A Randomized Trial of Planned Cesarean vs. Vaginal Delivery for Twin Pregnancy

by faithgibson on December 2, 2013

in Contemporary Childbirth Politics

Funded by the Canadian Institutes of Health Research; ClinicalTrials.gov

published in the NEJM
print version: http://www.nejm.org/doi/full/10.1056/NEJMoa1214939?viewType=Print&viewClass=Print
pdf version: http://www.nejm.org/doi/pdf/10.1056/NEJMoa1214939

Background Question:

Twin birth is associated with a higher risk of adverse perinatal outcomes than singleton birth. It is unclear whether planned cesarean section results in a lower risk of adverse outcomes than planned vaginal delivery in twin pregnancy….

Conclusion:

…. between 32 weeks 0 days and 38 weeks 6 days of gestation,  twin pregnancy with the first twin in the cephalic presentationplanned cesarean delivery did NOT significantly decrease or increase the risk of fetal or neonatal death or serious neonatal morbidity, as compared with planned vaginal delivery

Study Methods

We randomly assigned women between 32 weeks 0 days and 38 weeks 6 days of gestation with twin pregnancy and with the first twin in the cephalic
presentation to planned cesarean section or planned vaginal delivery with cesarean only if indicated. Elective delivery was planned between
37 weeks 5 days and 38 weeks 6 days of gestation. The primary outcome was a composite of fetal or neonatal death or serious neonatal morbidity, with the fetus or infant as the unit of analysis for the statistical comparison.

Results

A total of 1398 women (2795 fetuses) were randomly assigned to planned cesarean delivery and 1406 women (2812 fetuses) to planned vaginal
delivery. The rate of cesarean delivery was 90.7% in the planned-cesarean-delivery group and 43.8% in the planned-vaginal-delivery group. Women in the planned-cesarean-delivery group delivered earlier than did those in the planned-vaginal-delivery group (mean number of days from randomization to delivery, 12.4 vs. 13.3; P=0.04). There was no significant difference in the composite primary outcome between the planned-cesarean-delivery group and the planned-vaginal-delivery group (2.2% and 1.9%, respectively; odds ratio with planned cesarean delivery, 1.16; 95% confidence interval, 0.77 to
1.74; P=0.49).

Conclusions

In twin pregnancy between 32 weeks 0 days and 38 weeks 6 days of gestation, with the first twin in the cephalic presentation, planned 
cesarean delivery did not significantly decrease or increase the risk of fetal or neonatal death or serious neonatal morbidity, as compared with planned vaginal delivery.
http://www.nejm.org/doi/full/10.1056/NEJMoa1214939

Correction:
http://www.nejm.org/doi/full/10.1056/NEJMx130055

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