G. Capogna and D. Celleno, Dpt of Anesthesiology, Fatebenefratelli General Hospital, Roma, Italy.

1. MULTIPLE GESTATIONS 1.1. GENERAL CONSIDERATIONS Twin gestations occur in 1 % of pregnancies. Both infants are vertex 31-47 % of the time, while the first infant is vertex and the second infant is breech 30-40 % of the time. Breech-vertex or breech-breech presentations occur 8-12 % of the time and transverse lies occur in approximately 5-7 % of twins gestation. This variety of presentations influences both obstetric and anesthetic management. The implications for anesthesia presented by twin and multiple gestation pregnancies is, in part, determined by the planned mode of delivery. In fact, some obstetrician advocate elective cesarean section as a means of reducing the high perinatal mortality rate seen with vaginal delivery [1]. The risks associated with twin pregnancy are well described and perinatal mortality rate for twins born by vaginal delivery is 3 to 6 times that for singleton pregnancies [2,3]. The increased perinatal morbidity and mortality relates in maternal and fetal factors as reported in Table I [1-5].

6. 7]. 2. The latter may result from contraction or partial separation of the placenta after delivery of the first twin or a longer period during which the infant is subjected to the effects of aortocaval compression. On the basis of this. MATERNAL. Similarly. OBSTETRIC pre-eclampsia gestational hypertension uterine atony abruption placenta previa polyhydramnios premature rupture of membranes preterm labor FETAL prematurity (50 % of twins are between 32 and 38 weeks) intracranial hemorrhage (a result of compression and traction of the soft cranial vault during its descent through the pelvis) low birthweight high incidence of malpresentation congenital malformation prolapsed umbilical cord The second twin carries the highest perinatal risk as a result of breech presentation and birth asphyxia. both of which procedures are associated with a high incidence of morbidity-mortality [2]. it has become a general principle to minimize the second stage of delivery of the second twin [1. with triplets and quadruplets. back edema MATERNAL. 90 . the possibility of malpresentation in the later fetuses increases. increasing the requirement for version and breech extraction.MAPAR 1997 Table I Perinatal problems associated with multiple gestation. PHYSIOLOGIC anemia increased cardiac stress aspiration supine hypotension respiratory difficulty increased lumbar lordosis.

. Management varies when the presenting twin is vertex and the second twin is non-vertex. progressive sparing of involuntary expulsive reflexes may be less desirable in the delivery of twins.prevention of the bearing-down reflex.analgesia may allow the mother to avoid unnecessary muscle activity and may diminish the cardiovascular work. It provides satisfactory analgesia throughout first and second stages. especially for premature and breech infants. Similar duration of labor and mode of delivery when epidural analgesia was compared to parenteral narcotics [9] and a better second twin's condition with epidural analgesia [11] has been reported.ultrasound determinations of the presentation of the fetuses.elimination of the need for parenteral narcotics and sedatives (desirable in premature infants). . Twins presenting as vertex/vertex are usually delivered vaginally.2. VAGINAL DELIVERY Vaginal delivery of twins requires: the provision of good analgesia which facilitates a non-precipitate. cesarean delivery is usually chosen. This may implies a reduced role for very low concentration solutions.aggressive antepartum monitoring. allowing a controlled delivery. the capacity to provide conditions for rapid delivery by cesarean section. If the first twin is breech. However it does not provide uterine relaxation. atraumatic delivery. 91 . .125 % dose [13]. including the following: . Experience with singleton pregnancies on the progress of labor support a reduction in motor block and instrumental delivery with concentrations of bupivacaine of 0. tocolysis). avoidance of factors which may contribute to fetal distress or depression. However. a minimal duration of second stage for the second twin.125 % or less. Continuous epidural analgesia would appear to achieve many of the goals outlined for twin deliveries. forceps delivery (with adequate perineal anesthesia and relaxation) or version and extraction (adequate perineal anesthesia and uterine relaxation). - Epidural analgesia for twin deliveries offers many advantages [8-11]. and is readily modified to provide conditions for either cesarean section or instrumental vaginal delivery. 1. a recent report demonstrated the value of ultra-low concentrations of bupivacaine associated with sufentanil which provided similar analgesia and did not affect neither the duration of labor nor the incidence of instrumental or surgical delivery when compared with the standard 0. which. traditionally. However.Obstétrique Obstetric management of twins include: . . In multiple pregnancy the incidence of instrumental delivery is also increased [12].prevention of preterm labor (bed rest.the ability to do an operative or instrumental delivery if needed. necessitates general anesthesia. .

