2.1. Study design and setting
The results of twin pregnancy cases followed and delivered between
January 2013 and December 2015 at Health Sciences University, Gazi
Yasargil Research and Training Hospital, were obtained retrospectively
from the hospital’s automation system records. Obstetric ultrasound was
performed on all women involved in this study, with verbal consent, and
the results were compared with the last menstrual period and first
trimester obstetric ultrasound to determine the gestational week and
chorionicity. The presentations and estimated fetal weights of the twins
were determined via prenatal obstetric ultrasound. Out of all twin
pregnancies, women who desire VB with the first twin in vertex
presentation that were undergoing VB were included in group 1. Women who
do not want VB with the first twin in vertex presentation that were
undergoing a primary ‘elective’ CB for the first time were included in
group 2 and VB has not been attempted for this patient group.
The primary outcome was early neonatal mortality and secondary outcomes
related to maternal and perinatal clinical characteristics were analysed
between the groups. The groups were compared in terms of maternal age,
gravida, parity, body mass index (BMI), assisted reproductive technology
(ART), term birth rates (≥37 weeks 0 days) and preterm birth rates
(<37 weeks, divided into two groups: between 32 weeks 0 days
and 33 weeks 6 days and between 34 weeks 0 days and 36 weeks 6 days),
type of birth (infant 1 and 2), birth weight, five-minute
activity–pulse–grimace–appearance–respiration (APGAR) score,
five-minute APGAR less than 7, trauma-associated morbidity (was
identified as spinal cord injury, fracture of skull, humerus, femur or
clavicle, brachial plexus injuries, facial nerve injuries, subdural,
subarachnoid and intracerebral hemorrhages), early neonatal mortality
rate (ENMR: number of neonatal deaths in 0–7 days x 1000/total live
births), maternal death and severe postpartum hemorrhage.
Experienced obstetricians evaluated all twin pregnancies that were
accepted to the birth room after the start of spontaneous labor pains,
and these pregnancies were continuously monitored during labor. The
oxytocin regimen is the same as in singleton pregnancies. After the
birth of the first twin, the presentation of the second twin was
determined by ultrasound. For pregnancies with the second twin in vertex
presentation, amniotomy was not performed before the head of the twin
was engaged unless forceps or vacuum was required due to unsafe fetal
condition. In the second twin with non-vertex presentation, the
obstetrician decided the best birth method (spontaneous breech birth,
assisted breech birth, external cephalic version, internal cephalic
version, etc.) and implemented it following consultation with the
pregnant woman. If the second twin is not in a cephalic presentation
(eg, breech or transverse), our preference is breech extraction if there
are no contraindications to this procedure. All twin VBs were performed
by experienced obstetricians (13,14). The women for whom the
obstetrician decided CB was needed for the second twin were taken to an
operating room quickly, and the twin CB was performed. The hospital
serves a wide area, and because of the high number of births, four
operating rooms and an anaesthesia team are ready around the clock so
CBs can be performed in these operating rooms without loss of time if
necessary.