Delivery of Twins

Objectives
Incidence
Types of presentation
Where to deliver
Mode of delivery
Management of labour

Incidence
spontaneous twins occur in approximately 1

in 90 pregnancies
increased use of reproductive technology

has significantly increased this rate

Lies and Presentation of Twins (%)

FIRST TWIN
Cephalic

SECOND
TWIN

Breech

Other

Cephalic

39

13

0.6

Breech

26

0.6

Other

0.5

Thompson et al, 1987

Location for Delivery of Twins

discussed and planned in advance
consultation with patient, family, attending
physician and obstetrician
recommended delivery in hospital

Location for Delivery of Twins

obstetrician in attendance for labour and delivery, if
possible
same resources as required for singleton with extra
staffing (nursing, physicians, midwives)
consider transfer of labouring patient if resources
unavailable locally

Method of Delivery
consider the lie and presentation of each fetus
vaginal delivery is the goal unless there are
specific contraindications
placenta should not be drained and cord bloods
not taken until after delivery of second twin

First Twin Cephalic

first twin cephalic - vaginal
second twin
cephalic - vaginal
breech - vaginal - breech extraction acceptable
- caution if EFW of B >> A
other

- prompt internal or external version

- if fails perform caesarean

First Twin Breech

selection for labour and vaginal delivery similar to
singleton breech
consider risk of locked twins if twin B is cephalic
second twin (if first twin delivered vaginally)
cephalic - vaginal
breech - vaginal - breech extraction acceptable
- caution if EFW of B >> A
other
- prompt internal or external version
- if fails perform caesarean

First Twin NonLongitudinal

caesarean section

Management of Labour
preterm labour common
educate re: warning signs
steroids indicated as in singleton
use tocolytics judiciously (pulmonary edema)
induction as per singleton indications plus twin
specific indications (e.g. EFW disparity)
augmentation as per singleton, may be helpful
following delivery of first twin

Management of Labour - Fetal WellBeing

intermittent auscultation of both fetal heart rates
no absolute time limit on duration between delivery
of twins if second twin is well

Postpartum Management of Twins

active management of third stage
pathology examination of placenta
increased risk of postpartum depression
discussion of issues from early pregnancy
extra support with babies