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Study flowchart for a systematic review/meta-analyses on the safest mode of delivery for extremely preterm cephalic/non-cephalic twin pairs
Source publication
Background:
Given the controversy around mode of delivery, our objective was to assess the evidence regarding the safest mode of delivery for actively resuscitated extremely preterm cephalic/non-cephalic twin pairs before 28 weeks of gestation.
Methods:
We searched Cochrane CENTRAL, MEDLINE, EMBASE and http://clinicaltrials.gov from January 1994...
Similar publications
Objectives
To identify obstetrical subgroups in which (1) the caesarean delivery (CD) rate may be reduced without compromising safety and (2) CD may be associated with better perinatal outcomes.
Design
A multicentre cross-sectional study.
Setting
19 hospitals in the USA that participated in the Consortium on Safe Labor.
Participants
228 562 preg...
Citations
... However, cesarean section in twin pregnancy is still in a high level compared with singleton pregnancies. Especially in twin pregnancies of preterm labor, there is no consensus regarding the benefits and risks of delivery method for the twin fetus [6]. Due to the choice of the mothers and the endeavor of reducing risks and uncertainties related with vaginal delivery, CS is the more preferred mode of delivery for preterm twin pregnancy. ...
Purpose
The “en caul” cesarean section (CS) is a method to keep the amnion intact during CS. This amnion protection effect may have benefits in preterm twin pregnancy. This study aimed to explore the benefits and risks of this method in preterm twin pregnancy.
Methods
This study is a retrospective analysis of preterm twin pregnancies underwent CS in West China Second University Hospital of Sichuan University from January 2011 to December 2022. Data on maternal and fetal outcomes were collected. Univariable analyses and multivariate logistic regression analyses were applied. The level of significance was set at p < 0.05.
Results
A total of 182 patients were included (90 in the “en caul” group, 92 in the conventional group). “en caul” CS was associated with lower incidence for respiratory distress (aOR 0.47, 95% CI 0.25–0.88, for the first fetus; aOR 0.42, 95% CI 0.21–0.82, for the second fetus). This method was proved to have beneficial effects in improving the Apgar scores at 1st minute and reducing the mechanical ventilation rate in the second neonates (aOR 0.41, 95% CI 0.19–0.88).
Conclusion
“En caul” CS is an easy and safe technique to perform during CS for preterm twin pregnancy. The efficacy and safety of this method could be tested by future studies with larger sample size.
... Our study included pregnancies from 28 weeks of gestation. Additionally in twins with cephalic and non-cephalic presentation, some studies recommended elective caesarean delivery, but others had found no benefits even in those at extremely premature gestations [9,[27][28][29][30]. ...
Objectives
To investigate factors associated with outcome of second twin during labour.
Methods
The study was a retrospective cohort study in a single tertiary centre in Malaysia from 2014 until 2018 involving all twin pregnancies delivered at or more than 24 weeks of gestation.
Results
Total of 409 twin pregnancies were included. Dichorionic twin comprises of 54.5 % (n=223) and 45.5 % (n=186) are monochorionic. Women with dichorionic pregnancies are significantly older (p<0.001), have more pre-existing medical disorders (p=0.011) and fetal structural anomalies (p=0.009). Monochorionic pregnancies are significantly more amongst Malay (p=0.01) and conceived spontaneously (p<0.001). There are significantly more fetuses both in cephalic presentation (p=0.026), birthweight discrepancy more than 20 % (p=0.038) and shorter mean inter-twin delivery duration (p=0.048) in monochorionic pregnancies. Second twin delivered with Apgar score <7 is significantly more in dichorionic pregnancies (p=0.006). The second twin is associated with lower birthweight, small for gestational age and arterial cord pH<7.25. Within the group of women who delivered both fetuses vaginally, there was significantly more second twins with intertwin delivery duration less than 30 min who were delivered vaginally without instrumentation (p=0.018). There was significantly more second twin with intertwin delivery duration of 30 min and more with arterial cord pH<7.25 (p=0.045). Those who delivered spontaneously had inter-twin delivery duration within 15–29 min. The outcome of second twin is not influenced by type of twin, gestational age at delivery, inter-twin delivery duration, mode of delivery and presentation at birth.
