Internal Version Compared With Pushing for Delivery of Cephalic Second Twins

Abstract

OBJECTIVE: To assess neonatal morbidity and mortality according to whether cephalic second twins were born after internal version followed by total breech extraction or after instructions to push. We hypothesized that interval version would result in shorter intertwin delivery intervals and lower cesarean delivery rates for the second twin and therefore better neonatal outcomes. METHODS: These planned analyses of the JUMODA (JUmeaux MODe d'Accouchement) cohort, a national prospective population-based study of twin deliveries, examined births of cephalic second twins after vaginal birth of the first twin at or after 32 weeks of gestation. The internal version group of second twins born in breech presentation after obstetric maneuvers was compared with the pushing group, comprising those born in cephalic presentation. The primary outcome was a composite of neonatal morbidity and mortality. Multivariate modified Poisson regression models were used to control for potential confounders. RESULTS: Of 2,256 cephalic second twins, 487 (21.6%) were born in breech presentation after internal version and total breech extraction and 1,769 (78.4%) in cephalic presentation after pushing. Composite neonatal morbidity and mortality was not lower in the internal version (17/487 [3.5%]) compared with the pushing group (38/1,769 [2.1%]; adjusted relative risk [aRR] 1.73 [95% CI 0.98–3.05]), although median [quartile 1–quartile 3] intertwin delivery intervals were shorter (5 [4–8] vs 8 [5–12] minutes, P<.001) and the cesarean delivery rate for the second twin lower (5/487 [1.0%] vs 66/1,769 [3.7%], P=.002). Subgroup analyses showed no difference between groups at or after 37 weeks of gestation but higher composite neonatal morbidity and mortality after internal version before 37 weeks (14/215 [6.5%] vs 26/841 [3.1%]; aRR 2.18 [95% CI 1.15–4.13]). Secondary analyses according to center expertise in the overall population and stratified by gestational age yielded concordant results. CONCLUSION: Although our sample size precluded a robust assessment for small differences in outcomes between groups, internal version followed by total breech extraction of cephalic second twins was not associated with better neonatal outcomes than pushing.

Prospective observational study investigating the effectiveness, safety, women’s experiences and quality of life at 3 months regarding cervical ripening methods for induction of labor at term—The MATUCOL study protocol

“…are guided by a pragmatic view about cervical ripening, such as all large prospective observational studies in obstetrics [30][31][32][33]. These studies allow multiple analyses of data and conclusions about pragmatic management and consequences of some current obstetric conditions that were not adapted to randomized controlled trials (i.e., twins with The JUmeaux MODe d'Accouchement (JUMODA) study) [30,[34][35][36][37][38][39].…”

Mode of delivery in multiple pregnancies

“…Anecdotally, some have advocated that breech extraction may even offer better results when the second twin is in a cephalic presentation, 57 yet a recent sub-analysis of the JUMODA study of more than 4,000 second twins have concluded that internal version followed by total breech extraction of the cephalic second twin is not associated with better neonatal outcomes than pushing. 58 Breech extraction is accomplished in the manner described by Rabinovici et al: 59 the feet of the second fetus are grasped through the intact membranes, without rupturing the amniotic sac. Gentle, continuous traction is exerted on both feet toward the birth canal.…”

Internal podalic version of second twin: Improving feet identification using a simulation model

“…On the other hand, the obstetrical skills in internal podalic version, breech extraction, and operative vaginal deliveries for twin delivery tend to disappear due to ongoing debates about the better route of delivery for twins, singleton breech fetuses, or the safety of assisted delivery [2]. There is consistent data supporting active management of the second twin delivery: the reduction of the inter-twin delivery interval could improve neonatal outcomes [3]. Even in the case of cephalic/cephalic twin presentations, 20% of vertex presenting second twins will change presentation spontaneously after the first twin is delivered requiring obstetrical maneuvers [4].…”