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      The effect of induction method in twin pregnancies: a secondary analysis for the twin birth study

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          Abstract

          Background

          This secondary analysis for the Twin Birth Study, an international, multicenter trial, aimed to compare the cesarean section rates and safety between methods of induction of labor in twin pregnancies.

          Methods

          Women with twin pregnancies where the first twin was in a cephalic presentation and who presented for labor induction, were non-randomly assigned to receive prostaglandin or amniotomy and/or oxytocin. Main outcome measures were the rates of unplanned cesarean section and neonatal and maternal mortality or serious morbidity.

          Results

          153 (41.5%) were induced by prostaglandin (prostaglandin group) and 215 (58.5%) were induced by amniotomy and/or oxytocin alone (no prostaglandin group). Induction using prostaglandin was more common in countries with a low perinatal mortality rate <10/1000 (45.7 versus 32.5%, p = 0.02). Cesarean section rates were similar in the two groups: 62/153 (40.5%) in the prostaglandin group and 87/215 (40.5%) in the no prostaglandin group (odds ratio 1, 95% CI 0.65-1.5). Nulliparity, late maternal age, non-cephalic presentation of twin B and high country’s perinatal mortality rate were found to be independently associated with the induction to end with an unplanned cesarean section. There were no significant differences between groups with respect to maternal or neonatal adverse outcomes.

          Conclusions

          The need for cervical ripening by prostaglandin had no effect on the incidence of cesarean delivery or an abnormal outcome. There is a significant risk of unplanned cesarean section independent of chosen induction method.

          Trial registration

          This trial was registered at the International Standard Randomized Controlled Trial Register (identifier ISRCTN74420086; December 9, 2003) and retrospectively registered at the www.clinicaltrials.gov (identifier NCT 00187369; September 12, 2005).

          Electronic supplementary material

          The online version of this article (doi:10.1186/s12884-016-1201-8) contains supplementary material, which is available to authorized users.

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          Most cited references28

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          Timing of indicated late-preterm and early-term birth.

          George Saade, Eric Kilpatrick, Catherine Y. Spong … (2011)
          The growing public health awareness of prematurity and its complications has prompted careful evaluation of the timing of deliveries by clinicians and hospitals. Preterm birth is associated with significant morbidity and mortality, and affects more than half a million births in the United States each year. In some situations, however, a late-preterm or early-term birth is the optimal outcome for the mother, child, or both owing to conditions that can result in worse outcomes if pregnancy is allowed to continue. These conditions may be categorized as placental, maternal, or fetal, including conditions such as placenta previa, preeclampsia, and multiple gestations. Some risks associated with early delivery are common to all conditions, including prematurity-related morbidities (eg, respiratory distress syndrome and intraventricular hemorrhage) as well as maternal intrapartum morbidities such as failed induction and cesarean delivery. However, when continuation of the pregnancy is associated with more risks such as hemorrhage, uterine rupture, and stillbirth, preterm delivery maybe indicated. In February 2011, the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Society for Maternal-Fetal Medicine held a workshop titled "Timing of Indicated Late Preterm and Early Term Births." The goal of the workshop was to synthesize the available information regarding conditions that may result in medically indicated late-preterm and early-term births to determine the potential risks and benefits of delivery compared with continued pregnancy, determine the optimal gestational age for delivery of affected pregnancies when possible, and inform future research regarding these issues. Based on available data and expert opinion, optimal timing for delivery for specific conditions was determined by consensus.
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            A randomized trial of planned cesarean or vaginal delivery for twin pregnancy.

            Eileen K. Hutton, D. Mason, Suresh K. Joseph … (2013)
            Twin birth is associated with a higher risk of adverse perinatal outcomes than singleton birth. It is unclear whether planned cesarean section results in a lower risk of adverse outcomes than planned vaginal delivery in twin pregnancy. We randomly assigned women between 32 weeks 0 days and 38 weeks 6 days of gestation with twin pregnancy and with the first twin in the cephalic presentation to planned cesarean section or planned vaginal delivery with cesarean only if indicated. Elective delivery was planned between 37 weeks 5 days and 38 weeks 6 days of gestation. The primary outcome was a composite of fetal or neonatal death or serious neonatal morbidity, with the fetus or infant as the unit of analysis for the statistical comparison. A total of 1398 women (2795 fetuses) were randomly assigned to planned cesarean delivery and 1406 women (2812 fetuses) to planned vaginal delivery. The rate of cesarean delivery was 90.7% in the planned-cesarean-delivery group and 43.8% in the planned-vaginal-delivery group. Women in the planned-cesarean-delivery group delivered earlier than did those in the planned-vaginal-delivery group (mean number of days from randomization to delivery, 12.4 vs. 13.3; P=0.04). There was no significant difference in the composite primary outcome between the planned-cesarean-delivery group and the planned-vaginal-delivery group (2.2% and 1.9%, respectively; odds ratio with planned cesarean delivery, 1.16; 95% confidence interval, 0.77 to 1.74; P=0.49). In twin pregnancy between 32 weeks 0 days and 38 weeks 6 days of gestation, with the first twin in the cephalic presentation, planned cesarean delivery did not significantly decrease or increase the risk of fetal or neonatal death or serious neonatal morbidity, as compared with planned vaginal delivery. (Funded by the Canadian Institutes of Health Research; ClinicalTrials.gov number, NCT00187369; Current Controlled Trials number, ISRCTN74420086.).
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              Bishop score and risk of cesarean delivery after induction of labor in nulliparous women.

