Intrapartum management of second twin

Prevalence of vaginal delivery of twins, both vertex and breech, has increased over the years at Brigham and Women’s Hospital in Boston, paralleling a decrease in incidence of cesarean birth. These trends may be due, in part, to a comprehensive program at the institution that entails patient counseling, staff simulation training and an available team for twin deliveries.

A practical, hands-on approach to intrapartum management of the second twin was presented at the 2018 Annual ACOG Meeting in Austin.

“Although the literature about the delivery of twins is understandably limited, we believe that vaginal delivery is generally a safe thing to do,” said Julian Robinson, MD, chief of obstetrics at Brigham and Women’s Hospital. “However, there is no optimal technique that can be used for the delivery of the second twin. Furthermore, the choice of the technique may change as the case progresses.”

Dr. Robinson told Contemporary OB/GYN that traditionally, ob/gyns tend to favor a single technique for all situations.

He counsels families that if the first twin is breech, both twins are delivered by cesarean. But if the first twin is head down, a vaginal delivery is planned for both twins, unless there is a good reason not to do so, such as the second twin being much larger than the first.

“We also factor in maternal wishes,” said Dr. Robinson. “For example, if the mother is very keen on having a C-section delivery rather than a vaginal delivery, we honor that request.”

In the case of both twins being head down, one approach is to be fairly hands off. “You deliver the first baby and then stabilize the lie of the second baby, head down,” he said. “You actually let the second baby labor down before rupturing the membranes, so the head is well engaged.”

This approach is much more suitable for mothers who have previously delivered. “But for the mother who has not had a baby before, we are more proactive with early rupture of the membranes,” said Dr. Robinson.

In this scenario, he rarely uses a high-vacuum to pull the baby down quickly (a technique that he used to use preferentially) because the vacuum has a tendency to disengage, plus it avoids two different instruments for vaginal delivery, such as vacuum and forceps.

A second method to consider is to deliver the first twin vaginally and the second twin breech, if the head of the second twin is high but surrounded by amniotic fluid. “You change the second baby to a breech presentation by an internal podalic version for an almost instantaneous delivery,” said Dr. Robinson.

Dr. Robinson said mothers do not want a vaginal delivery of the first baby and a cesarean for the second. “What increases the probability of a C-section is the length of time between the delivery of the first and second baby,” he said. “The longer the wait, the more likely something will go wrong, like bleeding or a non-reassuring fetal heart rate, which precipitates intervention with a C-section.”

Organization and planning ahead are key to increasing the odds of a vaginal delivery of twins. What are the roles of each member of the obstetric team? What does the mother want?

Logistically, will the twins be delivered in a labor room or the OR? “Personally, I tell all my patients we are going to deliver in the OR, not because we think there is going to be an increased chance of an operation, but because we want the space,” said Dr. Robinson. “It takes a lot of room, particularly when you bring in two separate pediatric teams.”

For an inexperienced delivery team, “you should be considering who you have for backup, either an experienced obstetrician or a perinatologist,” said Dr. Robinson. “Also, are you using ultrasound and do you have a C-section operating set in the room? Is the set open or closed? Is a surgical technician available or present?” 

Brigham and Women’s Hospital has introduced a patient and provider education program for the delivery of twins, including an information video and web page.

The latest statistics, from 2015, show that the vaginal rate of twins at the hospital is 56%, compared to only 28% in 2010. “We have noticed a much greater change among our faculty in embracing vaginal delivery because that has been our target audience,” said Dr. Robinson. “However, as we share the program more with our private practitioners and independent staff, I expect our vaginal rate to increase even further.”

An ob/gyn should be able to offer all options to the mother, according to Dr. Robinson. “It is in your interest to be educated, experienced and prepared to perform vaginal delivery,” he said.

Disclosures:

Dr. Robinson reports no relevant financial disclosures.