Twin VBAC (vaginal birth after caesarean)

Here is a summary of all the research I have found on VBAC for multiple births, together with some links, and full copies of the Medline abstracts of the studies in question.

Summary of research

[1] This study looked only at mothers with a prior caesarean who were expecting twins, and compared trial of labour to elective repeat section. 21 mothers attempting VBAC were compared to 15 mothers having elective repeat sections. 80.9% of the mothers attempting VBAC delivered vaginally. Comparing trial of labour to elective repeat section, there were no differences in outcomes for the babies. However, for the mothers, elective repeat section produced worse outcomes. Blood transfusions were received in 9.5% of the group which attempted vaginal birth, and 26.6% of the group having elective repeat sections. Postpartum infections were recorded in 9.5% of women in the group attempting vaginal birth, and 46.6% of those having elective repeat sections. Average hospital stay was 4.4 days after attempted vaginal birth, and 8.0 days after elective section.

[2] 19 women carrying twins and attempting VBAC were compared to 57 women carrying single babies and attempting VBAC. Women carrying twins were actually more likely to deliver vaginally than women carrying single babies - 84.2% of them, as opposed to 75.4% of the single baby VBAC attempts. There were no other differences in outcome.

The authors conclude that: "The option of VBAC for twin pregnancy (TP) appears to be safe and shares a similar likelihood of success as a singleton pregnancy. In view of the lack of increased complications, this option should be offered to patients with TP who are eligible for VBAC.

[3] 25 twin pregnancies where VBAC was attempted were compared to outcomes for VBAC attempts with a single baby. 21 mothers of twins had a VBAC (84% success rate). No difference in outcome for babies compared to singleton babies. One scar dehiscence occurred in a mother with two prior caesareans who had a full breech extraction.

[4] small study - 10 out of 12 women attempting VBAC with twins delivered vaginally. No difference in outcomes compared to women delivering twins with no prior caesarean, except a longer average stay in intensive care for the second twins. No suggestions made in the abstract for reasons.

[5] looked at 1,000 women attempting VBAC, but it doesn't tell us how many were carrying twins. However, "Successful trial of labor was observed in 75% of twin pregnancies".

[6] This study looked at vaginal birth of triplets. One set of triplets was born vaginally to a mother with a past caesarean.

[7] Considering 92 women who attempted VBAC with twins, the authors concluded: "In women with twins a trial of labor after a previous cesarean section is a safe and effective alternative to routine repeat cesarean delivery."

Links

When making the choice between elective repeat caesarean or vaginal birth for twins, you may find the following pages helpful:

UK Midwifery archive page on multiple birth
(www.radmid.demon.co.uk/twinbirth.htm)

UK Midwifery archive page on risks of caesareans - links to page on implications of caesareans for the baby, too.
(www.radmid.demon.co.uk/csrisks.htm)

Planning a good caesarean - another page of links and suggestions from the UK Midwifery Archives
(www.radmid.demon.co.uk/csgood.htm)

Abstracts

[1] Evidence that women with a history of cesarean section can deliver twins safely.

Acta Obstet Gynecol Scand 1997 Aug;76(7):663-6

Odeh M, Tarazova L, Wolfson M, Oettinger M.

Department of Obstetrics and Gynecology, Western Galille Medical Center, Nahariya, Israel.

OBJECTIVE: To determine whether a trial of labor is safe in twin pregnancies after one previous cesarean section. STUDY DESIGN: Retrospective analysis of all cases of multiple pregnancies after cesarean section during the years 1970-1993, including twin gestations after one cesarean section.
RESULTS: Forty-six cases of multiple gestations were found, 36 of which were eligible for the study presented herein. Fifteen women (41.7%) were denied trial of labor. Twenty-one women (58.3%) were allowed trial of labor, 17 (80.9%) of whom were delivered vaginally and four (19.1%) by a repeated cesarean section. The group of trial of labor was compared to the group of elective cesarean section. Hospitalization period was 4.4 +/- 1.9 days and 8.0 +/-2.6 days in the trial of labor group and elective cesarean section group, respectively (p<0.01). Blood transfusions required were 9.5% and 26.6% in both groups, respectively (NS). Puerperal infections were 9.5% in the trial of labor group, compared to 46.6% in the elective cesarean section group (NS). No scar dehiscence occurred in either groups. There were no statistically significant differences in age, parity, gestational age at delivery, mean newborn weight, Apgar score at one and five minutes, Neonatal Intensive Care Unit admission and mean Neonatal Intensive Care Unit stay.
CONCLUSIONS: Vaginal delivery in twin gestation after one previous cesarean section may be considered in appropriate cases. A large multicentral randomized prospective study may further confirm this conclusion.

