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Twin Birth Study: 2-year neurodevelopmental follow-up of the randomized trial of planned cesarean or planned vaginal delivery for twin pregnancy

American Journal of Obstetrics and Gynecology, In Press, Corrected Proof, Available online 29 January 2016, Available online 29 January 2016

Editor’s comment: Prof. Dan Farine: The twin study
This is a very important study as it complements the initial results of the Twins Birth Study. Both of these studies are likely to reflect a world-wide results of twins delivery as this a rigorously designed RCT looked at patients in a multitude of centers around the world. As opposed to a common belief before the study, that Caesarean delivery is the “easy way out” in twins’ birth (as in many other conditions), these were not the results of this study. Neither the short term results nor the long term ones showed benefit of an elective Caesarean delivery in term or late preterm twins where the first twin is in a vertex presentation. This may be important to the young mother who has to take care of two babies who do not need to be hampered by inconvenience and possible complications of a Caesarean delivery. There is a new keen and justified interest in the long term effect of Caesarean deliveries. There is an impressive set of data correlating Caesarean birth with increased risks of: diabetes, asthma and increased weight. It is important to mention that this association does not necessarily mean causation. In contrast, there is also an alarming data about the rising rates of adhesive placentas (accreta and percreta). These are definitely related to the scar in the uterus. Luckily, the study by Silver from the MFM network in the USA suggested that this risk is increased mainly after 3 Caesarean deliveries.

It is interesting to see that the results of this study could be interpreted in exactly the opposite way. Women who prefer a Caesarean birth for whatever reason (worries about double vaginal births, apprehension of the small risk of having both vaginal and Caesarean deliveries, need to plan delivery time etc.) may be reassured that a caesarean approach does not increase mortality or major neurological deficits. The same may apply to the obstetricians who are very uncomfortable with the delivery of the second twin. In other words this study is good for both the vaginal and CS camps.

Background

The Twin Birth Study randomized women with uncomplicated pregnancies, between 320/7-386/7 weeks’ gestation where the first twin was in cephalic presentation, to a policy of either a planned cesarean or planned vaginal delivery. The primary analysis showed that planned cesarean delivery did not increase or decrease the risk of fetal/neonatal death or serious neonatal morbidity as compared with planned vaginal delivery.

Objective

This study presents the secondary outcome of death or neurodevelopmental delay at 2 years of age.

Study Design

A total of 4603 children from the initial cohort of 5565 fetuses/infants (83%) contributed to the outcome of death or neurodevelopmental delay. Surviving children were screened using the Ages and Stages Questionnaire with abnormal scores validated by a clinical neurodevelopmental assessment. The effect of planned cesarean vs planned vaginal delivery on death or neurodevelopmental delay was quantified using a logistic model to control for stratification variables and using generalized estimating equations to account for the nonindependence of twin births.

Results

Baseline maternal, pregnancy, and infant characteristics were similar. Mean age at assessment was 26 months. There was no significant difference in the outcome of death or neurodevelopmental delay: 5.99% in the planned cesarean vs 5.83% in the planned vaginal delivery group (odds ratio, 1.04; 95% confidence interval, 0.77–1.41; P = .79).

Conclusion

A policy of planned cesarean delivery provides no benefit to children at 2 years of age compared with a policy of planned vaginal delivery in uncomplicated twin pregnancies between 320/7-386/7weeks’ gestation where the first twin is in cephalic presentation.

Key words: cesarean vs vaginal delivery, neurodevelopmental outcome, twin pregnancies.

Footnotes

a Department of Newborn and Developmental Pediatrics, Sunnybrook Health Sciences Center, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada

b Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada

c Center for Mother, Infant, and Child Research, Sunnybrook Health Sciences Center, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada

d Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada

e Department of Ontario Child Health Support Unit, SickKids Research Institute, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada

f Department of Pediatrics, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada

g Midwifery Education Program, McMaster University, Hamilton, Ontario, Canada

h Center for Health Economics and Policy Analysis, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada

i Department of Pediatrics, Izaak Walton Killam Health Center, Dalhousie University, Halifax, Nova Scotia, Canada

j Department of Obstetrics and Gynecology, IWK Health Center, Dalhousie University, Halifax, Nova Scotia, Canada

k Department of Obstetrics and Gynecology and the School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada

l Department of Obstetrics and Gynecology, University of Alberta, Edmonton, Alberta, Canada

Corresponding author: Elizabeth V. Asztalos, MD.

The Twin Birth Study Collaborative Group is listed at the end of the article.

This study was supported by a grant (63164) from the Canadian Institutes of Health Research.

The authors report no conflict of interest.

Cite this article as: Asztalos EV, Hannah ME, Hutton EK, et al. Twin Birth Study: 2-year neurodevelopmental follow-up of the randomized trial of planned cesarean or planned vaginal delivery for twin pregnancy. Am J Obstet Gynecol 2016;volume;x.ex-x.ex.