Document Detail

Mode of delivery in non-cephalic presenting twins: a systematic review.
Jump to Full Text
MedLine Citation:
PMID:  22465994     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
PURPOSE: This systematic review aims to determine if there are evidence-based recommendations for the optimal mode of delivery for non-cephalic presenting first- and/or second twins. We investigated the impact of the mode of delivery on neonatal outcome for twin deliveries with (1) the first twin (twin A) in non-cephalic presentation, (2) the second (twin B) in non-cephalic presentation and (3) both twins in non-cephalic presentation.
METHODS: A computer-aided search of Medline, Embase, Cinahl and Cochrane databases was carried out and quality of the studies was assessed with the Cochrane Collaboration's tool for assessing risk of bias and the GRADE approach.
RESULTS: One high-quality clinical trial (60 twin pairs) and 16 moderate/low-quality observational studies (3,167 twin pairs) showed no difference in neonatal outcome between vaginal and caesarean delivery in twin A and/or B.
CONCLUSION: Our results do not suggest benefit of caesarean over vaginal delivery for selected twin gestations with twin A and/or twin B in non-cephalic presentation. However, no final conclusion can be drawn due to the small sample sizes and statistic limitations of the included studies. Randomized studies with sufficient power are required to make a strong recommendation.
Authors:
Charlotte N Steins Bisschop; Tatjana E Vogelvang; Anne M May; Nico W E Schuitemaker
Related Documents :
6625114 - Impetigo herpetiformis and pustular psoriasis during pregnancy.
9137654 - A young female with a cholangiocarcinoma in the past: is pregnancy allowed?
14698824 - Maternal and fetal outcome in valvular heart disease.
2409254 - Nonobstetric surgery during pregnancy.
7246084 - Smoking in pregnancy. effects on the birth weight and on thiocyanate concentration in m...
22900184 - No relationship between maternal iron status and postpartum depression in two samples i...
Publication Detail:
Type:  Journal Article; Review     Date:  2012-04-01
Journal Detail:
Title:  Archives of gynecology and obstetrics     Volume:  286     ISSN:  1432-0711     ISO Abbreviation:  Arch. Gynecol. Obstet.     Publication Date:  2012 Jul 
Date Detail:
Created Date:  2012-06-13     Completed Date:  2012-12-07     Revised Date:  2013-06-26    
Medline Journal Info:
Nlm Unique ID:  8710213     Medline TA:  Arch Gynecol Obstet     Country:  Germany    
Other Details:
Languages:  eng     Pagination:  237-47     Citation Subset:  IM    
Affiliation:
Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands. c.n.steinsbisschop@umcutrecht.com
Export Citation:
APA/MLA Format     Download EndNote     Download BibTex
MeSH Terms
Descriptor/Qualifier:
Apgar Score
Breech Presentation / therapy*
Cesarean Section
Delivery, Obstetric / methods*
Female
Humans
Pregnancy
Pregnancy, Twin
Comments/Corrections

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): Arch Gynecol Obstet
Journal ID (iso-abbrev): Arch. Gynecol. Obstet
ISSN: 0932-0067
ISSN: 1432-0711
Publisher: Springer-Verlag, Berlin/Heidelberg
Article Information
Download PDF
© The Author(s) 2012
Received Day: 18 Month: 11 Year: 2011
Accepted Day: 6 Month: 3 Year: 2012
Electronic publication date: Day: 1 Month: 4 Year: 2012
pmc-release publication date: Day: 1 Month: 4 Year: 2012
Print publication date: Month: 7 Year: 2012
Volume: 286 Issue: 1
First Page: 237 Last Page: 247
ID: 3374120
PubMed Id: 22465994
Publisher Id: 2294
DOI: 10.1007/s00404-012-2294-6

Mode of delivery in non-cephalic presenting twins: a systematic review
Charlotte N. Steins Bisschop1 Address: +31-88-7553507 +31-88-7568099 c.n.steinsbisschop@umcutrecht.com
Tatjana E. Vogelvang2
Anne M. May1
Nico W. E. Schuitemaker2
1Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Str. 6.131, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
2Department of Obstetrics and Gynecology, Diakonessenhuis, Utrecht, The Netherlands

Introduction

The incidence of twin pregnancy has increased largely because of the proliferation of assisted reproductive technologies and the rise in maternal age [1]. Twin gestations comprise approximately 1 % of all pregnancies but account for nearly 10 % of perinatal mortality [2, 3]. The increased morbidity and mortality of twin gestations is frequently attributed to preterm birth, intrauterine growth restriction and other unique complications of twin gestations such as twin–twin transfusion syndrome [4]. Hazards of twin delivery can be attributed to non-cephalic presentation as well [5]. Non-cephalic presentation of the first twin (twin A), the second twin (twin B) or both twins occurs in about 60 % of all twin pregnancies [2, 4, 5].

No consensus about the appropriate mode of delivery for non-cephalic presenting twins exists [6, 7]. Neither the practice bulletin on multiple gestation of the American College of Obstetricians and Gynecologists (ACOG) nor the guideline on multiple gestation of the Dutch Society for Obstetrics and Gynecology (NVOG) makes a recommendation for their route of delivery [6, 7]. Additionally, there is a general uncertainty about vaginal delivery of non-cephalic presenting twins, which is reflected by an increasing number of caesarean deliveries in twin gestations. In the United States, in 2003, 67 % of all twins were delivered by a caesarean section. Some obstetricians cite ‘twins’ as their only indication [8]. A policy of planned caesarean section might increase the risk of neonatal and maternal complications, like neonatal respiratory problems [2] or maternal febrile morbidity [9].

