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Twin Pregnancy: Cesarean or Vaginal Delivery?

By Emily Libby

A routine ultrasound at your latest obstetrics appointment shows not one fuzzy image of a tiny baby, but two – indeed, you are carrying twins! Amidst the exciting preparations of double baby clothes and car seats, you also need to consider the most appropriate way to safely deliver the babies. It has been shown that a twin birth is associated with a higher risk of complications compared to a single baby birth, though it has been unclear whether having a cesarean section (C-section) instead of a planned vaginal delivery reduces this risk.

A C-section is a surgical procedure to deliver a baby through incisions made in the mother’s abdomen and is generally recommended for more complex pregnancies, such as when a preexisting health condition affects the baby or mother or the baby is in an abnormal position. The rates of C-sections for twin deliveries has increased worldwide, in spite of the lack of evidence supporting this mode of delivery as being safer than vaginal twin deliveries. A group of researchers sought to address this issue in the Twin Birth Study, published recently in The New England Journal of Medicine.

The Twin Birth Study was a large randomized controlled trial, meaning that pregnant women carrying twins were randomly divided into two groups, one of which was to have a planned vaginal delivery (1406 women) and the other to have a planned C-section (1398 women). Eligible pregnancies included only those with the first baby in the “cephalic” presentation (meaning head-down), since a baby in the “breech” position (bottom-down) is more apt to develop other complications requiring a surgical intervention. The researchers followed the pregnancies and deliveries of the women and noted any occurrences of adverse outcomes in the newborns, including death and other complications such as birth trauma, nerve injury or serious medical conditions.

The results of the study showed that:
There was no significant difference in the occurrence of these outcomes between the planned C-section and planned vaginal births.
There was a higher risk of adverse outcomes for the second twin than for the first, but this risk did not change regardless of whether the delivery was vaginal or cesarean.

What does this mean for you?
The findings from this study suggest that a planned C-section does not offer any more benefits in delivering twins compared to a vaginal delivery (remembering that this is only applicable when baby #1 is head down!) Be sure to discuss delivery options with your physician to ensure a plan that is most appropriate for your care.
Barrett J, Hannah M, Hutton E, et al. A randomized trial of planned cesarean or vaginal delivery for twin pregnancy. N Engl J Med. 2013 Oct 3;369(14):1295-1305.