SECOND EDITION OF THE ALARM INTERNATIONAL PROGRAM SYLLABUS

CHAPTER 10
DELIVERY OF TWINS
Learning Objectives:
Select the appropriate method, caregiver and location for the delivery of twins
Determine the proper management of twin deliveries with attention to the issues specific to the second twin
A 25 year old G1 with a twin pregnancy presents at 30 weeks to hospital with regular contractions for 4 hours and
also has noted p.v. leakage of watery fluid. Ea!ination confir!s ruptured !e!"ranes and active la"or at # c!
dilatation. $hat do you do now%
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10.0.1 Incidence
The purpose of this discussion is to provide guidelines on where to deliver and how labor and delivery should be
conducted. Spontaneous twin pregnancy occurs in approximately 1/! pregnancies. "ith the increased use of
ovulation induction the rate of multiple gestations has increased significantly.
10.0.2 Types of Presentations
The usual distribution of lies and positions of the fetuses in twin gestation is shown#
First Twin
$ephalic %reech &on 'ongitudinal
$ephalic ( 1( !.)
%reech *) !.)
&on 'ongitudinal + , !.)
10.0.3 !oice of Location for "e#ivery of Twins
The location of delivery should be discussed and agreed upon by the woman, her family and her caregiver. -f
possible, a caregiver s.illed in twin delivery should be involved from the onset of labor and should be in attendance
at the birth. There must be the same resources and ability to provide care as for a singleton. "hen a mother with
twins presents in labor at a facility without these resources, transport to a suitable facility should be considered.
10.0.$ %et!od of "e#ivery
The planned method of delivery must consider the lie and presentation of each fetus. /aginal delivery should be the
goal unless there are specific contraindications.
ALARM INTERNATIONAL 0 Chapter 10 - Delivery of Twins 0 117
&econd
Twin
SECOND EDITION OF THE ALARM INTERNATIONAL PROGRAM SYLLABUS
First Twin ep!a#ic
"hen the first twin is in a cephalic presentation, vaginal delivery should be expected as for a singleton. %ecause of
the possibility of communicating circulations, the placenta should not be drained and cord bloods should not be
ta.en until after delivery of the second twin.
First Twin 'reec!
"hen the first twin is presenting as a breech, management of labor should be similar as with a singleton pregnancy.
1n additional factor to consider is the possibility of 2loc.ed2 twins, although the incidence is low 31#+4
breech/vertex combinations.5
First Twin non(#ongit)dina#
-f the first twin is non6longitudinal caesarean delivery is suggested, as external version is virtually impossible.
&econd Twin ep!a#ic * first twin delivered vaginally
Deliver vaginally.
&econd Twin 'reec! 7 first twin delivered vaginally
"ith the second twin as breech a vaginal breech extraction is acceptable. $onsideration should be given to disparity
in weight of the twins if the second twin is significantly larger.
&econd Twin non(#ongit)dina# 7 first twin delivered vaginally
-f the second twin is non6longitudinal, prompt external version or internal podalic version can be attempted. -f
these manoeuvres fail, caesarean section should be done.
10.0.+ %anage,ent of Labor
&pontaneo)s Labor
8or the patient with .nown multiple gestation, who has entered spontaneous labor at term, the plans regarding the
place of delivery should have been previously discussed, tentatively arranged, and now be put into effect.
9reterm labor is a fre:uent complication of multiple gestations. 9reterm delivery is the primary cause of the increase
in perinatal morbidity and mortality in multiple gestations. "omen with multiple gestations should be taught the
early warning signs and symptoms of preterm labor, and report promptly for evaluation.
Ind)ction
-ndications and contraindications for induction with multiple gestation include all of the factors that would apply to
a singleton gestation. -n addition, a significant disparity in estimated weight between twin fetuses is a sufficient
indication for induction. The methods used for induction would be the same as those for a singleton pregnancy. The
safety of induction in the presence of a previous caesarean section in multiple pregnancy is un.nown.
ALARM INTERNATIONAL 0 Chapter 10 - Delivery of Twins 0 118
"hen preterm labor is diagnosed, consideration must be given to tocolytic therapy, administration of
glucocorticoids, and transport of the woman to a regional referral centre. $aution must be exercised not to
induce pulmonary edema with the use of betamimetic tocolytics and betamethasone in combination.
SECOND EDITION OF THE ALARM INTERNATIONAL PROGRAM SYLLABUS
Transport onsiderations
-f transportation is possible, the patient with a twin pregnancy should be transferred to a referral centre.
$ommunication between the sending and receiving centre is essential.
-ssess,ent of Feta# .e##(being in Labor
1ll fetuses must have assessment of their well6being in labor. Twin pregnancy constitutes a potential high ris. for
perinatal morbidity and mortality. This is related to a number of factors including umbilical cord problems, placental
dysfunction, or twin6to6twin transfusion. 1fter delivery of the first twin there is an additional ris. for the second
twin because of cord compromise and intrapartum placental abruption. 8ollowing delivery of the first twin,
monitoring of the well6being of the second twin should be continued.

-)g,entation of Labor
-f dysfunctional labor is encountered, augmentation of labour is an option. The same indications and methods are
used as in a singleton pregnancy. 3See $hapter * ;<anagement of 'abor=.5 1ugmentation of labor after delivery of
the first twin may be appropriate.
T!ird &tage and Postpart), %anage,ent
1fter the second twin has been delivered, there should be active management of the third stage of labor. The
infusion of oxytocin should be continued for two to three hours following delivery of the placenta to ensure the
uterus stays well contracted.
The increased ris. of postpartum depression following multiple birth should be .ept in mind and renewed contact
should be made with identified supports.
&)ggested /eading:
1. &ntrapartu! 'anage!ent of 'ultiple gestations# >oulihan, $., ?nuppell, @.A $lini in 9erinatol 1). *(# 1611)
ALARM INTERNATIONAL 0 Chapter 10 - Delivery of Twins 0 119
Blectronic monitoring may be more successful at producing interpretable tracings if the leading twin is monitored
with a scalp electrode and the second twin with doppler ultrasound. The scalp electrode should be applied as
soon as labor is well established.
"hen the second twin is in a longitudinal lie and membranes can be safely ruptured, monitoring with a fetal
electrode can be commenced.
The use of the ultrasound in the delivery room with twins is helpful to determine presentations and fetal well6
being.
1nalgesia/1naesthesia for <ultiple Cestation
The usual options with their ris.s, benefits and limitations should be discussed. Bpidural analgesia is widely
utiliDed during labor with twin gestation. This provides :uality pain relief and also allows for the provision of
urgent anesthesia, if re:uired.