Planned caesarean section for women with a twin pregnancy

G Justus Hofmeyr; Jon F Barrett; Caroline A Crowther

doi:10.1002/14651858.CD006553.pub3

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Figure 1

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 2

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

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Analysis 1.1

Comparison 1 Planned caesarean section versus planned vaginal birth, Outcome 1 Maternal death or serious maternal morbidity.

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Analysis 1.2

Comparison 1 Planned caesarean section versus planned vaginal birth, Outcome 2 Perinatal or neonatal death or serious neonatal morbidity.

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Analysis 1.4

Comparison 1 Planned caesarean section versus planned vaginal birth, Outcome 4 Perinatal or neonatal death.

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Analysis 1.5

Comparison 1 Planned caesarean section versus planned vaginal birth, Outcome 5 Serious neonatal morbidity.

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Analysis 1.6

Comparison 1 Planned caesarean section versus planned vaginal birth, Outcome 6 Apgar score less than eight at five minutes.

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Analysis 1.7

Comparison 1 Planned caesarean section versus planned vaginal birth, Outcome 7 Apgar score less than four at five minutes.

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Analysis 1.8

Comparison 1 Planned caesarean section versus planned vaginal birth, Outcome 8 Neonatal encephalopathy, as defined by trial authors.

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Analysis 1.9

Comparison 1 Planned caesarean section versus planned vaginal birth, Outcome 9 Birth trauma, as defined by trial authors.

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Analysis 1.10

Comparison 1 Planned caesarean section versus planned vaginal birth, Outcome 10 Nerve palsy (including brachial plexus injury).

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Analysis 1.11

Comparison 1 Planned caesarean section versus planned vaginal birth, Outcome 11 Subdural or intracerebral haemorrhage.

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Analysis 1.12

Comparison 1 Planned caesarean section versus planned vaginal birth, Outcome 12 Intraventricular haemorrhage: grade III or IV.

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Analysis 1.13

Comparison 1 Planned caesarean section versus planned vaginal birth, Outcome 13 Cystic periventricular leukomalacia.

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Analysis 1.14

Comparison 1 Planned caesarean section versus planned vaginal birth, Outcome 14 Neonatal sepsis up to 72 hours.

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Analysis 1.15

Comparison 1 Planned caesarean section versus planned vaginal birth, Outcome 15 Necrotising enterocolitis.

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Analysis 1.16

Comparison 1 Planned caesarean section versus planned vaginal birth, Outcome 16 Assisted ventilation for 24 hours or more.

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Analysis 1.17

Comparison 1 Planned caesarean section versus planned vaginal birth, Outcome 17 Short‐term maternal outcomes: caesarean section.

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Analysis 1.18

Comparison 1 Planned caesarean section versus planned vaginal birth, Outcome 18 Short‐term maternal outcomes: mortality.

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Analysis 1.19

Comparison 1 Planned caesarean section versus planned vaginal birth, Outcome 19 Short‐term maternal outcomes: serious maternal morbidity.

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Analysis 1.20

Comparison 1 Planned caesarean section versus planned vaginal birth, Outcome 20 Short‐term maternal outcomes: thromboembolism requiring anticoagulant therapy.

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Analysis 1.21

Comparison 1 Planned caesarean section versus planned vaginal birth, Outcome 21 Short‐term maternal outcomes: wound infection.

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Analysis 1.22

Comparison 1 Planned caesarean section versus planned vaginal birth, Outcome 22 Short‐term maternal outcomes: systemic infection.

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Analysis 1.23

Comparison 1 Planned caesarean section versus planned vaginal birth, Outcome 23 Short‐term maternal outcomes: disseminated intravascular coagulation.

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Analysis 1.24

Comparison 1 Planned caesarean section versus planned vaginal birth, Outcome 24 Short‐term maternal outcomes: amniotic fluid embolism.

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Analysis 1.25

Comparison 1 Planned caesarean section versus planned vaginal birth, Outcome 25 Short‐term maternal outcomes: postpartum haemorrhage.

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Analysis 1.26

Comparison 1 Planned caesarean section versus planned vaginal birth, Outcome 26 Short‐term maternal outcomes: blood transfusion.

