Vaginal Delivery of Twins

Abstract

In 1982, Hawrylshyn and colleagues described twin pregnancies as a ''continuing perinatal challenge.'' 1 More than 2 decades later, the proper conduct of a twin delivery by the vaginal route constitutes one of the few remaining challenges in the day-to-day practice of the specialty of obstetrics. The greatest impediment to the vaginal delivery of twins is that at least one and occasionally both twins will be malpresenting. Experience with vaginal breech delivery is declining worldwide and cesarean delivery for twins is on the rise. The objective of this review is to examine the existing body of literature pertaining to twin delivery and to suggest an approach that has worked well for us and others.

The Planned Mode of Delivery and Neonatal Outcomes of Uncomplicated Dichorionic Twin pregnancies

“…The overall cesarean rate in our study was 57.9%. This is similar to 61.6% (177 out of 287) in Fox et al [3], approximately 60% in UK practice [4], and 67% in United States in 2003 [5]. This high rate of cesarean delivery may reflect some obstetricians' anxieties about vaginal twin delivery and may be seen as defensive practice.…”

“…This can affect the physician counseling, and maternal requests for elective cesarean delivery. The cesarean section rate for twins is 61.6% [3], approximately 60% in UK practice [4], and 67% in United States in 2003 [5]. Planned caesarean delivery could theoretically avoid some of the risks but direct evidence of a protective effect is currently lacking.…”

Fetal presentation and successful twin vaginal delivery

“…This high rate, as well as variation in cesarean rates for twin pregnancies across providers, may be strongly influenced by concern about delivery of the second twin, particularly when in a non-vertex presentation (14,15).…”

Management of Nonvertex Second Twin

“…Based on observational data, some advocate elective cesarean section for all women with a noncephalic second twin to minimize the risk of fetal trauma and asphyxia. The cesarean section rate in the current study in women who opted for vaginal delivery was 10.9 % among laboring, with overall cesarean rate being 50.9 % which is less compared with others [9]. Possible reasons behind this may be the greater inclination on the part of women in the current social setup to deliver vaginally, performing thorough case selection during antenatal period, active management of second stage of labor, and availability of expertise at the time of delivery.…”

“…Lack of training is one of the factors contributing to increased trend in performing cesarean section for the second malpresenting twin. The rate of this event is as low as 2.2 % in some centers but as high as 17 % in others-in the largest cohort reported in the literature, the rate was 9.45 % [9].…”