PMID: 9292641

[2] Vaginal birth after cesarean delivery in the twin gestation.

Obstet Gynecol 2000 Apr;95(4 Suppl 1):S65

Myles TD, Miranda R.

Texas Technical University Health Sciences Center, Amarillo, TX, USA

Objective: The safety of vaginal birth after cesarean delivery (VBAC) in the singleton pregnancy has been known for many years. Despite this knowledge, most physicians feel the risk of VBAC in a twin pregnancy (TP) is too high despite the lack of documentation in the literature. We sought to determine if a VBAC for a TP carried greater risk than a singleton gestation.Methods: A retrospective study of all TP attempting VBAC from 1991 to 1999 were evaluated. The next three consecutive singleton pregnancies attempting VBAC also were evaluated. Comparisons were made for VBAC success and complications (blood loss, uterine rupture, hysterectomy, chorioamnionitis, blood transfusion, postpartum hemorrhage [PPH], and neonatal morbidity), and chi(2) test of association or Student's t tests were used where appropriate. Significance was set at P <0.05.Results: Nineteen TP met study criteria. There were 57 controls. Gestational ages were similar (TP 38.5; controls 38.7). The VBAC success rate was 84.2% for the TP and 75.4% for controls. The incidence of PPH was 5.3% for both groups. No PPH occurred in a TP with a successful VBAC. One uterine rupture occurred in the control group; none occurred in the TP group. No significant differences were found for any parameters tested, including 1- or 5-minute Apgar scores, venous or arterial pH, or neonatal intensive care unit admission.Conclusions: The option of VBAC for TP appears to be safe and shares a similar likelihood of success as a singleton pregnancy. In view of the lack of increased complications, this option should be offered to patients with TP who are eligible for VBAC.

PMID: 10729552

[3] [Twin delivery after cesarean section: is a trial of labor warranted]?

[Article in French]

J Gynecol Obstet Biol Reprod (Paris) 1999 Dec;28(8):820-4

Aboulfalah A, Abbassi H, el Karroumi M, Himmi A, el Mansouri A.

Maternite Lalla Meryem, CHU Ibn Rochd, Casablanca, Maroc.

OBJECTIVE: To determine whether a trial of labor in twin pregnancy is a valuable alternative to routine repeat cesarean section.
MATERIAL AND METHODS: Based on retrospective analysis of 31 cases of twin gestation with previous cesarean section, we tried to assess the outcomes of 25 cases of trial of labor. The outcomes of trial of labor in twin pregnancy were compared to those of trial of labor in singleton pregnancy.
RESULTS: The trial of labor was successful in 21 cases (84%). There was one case of scar dehiscence among the women who underwent a trial of labor, that occurred in the parturient with two previous cesarean sections after complete breech extraction. There were no significant differences in perinatal outcomes in any comparison of trial of labor versus no trial of labor. The outcomes of trial of labor in the twin pregnancy were similar to singleton pregnancy.
CONCLUSIONS: Routine repeat cesarean section in the twin pregnancy is not necessarily warranted; a controlled trial of labor in selected cases would be a valuable alternative.

PMID: 10635485

[4] Twin vaginal birth after cesarean.

Conn Med 2000 Apr;64(4):205-8

Wax JR, Philput C, Mather J, Steinfeld JD, Ingardia CJ.

