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Cesarean Delivery of the Second Twin… Why? 

029I was talking to one of my on-line Twitter friends @onefinebreeder about twin delivery. I was telling her about how things used to be.. how vertex-nonvertex twin gestation’s were always delivered vaginally ….. and she commented on how it was sad that some of the old OB skills have been totally lost to surgery… So Very True!

I got to thinking about the first combination Twin delivery I had witnessed back in the very early 80’s. This was actually one of our own (hospital employee) nurses .  She was a multip…. around 37-38 weeks and healthy…no complications during pregnancy. Twin A delivered spontaneously, vaginally with a generous episiotomy as they often performed at that time… The baby , a girl, was about 6 pounds, vigorous and had no problems. We were all marveling at the first baby, checked fetal hearts on the second twin and started waiting for him to get in position.  Still before consistent ultrasound, we were not worried. However, we had a newer doctor who was attending this birth. He began to get concerned after 5- 10 min when contractions slowed and he was worried that if this baby was breech, he would have difficulty with the “after-coming” head. Up to this point, all I had learned was this can be a real concern if the smaller feet or buttocks present through a cervix which is not fully dilated. Much research was done later on but at the time, I did not know about it. He began to ask us to call the OR for a C/S. This was unheard of in my limited experience at the time…. my 70’s world. I thought.. how can they do a C/S now when one baby was already born??? I tried to be an advocate… (my early days… )”We have Piper forceps…”  I said meekly… “Have you tried to grab a large part and help bring the baby down… ?” This was my limited knowledge… all I knew to suggest. I kept wishing one of the other doctors was on duty that day.. or maybe we could call them???

In front of the mother, he said to me “I’m not going to have a bad outcome here!” By now it was 20 minutes or so. There was no cord prolapse, no drop in fetal hearts, no evidence of immediate trouble… the baby was seeming to work itself into breech position…. To the mother he said “Your baby is in serious danger and the best thing to save him is to take you for a Cesarean now!” “I’ll sew your episiotomy together while we are in the OR.”

I was in shock. She signed, scared to death of course. So we prepped her for the OR. She went up for a C/S of her second twin and repair of her generous episiotomy. Her second baby was delivered frank breech…  a beautiful boy about the same size and was also vigorous and healthy. I remember I felt as though she was almost assaulted. I remember feeling that this was a true rare event if it every happened before. There was no immediate access to information like today.

Luckily mom and babies did fairly well in the postpartum period even though healing from both the episiotomy and the C/S was difficult for her.

"How can I get out if I'm not head 1st ??"

" Psst-- How can I get out if I'm not head 1st ??"

I wanted to see how much research I could find on this topic. I had gone to the green journal (OB & GYN) website but then it locked me out. (You can only look at abstracts anyway unless you want to purchase the article. You are on your own for that.) I had some luck with the abstracts at PubMed so I have put a few here.

I decided to take a look across time…….

This first one is from 1981. . Quoted abstract from the PubMed site:

Cesarean Section for Delivery of the Second Twin

Evrard,JohnR.; Gold, Edwin M.
Obstetrics & Gynecology. 57(5):581-583, May 1981.

Four cases of combined vaginal-abdominal delivery of twins are presented, and an additional 5 cases from the recent literature are discussed. Malposition, malpresentation, and contracted cervix were the main indications for cesarean section for the birth of twin B. In the 9 cases presented, there were 2 perinatal deaths.

Interesting that this research was done during the same time frame as my experience above. I’d like to know more about those poor outcomes 😦

The next interesting article I found was researched over a 10 yr period, somewhat close to here in a larger facility, published 1997. THIS study examines the delivery of the second twin by utilizing external version vs breech extraction . 😉 The results are showing in favor of breech delivery vs version (those meeting exclusionary criteria ).. Versions were associated with higher a incidence of Cesarean and fetal distress. Neonatal outcomes no different and are stated below:

Method of delivery of the nonvertex second twin: a community hospital experience.

 Smith SJ, Zebrowitz J, Latta RA.   J Matern Fetal Med. 1997 May-Jun;6(3):146-50

Abington Memorial Hospital, Pennsylvania, USA.

