DELIVERY IN MULTIPLE

GESTATIONS
INTRODUCTION

Since the 1980s, the

Multiple pregnancies global twinning rate In 2021, twin births
are defined as more The prevalence of has increased by a accounted for 21.3 per
than one fetus multiple pregnancy 1000 live births; triplet
varies between 0.7 %– third, from 9.1% to 12%
simultaneously twin deliveries per and higher-order births
developing in the 3.34 % of women 1,000 deliveries. About were 80 per 100,000
uterus.1 worldwide.2 live births.3
1.6 million twin pairs
deliver every year.1
INTRODUCTION

• Morbidity and mortality rates ➔ 3–7 times greater than single pregnancies.4

• Multiple pregnancies ➔ high-risk pregnancies ➔ perinatal complications (responsible for

approximately 10–12.1% of perinatal mortality)1 :

▸ Prematurity (most common)

▸ Intrauterine growth restriction (IUGR)

▸ Discordant twins

▸ Twin-to-twin transfusion syndrome

INTRODUCTION

• The usual practices that are used in singleton deliveries (eg. intrapartum monitoring, operative
interventions, etc.) are compounded by the presence of the second fetus.5
• 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.3
CHORIONICITY AND
AMNIONICITY IN TWIN AND
TRIPLET PREGNANCY
Cr : Gibson JL, Castleman JS, Meher S, Kilby MD. Updated
guidance for the management of twin and triplet pregnancies
from the National Institute for Health and Care Excellence
guidance, UK: What’s new that may improve perinatal
outcomes? Acta Obstetricia et Gynecologica Scandinavica.
2020;99(2):147–52.
DELIVERY PLANNING
• Delivery planning of twins is dependent on twin types: dichorionic/diamniotic (DCDA),
monochorionic/diamniotic (MCDA) and monochorionic/monoamniotic (MCMA) pregnancies.3

• Monochorionicity increases gestational-age-specific mortality due to complications [selective

growth restriction (sIGR), twin reverse arterial perfusion sequence (TRAP), twin-to-twin
transfusion syndrome (TTTS) and twin anemia-polythaemia sequence (TAPS)] arising from the
conjoined fetal circulations within the shared placenta.6,2

• Monoamniotic fetuses are rare (<1% of all twin pregnancies) and are associated with high-
perinatal loss rates (20%-50%).6
DELIVERY PLANNING
• A single measurement of transvaginal cervical length at 20-24 weeks of gestation <20 mm or <25
mm ➔ predictor of spontaneous preterm birth at <28, <32, and <34 weeks of gestation.6

• One course of antenatal corticosteroids ➔ patients who are between 24 weeks - 34 weeks of
gestation and at risk of delivery within 7 days, irrespective of the fetal number.8

• The choice of optimal gestational age for delivery has to be balanced between the risk of
intrauterine fetal death which grows with the progression of the twin pregnancy opposed to the
potential loss of the newborn after a premature delivery.7

• Contraindications (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) to vaginal delivery in singleton pregnancies = in twin gestations 3
TIMING OF DELIVERY
 American College of
National Institute for Health and
Obstetricians and Gynecologists
(ACOG) Care Excellence (NICE)

Uncomplicated Uncomplicated
• DCDA ➔ 38 weeks of gestation • DCDA ➔ 37 weeks of gestation
• MCDA ➔ 34 0/7- 37 6/7 • MCDA ➔ 36 weeks of gestation
weeks of gestation • MCMA ➔ 32 0/7 - 33 6/7
• MCMA ➔ 32 0/7 – 34 0/7 weeks of gestation
weeks of gestation • Trichorionic triamniotic or
dichorionic triamniotic triplet ➔
35 weeks of gestation
MODE OF DELIVERY
Factors to Fetus presentation (especially the first twin)
be
considered
on Fetal weight
deciding
the
delivery Weight difference between the fetuses
mode :4

Gestational weight

Maternal clinical conditions

• Irrespective of chorionicity, no reason to recommend one type of delivery over another in a twin
pregnancy when the presenting fetus is in cephalic presentation after 32 weeks, when there are
no additional obstetric complications and no significant discordancy in the size of the twins.6

• Cesarean delivery : 6,8

▸ Presenting twin is not cephalic, including if they are in preterm labor between 26 and 32
weeks.