University of Connecticut School of Medicine, Department of Obstetrics and Gynecology, USA.

OBJECTIVE: To determine both success rate and maternal-fetal outcome of vaginal birth after cesarean in twin gestations.
METHODS: We identified all women from a single center attempting vaginal birth of twins after cesarean from 1988-98. Twin pairs were excluded for delivery < or = 25 weeks gestation, monoamnionicity, nonvertex twin A, or major anomaly or death of either twin. Cases were matched to the next three consecutive twin gestations attempting vaginal delivery without a prior cesarean. Variables matched were gestational age at delivery (+/- 1 week), presentations of both fetuses, labor onset (spontaneous or induced), and prior vaginal delivery (yes or no). The primary outcome was successful vaginal delivery of both fetuses. Secondary maternal outcomes included chorioamnionitis, hemorrhage requiring transfusion, hysterectomy, uterine rupture, and length of stay. Neonatal outcomes included one and five minute Apgars, NICU admission, and length of NICU stay.
RESULTS: Twelve parturients were matched to 36 controls. There were no differences between the groups with respect to maternal demographics, intrapartum variables, fetal genders, birthweights, or chorionicity. Women with a prior cesarean (10/12) delivered both twins vaginally compared to 31/36 parturients without a prior cesarean (P = 1.0). There were no differences between cases and controls with respect to maternal morbidity (1/12 vs 4/36, P = 1.0), or postpartum stay (2.5 +/- 1.0 vs 2.5 +/- 2.3 days, P = .25). Neonatal outcomes were similar by birth order, except that second-born twins of cases had significantly longer NICU stays than controls (22.7 +/- 3.8 vs 10.4 +/- 7.8 days, P = .04).

CONCLUSION: Twin trial of labor after cesarean is associated with a high success rate of vaginal delivery but may be associated with a more lengthy NICU stay for the second twin.

PMID: 10812766

[5] Vaginal birth after cesarean delivery: can the trial of labor be extended?

Source J Gynecol Obstet Biol Reprod (Paris), 27(4):425-9 1998 Jun

Author Abbassi H ; Aboulfalah A ; el Karroumi M ; Bouhya S ; Bekkay M
Address Maternit´e Lalla Meryem, CHU Ibn Rochd, Casablanca, Maroc.


Abstract
Based on a retrospective analysis of 1000 cases of scared uteri following cesarean section(s) (one cesarean, n = 857, 85.7%); two n = 129, 12.9%; three n = 14, 1.4%), we tried to answer two questions. Is trial of labor in case of low segment uterine-scar (excepting pelvic abnormalities, corporeal scar and more than two scars) free of risk for the mother and child? Can trial of labor be extended to cases of breech presentation, two previous cesarean sections, twin pregnancy and suspected macrosomia? In this series, the cesarean was indicated before labor in 138 cases (13.8%). Trial of labor was conducted in 862 cases (86.2%), and led to vaginal birth in 728 (84.5%). Successful trial of labor was observed in 75% of twin pregnancies, in 100% of breech presentations and in 69.6% of macrosomic infants. Uterine rupture occurred in 23 cases (2.7%), especially in cases with unknown corporeal scars (15 cases). No case of perinatal death related to uterine rupture was observed in this series.

Language Fre
Unique Identifier 98354619

[6] Preliminary experience with a prospective protocol for planned vaginal delivery of triplet gestations.

AUTHORS: Alamia V Jr; Royek AB; Jaekle RK; Meyer BA

AUTHOR AFFILIATION: Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, State University of New York at Stony Brook, New York, USA.
SOURCE: Am J Obstet Gynecol 1998 Nov;179(5):1133-5

CITATION IDS: PMID: 9822488 UI: 99039941

ABSTRACT: OBJECTIVE: The objective of the study was to evaluate a protocol for vaginal delivery of triplet gestations.
STUDY DESIGN: All women with triplet gestations managed between January 1, 1995, and December 31, 1997, by University Medical Center's perinatal practice were offered enrollment in our vaginal delivery protocol. Our protocol offered attempt of vaginal delivery if triplet A was in vertex presentation, fetal monitoring was possible, and there were no other obstetric contraindications. Twenty-three triplet gestations were identified; 8 achieved vaginal delivery. Outcome parameters investigated included neonatal mortality, Apgar scores, neonatal intracranial hemorrhage, arterial cord pH, neonatal weight, and length of postpartum hospital stays of mother and neonates. All parameters were analyzed with analysis of variance and the Student t test as appropriate with the JMP 3.1 statistics program (Cary, NC).