This systematic review aims to determine if there are evidence-based recommendations for the optimal mode of delivery for non-cephalic presenting first and/or second twins. We will investigate the impact of the mode of delivery on neonatal outcome for twin deliveries with (1) twin A in non-cephalic presentation, (2) twin B in non-cephalic presentation and (3) both twins in non-cephalic presentation.


Methods
Search strategy

A computer-aided search of Medline, Embase, Cinahl and Cochrane databases was carried out. The following search terms (with synonyms) were used: ‘twins’, ‘non-cephalic’ and ‘delivery’ (Appendix 1). Reference lists of identified studies were searched for additional relevant studies.

Inclusion criteria

Studies that compared the neonatal outcome (5-min Apgar scores and neonatal mortality) after vaginal delivery with the neonatal outcome after caesarean delivery for non-cephalic presenting twins were included. Twin A, twin B or both twin(s) had to be in non-cephalic presentation. Data of neonatal outcome had to be presented according to the mode of delivery. The twin pregnancy had to reach at least 32 weeks of gestation and both of the twins had to weigh at least 1,500 g. Every study that was published in English language was considered for inclusion, except review articles, case reports or poster session abstracts.

Selection of studies

The first reviewer (CN) screened the titles and abstracts of identified studies for eligibility. Papers that seemed to be relevant were obtained, and the full text articles were read for inclusion. If there was doubt about the suitability of the studies, they were discussed with another independent reviewer (TE).

Quality assessment

The first reviewer (CN) independently assessed various aspects of methodological quality of the included studies without masking the source or authorship of the articles. The Cochrane Collaboration’s tool for assessing risk of bias was used [10]. This tool consists of nine items about selection-, performance-, detection-, attribution- and reporting bias. Furthermore, the included studies were scored according to the GRADE approach [10].

Data extraction and analysis

Due to the heterogeneity of the data, studies could not be pooled. Therefore, we described per study whether a significant difference between vaginal and caesarean delivery was found in (1) low 5-min Apgar scores (<7) and (2) neonatal mortality. The 5-min Apgar scores <7 are widely used in the literature as measurement for poor neonatal outcome [2, 3, 8]. We made a distinction between the neonatal outcome of twin A and twin B. Significant differences were defined according to the definitions and statistics used in the different studies. We described the studies according to the presentation of the twins, i.e. (1) twin A in non-cephalic presentation, (2) twin B in non-cephalic presentation and (3) both twins in non-cephalic presentation.


Results

We identified 578 articles. Nineteen articles reporting the results of 18 studies that compared vaginal delivery with caesarean delivery for non-cephalic presenting twins were included [9, 1128] (Fig. 1).

Quality assessment (Table 1)

None of the 18 included studies were blinded since blinding for the mode of delivery was not possible for patients, personnel and outcome assessors.

According to the GRADE classification [10], only one randomized clinical trial was identified which was of high quality [9]. According to the Cochrane Collaboration’s Tool for assessing the risk of bias [10], this trial described adequate methods of randomisation and concealment of allocation. Two out of 33 women randomized for vaginal delivery subsequently underwent caesarean section (one because of inadequate progress of labour and another because of heart rate monitoring of twin B suggesting foetal distress). Neonatal outcome was completely described for both twins in this study.

The remaining moderate- [11] or low-quality [1228] observational studies reported different completeness of neonatal outcome data for both twins. None of the observational studies provided information about how the possibility of selective outcome reporting was examined.

Twin A in non-cephalic presentation (Tables 2, 3)

Eight low-quality observational studies including 1,475 twin pairs compared the mode of delivery of twins with the twin A in non-cephalic presentation [1216, 2325, 27]. For twin A, none of the eight studies reported a significant difference in low 5-min Apgar scores or in neonatal mortality. For the twin B, no significant differences were reported, but in 50 % of the studies information about the neonatal outcome of twin B was lacking.

Twin B in non-cephalic presentation (Tables 2, 4)

Eleven studies including 2,166 twin pairs compared the mode of delivery of twins with twin B in non-cephalic presentation, including one high-quality randomized clinical trial [9] (60 twin pairs) and ten low-quality observational studies [1722, 24, 2628].

The randomized clinical trial that compared vaginal with caesarean delivery did not report a significant difference in low 5-min Apgar scores or in neonatal mortality for the twin A and B [9].

For the twin A, none of the studies did report significant differences in neonatal outcome but information about the neonatal outcome of twin A was lacking in 64 % (low 5-min Apgar scores) and 55 % (neonatal mortality) of the studies.

For the twin B, most studies (82 %) did not report a significant difference in low 5-min Apgar scores or neonatal mortality but one study [22] (482 twin pairs) did report a significant difference in low 5-min Apgar scores favouring caesarean delivery (p < 0.05). This study [22] did not report a significant difference in neonatal mortality.

Both twins in non-cephalic presentation (Tables 2, 5)

One moderate-quality observational study [11] including 68 twin pairs compared the mode of delivery of twins with both twins in non-cephalic presentation. No significant differences were reported for twins A and B.


