Reduction of planned cesarean delivery in twin pregnancy after a training intervention.

Reduction of planned cesarean delivery in twin pregnancy after a training intervention. | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 21 May 2025 V1 Latest version Share on Reduction of planned cesarean delivery in twin pregnancy after a training intervention. Authors : Claudio Celentano 0000-0003-4976-2957 [email protected] , Barbara Matarrelli , Maurizio Rosati , Claudio Meloni , Cecilia Molino , Aurora Padelli , Fiorella Conti , Federico Prefumo (Italy) 0000-0001-7793-714X , Martina Mercaldi , and Rixa Freeze 0009-0006-7928-8327 Authors Info & Affiliations https://doi.org/10.22541/au.174781112.27281211/v1 334 views 171 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Objective: The mode of birth for twin pregnancies has been a topic of debate, but vaginal birth in twin pregnancies appears both possible and safe, despite the upward trend of cesarean section. Design : This retrospective multicenter study compares outcomes before and after the implementation of a vaginal twin intervention in two Italian hospitals. Setting: In January 2021 in Pescara and in July 2022 in Florence, physicians with expertise in twin and breech vaginal birth started working in each center, and clinicians and midwives started quarterly training in these skills. Setting: The study period, divided into two equal time intervals, lasted 8 years in Pescara and 5 years in Florence. Providers were also surveyed about how the intervention affected their confidence, skill, and knowledge levels. Population: Diamniotic pregnancies with two viable twins; ≥34 weeks of gestation; cephalic presentation of the first twin were included. 278 women were evaluated, split into pre-intervention (n=131) and post-intervention (n=147). Results : Vaginal birth rates increased from 9.2% to 40.8% overall with no negative effect on maternal or neonatal outcomes. Participating providers felt more skilled, knowledgeable, and confident and agreed that the training improved vaginal birth rates as well as their vaginal breech skills. Conclusion: A rapid increase in the vaginal birth rate of twins is possible via either staff-wide training or specialist teams without adversely affecting maternal or neonatal outcomes. Simulation and skills training can improve provider confidence, knowledge, and skill levels as well as impact clinical practice in the labor ward. INTRODUCTION Twin pregnancies account for approximately 2-4% of all births worldwide [1], but this number has increased over the last decade due to higher maternal age and improved access to assisted reproductive technologies [2-3]. According to the latest Euro-Peristat report, the incidence of multiple pregnancies in Italy has continued to rise, increasing from 15 per 1,000 in 2010 to 16.4 per 1,000 in 2015, with stability observed from 2015 to 2019. Unfortunately, the cesarean section rate in Italy remains among the highest in Europe, reaching 33% in 2019, compared to 26% across Europe overall [4]. In twin pregnancies, the cesarean section rate reported in Italy was 81.4% [5]. Among the various challenges in managing twin pregnancies, the mode of delivery is one of the most crucial decisions to be made before birth. Although obstetric practice has shifted towards cesarean for twins over the past several decades, emerging evidence indicates that vaginal birth is preferable in most circumstances. Some studies have proposed that planned CS for twins may reduce the risk of adverse perinatal outcomes [6-7]. However, many other studies conclude that vaginal birth should be the standard of care, given that routine cesarean offers no benefit and adds risk, particularly long-term risk to the mother and to her future pregnancies [8-11]. Routine cesarean section also offers no benefit for breech-first twin pregnancies, which are often cited as the reason for cesarean section [12-15]. Despite the recognized safety of vaginal twin birth, as shown in The Twin Birth Study [8] and guidelines from the American College of Obstetricians and Gynecologists (ACOG) [16], and the National Institute for Health and Care Excellence [17-18], the rate of cesarean deliveries in twin gestations remains high [19-20]. But with diminishing experience due to high CS rates, how can clinicians gain the necessary skills? Numerous studies indicate that simulation-based training is effective in improving technical skills, enhancing awareness of clinical situations, and improving event management, thus significantly reducing maternal and neonatal risks [21]. Training in the management of twin birth, particularly for the extraction of the second twin, is crucial for all hospital centers that support vaginal birth in multiple pregnancies [22-23]. Simulation-based training can help build greater confidence during the vaginal birth of the second twin, potentially leading to reduced maternal and neonatal complications [24-27]. It is widely recognized that having an experienced provider [28] and implementing a systematic training program [29] can lower the originally high elective cesarean rates. To evaluate how effectively systematic training and specialist teams can impact twin cesarean section rates, we studied the clinical outcomes and effects on provider attitudes and behavior in two hospitals. Additionally, we