Reitter A, Daviss B A, Krimphove M J, Johnson K C, Schlößer R, Louwen F, Bisits A
a Department of Obstetrics and Gynaecology , University Hospital Frankfurt, Goethe-University , Frankfurt , Germany.
b Department of Obstetrics and Gynaecology, Midwifery Division , Montfort Hospital , Ottawa , Canada.
J Obstet Gynaecol. 2018 May;38(4):502-510. doi: 10.1080/01443615.2017.1393402. Epub 2018 Feb 12.
Our primary objective was to compare neonatal and maternal outcomes in women with twin pregnancies, beyond 32 weeks, having a planned vaginal birth or a planned caesarean section (CS). This was a retrospective cohort study from a single tertiary centre over nine years. 534 sets of twins ≥32 + 0 weeks of gestation were included. 401 sets were planned vaginally and 133 sets were planned by CS. We compared a composite adverse perinatal outcome (perinatal mortality or serious neonatal morbidity; five minute APGAR score ≤4, neurological abnormality and need for intubation) and a composite maternal adverse outcome (major haemorrhage, trauma or infection) between the groups. There were no significant differences. Given the similarity of these results with several other larger studies of twin birth, we sought to look at reasons why there is still a rising rate of CS for twin births. We further make suggestions for keeping this rate to a sensible minimum. Impact statement What is already known on this subject? The largest randomised controlled study comparing planned vaginal birth with planned CSs for lower risk twins between 32 and 39 weeks of gestation, showed no added safety from planned CS. However, in most of the Western countries this conclusion has failed to increase the number of planned vaginal births for lower risk twins. What do the results of this study add? This observational study from a single tertiary centre provides external validation of the twin trial results in a practical day-to-day setting. It also provides insights as to how planned vaginal birth can be developed and maintained, with a key focus on safety and maternal participation in decision making. It does focus on consent and providing accurate data. What are the implications of these findings for clinical practice and/or further research? There are good grounds to encourage vaginal birth for low-risk twin pregnancies. The trend of rising caesarean rates in low-risk twin pregnancies worldwide will erode important skills for the conduct of vaginal births without any clear benefit for mothers or babies. The current situation demands careful thought about implementing innovative training opportunities for younger obstetricians. Finally, we need intelligent responses to many non-evidence-based factors which can drive clinical practice.
我们的主要目标是比较孕周超过32周、计划经阴道分娩或计划剖宫产的双胎妊娠女性的新生儿及母亲结局。这是一项来自单一三级中心、为期9年的回顾性队列研究。纳入了534对孕周≥32+0周的双胞胎。401对计划经阴道分娩，133对计划剖宫产。我们比较了两组间的复合不良围产期结局（围产期死亡率或严重新生儿发病率；5分钟阿氏评分≤4、神经异常及需要插管）和复合母亲不良结局（大出血、创伤或感染）。两组间无显著差异。鉴于这些结果与其他几项关于双胎分娩的较大规模研究相似，我们试图探究双胎分娩剖宫产率仍在上升的原因。我们还进一步提出了将该比率保持在合理最低水平的建议。影响声明关于该主题已知的信息有哪些？最大的一项随机对照研究比较了孕周在32至39周的低风险双胎计划经阴道分娩与计划剖宫产，结果显示计划剖宫产并无额外安全性。然而，在大多数西方国家，这一结论并未增加低风险双胎计划经阴道分娩的数量。本研究结果有何补充？这项来自单一三级中心的观察性研究在日常实际环境中对双胎试验结果进行了外部验证。它还提供了关于如何开展和维持计划经阴道分娩的见解，重点关注安全性和母亲参与决策。它确实关注了知情同意和提供准确数据。这些发现对临床实践和/或进一步研究有何影响？有充分理由鼓励低风险双胎妊娠经阴道分娩。全球低风险双胎妊娠剖宫产率上升的趋势将削弱经阴道分娩的重要技能，而对母亲或婴儿并无明显益处。当前形势要求认真考虑为年轻产科医生提供创新培训机会。最后，我们需要对许多可能推动临床实践的非循证因素做出明智回应。