▸ Triplet pregnancy (irrespective of chorionicity)

▸ Monoamniotic twin gestations

• Vaginal delivery :

▸ Women with one previous low transverse cesarean delivery, may be considered candidates
for trial of labor after cesarean delivery.8

▸ Fetal weight should not be considered when both fetuses are cephalic. In those cases,
regardless the fetal weight, a vaginal delivery can be attempted.4

▸ Operative vaginal delivery may be required to complete the delivery of the second twin.
Indications ➔ prolonged second stage of labor, suspicion of fetal compromise, or maternal
benefit.3
MODE OF DELIVERY
Cr:Weerasekera DS. Twin Delivery. In: Chandraharan E,
Arulkumaran SS, editors. Obstetric and Intrapartum
Emergencies [Internet]. 2nd ed. Cambridge University
Press; 2021 [cited 2024 May 27]. p. 92–7. Available
from:
https://www.cambridge.org/core/product/identifier/97
81108807746%23CN-bp-13/type/book_part
MODE OF DELIVERY
Cr:Weerasekera DS. Twin Delivery. In: Chandraharan E,
Arulkumaran SS, editors. Obstetric and Intrapartum
Emergencies [Internet]. 2nd ed. Cambridge University
Press; 2021 [cited 2024 May 27]. p. 92–7. Available
from:
https://www.cambridge.org/core/product/identifier/97
81108807746%23CN-bp-13/type/book_part
• The presentation of twin pairs in a term twin pregnancy is 40% of the times cephalic/cephalic,
35–40% cephalic/non-cephalic and only 20% with the first twin non-cephalic.4

• In diamniotic twin pregnancies at 32 0/7 weeks of gestation or later with a presenting fetus that
is vertex, regardless of the presentation of the second twin, vaginal delivery is a reasonable
option and should be considered, provided that an obstetrician with experience in internal
podalic version and vaginal breech delivery is available.8

• During the breech delivery of the second twin, there is the risk of head entrapment. Head
entrapment is more common during a preterm delivery when the cervix is incompletely dilated.3
COMPLICATIONS
• Multifetal gestations are also associated with an increased risk of cesarean section, postpartum
hemorrhage, preeclampsia, and even death. Management of these conditions follows the same
guidelines as for singleton pregnancies.3

• The biggest risk in a vaginal delivery is for the second twin, as complications can occur after the delivery
of the first twin, including placental abruption, cord prolapse and long delivery intervals.4

• It was previously thought no longer than 30 minutes should be allowed between the delivery of the first
and second twin, as there was a concern that a prolonged interval was associated with a higher risk of
asphyxia for the second twin, and with a decreased likelihood of vaginal delivery of the second twin. In
the Twin Birth Study (TBS) the mean inter-twin delivery interval was 8 minutes with a range of 1-33
minutes.5
REFERENCES
1. Kundariya KR, Shah JM, Mewada BN, Shah MM, Patel AS. Fetomaternal Outcome in Twin Pregnancy. Journal of South Asian Federation of Obstetrics and
Gynaecology. 2023 Jan 31;14(6):663–6.

2. Farmer N, Hillier M, Kilby MD, Hodgetts-Morton V, Morris RK. Outcomes in intervention and management of multiple pregnancies trials: A systematic review.
European Journal of Obstetrics & Gynecology and Reproductive Biology. 2021 Jun;261:178–92.

3. Root E, Tonismae T. Multiple Birth Delivery. In: StatPearls [Internet] [Internet]. StatPearls Publishing; 2024 [cited 2024 May 27]. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK599524/

4. Félix Martins Santana E, Melo Corrêa V, Bottura I, Pedro Parise Filho J. Time and Mode of Delivery in Twin Pregnancies. In: Elito Jr. J, editor. Multiple Pregnancy
- New Challenges [Internet]. IntechOpen; 2019 [cited 2024 May 27]. Available from: https://www.intechopen.com/books/multiple-pregnancy-new-
challenges/time-and-mode-of-delivery-in-twin-pregnancies

5. Aviram A, Barrett JFR, Melamed N, Mei-Dan E. Mode of delivery in multiple pregnancies. American Journal of Obstetrics & Gynecology MFM. 2022
Mar;4(2):100470.

6. Gibson JL, Castleman JS, Meher S, Kilby MD. Updated guidance for the management of twin and triplet pregnancies from the National Institute for Health and
Care Excellence guidance, UK: What’s new that may improve perinatal outcomes? Acta Obstetricia et Gynecologica Scandinavica. 2020;99(2):147–52.

7. Markova I, Nikolov A, Markov P. Twin Pregnancy: Delivery and Complications. International Journal of Sciences. 2016;30(2).

8. Practice Bulletin No. 169 Summary: Multifetal Gestations: Twin, Triplet, and Higher-Order Multifetal Pregnancies. Obstetrics & Gynecology. 2016
Oct;128(4):926–8.

9. Overview: Twin and triplet pregnancy guidance[Internet]. NICE; 2019 [cited 2024 May 27]. Available from: https://www.nice.org.uk/guidance/ng137/

10. Weerasekera DS. Twin Delivery. In: Chandraharan E, Arulkumaran SS, editors. Obstetric and Intrapartum Emergencies [Internet]. 2nd ed. Cambridge University
Press; 2021 [cited 2024 May 27]. p. 92–7. Available from: https://www.cambridge.org/core/product/identifier/9781108807746%23CN-bp-13/type/book_part