RESULTS: Twenty-three sets of triplets were enrolled. Eight sets were delivered vaginally. Eight of 9 patients (88.9%) who attempted trial of labor were delivered vaginally, 1 of which was a vaginal birth after cesarean section. The remaining triplet gestation failed to progress at 4-cm dilation. Twelve sets of triplets had a nonvertex-presenting triplet and were delivered by the cesarean route. The remaining 2 triplet gestations were delivered by the cesarean route because of inadequate fetal monitoring. Neonatal survivals were 100% for both groups. No significant differences in neonatal mortality, Apgar scores, intracranial hemorrhage, arterial cord blood pH, hospital or neonatal intensive care unit stay of neonate, neonatal weight, and change in maternal or neonatal blood cell count were noted. There were no cases of grade III or IV intraventricular hemorrhage in either group. A significant reduction in postpartum hospital stay of mother was noted in the vaginal delivery group (2.8 vs 4.5 days, P <.001). The mean gestational age at delivery was significantly lower for the vaginal delivery group (31.3 vs 34.0 weeks, P <.02). The mean neonatal weight for the vaginal delivery group was significantly lower (1758 +/- 473 vs 2022 +/- 407 g, P <.02). There were no significant differences in outcome parameters for the first, second, and third triplets within each group when compared with each other or with the other study group. One patient who underwent vaginal delivery had retained products of conception and required curettage. A single fetal death occurred at 22 weeks' gestation from twin-twin transfusion, with the remaining triplets being delivered vaginally at 35 weeks' gestation. Cesarean hysterectomy was required in 1 case for uncontrollable bleeding at the time of cesarean delivery. Perinatal complications occurred in a large number of patients, with the incidence of premature labor 47. 8% (n = 11), that of preterm premature rupture of membranes 26.1% (n = 6), and that of preeclampsia 34.8% (n = 8).

CONCLUSION: In selected cases vaginal delivery of triplet gestations can be accomplished without increased maternal or neonatal morbidity and mortality and may significantly decrease maternal hospital stay and postoperative morbidity.

[7] Vaginal birth after cesarean section in twin gestation.

Miller DA, Mullin P, Hou D, Paul RH.
Department of Obstetrics and Gynecology, Los Angeles County/University of Southern California Women's and Children's Hospital 90033, USA.
Am J Obstet Gynecol 1996 Jul;175(1):194-8

OBJECTIVE: We report a 10-year experience with vaginal birth after cesarean section in women with twins.
STUDY DESIGN: Data were gathered from labor and delivery records and maternal and neonatal hospital charts. Women with a vertical uterine scar, a previous uterine rupture, an unrepaired dehiscence, or obstetric contraindications to labor were excluded from a trial of labor. Full-thickness uterine defects requiring intervention were classified as ruptures; all others were classified as dehiscences.

RESULTS: Between Jan. 1, 1985, and Dec. 31, 1994, at Los Angeles County/University of Southern California Women's Hospital, 210 women with previous cesarean births were delivered of twins. One hundred eighteen (56%) underwent repeat cesarean delivery without a trial of labor. Ninety-two (44%) undertook a trial of labor with no uterine ruptures and no increase in maternal or perinatal morbidity or mortality.

CONCLUSIONS: In women with twins a trial of labor after a previous cesarean section is a safe and effective alternative to routine repeat cesarean delivery.

PMID: 8694051 [PubMed - indexed for MEDLINE]

This page last updated 29 May 2002

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