Discussion

The aim of the current review was to compare vaginal with caesarean delivery for twin deliveries with twin A in non-cephalic presentation, twin B in non-cephalic presentation and both twins in non-cephalic presentation. This evaluation is important because of the increasing numbers of caesarean sections without adequate supporting evidence for their use [8].

One high-quality clinical trial [9] (60 twin pairs) and 16 moderate/low-quality observational studies [1121, 2328] (3,167 twin pairs) showed no difference in neonatal outcome between vaginal and caesarean deliveries in twin A and/or B. Only one low-quality observational study [22] (482 twin pairs) reported a significant difference in low 5-min Apgar scores favouring caesarean delivery but there was no significant difference in neonatal mortality.

A reason to recommend caesarean over vaginal delivery if twin A is presenting non-cephalically might be to avoid the possibility of interlocking twins, which theoretically could occur in breech/cephalic and breech/transverse presenting twins. However, the incidence of interlocked twins is very low [1]. Furthermore, according to Hannah et al. [29] in term breech singletons, planned caesarean section is better than vaginal delivery. However, a previous Cochrane review did describe the maternal and neonatal outcome of the same clinical trial [9] we cited, and they stated that caesarean delivery of a non cephalic presenting twin B is associated with increased maternal morbidity but not with improved neonatal outcome, and that a policy of caesarean delivery should not be adopted without further controlled trials [30]. Additionally, previous research did not find excessive morbidity or mortality associated with vaginal delivery of non-cephalic presenting twins compared with cephalic presenting twins [3135]. Because we include only studies that compared non-cephalic presenting twins with each other, these reports were excluded.

A few studies provided detailed information about the mode of vaginal delivery like external cephalic version or (assisted) breech extraction. Both external version [3638] and breech extraction [3941] are recommended in the literature. To our knowledge, there are no randomized controlled data comparing external version with breech extraction. Future research about this subject might be useful.

A limitation of this review is that the included studies had relatively small sample sizes. However, in a meta-analysis from 2003, Hodge et al. [2] pooled the data of four studies that we described separately [9, 13, 17, 25]. They remarked that even the sample size of the pooled data was too small to draw conclusions. Therefore, although after including more recent studies statistic evidence for the best mode of delivery for twins presenting non-cephalically is still missing and no strong recommendation can be made. Furthermore, most studies did not correct (statistically or by randomisation) for confounding factors. Important confounding factors are parity or medical, obstetric or emergency indications for a caesarean section.

Additionally, most studies did not provide information about monoamnioticity. Therefore, it is mostly unknown if only diamniotic twins were included, or if monoamniotic and diamniotic twins were mixed. Ideally, you should analyse these groups separately. However, the bias due to this cause might be limited if the percentage of monoamniotic twins is equal in both the vaginal and the caesarean delivery group.

Finally, in two studies [11, 16], we used information from the abstract only because we were not able to get full text of both papers. However, we were able to retrieve all information we needed from the abstract, but ideally studies should be assessed with the full text available.

Therefore, our results have to be interpreted with caution.


Conclusion

Our results do not suggest benefit of caesarean over vaginal delivery for selected twin gestations with twin A and/or twin B in non-cephalic presentation. However, no final conclusion can be drawn. Randomized studies with sufficient power are required to make a strong recommendation.


Conflict of interest

None of the authors have conflict of interest.

Open Access

This article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.


