1. Labor progression was slower in twin compared to singleton deliveries.
2. Cesarean delivery was more common in twin gestations.
Evidence Rating Level: 2 (Good)
Study Rundown: This study compared differences in the labor curve for singleton and twin gestations and found that women with twin gestations experienced a slower labor progression through the active phase and a higher incidence of cesarean delivery. Previous studies have yielded conflicting results with regards to how the duration of active labor differs in twin deliveries. This study supports the hypothesis that labor in twin gestations is prolonged.
Strengths of this study include a large sample size and access to maternal records, allowing for evaluation of numerous potential confounders. Limitations include retrospective design and lack of standardized labor protocols across hospitals. Additionally, twin deliveries are known to occur at an earlier gestational age (37weeks compared to 40weeks in singletons), such that delivery at an earlier gestational age in twins could result in slower labor course due to cervical unpreparedness for dilation and effacement.
Prospective investigation might match singleton and twin deliveries by gestational age at time of induction of labor or onset of spontaneous labor, respectively, and employ a standardized protocol at a single institution to further develop the difference in labor patterns by gestational number.
Relevant Reading: Contemporary patterns of spontaneous labor with normal neonatal outcomes
In-Depth [retrospective cohort study]: This study used data from the Consortium on Safe Labor database, which combined data collected from 8 university hospitals, 9 community hospitals and 2 non-teaching hospitals across the United States to evaluate labor patterns in 891 twin deliveries as compared to 100,531 singleton births. Inclusion criteria for both twin gestations (cases) and singleton deliveries (controls) were cephalic presentation of the presenting twin or singleton, gestational age ≥34 weeks and ≥2 cervical examinations. Outcomes evaluated included cervical dilation and effacement, induction or augmentation of labor, epidural use, prior cesarean delivery, and birth weight.
Women with twin gestations experienced a slower progression of active labor, across presenting cervical dilations, as compared to singleton gestations. Overall, nulliparous women were in labor for 12.7 hours with twin gestations and 9.6 with singleton, while multiparous women were in labor for 12.4 hours with twin gestations and 10.0 for singletons. Twin gestations were more likely to result in cesarean section (30.5% vs. 16.1%) and were also associated with baseline demographic differences, including older maternal age (29.4 vs. 27.2 years), earlier gestational age at delivery (36.5 vs. 39.1 weeks) and lower birth weight (2567 vs. 3326 grams).
By Denise Pong, MPH and Leah Hawkins, MD, MPH
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