Neonatal safety data along with national guidelines have prompted renewed interest
in vaginal delivery of twins, particularly in the case of the noncephalic second twin.
Yet, the rising rate of twin cesarean deliveries, coupled with the national decline
in operative obstetrics, raises concerns about the availability of providers who are
skilled in twin vaginal birth. Providers are key stakeholders for increasing rates
of twin vaginal delivery. We surveyed a group of practicing obstetricians to explore
potential barriers to the vaginal birth of twins with a focus on delivery of the noncephalic
second twin. Among 107 responding providers, only 57% would deliver a noncephalic
second twin by breech extraction. Providers who preferred breech extraction had a
higher rate of maternal-fetal medicine subspecialty training (26.2% vs 4.3%; P<.01) and were more likely to be in an academic practice environment (36.1% vs 10.9%;
P<.01) and to practice in high-volume centers that deliver >30 sets of twins annually
(57.4% vs 34.8%; P=.02). Most providers (54.2%) were familiar with the findings from the recent randomized
trial that demonstrated the safety of twin vaginal birth. However, knowledge of the
trial was not associated statistically with a preference for breech extraction (62.3%
vs 43.5%; P=.05). Providers who preferred breech extraction were more likely to agree with recent
society guidelines that encourage the vaginal birth of twins (86.9% vs 63.0%; P<.01). In an adjusted analysis, the 46% of providers with a perceived need for more
training were far less likely to prefer breech extraction for delivery of a noncephalic
second twin (adjusted odds ratio, 0.38; 95% confidence interval, 0.16–0.95). Furthermore,
57% of providers who would not offer their patient breech extraction would be willing
to consult a colleague for support with a noncephalic twin delivery. These results
suggest that scientific evidence and society opinion are likely insufficient to reverse
the national trends that favor cesarean delivery for twins. Instead, implementation
of provider training and support programs is critical for increasing the rates of
twin vaginal birth. Changing our national landscape of vaginal twin delivery may require
innovation. Without novel provider-focused strategies, we may relinquish passively
the requisite skills for not only our patients but also for future generations of
obstetricians.
Key words
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Article Info
Publication History
Published online: February 07, 2017
Accepted:
January 31,
2017
Received in revised form:
January 20,
2017
Received:
November 29,
2016
Footnotes
Supported by the Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, and Department of Health and Human Services (HHS) via grant number R60MC 05674.
The funding source had no role in design, analysis, interpretation, drafting, or revision of this manuscript.
The authors report no conflict of interest.
The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the Association of American Medical Colleges.
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