A C TA Obstetricia et Gynecologica

AOGS M A I N R E SE A RC H A R TI C LE

Does internal podalic version of the non-vertex second twin

still have a place in obstetrics? A Danish national
retrospective cohort study
FJOLA JONSDOTTIR1, LONNY HENRIKSEN2, NIELS J. SECHER2,3 & NANNA MAALE4
1
Department of Gynecology and Obstetrics, Roskilde University Hospital, Roskilde, 2The Research Unit Womens and
Childrens Health, Rigshospitalet, Copenhagen University Hospital, Copenhagen, 3Department of Gynecology and
Obstetrics, Skejby University Hospital, Aarhus, and 4Department of Gynecology and Obstetrics, Hvidovre University
Hospital, Copenhagen, Denmark

Key words Abstract

Active management of labor, breech
extraction, cesarean section, combined
delivery, internal podalic version, twin delivery
Correspondence
Fjola Jonsdottir, Roskilde University Hospital,
Kgevej 7-13, 4000 Roskilde, Denmark.
E-mail: fjjo@regionsjaelland.dk
Conflict of interest
The authors have stated explicitly that there
are no conflicts of interest in connection with
this article.
Please cite this article as: Jonsdottir F,
Henriksen L, Secher NJ, Maale N. Does
internal podalic version of the non-vertex
second twin still have a place in obstetrics?
A Danish national retrospective cohort study.
Acta Obstet Gynecol Scand 2015; 94: 5964.
Received: 27 April 2014
Accepted: 29 September 2014
DOI: 10.1111/aogs.12521
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. Meth-
ods. 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.

Abbreviations: CS, cesarean section; IPV, internal podalic version.

Introduction
A recent randomized trial has shown that in twin preg-
nancies with the first twin in vertex position, planned Key Message
cesarean section (CS) did not significantly decrease or Obstetricians should still be able to perform internal
increase the risk of perinatal mortality or serious morbid- podalic version and extraction of the second non-ver-
ity, compared with planned vaginal delivery (1). Mode of tex twin as an alternative to cesarean section.
delivery in twin pregnancies complicated by a non-vertex

2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 5964 59
Internal version of the second twin F. Jonsdottir et al.

second twin thus remains controversial (1,2), particularly
when bearing in mind that the least desirable mode of
delivery is an emergency CS for the second twin (3).
Before onset of labor the second twin is in a non-
vertex position in approximately 40% of twin pregnancies
when the first twin is in a vertex position (4). While
external version after delivery of the first twin has a suc-
cess rate of 5070%, the success rate for internal podalic
version (IPV) followed by breech extraction is around
90% (57). Despite the high success rate of the latter
technique when compared with the well-known increased
maternal risks of emergency CS (8), the limited informa-
tion available suggests that internal version is a rarely
used alternative in high-income countries such as the UK,
where a steep decline in the use of IPV and breech
extraction has been seen in recent years (5). In Denmark
the current national guidelines advocate that vertex/non-
vertex twins should be delivered vaginally after 24 gesta-
tional weeks and when the estimated birthweight is over
1700 g. If this is required, it is recommended that exter-
nal version of the second non-vertex twin should be
attempted, or IPV and breech extraction tried if the
obstetrician is comfortable with performing the procedure
(9).
The aim of this study was to compare the rates and
neonatal outcomes of non-vertex second twins delivered
by either IPV followed by breech extraction or emergency
CS in 19972012 in Denmark. Additionally, the experi-
ence level of the obstetricians was assessed to explore
whether the younger doctors have been trained to
perform the IPV technique.
Material and methods
This study was based on data obtained from the Dan-
ish National Patient Register (DNPR) and linked to the
Danish National Birth Register, using the Danish per-
sonal identification numbers of all women diagnosed

All women in Denmark (1997-2012) with twin pregnancies and delivery of the
second nonvertex twin by either IPV and breech extraction or emergency cesarean
section, following a vaginal delivery of the first twin:

497 cases

The IPV and breech The cesarean section

extraction group: group:
79 cases 418 cases

Missing case files: Included cases:

14 cases 418 cases

Faulty registration:
24 cases

Dead fetus
preceding labor:
2 cases

Included cases:
39 cases

Figure 1. The sampling of case files. All pregnant women in Denmark (1997 and 2012) with twin pregnancies and delivery of the second non-
vertex twin by either internal podalic version (IPV) and breech extraction or emergency cesarean section, following vaginal birth of the leading
twin, were extracted from the Danish national registers. All IPV and breech extraction cases were validated by reviewing patient records manually.