The purpose of this study is to examine the incidence of cesarean section and fetal distress complicating the delivery of the second twin in vertex-nonvertex twin gestations in which the second twin underwent either breech extraction or external version. The intrapartum courses of 510 twin gestations delivered at a community hospital over a 10-year period were retrospectively analyzed. All vertex-nonvertex twin gestations were identified in which the second twin underwent attempted breech extraction or external version. Exclusion criteria included birthweight < or = 1,500 g, fetal anomaly, intrauterine demise, and monoamniotic twins. Of the 76 twin sets that met inclusion criteria, 33 underwent external version and 43 underwent primary breech extraction. The two groups had similar demographic characteristics. External version compared to breech extraction was associated with a significantly greater incidence of cesarean section (8/33 vs. 1/43, P = .008) and fetal distress (8/33 vs. 1/43, P = .008). There was no difference between groups in neonatal outcome for the second twin as measured by length of stay, 5-minute Apgar < 7, intensive care unit admissions, hyaline membrane disease, intraventricular hemorrhage, and traumatic birth injury. In conclusion, the increased incidence of cesarean section and fetal distress in patients undergoing attempted external version suggests that breech extraction may be the preferable route of delivery for the nonvertex second twin weighing more than 1,500 g

The next study was published a little later in 2001 and covered a 20 year span of time… during the 80’s and 90’s at a larger center in Nova Scotia, Canada. They noted an increase in their combination vaginal/cesarean twin births and documented some statistical data, looked at reasons for an operative second twin birth. I wish to read this study further some day to see if there is mention pertaining to mother/baby outcomes other than statistics outlined (even though that wasn’t their objective) in this abstract:

Combined Vaginal-Cesarean Delivery of Twin Pregnancies

Obstetrics & Gynecology . 98(6):1032-1037, December 2001.

Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada.

OBJECTIVE: To estimate the incidence and factors associated with combined vaginal-cesarean delivery in twin pregnancies. METHODS: We studied all twin births weighing 500 g or more during a 20-year period (1980-1999) at a tertiary care center. Major anomalies, monoamniotic and conjoined twins, and antepartum fetal deaths were excluded.

RESULTS: During this 20-year period, 105,987 women delivered, of whom 1565 (1.5%) had twins. Of these, 1151 twin sets fulfilled the study criteria. The mode of delivery was vaginal in 653 (56.8%), cesarean in 448 (38.9%), and vaginal-cesarean in 50 (4.3%). During the 20 years there was a statistically significant increase in combined vaginal-cesarean and elective cesarean deliveries, with a decrease in vaginal deliveries. Parity, gestational age, and birth weight discordance (>25%) were not associated with combined delivery. Compared with vaginal delivery, the nonvertex second twin was associated with a twofold higher risk of cesarean delivery (relative risk [RR] 2.3; 95% confidence interval [CI] 1.3, 3.8; P =.002); and an interdelivery interval of over 60 minutes with an eightfold higher risk (RR 8.2; CI 4.6,14.6; P <.001). Vaginal-cesarean delivery had a 22-fold higher use of general anesthesia compared with vaginal delivery (RR 21.8; CI 5.4, 88.5; P <.001). CONCLUSION: There has been a significant increase in combined vaginal-cesarean and elective cesarean deliveries among twin gestations, with a decrease in vaginal births. Vaginal-cesarean delivery is associated with nonvertex second twin and a prolonged interdelivery interval.

Now we come to 2008!  There is a study here from Texas. This study looked a twins born by C/S after labor and twins who had cesarean birth of the second twin. they campared outcomes to see if the twin of a combined delivery had more problems. The most important pieces of information I gather from this abstract of results…. (again, having NOT read the entire study):

“Combined twin delivery may be associated with endometritis and neonatal sepsis when compared with a twin delivery where both are delivered by cesarean in twin pregnancies experiencing labor. More serious neonatal sequelae, including hypoxic ischemic encephalopathy and death, were not affected by the route of delivery of the second twin.”  Hmmm 

Cesarean Delivery for the Second Twin

Alexander, James M.; Leveno, Kenneth J.; ….et al:for the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units Network (MFMU)   Obstetrics & Gynecology . 112(4):748-752, October 2008.

Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas, TX 75235-9032, USA. james.alexander@utsouthwestern.edu

OBJECTIVE: To examine maternal and infant outcomes after a vaginal delivery of twin A and a cesarean delivery of twin B, and to identify whether the second twin experienced increased short-term morbidity as part of a combined route of delivery. METHODS: Between January 1, 1999, and December 31, 2000, a prospective cohort study of all cesarean deliveries was conducted at 13 university centers. This secondary analysis was limited to women with twin gestations who experienced labor and underwent cesarean delivery. We compared outcomes of the second twin in women who had vaginal delivery of the first twin and a cesarean delivery of the second twin to those who had cesarean delivery of both twins. RESULTS: One thousand twenty-eight twin pregnancies experienced labor and underwent cesarean delivery; 179 (17%) had a combined vaginal/cesarean delivery. Gestational age at delivery was 34.6 weeks in both groups (P=.97). The rupture of membranes to delivery interval was longer in the combined group (3.2 compared with 2.3 hours, P<.001). Endometritis and culture-proven sepsis in the second twin were more common in the combined group, respectively (n=24, odds ratio 1.6, 95% confidence interval, 1.0-2.7; n=15, odds ratio 1.8, 95% confidence interval, 1.0-3.4). These differences were not significant after logistic regression analysis. There were no statistically significant differences in an arterial cord pH of less than 7.0, Apgar score less than or equal to 3 at 5 minutes, seizures, grade III or IV intraventricular hemorrhage, hypoxic ischemic encephalopathy, or neonatal death. CONCLUSION: Combined twin delivery may be associated with endometritis and neonatal sepsis when compared with a twin delivery where both are delivered by cesarean in twin pregnancies experiencing labor. More serious neonatal sequelae, including hypoxic ischemic encephalopathy and death, were not affected by the route of delivery of the second twin.

I gather from these studies that a combined delivery route leads to more problems.. however…there are probably more problems than breech presentation alone to lead the provider to make that choice. I believe that many newer providers of obstetrics in a hospital setting are more apt to do a scheduled C/S for any vertex-nonvertex twins they encounter. That is what is done in my facility today. The same for all breech presentation singleton gestation.

Where is that old-fashioned nurse when you need her?? How ’bout the old fashoined doc??? 😉

I am very interested in anyone’s story or experience either in healthcare or your personal birth. Please let me know if you know anything about this!

Thanks for reading!

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15 Comments Post a comment
  1. You know, I did just read an abstract recently but I didn’t pull the full text. I’ll see if I can find it.

    By the way, we should make a list of the worst childbirth terminology. “Generous episiotomy” would be right up there. You’re so generous for unnecessarily slicing my perineum! Thank you!

    Sarcasm and silliness aside, the more women in their fifties and sixties that I talk to about their births, the more I here over and over and over that the worst thing about it that they remember was the healing of the episiotomy. I feel so guilty sometimes that I just had a few wee tears that healed quickly.

    May 21, 2009
    • Birth_Lactation #

      You crack me up! That would be an interesting list to make….
      My sister was telling tonite that with her first baby in 1980, they did a
      big episiotomy.
      With her next, she didn’t want one. Now she pushed for 6 hours (unheard of
      today) with baby #2.. in 1982…he did have a big head …but no epis, just
      a few little tears and she said baby #1 she was sore for at least 6 weeks..
      baby #2– she thought “I can do this again” after ONE week!
      Let me know if you find the article. Thanks

      May 21, 2009
  2. Kathy #

    My SIL had an episiotomy and C-section (high forceps attempt failed) with her first, and the recovery was “double un-fun”. She breezed through her 2nd C-section in comparison, and I daresay that not having both vaginal and abdominal trauma had to play a role in it (that, and not having had nearly 50 hours of labor prior to surgery).

    I’ve heard that docs get scared that the cervix will close after the first twin, and I wonder, “Uh, why can it not dilate again? and faster, too, since it’s already done it once, and just a few minutes ago!” I’ve heard of twins being born vaginally more than an hour apart, so it can be done!

    Also one doula I know attended a vaginal birth in which the doctor fitted the above description, and when the second twin did not descend immediately, reached up and pulled it out (manually or with forceps), breaking its arm. The doc told the mom “better for the baby to have a broken arm than be dead,” so the mom was satisfied with her level of care. Sigh…

    May 21, 2009
    • Birth_Lactation #

      That is such a sad story for both your SIL #1 baby and the twin birth described by your doula friend! yes the cervix can dilate again… many times pressure of the next twin well applied to cervix helps. It is more of a concern with footling breech…there is also concern if too much time passes. I haven’t seen research to support it won’t dilate. If I am wrong, someone please show me the data! I just really think a vaginal breech delivery is a lost skill. It concerns me watching a “newer” OB deliver a breech via C/S even! ;-/
      Thanks for stopping by and leaving a note!