it may be preferable to consider the use of titrable techniques. which may allow a better hemodynamic stability. and lower umbilical venous pH and pO2. subarachnoid block will develop more rapidly and will ascend an average of two spinal segments higher than in singleton pregnancies [15]. Irrespective of the route of delivery. Other techniques available include epidural and subarachnoid opioids. The contribution of anesthesia to this poorer outcome is controversial.subarachnoid space may be more difficult in these women. 2. 8]. The unpredictability of response is a limitation of a single shot subarachnoid technique and for this reason. increasing hypoxemia in the supine position. whether born abdominally or vaginally. for equivalent doses and volumes of hyperbaric solution. Edema may further complicate identification of anatomical landmarks. All of these factors support the avoidance of general anesthesia. General anesthesia has been associated with poorer outcome in the second twin [1. Aortocaval compression is more pronounced in multiple pregnancies and incidence of hypotension may be greater with subarachnoid block. 1. Uterine hypotonia and blood loss are increased in multiple pregnancies which may necessitate aggressive fluid replacement and oxytocic therapy. the second baby delivered is at higher risk for death and depression than is the first one. Subarachnoid block may find occasional use if rapid anesthesia is desired.MAPAR 1997 More recently inhaled or parenteral glyceryl trinitrate has been used for this purpose [14]. spinal anesthesia can prove dangerously unpredictable. a better flexibility and control of upper sensory blockade. however a better second twin condition. Depression is related to birth order and not presentation. In multiple fetuses. continuous or intermittent subarachnoid block. but the considerations of prematurity and potential hypoxemia lend support to the caution of depressant drugs in these infants. because the tremendous enlarged uterus. Opioid analgesia provided acceptable analgesia only for the first stage of labor.3. In addition. because of the increased lumbar lordosis and the difficulty to assume a good position due to their greater enlarged uterus. including the avoidance of maternal 92 . An appropriate choice of the anesthetic technique and a perfect performance. Regional techniques include epidural and subarachnoid blocks. such as epidural and combined epidural-spinal anesthesia. caudal and pudendal block. Lumbar epidural anesthesia offers a slower onset of action. has been reported with epidural analgesia [11]. combined spinal-epidural analgesia. The second infant. has significantly lower 1-minute Apgar scores. and umbilical artery pO2 [16]. assessed by acid-base status. An unfavorable shift in the angle of the lower esophageal sphincter increases the possibility of regurgitation of gastric contents. such as in precipitous delivery. Identifying the epidural. CESAREAN DELIVERY The larger uterus encroaches to a greater degree upon the maternal functional residual capacity.

Breech presentation complicates 3-4 % of pregnancies [17] and in Table II is reported the incidence of the different breech presentations in relationship to the weight of the fetus. certainly may contribute to an happy outcome. 2. Three types are described: .Obstétrique and fetal depression and of aortocaval compression. in singleton term pregnancy. Table II Infant’s weight frank breech complete breech footling breech < 2500 g 38 % 12 % 50 % > 2500 g 51-73 % 4-11 % 20-24 % Table III Perinatal problems associated with breech presentation.1. 25 % of fetuses are breech.footling breech. where one or both hips are not flexed and one or both feet are below the buttocks. BREECH PRESENTATION 2. where the hips and knees are both flexed . GENERAL CONSIDERATIONS Breech presentation is defined as the entrance of the fetal lower extremities of pelvis into the maternal pelvic inlet. where the hips are flexed and the knees extended . MATERNAL postpartum infection uterine atony and postpartum hemorrhage FETAL prematurity congenital anomalies birth asphyxia birth trauma 6% umbilical cord prolapse (4-7 %) intracranial hemorrhage or other neonatal traumas cervical trauma and manipulation use of uterine relaxants 93 . since before 28 weeks' gestation.complete breech.frank breech. These different types of presentation depend on gestational age and fetal size.

