Intrapartum management of twin gestations

Delivery of breech first twins: a multicenter retrospective study

Death during childbirth was a significant risk for women in prehistoric and pre-modern societies, but it has rarely been documented by archaeology. The evidence for twins in the archaeological record has likewise been largely circumstantial, with few confirmed cases. Maternal mortality in childbirth is often obscured by the special ritual practices associated with this type of death. In the case of twin births that difficulty is compounded by past social attitudes to twins. The earliest confirmed evidence for obstructed labour comes from the burial of a young woman who died attempting to deliver twins in the middle Holocene hunter-gatherer cemetery at Lokomotiv in southern Siberia some 7000 to 8000 years ago.

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Death by twins: a remarkable case of dystocic childbirth in Early Neolithic Siberia

The incidence of twin pregnancy has increased worldwide over the past 10 years, largely as a consequence of the assisted reproductive technologies. Issues such as intrapartum monitoring and operative interventions, especially relating to the second twin, provide a unique challenge in labour and delivery. Epidemiological and cohort data suggest that twins have a three-fold higher mortality rate than singletons, and that the second twin might have a better outcome if delivered by lower segment caesarean section. The recently completed Twin Birth Study has found that planned vaginal lower segment caesarean section is not advantageous to the fetus. In the light of this large randomised-controlled trial, vaginal delivery if twin A presents by the vertex is recommended as long as guidelines for the conduct of such delivery are followed.

Twin delivery: Method, timing and conduct

Intrapartum management of multifetal pregnancies

The purpose of this population based study on twins born in Sweden between 1961 and 1987 was to estimate the risk to the fetuses of becoming entangled during birth, and to identify those pregnancies with an increased risk for this rare complication. By using 3 separate questionnaires, 41 of 26,428 twin pregnancies with entanglement were identified. Twins in breech-vertex presentation (group A; 29 cases) were at significantly greater risk of entanglement (chi 2 = 168.3, p less than 0.001) than twins not in breech-vertex presentation (group B; 8 in vertex-vertex, 3 in breech-breech, and 1 in vertex-breech presentation). Known risk factors for entanglement in group A were intra-uterine growth retardation, a birth weight less than 2000 g, and antenatal fetal death. Intrapartum-neonatal mortality reached 38.9% in group A (median gestational week 36); and for group B, 8.3% (median gestational week 38). Entanglement during the study period occurred in 1 of 645 twin deliveries, on average. A vaginal delivery is proposed for women with twins in breech-vertex presentation, unless other risk factors leading to an increased risk for entanglement warrant abdominal delivery.

Pregnancies with growth-retarded twins in breech-vertex presentation at increased risk for entanglement during delivery.

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Pregnancies with growth-retarded twins in breech-vertex presentation at increased risk for entanglement during delivery.