assessed the incidence of adverse maternal and neonatal outcomes in twin pregnancies before and after the intervention. Finally, we assessed providers’ perspectives on how much the implementation improved their skill, knowledge, and confidence levels as well as clinical practice during twin births. METHODS AND MATERIALS This was a retrospective multicenter study. The study period lasted 8 years, starting on January 1, 2017 and ending on December 31, 2024 in Santo Spirito Hospital in Pescara (Italy), and starting on January 1, 2019 and ending on December 31, 2024 in San Giovanni di Dio Hospital in Florence (Italy), with the midpoint corresponding to organizational changes in the management of twin pregnancies in each hospital. On January 1, 2021 in Pescara the obstetric team—consisting of senior physicians, resident doctors, and midwives—implemented quarterly training sessions focused on the management of twin births, breech presentations, shoulder dystocia, operative vaginal deliveries, and other obstetric emergencies. This would typically consist of a lecture, then hands-on practice on an obstetric mannequin for the remainder of the day. On July 1, 2022 in Florence, two teams skilled in twin and breech vaginal birth were implemented, giving almost all women the opportunity of a twin vaginal birth, during both daytime and nighttime. We analyzed the impact of these interventions on the percentages of vaginal births, as well as the rates of both emergency and elective cesarean sections. The initial data collection using hospital discharge forms was conducted using the digital birth records of the obstetrics and neonatology units of each hospital. The data collection process was refined through additional searches and reviews of individual medical records. The data were then de-identified. Physicians at both hospitals also completed qualitative surveys after the end of the study period assessing changes in their skill, knowledge, and confidence levels. The inclusion criteria were as follows: patient over 18 years old; an uncomplicated diamniotic twin pregnancy (irrespective of chorionicity); gestational age of ≥34 weeks, with accurate pregnancy dating confirmed by ultrasound in the first trimester; cephalic presentation of the first twin. Preterm births before 34 +0 weeks’ gestation, twin pregnancies with a non-vertex presenting twin, intrauterine demise of one twin, monochorionic monoamniotic twins, triplets, and higher-order multiples were excluded. Patients were given the option to choose their mode of birth (planned vaginal birth or planned cesarean section) after counselling with a senior physician, who explained the risks and benefits associated with both delivery methods, except in cases requiring emergency cesarean sections. Upon admission, an obstetric ultrasound was performed to evaluate fetal presentations, amniotic fluid volume, and the presence of cardiac activity in both fetuses. A cardiotocographic trace was obtained to assess fetal well-being and uterine contractions, and an obstetric examination was performed to evaluate cervical status. Patients received informed consent documentation in the case of planned cesarean or labor induction if indicated. Indications for elective cesarean section included the non-cephalic presentation of the first twin and the patient’s autonomy in decision-making. Indications for labor induction included reaching 38 weeks for dichorionic twins, 36 weeks for monochorionic twins, or premature rupture of membranes. The primary outcome assessed was the incidence of successful vaginal birth for both twins (either spontaneous or operative) versus cesarean deliveries (including combined vaginal/surgical births). Secondary outcomes included the incidence of adverse maternal and neonatal outcomes. Adverse maternal outcomes included postpartum hemorrhage (defined as an estimated blood loss of 1000 mL or more) and third- or fourth-degree perineal tears. Adverse neonatal outcomes included an Apgar score < 7 for one or both twins at 5 minutes and admission to neonatal intensive care. After the second evaluation period, a Google form questionnaire was administered to labor ward specialists in the two hospitals. The questionnaire first gathered demographic data such as age, seniority, and previous experiences in twin vaginal birth during and after residency with both mannequins and actual patients. Next, participants evaluated their experiences before and after training, assessing whether the intervention had improved their skills, behaviors, attitudes, and confidence levels (see Supplementary File 1 for a list of survey questions). Statistical analysis was conducted using IBM SPSS Statistics 23.0. Continuous variables were reported as means and standard deviations, while discrete variables were reported as numbers and percentages. Comparisons of continuous variables were analyzed using the t-test, while discrete variables were analyzed using Pearson’s Chi-square and Fisher’s exact test as appropriate. Multivariate logistic regression analysis was employed to identify independent variables predicting binary outcomes. A two-tailed p-value of < 0.05 was considered statistically significant. In accordance with guidelines for retrospective observational studies, no ethical approval was required for this study, as it is a retrospective cohort evaluation of departmental management and outcomes [30-31]. The study was registered on www.ClinicalTrials.gov (NCT06628843). RESULTS During the study period the total number of deliveries in the two hospitals was 24,342. 