VAGINAL DELIVERY OF

SELECTED TWINS
BIRTH MASTERCLASS
Dr Mojgan Vatani
Staff Obstetrician
Dr Adele Crowley
Visiting Obstetrician
A/Prof John Svigos AM
Maternal Fetal Medicine Unit
Women’s and Children’s Hospital
University of Adelaide
Mary
Patroness of
Vaginal
Delivery of
Selected
Twins
 DELIVERY OF TWINS
INCIDENCE
1. Twin pregnancy has risen 70% since
1970
(Martin et al 2006)
2. Twins now account for 3% of all births
due to the increasing use of Assisted
Reproductive Technology (ART) and
increasing maternal age
 DELIVERY OF TWINS
S J-P & M B

Twin
delivery
with a twist!
 DELIVERY OF TWINS
PERINATAL OUTCOME
Compared to singleton pregnancies it is
recognised that for twins there is an
increased:
1. Perinatal mortality – 5 -10 X higher
(Rydhstrom & Herath 2001)
2. Perinatal morbidity – cerebral palsy 8 X
higher
(Petterson, Nelson & Stanley 1993)
 DELIVERY OF TWINS
The increased risk of Perinatal mortality and morbidity mostly results
from
FACTORS UNRELATED TO THE MODE OF DELIVERY viz.

1. antepartum stillbirth
2. prematurity (30%) – hyaline membrane
disease, necrotising enterocolitis, intraventricular
haemorrhage, sepsis
3. intra-uterine growth restriction (30%)
4. congenital anomalies (4.9%)
5. chorionicity – dependent complications
.. TTTS, TRAP sequence, monoamniotic twins,
conjoined twins
 DELIVERY OF TWINS
MATERNAL MORTALITY
As an important aside it must also be
remembered that women with a multiple
pregnancy have a two fold increase in
their risk of maternal death compared with
women with a singleton pregnancy.
(Monde-Agudelo et al 2000)
This may be related to the increased
incidence of caesarean section
 DELIVERY OF TWINS
PC Twins
for Ricky!!
 DELIVERY OF TWINS
In contemporary practice approximately 60% of
twins (in a number of selected centres almost
100%) are delivered by caesarean section and
this practice is increasing in Australia and NZ
(Walker et al 2007).
This may reflect:
. some obstetricians’ anxiety re vaginal delivery of
twins
. Patient Preference after THEIR search of the
literature
We need to work on both areas to effect an
improvement
 DELIVERY OF TWINS
Patient Preference is variable:
Mt Sinai Hospital NYC 2010
287 mothers with twins with Twin B breech and > 1500g
59.7% chose caesarean section
45.3% chose vaginal birth
While Yee et al in California 2014 found
of 204 mothers with twins, 68% were eligible for vaginal
birth and 48% attempted vaginal birth (when counselled
they were given a 63% chance of success)
Overall of those choosing vaginal birth:
40% were successful, 58% had a LSCS, 2% had a
combined delivery –reported they did not regret their
decision
 DELIVERY OF TWINS
RETROSPECTIVE STUDY OF TWIN DELIVERIES
AT W&CH 2001 -2010
To give you an indication of outcomes at that time in an
institution favouring vaginal delivery of twins
Of the 50,523 deliveries during this period
Twin deliveries > 24 weeks – 1457
Vaginal delivery rate of First twin – 47.5%
Total caesarean section rate – 52.5%
Elective caesarean section rate – 30%
Induction of labour – 37.5 %
Emergency caesarean section rate – 18.9%
Caesarean section for Second twin – 3.6 %
( 5.7% in nulliparae, 2.8% in multiparae)
 DELIVERY OF TWINS
W&CH Study (continued)
11.1% had a vaginal breech delivery
7.8 % had an instrumental delivery
Of all live born babies 2.5 % had Apgar < 7,
1.9% had cord pH < 7.1, 39% required admission
to NICU, perinatal mortality rate of 15/1000
PPH - 23.4%
Episiotomy rate – 21% , anal sphincter injury 1.1%
in those delivering vaginally
 DELIVERY OF TWINS
W&CH Statistics (continued)
No differences between the Caesarean Section
for Second Twin group and the Vaginal Delivery
of First twin group in terms of:
maternal age, gestational age, epidural use,
induction of labour
but with the Second Twin delivered by caesarean
section:
a trend to a longer labour, increased maternal
blood loss, lower Apgar score at birth, lower cord
pH and increased admission to NICU.
 DELIVERY OF TWINS
M&R
They loved
their twin
girls so much
they tried
again and as
usual the
perfect match with a Grand Slam - twin boys
!!
 DELIVERY OF TWINS
High quality evidence on which to base clinical
management is difficult to obtain as serious
adverse obstetric outcomes are relatively
infrequent.
For example delivery related perinatal death of the
second twin is said to affect approximately 1 :
287 twin births.
To power a relevant RCT this would require a
study of 6,500 twin pregnancies to determine
whether elective caesarean section would
reduce the risk of perinatal death in the second
twin
MODE OF DELIVERY OF TWINS
A&B

