities.
Conclusion: With proper counseling, significantly more women who were suitable for vaginal
twin delivery would opt to do so. There was no significant increase in neonatal/maternal
morbidities despite the increased rate of vaginal twin delivery.

Introduction With the result of our cohort study, our unit from 2010
onwards re-promoted vaginal delivery for uncomplicated twin
With the increasing popularity of artificial reproductive
pregnancies if the first twin was in cephalic presentation.
technique, twin pregnancies occur more frequently now than
A standardized counseling approach for the mode of delivery
in the past, and complicate approximately 23% of all births
was used in a designated twin clinic, along with the addition
[1,2]. They are responsible for 10% of all perinatal mortality
of a labor ward consultant. We subsequently observed a
[3]. Previously several cohort studies have shown a reduced
rebound increase in vaginal twin delivery rate since 2008, and
risk of adverse perinatal outcomes for both twins, or for the
it gradually climbed up to as high as 40% in 2012 (Figure 1).
second twin, when twins at or near term were delivered by
This observation has recently been published in the work by
means of elective caesarean delivery (CD) [47]. However,
Tang et al. [16].
there were also cohort studies, meta-analyses [813], and
In view of this change in the trend of mode of twin
most importantly, a recent multi-centered large randomized
delivery, we decided to have another cohort study subsequent
controlled trial showing the opposite result [14]. Further, our
to our previous cohort in order to study any difference in
unit also did a cohort study evaluating the mode of delivery
pregnancy outcomes after increasing the rate of vaginal twin
and associated pregnancy outcomes of 197 sets of twins
delivery.
booked in our unit during 20062009. A high CD rate (82%)
was observed in our unit. Except for higher frequency of
Materials and methods
sepsis and cord blood acidosis in the 2nd twin delivered
vaginally, there were no significant differences in neonatal This was a retrospective cohort study, reviewing all twin
morbidity between the groups that attempted vaginal delivery pregnancies booked during the 3-year period from 1 April
or requested caesarean delivery [15]. 2009 to 31 March 2012. In our unit, all booked twin
pregnancies were recorded in a twin pregnancy clinic registry
[17]. The pregnancies were then followed up in a specialized
twin pregnancy clinic by a dedicated team of obstetricians and
Address for correspondence: Dr. Hiu Tung Tang, Department of midwives. The team of obstetricians was specialized in
Obstetrics and Gynaecology, N10, Kwong Wah Hospital, Waterloo
Road, Hong Kong. Tel: +852 94961068/+852 35177983. Fax: +852 maternal fetal medicine. Follow-up intervals were guided by
35177149. E-mail: helen.httang@gmail.com the department protocol (available from the corresponding
 2 H. T. Tang et al.
Figure 1. Vaginal delivery rate (%) of Twins
in a regional Obstetric Unit in Hong Kong
(19932012) [13].
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Nyu Medical Center on 06/14/15
author). Ultrasound examinations were performed on mono-
chorionic twins every 23 weeks until 30 weeks of gestation,
and at each visit after 30 weeks. For dichorionic twins,
ultrasound examinations were performed monthly till
30 weeks, and at each visit after 30 weeks. When approaching
term, the responsible obstetrician in the twin clinic discussed
For personal use only.
the mode of delivery with the mother and her partner (if
available). In the absence of other contraindications to a trial
of labor, vaginal twin delivery was considered an appropriate
option for all dichorionic diamniotic(DCDA) and monochor-
ionic diamniotic(MCDA) twin pregnancies if the first twin
was in cephalic presentation, and no previous uterine scar.
Induction of labor would be offered at 3738-week gestation
for MCDA as well as DCDA twins [18,19]. CD was
recommended for all monochorionic monoamniotic(MCMA)
twin pregnancies.
We used the same method in data collection as in our
previous cohort study [15]. Corresponding twin pregnancies
were identified from the twin pregnancy clinic registry.
Antenatal clinical notes, in-patients clinical notes and com-
puter records of the women and their babies were reviewed in
details. Moreover, women who were not booked but delivered
in our unit during that period of time were also identified
through our delivery registry in labor ward. For women who
did not deliver in our unit, they would be contacted upon
defaulting follow-up and their mode of delivery would be
recorded in the clinical notes. Three investigators (HT, SY,
CH) were involved in note review and data collection with
agreement of definition used in data entry to avoid discrep-
ancy during interpretation. A detailed data entry form (which
was similar to that used in previous cohort study) was filled in
for each set of twins. Maternal background information,
including demographic data, medical history, obstetrical
history, type of conception, antenatal and intrapartum com-
plications, fetal presentations, mode of delivery, placental
chorionicity, as well as neonatal and maternal outcomes were