      May 21, 2009
  3. In all honesty, recovering from the big tear I got during my third birth (no cutting for me!) was worse than recovery from the c-sections I’d had previously.

    I don’t know any women personally who have had twins. However, from the women I have talked with online, it seems as if a c-section is the default twin birth for most women. One woman was forced to deliver her twins in the OR so they could cut her open that much faster if they felt it necessary!

    I know another woman (and I have met her personally, though I only knew her online at the time) who argued successfully for c-section delivery of her twins, because she could not be assured of a good outcome for twin B (who, as I recall, was in a breech presentation) if she was delivered vaginally. Standard practice in military hospitals is apparently that the ONLY time breech births are “allowed” is when twin B is breech. That’s the OBs’ practice for sneak breeches! Honestly, I would not trust a single civilian contractor with a breech delivery; that’s a large part of why I had two c-sections.

    May 25, 2009
    • Birth_Lactation #

      You are right Sabra.. Breech deliveries are a lost art and do carry more risk…. outcomes not withstanding… the medical community advises a cesarean for the reasons I described above.. I know many who feel the same way you do… I also know others who want the information to decide for themselves…. especially with twins. I guess the main point I wanted to make was the unnecessary combined delivery for twins. Especially back in the early 80’s when we did a lot of breech deliveries. Thanks so much for stopping in again and letting me know you were here!

      May 25, 2009
  4. I found it. It was just the Alexander study you’ve already read. The positive, I guess, is that it validates the safety of starting with vaginal birth and performing a c/s if needed later.

    Do the younger doctors get the chance to learn forceps in this c/s age? Isn’t it weird that I only know ONE woman in their twenties or thirties that had a forceps delivery? Epidural, watched DVDs in labor on her back, baby didn’t finish rotating and was sunny side up and her doc stepped in and said she was a wiz with forceps. Her baby had a few marks on her face but is one seriously healthy kid.

    I do know a lot of ventouse babies, though.

    May 26, 2009
    • Birth_Lactation #

      Thanks for getting back to me Jill– I don’t know if forceps are included in OB training anymore.. I do know ventouse/ vacuum use is, at least for the docs I work with. We rarely use forceps at my hosp..they all opt for a Kiwi vacuum. They are also pretty good about only using it for one or two trys. Of course the iatrogenic reasons CAUSING the use of any device to deliver is a whole other ball-game. This situation happened so long ago..I cannot remember the last combination delivery at my facility. Thanks 🙂

      May 26, 2009
  5. In my online community, there seems to be more squeamishness (to put it mildly) around a doctor physically attempting to turn twin B than a cesarean. I wonder if there was more information about turning the babe if it would decrease the cesarean birthrate. I see more moms-to-be working on changing babe’s breech position prior to birth, thanks to sites like Spinning Babies. The twin community is smaller, but maybe if someone could tap on to different delivery styles it would help women be more empowered with decision-making.

    May 26, 2009
    • Birth_Lactation #

      I can understand that completely… they don’t do that anymore at my hospital that I know of..I had been talking about the mindset from back in the early 80’s and tried to research what was out there in the literature. Most all who have commented have your same perspective. I think I have seen so many successful second twin breeches, sometimes with manipulation into position by the OB–that I found it violating to mom to have both a vag and C/S birth.. I have no idea what I would say or ask for regarding decisions it were me having the twins. The skill level just isn’t there anymore. It is a lost art in the US in my opinion. However I emphatically agree that the information and available options should be there for empowering women in their decisions!! Thank You! 😉

      May 26, 2009
  6. TwoPeas #

    Thanks for the research & conversation on this important subject!

    I am 13 wks prego w/twins, working hard to find a caregiver who will support natural birth – which I have discovered is a difficult task. My biggest concern has become breech.

    Admittedly I am just beginning to research this subject, so this may sound like a silly question – but I’m curious about your point that breech delivery is a ‘lost art’. I would agree with that, hence my doc tells me c/s rates w/twins are about 75%!

    However, my question is that much of what I’m reading suggests that the ‘trick’ to dlvering breech is to ‘stay out of it’ … doc should just step back, and let the body do what it needs to, let baby deliver itself. If that’s the case, what’s the big fuss about ‘lost art’?