Sadly
split
twins
now !
 MODE OF DELIVERY OF TWINS
Elective
Caesarean
section
so unnatural !!
Just wait until you see
a natural vaginal birth
of twins !
 MODE OF DELIVERY OF TWINS
PLANNED (ELECTIVE) CAESAREAN
SECTION for UNCOMPLICATED DC / MC
TWINS – usually the same 4 studies are
cited: retrospective, not randomised, not
powered sufficiently
Smith et al BMJ 2002 – large
retrospective study of over 4,000 twin
deliveries suggesting benefit for second
twin
Yang et al Am J Obstet Gynecol 2005
Armson et al Obstet Gynecol 2006
Yang et al J Perinatol 2006
 MODE OF DELIVERY OF TWINS
PROPONENTS OF PLANNED VAGINAL DELIVERY
There is an abundance of observational data
supporting a choice of planned vaginal
delivery for vertex-vertex and vertex - non
vertex twins at late preterm and term
gestation without an increased risk of
composite morbidity or mortality:
Fox et al Obstet Gynecol 2012
Zhang et al Obstet Gynecol 1996
Acker et al Obstet Gynecol 1982
Chervenak et al Am J Obstet Gynecol 1984
Adam et al Am J Obstet Gynecol 1991
Chauhan et al Am J Obstet Gynecol 1995
*All studies suffer from the same limitations as proponents of PCS
 MODE OF DELIVERY OF TWINS
TWIN BIRTH STUDY (TBS)

Jon Barrett et al’s study 2014 from Toronto attempted to answer the following question:

For twin pregnancies of 32-38 weeks gestation which Twin A is presenting cephalic, does
a policy of Planned CS decrease the likelihood of perinatal death or neonatal
mortality or serious neonatal morbidity during the first 28 days after birth compared to
a policy of Planned VB ?

Inclusion Criteria:
1. Women at 32 0/7 – 38 6/7 weeks gestation
2. Estimated fetal weight of each fetus 1500 – 4000 g
3. Both twins alive at time of randomisation
4. Twin A in cephalic position

Exclusion Criteria:
1. Mono amniotic twins
2. Lethal fetal anomaly of either twin
3. Contraindication to labour or vaginal delivery for either twin
4. Previous participation in the Twin Birth Study
 MODE OF DELIVERY OF TWINS
Primary Outcome measures:

. perinatal/neonatal mortality and/or serious neonatal morbidity

Secondary Outcome measures:

. death or poor neuro-developmental outcome of children at 2 years of
age
. Problematic urinary or faecal/flatus incontinence of mothers at 2
years post delivery

Estimated enrolment: 2,800 women

Study start date: Dec 2003
Study completion date: June 2011
 MODE OF DELIVERY OF TWINS
Results of The Twin Birth Study