filled in for each set of twins. Neonatal outcomes included
birth weight, gender, gestation at delivery, Apgar scores, cord
blood pH, neonatal intensive care unit (NICU) admission,
J Matern Fetal Neonatal Med, Early Online: 17
birth trauma and neonatal morbidity. Neonatal morbidity was
defined as respiratory morbidity, neurological morbidity,
sepsis, or neonatal jaundice. Respiratory morbidity included
respiratory distress syndrome, transient tachypnoea of the new-
born, apnoea of prematurity, or pneumothorax. Neurological
morbidity included intraventricular hemorrhage. Sepsis
included those with clinical sepsis, cellulitis or necrotising
enterocolitis. Maternal outcomes included blood loss, receipt
of a blood transfusion, having compression sutures or hyster-
ectomy to control postpartum hemorrhage.
Statistical analysis was performed using the SPSS
(Statistical Package for the Social Science Mac Version 22,
Chicago, IL). Differences between categorical variables were
analyzed using the Chi-square test. Differences between
continuous variables were analyzed by independent samples
t-test. p value 50.05 was considered statistically significant.
Logistic regression was used to evaluate the relationship
between education, history of vaginal delivery, type of
conception, chorionicity and presentation of the 2nd twin,
and the mothers choice to attempt vaginal delivery or request
caesarean delivery.
Approval of the study was granted by the local research
ethics committee (Ref no: KW/EX-14-101(75-16)). As this
was a retrospective cohort study and the data were obtained
from patients records, management of patient was not
involved, and thus written informed consent was not needed
in our study.
Result
A total of 317 twins were booked in our unit during 1 April
2009 to 31 March 2012. Six non-booked cases were
identified. Sixteen mothers defaulted our follow up and
cannot be contacted. Eighteen of them delivered in private
hospitals, all by CD. Twenty mothers delivered in other public
hospitals: 4 via vaginal delivery and 16 via caesarean
delivery.
After excluding the 16 twin deliveries who defaulted from
our study, we found that 72 sets of twins (23.5%) were
delivered vaginally, 4 sets of twins involved vaginal delivery
 DOI: 10.3109/14767058.2015.1035640
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Nyu Medical Center on 06/14/15
For personal use only.
Figure 2. Flowchart of the number of twin pregnant mothers who were booked and finally delivered in our unit during 1 April 2009 to 31 March 2012.
of 1st twin and emergency CD of 2nd twin (1.3%). Two-
hundred thirty-one sets of twins (75.2%) were delivered by
CD. Compared to our previous cohort study [15], we noted a
substantial increase in the overall number of twins, and
percentage of vaginal twin deliveries (16.9% versus 23.9%,
p 0.0725).
Two-hundred sixty-nine sets of twins were delivered in our
unit during this period of time. Sixty-eight sets of twins
(25.3%) were delivered by vaginal delivery, and four sets of
twins (1.4%) involved vaginal delivery of first twin and
emergency CD of 2nd twin. One hundred ninety-seven sets
(73.2%) were delivered by CD for both twins. In our previous
cohort study, only 15.8% of twins were delivered vaginally.
A significant increase of vaginal delivery rate was identified
(p 0.0245).
Among those suitable for vaginal delivery, 93 out of 133
mothers (69.9%) attempted vaginal delivery in our current
study, while only 47 out of 100 mothers (47%) attempted
vaginal delivery in our previous cohort (p 0.0005). Success
rate was found to be similar (73.1% versus 70.2%), and risk of
requiring CD for 2nd twin did not significantly increase (4.3%
versus 4.3%) (Figure 2).
Reasons for choosing caesarean delivery were also
evaluated. The most common indications for CD were
Effect of vaginal twin delivery 3
malpresentation of first twin (33.6%) and maternal request
(20.3%). This group of maternal requests received CD, despite
them having the following three conditions which were
suitable for vaginal delivery: (1) DCDA or MCDA twin
pregnancies, (2) the first twin was in cephalic presentation,
and (3) there was no other obstetrics indication to have a CD.
Excluding maternal request and malpresentation, other indi-
cations for CD included intrauterine growth retardation
(14.7%), previous caesarean delivery (3.6%), no progress in
labour (3.6%), pre-eclampsia (3%), and placental praevia
(3%). Intrauterine growth retardation was defined as estimated
fetal weight510th percentile of our local growth chart with or
without abnormal Doppler. We realized that both guidelines
published by ACOG and SOGC suggested that twin preg-
nancy was not a contraindication for attempting vaginal birth
after previous caesarean (VBAC), while RCOG advised
a cautious approach when considering VBAC for twins
[2022]. In our unit, previous CD is still an indication for
repeat CD. However, in our previous cohort study, 32.7% of
caesarean delivery was done purely for maternal request only
(p 0.008).
For those suitable for vaginal delivery, significantly more
multiparous women (p 0.002), and women with second twin
in cephalic presentation (p 0.005) were willing to attempt
 4 H. T. Tang et al. J Matern Fetal Neonatal Med, Early Online: 17

