Mode of birth in twins: data and reflections.

Our primary objective was to compare neonatal and maternal outcomes in women with twin pregnancies, beyond 32 weeks, having a planned vaginal birth or a planned caesarean section (CS). This was a retrospective cohort study from a single tertiary centre over nine years. 534 sets of twins ≥32 + 0 weeks of gestation were included. 401 sets were planned vaginally and 133 sets were planned by CS. We compared a composite adverse perinatal outcome (perinatal mortality or serious neonatal morbidity; five minute APGAR score ≤4, neurological abnormality and need for intubation) and a composite maternal adverse outcome (major haemorrhage, trauma or infection) between the groups. There were no significant differences. Given the similarity of these results with several other larger studies of twin birth, we sought to look at reasons why there is still a rising rate of CS for twin births. We further make suggestions for keeping this rate to a sensible minimum. Impact statement What is already known on this subject? The largest randomised controlled study comparing planned vaginal birth with planned CSs for lower risk twins between 32 and 39 weeks of gestation, showed no added safety from planned CS. However, in most of the Western countries this conclusion has failed to increase the number of planned vaginal births for lower risk twins. What do the results of this study add? This observational study from a single tertiary centre provides external validation of the twin trial results in a practical day-to-day setting. It also provides insights as to how planned vaginal birth can be developed and maintained, with a key focus on safety and maternal participation in decision making. It does focus on consent and providing accurate data. What are the implications of these findings for clinical practice and/or further research? There are good grounds to encourage vaginal birth for low-risk twin pregnancies. The trend of rising caesarean rates in low-risk twin pregnancies worldwide will erode important skills for the conduct of vaginal births without any clear benefit for mothers or babies. The current situation demands careful thought about implementing innovative training opportunities for younger obstetricians. Finally, we need intelligent responses to many non-evidence-based factors which can drive clinical practice.

Postpartum hemorrhage today: ICM/FIGO initiative 2004-2006.

Postpartum hemorrhage (PPH) is the main cause of maternal mortality. Yet, even though solutions have been identified, governments and donor countries have been slow to implement programs to contain the problem. While poverty and low educational level remain the underlying cause of PPH, the current literature suggests that active management of the third stage of labor can prevent it. The International Confederation of Midwives (ICM) and the International Federation of Gynecology and Obstetrics (FIGO) are attempting to address the chronic PPH crisis by educating their members on best practices and on troubleshooting where resources are inadequate. Some studies found oxytocin to be preferable to misoprostol in settings where active management is the norm. However, secondary clinical effects may prove more troublesome with oxytocin than with misoprostol, and misoprostol may prove to be more practical and equally effective in low-resource settings. Two new interventions are also proposed, the anti-shock garment and the balloon tamponade.

Heeding warnings ... from the canary, the whale, and the Jnuit, Part Two.

There is a tension between traditional and modern definitions of reproductive risk and normalcy. These experts describe that tension as it plays out among the Inuit of Northern Canada from the perspective of a community midwife who has worked with the Inuit. She presents an analytical framework which classifies and illuminates the types of logic that compete in most birth settings around the world--a framework useful for showing how some types of logic can be supervalued while others, such as cultural or intuitive logic, are devalued or simply ignored, often at great cost. Part One presented political, scientific, clinical and cultural logic, and the influence of time. We now go on to look at professionalization and training and describe legal, personal, intuitive and economic logic. The author describes how the Inuit settlement of Povungnituk (POV) attempts to re-integrate the authoritative knowledge of the community by allowing Inuit midwives at The Maternity to choose their own criteria for balancing the imperatives of each kind of logic in decision-making for birth.

Heeding warnings from the canary, the whale, and the Inuit.

There is a tension between traditional and modern definitions of reproductive risk and normalcy. This excerpt describes that tension as it plays out among the Inuit of Northern Canada from the perspective of a community midwife who has worked with the Inuit. She presents an analytical framework which classifies and illuminates the types of logic that compete in most birth settings around the world-a framework useful for showing how some types of logic can be supervalued while others, such as cultural or intuitive logic, are devalued or simply ignored, often at great cost. The forced evacuation of all pregnant Inuit women from Northern Canada for the "privilege" of a hospital birth in the South illustrates the imbalance created when decisions purported to be based on one kind of logic (scientific) are in reality based on another (e.g., legal and clinical), or when any type of logic is given undue authority. After presenting the analytical framework and describing some of the history of Inuit childbirth, the author tells the story of one Inuit settlement's attempt to re-integrate the authoritative knowledge of the community by allowing Inuit midwives to choose their own criteria for balancing the imperatives of each kind of logic in decision-making for birth.