References
1.. Cruikshank DP. Intrapartum management of twin gestationsObstet GynecolYear: 20071091167117610.1097/01.AOG.0000260387.69720.5d17470599
2.. Hogle KL,Hutton EK,McBrien KA,et al. Cesarean delivery for twins: a systematic review and meta-analysisAm J Obstet GynecolYear: 200318822022710.1067/mob.2003.6412548221
3.. Stichting Perinatale Registratie Nederland, Perinatale Zorg in Nederland 2008. Utrecht: Stichting Perinatale Registratie nederland. (2011)
4.. Pope RJ,Weintraub AY,Sheiner E. Vaginal delivery of vertex–nonvertex twins: a fading skill?Arch Gynecol ObstetYear: 201028211712010.1007/s00404-010-1458-520383641
5.. Boggess KA,Chisholm CA. Delivery of the nonvertex second twin: a review of the literatureObstet Gynecol SurvYear: 19975272873510.1097/00006254-199712000-000039408928
6.. Dutch Society for Obstetrics and Gynecology (2011) Guideline Multiple Gestation version 2.0. March 2005. Available at http://www.nvog.nl
7.. American College of Obstetricians and Gynecologsits Committee on Practice Bulletins-Obstetrics et al (2004) ACOG Practice Bulletin #56: multiple gestation: complicated twin, triplet, and high-order multifetal pregnancy. Obstet Gynecol 104(4):869–883
8.. Carroll MA,Yeomans ER. Vaginal delivery of twinsClin Obstet GynecolYear: 20064915416610.1097/01.grf.0000197541.42067.9b16456353
9.. Rabinovici J,Barkai G,Reichman B,et al. Randomized management of the second nonvertex twin: vaginal delivery or cesarean sectionAm J Obstet GynecolYear: 198715652563799768
10.. Higgins JPT, Green S (2011) Cochrane handbook for Systematic Reviews of Interventions Version 5.1.0. The Cochrane Collaboration, 2011. Available at http://www.cohrane-handbook.org
11.. Essel JK,Opai-Tetteh ET. Is routine caesarean section necessary for breech-breech and breech-transverse twin gestations?S Afr Med JYear: 199686119612009180784
12.. Sentilhes L,Goffinet F,Talbot A,et al. Attempted vaginal versus planned cesarean delivery in 195 breech first twin pregnanciesActa Obstet Gynecol ScandYear: 200786556010.1080/0001634060108959417230290
13.. Grisaru D,Fuchs S,Kupferminc MJ,et al. Outcome of 306 twin deliveries according to first twin presentation and method of deliveryAm J PerinatolYear: 20001730330710.1055/s-2000-1344311144312
14.. Bu-Heija AT,Ziadeh S,Obeidat A. Mode of delivery and perinatal results of the breech first twinJ Obstet GynaecolYear: 199818474910.1080/0144361986827115512002
15.. Bu-Heija AT,Ziadeh S,Abukteish F,et al. Retrospective study of outcome on vaginal and abdominal delivery in twin pregnancy in which twin 1 is presenting by the breechArch Gynecol ObstetYear: 1998261717310.1007/s0040400502019544370
16.. Blickstein I,Weissman A,Ben-Hur H,et al. Vaginal delivery of breech-vertex twinsJ Reprod MedYear: 1993388798828277485
17.. Wells SR,Thorp JM Jr,Bowes WA Jr. Management of the nonvertex second twinSurg Gynecol ObstetYear: 19911723833852028373
18.. Gocke SE,Nageotte MP,Garite T,et al. Management of the nonvertex second twin: primary cesarean section, external version, or primary breech extractionAm J Obstet GynecolYear: 19891611111142750792
19.. Caukwell S,Murphy DJ. The effect of mode of delivery and gestational age on neonatal outcome of the non-cephalic- presenting second twinAm J Obstet GynecolYear: 20021871356136110.1067/mob.2002.12809012439531
20.. Winn HN,Cimino J,Powers J,et al. Intrapartum management of nonvertex second-born twins: a critical analysisAm J Obstet GynecolYear: 20011851204120810.1067/mob.2001.11814511717658
21.. Acker D,Lieberman M,Holbrook RH,et al. Delivery of the second twinObstet GynecolYear: 1982597107117078908
22.. Atis A,Aydin Y,Donmez M,et al. Apgar scores in assessing morbidity of the second neonate of cephalic/non-cephalic twins in different delivery modesJ Obstet GynaecolYear: 201131434710.3109/01443615.2010.52274821280992
23.. Nassar AH,Maarouf HH,Hobeika EM,et al. Breech presenting twin A: is vaginal delivery safe?J Perinat MedYear: 20043247047410.1515/JPM.2004.12915576266
24.. Roopnarinesingh AJ,Sirjusingh A,Bassaw B,et al. Vaginal breech delivery and perinatal mortality in twinsJ Obstet GynaecolYear: 20022229129310.1080/0144361022013059912521502
25.. Blickstein I,Goldman RD,Kupferminc M. Delivery of breech first twins: a multicenter retrospective studyObstet GynecolYear: 200095374210.1016/S0029-7844(99)00474-310636499
26.. Mauldin JG,Newman RB,Mauldin PD. Cost-effective delivery management of the vertex and nonvertex twin gestationAm J Obstet GynecolYear: 199817986486910.1016/S0002-9378(98)70179-69790360
27.. Kelsick F,Minkoff H. Management of the breech second twinAm J Obstet GynecolYear: 19821447837867148901
28.. Greig PC,Veille JC,Morgan T,et al. The effect of presentation and mode of delivery on neonatal outcome in the second twinAm J Obstet GynecolYear: 19921679019061415423
29.. Hannah ME,Hannah WJ,Hewson SA,Term Breech Trial Collaborative Groupet al. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trialLancetYear: 20003561375138310.1016/S0140-6736(00)02840-311052579
30.. Crowther CA (2000) Caesarean delivery for the second twin. Cochrane Database Syst Rev:CD000047
31.. Fishman A,Grubb DK,Kovacs BW. Vaginal delivery of the nonvertex second twinAm J Obstet GynecolYear: 19931688618648456893
32.. Mazor M,Leiberman JR,Dreval D,et al. Management and outcome of vertex-breech and vertex-vertex presentation in twin gestation: a comparative studyEur J Obstet Gynecol Reprod BiolYear: 198622697510.1016/0028-2243(86)90091-23721049
33.. Blickstein I,Schwartz-Shoham Z,Lancet M,et al. Vaginal delivery of the second twin in breech presentationObstet GynecolYear: 1987697747763574806
34.. Sibony O,Touitou S,Luton D,et al. Modes of delivery of first and second twins as a function of their presentation. Study of 614 consecutive patients from 1992 to 2000Eur J Obstet Gynecol Reprod BiolYear: 200612618018510.1016/j.ejogrb.2005.08.01316214286
35.. Oettinger M,Ophir E,Markovitz J,et al. Is cesarean section necessary for delivery of a breech first twin?Gynecol Obstet InvestYear: 199335384310.1159/0002926608449432
36.. Chervenak FA,Johnson RE,Berkowitz RL,et al. Intrapartum external version of the second twinObstet GynecolYear: 1983621601656866357
37.. Tchabo JG,Tomai T. Selected intrapartum external cephalic version of the second twinObstet GynecolYear: 19927942142310.1097/00006250-199203000-000191738526
38.. Kaplan B,Peled Y,Rabinerson D,et al. Successful external version of B-twin after the birth of A-twin for vertex–non-vertex twinsEur J Obstet Gynecol Reprod BiolYear: 1995581571607774743
39.. Berglund L,Axelsson O. Breech extraction versus cesarean section for the remaining second twinActa Obstet Gynecol ScandYear: 19896843543810.3109/000163489090210162520788
40.. Smith SJ,Zebrowitz J,Latta RA. Method of delivery of the nonvertex second twin: a community hospital experienceJ Matern Fetal MedYear: 1997614615010.1002/(SICI)1520-6661(199705/06)6:3<146::AID-MFM5>3.0.CO;2-L9172055
41.. Chauhan SP,Roberts WE,McLaren RA,et al. Delivery of the nonvertex second twin: breech extraction versus external cephalic versionAm J Obstet GynecolYear: 19951731015102010.1016/0002-9378(95)91319-X7485286
Appendix 1