Table 1. Comparison of neonatal outcome between the pregnant mothers (considered suitable for vaginal delivery) who attempted
vaginal delivery and planned caesarean delivery.

Total number (133)

Planned vaginal Planned caesarean
delivery (93) delivery (40)
Yes No Yes No p value
Chorionicity of Twin (Yes MCDA, 26 (27.7%) 58 (62.3%) 5 (12.5%) 32 (80%) 0.045
No DCDA)
1st twin: Mean birth weight (kg) 2.34 (95% CI: 2.242.43) 2.46 (95% CI: 2.342.58) 0.17
2nd twin: Mean birth weight (kg) 2.39 (95% CI: 2.292.49) 2.40 (95% CI 2.292.50) 0.97
1st twin: cord blood pH 57.2 7 (7.5%) 82 (88.2%) 3 (7.5%) 35 (87.5%) 0.984
2nd twin cord blood pH 57.2 13 (14.0%) 78 (83.9%) 2 (5%) 37 (92.5%) 0.324
1st twin AS at 5 min: 4 1 (1%) 92 (99%) 0 (0%) 40 (100%) 0.51
7 2 (2.1%) 91 (97.9%) 0 (0%) 40 (100%) 0.35
2nd twin AS at 5 min: 4 0 (0%) 93 (100%) 0 (0%) 40 (100%) NA
7 1 (1%) 92 (99%) 0 (0%) 40 (100%) 0.51
1st twin NICU admission 8 (8.6%) 85 (91.4%) 0 (0%) 40 (100%) 0.056
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2nd twin NICU admission 9 (9.7%) 84 (90.3%) 1 (2.6%) 39 (93.7%) 0.15

