The association of parity with mortality outcomes among triplets

OBJECTIVE: The purpose of this study was to evaluate the association of parity with stillbirth and neonatal and infant death among triplets. STUDY DESIGN: This was a retrospective cohort study of 15,930 triplets who were delivered in the United States between 1995 and 1997. Infants of nulliparous mothers were compared with infants of multiparous mothers. Adjusted relative risks for death by parity were computed with the use of the generalized estimating equations framework. RESULTS: The likelihood for stillbirth (odds ratio, 3.40; 95% CI, 2.20-5.26) was significantly greater among nulliparous mothers. Neonatal (odds ratio, 1.17; 95% CI, 0.95-1.43) and infant mortality rates (odds ratio, 1.10; 95% CI, 0.92-1.32) were comparable, however. With an increase in parity, there was a consistent declining trend in the risk for stillbirth (P<.0001). CONCLUSION: Nulliparity more than triples the risk for intrauterine fetal death among triplets. This parity-related disparity underscores the need for care providers to be particularly concerned about triplet gestations among nulliparous mothers.     

Vaginal breech delivery of selected infants weighing more than 2000 grams. A retrospective analysis of seven years' experience

This retrospective study analyzes 580 term and near-term singleton pregnancies complicated by breech presentation from 1976 through 1982. Vaginal delivery was achieved in 174 patients (30%), 135 of which were selectively allowed a trial of labor. Six infant deaths occurred (1%); all were neonatal deaths directly related to lethal congenital anomalies, for a corrected neonatal mortality rate of 0%. No significant difference was found in the incidence of low Apgar scores, traumatic birth injury, or requirement for neonatal resuscitation between those infants delivered by cesarean section and those delivered vaginally. Although no maternal deaths occurred, cesarean section was associated with a 38-fold increase in significant maternal morbidity. These data suggest that with careful patient selection and fetal monitoring, vaginal delivery of the term or near-term breech infant remains a real alternative to routine cesarean delivery of all breech infants. A selection and management protocol is proposed.     

Perinatal,postnatal, and maternal outcome parameters of triplet pregnancies according to the planned mode of delivery: results of a single tertiary center

Objective.?To compare the maternal and perinatal outcome of triplet pregnancies delivered by cesarean section with those delivered vaginally and to assess whether a vaginal delivery of triplets is still acceptable among women who are interested in further births.

Study design.?A retrospective analysis of 73 triplet pregnancies delivered at ≥28 week between 1997 and 2005 in a single tertiary center. Twenty-six triplets planned for a trial of labor were compared with 47 sets of women with triplet gestations who delivered by scheduled cesarean section.

Results.?Mean gestational age was 33.1?±?2.9 and 33.4?±?2.6 weeks for the vaginal and cesarean groups, respectively (NS). 88.4% of the vaginally-intended group had a successful vaginal delivery of all three newborns. There were four cases of mortality among the triplets that underwent a vaginal trial of labor (50/1000) but none in the planned cesarean delivery group. Neonatal and maternal complication rates were not different between the groups.

Conclusion.?According to the relatively small number of patients included in this study, the safety of vaginal delivery should be considered uncertain. Vaginal delivery for triplets might be possible just in particular cases, >28 weeks, with future risks for further pregnancies, after thorough consult with the couple and under strict protocol.     