Conclusions
The neonatal outcome for the second twin at birth is not influenced by type of twin, gestational age at delivery, inter-twin delivery duration, mode of delivery and presentation at birth in a cohort managed with non-active management of the second twin in Malaysia.
... The study suggests that obstetricians who have experience with vaginal twin deliveries should continue to use planned vaginal delivery in these situations. In a systematic review and meta-analysis by Dagenais et al., no differences were found in the odds of neonatal death and severe brain injury, composite outcome with either mode of delivery at 24 + 0-27 + 6 weeks; however this meta-analysis found very limited existing evidence [28]. Current research did not explicitly recommend the mode of delivery of very preterm birth twins, but most studies did not demonstrate the clear benefits of cesarean section compared to trial births [29]. ...
The mode of delivery for twins born before 32 weeks of gestation remains controversial. Our purpose is to conduct a meta-analysis of twin pregnancies less than 32 weeks or twin weight less than 1500 g, so as to find a suitable delivery mode.
We searched PubMed database, Cochrane Library database, and EMBASE database through December 2022. This protocol was registered with PROSPERO (CRD42023386946) prior to initiation. Studies that compared vaginal delivery to cesarean section for newborns less than 32 weeks of gestation or birthweight under 1500 g were included. The primary result was neonatal mortality rate. Secondary result was neonatal morbidity. The quality of literatures included in the research was evaluated in accordance with Newcastle–Ottawa Scale (NOS) literature quality evaluation scale. We use odds ratio (OR) as the effect index for binary variables. Point estimates and 95% confidence intervals (95% CI) were calculated. P < 0. 05 indicated statistically significant difference.
Our search generated 5310 articles, and a total of 8 articles comprising a total of 14,703 newborns were included in the analysis. The odds ratios of neonatal mortality rate were for twins delivered by vaginal delivery compared to cesarean section were 0.84 (95% CI 0.57–1.24, P = 0.38). The 5-min Apgar score < 7 (95% CI 0.44–1.75, P = 0.72), necrotizing enterocolitis (95% CI 0.81–1.19, P = 0.82), intraventricular hemorrhage (95% CI 0.41–1.86, P = 0.71), periventricular leukomalacia (95% CI 0.16–4.52, P = 0.84), bronchopulmonary dysplasia (95% CI 0.88–1.36, P = 0.42), and respiratory distress syndrome (95% CI 0.23–2.01, P = 0.48) were not statistically significant between the two groups.
We have observed that vaginal delivery does not confer an increased risk of neonatal morbidity and mortality in twins born before 32 weeks of gestation. However, the current results are affected by substantial heterogeneity and confounding factors. We still need high-quality randomized-controlled studies require to address this important question.
... [76]. Therefore, vaginal delivery is considered safe for both singleton and twin preterm fetuses with vertex presentation [77]. Notably, vaginal birth after previous cesarean delivery is not contraindicated in cases of PTL [78]. ...
... A nivel mundial, la prematuridad tiene una prevalencia de alrededor del 8,6%. El parto vaginal pretérmino es una alternativa recomendada cuando la posición del recién nacido es adecuada en el marco de un trabajo de parto pretérmino refractario a tratamiento; y cuando la condición materna fuerza a inducir el parto antes de las 37 semanas 19,20 . La creencia ancestral de que la luna llena se asocia a una mayor incidencia de partos no diferencia entre partos a término o no, por lo que el presente estudio tuvo el objetivo de determinar la asociación entre la luna llena y la incidencia de partos prematuros vaginales entre mujeres con parto vaginal de un hospital de tercer nivel de Lima, Perú, con el fin de aumentar el conocimiento en este tópico. ...