Mean gestation age (week) 35.9 (95% CI: 35.436.5) 36.6 (95% CI: 36.237.1) 0.163
Gestation at delivery 532 7 (7.5%) 86 (92.5%) 0 (0%) 40 (100%) 0.075
1st twin birth trauma 4 (4.3%) 89 (95.7%) 0 (0%) 40 (100%) 0.183
2nd twin birth trauma 2 (2.1%) 91 (97.9%) 0 (0%) 40 (100%) 0.35
1st twin neonatal resuscitation 6 (6.5%) 87 (93.5%) 0 (0%) 40 (100%) 0.1
2nd twin neonatal resuscitation 7 (7.5%) 86 (88.2%) 1 (2.6%) 39 (93.7%) 0.264
1st twin respiratory morbidity 20 (21.5%) 73 (78.5%) 5 (12.5%) 35 (87.5%) 0.223
1st twin sepsis 8 (8.6%) 85 (91.4%) 5 (12.5%) 35 (87.5%) 0.488
1st twin neonatal jaundice 17 (18.3%) 76 (82.7%) 11 (27.5%) 29 (72.5%) 0.232
1st twin neurological morbidity 5 (5.4%) 88 (94.6%) 0 (0%) 40 (100%) 0.135
2nd twin respiratory morbidity 20 (21.5%) 73 (78.5%) 4 (10%) 36 (90%) 0.114
2nd twin sepsis 10 (10.7%) 83 (89.2%) 4 (10%) 36 (90%) 0.897
2nd twin neonatal jaundice 13 (14.0%) 80 (86.0%) 4 (10%) 36 (90%) 0.529
For personal use only.

2nd twin neurological morbidity 3 (3.2%) 90 (96.8%) 1 (2.6%) 39 (93.7%) 40.99

MCDA Monochorionic Diamniotic; DCDA Dichorionic Diamniotic; AS Apgar Score; NICU Neonatal Intensive Care Unit.

vaginal delivery. Moreover, our multiparous women had a
higher successful vaginal rate (88%) compared to nulliparous
women (60%) (p 0.0023), while for the presentation of the
2nd twin, there was no significant difference in the success
rate (76.1% versus 65.4%) (p 0.31).
Although apparently more DCDA twins ended up with CD,
after evaluating with multinomial logistic linear regression
and controlling other factors such as history of vaginal
delivery, presentation of 2nd twin, education level of mother
and mode of conception, chorionicity was not significant.
Neonatal outcomes and maternal outcomes were evaluated
in twoways. Firstly, it was compared between those who
attempted vaginal delivery and planned caesarean delivery for
the pregnant mothers who were considered suitable for
vaginal delivery. No significant difference between the AS,
need for NICU admissions/neonatal resuscitation/respiratory/
sepsis/neurological morbidity was identified (Table 1).
Secondly, neonatal outcomes were compared between
those with vaginal delivery and caesarean delivery for
both twins. Significantly more 2nd twins had cord blood
pH 57.2 in vaginal twin deliveries. Otherwise, no significant
difference between the need for NICU admissions/neonatal
resuscitation/respiratory/sepsis/neurological morbidity was
seen (Table 2).
In our study, there were four pairs of twins who attempted
vaginal delivery for 1st twin but required caesarean delivery
for 2nd twin. Hand presentation of the 2nd twin was noted in
one of the cases while there was another case where the
second twin was noted to be in oblique breech position with
the cervix being clamped down to 5 cm. Amniotic membrane
remained intact and syntocinon drip was not given in both
cases. In the other 2 cases, 2nd twins were in cephalic
presentation, uterine contractions subsided after delivery of
1st twins, amniotomy was not performed but a syntocinon
drip was subsequently given; there was no strong uterine
contraction in both cases despite syntocincon administration,
and cervix remained 2 and 5 cm dilated, respectively, after
30 min. Emergency CD were arranged for these four cases.
They all had good outcomes. None of the babies required
NICU admissions or developed sepsis, respiratory, neuro-
logical or other neonatal complications except neonatal
jaundice. The cord blood pHs of the 2nd twins were 7.13,
7.14, 7.26 and 7.28.
Maternal outcome is outlined in Table 3. There was no
statistically significant difference in the incidence of post-
partum hemorrhage or blood transfusions. All patients
requiring compression sutures were in the caesarean group,
though the difference was not statistically significant. One
patient required hysterectomy due to massive postpartum
hemorrhage and she was in the caesarean group.
Discussion
In 2000, Term Breech Trial [23] was published. The result
indicated that planned caesarean delivery was associated with
a better perinatal outcome. After this publication, rates of
vaginal breech delivery decreased significantly, and rates
of vaginal twin delivery also decreased throughout the
 DOI: 10.3109/14767058.2015.1035640 Effect of vaginal twin delivery 5
Table 2. Comparison of neonatal outcome between the pregnant mothers with vaginal delivery and caesarean delivery for both twins.