First presented at SMFM, San Francisco 2013, published

2014
2804 women randomised at 106 centres from 26 countries
1398 Planned CS v 1406 Planned VB
57 babies of 2781 (2.05%) in Planned CS group
experienced primary outcome (perinatal/neonatal
mortality and/or serious neonatal morbidity)
52 babies of 2782 (1.87%) in Planned VB experienced the
primary outcome
(OR 1.098, CI 0.726 – 1.663, p = 0.6569)
 MODE OF DELIVERY OF TWINS
Results of The Twin Birth Study (cont)

There was no significant interaction between the treatment groups and parity,
GA at randomisation, mother’s age, presentation of Twin B, chorionicity
and the country’s PNM.
Twin B was more likely to experience the primary outcome[ perinatal mortality
or severe morbidity] (OR 1.895, CI 1.329 – 2.703, p = 0.6569)
89.9% in Planned CS delivered both babies by CS
60.45% in Planned VB delivered at least Twin A vaginally
4% of Planned VB delivered Twin B by CS following VB of Twin A
Women in Planned CS delivered earlier but had no increased maternal
mortality or morbidity compared to Planned VB
Although a higher risk of an adverse outcome for Twin B, Planned CS did not
reduce the risk
 MODE OF DELIVERY OF TWINS
Conclusions of The Twin Birth Study
1. Planned CS in twins 32 – 38 weeks does not decrease ( or increase)
perinatal/ neonatal death or serious neonatal morbidity v planned
VB when Twin A is cephalic
2. Higher risk of adverse perinatal outcome for the second twin but
Planned Caesarean Section did not reduce this risk
3. Planned CS was not associated with a higher (or lower) risk of
maternal death or serious maternal morbidity compared to planned
vaginal birth
** Hence our previous contention remains – a choice between
caesarean section and vaginal birth can be selectively given to
women with twins.
*** Jon Barrett : “ To the obstetricians of our generation, this is a
wakeup call to train obstetricians of the next generation that the best
way to deliver twins is vaginally”
 MODE OF DELIVERY OF TWINS
Observations of Twin Birth Study:
Summary of predictors of successful Vaginal Birth

1.If multiparous women not induced in countries

with low PNM then > 80% successful vaginal
birth irrespective of presentation of Twin B
2.If nulliparous women not induced then 67% to
77% chance of successful vaginal birth.
If nulliparous women induced then probability
51%-64%
3.In a country with low PNM <10/1000,
multiparous women under the age of 30 years
with Twin B in cephalic presentation who were
not induced, are more likely to have a successful
vaginal delivery
 MODE OF DELIVERY OF
TWINS
**STOP PRESS – Twin Birth Study
2 year neurodevelopmental follow-up of the
randomized trial of planned cesarean or
planned vaginal delivery for a twin
pregnancy (AJOG March 2016)
Conclusion: a policy of planned cesarean
delivery provides no benefit to children at 2
years of age in relation to cerebral palsy,
motor delay or cognitive delay
 MODE OF DELIVERY OF
TWINS
Additional Recent Study
T.Schmitz et al: Association between
planned cesarean delivery and neonatal
mortality and morbidity in twin pregnancies
Obstet Gynecol 2017 June; 129(6):986-992
National prospective population based study
in France.
All women with twins > 32 weeks with first
twin cephalic recruited in 176 maternity units
Feb 2014 – Mar 2015
 MODE OF DELIVERY OF
TWINS
The primary outcome was a composite of
intrapartum mortality and neonatal morbidity
and mortality with comparisons performed
according to planned mode of delivery
The primary analysis to control for potential
indication bias used propensity score
matching. Subgroup analyses were
conducted – one according to gestation at
delivery and one after exclusion of high risk
prgenancies.
 MODE OF DELIVERY OF
TWINS
5,915 women enrolled with 1,454 (24.6%)
had PCS and 4,461 (75.4%) had PVD
(80.3% , 3,583 women, delivered both twins
vaginally)
Composite neonatal morbidity and mortality
5.2% in PCS v 2.2% in PVD
OR 2.88 CI 1.86 – 3.05)
 MODE OF DELIVERY OF
TWINS
This difference only applied to neonates
born before but not after 37 weeks gestation
Multivariable and subgroup analyses
performed after exclusion of high risk
pregnancies found similar trends.
 MODE OF DELIVERY OF TWINS

assisted
vaginally
delivered
Twins --
Happy
Happy !!
 MODE OF DELIVERY OF TWINS
elective
caesarean
section
delivered
Twins
not so happy !!
 MODE OF DELIVERY OF TWINS
Presentation of Uncomplicated Twins and Recommended Mode of Delivery

Where are we now?