60 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 5964
F. Jonsdottir et al. Internal version of the second twin

with twin pregnancies between 1997 and 2012 where 12 (StataCorp, College Station, TX, USA) with a signifi-
the first twin was delivered vaginally and the second cance level of p < 0.05.
twin by either IPV and breech extraction [code
KMAG20 in the Nordic Classification of Surgical proce-
Results
dures (NCSP), http://nowbase.org/~/media, Danish ver-
sion], or by emergency CS (NCSP codes: KMCA10E/ Information on a total of 497 twin births matched our
KMCA10D) (10). Delivery at gestational age <34 weeks criteria and were extracted. The cases were distributed
was used as the cut-off for inclusion, as several Danish between 26 hospitals. According to the registers, 79
hospitals have local instructions recommending elective non-vertex second twins were born by IPV and breech
CS of all twin deliveries prior to this gestational age. extraction and 418 by an emergency CS. After in-depth
The present study was approved by the Danish Data review of case records in the IPV and breech extraction
Protection Authority (reference number 2012-41-0606). group, 39 second twins were included (Figure 1). The
Collection of information from patient files was permit- remaining 40 cases were excluded due to destroyed case
ted by the Danish Health and Medicine Authority (ref- records (n = 14), faulty registration of mode of delivery
erence number 3-3013-314/1/). Register research (n = 24; singleton = 19, emergency CS = 3, elective
projects that do not incorporate biological material do CS = 2), and fetal death prior to labor (n = 2). Distri-
not require further permission from the Danish ethical bution of IPV cases was even over the study years. In
committee. the CS group, we found 28 second twins (6.7% of all
Mode of delivery for the second non-vertex twin was CS cases) with 5-min Apgar score <7, and these were
extracted from the Danish National Patient Register regis- selected for in-depth record review. The review was pos-
try. The following variables were extracted from the Dan- sible in 24 cases; four case records did not state an exact
ish National Birth Register: gestational age, birthweight, Apgar score. In two of the 24 CS cases, breech extrac-
5-min Apgar score, asphyxia (defined by a 1-min Apgar tion was attempted without preceding IPV, but failed,
score <7 and the ICD-10 Danish version codes DP210/ and in one case, IPV was attempted from a transverse
DP211/DP219), umbilical cord pH < 7.05 at birth, lie and failed.
admission to neonatal intensive care unit, and treatment The two groups were comparable for all baseline char-
by mechanical ventilation. In the IPV and breech extrac- acteristics (Tables 1 and 2). Asphyxia was recorded sig-
tion cases, it was investigated whether the obstetrician nificantly less often in the IPV and breech extraction
had finished the 5 years of specialization in gynecology group than the CS group (25.6% vs. 43%, p = 0.035).
and obstetrics. Information regarding postgraduate educa-
tion of Danish physicians was available online at the
Danish Health and Medicine Authority (http://www.
sundhedsstyrelsen.dk/DS/OpslagAutReg.aspx). Table 1. Maternal age and gestational age in cases where the
second twin was delivered by internal podalic version (IPV) and breech
All cases of IPV followed by breech extraction were
extraction or by emergency cesarean section, following vaginal
validated by scrutiny of patient records to assure correct delivery of the first twin. A nationwide sample of Danish second
registration of mode of delivery, and details on presenta- twins born between 1997 and 2012.
tion of the second twin at the time of delivery were
noted. Identity of the obstetrician was recorded to IPV and breech Cesarean
extraction section
explore the education level at the time of the procedure.
(n = 39) (n = 418) p-value
Identity of obstetricians and patients was kept confiden-
tial. Validation in the emergency CS group was limited Maternal age
to cases with 5-min Apgar score <7. Cases without suffi- <25 2 (5.1%) 42 (10.0%) 0.683
cient information to ensure validation were recorded as 2630 17 (43.6%) 125 (29.9%)
3135 13 (33.3%) 181 (43.3%)
missing.
36+ 7 (18.0%) 70 (16.8%)
Mean maternal 31.3 (23/43) 31.3 (18/42) 0.665
Statistical analyses age (min/max)
Gestational age (week)
All continuous variables were transformed to an ordinal 3435 5 (12.8%) 56 (13.4%) 0.097
level and presented by numbers and frequencies for sec- 3638 26 (66.7%) 330 (78.9%)
ond twins delivered by IPV followed by breech extraction 39+ 8 (20.5%) 31 (7.4%)
Missing data 0 1 (0.2%)
and second twins delivered by CS. The MannWhitney
Mean gestational age 37 37.04 0.198
non-parametric test was used to compare the groups. The Median (min/max) 38 (34/40) 37 (34/42)
statistical analyses were performed using STATA version

