The aim of our study was to compare the neonatal outcome of vaginally delivered breech-presenting twins (VD) to those delivered by cesarean (CS). Maternal and neonatal charts of all live, non-anomalous twins delivered at > or =25 weeks of gestation, in a single tertiary care center, over an 11-year period were reviewed. Of 517 twins delivered, 130 breech-presenting twins were analyzed. Thirty-five (26.9%) were delivered vaginally and 95 (73.1%) by cesarean. More patients presented in labor with advanced cervical dilation in the VD compared to the CS group. There was no difference in the incidence of respiratory distress syndrome, intraventricular hemorrhage, need for mechanical ventilation, length of nursery stay or neonatal mortality rate when twin A was compared in the two groups. However, one breech-presenting twin in the VD group had a traumatic delivery at 32 weeks of gestation that caused a spine fracture followed by immediate neonatal death. Although there seems to be no compromise in the immediate neonatal outcome of breech-presenting twins delivered vaginally compared to those delivered by cesarean, the case of head entrapment that led to intrapartum death is quite alarming. Based on our study, we cannot advocate normal vaginal delivery when twin A is non-vertex: cesarean seems to be a safer route of delivery.