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Management of Twin Delivery

5/4/2016 - Holly-Marie Bolger, DO

Mentor: Marygrace Elson, MD

Editor: Roger Smith, MD

Important factors in determining the route of delivery for a twin gestation include:

  • Chorionicity
  • Fetal presentations
  • Gestational age
  • Estimated fetal weights and discordance
  • Availability of a skilled obstetrician trained in vaginal breech extraction including internal podalic version, management of nuchal arms, and use of Piper forceps.

Cesarean delivery is required for monochorionic/monoamniotic twin gestations.  It is reasonable to consider vaginal delivery for patients with no other contraindications to vaginal delivery who have either a monochorionic/diamniotic or dichorionic/diamniotic gestation if the presenting twin (Twin A) is in vertex presentation.  If twin A is non-vertex, then cesarean delivery is indicated. 

For non-vertex second twin, the potential options for delivery include internal podalic version with vaginal breech extraction, external cephalic version followed by vaginal delivery, or cesarean delivery. There is a higher incidence of complications and emergency cesarean delivery associated with external cephalic version of a second twin compared to vaginal breech extraction, so breech extraction is preferred. Typical eligibility requirements for breech extraction include the pregnancy be > 28 weeks gestational age, EFW of the non-vertex second twin should be >1500 grams, and if the presenting twin is smaller, the fetal weight discordance should be <20-25%. Given the margin of error in ultrasonography it is reasonable to use 1800-2000 grams as a lower limit threshold; however an EFW between 1500-3500 grams is acceptable.

Studies suggest increased neonatal morbidity associated with discordant routes of delivery for twins (vaginal/cesarean vs. vaginal/vaginal or cesarean delivery for both). Active management of delivery of the second twin is strongly recommended as it has been shown to significantly decrease discordant delivery and neonatal morbidity.  The patient should be adequately counseled and consent obtained. The patient should have IV access, continuous fetal monitoring and adequate anesthesia (regional preferred). Labor progress should be monitored closely. An anesthesia provider should be present at time of delivery.  It is recommended that delivery occur in the operating suite in the event that an emergent cesarean delivery is indicated. Ultrasonography should be available to determine fetal presentation of twin B following delivery of twin A.

If twin B is vertex and fetal heart tones reassuring, vaginal delivery may proceed. If Twin B is non-vertex, breech extraction is preferred and should be committed to quickly, prior to the cervix beginning to contract.  If twin B is frank or complete breech and fetal heart tones are reassuring, it is acceptable to allow maternal expulsive forces to facilitate engagement of the presenting part into the pelvis prior to amniotomy, and then proceed with standard maneuvers of breech delivery. If the presenting part is not engaged in the pelvis, it is recommended to secure the feet into the pelvis, then proceed with amniotomy and initiate standard maneuvers of breech extraction.

Trial of labor after cesarean delivery may be offered to women with a history of prior low transverse cesarean delivery and no other contraindications to vaginal delivery.

Further Reading:

Multifetal gestations: twin, triplet, and higher-order multifetal pregnancies. Practice Bulletin No. 144. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:1118–32.

Malone FD, D’Alton ME. Multiple Gestation:  Clinical Characteristics and Management. In: Resnik R, Creasey RK, Iams JD, Lockwood CJ, Moore T, Greene MF Eds. Creasy and Resnik’s Maternal-Fetal-Medicine: Principles and Practice.   Saunders Publishing, 2013.

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