Mode of Delivery and Neonatal Outcomes in Twin Pregnancies

Twin gestations present unique challenges for obstetric care owing to the potential for discordant presentations, varying chorionicity and shared placental physiology. The principal modes of delivery include planned vaginal birth, elective caesarean section and a mixed approach in which vaginal delivery of the first twin may be followed by caesarean delivery of the second. Maternal and neonatal outcomes hinge on factors such as presentation of each twin (cephalic versus non-cephalic), inter-twin delivery interval, gestational age at birth and the induction method. Neonatal metrics of interest encompass Apgar scores, umbilical artery pH, admission to neonatal intensive care and longer-term neurodevelopment. Maternal outcomes include severe acute morbidity, blood transfusion and intensive care admission. Global trends in caesarean rates have risen in parallel with improvements in neonatal survival, yet the balance between reducing perinatal distress and avoiding surgical morbidity remains under active investigation. Emerging evidence supports selective vaginal delivery when the first twin is cephalic, with careful monitoring of the second twin’s presentation and timely decision-making to optimise both maternal safety and neonatal well-being.

Research from Nature Portfolio

Analyses of a large prospective national cohort have assessed severe acute maternal morbidity (SAMM) in women with planned vaginal twin delivery. Compared with wholly vaginal births, caesarean delivery of both twins or caesarean section for the second twin only was associated with a two-fold increase in the risk of severe maternal complications, including haemorrhage and transfusion. These findings underscore that unplanned or secondary caesarean interventions after the onset of labour contribute disproportionately to maternal morbidity. The study advocates refined labour-management protocols and enhanced intrapartum surveillance to reduce the need for emergent surgical intervention in twin pregnancies.

Mode of Delivery and Neonatal Outcomes in Twin Pregnancies publication trend

The graph below shows the total number of articles in mode of delivery and neonatal outcomes in twin pregnancies across all publications each year (not limited to Nature Index journals).

Technical terms

Cephalic presentation: Fetal orientation with the head positioned to enter the birth canal first.

Chorionicity: The number of placentas in a multiple pregnancy; monochorionic twins share one placenta, dichorionic twins each have their own.

Apgar score: A rapid assessment of neonatal adaptation based on heart rate, respiration, muscle tone, reflex irritability and colour, scored at 1 and 5 minutes after birth.

Twin-to-twin delivery interval: The elapsed time between the birth of the first and second twin, with implications for acid–base balance in the second twin.

Severe acute maternal morbidity (SAMM): A composite of life-threatening maternal complications such as massive haemorrhage, organ failure or intensive care admission associated with childbirth.

References

1. The effect of twin-to-twin delivery time intervals on neonatal outcome for second twins. BMC Pregnancy and Childbirth (2018).
2. Is Cesarean Delivery Preferable in Twin Pregnancies at >=36 Weeks Gestation?. PLOS ONE (2016).
3. Severe maternal morbidity by mode of delivery in women with twin pregnancy and planned vaginal delivery. Scientific Reports (2020).
4. Mode of delivery, perinatal outcome and neurodevelopment in uncomplicated monochorionic diamniotic twins: a single-center retrospective cohort study. BMC Pregnancy and Childbirth (2022).
5. Trend in major neonatal and maternal morbidities accompanying the rise in the cesarean delivery rate. Scientific Reports (2015).