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 issue specific to the second twin
Objectives

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

 Spontaneus 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 Breech Other

Second Cephalic 39 13 0,6
twin
Breech 26 9 0,6
Other 8 4 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 (2)

 Obstetrician in attendance for labour, 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 untill 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
 Consideration should be given to disparity in weight of the
twins if the second twin is significantly larger
 Other
 Prompt internal or external version
 If fails perform caesarean
 First Twin Non-Longitudinal

If the first twin is non-longitudinal caesarean

delivery is suggested, as external version is virtually
impossible
Management of Labour
 Preterm labour common
 Educate re: warning sign
 Steroid indicated as in singleton
 Use tocolytics judiciously (pulmonary edema)
 Indication and contraindication with multiple gestation
include all of the factors that would apply to a singleton
gestation
 In addition, a significant disparity in estimated weight
between twin fetuses is a sufficient indication for induction
 Transport Considerations
If transportation is possible, the patient with a twin pregnancy should be
transferred to a referral centre. Communication between the sending and
receiving centre is essential

 Assesment of Fetal Well- being in Labor

All fetuses must have assessment of their well-being in labor. Twin
pregnancy constitutes a potential high rizk for perinatal morbidity and
mortality. This is related to a number of factors inscluding umbilical cord
problems, placental dysfunction, or twin-to-twin transfusion
 Augmentation of Labor
If dysfunctional labor is encountered, augmentation of labour is an
option. The same indications and methods are used as in a singleton
pregnancy.

 Third stage and postpartum management

After 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 stay well contracted