Neonatal morbidity and mortality associated with triplet pregnancy

Objective: To compare neonatal morbidity and mortality in a large cohort of triplet pregnancies with singleton and twin neonates managed at a single tertiary center over a short time.Methods: Records from all triplet pregnancies managed and delivered from 1992 to 1996 were reviewed for neonatal outcome data. Pregnancies delivered before 20 weeks' gestation and neonates with lethal congenital anomalies were excluded. The comparison group comprised all singleton and twin neonates managed in the same neonatal intensive care unit (NICU) during the same period.Results: During the 5-year period, 55 triplet pregnancies and their resulting 165 neonates were managed and delivered at this center. Their outcomes were compared with those of 959 singleton and 357 twin neonates born at similar gestational ages. The median gestational age at delivery for triplets was 32.1 weeks, and 149 of the 165 infants were admitted. Sixteen triplet neonates were not admitted to our neonatal intensive care unit, 12 because of previable gestational age, three because of stillbirth, and one because of a lethal congenital anomaly. The crude perinatal mortality rate in triplets was 121 per 1000 births, and there was no significant difference in outcome based on triplet birth order. There were no significant differences in survival rates between singleton, twin, and triplet neonates, with an overall neonatal survival of 95%, 95%, and 97%, respectively. The only significant differences in morbidity were an increased incidence of mild intraventricular hemorrhage (relative risk [RR] 6.20; 95% confidence interval [Cl] 2.64, 14.61), mild retinopathy of prematurity (RR 20.05; 95% CI 3.59, 111.79), and severe retinopathy of prematurity (RR 46.69; 95% CI 6.25, 348.85) in triplets compared with singletons, and severe retinopathy of prematurity (RR 6.83; 95% CI 1.24, 37.56) in triplets compared with twins.Conlusion: When stratified by gestational age, triplet neonates delivered at 24–34 weeks' gestation have similar outcomes as singleton and twin neonates, with the only clinically significant difference being an increased incidence of retinopathy of prematurity in triplets.     

Incidence of stillbirth and perinatal mortality and their associated factors among women delivering at Harare Maternity Hospital, Zimbabwe: a cross-sectional retrospective analysis

BACKGROUND: Death of an infant in utero or at birth has always been a devastating experience for the mother and of concern in clinical practice. Infant mortality remains a challenge in the care of pregnant women worldwide, but particularly for developing countries and the need to understand contributory factors is crucial for addressing appropriate perinatal health. METHODS: Using information available in obstetric records for all deliveries (17,072 births) at Harare Maternity Hospital, Zimbabwe, we conducted a cross-sectional retrospective analysis of a one-year data, (1997-1998) to assess demographic and obstetric risk factors for stillbirth and early neonatal death. We estimated risk of stillbirth and early neonatal death for each potential risk factor. RESULTS: The annual frequency of stillbirth was 56 per 1,000 total births. Women delivering stillbirths and early neonatal deaths were less likely to receive prenatal care (adjusted relative risk [RR] = 2.54; 95% confidence intervals [CI] 2.19-2.94 and RR = 2.52; 95% CI 1.63-3.91), which for combined stillbirths and early neonatal deaths increased with increasing gestational age (Hazard Ratio [HR] = 3.98, HR = 7.49 at 28 and 40 weeks of gestation, respectively). Rural residence was associated with risk of infant dying in utero, (RR = 1.33; 95% CI 1.12-1.59), and the risk of death increased with increasing gestational age (HR = 1.04, HR = 1.69, at 28 and 40 weeks of gestation, respectively). Older maternal age was associated with risk of death (HR = 1.50; 95% CI 1.21-1.84). Stillbirths were less likely to be delivered by Cesarean section (RR = 0.64; 95% CI 0.51-0.79), but more likely to be delivered as breech (RR = 4.65; 95% CI 3.88-5.57, as were early neonatal deaths (RR = 3.38; 95% CI 1.64-6.96). CONCLUSION: The frequency of stillbirth, especially macerated, is high, 27 per 1000 total births. Early prenatal care could help reduce perinatal death linking the woman to the health care system, increasing the probability that she would seek timely emergency care that would reduce the likelihood of death of her infant in utero. Improved quality of obstetric care during labor and delivery may help reduce the number of fresh stillbirths and early neonatal deaths.     

