PRELIMINARY EXPERIENCE WITH A PROSPECTIVE PROTOCOL FOR PLANNED VAGINAL DELIVERY OF TRIPLET GESTATIONS

OBJECTIVE: The objective of the study was to evaluate a protocol for v aginal delivery of triplet gestations. STUDY DESIGN: All women with tr iplet gestations managed between January 1, 1995, and December 31, 199 7, by University Medical Center's perinatal practice were offered enro llment in our vaginal delivery protocol. Our protocol offered attempt of vaginal delivery if triplet A was in vertex presentation, fetal mon itoring was possible, and there were no other obstetric contraindicati ons. Twenty-three triplet gestations were identified; 8 achieved vagin al delivery. Outcome parameters investigated included neonatal mortali ty, Apgar scores, neonatal intracranial hemorrhage, arterial cord pH, neonatal weight, and length of postpartum hospital stays of mother and neonates. All parameters were analyzed with analysis of variance and the Student t test as appropriate with the JMP 3.1 statistics program (Cary, NC). RESULTS: Twenty-three sets of triplets were enrolled. Eigh t sets were delivered vaginally. Eight of 9 patients (88.9%) who attem pted trial of labor were delivered vaginally, I of which was a vaginal birth after cesarean section. The remaining triplet gestation failed to progress at 4-cm dilation. Twelve sets of triplets had a nonvertex- presenting triplet and were delivered by the cesarean route. The remai ning 2 triplet gestations were delivered by the cesarean route because of inadequate fetal monitoring. Neonatal survivals were 100% for both groups. No significant differences in neonatal mortality, Apgar score s, intracranial hemorrhage, arterial cord blood pH, hospital or neonat al intensive care unit stay of neonate, neonatal weight, and change in maternal or neonatal blood cell count were noted. There were no cases of grade III or IV intraventricular hemorrhage in either group. A sig nificant reduction in postpartum hospital stay of mother was noted in the vaginal delivery group (2.8 vs 4.5 days, P < .001). The mean gesta tional age at delivery was significantly lower for the vaginal deliver y group (31.3 vs 34.0 weeks, P < .02). The mean neonatal weight for th e vaginal delivery group was significantly lower (1758 +/- 473 vs 2022 +/- 407 g, P < .02). There were no significant differences in outcome parameters for the first, second, and third triplets within each grou p when compared with each other or with the other study group. One pat ient who underwent vaginal delivery had retained products of conceptio n and required curettage. A single fetal death occurred at 22 weeks' g estation from twin-twin transfusion, with the remaining triplets being delivered vaginally at 35 weeks' gestation. Cesarean hysterectomy was required in 1 case for uncontrollable bleeding at the time of cesarea n delivery. Perinatal complications occurred in a large number of pati ents, with the incidence of premature labor 47.8% (n = 11), that of pr eterm premature rupture of membranes 26.1% (n = 6), and that of preecl ampsia 34.8% (n = 8). CONCLUSION: In selected cases vaginal delivery o f triplet gestations can be accomplished without increased maternal or neonatal morbidity and mortality and may significantly decrease mater nal hospital stay and postoperative morbidity.