Does internal podalic version of the non-vertex second twin still have a place in obstetrics? A Danish national retrospective cohort study

Abstract

Objective: Investigate the rate of internal podalic version followed by breech extraction for a second non-vertex twin with the first delivered vaginally, and compare neonatal outcome with emergency cesarean section.

Design: Cohort study.

Setting: National Danish Registers.

Population: Twin pregnancies (1997-2012) with gestational age ≥34 weeks; first twin delivered vaginally, second by internal podalic version and breech extraction or cesarean section.

Methods: Data were collected from the Danish National Patient Register and the Danish National Birth Register.

Main outcome measures: Rates of delivery mode, 5-min Apgar score, asphyxia, umbilical cord pH, admission to neonatal intensive care unit, treatment by mechanical ventilation, and experience level of obstetricians performing internal podalic version.

Results: 457 births were available for analysis: 39 cases of internal podalic version and breech extraction and 418 cesarean section cases for second twin. Compared with the cesarean section group, the internal podalic version group had lower rates of asphyxia. Apgar scores and umbilical cord pH levels were not significantly different, although with a tendency to be higher in the internal version than the cesarean section group, however, fewer cases needed mechanical ventilation. Thirty internal versions and breech extractions were performed by obstetricians with >5 years clinical experience and three by trainees.

Conclusion: Cesarean sections for a second twin seem to have been frequent during the last 15 years while internal podalic version is a vanishing procedure. A slight tendency for better neonatal outcome was found in the internal podalic version and extraction group than cesarean section.

Keywords: Active management of labor; breech extraction; cesarean section; combined delivery; internal podalic version; twin delivery.