278 twin pregnancies of 34 weeks’ gestation or more were eligible for analysis, for a total of 556 newborns. 103 additional multiple pregnancies ≥ 34 weeks were excluded, including 91 with a non-cephalic first twin, four triplet pregnancies, four monochorionic monoamniotic pregnancies, two pregnancies with uncertain chorionicity, and three patients whose medical records could not be evaluated. Out of the participants, 131 patients were in the pre-intervention group, and 147 patients were in the post-intervention group Figures 1 and 2 show flowcharts of the two groups from enrollment to delivery. Data collection was stratified and analysed in the two groups. Table 1 reports maternal age, body mass index, conception by assisted reproductive technologies, parity, previous cesarean section, chorionicity, incidence of maternal pathologies (i.e. gestational diabetes mellitus, hypertension, etc.) and fetal pathologies (i.e. small for gestational age/fetal growth restriction, etc.). Evaluating the association between clinical characteristics and cesarean section rates overall and individually in Pescara and Florence, no statistically significant differences were found for any characteristics except for a slightly higher incidence of monochorionic pregnancies and slightly higher cesarean section rates for those pregnancies (p < .001, p < .001, and p = .038, overall, Pescara, and Florence, respectively). Table 2 describes birth outcomes such as gestational age at birth, incidence of cesarean section in labor, and neonatal complications. The incidence of vaginal birth increased significantly in the second period, whether considering both hospitals together or each hospital individually (p <.0001, p < .0001, p = .0001; overall, Pescara, and Florence respectively). The incidence of nulliparity vs multiparity was not significantly different between the two study periods (p = .0004, p = .0161, and p = .008, respectively). No statistically significant differences were found for maternal and neonatal adverse outcomes analyzed between the before and after groups (see Table 2). The neonatal Apgar score of <7 for the first and/or the second twins was comparable between the two groups. The number of neonatal intensive care unit admissions was higher for newborns delivered by cesarean section in both groups (17 vs. 0, and 25 vs. 11; cesarean section vs. vaginal delivery), but this difference was not statistically significant (p = 0.899). Figure 3 shows the improvements in vaginal birth rates pre- and post-intervention, increasing from 9.2 pre- to 40.8% post overall. Figure 4 shows the change in vaginal twin birth rate in each site. In Pescara, it increased from 6.4% to 31.5%, and in Florence it increased from 16.2% to 56.4%. Out of twenty-eight specialists working regularly in the two hospitals, twenty-five completed the questionnaire (89.3% response rate). The rate of specialists attending vaginal twin births in the pre-intervention period was similar in both hospitals (7 out of 12 in Pescara, 7 out of 13 in Florence, p=0.821), while the number of specialists during the post-intervention period increased to 12 out of 12 in Pescara and 12 out of 13 in Florence (p=1.000). The questionnaires revealed consistent agreement about the value and impact of the training programs for improving behavior, confidence levels, awareness, and skill levels. Figures 5 and 6 show the demographic results and levels of previous experience in obstetric emergencies and vaginal twin birth. Attendees had slightly more experience with simulated or real vaginal twin birth after than during residency, but high levels of training in managing obstetric emergencies in both during and after residency. Figures 7 to 9 show the results of the training intervention, both site-specific and one overall. Confidence levels increased identically in both locations. With the exception of the intervention’s effect on operative vaginal delivery rates, participants strongly agreed that the intervention reduces future mistakes, increases knowledge, lowers cesarean section rates, improves vaginal breech birth skills, and improves future management of vaginal twin birth. Main findings Our study demonstrated that, in settings with a high background cesarean section rate for twin pregnancies, two different interventions (periodic training for healthcare staff and availability of teams skilled in twin and breech vaginal birth) proved effective in increasing vaginal twin birth rates. Population characteristics did not exhibit statistically significant differences in terms of maternal age, previous CS, parity, or gestational age in the pre- and post-intervention groups. The only notable difference was the higher incidence of nulliparity within vaginal births in the post-intervention groups (p = .0004, p = .0161, and p = .008, globally, in Pescara, and in Florence, respectively). Following the introduction of periodic training for healthcare staff, the incidence of vaginal twin births at Pescara Hospital significantly increased starting in 2021, rising from 6.3% before 2021 to 31.5% afterwards. This change resulted in a significant reduction