1. Vertex – Vertex (45%)

* offer trial of labour Level I evidence per TBS

2. Vertex – Von-vertex (35%)

Second twin may be breech (20%)

transverse (10%)
oblique (5%)
* offer trial of labour Level I evidence per TBS
 MODE OF DELIVERY
Presentation of Uncomplicated Twins and Recommended Mode of
Delivery

3. Breech – Vertex (7%)

* Caesarean section usually offered but this is unfairly influenced by
the flawed Term Breech Trial and also the possible rare occurrence
of Locked Twins (estimated risk of Locked Twins of 1 in 645 twin
births [147 reported cases] with mortality of 30 – 43 %)

4. Breech – non Vertex (13%)

. breech (6%)
. transverse (7%)

* Caesarean section offered GPP evidence

MODE OF DELIVERY OF TWINS
LOCKED TWINS
 MODE OF DELIVERY OF TWINS
GPP would dictate caesarean section for :
1. Preterm twins <1500 g
2. Discordant twins
3. Mono amniotic twins – delivery at 32 weeks
4. Conjoined twins
5. VBAC – ** however if the limited literature is
studied in detail there would appear to be
equipoise between VBAC success for twins and
singletons and that uterine rupture rate and
transfusion rates are similar to those of singleton
pregnancies
TIMING OF DELIVERY OF TWINS
The signature paper by our colleague Jodie Dodd et al
BJOG 2012: “Elective birth at 37 weeks gestation versus
standard care for women with uncomplicated twin
pregnancy at term: The Twins Timing of Birth Trial”
concluded that elective birth at 37 weeks gestation was
associated with:
.significant reduction in the risk of serious adverse outcome
for the infant
4.7% v 12.2% RR 0.39(95% CI 0.20 – 0.75) p=0.005
.reduction in birth weight less than third percentile
3.0% v 10.1% RR 0.30 (95% CI 0.13 – 0.67) p= 0.004
.trend in primary composite of adverse infant outcome
1.7% v 5.0% RR 0.34 (95% CI 0.11 – 1.05) p= 0.006
TIMING OF DELIVERY OF TWINS
PROF
JODIE
DODD

She is not
happy about
this photo !!
 TIMING AND MODE OF
DELIVERY OF TWINS
1. Jon Barrett’s study looking at mode of delivery of twins
found amongst his conclusions for successful vaginal
birth that NON INDUCED twins were more likely to
deliver vaginally (>80% in multips and 67% - 77% in
nullips)
2.Jodie Dodd’s trial concluded that ELECTIVE DELIVERY
AT 37 WEEKS in twins reduced adverse outcomes for
the infants.
SO
a. DO WE WAIT for the spontaneous onset of labour to
maximise the chance of vaginal delivery and accept a
possibly poorer outcome for the infants?
OR
b. DO WE INDUCE at 37 weeks to get a better outcome
for the infants but reduce the chance of successful
vaginal birth?
3. What choice do you think the mother would take ?
 VAGINAL DELIVERY OF
SELECTED TWINS
PRE-REQUISITES FOR VAGINAL DELIVERY OF TWINS

