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Neonatal Morbidity After Management of Vaginal Noncephalic Second-Twin Delivery by Residents

Schmitz, Thomas, MD, PhD; Korb, Diane, MD; Azria, Elie, MD, PhD; Deruelle, Philippe, MD, PhD; Kayem, Gilles, MD, PhD; Rozenberg, Patrick, MD; Sananès, Nicolas, MD, PhD; Sénat, Marie-Victoire, MD, PhD; Sentilhes, Loic, MD, PhD; Vayssière, Christophe, MD, PhD; Winer, Norbert, MD, PhD; Goffinet, François, MD, PhD for the JUmeaux MODe d’Accouchement (JUMODA) Study Group and the Groupe de Recherche en Obstétrique et Gynécologie (GROG)

doi: 10.1097/AOG.0000000000002955
Contents: Multiple Gestation: Original Research
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OBJECTIVE: To assess neonatal mortality and morbidity according to whether a resident or senior obstetrician initially managed vaginal delivery of noncephalic second twins.

METHODS: The JUmeaux MODe d'Accouchement study was a national, prospective, population-based, cohort study of twin deliveries in 176 maternity units in France, where active management of second-twin delivery is recommended. The primary outcome of our study was a composite of neonatal mortality and morbidity. Neonatal outcomes of noncephalic second twins born at or after 32 weeks of gestation after vaginal delivery of the first twin were compared according to the initial managing practitioner—supervised resident or senior obstetrician. Deliveries performed by a senior obstetrician after failure by a resident were classified as resident deliveries. Deliveries in maternity units without residents were excluded. We used multilevel multivariable Poisson regression models and propensity score matching to control for indication bias and potential confounders, including the maternity unit status. We performed subgroup analyses according to gestational age at delivery, before or after 37 weeks of gestation, and to the noncephalic second twin presentation, breech or transverse.

RESULTS: Among 1,376 noncephalic second-twin deliveries, 545 (39.6%) were initially managed by a resident and 831 (60.4%) by a senior obstetrician. Residents failed to deliver the second twin in 125 (22.9%) women. Composite neonatal mortality and morbidity did not differ between the resident and senior groups (13/545 [2.4%] vs 29/831 [3.5%]; adjusted relative risk 0.78, 95% CI 0.35–1.74). Subgroup analyses were consistent with the overall analysis.

CONCLUSION: Supervised resident and senior staff management of noncephalic second-twin vaginal delivery is associated with similar neonatal morbidity and mortality, which supports continued training of residents in such deliveries.

Supervised resident and senior staff management of noncephalic second-twin vaginal delivery is associated with similar neonatal morbidity.

Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, Service de Gynécologie Obstétrique, Université Paris Diderot, INSERM, U1153, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, Maternité Notre Dame de Bon Secours, Groupe Hospitalier Saint-Joseph, and Université René Descartes, Paris, CHRU de Lille, Maternité Jeanne de Flandre, and Université de Lille 2, Lille, Assistance Publique-Hôpitaux de Paris, Hôpital Trousseau, Service de Gynécologie Obstétrique, and Université Pierre et Marie Curie, Paris, Centre Hospitalier Intercommunal de Poissy, Service de Gynécologie Obstétrique, Poissy, Université de Versailles Saint-Quentin-en-Yvelines, Versailles, CHU de Strasbourg, Hôpital Hautepierre, and Université de Strasbourg, Strasbourg, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service de Gynécologie Obstétrique, and; Université Paris Sud, Le Kremlin Bicêtre, CHU de Bordeaux, Service de Gynécologie Obstétrique, and Université de Bordeaux, Bordeaux, CHU de Toulouse, Service de Gynécologie Obstétrique, and Université Toulouse III Paul Sabatier, Toulouse, CHU de Nantes, Service de Gynécologie Obstétrique, CIC Mère enfant, INRA, UMR 1280 Physiologie des adaptations nutritionnelles; Université de Nantes, Nantes, and Assistance Publique-Hôpitaux de Paris, Maternité Port-Royal, and DHU risques et grossesse, Paris, France.

Corresponding author: Thomas Schmitz, MD, PhD, Service de Gynécologie Obstétrique, Hôpital Robert Debré, 48 boulevard Sérurier, 75019 Paris, France; email:

Supported by a grant from the French Ministry of Health (Programme Hospitalier de Recherche Clinique, AOM2012).

Financial Disclosure Loic Sentilhes carried out consultancy work and was a lecturer for Ferring Laboratories in the previous 3 years. The other authors did not report any potential conflicts of interest.

The authors thank URC-CIC Paris Descartes Necker/Cochin (Laurence Lecomte) for implementation, monitoring and data management of the study.

Presented at the 38th Annual Meeting of the Society for Maternal-Fetal Medicine, January 29–February 3, 2018, Dallas, Texas.

* For a list of participating centers and collaborators related to this study, see Appendix 1, available online at

Each author has indicated that he or she has met the journal's requirements for authorship.

Peer review history is available at

Received July 10, 2018

Received in revised form August 21, 2018

Accepted August 29, 2018

© 2018 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.