Infant and Neonatal Mortality for Primary Cesarean and Vaginal Births to Women with “No Indicated Risk,” United States, 1998–2001 Birth Cohorts

ABSTRACT: Background: The percentage of United States’ births delivered by cesarean section has increased rapidly in recent years, even for women considered to be at low risk for a cesarean section. The purpose of this paper is to examine infant and neonatal mortality risks associated with primary cesarean section compared with vaginal delivery for singleton full‐term (37–41 weeks’ gestation) women with no indicated medical risks or complications. Methods: National linked birth and infant death data for the 1998–2001 birth cohorts (5,762,037 live births and 11,897 infant deaths) were analyzed to assess the risk of infant and neonatal mortality for women with no indicated risk by method of delivery and cause of death. Multivariable logistic regression was used to model neonatal survival probabilities as a function of delivery method, and sociodemographic and medical risk factors. Results: Neonatal mortality rates were higher among infants delivered by cesarean section (1.77 per 1,000 live births) than for those delivered vaginally (0.62). The magnitude of this difference was reduced only moderately on statistical adjustment for demographic and medical factors, and when deaths due to congenital malformations and events with Apgar scores less than 4 were excluded. The cesarean/vaginal mortality differential was widespread, and not confined to a few causes of death. Conclusions: Understanding the causes of these differentials is important, given the rapid growth in the number of primary cesareans without a reported medical indication. (BIRTH 33:3 September 2006)     

Racial disparity in stillbirth among singleton, twin, and triplet gestations in the United States

OBJECTIVE: We investigated the relationship between maternal race and stillbirth among singletons, twins, and triplets. METHODS: We conducted a retrospective cohort study on 14,348,318 singletons, 387,419 twins, and 20,953 triplets delivered in the United States from 1995 through 1998. We compared the risk of stillbirth between pregnancies of black and those of white mothers using the generalized estimating equations framework to adjust for intracluster correlation in multiples. RESULTS: The proportion of black infants was 16%, 18%, and 8% among singletons, twins, and triplets, respectively. Crude stillbirth rate among singletons was 6.6 per 1,000 and 3.5 per 1,000 for black and white fetuses, respectively. Among twins, 796 stillbirths (11.6 per 1,000) were recorded for black mothers versus 3,209 stillbirths (10.1 per 1,000) among white mothers, whereas among triplets there were 233 stillbirths, of which 39 stillbirths were black fetuses (24.6 per 1,000) and 194 stillbirths were white fetuses (10.0 per 1,000). Black singletons, twins, and triplets weighed 278 g, 186 g, and 216 g less than white fetuses, respectively (P <.001). Risk of stillbirth was elevated in black fetuses compared with white fetuses among singletons (adjusted odds ratio [OR] 2.9, 95% confidence interval [CI] 2.8-3.0) and twins (OR 1.3. 95% CI 1.2-1.4) but comparable among triplets (OR 1.2, 95% CI 0.7-2.1). This decreasing trend was significant (P for trend <.001). CONCLUSION: The disparity of stillbirths between black and white fetuses still persists among singletons and twins. Among triplet gestations, however, the 2 racial groups have a comparable risk level. Our findings highlight the need for a rigorous research agenda to elucidate causes of stillbirth across racial/ethnic entities in the United States. LEVEL OF EVIDENCE: II-2     

Triplet infants with birthweight < or = 1250 grams: how well do they compare with twin and singleton infants at 36 to 48 months of age?

The purpose of this study was to determine if triplet infants with birthweight < or = 1250 g were at increased risk of long-term disability compared with similar birthweight and gestational age singletons and twins. This was a retrospective cohort study of < or = 1250-g infants admitted to a regional neonatal intensive care unit from 1986 to 2001 with follow-up to 36 to 48 months corrected gestational age. Outcomes studied were cognitive ability, cerebral palsy, and neurosensory impairment at 36 to 48 months. Enrollment was 1717 infants: 59 triplets, 402 twins, and 1256 singletons. Triplet infants differed from twin or singleton infants because they were more likely to have older, married mothers (relative risk [RR] 3.62, 95% CI 1.31, 5.94), be products of assisted reproductive technology pregnancies (RR 29.59, 95% CI 13.97, 62.68), be exposed to antenatal steroids (RR 1.55, 95% CI 1.38, 1.75), and were all delivered by cesarean section. Triplet infants had lower risk of having intraventricular hemorrhage (RR 0.19, 95% CI 0.05, 0.75). The risk of cerebral palsy, cognitive delay, total major disability, or chronic lung disease was similar in triplet and twin infants compared with singleton infants. The lower risk of having intraventricular hemorrhage in triplet infants may have been due to the use of antenatal corticosteroids and cesarean section delivery.     

