Delivery of Twins

International

Delivery of Twins

Delivery of Twins

International

Objectives

• Incidence

• Types of presentation

• Where to deliver

• Mode of delivery

• Management of labour

Delivery of Twins

International

Incidence

• spontaneous twins occur in approximately

1 in 90 pregnancies

• increased use of reproductive technology

has significantly increased this rate

Delivery of Twins

International

Lies and Presentation of Twins (%)

FIRST TWIN

Cephalic Breech Other

Cephalic 39 13 0.6

Breech 26 9 0.6

Other 8 4 0.5

Thompson et al, 1987

SECOND

TWIN

Delivery of Twins

International

Location for Delivery of Twins

• discussed and planned in advance

• consultation with patient, family, attending

physician and obstetrician

• recommended delivery in hospital

Delivery of Twins

International

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

Delivery of Twins

International

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

Delivery of Twins

International

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

Delivery of Twins

International

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

Delivery of Twins

International

First Twin Non-Longitudinal

• caesarean section

Delivery of Twins

International

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

Delivery of Twins

International

Management of Labour - Fetal Well-Being

• intermittent auscultation of both fetal heart rates

• no absolute time limit on duration between delivery

of twins if second twin is well

Delivery of Twins

International

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