Management of the nonvertex second twin: primary cesarean section, external version, or primary breech extraction

Six hundred eighty-two consecutive twin deliveries were reviewed. Included in the study were 136 sets of vertex-nonvertex twins with birth weights greater than 1500 gm. A primary attempt at delivery of the second twin by external version was performed on 41 twins, 55 twins underwent attempted breech extraction, and 40 patients had a primary cesarean section solely because of physician preference. There were no differences in the incidence of neonatal morbidity or mortality among the modes of delivery. External version was associated with a higher failure rate than primary breech extraction (p less than 0.01). External version was associated with complications (fetal distress, cord prolapse, and compound presentation) that were not seen in the other two groups. Primary breech extraction of the second nonvertex twin weighing greater than 1500 gm appears to be a reasonable alternative to either cesarean section or external version.     

Randomized management of the second nonvertex twin: vaginal delivery or cesarean section

Sixty twin deliveries after the thirty-fifth gestational week with vertex-breech and vertex-transverse presentations were managed according to a randomization protocol. Thirty-three parturient women (21 vertex-breech and 12 vertex-transverse presentations) were allocated for vaginal delivery and 27 for cesarean section (18 vertex-breech and nine vertex-transverse). Six pairs of twins in the vaginal delivery group were delivered in a different mode than requested by the protocol (two women underwent cesarean section; in four cases the second twin spontaneously changed to vertex presentation). There were no significant differences between 1- and 5-minute Apgar scores and incidence of neonatal morbidity between the second-born twins in both study groups. Firstborn twins had higher 1-minute Apgar scores than the second-born infants irrespective of route of delivery (p less than 0.05). No case of birth trauma or neonatal death was recorded. Maternal febrile morbidity was significantly higher in the cesarean section group than in the vaginal delivery group (40.7% versus 11.1%, p less than 0.05). These results suggest that in twins with vertex-breech or vertex-transverse presentations after the thirty-fifth week of gestational age the neonatal outcome of the second twin was not significantly influenced by the route of delivery.     

Cesarean delivery for twins: a systematic review and meta-analysis

OBJECTIVE: We undertook a systematic review and meta-analysis to determine whether a policy of planned cesarean section or vaginal delivery is better for twins. STUDY DESIGN: We searched MEDLINE and EMBASE from 1980 through May 2001 using combinations of the following terms: twin, delivery, cesarean section, vaginal birth, birth weight, and gestational age. Studies that compared planned cesarean section to planned vaginal birth for babies weighing at least 1500 g or reaching at least 32 weeks' gestation were included. We computed pooled odds ratios for perinatal or neonatal mortality, low 5-minute Apgar score, neonatal morbidity, and maternal morbidity. The infant was the unit of statistical analysis. Results were considered statistically significant if the 95% CI did not encompass 1.0. RESULTS: We retrieved 67 articles, 63 of which were excluded. Four studies with a total of 1932 infants were included in the analysis. A low 5-minute Apgar score occurred less frequently in twins delivered by planned cesarean section (odds ratio, 0.47; 95% CI, 0.26-0.88) principally because of a reduction among twins if twin A was in breech position (odds ratio, 0.33; 95% CI, 0.17-0.65). Twins delivered by planned cesarean section spent significantly longer in the hospital (mean difference, 4.01 days; 95% CI, 0.73-7.28 days). There were no significant differences in perinatal or neonatal mortality, neonatal morbidity, or maternal morbidity. CONCLUSION: Planned cesarean section may decrease the risk of a low 5-minute Apgar score, particularly if twin A is breech. Otherwise, there is no evidence to support planned cesarean section for twins.     

Effect of labor induction on cesarean section rates in diabetic pregnancies

OBJECTIVE: To determine if induced labor increases the incidence of cesarean delivery in pregnancies complicated by diabetes. STUDY DESIGN: This retrospective cohort study of pregnancies complicated with diabetes involved data from birth certificates reported to the New Mexico Department of Health between January 1996 and December 1999. RESULTS: There were 108,487 births, with 3,392 (3.1%) in women with diabetes. As compared to those without diabetes, this group had an almost twofold-increased risk of primary cesarean delivery (20.3% versus 11.3%; OR 2.00; 95% CI 1.83, 2.19). The risk of primary cesarean delivery in diabetic women was lower in the presence than in the absence of induced labor (17.7% versus 21.9%; OR .77; 95% CI .50, 0.89). This association continued after controlling for birth weight > or = 4,000 g, breech presentation, twins, maternal age > 35 and gestational age > 42 weeks. CONCLUSION: Induction of labor was not an independent risk factor that could explain the higher cesarean delivery rate in diabetic pregnancies.     