of the cesarean section rate for twin pregnancies where no other obstetric indications warranted a cesarean section. In Florence, with the introduction of new staff actively involved in attending vaginal twin births, the vaginal birth rate rose from 16.2% to 56.4%. This evidence highlights the importance of continuous training for healthcare personnel, as supported by existing literature [24-26, 32-36], which confirms that dedicated training programs can enhance maternal-fetal outcomes by reducing the incidence of unnecessary cesarean sections. The observed improvement is likely attributed to increased awareness and confidence among healthcare staff in managing twin labors due to the training they received in Pescara, and even more in Florence due to adding teams skilled in and dedicated to supporting vaginal twin birth. When analyzing adverse outcomes such as postpartum hemorrhage (> 1000 cc), severe perineal trauma, 5-minute Apgar scores < 7, and the number of infants admitted to the neonatal intensive care unit, no statistically significant differences were found between the two periods. Strengths and limitations The two hospitals in this study had different interventions that resulted in different increases in vaginal twin birth rates. In Pescara, the strategy was to re-train the entire labor ward via periodic skills training. In Florence, the strategy was to create two skilled specialist teams but not to train the entire staff [29]. Our results suggest that dedicated teams may be able to support a more rapid implementation of vaginal twin birth, as evidenced by the higher vaginal birth rates in Florence. However, it is possible that with more time, the vaginal birth rate in Pescara may also be able to attain similar figures. We anticipate that with additional training and more years of data collection, the rate of vaginal twin birth could continue to rise to levels similar to or higher than those found in the JUMODA study [10], with a 61% overall vaginal birth rate for cephalic-first twins and 80.3% of planned vaginal twins ending in successful vaginal births. Reskilling is not an immediate process, but it is imperative to train maternity care providers in vaginal breech and twin birth to ensure that women can choose their mode of birth and avoid the risks of cesarean section. Specialist teams supporting vaginal twin birth could be a short-term strategy with department-level skills training as a long-term strategy. Interpretation The increase in cesarean section rate is a difficult trend to reverse. As the authors of a study on vaginal twin birth noted, “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” [37]. Our iniatitives demonstrate two strategies to increase the rate of vaginal twin birth without compromising maternal or neonatal outcomes, both provider-focused. Our findings are different from a similar study [38], which also compared outcomes before and after an initative to increase the rate of vaginal twin births. While their vaginal birth rates increased post-initative, the increase was much less dramatic and mostly attributed to secular change. Emerging research also demonstrates novel strategies to increase the fidelity of simulation training, such as using water-filled balloons with a fetal doll inside to mimic the feel of performing breech extractions with an intact amniotic sac [39-40] adapting simulators into upright birth positions [41], and developing more realistic soft tissues [42]. We encourage further innovation to help simulation training approach the realism of attending live births. The staff experience with this intervention was very positive, with almost all feeling that the implementation improved vaginal birth skills, knowledge, and confidence levels and decreased cesarean section rates. This study is significant because it also tracks clinical outcomes post-training, something that many studies on simulation training lack. Our study shows a correlation between training and actual changes in clinical practice (higher vaginal birth rate) as well as no worsening of maternal or neonatal outcomes. These results may not be replicable in hospitals where the staff are unsupportive of vaginal twin birth or where specialists are unable or unwilling to form supportive teams. We acknowledge that in some parts of the world, vaginal twin/breech birth is met with resistance and sometimes outright bans, due to medico-legal concerns or cultural beliefs in cesarean section as a safer option. Our results are also underpowered to detect rates of some rare adverse outcomes. It is also unknown whether in the long-term the vaginal birth rate will continue to rise, to plateau, or to fall after the implementation of vaginal twin intervention. CONCLUSION From this study, we can conclude that a rapid increase in the vaginal birth rate of twins is possible via either staff-wide training or specialist teams without adversely affecting maternal or neonatal outcomes. Our study examined only twin pregnancies with the first baby in a vertex position. The same results may be possible when the first baby is presenting breech but was beyond the scope of this project. Because the literature shows that vaginal birth of twins with the first baby in a breech position is also a reasonable option [43], we encourage other centers with teams skilled in both vaginal breech and twin