KEMBAR

Delivery of Twins

ObjectivesIncidenceTypes of presentationWhere to deliverMode of deliveryManagement of labour

Incidencespontaneous twins occur in approximately 1 in 90 pregnanciesincreased use of reproductive technology has significantly increased this rate

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, 1987SECOND TWIN

Location for Delivery of Twins

discussed and planned in advanceconsultation with patient, family, attending physician and obstetricianrecommended delivery in hospital

Location for Delivery of Twinsobstetrician in attendance for labour and delivery, if possiblesame 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 fetusvaginal delivery is the goal unless there are specific contraindicationsplacenta should not be drained and cord bloods not taken until after delivery of second twin

First Twin Cephalicfirst 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 Breechselection for labour and vaginal delivery similar to singleton breech consider risk of locked twins if twin B is cephalicsecond 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

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 ratesno absolute time limit on duration between delivery of twins if second twin is well

Postpartum Management of Twins

active management of third stagepathology examination of placenta increased risk of postpartum depression discussion of issues from early pregnancy extra support with babies