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Management of Twin Delivery

Author: Holly-Marie Bolger, DO

Mentor: Marygrace Elson, MD
Editor: Katherine Rivlin, MD

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Factors that determine the route of delivery for a twin gestation can include chorionicity, fetal presentations, gestational age, and estimated fetal weights and discordance, as well as the 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 given the likelihood of cord entanglement.  Patients with no other contraindications to vaginal delivery who have either a monochorionic/diamniotic or dichorionic/diamniotic gestation with the presenting twin (Twin A) in vertex presentation can consider a vaginal delivery.  If twin A is non-vertex, then cesarean delivery is indicated.

In the scenario of a non-vertex second twin, assuming a vaginal delivery of the first, 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. Therefore breech extraction is preferred. Typical eligibility requirements for breech extraction include gestational age above 32 weeks, and estimated fetal weight (EFW) above 1500 grams for the non-vertex second twin. Given the margin of error in ultrasonography 1800-2000 grams can be used as a lower limit threshold for breech extraction.

Studies suggest increased neonatal morbidity associated with discordant routes of delivery for twins (vaginal/cesarean vs. vaginal/vaginal or cesarean delivery for both). The patient should be adequately counseled and consented regarding such risks,  have IV access, continuous fetal monitoring, and adequate anesthesia (regional preferred). Labor progress should be monitored closely..  Delivery should occur in the operating suite with an anesthesia provider present 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.

In a planned vaginal birth of twins, active management of delivery of the second twin is strongly recommended, as it can significantly decrease discordant delivery modes and neonatal morbidity. If twin B is vertex and fetal heart tones remain reassuring, vaginal delivery may proceed. If Twin B is non-vertex, breech extraction is preferred and should be performed prior to the cervix contracting. 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:

American College of Obstetricians and Gynecologists; Practice Bulletin No. 169 Summary: Multifetal Gestations: Twin, Triplet, and Higher-Order Multifetal Pregnancies. Obstet Gynecol. 2016 Oct;128(4):926-8. doi: 10.1097/AOG.0000000000001700.

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.

Initial approval: May 2016; Reaffirmed and reference updated 9/5/2017; Revised May 2019; Revised January 2021. Reaffirmed July 2022. Revised May 2024.


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