Breech presentation and shoulder dystocia in childbirth.

This review covers the recent literature relevant to breech presentation and shoulder dystocia. Further evidence in favor of external cephalic version at term has emerged, and the possibility of its use in women with previous cesarean section has been suggested. Attention has been given to trial of labor in selected cases of term breech presentation. The evidence to guide the method of delivery for preterm breech presentations remains inadequate. No perinatal differences have been demonstrated among the outcome of breech second-born twins delivered by external cephalic version, breech extraction, or cesarean section. The evidence in favor of elective cesarean for suspected macrosomia to prevent shoulder dystocia is unconvincing for nondiabetics and is doubtful for pregnant diabetics. The McRoberts maneuver for shoulder dystocia has not received the prominence that it deserves.     

A comparison of risk factors for breech presentation in preterm and term labor: a nationwide,population-based case–control study

To determine if the common risks for breech presentation at term labor are also eligible in preterm labor. A Finnish cross-sectional study included 737,788 singleton births (24–42 gestational weeks) during 2004–2014. A multivariable logistic regression analysis was used to calculate the risks of breech presentation. The incidence of breech presentation at delivery decreased from 23.5% in pregnancy weeks 24–27 to 2.5% in term pregnancies. In gestational weeks 24–27, preterm premature rupture of membranes was associated with breech presentation. In 28–31 gestational weeks, breech presentation was associated with maternal pre-eclampsia/hypertension, preterm premature rupture of membranes, and fetal birth weight below the tenth percentile. In gestational weeks 32–36, the risks were advanced maternal age, nulliparity, previous cesarean section, preterm premature rupture of membranes, oligohydramnios, birth weight below the tenth percentile, female sex, and congenital anomaly. In term pregnancies, breech presentation was associated with advanced maternal age, nulliparity, maternal hypothyroidism, pre-gestational diabetes, placenta praevia, premature rupture of membranes, oligohydramnios, congenital anomaly, female sex, and birth weight below the tenth percentile. Breech presentation in preterm labor is associated with obstetric risk factors compared to cephalic presentation. These risks decrease linearly with the gestational age. In moderate to late preterm delivery, breech presentation is a high-risk state and some obstetric risk factors are yet visible in early preterm delivery. Breech presentation in extremely preterm deliveries has, with the exception of preterm premature rupture of membranes, similar clinical risk profiles as in cephalic presentation.     

Attempted vaginal versus planned cesarean delivery in 195 breech first twin pregnancies

BACKGROUND: To compare neonatal and maternal outcomes for breech first twins according to whether vaginal or cesarean delivery was planned and to verify that in appropriate selected cases, attempted vaginal delivery is a reasonable choice. METHODS: A retrospective study of all twin pregnancies with the first twin in breech position and gestational age at least 35 weeks at birth at two French university hospital centers from January 1994 through December 2000. The primary outcome was a combined indicator of neonatal mortality and severe morbidity, as defined by one or more of the following: death before discharge, admission to neonatal intensive care unit, 5-minute Apgar score <7, cord blood pH <7.10, or birth trauma. RESULTS: Cesarean delivery was planned for 71 (36.4%) patients, and attempted vaginal delivery for 124 (63.6%), 59 (47.6%) of whom were delivered vaginally and 65 (52.4%) by cesarean during labor. Neither the combined negative outcome indicator nor neonatal mortality differed significantly for either twin or either group. There were no significant differences in maternal mortality or morbidity between the two groups. The frequency of deep vein thrombophlebitis or pulmonary embolism requiring anticoagulant therapy was significantly higher in the planned cesarean group [3/71 (4.2%) versus 0/124; p=0.047]. CONCLUSION: When appropriate criteria are used to decide mode of delivery, a careful intrapartum protocol is followed, and an experienced obstetrician, midwife, and anesthesiologist are in attendance, attempted vaginal delivery is a reasonable option for first twins in breech position.     