Survival of triplets who are born to teen mothers in the United States

OBJECTIVE: The purposes of this study were to assess survival among triplets who are born to teen mothers and to determine whether fetal number influences the mortality rates of the offspring of teen mothers when compared with the offspring of older women. STUDY DESIGN: A retrospective cohort study of 354 triplet births to teenage mothers and 6858 to young mature mothers (20-29 years) who were delivered from 1995 through 1998. We compared the occurrence of stillbirth and neonatal and infant mortality rates between the 2 categories by means of the generalized estimating equation. Similar analyses were conducted for singleton pregnancies and twin pregnancies. RESULTS: Triplets of teenage mothers experienced a higher level of stillbirth (odds ratio, 3.24; 95% CI, 1.44-7.24), neonatal mortality (odds ratio, 2.00; 95% CI, 1.11-3.61), and infant death (odds ratio, 1.66; 95% CI, 1.01-2.87). Moreover, as the plurality increased from singleton infant to triplet, the offspring of teenagers fared progressively worse ( P < .0001). CONCLUSION: This study confirms the association between teenage motherhood and feto-infant death and indicates that this mortality relationship varies in a dose-dependent fashion.     

Safety of vaginal delivery in very low birthweight vertex singletons: a meta-analysis

Objective: The objective of this study is to assess the safety of vaginal delivery in VLBW singletons in the vertex presentation.

Methods: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Web of Science databases were searched for studies on mode of delivery and neonatal outcome in VLBW singletons in the vertex presentation. A total of 28 studies met our inclusion criteria.

Results: Vaginal delivery was not associated with an increase in overall neonatal mortality compared with cesarean delivery (OR 0.87, 95% CI 0.72–1.04). Vaginal delivery was associated with a significant decrease in mortality for the 1250–1500?g birthweight category (OR 0.57, 95% CI 0.36–0.92), while an increase in mortality in the 500–750?g category was not significant (OR 1.5, 95% CI 0.86–2.61). Severe intraventricular hemorrhage (IVH) was not associated with mode of delivery (OR 1.05, 95% CI 0.85–1.29), but the only two high quality study that assessed IVH of all grades found an increase in risk for IVH in vaginal delivery (OR 1.33, 95% CI 1.16–1.51).

Conclusions: Vaginal delivery does not appear to increase the risk for neonatal mortality. However, current available data on neonatal morbidity are limited. More high-quality studies are needed to assess the association between mode of delivery and neonatal morbidity.     

Stillbirth and infant mortality among Hispanic singletons, twins, and triplets in the United States

OBJECTIVE: We estimate the impact of increasing fetal number on fetal and infant mortality among Hispanic mothers. METHODS: Retrospective cohort study involving singletons, twins, and triplets delivered in the United States from 1995 through 2000, except for the analysis on infant mortality in singletons (1995 through 1999). Main outcome measures were stillbirth (> or = 20 weeks) and infant mortality (< 365 days). RESULTS: A total of 37,489,600 individual births were reviewed, consisting of 36,840,704 singletons, 613,930 twins, and 34,966 triplets. Hispanics accounted for 6,848,027 (18.6%) singletons, 85,887 (14.0%) individual twins, and 2,725 (7.8%) individual triplets. Among singletons, stillbirth (odds ratio [OR] 0.91, 95% confidence interval [CI] 0.90-0.92) and infant mortality (OR 0.85, 95% CI 0.84-0.86) were both lower in Hispanics than in whites. Among twins, Hispanics had a lower risk for infant mortality (OR 0.93, 95% CI 0.88-0.97) but a comparable risk for stillbirth (OR 1.06, 95% CI 0.98-1.13). Although the risk for infant mortality in Hispanic triplets was comparable to that of whites (OR 1.20, 95% CI 0.94-1.54), Hispanic triplets had a 50% higher likelihood of dying in utero (OR 1.50, 95% CI 1.06-2.14). CONCLUSION: Although Hispanic infants generally show better or comparable survival indices compared with whites, the risk for fetal and infant death in Hispanics increases in fetal number in a dose-dependent fashion, thereby obliterating the Hispanic advantage. The elevated risk for stillbirth among Hispanic triplets is particularly noteworthy and underscores the need for caution in making generalizations of favorable birth outcomes in Hispanics.     