Medline: (((((twins[Title/Abstract] OR twin[Title/Abstract]) OR sibling[Title/Abstract]) OR siblings[Title/Abstract]) OR reciprocal[Title/Abstract]) OR reciprocals[Title/Abstract])) AND (((((((((breech presentation[Title/Abstract] OR breech-presentation[Title/Abstract]) OR breech-presentations[Title/Abstract]) OR breech[Title/Abstract]) OR non-vertex[Title/Abstract]) OR non-vertex-presentation[Title/Abstract]) OR non-vertex-presentations[Title/Abstract]) OR non-cephalic[Title/Abstract]) OR non-cephalic-presentation[Title/Abstract]) OR non-cephalic-presentations[Title/Abstract])) AND ((((((((((((((((((((((((((vaginal delivery[Title/Abstract] OR vaginal[Title/Abstract]) OR vaginally[Title/Abstract]) OR deliver[Title/Abstract]) OR delivered[Title/Abstract]) OR delivery[Title/Abstract]) OR deliveries[Title/Abstract]) OR childbirth[Title/Abstract]) OR childbirths[Title/Abstract]) OR accouchement[Title/Abstract]) OR bearing[Title/Abstract]) OR birth[Title/Abstract]) OR births[Title/Abstract]) OR birthing[Title/Abstract]) OR bringing forth[Title/Abstract]) OR childbearing[Title/Abstract]) OR confinement[Title/Abstract]) OR geniture[Title/Abstract]) OR labor[Title/Abstract]) OR labour[Title/Abstract]) OR lying-in[Title/Abstract]) OR paturition[Title/Abstract]) OR parturitions[Title/Abstract]) OR travail[Title/Abstract]) OR extraction[Title/Abstract]) OR extractions[Title/Abstract]) OR (((((((caesarian section[Title/Abstract] OR caesarian sections[Title/Abstract]) OR caesarian[Title/Abstract]) OR caesarian[Title/Abstract]) OR section[Title/Abstract]) OR sections[Title/Abstract]) OR abdominal[Title/Abstract]) OR abdominally[Title/Abstract])).

Embase: (((((twins:ab,ti OR twin:ab,ti) OR sibling:ab,ti) OR siblings:ab,ti) OR reciprocal:ab,ti) OR reciprocals:ab,ti) AND (((((((((breech presentation:ab,ti OR breech-presentation:ab,ti) OR breech-presentations:ab,ti) OR breech:ab,ti) OR non-vertex:ab,ti) OR non-vertex-presentation:ab,ti) OR non-vertex-presentations:ab,ti) OR non-cephalic:ab,ti) OR non-cephalic-presentation:ab,ti) OR non-cephalic-presentations:ab,ti) AND ((((((((((((((((((((((((((vaginal delivery:ab,ti OR vaginal:ab,ti) OR vaginally:ab,ti) OR deliver:ab,ti) OR delivered:ab,ti) OR delivery:ab,ti) OR deliveries:ab,ti) OR childbirth:ab,ti) OR childbirths:ab,ti) OR accouchement:ab,ti) OR bearing:ab,ti) OR birth:ab,ti) OR births:ab,ti) OR birthing:ab,ti) OR bringing forth:ab,ti) OR childbearing:ab,ti) OR confinement:ab,ti) OR geniture:ab,ti) OR labor:ab,ti) OR labour:ab,ti) OR lying-in:ab,ti) OR paturition:ab,ti) OR parturitions:ab,ti) OR travail:ab,ti) OR extraction:ab,ti) OR extractions:ab,ti) OR (((((((caesarian section:ab,ti OR caesarian sections:ab,ti) OR caesarian:ab,ti) OR caesarian:ab,ti) OR section:ab,ti) OR sections:ab,ti) OR abdominal:ab,ti) OR abdominally:ab,ti)).

Cochrane: (Twin OR twins OR sibling OR siblings OR reciprocal OR reciprocals) AND (breech-presentation OR breech-presentation OR breech OR non-vertex OR non-cephalic) AND (vaginal OR vaginally or deliver OR delivered OR delivery OR deliveries OR childbirth OR childbirths OR accouchement OR bearing OR birth OR births OR birthing OR brining forth OR childbearing OR confinement OR geniture OR labor OR labour OR caesarian OR caesarians OR section OR sections OR abdominal OR abdominally) Field: abstract.