2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 5964 61
Internal version of the second twin F. Jonsdottir et al.

Table 2. Neonatal outcome of the second twin delivered by internal cases it was not possible to correctly identify experience
podalic version (IPV) and breech extraction or emergency cesarean level.
section, following vaginal delivery of the first twin. A nationwide
sample of Danish second twins born between 1997 and 2012.
Discussion
IPV and breech Cesarean
extraction section In this study the results indicated a slight tendency
(n = 39) (n = 418) p-value toward better outcome for the second twins delivered by
Gender IPV and breech extraction than by emergency CS. Nearly
Male 20 (51.3%) 242 (57.9%) 0.475 all IPV and breech extraction cases were handled by expe-
Female 19 (48.7%) 176 (42.1%) rienced obstetricians. As reported in a systematic review
Birthweight, g from 2011 (3), the neonatal outcomes in the current
<2000 4 (10.3%) 28 (6.7%) 0.658 study indicate that a vaginal delivery of the first twin fol-
>2000 34 (87.2%) 386 (92.3%)
lowed by emergency CS for the second may be the least
Missing 1 (2.5%) 4 (1%)
desirable delivery mode for non-vertex second twins. This
Asphyxia
No 29 (74.4%) 238 (57%) 0.035 is also in accordance with an Irish prospective cohort
Yes 10 (25.6%) 180 (43%) study where the subgroup of second twins delivered by
Apgar score emergency CS following vaginal delivery of the presenting
<7 5 24 0.675 twin had a higher, although not significant, perinatal
7 33 382 morbidity rate compared with the other subgroups (11).
Missing 1 12
Thus, as seen in many high-income countries, elective
Mechanical ventilation
CS may be widely preferred mode of delivery instead of a
No 39 (100%) 414 (99%) 0.539
Yes 0 (0%) 4 (1%) trial of vaginal delivery for vertex/non-vertex twin preg-
Umbilical cord pH value nancies to avoid the potential problems associated with
7.05 1 (2.6%) 20 (4.8%) 0.378 emergency CS for the second twin. Such a development
>7.05 12 (30.8%) 96 (23.0%) may, however, be questioned, as shown in two single-cen-
Missing 26 (66.7%) 302 (72.2%) ter cohort studies from France and the USA where dedi-
Admission to neonatal intensive care unit
cated institutional practices lead to high success rates of
No 15 (38.5%) 121 (29.0%) 0.483
IPV and breech extraction in twin delivery. The proce-
Yes 18 (46.2%) 188 (45.0%)
Missing 6 (15.4%) 109 (26.1%) dure was successful in respectively 33 of 35 and 77 of 77
Days of admission to neonatal intensive care unit cases in these studies, and similar neonatal outcomes were
0 15 (38.5%) 121 (29.0%) 0.392 found when compared with elective CS. Importantly, in
1 6 (15.4%) 51 (12.2%) both studies it was stressed that all the obstetricians were
2+ 12 (30.1%) 137 (32.8%) familiar with active management for the second twin,
Missing 6 (15.4%) 109 (26.0%)
including IPV, and management protocols included con-
tinuous intrapartum fetal monitoring and regional anes-
thesia (12,13). Additionally, the first randomized
No neonates in the IPV and breech extraction group controlled trial of planned vaginal birth and elective CS
were mechanically ventilated, but four cases in the CS for twin pregnancies indicated that assisted vaginal birth
group were (0% vs. 1%, p = 0.539). A comparable num- of the non-vertex second twin was in general successful
ber of cases were admitted to the neonatal intensive care (1). There were no benefits from elective CS if the first
unit (46.2% vs. 45%, p = 0.483), and the number of twin was in cephalic presentation, and subgroup analyses
admission days to the unit was also comparable on non-vertex second twins did not show any effect on
(Table 2). The IPV and breech extraction group more the primary outcome. However, the power of the study
often had a 5-min Apgar score <7 compared with the CS to ascertain this was questionable. The study protocol sta-
group, but the difference was not significant (12.8% vs. ted that all obstetricians should be capable of performing
5.7%, p = 0.084). Umbilical cord pH values were avail- a total breech extraction with or without IPV. A recent
able in close to 30% of cases in both groups. Umbilical multicenter study from low- and middle-income coun-
cord pH < 7.05 was not significantly lower in the IPV tries including 1424 twin pregnancies with the first twin
and breech extraction group than the CS group (2.6% vs. delivered vaginally in vertex position showed that only
4.8%, p = 0.378). Of the IPV and breech extractions, 30 6.2% of the 369 non-vertex second twins were delivered
of 39 procedures were performed by an obstetrician with by emergency CS. This demonstrates that the success rate
>5 years of clinical obstetric experience and three by an of IPV and breech extraction is high if the birth atten-
obstetric trainee under supervision. In the remaining six dants are familiar with the IPV procedure (14).