Perinatal mortality in the normal siblings of anomalous triplets

OBJECTIVE: To estimate the risk of survival of unaffected cofetuses of anomalous triplets. METHODS: Retrospective cohort study of triplets delivered in the United States from 1995 through 1998. Four triplet clusters were identified: cluster A (all members anomaly-free); cluster B (1 anomalous member); cluster C (2 anomalous members), and cluster D (all 3 members anomalous). We compared the risk for stillbirth and infant mortality among nonanomalous fetuses in clusters A, B, and C after adjusting for intracluster correlations. RESULTS: A total of 7,560 triplet clusters (98.9%) were analyzed after excluding cluster D (1.1%). The total stillbirth rate was 20.9 (cluster A), 61.0 (cluster B), and 81.1 (cluster C) per 1,000 (P for trend < .001), and infant mortality rate was 56.4 (cluster A), 108.8 (cluster B), and 196.1 (cluster C) per 1,000 (P for trend < .001). Using cluster A as the referent category, the risk for stillbirth among anomaly-free clustermates climbed with increase in the number of siblings with anomalies in a dose-response pattern (adjusted odds ratio, 95% confidence interval 1.5, 0.7-3.1, for cluster B; and 5.2, 1.4-18.8, for cluster C; P for trend = .03). For infant mortality, the only rise in risk was in cluster C (3.3, 1.6-6.7), whereas cluster B showed comparable risk with the referent category (0.8, 0.5-1.4; P for trend > .05). CONCLUSION: The presence of anomalous fetuses compromises the survival of normal cotriplets. These findings could prove useful for counseling affected parents and highlight the need for follow-up of normal coinfants of anomalous fetuses.     

Adverse perinatal outcomes among interracial couples in the United States

OBJECTIVE: We examined the association between parental race and stillbirth and adverse perinatal and infant outcomes. METHODS: We conducted a retrospective cohort analysis using the 1995-2001 linked birth and infant death files that are composed of live births and fetal and infant deaths in the United States. The study included singleton births delivered at 20 or more weeks of gestation with a fetus weighing 500 g or more (N = 21,005,786). Parental race was categorized as mother white-father white, mother white-father black, mother black-father white, and mother black-father black. Multivariable logistic regression analysis was performed to examine the association between parental race and risks of stillbirth (at > or = 20 weeks), small for gestational age (defined as birth weight < 5th and < 10th percentile for gestational age), and early neonatal (< 7 days), late neonatal (7-27 days), and postneonatal (28-364 days) mortality. All analyses were adjusted for the confounding effects of maternal age, education, trimester at which prenatal care began, parity, marital status, and smoking during pregnancy. RESULTS: Although risks varied across parental race categories, stillbirth was associated with a higher-than-expected risk for interracial couples: mother white-father black, relative risk (RR) 1.17 (95% confidence interval [CI] 1.10-1.26) and mother black-father white, RR 1.37 (95% CI 1.21-1.54) compared with mother white-father white parents. The RR for stillbirth was even higher among mother black-father black parents (RR 1.67, 95% CI 1.62-1.72). The overall patterns of association for small for gestational age births (< 5th and < 10th percentile) and early neonatal mortality were similar to those seen for stillbirth. CONCLUSION: There is an increased risk of adverse perinatal outcomes for interracial couples, including stillbirth, small for gestational age infants, and neonatal mortality. LEVEL OF EVIDENCE: II-2.     