Neonatal death and morbidity in vertex-nonvertex second twins according to mode of delivery and birth weight

OBJECTIVE: The purpose of this study was to assess the risk of neonatal death and morbidity in vertex-nonvertex second twins according to the mode of delivery and birth weight. STUDY DESIGN: Data from a retrospective cohort study that was based on all twin births in the United States (1995-1997) were used. RESULTS: A total of 15,185 vertex-nonvertex second twins were classified into 3 groups: (1) both twins were delivered by cesarean delivery (37.7%), (2) both twins were delivered vaginally (46.8%), and (3) the second twin was delivered by cesarean delivery after vaginal delivery of the first twin (15.5%). The risk of asphyxia-related neonatal deaths and morbidity was increased in the group in which both twins were delivered vaginally and the group in which both twins were delivered by cesarean delivery. The increase in neonatal death in the group in which both twins were delivered vaginally was stronger in the birth weight of < 1500 g. In contrast, in the group in which both twins were delivered vaginally and the group in which the second twin was delivered by cesarean delivery after the first twin was delivered vaginally, the increase in neonatal morbidity was greater in the group in which the birth weight was 1500 to 4000 g. CONCLUSION: The risk of neonatal death and morbidity in second-born twins is higher in the group in which both twins were delivered vaginally and the group in which the second twin was delivered by cesarean delivery after the first twin was delivered vaginally compared with the group in which both twins were delivered by cesarean delivery.     

A comparison of the neonatal morbidity of second twins to that of a low-risk population

OBJECTIVE: To assess the neonatal morbidity of second twins. STUDY DESIGN: Cohort study in a department of perinatalogy. The neonatal morbidity of second twins was compared to that of a low-risk population: singletons in the cephalic presentation delivered vaginally. RESULTS: Five hundred fifty-nine second twins and 18,061 vaginally delivered singletons in the cephalic presentation were studied. Of 452 (81%) second twins delivered vaginally, 310 (69%) were extracted using obstetrical maneuvers: internal version and breech extraction, breech extraction alone, or assisted breech delivery if the breech was already engaged. Before 33 weeks of gestation, there was no significant difference between the neonatal morbidity of the vaginally delivered second twins and the vaginally delivered singletons in the cephalic presentation. After 33 weeks of gestation, only the 1-min Apgar score <7 and the rate of intubation at birth were significantly higher in the second twins. Whatever the gestational age, there was no significant difference between the neonatal morbidity of the vaginally delivered second twins and that of the second twins born by cesarean section before labor. At comparable gestational ages, there was no significant difference between the death rate of the vaginally delivered second twins and that in the reference population. CONCLUSION: The neonatal morbidity of second twins was comparable to that of a low-risk population. Immediate management of the vaginally delivered second twins was, however, more intensive than that of vaginally delivered singletons in the cephalic presentation. It, therefore, requires appropriate equipment in a suitable obstetric-pediatric setting.     

Extremely preterm vaginal breech delivery en caul

OBJECTIVE: To describe an alternative method of vaginal birth to the conventional assisted delivery for extremely preterm breech infants within intact amnions, and to compare the immediate neonatal outcomes with those delivered by cesarean. METHODS: Retrospective review of singleton breech deliveries under 26 weeks' gestation after spontaneous labor with intact membranes. Nine "en caul" vaginal births after tocolysis and six cesarean deliveries performed for the sole indication of preterm labor were identified between 1996 and 2001. RESULTS: The vaginal group's mean gestation and cervical dilatation on admission were 23(+6) weeks and 3.2 cm, respectively, and 24(+6) weeks and 2.8 cm in the cesarean group. Vaginal delivery occurred an average of 4 days after admission and 1 day for cesarean delivery. Mean time interval between the first corticosteroid injection and delivery was greater in the vaginal group (90 versus 22 hours). Failure to start or complete a steroid course was more likely in the operative group (67% versus 11%). Mean birth weights were comparable. Five-minute Apgar scores and cord pHs were 6 and 7.41, respectively, for vaginal births, and 5.5 and 7.32 after cesarean deliveries. Fifty-five percent of vaginally delivered infants had a 5-minute Apgar score less than 7, with 22% of the whole group dying during the first week of life. This compared with 66% and 50%, respectively, for cesarean infants. Of the survivors, average age at discharge was 121 days for both groups. CONCLUSION: Vaginal birth can be effected in extremely preterm breech pregnancies with intact membranes by adopting the "en caul" delivery method.     

