October 3, 2013
News Review From Harvard Medical School -- Study: Twins May Not Require C-Section
Women pregnant with twins may not need to have a cesarean section, a new study suggests. Many can have a safe vaginal delivery, the study found. The study included nearly 2,800 women who were scheduled to deliver full-term twins. The babies were at a healthy weight, and the first twin was in the usual head-down position. Women were randomly assigned to have either a planned C-section or a planned vaginal delivery. But doctors could make a different decision based on their judgment at the time of delivery. About 91% of women in the planned-cesarean group had C-sections. About 56% of those in the other group did have vaginal deliveries. The others had C-sections or a combination delivery. Researchers kept track of mothers and babies for a month after the births. Problem rates were similar for both groups. Authors of the study and an editorial said women who want to deliver twins vaginally should choose a doctor who is experienced with delivering twins this way. The New England Journal of Medicine published the study. HealthDay News wrote about it October 2.
By Robert H. Shmerling, M.D.
Harvard Medical School
What Is the Doctor's Reaction?
In recent years, there has been much concern about the high rate of cesarean sections (C-sections) in the United States. It has increased 40% in the last 15 years. The current rate -- about one-third of all births -- is significantly higher than in most other countries.
Experts cite several reasons. They include:
- More medical problems (such as obesity and diabetes) among pregnant women
- The increased number of twin births and obstetricians' belief that a C-section should be routine for them
- Concern about malpractice suits if something goes wrong during a vaginal delivery
- Doctor or patient convenience
For twin pregnancies, the current rate of C-section is even higher, 75%. As recently as 1995, it was 54%.
A remarkable new study examines whether this high rate of C-section comes with health advantages for mothers and babies. In this study, nearly 2,800 women who were pregnant with twins were randomly assigned to have a planned C-section or vaginal delivery.
Each pregnancy was uncomplicated and full term, and the first twin had its head down in the normal position for delivery. The obstetrician could elect to change the method of delivery based on his or her medical judgment. As it turned out, about 90% of planned C-sections and 44% of planned vaginal deliveries were delivered by C-section.
Here's what the study found out:
- Women in the planned C-section group delivered about one day earlier than women in the other group.
- Complications were rare (about 2%) in both groups.
- Outcomes for the mothers were also similar in both groups.
The study shows that planned vaginal delivery of twins often must be converted to a C-section. But it also suggests that there is no medical advantage to routinely planning a C-section for twins. However, these results don't apply to all twin pregnancies. This study included only those that were full term. The first twin also was not in a breech position (legs or buttocks down, instead of the head).
This was not an easy study to conduct, and it's unlikely to be repeated. It took researchers more than 7 years to enroll enough women pregnant with twins in 106 medical centers in 25 countries.
What Changes Can I Make Now?
Many C-sections can't be avoided. Often, they are urgent and may even be life-saving for the baby or mother.
Still, when it's not clearly necessary, a C-section is worth avoiding. It is a major operation. Risks to the mother include pain, bleeding, infections and a longer recovery. There are risks to the baby as well. For example, babies delivered by elective C-section before the 39th week have more breathing problems than babies delivered vaginally after 39 weeks.
So it's important to understand the reasons that doctors recommend C-sections. Most are situations thought to make a vaginal delivery riskier than normal. They include:
- Multiple fetuses (although this latest research shows that twins can often be delivered vaginally)
- Problems with the placenta or umbilical cord
- Fetal distress, abnormal development or large size
- A breech position
- Early or long labor
- Medical conditions of the mother, such as an infection or diabetes
Of course, labor is not an ideal time to "negotiate" whether to perform a C-section. Well before labor, however, there may be steps you can take to reduce your chances of having a C-section. For example:
- Don't assume that because you had a C-section before you must have one in the future. Vaginal birth after cesarean (VBAC) was once rarely offered. Now it is often acceptably safe and appropriate.
- Pick your hospital and obstetrician carefully. Increasingly, C-section rates are available to the public. Look for doctors with a low C-section rate (and, of course, a low complication rate).
- Avoid induction of labor for matters of convenience (such as picking a time when your own doctor is on call). When labor is started by taking medicines, such as oxytocin, the chance of having a C-section rises.
- Get an advocate. For some, it's a spouse or partner. Others hire a birth coach or have some other trusted person in the delivery room with them. If the situation is not an emergency, it may be helpful to have others helping you to ask the right questions.
- Spend your early labor at home. The longer you're in the hospital, the more stress, tests, monitoring and treatments you're likely to get. Each of these may contribute to slowed labor and may increase the chances of getting a C-section.
- Try to avoid epidural anesthesia in early labor.
The decision to have a C-section requires medical judgment and careful consideration of the mother's preferences. Make sure you are seeing a practitioner who knows yours.
What Can I Expect Looking to the Future?
In recent years, the U.S. C-section rate has stabilized. I hope that will continue. Studies such as this one could encourage doctors and mothers to plan a vaginal delivery even for twins. However, an editorial published with this research expressed pessimism that the C-section rate for twins would fall. That's because as C-sections have become common, obstetricians may no longer have the skills (or willingness) to deliver twins vaginally. Considering the results of this latest research, that's disappointing.