    May 28, 2009
    • Birth_Lactation #

      Hi TwoPeas.. First~ CONGRATULATIONS on your Twin pregnancy!!! Exciting!!!
      Thanks for reading and commenting– You bring up a really good question! I found some more data below which I SHOULD have found before writing this… so sorry… Just what is this “lost art” I am referring to??? Similar to the lost art of breastfeeding is what first comes to mind. There are no longer skilled, wiser, more experienced practitioners in the radius surrounding a newer OB~~ similar to the lack of experienced breastfeeding women surrounding the immediate radius of a brand new mother first time mother. I am not as well read on a natural approach for breech delivery that you are referring to..I’d love a reference if you have one. I am more knowledgeable a natural birth process for a vertex or head down birth.
      It is documented that there are more risk factors for a breech over vertex. Some of these are due to the smaller parts…bottom or the feet slipping through the cervix before dilatation is complete which can cause the head to become entrapped. Another is the risk of prolapse or compression of the cord. It is tricky to deliver a breech sometimes– requiring a lot of skill…sometimes a breech extraction where the doctor carefully delivers first bottom, each leg, then each individual arm, shoulders.. an assistant helps to hold up the legs and the OB carefully assists the delivery of the aftercoming head. Keep in mind, many times they are dealing with a medicated mother in my experience and she may not be able to tap into the full power of her uterus!Other times, I have seen them deliver very fast without anything other than a “catcher”…. but not usually. They started to do external versions to help avoid a breech delivery and to help avoid a C/S.
      The concern over the increased risks and the skill required to carefully deliver a difficult breech was the mindset causing ACOG (American College of Obstetrics and Gynecology) to issue the following in 2001:
      Abstract From: Int J Gynaecol Obstet. 2002 Apr;77(1):65-6.

      ACOG committee opinion. Mode of term singleton breech delivery. Number 265, December 2001.
      American College of Obstetricians and Gynecologists.
      Committee on Obstetric Practice.
      Recently, researchers conducted a large, international multicenter randomized clinical trial comparing a policy of planned cesarean birth with planned vaginal birth. Given the results of this exceptionally large and well-controlled clinical trial, the American College of Obstetricians and Gynecologists Committee on Obstetric Practice recommends that obstetricians continue their efforts to reduce breech presentations in singleton gestations through the application of external cephalic version whenever possible. As a result of the findings of the study, planned vaginal delivery of a term singleton breech may no longer be appropriate. In those instances in which breech vaginal deliveries are pursued, great caution should be exercised. Patients with persistent breech presentation at term in a singleton gestation should undergo a planned cesarean delivery. A planned cesarean delivery does not apply to patients presenting in advanced labor with a fetus in the breech presentation in whom delivery is likely to be imminent or to patients whose second twin is in a nonvertex presentation

      And then the latest issue I found …. Abstract from:Obstet Gynecol. 2006 Jul;108(1):235-7.

      ACOG Committee on Obstetric Practice.
      In light of recent studies that further clarify the long-term risks of vaginal breech delivery, the American College of Obstetricians and Gynecologists recommends that the decision regarding mode of delivery should depend on the experience of the health care provider Cesarean delivery will be the preferred mode for most physicians because of the diminish-ing expertise in vaginal breech delivery. Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for both eligibility and labor management. Before a vaginal breech delivery is planned, women should be informed that the risk of peri-natal or neonatal mortality or short-term serious neonatal morbidity may be higher than if a cesarean delivery is planned, and the patient’s informed con-sent should be documented.

      ACOG recommendations are what the doctors usually go by.. If there has been a committee report regarding this issue since 2006, I did not find it. Those I work with do NOT currently offer a planned vaginal breech (singleton) as an option because they don’t have the skills or experience and are more likely to C/S even twins with twin B in anything but vertex position. There are many doctors out there who may be able to provide you with the delivery you wish for if one or both or your babies end up in breech position. I am so happy to see people dong their homework like this!
      Thanks for prompting more research on my part.

      May 29, 2009
  7. It does seem incredibly rare nowadays to hear of a twin births being performed vaginally, let alone with one as a breach presentation.

    I can’t imagine having to recover from both a vaginal delivery w/ episiotomy AND abdominal surgery! One of the nice things about having a c-section was NOT having to be sore “down there”.

    May 30, 2009
  8. Sara #

    My mother’s experience in 1982 was that I was born vaginally, and then my twin sister was turned by way of a version and born 9 minutes later. She told me that they said that if the version didn’t work, they were going to do a c-section. All of this happened at 31 weeks gestation- I think most of the time now docs would be pushing for an automatic c-section based on prematurity alone. My sister and I both made it out unscathed, though, and are very healthy today.

    January 12, 2011

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