Total number (269)

Vaginal delivery Caesarean delivery
for both (68) for both (197)
Yes No Yes No p value
Chorionicity of Twin (Yes MCDA, No DCDA) 22 (32.3%) 38 (55.9%) 40 (16.2%) 141 (71.6%) 0.04
1st twin: Mean birth weight (kg) 2.28 (95% CI: 2.162.38) 2.35 (95% CI: 2.282.42) 0.28
2nd twin: Mean birth weight (kg) 2.32 (95% CI: 2.202.43) 2.28 (95% CI: 2.212.36) 0.62
1st twin: cord blood pH 57.2 5 (7.4%) 60 (88.2%) 9 (4.6%) 185 (93.9%) 0.3502
2nd twin cord blood pH 57.2 10 (14.7%) 56 (82.4%) 10 (5.1%) 185 (93.9%) 0.014
1st twin AS at 5 min: 4 1 (1.5%) 67 (98.5%) 1 (0.5%) 196 (99.5%) 0.4481
7 2 (2.9%) 66 (97.1%) 3 (1.5%) 194 (98.5%) 0.6053
2nd twin AS at 5 min: 4 0 (0%) 68 (100%) 0 (0%) 194 (98.5%) 40.99
7 1 (1.5%) 67 (98.5%) 1 (0.5%) 196 (99.5%) 0.4481
1st twin NICU admission 6 (9.7%) 62 (90.3%) 24 (10.7%) 173 (87.8%) 0.5141
2nd twin NICU admission 6 (9.7%) 62 (90.3%) 35 (17.8%) 162 (82.2%) 0.0836
Mean gestation age (week) 35.8 (95% CI 35.136.5) 36 (95% CI 35.736.3) 0.507
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Gestation at delivery 532 6 (9.7%) 62 (90.3%) 11 (5.6%) 186 (94.4%) 0.7872

1st twin birth trauma 2 (2.9%) 66 (97.1%) 4 (20.3%) 193 (79.7%) 0.6484
2nd twin birth trauma 2 (2.9%) 66 (97.1%) 0 (0%) 197 (100%) 0.0651
1st twin neonatal resuscitation 4 (5.9%) 64 (94.1%) 13 (6.6%) 184 (93.4%) 40.99
2nd twin neonatal resuscitation 6 (9.7%) 62 (90.3%) 16 (8.1%) 181 (91.9%) 0.8037
1st twin respiratory morbidity 15 (28.3%) 53 (71.7%) 47 (23.9%) 150 (76.1%) 0.8685
1st twin sepsis 5 (7.4%) 63 (92.6%) 24 (12.2%) 173 (87.8%) 0.3685
1st twin neonatal jaundice 13 (19.1%) 55 (80.9%) 43 (21.8%) 154 (78.2%) 0.7317
1st twin neurological morbidity 4 (5.9%) 64 (94.1%) 9 (4.6%) 188 (95.4%) 0.7453
2nd twin respiratory morbidity 16 (23.6%) 52 (76.4%) 52 (26.4%) 142 (72.1%) 0.6335
2nd twin sepsis 7 (10.3%) 61 (89.7%) 28 (14.2%) 169 (84.7%) 0.5341
2nd twin neonatal jaundice 11 (16.2%) 57 (83.8%) 39 (19.8%) 158 (80.2%) 0.5920
2nd twin neurological morbidity 2 (2.9%) 66 (97.1%) 12 (6.1%) 185 (93.9%) 0.5295
For personal use only.