62 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 5964
F. Jonsdottir et al.
The present study suggests that the new generation of
Danish obstetricians is not sufficiently trained in the
necessary skills to perform IPV and breech extraction.
Moreover, while active management of the second non-
vertex twin appears to be common practice in low- and
middle-income countries, Denmark does not seem to be
the only high-income country where this method for
delivering the second twin is being forgotten (5,14).
Even in the single-center cohort study from the USA,
the authors noted that although housestaff were
involved in many deliveries, they never functioned as
the primary operator (12). If the younger obstetricians
are not trained in IPV, the technique will gradually be
eliminated. A trial of vaginal twin delivery should none-
theless only be attempted if the attending obstetrician is
skilled in the requisite maneuvers for the delivery of a
non-vertex second twin; otherwise, elective CS should be
recommended for all vertex and non-vertex twin preg-
nancies (3,15).
The current study was limited by the small study popu-
lation and the retrospective design. A randomized con-
trolled trial would be next to impossible, not only
because cases of vertex followed by a non-vertex twin are
few and experienced clinical skills have to be available,
but also because obtaining informed consent and ran-
domizing patients at that stage of labor would be both
unethical and impractical to perform.
The partial validation of the CS group is another
concern, as close to 30% (24 of 79) of the cases in the
IPV group were excluded following the validation
review of the case records. However, although IPV
appeared to be suboptimally registered in the national
registers we believe that emergency CS was correctly
recorded in the vast majority of cases, as was seen to
be the case when we validated the emergency CS sub-
group with regard to a 5-min Apgar score of <7. Addi-
tionally, some outcome data were missing and bias
introduced to register data can not be avoided (16).
Despite such drawbacks, the results still provide an
overview of how vaginal vertex/non-vertex twin deliver-
ies are managed.
In conclusion, it may be timely to reconsider guidelines
on vertex/non-vertex twin deliveries and decide which
direction to follow. Either obstetricians skilled in IPV fol-
lowed by breech extraction must train the younger col-
leagues, or, as stated by DAlton, active management of
the second stage in twin deliveries should be gradually
eliminated from clinical practice and elective CS pre-
ferred (2).
Funding
No specific funding was acquired.
2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 5964
Internal version of the second twin
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