A new study was just released on best practice for twin delivery: planned c-section or planned vaginal birth.  You can read lay-versions of the study from the Los Angeles Times, Medscape, and the Daily Globe and Mail (the leads on the study are Canadian).  You can also watch a video outlining the study where the article appears on the New England Journal of Medicine website (note that the woman birthing vaginally in the video is on her back–not an evidence based position for birthing).

The basic conclusion of the study is that in absence of complications, there is no reason to plan a cesarean for a twin birth.  While many women who plan vaginal twin births still wind up facing complications that lead to cesareans, well over half successfully deliver vaginally.  Among women who had planned twin cesareans, outcomes were no better than among the planned vaginal birth group (in which the majority of cesareans were not planned and would therefore be classified as “emergency” cesareans).  One of the only differences found was that, on average, the vaginally birthed twins gained about a day of gestational age before birth, a small gain that can make a big difference for a preterm infant.  Nearly half of the twins in the study were born preterm (before 37 weeks gestation).

Despite the finding that there is no advantage to planned cesarean, according to the Globe and Mail article

Michael Greene of the department of obstetrics and gynecology at Massachusetts General Hospital in Boston said that while the outcomes are the same, “these results do not indicate that all sets of twins should be delivered vaginally.” Rather, he said that decision should rest with the obstetrician-gynecologist and that current practices – 75 per cent of twins born by C-section in the United States – should remain.*

Should remain.  Should.

And the decision should rest with the obstetrician-gynecologist.  Not with the person giving birth.  With the person who is not.

Because if you are a pregnant woman, planning major abdominal surgery when there is no advantage to you or your infants should be your doctor’s choice?

As the title says, fun and profit.

The study notes that even under current practice, about a quarter of twins are born vaginally, so there must be OBs who support planned vaginal birth even without the results of randomized control trial (RCT, considered the gold standard for evidence-based practice) that show it is safe as the alternative.

I would always recommend working with OBs who practice evidence based medicine and with OBs who don’t feel that their own preferences entitle them to perform unnecessary surgery on other people.

* Michael Green has an editorial in the NEJM to accompany the twin study article.  Here is the link, but you need a subscription to read it.

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