Intrapartum influences on cesarean delivery in multiple gestation

OBJECTIVE: To evaluate which intrapartum factors influence the method of delivery in a group of twin pregnancies eligible for vaginal delivery. STUDY DESIGN: Over a 10-year period, 967 consecutive twin pregnancies at gestational age >/=32 weeks with twin A presenting as a vertex and eligible for vaginal delivery were reviewed. Excluded were 40 (4.1%) patients who underwent a repeat and elective cesarean section. All patients who underwent a cesarean section were placed into one of two groups according to the method of delivery of both twins: group 1, cesarean section/cesarean section delivery; and group 2, vaginal/cesarean section delivery. The impact of the following intrapartum factors on the type of delivery were assessed: (1) presentation of the 2nd twin: vertex vs. breech vs. other; (2) experience of the obstetrician: 10 years in practice; (3) multiparity: nulliparous vs. multiparous; (4) incidence of epidural usage; (5) induction vs. spontaneous labor; and (6) difference in fetal weight between twin B and twin A: /= 25% difference. The chi-square statistic was used to compare differences in the incidence of cesarean section between the groups. RESULTS: Total incidence of cesarean section was 266/927 (28.7%). Risk of delivering by a combined vaginal delivery and cesarean section was reduced if the presentation of twin B was vertex or breech (RR: 0.114; 95% confidence interval: 0.049-0.266) or if an epidural was used (RR: 0.380; 95% confidence interval: 0.163-0.883). In twin gestations eligible for vaginal delivery the risk of requiring delivery by cesarean section for both twins is reduced if the presentation of twin B was vertex (RR: 0.782; 95% confidence interval; 0.631-0.968), if an epidural was used (RR: 0.461; 95% confidence interval: 0.375-0.566), or if the birthweight discrepancy was 相似文献   

Delivery of breech first twins: a multicenter retrospective study

OBJECTIVE: To assess the risk of vaginal birth of breech first twins by Apgar scores and mortality. METHODS: We did a retrospective case-control analysis of data from 13 centers that allow vaginal birth for breech first twins. We used depressed 5-minute Apgar scores and neonatal mortality as main outcome measures between vaginal (n = 239) and cesarean (n = 374) deliveries of pairs with breech first twins, stratified by parity, birth weights of first twins, and types of cesarean. The 95% power of our sample size (alpha = .05) was sensitive enough to detect differences of 5% of the overall sample and 25-30% of subgroups. RESULTS: Vaginal birth was attempted in 61% of 613 pairs. There were significantly more depressed Apgar scores (P = .008, odds ratio [OR] 2.4, 95% confidence interval [CI] 1.2, 4.7) and neonatal deaths (P < .001, OR 9.5, 95% CI 4.0, 23.4) among vaginal births of pairs in whom first twins weighed less than 1500 g but not among the higher-birth-weight cohort (for depressed Apgar scores: P = .76, OR 1.1, 95% CI 0.6, 2.1). Multiparity and elective cesarean seemed to have little influence on outcome measures. Neonatal mortality was associated with extremely preterm twins. CONCLUSION: There was no evidence that vaginal birth is unsafe, in terms of depressed Apgar scores and neonatal mortality, for breech first twins that weighed at least 1500 g.     

Comparison of vaginal and cesarean section delivery for fetuses in breech presentation

OBJECTIVES: Our purpose was to evaluate the perinatal mortality and morbidity of deliveries with fetuses presenting by the breech comparing outcomes of two groups according to mode of delivery: vaginal and cesarean section. RESULTS: Of 756 fetuses studied, 271 were delivered vaginally and 485 by cesarean section. In infants weighing > or = 1500 grams, "further corrected" mortality and morbidity rates were low and similar for both delivery routes: one neonatal death (NNM) in each. Among very low birth weight (VLBW) infants (< 1500 grams) the "further corrected" mortality rate was higher in the vaginal group: 57.4%, and 18.0% in abdominal deliveries (odds ratio [OR] = 6.1, 95% CI: 3.1 to 12.1). Likewise, rate of depression at five minutes were higher in the vaginal group (p < 0.001). However, the average fetal weight among the vaginal deliveries VLBW (787 grams) was 250 grams less than in the cesarean section group (1040 grams). After adjustment for fetal weight, gestational age, and other prognostic variables the odds ratio for neonatal death was no longer statistically significant (adjusted OR = 2.1, 95% CI: 0.9 to 5.2, p = 0.105). Comparison of planned vaginal delivery with elective cesarean section yielded smaller differences (adjusted OR for neonatal death = 1.3, 95% CI: 0.6 to 2.9, p = 0.525). CONCLUSION: The poor perinatal outcomes of breech delivered infants are due primarily to VLBW, congenital malformations, and premature labor. Although abdominal delivery had a lower NNM rate than vaginal delivery, the difference was not significant after adjustment for confounding factors. The results confirm the findings of a previously analyzed similar series delivered at our institution between 1980 and 1987. They suggest that, with appropriate technique, abdominal delivery is not mandatory in breech presentation.     