1. Birth in hospital
2. Experienced obstetrician
3. Continuous fetal monitoring in labour
4. Epidural analgesia and IV access, G&XM,
5. Anaesthetist
6. IGGA
7. Two midwives, paediatricians, resuscitation trolleys
8. Delivery trolley set up for two babies
9. Ultrasound machine
10. Lithotomy bed
11. ? Delivery conducted in theatre or theatre availability
 VAGINAL DELIVERY OF
SELECTED TWINS
Of course
perfectly
natural
and not
intrusive
at all ?!!
 VAGINAL DELIVERY OF
SELECTED TWINS
DELIVERY OF THE FIRST TWIN
1. Managed as a singleton initially apart from
having an effective ‘full block’ epidural during
labour well before full dilatation of the cervix.
2. Deliver in the lithotomy position.
3. Patient to be catheterised.
4. OBSTETRICIAN TO BE IN FULL COMMAND !!
Control the crowd, watch the timing of the oxytocic,
dispense with the immediate skin to skin contact
 VAGINAL DELIVERY OF
SELECTED TWINS
DELIVERY OF THE SECOND TWIN
1. After delivery of the First Twin the obstetrician
should assess the lie and presentation of the
Second Twin.
2. This assessment can be performed by vaginal
examination, abdominal palpation or trans-
abdominal ultrasound.
3. Most authors recommend continuous fetal
monitoring of the Second Twin with the risk of
fetal distress and acidosis being increased if the
Twin – Twin delivery interval is > 30 minutes
(Leung et al 2002)
 VAGINAL DELIVERY OF
SELECTED TWINS
* IF LONGITUDINAL LIE (Vertex or Breech)
. await onset of uterine contractions (within
10 minutes) and with descent of the
presenting part perform Artificial Rupture
of Membranes (ARM) and delivery of the
Second Twin.
. if no uterine contractions then institute a
syntocinon infusion (10 i.u./L @
100ml/hour)
 VAGINAL DELIVERY OF
SELECTED TWINS
DELIVERY OF SECOND TWIN
* IF ABNORMAL LIE
. this should be corrected by either External
Cephalic Version (ECV) or Internal Podalic
Version (IPV) and Breech Extraction (BE)
.. in two series (Gocke et al 1989; Adam et al
1991) ECV was less likely than IPV & BE to
result in vaginal birth with emergency caesarean
section, cord prolapse and fetal distress more
frequent with ECV than IPV & BE
 VAGINAL DELIVERY OF
SELECTED TWINS
EXTERNAL
CEPHALIC
VERSION (ECV)
Grasp the fetus with
two hands – one over
the breech the other
over the head.
Encourage flexion and
Rotate to either breech
or cephalic (whichever
way the baby moves
easiest)
 VAGINAL DELIVERY OF
SELECTED TWINS
External Cephalic Version (continued)
Once the lie is longitudinal ensure the IGGA
maintains the lie
Commence a syntocinon infusion
Undertake amniotomy when the presenting
part is fixed in the pelvic brim
If the fetal heart remains normal then deliver
as a spontaneous vertex or assisted
breech
 VAGINAL DELIVERY OF
SELECTED TWINS
* IF ECV FAILS then some may proceed to
caesarean section whilst others may proceed to
IPV and BE particularly with intact membranes
and normal fetal heart monitoring.
* IF THERE IS FETAL DISTRESS then a judicious
decision must be made with regard to the mode
of delivery of the Second Twin with most
favouring IPV and BE.
 VAGINAL DELIVERY OF
SELECTED TWINS
INTERNAL PODALIC VERSION and BREECH EXTRACTION

