Dec 22, 2010

Twin Study

In 2007, the British Medical Journal (BMJ) reported that second-born term twins are twice as like to die at birth or shortly after birth as first born twins, if delivered vaginally. This finding reflects a relative risk, not an absolute risk which remains very small, and it was for term births only.

The Atlanta Journal Constitution (3/2/07) reported:
"'I would hate to see this study used as an excuse to have every mother with twins have a Caesarean section,' said Dr. F. Sessions Cole, the head of the neonatal intensive care unit at St. Louis Children's Hospital." Dr. Cole also that the study may apply more to Britain than the US, because we monitor twins better here.

Today, many doctors are all too willing to follow the lead author of the BMJ study, who concluded that: "the findings of this and other studies suggest that planned cesarean section may be beneficial for all twins."

The key word is MAY. Medical opinion is divided on whether cesareans are protective for all twin deliveries. Two French studies from 2006 and from 2003 showed excellent outcomes for vaginal deliveries of twins, regardless of presentation.

So why are so many doctors afraid to deliver twins vaginally? Because of a hostile legal climate in which a public expects a perfect birth and is unwilling to accept the very real risks of breech and twin deliveries, regardless of mode of delivery. When something goes wrong, when the doctor can show a cesarean was ordered, patients rarely complain.

Today, between 50% and 90% of all twins were delivered by cesarean, depending on their orientation (ie. headfirst or not). Yet roughly 60% of all twin pregnancies includes one twin who is not headfirst. This amounts to more than 80 thousand babies a year in the US, many if not all of whom will be delivered by cesarean.

Pregnant with breech twins in 2004, I had great difficulty finding a doctor willing to consider a vaginal delivery. Even though the studies were not conclusive in my case---for it was the second not the first twin who was breech---every single OB balked, even those in midwifery practices, even those who touted themselves as pro-vaginal delivery. Ironically, I delivered my twins an IVY league research hospital with the one obstetrician willing to deliver breech twins vaginally---at 26 weeks. None of the maternal fetal specialists at Harvard, Yale, or Northwestern I have since interviewed would have considered such a move. I still wonder if my twins success in the NICU had something to do with the well-known fact that labor and vaginal deliveries are known to hasten lung maturity?

It will be interesting to see what happens when the next generation of OBs and neonatologists take over, few of whom recall an era when any twins (never mind breech or preterm) were regularly delivered vaginally. For now, I hope that medical residents keep reading studies from other countries where doctors still perform vaginal deliveries of twins and breech babies, before these skills are utterly lost to history.