Neonatal mortality and morbidity in vertex-vertex second twins according to mode of delivery and birth weight.

OBJECTIVE: To assess the risk of neonatal mortality and morbidity in vertex-vertex second twins according to mode of delivery and birth weight. STUDY DESIGN: Data from a historical cohort study based on a twin registry in the US (1995-1997) were used. Multivariate logistic regression was used to control for maternal age, race, marital status, cigarette smoking during pregnancy, parity, medical complications, gestational age, and other confounders. RESULTS: A total of 86 041 vertex-vertex second twins were classified into two groups: second twins delivered by cesarean section after cesarean delivery of first twin (C-C) (43.0%), second twins whose co-twins delivered vaginally (V-X) (57.0%). In infants of birth weight>or=2500 g group, the risks of noncongenital anomaly-related death (adjusted odds ratio (aOR): 4.64, 95% confidence interval (95% CI): 1.90, 13.92), low Apgar score (aOR: 2.39, 95% CI: 1.43, 4.14), and ventilation use (aOR: 1.31, 95% CI: 1.18, 1.47) were higher in the V-X group compared with the C-C group. No asphyxia-related neonatal deaths occurred in C-C group, whereas the incidence of this death was 0.04% in the V-X group. CONCLUSION: The risks of neonatal mortality and morbidity are increased in vertex-vertex second twins with birth weight>or=2500 g whose co-twins delivered vaginally compared with second twins delivered by cesarean section after cesarean delivery of first twin.     

Perinatal outcome in 41 sets of triplets

OBJECTIVE: To determine the perinatal outcome associated with triplet pregnancies and to compare abdominal delivery with vaginal delivery. METHODS: Retrospective analysis of maternal and neonatal medical records of 41 triplets. 21 were delivered vaginally and 20 were delivered by cesarean section. MAIN OUTCOME: To measure perinatal mortality and early neonatal complications. RESULTS: Between January 1, 1994, and June 30, 1999, there were 41 triplets delivered at our institution. Of these 21 triplets were delivered vaginally and 20 triplets were delivered abdominally. The perinatal mortality rate was 32/123 (26.0%), primarily due to the respiratory distress syndrome. The perinatal deaths are mainly at a birth weight of 500-1,500 g (29/32; 90.6%). Breech presentation was associated with a significantly higher perinatal mortality rate than vertex presentation (62.5 vs. 37.5%). Cesarean delivery was associated with a higher perinatal mortality rate than vaginal delivery (30.0 vs. 22. 2%). CONCLUSIONS: Abdominal delivery in triplets is not superior to vaginal delivery in terms of fetal and early neonatal outcome. The perinatal deaths are increased with low birth weight (500-1,500 g) and with breech presentation. The main cause of neonatal mortality is the respiratory distress syndrome.     

Neonatal Mortality for Primary Cesarean and Vaginal Births to Low‐Risk Women: Application of an “Intention‐to‐Treat” Model

