Intervention Review

You have free access to this content

Elective birth at 37 weeks’ gestation for women with an uncomplicated twin pregnancy

  1. Jodie M Dodd1,*,
  2. Andrea R Deussen1,
  3. Rosalie M Grivell1,
  4. Caroline A Crowther2,3

Editorial Group: Cochrane Pregnancy and Childbirth Group

Published Online: 10 FEB 2014

Assessed as up-to-date: 12 DEC 2013

DOI: 10.1002/14651858.CD003582.pub2


How to Cite

Dodd JM, Deussen AR, Grivell RM, Crowther CA. Elective birth at 37 weeks’ gestation for women with an uncomplicated twin pregnancy. Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD003582. DOI: 10.1002/14651858.CD003582.pub2.

Author Information

  1. 1

    The University of Adelaide, Women's and Children's Hospital, School of Paediatrics and Reproductive Health, Discipline of Obstetrics and Gynaecology, Adelaide, South Australia, Australia

  2. 2

    The University of Auckland, Liggins Institute, Auckland, New Zealand

  3. 3

    The University of Adelaide, ARCH: Australian Research Centre for Health of Women and Babies, The Robinson Institute, Discipline of Obstetrics and Gynaecology, Adelaide, South Australia, Australia

*Jodie M Dodd, School of Paediatrics and Reproductive Health, Discipline of Obstetrics and Gynaecology, The University of Adelaide, Women's and Children's Hospital, 72 King William Road, Adelaide, South Australia, 5006, Australia. jodie.dodd@adelaide.edu.au.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 10 FEB 2014

SEARCH

 
Characteristics of included studies [ordered by study ID]
Dodd 2012a

MethodsRandomised controlled trial.


Participants235 women were randomised.

Inclusion criteria: women with a twin pregnancy at gestational age 36 + 6 weeks or more, with no contraindication to continuation of their pregnancy who present to participating centres were eligible for participation.

Exclusion criteria: women with fetal death of 1 or both fetuses at the time of trial entry, in active labour, with a non-reassuring fetal heart rate tracing, or with maternal or fetal compromise precluding continued antenatal surveillance were excluded from participation.


Interventions"Elective delivery group" (n = 116)

Women randomised to the "elective delivery group" underwent elective birth at 37 weeks' gestation (either by induction of labour or caesarean section as assessed and determined by the woman and her caregiver).

"Standard care group" (n = 119)

Women randomised to the "standard care group" had their care according to local hospital guidelines. Where there was a plan for vaginal birth this involved induction of labour after 38 weeks' gestation, or awaiting the spontaneous onset of labour. Where caesarean section was the preferred mode of birth, this was booked after 38 weeks and as close to 39 weeks' gestation as was possible.


OutcomesThe primary outcome was a composite of perinatal mortality and morbidity, including perinatal death after trial entry, and serious neonatal morbidity (including birth trauma, Apgar score < 4 at 5 minutes, neonatal encephalopathy, ventilation requirement greater than 24 hours).

Secondary outcomes included antenatal medical and obstetric complications, labour and birth complications, other adverse outcomes for the infant, and serious adverse outcomes for the woman.


NotesNil.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskThe randomisation schedule was computer-generated by a researcher not involved in the study, using balanced variable blocks, and stratification for collaborating centre and planned mode of birth (planned caesarean birth or planned vaginal birth).

Allocation concealment (selection bias)Low riskCentral telephone randomisation service.

Blinding (performance bias and detection bias)
All outcomes
Unclear riskNot possible to blind this clinical intervention.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome assessors were blinded to treatment allocation.

Incomplete outcome data (attrition bias)
All outcomes
Low riskOutcomes available for all participants.

Selective reporting (reporting bias)Low riskOutcomes specified in published protocol have been reported.

Other biasLow riskRecruitment ceased before sample size reached.

Suzuki 2000

MethodsRandomised controlled trial.


Participants36 women were randomised.

Inclusion criteria: women with a twin pregnancy at 37 weeks' gestation, with the first twin in a cephalic presentation.


InterventionsInduction group (n = 17)

Induction of labour at 37 weeks' gestation with vaginal prostaglandin E2 gel followed by ARM and oxytocin infusion as required.
Expectant management group (n = 19)

Women continued pregnancy surveillance until spontaneous onset of labour, provided no antenatal complications developed and fetal well being confirmed (involved daily CTG and twice-weekly ultrasound examination).


OutcomesGestational age at birth; incidence of PROM; uterine hyperactivity or meconium-stained amniotic fluid; caesarean delivery rates; indication for caesarean section; total blood loss; need for maternal blood transfusion; infant birthweight; infant Apgar scores.


NotesNo reported sample size calculation.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskDescribed as "eligible patients were then randomised to one of two management groups".

Allocation concealment (selection bias)Unclear riskNo information was given on allocation concealment.

Blinding (performance bias and detection bias)
All outcomes
Unclear riskNo information given on who remained blinded to treatment allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNo information given.

Incomplete outcome data (attrition bias)
All outcomes
Low riskOutcome data available on all randomised participants. No post-randomisation exclusions. No losses to follow-up reported.

Selective reporting (reporting bias)Low riskAll outcomes stated in methods are reported. There is no published protocol.

Other biasLow riskNone identified.

 
Comparison 1. Elective birth at 37 weeks versus expectant management

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Caesarean birth - all2271Risk Ratio (M-H, Fixed, 95% CI)1.05 [0.83, 1.32]

 2 Caesarean birth - fetal distress2271Risk Ratio (M-H, Fixed, 95% CI)0.79 [0.29, 2.15]

 3 Perinatal death or serious morbidity2542Risk Ratio (M-H, Fixed, 95% CI)0.34 [0.01, 8.35]

 4 Maternal death or serious morbidity1235Risk Ratio (M-H, Fixed, 95% CI)0.29 [0.06, 1.38]

 5 Haemorrhage requiring blood transfusion2271Risk Ratio (M-H, Fixed, 95% CI)0.48 [0.11, 2.08]

 6 Instrumental vaginal birth1470Risk Ratio (M-H, Fixed, 95% CI)0.63 [0.35, 1.15]

 7 Meconium-stained liquor2542Risk Ratio (M-H, Random, 95% CI)0.52 [0.04, 7.35]

 8 Apgar score less than seven at five minutes2542Risk Ratio (M-H, Fixed, 95% CI)0.15 [0.01, 2.82]

 9 Need for neonatal intensive care unit admission1470Risk Ratio (M-H, Fixed, 95% CI)1.03 [0.37, 2.88]

 10 Birthweight less than 2500 g2542Risk Ratio (M-H, Fixed, 95% CI)1.28 [0.93, 1.75]

 11 Neonatal encephalopathy1470Risk Ratio (M-H, Fixed, 95% CI)3.08 [0.13, 75.16]

 12 Respiratory distress syndrome1470Risk Ratio (M-H, Fixed, 95% CI)2.05 [0.19, 22.47]

 13 Birthweight less than third centile (SGA)1470Risk Ratio (M-H, Fixed, 95% CI)0.30 [0.13, 0.68]