CINAHL: (Twin OR twins OR sibling OR siblings OR reciprocal OR reciprocals) AND (breech-presentation OR breech-presentation OR breech OR non-vertex OR non-cephalic) AND (vaginal OR vaginally or deliver OR delivered OR delivery OR deliveries OR childbirth OR childbirhs OR accouchement OR bearing OR birth OR births OR birthing OR brining forth OR childbearing OR confinement OR geniture OR labor OR labour OR caesarian OR caesarians OR section OR sections OR abdominal OR abdominally) Field: abstract.


Figures

[Figure ID: Fig1]
Fig. 1 

Literature search. Search updated September 18th 2011. N number of articles. Single asterisk indicates that one study was published in two articles [14, 15]. Double asterisks indicate that two articles [24, 27] included one subgroup with twin A and one subgroup with twin B in non-cephalic presentation



Tables
[TableWrap ID: Tab1] Table 1 

Quality assessment: risk of bias


Author Year Study design Selection bias Performance bias Detection bias Attribution bias Reporting bias Total GRADE
Random sequence generation Allocation concealment Blinding of participants and personnel Blinding of out come assessment Incomplete outcome data 5-min AS <7 twin A Incomplete outcome data 5-min AS <7 twin B Incomplete outcome data Neonatal mortality twin A Incomplete outcome data Neonatal mortality twin B Selective outcome dataporting Items ‘high re-risk of bias’
Rabinovici [9] 1986 RCT Low Low High High Low Low Low Low Low 2 1
Essel [11]a 1996 Prosp cohort High High High High Low Low Low Low Unclear 4 2
Sentilhes [12] 2007 Retr cohort High High High High Low Low Low Low Unclear 4 3
Griasaru [13] 2000 Retr cohort High High High High Low Low Low Low Unclear 4 3
Abu-Heija [14, 15] 1998 Retr cohort High High High High Low Low Low Low Unclear 4 3
Blickstein [16]b 1993 Retr cohort High High High High Low Low Low Low Unclear 4 3
Wells [17] 1991 Retr cohort High High High High Low Low Low Low Unclear 4 3
Gocke [18] 1989 Retr cohort High High High High Low Low Low Low Unclear 4 3
Caukwell [19] 2002 Retr cohort High High High High High Low Low Low Unclear 5 3
Winn [20] 2001 Retr cohort High High High High High Low Low Low Unclear 5 3
Acker [21] 1981 Retr cohort High High High High High Low Low Low Unclear 5 3
Atis [22] 2011 Retr cohort High High High High High Low High Low Unclear 6 3
Nassar [23] 2004 Retr cohort High High High High No High Low High Unclear 6 3
Roopnarinesingh [24] 2002 Retr cohort High High High High Low High Low High Unclear 6 3
Blickstein [25] 2000 Retr cohort High High High High Low High Low High Unclear 6 3
Mauldin [26] 1998 Prosp cohort High High High High Low Low High High Unclear 6 3
Kelsick [27] 1982 Retr cohort High High High High High High Low High Unclear 7 3
Greig [28] 1992 Retr cohort High High High High High Low High High Unclear 7 3

For quality assessement the Cochrane Collaboration’s tool for assessing risk of bias [10] and the GRADE classification [10] was used

1 = GRADE: high = randomized trials, or double upgraded observational studies

2 = GRADE: moderate = downgraded randomized trials, or upgraded observational studies

3 = GRADE: low = double downgraded randomized trials, or observational studies

4 = GRADE: very low = triple downgraded randomized trials, or downgraded observational studies, or case series/case reports

RCT Randomized clinical trial, Prosp Prospective, Retr Retrospective

aEssel [11]: only the abstract was available

bBlickstein [16]: only the abstract was available


[TableWrap ID: Tab2] Table 2 

Overview results


Presentation of the twins 5-min Apgar scores <7 Neonatal mortality
No significant difference Significant difference favouring vaginal delivery Significant difference favouring caesarean delivery Not reported No significant difference Significant difference favouring vaginal delivery Significant difference favouring caesarean delivery Not reported
Non-cephalic presentation twin A (8 studies [1216, 2325, 27]) Twin A 100 % (8 studies [1216, 2325, 27]) 100 % (8 studies [1216, 2325, 27])
Twin B 50 % (4 studies [1216]) 50 % (4 studies [2325, 27]) 50 % (4 studies [1216]) 50 % (4 studies [2325, 27])
Non-cephalic presentation twin B (11 studies [9, 1722, 24, 2628]) Twin A 36 % (4 studies [9, 17, 18, 26]) 64 % (7 studies [1922, 24, 27, 28]) 45 % (5 studies [9, 17, 18, 20, 21]) 55 % (6 studies [19, 22, 24, 2628])
Twin B 82 % (9 studies [9, 1721, 24, 26, 28]) 9 % (1 study [22]) 9 % (1 study[27]) 82 % (9 studies [9, 1722, 24, 27]) 18 % (2 studies [26, 28])
Non-cephalic presentation twin A and B (1 study [11]) Twin A 100 % (1 study11) 100 % (1 study [11])
Twin B 100 % (1 study [11]) 100 % (1 study [11])