ABSTRACT: Background: The percentage of United States births delivered by cesarean section continues to increase, even for women considered to be at low risk for the procedure. The purpose of this study was to use an “intention‐to‐treat” methodology, as recommended by a National Institutes of Health conference, to examine neonatal mortality risk by method of delivery for low‐risk women. Methods: Low‐risk births were singleton, term (37–41 weeks’ gestation), vertex births, with no reported medical risk factors or placenta previa and with no prior cesarean section. All U.S. live births and infant deaths for the 1999 to 2002 birth cohorts (8,026,415 births and 17,412 infant deaths) were examined. Using the intention‐to‐treat methodology, a “planned vaginal delivery” category was formed by combining vaginal births and cesareans with labor complications or procedures since the original intention in both cases was presumably a vaginal delivery. This group was compared with cesareans with no labor complications or procedures, which is the closest approximation to a “planned cesarean delivery” category possible, given data limitations. Multivariable logistic regression was used to model neonatal mortality as a function of delivery method, adjusting for sociodemographic and medical risk factors. Results: The unadjusted neonatal mortality rate for cesarean deliveries with no labor complications or procedures was 2.4 times that for planned vaginal deliveries. In the most conservative model, the adjusted odds ratio for neonatal mortality was 1.69 (95% CI 1.35–2.11) for cesareans with no labor complications or procedures, compared with planned vaginal deliveries. Conclusions: The finding that cesarean deliveries with no labor complications or procedures remained at a 69 percent higher risk of neonatal mortality than planned vaginal deliveries is important, given the rapid increase in the number of primary cesarean deliveries without a reported medical indication. (BIRTH 35:1 March 2008)     

Premature rupture of membranes and early mortality among triplets in the United States

OBJECTIVES: We investigated the relationship between premature rupture of the membranes (PROM) and early mortality among triplets in the United States. STUDY DESIGN: Analysis was conducted on matched and linked triplet sets born to mothers in the United States between 1995 and 1997. The generalized estimating equation framework was used to generate odds ratios after capturing the effects of sibling correlations within triplet clusters. RESULTS: Triplets exposed to PROM were twice as likely to experience stillbirth (OR=2.17, 95% CI [1.26-3.41]), neonatal death (OR=2.23, 95% CI [1.70-3.0]) and infant death (OR=2.21, 95% CI [1.72-2.85]), as compared to those who did not. The population-attributable risk for early mortality due to PROM was 11-12%. CONCLUSIONS: Triplets associated with PROM had a significantly higher level of early mortality than those without. Assuming a causal relationship, 11-12% of all early deaths among triplets in the United States are accounted for by PROM.     

Perinatal mortality and route of delivery in term breech presentations

Objective To compare intrapartum related infant mortality in term (> 34 weeks) breech presentations in relation to vaginal delivery or delivery by caesarean section.
Design Register based nationwide study.
Setting Sweden from 1991 to 1992.
Participants 6542 singleton fetuses born in the breech presentation.
Main outcome measures Intrapartum and early neonatal deaths, stillbirths and congenital malformations, low Apgar score < 7 at 5 min, mode of delivery.
Results After exclusion of antepartum stillbirths and congenital malformation, the intrapartum and early neonatal mortality rate was 2/2248 (0.09%) in the group delivered vaginally and 2/4029 (0.05%) in the group delivered by caesarean section. The relative risk was 1.81 (95% CI 0.26–12.84). Thus the difference was not statistically significant. This result was further supported after reviewing individual cases.
Conclusions The intrapartum related mortality in the group delivered vaginally was low and the result could not verify an increased mortality in term breech presentations delivered vaginally compared with those delivered by caesarean section.     

A Review of 19 Sets of Triplets: The Positive Results of Vaginal Delivery

Summary: The outcome of 19 triplet pregnancies delivered at Waikato Women's Hospital is analyzed, with particular regard to the mode of delivery. During the period 1981–1992 the incidence of triplets was 1:1,945. Twelve sets of triplets were delivered by Caesarean section (63%) with 6 perinatal deaths occurring in this group, compared to none in 7 sets of triplets delivered vaginally (37%).
All triplet pregnancies were correctly diagnosed antenatally by ultrasound examination at a mean gestational age of 19 weeks (range 11–28 weeks). The most common antenatal complications were preterm labour in 18 pregnancies (95%) and preeclampsia in 4 (21%). The mean gestation at delivery was 33 weeks (range 25–39 weeks).
The outcome of triplet pregnancies was better in the group that delivered vaginally than those delivered by Caesarean section. Greater maturity of the infants delivered vaginally appeared to be the major factor for the lower neonatal morbidity and mortality.     

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.