Objetivo. Determinar la asociación entre la luna llena y la incidencia de partos prematuros vaginales entre mujeres con parto vaginal de un hospital de tercer nivel de Lima, Perú. Material y método. Se realizó un estudio transversal analítico de base secundaria del Certificado de Nacido Vivo (CNV) de Perú. Se estudiaron a todos los recién nacidos del Instituto Nacional Materno Perinatal entre los años 2013 a 2021. La duración de la fase de luna llena se determinó a través de lenguaje de programación con Python 6.3 y el análisis de la incidencia de prematuridad con el paquete estadístico STATA v15. Resultados. Se seleccionaron 90 653 recién nacidos del CNV de los cuales 11563 (12.75%) participantes nacieron durante los días de luna llena y 79089 (87.25%) durante las otras fases. Se observó una mayor incidencia de partos prematuros vaginales durante la fase de luna llena en comparación con otras fases (p<0.01). El análisis multivariado encontró que la luna llena tenía un 1.17% más de valor promedio de incidencia de partos prematuros vaginales ajustado por año en comparación con las demás fases (IC 95% 1.050 - 1.292, p<0.01). Conclusiones. Se encontró una mayor incidencia de partos prematuros vaginales durante la fase de luna llena en la población estudiada. Se deben tomar con cuidado estos resultados debido a que en el análisis se incluyeron los partos inducidos.
... The mode of delivery had no influence on the incidence of RDS and only a weakly significant influence on the occurrence of IVH. The advantages and disadvantages for mother and child of caesarean section versus spontaneous delivery in preterm birth have been widely discussed for years (37)(38)(39). The majority of large cohort studies showed no difference in outcome of preterm infants regarding the mode of delivery (40,41). ...
Background/aim:
We investigated the impact of the timing of antenatal corticosteroid (ACS) administration on the clinical outcome of preterm infants.
Patients and methods:
Two hundred and fifty-five preterm infants between 28+0 and 34+0 weeks of gestation were retrospectively assigned to one of two groups: In the first group, ACS was given within 7 days before birth; the second group, did not receive ACS during that period. The primary outcome parameter was respiratory failure (defined by need for continuous positive airway pressure or mechanical ventilation) due to grade 1-4 respiratory distress syndrome (RDS). Secondary outcomes included the rates of intraventricular hemorrhage (IVH), periventricular leukomalacia, and necrotizing enterocolitis.
Results:
The rate of RDS was significantly higher in the no ACS group (40% vs. 62%, p=0.0009), especially of the more severe grades 24 (n=37 vs. n=48, p=0.0121). In addition, IVH (1% vs. 9%, p=0.0041) and neonatal infections (72% vs. 89%, p=0.0025) were significantly increased. Univariable and multivariable regression analyses showed a lower likelihood of RDS in the ACS group [odds ratio (OR)=0.295] in infants born closer to term (OR=0.907) and following preterm onset of labor (OR=0.495). Similarly, we observed a lower probability of IVH in the ACS group (OR=0.098), with a higher probability of occurrence of IVH in pre-eclampsia/HELLP syndrome (hemolysis, elevated liver enzyme levels, low platelet count) (OR=7.914).
Conclusion:
ACS treatment within the last 7 days before birth significantly reduced the risk of RDS and IVH in preterm. These data emphasize that the timing of ACS administration determines its success.
... 59 and thus is considered to be the criterion standard method for both singleton and twin preterm fetuses with vertex presentation (EAPM). 60 On the other hand, cesarean delivery is recommended by EAPM in case of preterm breech presentation based on a Cochrane review and meta-analysis, which proved that cesarean delivery in such cases is associated with lower neonatal mortality compared with vaginal delivery (RR, 0.63; 95% CI, 0.48-0.81). 61 The NICE mentions that cesarean delivery should be considered in PTL between 26 +0 and 36 +6 weeks of pregnancy with breech presentation, which is in accordance with a guideline by the Royal College of Obstetricians and Gynecologists. ...
Importance:
Preterm labor (PTL) is one of the most common and serious pregnancy complications associated with significant perinatal morbidity and mortality, as well as long-term neurologic impairment in the offspring.