              Cary J G Dehing, Jack van Loon, Henk J. M. Aarts … (2005)
              To quantify the risk and risk factors for cesarean delivery associated with medical and elective induction of labor in nulliparous women. A prospective cohort study was performed in nulliparous women at term with vertex singleton gestations who had labor induced at 2 obstetrical centers. Medical and elective indications and Bishop scores were recorded before labor induction. Obstetric and neonatal data were analyzed and compared with the results in women with a spontaneous onset of labor. Data were analyzed using univariate and multivariable regression modeling. A total of 1,389 women were included in the study. The cesarean delivery rate was 12.0% in women with a spontaneous onset of labor (n = 765), 23.4% in women undergoing labor induction for medical reasons (n = 435) (unadjusted odds ratio [OR] 2.24; 95% confidence interval [CI] 1.64-3.06), and 23.8% in women whose labor was electively induced (n = 189) (unadjusted OR 2.29; 95% CI 1.53-3.41). However, after adjusting for the Bishop score at admission, no significant differences in cesarean delivery rates were found among the 3 groups. A Bishop score of 5 or less was a predominant risk factor for a cesarean delivery in all 3 groups (adjusted OR 2.32; 95% CI 1.66-3.25). Other variables with significantly increased risk for cesarean delivery included maternal age of 30 years or older, body mass index of 31 or higher, use of epidural analgesia during the first stage of labor, and birth weight of 3,500 g or higher. In both induction groups, more newborns required neonatal care, more mothers needed a blood transfusion, and the maternal hospital stay was longer. Compared with spontaneous onset of labor, medical and elective induction of labor in nulliparous women at term with a single fetus in cephalic presentation is associated with an increased risk of cesarean delivery, predominantly related to an unfavorable Bishop score at admission. II-2.
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                Author and article information

                Contributors
                Elad Mei-Dan: elad.mei-dan@sunnybrook.ca
                Elizabeth V. Asztalos: Elizabeth.Asztalos@sunnybrook.ca
                Andrew R. Willan: andy@andywillan.com
                Jon F. R. Barrett: jon.barrett@Sunnybrook.ca
                Journal
                Journal ID (nlm-ta): BMC Pregnancy Childbirth
                Journal ID (iso-abbrev): BMC Pregnancy Childbirth
                Title: BMC Pregnancy and Childbirth
                Publisher: BioMed Central (London )
                ISSN (Electronic): 1471-2393
                Publication date (Electronic): 6 January 2017
                Publication date PMC-release: 6 January 2017
                Publication date Collection: 2017
                Volume: 17
                Electronic Location Identifier: 9
                Affiliations
                [1 ]Women and Babies Program, Sunnybrook Health Sciences Center, Sunnybrook Research Institute, 2075 Bayview Ave, Toronto, ON M4N 3M5 Canada
                [2 ]Child Health Evaluative Sciences, SickKids Research Institute, University of Toronto, The Hospital for Sick Children, 555 University Avenue, Toronto, M5G 1X8 ON Canada
                Article
                Publisher ID: 1201
                DOI: 10.1186/s12884-016-1201-8
                PMC ID: 5217445
                PubMed ID: 28061767
                SO-VID: 8391860b-17fe-4dad-ac06-b97cfc13e36a
                Copyright © © The Author(s). 2017
                License:

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Date received : 24 December 2015
                Date accepted : 16 December 2016
                Funding
                Funded by: Canadian Institutes of Health Research (CIHR)
                Award ID: 63164
                Categories
                Subject: Research Article
                Custom metadata
                issue-copyright-statement © The Author(s) 2017

                ScienceOpen disciplines: Obstetrics & Gynecology
                Keywords: cesarean section,induction of labor,prostaglandins,twins
                Data availability:
                ScienceOpen disciplines: Obstetrics & Gynecology
                Keywords: cesarean section, induction of labor, prostaglandins, twins

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