Multiple Birth Delivery

Excerpt

Multifetal gestations are associated with higher risks than their singleton counterparts. In 2021, twin births accounted for 21.3 per 1000 live births; triplet and higher-order births were 80 per 100,000 live births. The recommended mode of delivery for twin gestations has been debated in the literature. Current American College of Obstetrics and Gynecology (ACOG) guidelines state that twin gestation, in general, is not an indication for a cesarean section. There has been further debate regarding what types of twin pregnancies are candidates for vaginal delivery given the risks associated with a change in fetal lie after delivery of the first twin, risk of placental abruption due to the abrupt decompression of the uterus after delivery of the first twin, cord prolapse, and changes in cervical dilation that may hinder the delivery of the second twin. The Twin Birth Study, the first large randomized controlled trial evaluating twin birth outcomes, found there was no increased risk of neonatal morbidity or mortality in patients who underwent vaginal delivery versus cesarean section. However, the management of twin delivery is challenging for obstetricians due to issues associated with monitoring both twins during labor and the maneuvers that may be necessary to deliver the second twin.

Not all patients with a twin gestation should attempt a vaginal delivery. First, the patient should desire a trial of labor. The presenting twin must be in the cephalic position for vaginal delivery to be considered. Twins with fetal growth discordance (greater than 20% difference in estimated fetal weight) preclude a patient from a vaginal delivery. All conditions that are contraindications to vaginal delivery in singleton pregnancies will also prevent vaginal delivery in twin gestations. These conditions include cord prolapse, vertical incision on the uterus from prior surgery, placenta previa or accreta spectrum, infections such as current herpes outbreak, or fetal intolerance of labor. The delivery of twins is determined by twin type and maternal and fetal conditions around the time of delivery.