Objective:
The aim of this study was to review and compare the most recently published major guidelines on diagnosis, management, prediction, and prevention of this severe complication of pregnancy.
Evidence acquisition:
A descriptive review of guidelines from the National Institute for Health and Care Excellence (NICE), the World Health Organization, the American College of Obstetricians and Gynecologists, the New South Wales Government, and the European Association of Perinatal Medicine (EAPM) on PTL was carried out.
Results:
There is a consensus among the reviewed guidelines that the diagnosis of PTL is based on clinical criteria, physical examination, measurement of cervical length (CL) with transvaginal ultrasound (TVUS) and use of biomarkers, although there is disagreement on the first-line diagnostic test. The NICE and the EAPM are in favor of TVUS CL measurement, whereas the New South Wales Government mentions that fetal fibronectin testing is the mainstay for PTL diagnosis. Moreover, there is consistency among the guidelines regarding the importance of treating PTL up to 34 weeks of gestation, to delay delivery for 48 hours, for the administration of antenatal corticosteroids, magnesium sulfate, and in utero transfer to higher care facility, although several discrepancies exist regarding the tocolytic drugs of choice and the administration of corticosteroids and magnesium sulfate after 34 and 30 gestational weeks, respectively. Routine cesarean delivery in case of PTL is unanimously not recommended. Finally, the NICE, the American College of Obstetricians and Gynecologists, and the EAPM highlight the significance of screening for PTL by TVUS CL measurement between 16 and 24 weeks of gestation and suggest the use of either vaginal progesterone or cervical cerclage for the prevention of PTL, based on specific indications. Cervical pessary is not recommended as a preventive measure.
Conclusions:
Preterm labor is a significant contributor of perinatal morbidity and mortality with a substantial impact on health care systems. Thus, it seems of paramount importance to develop consistent international practice protocols for timely diagnosis and effective management of this major obstetric complication and subsequently improve pregnancy outcomes.
... Regarding extremely preterm (23-28 weeks) singleton fetuses in breech presentation, CS has been associated with both significantly lower risk of intraventricular haemorrhage and of neonatal death [34]. Finally, the conclusions of a recent systematic review regarding vertex/non-vertex twin pairs were that there was little to no conclusive evidence of any significant difference between vaginal delivery and CS [35]. It is our belief that once the woman has been counselled concerning the increased surgical risks of CS and provided with an individualized gestation-based prognosis of her babies, CS may reasonably be offered to her during spontaneous labour in the case of an extremely preterm gestation where vaginal delivery is not immediately imminent. ...
This authoritative textbook provides a much-needed guide for postgraduate trainees preparing for the European Board and College of Obstetrics and Gynaecology (EBCOG) Fellowship examination. Published in association with EBCOG, it fully addresses the competencies defined by the EBCOG curriculum and builds the clinical practice related to these competencies upon the basic science foundations. Volume 1 covers the depth and breadth of obstetrics, and draws on the specialist knowledge of four highly experienced Editors and over 100 contributors from across Europe, reflecting the high-quality training needed to ensure the safety and quality of healthcare for women and their babies. It incorporates key international guidelines throughout, along with colour diagrams and photographs for easy understanding. This is an invaluable resource, not only for postgraduate trainees planning to sit the EFOG examination, but also for practising specialists looking to update their knowledge and skills to meet the ever-evolving complexity of clinical practice.
... Moreover, our study showed a strong protective association of CD among pregnancies with multiple and preterm births. There is limited evidence in the literature of an association between mode of delivery and neonatal or child mortality in either multiple or preterm births [28,29]. Deaths of babies in a noncephalic presentation following a vaginal delivery can either be related to difficulty with the vaginal mode of delivery itself, such as when a foot presents first (footling) or if the fetus is large and causes a mechanical problem or experiences other problems during labor, such as birth trauma [30]. ...
Background:
There is an increasing use of cesarean delivery (CD) based on preference rather than on medical indication. However, the extent to which nonmedically indicated CD benefits or harms child survival remains unclear. Our hypothesis was that in groups with a low indication for CD, this procedure would be associated with higher child mortality and in groups with a clear medical indication CD would be associated with improved child survival chances.