MCDA Monochorionic Diamniotic; DCDA Dichorionic Diamniotic; AS Apgar Score; NICU Neonatal Intensive Care Unit.

Table 3. Comparison of maternal outcomes.

Planned vaginal Planned caesarean Vaginal delivery Caesarean delivery

delivery (93) delivery (40) for both (68) for both (197)
Maternal outcome Yes No Yes No p value Yes No Yes No p value
PPH 4500mL 23 (24.7%) 70 (75.3%) 13 (32.5%) 27 (67.5%) 0.355 12 (17.6%) 56 (82.4%) 53 (26.9%) 144 (73.1%) 0.1432
PPH requiring extra drugs 7 (7.5%) 86 (92.5%) 6 (15%) 34 (85%) 0.183 5 (7.4%) 63 (92.6%) 17 (8.63%) 180 (91.4%) 40.99
PPH requiring 0 (0%) 93 (100%) 1 (2.5%) 39 (97.5%) 0.126 0 (0%) 68 (100%) 5 (2.5%) 192 (97.5%) 0.3326
compression suture
PPH requiring hysterectomy 0 (0%) 93 (100%) 1 (2.5%) 39 (97.5%) 0.126 0 (0%) 68 (100%) 1 (0.5%) 196 (99.5%) 40.99
Need for blood transfusion 4 (4.3%) 89 (95.7%) 2 (5%) 38 (95%) 0.859 4 (5.9%) 64 (94.1%) 7 (3.6%) 190 (96.4%) 0.4806

PPH Postpartum Hemorrhage.

