WOMEN with a twin pregnancy in Australia lack choice in the mode of delivery, according to an expert who says obstetricians’ declining skills in vaginal twin delivery may be driving an increase in caesarean deliveries.

Professor Euan Wallace is the co-author of research published in the MJA that has found a tripling of the rate of caesarean twin deliveries in Victoria between 1983 and 2015.

Professor Wallace, Professor of Obstetrics and Gynaecology at Monash University, told InSight+ that the increased rate of caesarean twin deliveries may reflect changes in clinician training, skill and confidence in vaginal twin birth.

“The increase in caesarean sections for twins may reflect clinicians themselves knowing they are not skilled so, in their hands, they think it’s safer to do a caesarean section,” Professor Wallace said.

The researchers found that in Victoria, the rate of caesarean delivery for twin births increased from 24% (156 deliveries) in 1983 to 71% (782 deliveries) in 2015. They found that the proportion of twin births by planned caesarean delivery with twin pregnancy as the sole indication for the delivery choice increased across the study period from 1.8% to 21%.

They noted that the greatest increases in caesarean twin deliveries occurred between 1983 and 2003, with no substantial increase in the last decade studied.

The authors said while earlier retrospective cohort studies had suggested that caesarean delivery was the safer option for twin births, the 2013 Twin Births Study – a randomised controlled trial coordinated in Canada and including several Australian centres – had found that routine caesarean delivery of twins did not benefit mothers or their babies.

In the Twin Births Study, 1398 women (2795 fetuses) were randomly assigned to planned caesarean delivery and 1406 women (2812 fetuses) to planned vaginal delivery. The researchers found that, compared with planned vaginal delivery, planned caesarean delivery did not significantly increase or decrease the risk of fetal or neonatal death or serious neonatal morbidity.

The MJA researchers noted that Victorian trends towards caesarean twin delivery mirrored those across Australia and in some other high income countries, such as the US (92%), Germany (75%) and Scotland (73%). However, the Victorian rate was higher than in Scandinavia (47–60%), the Netherlands (44%) and England (63%).

They also identified regional differences in Victoria, with Gippsland having the lowest rate of twin caesarean deliveries (54%, or 100 of 187 deliveries between 2010 and 2013).

Professor Wallace said a regrettable unintended consequence of enforcing safer working hours for trainee was a reduction  in trainees’ exposure to more complex births, including multiple birth deliveries. He said safer working hours were essential but the duration of the training program had remained at 6 years.

“I am not arguing in favour of 80 to 100-hour weeks at all, but how do we expect our trainees and young consultants to acquire all of the skills they need?” he said. “Surely, our role as a profession is to provide women with a skilled workforce so they can choose whether they wish for a vaginal birth or a caesarean section. Now, they really don’t have a choice, because chances are the obstetrician will say ‘well, we should do a caesarean section’.”

While Australian data are lacking on patient preference, the MJA authors pointed to 2004 Canadian research that found that women bearing twins preferred vaginal birth.

Professor Wallace said this was his experience.

“In our own twin clinic in Monash, women mostly would say, ‘if it’s safe, there is no reason why I shouldn’t then prefer a vaginal birth’,” he said. “The recovery is faster, and women are going to have two babies to look after, not one.”

Professor Mark Umstad, Director of Maternity Services at the Royal Women’s Hospital, Melbourne, agreed that reduced hours – while welcome – had affected skills development. But, he said, women with twin pregnancies often presented with fixed views on their preferred mode of delivery.

“My experience in looking after many thousands of women having twins is that they would often come in with an established plan. Twenty years ago, most women came in expecting vaginal birth, but over the subsequent decades there was a steady increase in women expecting a caesarean section,” said Professor Umstad, who is also Chief Research Investigator for Twins Research Australia.

He said women with twin pregnancies often perceived caesarean delivery to be the safer choice and these ideas can “take some unpicking”.

He said it was important to present women with the facts to enable them to make an informed choice about the type of delivery that was best for them.

“In certain circumstances, and they are really specific, vaginal twin delivery is just as safe as caesarean section delivery for twins,” he said. “You have to remember the Twin Birth Study was in hospitals with obstetricians experienced in vaginal twin delivery, immediate access to an operating theatre, access to paediatricians, and access to anaesthetists, so that doesn’t necessarily mean that vaginal delivery of twins is safe in every hospital.”

Professor Umstad said many of his colleagues made the decision to recommend caesarean delivery for twin pregnancies on the basis of access to services.

“It’s an easy decision in my hospital. We have access to all of those required services, as do all tertiary hospitals, but that may not be the case in a smaller peripheral hospital or in a regional hospital.