Significant differences were defined according to the definitions and statistics used in the different studies

aEssel [11]: only the abstract was available

bBlickstein [16]: only the abstract was available


[TableWrap ID: Tab3] Table 3 

First twin in non-cephalic presentation


Author Year Study design Mode of delivery Gestational age (weeks) Presentation Birth weight 5-min Apgar score <7 Neonatal mortality
VD/CS N Twin A breech (%) Twin B cephalic (%) Twin A (g) Twin B (g) Twin A N (%) Twin B N (%) Twin A N (%) Twin B N (%)
Sentilhes [12] 2007 Retr cohort VD 124 37 ± 1 100 % 45 % 2,620 ± 363 2,555 ± 410 2 (2 %) 0 1 (1 %) 0
CS 71 37 ± 1 100 % 52 % 2,762 ± 429 2,490 ± 446 2 (3 %) 1 (1 %) 0 1 (1 %)
p > 0.05 p > 0.05 p > 0.05 p > 0.05
Griasaru [13] 2000 Retr cohort VD 33 >32 100 % 52 % 2,636 ± 385 2,588 ± 456 0 0 0 0
CS 38 >32 89 % NR 2,589 ± 450 2,488 ± 475 0 0 0 0
Abu-Heija [14, 15]a 1998 Retr cohort VD 42 37 ± 3 100 % NR 2,566 ± 555 2,450 ± 482 NR NR 3 (7 %) 1 (2 %)
CS 87 38 ± 2 100 % NR 2,712 ± 553 2,577 ± 594 NR NR 2 (3 %) 0
p > 0.05 p > 0.05 p > 0.05 p > 0.05
Blickstein [16]b 1993 Retr cohort VD 24 NRa 100 % 100 % NRa NRa NR NR NR NR
CS 35 NRa 100 % 100 % NRa NRa NR NR NR NR
p > 0.05 p > 0.05 p > 0.05 p > 0.05
Nassar [23] 2004 Retr cohort VD 35 36 ± 3 100 % 35 % 2,274 ± 486 NR 3 % NR 6 % NR
CS 95 36 ± 3 100 % 45 % 2,344 ± 617 NR 15 % NR 6 % NR
p > 0.05 p > 0.05
Roopnarinesingh [24] 2002 Retr cohort VD 18 >32 100 % NR 1,560–2,960 NR 0 NR 0 NR
CS 32 >32 100 % NR 1,220–3,040 NR 0 NR 0 NR
Blickstein [25] 2000 Retr cohort VD 53 36 ± 3 100 % NR 2,454 ± 466 2,539 ± 547 7 (7 %) NR 0 NR
(Nullipara) CS 156 36 ± 2 100 % NR 2,527 ± 485 2,441 ± 533 16 (5 %) NR 1 (0.3 %) NR
p > 0.05 p > 0.05
Retr cohort VD 129 37 ± 2 100 % 49 % 2,609 ± 524 2,626 ± 519 14 (5 %) NR 1 (0.4 %) NR
(Multipara) CS 167 37 ± 3 100 % 44 % 2,662 ± 551 2,577 ± 568 17 (5 %) NR 0 NR
p > 0.05 p > 0.05
Kelsick [27] 1982 Retr cohort VD 194 NR 100 % NR 2,000–4,000 2,000–4,000 NR NR 2 (1 %) NR
CS 142 NR 100 % NR 2,000–4,000 2,000–4,000 NR NR 2 (1 %) NR
p > 0.05

Significant differences were defined according to the definitions and statistics used in the different studies

VD Vaginal delivery, CS Caesarean section, N Number of twin pairs, Retr Retrospective, NR Not reported

aAbu-Heija [14, 15] did not report the percentage of 5-min Apgar scores <7, but did report the mean 5-min Apgar scores: 8 ± 1 in all groups (without significant differences)