birth to publish their outcomes for breech-first as well as head-first twins. Author contributions C.C., C.M., F. P., B.M., M.M., M.R., planned the study. C.C., R.F., interpreted the results. C.C:, M.M., F.C., collected data from Pescara, C.M., C.M., A.P., collected data from Florence. R.F., C.C. analysed the final data set. C.C., B.M., M.M., C.M., R.F. wrote the first draft of the manuscript. R.F., C.C., F.P. critically reviewed the manuscript. Acknowledgements The authors especially thank Tommaso De Vita (1992-2025) for his support and brilliant suggestions regarding simulation programs and their clinical outcomes. Ethic Statement Our study was conducted using fully anonymized retrospective clinical data, ensuring compliance with ethical and regulatory requirements across both participating centres. Under EU GDPR, anonymized data are not considered personal data. Retrospective studies using fully anonymized data do not require ethical approval unless mandated by Law, which was not the case for our research. Accordingly, our study adhered to all relevant ethical and legal standards. Data Availability Statement The data that support the findings of this study are available as supplementary files. References 1. Santana DS, Surita FG, Cecatti JG. Multiple Pregnancy: Epidemiology and Association with Maternal and Perinatal Morbidity. Rev Bras Ginecol Obstet. 2018 Sep;40(9):554-562. doi: 10.1055/s-0038-1668117. 2. Adashi EY, Gutman R. Delayed Childbearing as a Growing, Previously Unrecognized Contributor to the National Plural Birth Excess. 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Fast soft-tissue deformations coupled with mixed reality toward the next-generation childbirth training simulator. Med Biol Eng Comput 2023 Aug;61(8):2207-2226. doi: 10.1007/s11517-023-02864-5. 42. Farin A, Ceccaldi PF, Tapie L, Derisbourg S, Desseauve D, Daelemans C. Training for breech deliveries with the mother in an upright position: an innovative adaptation of a simulation model. Eur J Obstet Gynecol Reprod Biol 2023 Jan;280:108-111. doi: 10.1016/j.ejogrb.2022.11.015. 43. Sugulle M, Laine K, Tingleff T, Murzakanova G, Räisänen S. Effects of fetal presentation on mode of delivery in 26,143 twin pregnancies: A nationwide, population-based observational study of 31-year real-world data. Int J Gynaecol Obstet. 2025 Mar 29. doi: 10.1002/ijgo.70103. Supporting Information Additional supporting information can be found online in the Supporting Information section. Legend Table 1. Clinical characteristics Table 2. Mode of birth and Maternal & neonatal outcomes Table 3. Type of presentation and mode of birth for non-cephalic second twins Figure 1: Mode of birth in Group 1 (pre-intervention) Figure 2: Mode of birth in Group 2 (post-intervention) Figure 3: Overall change in vaginal twin birth rates pre- and post-implementation Figure 4: Change in vaginal birth rates by location, pre- and post-implementation Figure 5: Provider demographic information (age & experience levels) Figure 6: Previous experiences in obstetric emergencies, mannequin training, and vaginal twin birth Figure 7: Effects & usefulness of implementation Figure 8: Effects of implementation on behavior, confidence, & knowledge levels (site specific) Figure 9: Impact of the intervention on knowledge, skill, & clinical practice Supplementary Material File (figure_1.docx) Download 3.01 MB File (figure_2.docx) Download 3.01 MB File (figure_3.docx) Download 6.22 MB File (figure_4.docx) Download 6.22 MB File (figure_5.docx) Download 4.68 MB File (figure_6.docx) Download 4.68 MB File (figure_7.docx) Download 4.68 MB File (figure_8.docx) Download 4.68 MB File (figure_9.docx) Download 4.68 MB File (table 1.docx) Download 18.53 KB File (table 2.docx) Download 19.09 KB File (table 3.docx) Download 2.20 MB Information & Authors Information Version history V1 Version 1 21 May 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords delivery: assisted vaginal delivery: caesarean section intrapartum care multiple pregnancy Authors Affiliations Claudio Celentano 0000-0003-4976-2957 [email protected] Universita degli Studi Gabriele d'Annunzio Chieti Pescara - Sede di Pescara View all articles by this author Barbara Matarrelli Ospedale Policlinico SS Annunziata View all articles by this author Maurizio Rosati Universita degli Studi Gabriele d'Annunzio Chieti Pescara - Sede di Pescara View all articles by this author Claudio Meloni Ospedale San Giovanni di Dio View all articles by this author Cecilia Molino Ospedale San Giovanni di Dio View all articles by this author Aurora Padelli Ospedale San Giovanni di Dio View all articles by this author Fiorella Conti Universita degli Studi Gabriele d'Annunzio Chieti Pescara - Sede di Pescara View all articles by this author Federico Prefumo (Italy) 0000-0001-7793-714X Istituto Giannina Gaslini Unita Operativa Complessa di Anatomia Patologica View all articles by this author Martina Mercaldi Universita degli Studi Gabriele d'Annunzio Chieti Pescara - Sede di Pescara View all articles by this author Rixa Freeze 0009-0006-7928-8327 Breech Without Borders View all articles by this author Metrics & Citations Metrics Article Usage 334 views 171 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Claudio Celentano, Barbara Matarrelli, Maurizio Rosati, et al. 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