possible injuries to the spinal cord. few breech infants are delivered vaginally. The choice of method of delivery (cesarean section vs trial of vaginal delivery) is dependent on fetal gestational age.the ability to rapidly create the conditions for an instrumental delivery. . . and this may represent a particular problem with premature breech infants. analgesia and reduction of the bearing down-reflex may be easily achieved increasing local anesthetic concentration. 19-21]: . . VAGINAL DELIVERY The risks associated with vaginal delivery include [2.increased risk of cord prolapse. 0. The sparing effect on perineal muscle tone which has been achieved in cephalic presentations with very low concentrations of bupivacaine and opioids (e. A titration of the dose to obtain an adequate perineal relaxation. with a prolonged first as well as second stage. 75 % cesarean section rate has been reported [18]. controlled delivery over a relaxed perineum. The remainder of breech fetuses are delivered by cesarean section. on the type of breech presentation (term frank or complete breech).0625 %) may be associated with a less reliable suppression of the bearingdown reflex.a higher incidence of dysfunctional labor. in order to obtund the involuntary urge to push. Spinal analgesia may also provide an excellent perineal relaxation for breech delivery. . if needed. The anesthetic management in breech vaginal delivery include: . . In many institutions all viable breech fetuses are delivered by cesarean section.a special attention in case of premature or distressed fetus. 94 . Because of the risks of birth anoxia and trauma. with or without opioids [23-25]. 2.the ability to relax the uterus. and on local obstetrical consensus [22]. The extent of sensory and motor block can be controlled by exploiting concentration and baricity. . especially in case of premature pushing or small infants in premature labor with consequent fetal asphyxia due to umbilical cord compression.g. .an adequate perineal analgesia to facilitate regular examinations and to prevent a premature bearing-down reflex before full cervical dilatation. . with the fetal head in the flexed position may deliver vaginally with little increased risk [17].MAPAR 1997 In Table III are reported the most common problems related to breech delivery.a slow. For these reasons very dilute solutions of local anesthetics and opioids may be used in the first stage followed by more concentrated solutions later on.arrest of the after-coming head either due to dystocia or containment by an incompletely dilated cervix. Term frank breech infants weighting between 2500 and 3800 g.2. peripheral nerves or intra-abdominal organs. 4. In the recent years. and may be used when these conditions are required rapidly and epidural analgesia has not been established.forceps delivery is associated with an increased intracranial hemorrhage.

CESAREAN DELIVERY Emergency cesarean delivery for cord prolapse or fetal distress requires general anesthesia unless an epidural catheter is already in place. If uterine relaxation is needed and general anesthesia is not possible or undesirable. It should be remembered that the patient in preterm labor may have received tocolytic therapy that may predispose her to pulmonary edema with aggressive hydration. For elective cesarean delivery. as well as assisted delivery of the aftercoming head following spontaneous delivery of the breech and total breech extraction are not uncommon situations. 2. Acute cord prolapse and fetal distress. making regional anesthesia even more desirable in this case. Particularly for breech infants. small boluses of glyceryl trinitrate have been suggested as the technique compatible with regional anesthesia without a prolonged uterine atony because its short half-life [14]. Local anesthetics are not tocolytic and extending the block does not create any advantage. epidural anesthesia warrants better neonatal conditions at birth when compared with general anesthesia [26]. spinal anesthesia may be also used for the "urgent" cesarean delivery. If time permits.3. in case of asphyxia. all these situations may be managed using a regional technique. regional anesthesia is the technique of choice. If time permits. 95 . is more sensitive to maternal depressant agents.Obstétrique The requirements for an emergency intervention is higher in breech delivery. The premature breech fetus.

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