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Analysis 1.27

Comparison 1 Planned caesarean section versus planned vaginal birth, Outcome 27 Longer‐term maternal outcomes: failure to breastfeed.

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Analysis 1.28

Comparison 1 Planned caesarean section versus planned vaginal birth, Outcome 28 Longer‐term maternal outcomes: urinary incontinence.

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Analysis 1.29

Comparison 1 Planned caesarean section versus planned vaginal birth, Outcome 29 Longer‐term maternal outcomes: flatus incontinence.

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Analysis 1.30

Comparison 1 Planned caesarean section versus planned vaginal birth, Outcome 30 Longer‐term maternal outcomes: faecal incontinence.

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Analysis 1.31

Comparison 1 Planned caesarean section versus planned vaginal birth, Outcome 31 Longer‐term maternal outcomes: postnatal depression, as defined by trial authors (EPDS > 12).

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Summary of findings for the main comparison. Planned caesarean section versus planned vaginal birth for women with a twin pregnancy

Planned caesarean section versus planned vaginal birth for women with a twin pregnancy
Patient or population: women with a twin pregnancy Setting: hospital settings Intervention: planned caesarean section Comparison: planned vaginal birth
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with planned vaginal birth	Risk with Planned caesarean section
Maternal death or serious maternal morbidity	Study population		RR 0.86 (0.67 to 1.11)	2844 (2 RCTs)	⊕⊕⊕⊝ MODERATE ¹
	83 per 1000	71 per 1000 (55 to 92)
	Moderate
	42 per 1000	36 per 1000 (28 to 47)
Perinatal or neonatal death or serious neonatal morbidity	Study population		RR 1.15 (0.80 to 1.67)	5565 (1 RCT)	⊕⊕⊕⊝ MODERATE ¹
	19 per 1000	21 per 1000 (15 to 31)
Disability in childhood	Study population		not pooled	0 (0 study)		No data were available for this outcome
	not pooled	not pooled
Perinatal or neonatal death	Study population		RR 1.41 (0.76 to 2.62)	5685 (2 RCTs)	⊕⊕⊕⊝ MODERATE ¹
	6 per 1000	8 per 1000 (5 to 16)
	Moderate
	3 per 1000	4 per 1000 (2 to 8)
Serious neonatal morbidity	Study population		RR 1.03 (0.65 to 1.64)	5644 (2 RCTs)	⊕⊕⊕⊝ MODERATE ¹
	12 per 1000	13 per 1000 (8 to 20)
	Moderate
	6 per 1000	6 per 1000 (4 to 10)
Longer‐term maternal outcomes: failure to breastfeed	Study population		RR 1.14 (0.95 to 1.38)	2570 (1 RCT)	⊕⊕⊕⊝ MODERATE ¹
	136 per 1000	155 per 1000 (129 to 188)
Longer‐term maternal outcomes: postnatal depression, as defined by trial authors (EPDS > 12)	Study population		RR 0.95 (0.78 to 1.14)	2570 (1 RCT)	⊕⊕⊕⊝ MODERATE ¹
	148 per 1000	140 per 1000 (115 to 169)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
¹ Wide 95% CI crossing the line of no effect

Summary of findings for the main comparison. Planned caesarean section versus planned vaginal birth for women with a twin pregnancy

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Comparison 1. Planned caesarean section versus planned vaginal birth

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maternal death or serious maternal morbidity Show forest plot	2	2844	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.67, 1.11]

2 Perinatal or neonatal death or serious neonatal morbidity Show forest plot	1	5565	Risk Ratio (M‐H, Fixed, 95% CI)	1.15 [0.80, 1.67]

3 Perinatal or infant death or disability in childhood	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4 Perinatal or neonatal death Show forest plot	2	5685	Risk Ratio (M‐H, Fixed, 95% CI)	1.41 [0.76, 2.62]

5 Serious neonatal morbidity Show forest plot	2	5644	Risk Ratio (M‐H, Fixed, 95% CI)	1.03 [0.65, 1.64]

6 Apgar score less than eight at five minutes Show forest plot	1	120	Risk Ratio (M‐H, Fixed, 95% CI)	1.22 [0.18, 8.39]

7 Apgar score less than four at five minutes Show forest plot	2	5644	Risk Ratio (M‐H, Fixed, 95% CI)	0.29 [0.06, 1.38]

8 Neonatal encephalopathy, as defined by trial authors Show forest plot	1	120	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