Intracranial hemorrhage in low-birth-weight twins during neonatal period

Since twins have a higher incidence of premature birth, fetal distress, asphyxia and other pre- and intrapartum high-risk factors, it is reasonable to expect that they may be vulnerable to intracranial hemorrhage. Forty-seven pairs of low-birth-weight twins were studied during the newborn period by serial cranial ultrasound. The comparisons of groups, based on birth order, relative size of the neonates, and the mode of delivery, showed no significant differences in the incidence of intracranial hemorrhage between first and second twins, smaller and larger twins, or vaginal and cesarean delivery. However, the comparison based on the presentation of the infant revealed a significantly higher number of intracranial hemorrhages within the first week of life in the breech group than in the cephalic presentation group. The adverse effect of breech presentation on intracranial hemorrhage did not appear to be mediated by the well recognized risk factors such as lower gestational age, lower Apgar scores, and higher incidence of respiratory distress syndrome and assisted ventilation. Since most of the twins with ICH had breech presentation and were delivered by cesarean section, this mode of delivery does not seem to protect the twins with breech presentation from intracranial hemorrhage.     

Safety of term vaginal breech delivery

Of 247 women who were pregnant of one healthy child in breech presentation at term, 13 (5.3%) were delivered by a primary cesarean section. The other 234 (94.7%) were allowed to attempt vaginal birth. In these women, the only factor to determine the possibility of a vaginal delivery was normal progression of labor during the first stage, without secondary arrest or signs of fetal distress. 109 Women (44.1%) were delivered spontaneously according to Bracht, 87 (35.2%) had an assisted breech delivery, and 38 (15.4%) underwent a secondary cesarean section. There were two perinatal deaths (0.8%). One of them was directly related to the trial of labor. Two children with a birth trauma had an uneventful recovery. The 1 min Apgar score in all breech delivery groups was more often lower than in a control group of children, who were born spontaneously at term in vertex presentation. However, the 5 min Apgar score and the mean umbilical artery pH were within normal limits in all groups. The secondary cesarean section rate was inversely related to vaginal parity of the mother, and directly related to the newborns' birth weight. There was no relation between the secondary cesarean section rate and the type of breech presentation. It is concluded, that a trial of labor in carefully selected patients with a child in breech presentation at term is a safe procedure, that can be successfully completed in almost 80% of cases. In retrospect, low vaginal parity and high birth weight of the newborn have a negative influence on normal progression of labor.     

Prognosis for twins with birth weight less than 1500 gm: the impact of cesarean section in relation to fetal presentation

The purpose of this study of twins weighing less than 1500 gm was to evaluate the impact of cesarean section on intrapartum and neonatal mortality, as well as on cerebral palsy and mental retardation. National data held at the Medical Birth Registry was used for identification of cases. The original medical records were retrieved for 862 such twins born between 1973 and 1983. Twins with cerebral palsy and/or mental retardation born between 1973 and 1980 were identified by questionnaires to all rehabilitation centers for disabled children, offices for the Provision of Care for the Mentally Retarded, and to all local Boards of Education throughout Sweden. The analyses, including calculation of relative risk and 95% confidence interval, were performed after stratification for birth weight (250 gm classes) and period of delivery (1973 to 1976, 1977 to 1980, 1981 to 1983). The cesarean section rate increased from 7.7% (1973 to 1976), and 40.5% (1977 to 1980) to 68.9% (1981 to 1983). Concomitantly, intrapartum and neonatal mortality decreased markedly (51.7% to 29.1%) particularly for twin II but to a much lesser extent for twin I. The relative risk for intrapartum and neonatal mortality (vaginal/abdominal birth) did not increase significantly for twin I in vertex presentation (relative risk 2.0, 95% confidence limits 0.9 to 4.3), for twin I in breech presentation (relative risk 1.8, 95% confidence limits 0.7 to 4.3), for twin II in vertex presentation (relative risk 0.6, 95% confidence limits 0.2 to 1.6), or for twin II in breech presentation (relative risk 1.5, 95% confidence limits 0.7 to 3.0). The rate of cerebral palsy and/or mental retardation was 8.8% during 1973 to 1976 and 8.0 during 1977 to 1980 (chi 2 = 0.1, p greater than 0.05). For twins born in breech presentation the handicap rate in the first period (cesarean section rate 6.0%) was the same as in the second period (cesarean section rate 59.6%). The analysis failed to reveal any significant impact of abdominal birth on the fetal outcome for low-birth-weight twins, even when fetal presentation was taken into consideration.     