“What we should be doing is encouraging choice and advising women on the circumstances for their hospital and their doctors. It may well be that, given vaginal delivery is as safe as caesarean section and, if that’s the case, then that’s an option that should be offered to them, if it’s within the skill of the clinician to be able to provide that type of delivery.”

Dr Scott White, spokesperson for the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), said increases in the rates of caesarean twin deliveries was not surprising given the general trend toward caesarean deliveries in Australia.

He said while clinician preference was not the sole driver of the increase, it undoubtedly played a role.

“Clinicians consider patient preference, but there is also fear of litigation,” he said. “Obstetricians are generally of the mindset that you will be criticised for the caesarean section that you didn’t do not for the one that you did.”

Dr White agreed that training opportunities were now divided among a greater number of trainees.

“We are at risk of breeding a generation of obstetricians who have limited experience in these complex deliveries, which is a challenge not just in twin delivery but in all aspects of our specialty.”

Dr White said the message from RANZCOG was that women should be presented with the appropriate evidence and allowed to make decisions based on that evidence.

“This may mean referring to an obstetrician who has more skill and experience in vaginal twin birth delivery, which is undoubtedly a complex area of obstetrics,” he said.

Also, he said, more training was needed to develop the skills of clinicians with a particular interest in complex obstetrics care.

“We need to take a group of people who express an interest in complex obstetrics and concentrate the experience in the people who are actually going to be providing more complex care,” he said. “That way we can maintain a skilled workforce.”

Professor Wallace agreed that clinicians should be supported to gain advanced training, but he went one step further.

“And then we restrict the right of practitioners to provide care for women with twin pregnancies to those with advanced training in twin pregnancy care. That would not be a popular option, but I think we have to wake up and say that that data reflects a workforce that no longer feels confident or safe, so why are they providing care?”

Twins Research Australia will hold a workshop on 5 December 2019 to co-design national priorities to support better outcomes for multiple birth families.


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There should be increased training in complex births, including vaginal twin delivery








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11 thoughts on “Women with twins lack delivery mode choice

  1. Anonymous says:

    As an anaesthetist in a low resource semi rural setting where delivery to decision times for out of hours emergencies are routinely 60 minutes the thought of vaginal twins gives me nightmares. I’m sure its fine when you have in house staff!

  2. Private says:

    The main reason for twins = caesarian is medico-legal !!!!!!!
    Ever since Rod Shearman gave expert evidence back in the 70s !!!!!!!

  3. Anonymous says:

    A more nuanced analysis of the Twins Birth Study is warranted. 40% of women who were in the vaginal delivery arm actually delivered via Cesarean section, with further 4.2% requiring Cesarean section for the second twin after vaginal delivery of the first. Women who contemplate twin vaginal delivery need to be informed about these statistics and I suspect that a large proportion will lean towards an elective Cesarean delivery. The study in the MJA clearly shows that some women still deliver twins vaginally so the choice of delivery is available in Victoria. Vaginal twin deliveries should only be attempted in hospitals that have 24 hours access to an emergency Cesarean section within 30 minutes as 4-5% of deliveries will require an emergency Cesarean section for the second twin.

  4. Tony Cohen says:

    In our GP run rural hospital 20 years ago we used to offer vaginal twin deliveries. The criteria were that it had to be an elective induction after 37 weeks with the first twin cephalic and no other complications. The days were chosen when theatre staff was in town and a GP Anaesthetist was available as well as experienced doctors to help with the babies. Spontaneous labour earlier than 37 w was transferred to somewhere with a paediatrician. We did well and the families were thankful
    No only are younger obstetricians giving up or not gaining their skills and so becoming anxious but the administration that they advise are also becoming fearful. They have become convinced that GPs aren’t possibly clever enough to manage these situations or to determine and manage risk preemptively

  5. Frances Cadden says:

    Many years ago, I delivered twins vaginally – being induced at 38 weeks. Both were Cephalic so one was placed in breech position. First was a vacuum
    extraction the second was delivered with Kielland forceps. There was the then fashionable episiotomy. I do not think anyone would try that method nowadays but we all survived.

  6. Anonymous says:

    one could query the obstetrician’s motive for elective caesarean section may be convenience rather than skills. Another factor is availability of anaesthetists, theatre staff, paediatrician and midwifery staff out of hours. this can be circumvented by elective planned induction which is actually indicated and recommended with twins anyway.

  7. Anonymous says:

    I decided to aim for a vaginal twin birth at a tertiary hospital and waited for a spontaneous onset of labour . I was supported by one of the cited practitioners in my (carefully researched) decision but on-call staff were not supportive. . Mothers are independent decision makers – we value being informed (not scared or patronised). Our choices need to be respected – not just hypothetically- but at the time of presentation for birth.

