Predicting cesarean delivery in twin pregnancies undergoing trial of labor: a multicenter cohort study

Objective: To identify risk factors associated with intrapartum cesarean delivery (CD) among twin pregnancies undergoing a trial of labor (TOL). Study design: A retrospective, multicenter cohort study was conducted at two medical centers between 2005 and 2024. Inclusion criteria were diamniotic twin pregnancies who underwent TOL, first twin in cephalic presentation, gestational age between 32 0/7 and 40 6/7 weeks, and undergoing a TOL. Multivariate logistic regression was performed to identify independent risk factors for intrapartum CD. Results: A total of 2,730 twin pregnancies who underwent TOL met criteria and were included. The intrapartum CD rate was 6.5% (n = 177); 15.3% for primiparous women and 4.1% for multiparous women. Suspected fetal distress and labor dystocia were the most frequent indications for CD, 45.2% and 35.0% respectively. Multivariate analysis revealed that primiparity was the strongest independent predictor of intrapartum CD (adjusted Odds Ratio [aOR] 5.81, 95% CI: 2.67–12.63). Additional significant risk factors included large for gestational age (LGA) presenting twin (aOR 4.27, 95% CI: 1.95–9.34), maternal obesity (BMI > 30 kg/m2) (aOR 3.29, 95% CI 1.72–6.30), and cervical dilation < 3 cm at admission (aOR 2.30, 95% CI: 1.18–4.50). Conclusion: In twin pregnancies undergoing TOL, primiparity, LGA presenting twin, maternal obesity, and limited cervical dilation upon admission are significant, independent risk factors for intrapartum CD. These findings can improve risk stratification and support evidence-based patient counseling.