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Intrapartum Management of Twins

A discussion of the intrapartum management of multiple gestations, especially twin pregnancy, is important for at least four reasons. First, the incidence of twin gestation is increasing due to the availability and use of ovulation–induction agents and assisted reproductive technologies. Currently 3% of pregnancies are multiple gestations and the majority of these are twins. Second, the delivery of 2 fetuses dramatically increases the options for intrapartum management. Both fetuses, for example, may be delivered vaginally or by cesarean delivery. Additionally, after the birth of first fetus, a breech extraction, an external cephalic version, internal podalic version with assisted or total breech extraction, a cesarean or combinations of operative interventions may be necessary to deliver the second fetus. Third, recent publications on breech extraction of singletons, on the optimum time interval between delivery of the 2 fetuses, and on the risk of perinatal death in twins related to birth order, require us to rethink accepted practices. Fourth, if the rising rate of cesarean birth among twins is to be curbed, an understanding of alternative options are essential. The purpose of this review article is to describe the intrapartum management of multiple gestations, with emphasis on twin pregnancies; to evaluate the quality of studies according to the method outlined by the U.S. Preventive Services Task Force and; based on the highest level of evidence found in the articles, grade the recommendations as being Level A (based on good and consistent scientific evidence), B (based on limited or inconsistent scientific evidence) or C (based primarily on consensus and expert opinion). The publications cited here were obtained from a Pub Med search using the query terms “twin, delivery,” “twin, combined delivery,” “twin, vaginal delivery,” “twin, breech extraction,” “twin, delayed interval delivery” and “twin, umbilical artery pH.”