9 Birth trauma, as defined by trial authors Show forest plot	2	5644	Risk Ratio (M‐H, Fixed, 95% CI)	0.57 [0.17, 1.95]

10 Nerve palsy (including brachial plexus injury) Show forest plot	1	120	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

11 Subdural or intracerebral haemorrhage Show forest plot	2	5644	Risk Ratio (M‐H, Fixed, 95% CI)	3.01 [0.31, 28.89]

12 Intraventricular haemorrhage: grade III or IV Show forest plot	1	120	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

13 Cystic periventricular leukomalacia Show forest plot	1	5524	Risk Ratio (M‐H, Fixed, 95% CI)	5.01 [0.24, 104.33]

14 Neonatal sepsis up to 72 hours Show forest plot	1	5524	Risk Ratio (M‐H, Fixed, 95% CI)	0.50 [0.05, 5.52]

15 Necrotising enterocolitis Show forest plot	1	5524	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.03, 3.21]

16 Assisted ventilation for 24 hours or more Show forest plot	1	5524	Risk Ratio (M‐H, Fixed, 95% CI)	1.59 [0.87, 2.91]

17 Short‐term maternal outcomes: caesarean section Show forest plot	2	2845	Risk Ratio (M‐H, Random, 95% CI)	4.77 [0.76, 30.00]

18 Short‐term maternal outcomes: mortality Show forest plot	2	2844	Risk Ratio (M‐H, Fixed, 95% CI)	1.0 [0.06, 15.97]

19 Short‐term maternal outcomes: serious maternal morbidity Show forest plot	2	2842	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.67, 1.11]

20 Short‐term maternal outcomes: thromboembolism requiring anticoagulant therapy Show forest plot	1	2782	Risk Ratio (M‐H, Fixed, 95% CI)	2.5 [0.49, 12.86]

21 Short‐term maternal outcomes: wound infection Show forest plot	1	2782	Risk Ratio (M‐H, Fixed, 95% CI)	1.5 [0.83, 2.71]

22 Short‐term maternal outcomes: systemic infection Show forest plot	1	2782	Risk Ratio (M‐H, Fixed, 95% CI)	1.39 [0.76, 2.53]

23 Short‐term maternal outcomes: disseminated intravascular coagulation Show forest plot	1	2782	Risk Ratio (M‐H, Fixed, 95% CI)	5.0 [0.24, 104.05]

24 Short‐term maternal outcomes: amniotic fluid embolism Show forest plot	1	2782	Risk Ratio (M‐H, Fixed, 95% CI)	3.0 [0.12, 73.58]

25 Short‐term maternal outcomes: postpartum haemorrhage Show forest plot	1	2782	Risk Ratio (M‐H, Fixed, 95% CI)	0.78 [0.59, 1.02]

26 Short‐term maternal outcomes: blood transfusion Show forest plot	1	2782	Risk Ratio (M‐H, Fixed, 95% CI)	0.88 [0.64, 1.21]

27 Longer‐term maternal outcomes: failure to breastfeed Show forest plot	1	2570	Risk Ratio (M‐H, Fixed, 95% CI)	1.14 [0.95, 1.38]

28 Longer‐term maternal outcomes: urinary incontinence Show forest plot	1	2570	Risk Ratio (M‐H, Fixed, 95% CI)	0.87 [0.64, 1.18]

29 Longer‐term maternal outcomes: flatus incontinence Show forest plot	1	2570	Risk Ratio (M‐H, Fixed, 95% CI)	0.92 [0.77, 1.09]

30 Longer‐term maternal outcomes: faecal incontinence Show forest plot	1	2570	Risk Ratio (M‐H, Fixed, 95% CI)	1.02 [0.69, 1.51]

31 Longer‐term maternal outcomes: postnatal depression, as defined by trial authors (EPDS > 12) Show forest plot	1	2570	Risk Ratio (M‐H, Fixed, 95% CI)	0.95 [0.78, 1.14]

Comparison 1. Planned caesarean section versus planned vaginal birth

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