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 TWINCephalic Breech Other

SECONDCephalic 39 13 0.6TWINSBreech 26 9 0.6

Other 8 4 0.5

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, physician, midwives)

Consider transier 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 spcific contraindications

Placenta should not be drained and cord bloods not taken until after delivery of second twins

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 B >> A- Other- prompt internal of external version- if fails perform caesarean

FIRST TWIN NON-LONGITUDINAL* Caesarean section

Management of labourPreterm 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 Well Being

Intermittent auscultation of both fetal heart rates No absolute time limits on duration between delivery of twins if second twin is well

Post partum 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