Hiersch L, Shah PS, Khurshid F, et al. - In the management of twin gestations, controversies remain concerning the mode of delivery, especially when the second twin is in a non-vertex presentation (Vx/nonVx pairs) and birth is imminent at extremely low gestation. Researchers here tested their hypothesis that, for Vx/nonVx twins born before 28 weeks of gestation, cesarean section (CS) would be linked with a lower risk of adverse neonatal outcomes compared with trial of vaginal delivery, via comparing the neonatal outcomes of Vx/nonVx twins born before 28 weeks of gestation by mode of delivery using a large national cohort. A total of 1,082 twin infants (541 twin pairs) meeting inclusion criteria were assessed in this study; these comprised 220 Vx/nonVx pairs, of which 112 had a trial of vaginal delivery (study group) and 108 had CS for both twins (control group 1); 170 pairs with the first twin in nonVx presentation, all of which were born by CS (control group 2); and 151 pairs with both twins in vertex presentation (Vx/Vx). Outcomes revealed no difference in the risk for adverse neonatal outcome between a trial of vaginal delivery and a primary CS for preterm Vx/nonVx twins born at < 28 weeks’ gestation. However, there was an association of a trial of vaginal delivery with a high rate of urgent CS for the second twin.