  8. Jules Black, FRANZCOG, FRCOG says:

    I am retired now from O&G for 6 years. During my career, I mainly worked in major teaching hospitals in Sydney and in my closing years I was a locum O&G in >30 hospitals spanning 5 Australian states. As a result of my own training that started at the Women’s Hospital (Crown Street) in Sydney I had superb training at what was then Australia’s largest maternity hospital. The superintendents lived in with their families saving them thousands in rent and they were there for every complicated delivery. In our final year they would still be on the floor hovering outside if needed. This resulted in fabulous training in breech, twin and other complicated births.
    I found an arrogance among the registrars where I worked, even in provincial hospitals. I always invited them in to observe a breech or twin birth but they never came unless summoned to assist. On the other hand the midwives not directly in charge of a case would always come in to observe and learn. When I was a locum, and where a registrar was sufficiently senior for our presence in theatre or labour room being no longer prescribed, I would still go into theatre for example for a breech or twin Cæsarean. I always observed a lack of full skills in the breech operations — the manœuvres being the same as per a vaginal birth, and likewise for twins.
    At some stage I think our College floated the idea of seniors like us volunteering our services during these complicated deliveries. We have much to pass on. I moved permanently to Brisbane, offered such services, but my phone remains silent. (Are they scared of us “oldies”?)

  9. Anonymous says:

    As a result of improved working hours for trainees in all disciplines , their exposure to complex cases has reduced significantly and is reflected in the performance of new consultants in the workforce. One of the ways to improve the situation would be to increase the number of complex cases trainee has to complete prior to certification as a specialist/consultant.
    One can not dismiss the fact that fear of litigation may be a major factor in the decision making process and hence the preference for C-section over vaginal delivery. In a court of law accusation levelled against the practitioner would be “why C-section was not performed rather than why unwarranted C-section done”

  10. Jen Hocking says:

    Is it a legitimate argument that junior OB’s are not getting access to complex births when there is a general and significant increase in multiple births?
    It is legitimate to argue that they are not getting access to vaginal birth management for multiples because they are not occurring … we need mechanisms set up to change one and the other will follow.
    We are also in danger of setting up and maintaining a maternity system that is focused on safe caesarean birth. Caesarean birth is not always the solution for lifelong health – for the passenger/s or the vehicle.

  11. Steve Robson says:

    I’ve been a specialist obstetrician for 20 years. I have put a major effort into being the best procedural intrapartum obstetrician I can be – to the point that I set up, with enthusiastic senior colleagues, a workshop aiming to keep the skills of complex vaginal birth alive: twins, breech birth, rotational deliveries in particular. I regularly deliver twins vaginally, indeed I delivered two sets on one night recently.

    You know what? I dread it. Any nitwit can deliver a cephalic first twin, but managing a second twin in a vaginal birth can be about the most difficult thing there is in obstetrics. I’m a past-president of the College of obstetricians with almost 30 years experience all up, and I still find managing a vaginal twin labour and birth very stressful.

    Hannah and colleagues’ twin birth prospective RCT showed that peripartum outcomes are no different at the time of birth whether it’s vaginal or by caesarean, and the babies are neurodevelopmentally that same at two years, whereas women are more likely to have urinary incontinence down the track. My take on those data? Well, C-section has outcomes the same for babies but safer for their mothers in the long term (don’t ask me about the mesh used to treat urinary incontinence!). So if a woman chooses C-section then she is choosing a mode of birth that is equivalent to vaginal birth for her babies – no better but no worse.

    I admit it – despite my experience and enthusiasm I find the informed choice of a C-section delivery cheers me up. I know that I won’t have that overwhelming helpless fear that grips me at times with a second twin – and that I can almost guarantee the woman and her family that everything will be OK with the birth. Intrapartum death of a second twin is a shocking outcome and I have had close personal experience of this – it is something we all want to avoid at all costs. I always do my level best to appear as calm and serene as I can during a vaginal twin birth, but on the inside I’m invariably anxious.

    So, I’ll continue to do vaginal births of twins. I’m a strong respecter of informed choice. But I never feel completely confident doing it, despite decades of experience, seniority, enthusiasm, and training to the point of setting up a workshop. For those reasons I totally understand my colleagues making a choice to avoid vaginal birth of twins. I get it.

    In the end, the median number of children that Australian women have is 1.75 now, so for most women having twins, it will be the only birth they have – in that setting, a C-section is hardly the end of the world.

    I’m sure a shower of *whatever* will come down on me for making these comments, but I hope it opens up the debate a little. I’m not going to hide behind anonymous, but don’t want the usual trolling that always happens.

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