bBlickstein [16]: only the abstract was available


[TableWrap ID: Tab4] Table 4 

Second twin in non-cephalic presentation


Author Year Study design Mode of delivery Gestational age (weeks) Presentation Birth weight 5-min Apgar score <7 Neonatal mortality
VD/CS N Twin A cephalic (%) Twin B breech (%) Twin A (g) Twin B (g) Twin A N (%) Twin B N (%) Twin A N (%) Twin B N (%)
Differences in neonatal outcome
 Atis [22]a 2011 Retr cohort VD 289 36 ± 6 100 % NR NR 2,335 ± 443 NR 44 (15 %) NR 2 (1 %)
CS 193 36 ± 6 100 % NR NR 2,558 ± 648 NR 16 (8 %) NR 1 (1 %)
p < 0.05 p > 0.05
No differences in neonatal outcome
 Rabinovici [9] 1986 RCT VD 33 38 ± 2 100 % 61 % 2,477 ± 370 2,459 ± 510 0 1 (3 %) 0 0
CS 27 38 ± 2 100 % 67 % 2,533 ± 423 2484 ± 632 1 (4 %) 1 (4 %) 0 0
p > 0.05
 Wells [17] 1991 Retr cohort VD-breech extraction 42 37 100 % 100 % 2,660 2,537 0 1 (2 %) 0 0
VD-external version 11 35 100 % 100 % 2,363 2,389 0 0 0 0
CS 29 37 100 % 100 % 2,701 2,521 0 0 0 0
p > 0.05 p > 0.05
 Gocke [18] 1989 Retr cohort VD-breech extraction 55 37 100 % 100 % 2,544 2,569 0 1 (3 %) 0 0
VD-exernal version 41 36 100 % 100 % 2,399 2,365 0 0 0 0
CS 40 36 100 % 100 % 2,356 2,347 0 0 0 0
p > 0.05
 Caukwell [19]a 2002 Retr cohort VD 64 ≥37 NR NR NR NR NR 4 (6 %) NR 0
CS 34 ≥37 NR NR NR NR NR 3 (9 %) NR 0
p > 0.05
 Winn [20]b 2001 Retr cohort VD 31 34 ± 2 NR 100 % NR 2,115 ± 415 NR NR 0 0
CS-without labour 34 35 ± 2 NR 100 % NR 2,242 ± 456 NR NR 0 0
CS-with labour 36 34 ± 2 NR 100 % NR 2,215 ± 442 NR NR 0 0
p > 0.05
 Acker [21]c 1981 Retr cohort VD 76 NR NR 100 % >1,500 >1,500 NR 11 (15 %) 0 0
CS 75 NR NR NR >1,500 >1,500 NR 7 (10 %) 0 0
p > 0.05
 Roopnarinesingh [24] 2002 Retr cohort VD 54 >32 NR 100 % NR 1,560–2,960 NR 0 NR 0
CS 33 >32 NR 100 % NR 1,220–3,040 NR 0 NR 1 (3 %)
 Mauldin [26]a 1998 Prosp cohort VD-breech extraction 41 35 ± 4 NR NR 2,270 ± 741 2,167 ± 728 14 17 NR NR
VD-external version 19 34 ± 2 NR NR 2,233 ± 561 2,295 ± 702 0 10 NR NR
CS 24 35 ± 4 NR NR 2,169 ± 680 2,116 ± 739 16 20 NR NR
p > 0.05 p > 0.05
 Kelsick [27] 1982 Retr cohort VD 590 NR NR 100 % 2,000–4,000 2,000–4,000 NR NR NR 1 (0.2 %)
CS 141 NR NR 100 % 2,000–4,000 2,000–4000 NR NR NR 1 (0.2 %)
p > 0.05
 Greig [28]a,d 1992 Retr cohort VD 12 NR NR NR NR 1,500–1,999 NR NR NR NR
(1,500–1,999 g) CS 24 NR NR NR NR 1,500–1,999 NR NR NR NR
p > 0.05
Retr cohort VD 21 NR NR NR NR 1,500–1,999 NR NR NR NR
(2,000–2,499 g) CS 31 NR NR NR NR 1,500–1,999 NR NR NR NR
p > 0.05
Retr cohort VD 21 NR NR NR NR 1,500–1,999 NR NR NR NR
(≥2,500 g) CS 46 NR NR NR NR 1,500–1,999 NR NR NR NR
p > 0.05

Significant differences were defined according to the definitions and statistics used in the different studies

VD Vaginal delivery, CS Caesarean section, N Number of twin pairs, RCT Randomized controlled trial, Retr Retrospective, Prosp Prospective, NR Not reported

aAtis [22], Caukwell [19], Mauldin [26], Greig [28]: twin B in non-cephalic postition, not further specified to breech or transverse position

bWinn [20] did not report the percentage of 5-min Apgar scores <7, but did report the mean 5-min Apgar scores: 8 ± 1 in VD and CS-with labour group, and 9 ± 1 in the CS-without labour group (without significant differences)

cAcker [21]: twins delivered by caesarean section: twin A or B was in non-cephalic presentation

dGreig [28] did not report the percentage of 5-min Apgar scores <7, but did report the mean 5-min Apgar scores: 1,500–1,999 g and 2,000–2,499 g: 9 in the VD and 8 in the CS group (without significant differences); ≥2,500 g: 9 in the VD group and 9 in the CS group (without significant differences)


[TableWrap ID: Tab5] Table 5 

Both twins in non-cephalic presentation


Author Year Study design Mode of delivery Gestational age (weeks) Presentation Birth weight 5-min Apgar score <7 Neonatal mortality
VD/CS N Twin A breech (%) Twin B breech (%) Twin A (g) Twin B (g) Twin A N (%) Twin B N (%) Twin A N (%) Twin B N (%)
Essel [11] 1996 Prosp cohort VD 41 NR 100 % 85 % NRa NRa NRa NRa NRa NRa
SC 27 NR 100 % 93 % NRa NRa NRa NRa NRa NRa
p > 0.05 p > 0.05 p > 0.05 p > 0.05

Significant differences were defined according to the definitions and statistics used in the different studies

VD Vaginal delivery, CS Caesarean section, N Number 1 of twin pairs, Prosp Prospective, NR Not reported

aEssel [11]: only the abstract was available



Article Categories:
  • Reproductive Medicine

Keywords: Keywords Twins, Non-cephalic presentation, Mode of delivery, Systematic review.

Previous Document:  RELATIONSHIP BETWEEN INDICATORS OF TRAINING LOAD IN SOCCER PLAYERS.
Next Document:  Deterioration of endothelial function and carotid intima-media thickness in Tibetan male adolescents...