world [24,25]. More units were delivering twins by caesarean
delivery, although there was no strong evidence to support
such a policy. This trend was also observed in our unit. Our
vaginal twin delivery rate dropped from 70% in 1993 to as
low as 10% in 2008 [16].
We had a substantial increase in the number of twin
deliveries in 20092012 compared to 20062009. Reasons
included a general increase in the number of total deliveries
(18 221 versus 16 953 respectively) in our unit and also
increased prevalence of artificial reproductive technique/IVF
pregnancies. Artificial reproductive cases account for 45.8%
(148/323) of all twin deliveries. 103/148 (69.6%) were
performed in private hospitals, and another 22 (14.9%) were
done in Mainland China. The rest were either performed in
Hong Kong public hospitals (17/148 ! 11.5%) or other
countries such as Taiwan or Thailand (6/148 ! 4%).
Compared with our previous cohort study, we noted a
significant increase in vaginal twin delivery rate in these
two 3-year periods, from 16.9% to 25.3%. Particularly for
women who were suitable for vaginal delivery, the rate of
attempting vaginal delivery increased tremendously from
47% to 69.9%. Despite the increase in attempt for vaginal
delivery, the success rate was similar in these two periods
(73.1% versus 74%). The rate of requiring caesarean
delivery for 2nd twin did not increase significantly either
(1% versus 1.5%) (p40.99). With proper counseling
involving discussing pros and cons of vaginal delivery
and caesarean delivery, a significant number of women who
were suitable for vaginal twin delivery would be willing to
attempt vaginal delivery. Caesarean delivery is not without
risk. It leads to short-term complications (maternal mor-
bidity and mortality) [26,27] and long-term complications
 6 H. T. Tang et al.
(e.g. placenta praevia and accreta in future pregnancies)
[28,29].
Vaginal delivery of 2nd twins requires skills in breech
extraction, operative vaginal delivery, internal podalic ver-
sion, and intrapartum ultrasound technique. Previous studies
have shown that umbilical artery pH would be lower with
longer intervals between the birth of the twins, both in
monochorionic and dichorionic twins [30,31]. Presence of an
experienced physician was one of the factors that could help
to shorten the time-interval; for example, (s)he can perform a
breech extraction by gripping the babys feet with intact
membranes [32]. Mauldin and colleagues prospectively
investigated 266 twin gestations, which supported that
breech extraction in second non-vertex twins was the most
cost-effective delivery management strategy, and these infants
had significantly lower rates of pulmonary and neonatal
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infectious disease [33]. In our unit, internal podalic version
would be performed for delivery of 2nd twin if baby was in
oblique/transverse presentation, while breech extraction
would be used for footling/flexed breech. Manual rotation
would also be attempted for occipito-transverse/occipito-
posterior (OT/OP) position if poor descent was noted for the
2nd twin even if it was in cephalic presentation [34].
Whenever we had a mother attempting vaginal delivery in
labor ward, our labor ward consultant (WL) would discuss
with the corresponding team, and be involved in decision
making of suitability for vaginal twin delivery, assessment of
For personal use only.
progression, timing of deciding caesarean delivery in cases of
failure to progress, and maneuvers used for 2nd twin delivery.
Moreover, our unit tried time delivery of vaginal twins to
ensure daytime delivery as much as possible. By starting the
induction of labor for twins early in the morning, majority of
them would be delivered in afternoon or early evening. Thus,
more experienced personnel or even our labor ward consultant
would be available in labor ward, supervising and teaching
juniors how to perform various twin delivery maneuvers. To
further enhance various vaginal twin delivery techniques of
our trainees, we also arranged various team training work-
shops using manikins.
Despite the increased vaginal twin delivery rate and the
increased total twin delivery number in our unit, we did not
find any significant differences between the neonatal/maternal
morbidities of vaginal twin delivery and the neonatal/
maternal morbidities of elective CD for twins. From our
data, apparently more 1st and 2nd twins in the attempted
vaginal group required NICU admissions and neonatal
resuscitation compared to that of the CD group. Many of
them suffered from respiratory morbidities too. However, no
statistical significance was identified after calculation.
Moreover, all preterm deliveries 532 week belonged to the
attempted vaginal group. Increased NICU admissions/neo-
natal resuscitation/respiratory morbidity was also anticipated
observations of premature delivery. In terms of maternal
morbidity, more postpartum hemorrhage was observed in
caesarean group and planned caesarean group, but statistical
significance was again not found. A similar trend for
maternal/neonatal morbidity was also observed in our previ-
ous cohort study [15].
In conclusion, our data, together the recent publication of
NEJM, supported our unit policy of promoting vaginal twin
J Matern Fetal Neonatal Med, Early Online: 17
delivery. The key to successful vaginal twin delivery included
practice and skill acquisition, appropriate training and super-
vision, presence of experienced staff at time of twin delivery
and good use of intrapartum ultrasound [35]. Nevertheless, it
was also important for continuous auditing in our unit to note
for any increase in neonatal/maternal morbidities if our twin
vaginal delivery rate is further increased.
One limitation of our study was that there was a change in
the computer coding policy of our hospital in 2009. When we
went through the computer record during data collection, we
found that more minor cases of morbidities, e.g. very minor
cases of respiratory distress were coded in the computer
system since 2009. Therefore, we did not make a direct
statistical calculation comparing neonatal outcomes between
data of both cohort studies. However, we had regular perinatal
meetings and case reviews for adverse neonatal outcomes. No
increased neonatal and maternal morbidities were observed
for twins that were delivered in our unit throughout these
years. Therefore, even without definite statistical calculation,
we could say that there was no major worsening of neonatal
and maternal outcomes despite our change of practice.
Another limitation was that we did not evaluate the
relationship between the neonatal outcomes of 2nd twin and
the time interval between deliveries of both twins.
Declaration of interest
The authors have no conflict of interest
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