The second-born twin: Can we improve outcomes?

OBJECTIVE: Second-born twin outcome was compared with that of the first-twin birth mate to determine whether there were differences, the reason for the differences, if any, and the clinical decisions that could be made to eliminate or ameliorate these differences. STUDY DESIGN: Twin pregnancies from 1989 through 1992 were retrospectively reviewed. Charts demonstrating both twins stillborn, either twin weighing <500 gm, or either twin with a serious congenital anomaly were excluded from evaluation. After these exclusions 200 twin pairs remained for analysis. Each twin was compared directly with its birth mate. The first twin is postulated as having the best possible outcome for the pregnancy involved, and second-twin outcomes are compared with these. RESULTS: The second-born twin was more likely to be intubated, have respiratory distress syndrome, need resuscitation, and have lower 5-minute Apgar scores. Second-born twins had more nursery complications. The <1500 gm group appeared to be at special risk. In this group there were more second-born twin neonatal deaths and much higher rates of intubation and resuscitation. Nonvertex presentation in the second-born twin increased chances for resuscitation, intubation, respiratory distress syndrome, and nursery complications. These outcomes in the second-born were not affected by cesarean delivery. CONCLUSIONS: The second-born twin is at increased risk of untoward outcome compared with its birth mate. Some of this risk can be attributed to birth weight. The risk posed by nonvertex presentation is small. Cesarean section delivery does not appear to eliminate the difference between first- and second-twin outcome. Prospective studies are needed. (AM J Obstet Gynecol 1994;170:1649-57.)     

Intrapartum management of twin gestations

A trial of labor and vaginal delivery are usually indicated in vertex-vertex twins. For vertex-nonvertex twins, vaginal birth is preferred, with the second twin being delivered by breech extraction, unless it is significantly larger than the first. Cesarean delivery is indicated if the first twin is nonvertex and for all cases of monoamniotic or potentially viable conjoined twins. There is a limited role for trial of labor after cesarean delivery in twin gestations. In my opinion, combined vaginal-cesarean birth is the riskiest method for mother and infants and should be avoided if possible.     

Vaginal birth after cesarean section at the University of Texas.

Vaginal delivery was successful in 76% of the 242 women who underwent a trial of labor after cesarean section in a prior pregnancy. Separation of the uterine scar occurred in four women (1.7%). Women whose prior cesarean section was for breech presentation had the highest rate of successful vaginal delivery (86%). The vaginal delivery rates were similar in women who delivered infants with birth weights > or = 4,000 g (73%) and < 4,000 g (76%). The use of epidural anesthesia and oxytocin may enhance the success of vaginal delivery in women undergoing a trial of labor following an earlier cesarean section.     

Modes of delivery of first and second twins as a function of their presentation. Study of 614 consecutive patients from 1992 to 2000

Objectives

To study modes of delivery and neonatal morbidity of twins as a function of their presentation.

Study design

The study related to 614 consecutive patients who gave birth to twins in the maternity ward of the Hôpital Robert Debré from 1992 to 2000. Group A (n = 529) included patients who gave birth after 33 weeks of gestation and group B (n = 85) before 33 weeks. The parameters studied were the mode of delivery, the need for intubation at birth, 5-min Apgar score <9, transfer to intensive care, death in the neonatal period. The chi-square test was used for statistical analysis.

Results

In group A, significantly more cesarean sections were performed for breech–breech (22.6%) and breech–vertex (16%) presentations than for vertex–vertex (10.3%) and vertex–breech (4.6%) presentations. In group B, there was no significant difference in the rate of vaginal delivery. Second vertex twins of group A had significantly higher frequencies of intubation (3%) at birth and transfer to intensive care (3%) than the vertex first twins born by vaginal delivery (p = 0.01). These percentages were not significantly different from those observed for the second twins born by planned Cesarean section before the start of labor (2.8 and 5.6%, respectively). In group B, neonatal parameters did not differ significantly with the type of presentation at delivery.

Conclusions

The type of presentation should not influence the choice of mode of delivery of twin pregnancies, whatever the gestational age.