Methods and findings:
We conducted a population-based cohort study in Brazil by linking routine data on live births between January 1, 2012 and December 31, 2018 and assessing mortality up to 5 years of age. Women with a live birth who contributed records during this period were classified into one of 10 Robson groups based on their pregnancy and delivery characteristics. We used propensity scores to match CD with vaginal deliveries (1:1) and prelabor CD with unscheduled CD (1:1) and estimated associations with child mortality using Cox regressions. A total of 17,838,115 live births were analyzed. After propensity score matching (PSM), we found that live births to women in groups with low expected frequencies of CD (Robson groups 1 to 4) had a higher death rate up to age 5 years if they were born via CD compared with vaginal deliveries (HR = 1.25, 95% CI: 1.22 to 1.28; p < 0.001). The relative rate was greatest in the neonatal period (HR = 1.39, 95% CI: 1.34 to 1.45; p < 0.001). There was no difference in mortality rate when comparing offspring born by a prelabor CD to those born by unscheduled CD. For the live births to women with a CD in a prior pregnancy (Robson group 5), the relative rates for child mortality were similar for those born by CD compared with vaginal deliveries (HR = 1.05, 95% CI: 1.00 to 1.10; p = 0.024). In contrast, for live births to women in groups with high expected rates of CD (Robson groups 6 to 10), the child mortality rate was lower for CD than for vaginal deliveries (HR = 0.90, 95% CI: 0.89 to 0.91; p < 0.001), particularly in the neonatal period (HR = 0.84, 95% CI: 0.83 to 0.85; p < 0.001). Our results should be interpreted with caution in clinical practice, since relevant clinical data on CD indication were not available.
Conclusions:
In this study, we observed that in Robson groups with low expected frequencies of CD, this procedure was associated with a 25% increase in child mortality. However, in groups with high expected frequencies of CD, the findings suggest that clinically indicated CD is associated with a reduction in child mortality.
... Nonetheless, the confidence intervals were wide due to the small sample size, and the I 2 quite large, indicating significant heterogeneity and variety between the studies. 107 In another systematic review and meta-analysis (including 15 studies and more than 12,000 infants), it was demonstrated that a CD was associated with a 41% decreased likelihood of neonatal death between 23 0/7 and 27 6/7 weeks (OR 0.59, 95% CI 0.36-0.95, NNT 8), and especially <25 0/7 weeks of gestation (OR 0.58, 95% CI 0.44-0.75, ...
The mode of delivery in multiple pregnancies has been subject to vigorous debates during the last few decades. While observational and retrospective data accumulated, it was not until the publication of the Twin Birth Study (TBS) that evidence-based recommendations were able to emerge. Yet, while some of the most pressing questions were answered by the TBS, others were left outside the scope of the study. These questions are of great interest, and include topics such as the impact of gestational age, the influence of chorionicity, the generalizability of the results for women with a previous uterine scar, and more. Current evidence supports a trial of labor in dichorionic-diamniotic (DCDA) or monochorionic-diamniotic (MCDA) twin pregnancies in which the first twin is in cephalic presentation, at 32 weeks’ gestation or beyond. DCDA twin should be delivered no later than 370/7-380/7 weeks of gestation, MCDA twins no later than 360/7-370/7 weeks of gestation and monochorionic-monoamniotic (MCMA) twins at 320/7-340/7 weeks of gestation. Breech extraction done by a competent healthcare provider seems to offer the higher chance of a successful vaginal delivery of the second twin, compared with external cephalic version. The current data does not allow for a clear recommendation regarding mode of delivery in very preterm birth of low-birth-weight twins, but most of the studies do not demonstrate a clear benefit of cesarean section over a trial of labor. A trial of labor also seems safe in women with a previous cesarean delivery. Cesarean section is likely beneficial for twin gestation with breech first twin, MCMA twins and higher order multiple gestation. In all multiple gestations, the delivery should be undertaken by an experienced practitioner competent in those deliveries.