*If the back is dorso-superior (back up) then pass the right hand into
the uterus and with the membranes intact grasp the anterior leg -
differentiate the foot from hand by feeling for the prominence of the
heel (as per diagram 2.)
Once the foot is firmly grasped, between contractions pull on the
lower limb and the breech will descend towards the pelvic brim and
the membranes will usually rupture at that point.
Simultaneously the operator’s other hand (or the IGGA) is used to
dislodge and elevate the fetal head toward the uterine fundus by
pressure applied to the abdominal wall.
Keep the back uppermost and complete the breech delivery.
 VAGINAL DELIVERY OF
SELECTED TWINS
INTERNAL PODALIC VERSION AND BREECH
EXTRACTION (CONTINUED)
• If back is dorso – inferior (back down) (see
diagram 1)
the accoucheur should pass the right hand under
the body
the posterior leg and foot should be grasped and
in between contractions pulled downwards
which will result in the back rotating anteriorly as
the breech descends
 VAGINAL DELIVERY OF
SELECTED TWINS
Back down Back up
 VAGINAL DELIVERY OF
SELECTED TWINS
Potential Complications of IPV and BE.
. fetal anoxia
. difficulty with delivery of the head
. fetal trauma
. inadvertent delivery of a hand
. placental abruption
. cord accident
. endometritis
. maternal trauma (ruptured uterus)
 VAGINAL DELIVERY OF
SELECTED TWINS
TIME INTERVAL BETWEEN DELIVERY OF
TWINS
Generally agreed to be 30 minutes
In the Twin Birth Study the mean interval
was 8 minutes with range of
1 – 33 minutes
 VAGINAL DELIVERY OF
SELECTED TWINS
EXPEDITIOUS DELIVERY OF SECOND TWIN
This may be necessary with fetal distress in the
First Twin or while awaiting delivery of the
Second Twin
In the non vertex presenting second twin usual to
proceed to IPV and BE
In the vertex presenting second twin counter
intuitively great skill and judgement is required if
operative vaginal delivery is chosen particularly
if the head is high.
In either situation ultrasound may alert the
operator to an unexpectedly larger second twin
 VAGINAL DELIVERY OF
SELECTED TWINS
ACTIVE MANAGEMENT OF THE THIRD STAGE
1. Ensure oxytocic is given after delivery of
Second Twin
2. Obstetrician to bimanually massage uterus until
contraction is sustained with the use of a
syntocinon infusion (40 i.u./L @ 200 ml/hr) for 4
hours post delivery.
3. Ensure patient is catherised
4. Once all of the above are achieved then the
‘parenting process’ can begin and the Dom
Perignon can be opened!!
 VAGINAL DELIVERY OF
SELECTED TWINS
PATIENTS WHO REFUSE ASSISTANCE OR
PRESENT IN LABOUR BUT WISH TO
DELIVER VAGINALLY
. transfer to theatre
. continuous fetal monitoring
. ultrasound confirmation of fetal presentation
. deliver First Twin in lithotomy position
. if lie of Second Twin not longitudinal then ECV
.. if uncorrectable and no fetal distress then insert
spinal anaesthetic and perform IPV & BE
.. if fetal distress then perform LSCS under GA
 VAGINAL DELIVERY OF
SELECTED TWINS
M&F
Another
prince and
princess
 VAGINAL DELIVERY OF
SELECTED TWINS
DO WE ABDICATE
OR DO WE INNOVATE ? **
1. Multiple Pregnancy Birthing Service
2. Multiple Pregnancy Midwifery
Coordinators
3. Simulation and BMC Workshops
 VAGINAL DELIVERY OF
SELECTED TWINS
**Easter et al Am J OG May 2017
Conducted a survey of 400 ACOG Fellows
re their practice of Twin birth.
This identified the following relevant areas:
1. Provider knowledge
2. Provider priorities
3. Provider comfort and skill
++ Confirmed our nested study of 40 senior
registrar participants of the BMC
 VAGINAL DELIVERY OF
SELECTED TWINS
SELLING POINTS
1. Vaginal delivery of twins does not equal vaginal delivery
without assistance
2. Start discussion of the mode of delivery early and
certainly by 32 weeks gestation onwards
3. Introduce the concept of personal discipline to achieve
vaginal delivery
4. Introduce “non negotiable”/ “strongly recommended”
options
.. epidural
.. syntocinon
5. Introduce an ‘out’ for the patient if vaginal delivery is
not achieved or achievable
 VAGINAL DELIVERY OF
SELECTED TWINS
THE TWINS
DELIVERY
TEAM

The work of many !

 VAGINAL DELIVERY OF
SELECTED TWINS
Dont be afraid
to ask for
assistance from
a “wise” (old) Muppet:
ANTONAS,SVIGOS
MURRAY,PEAT
and the next generation
WEAVER, ROBSON, WILKINSON
who are only too happy to
be invited !!
Also don’t forget
The Younger (hungry) Muppets:
WOODS, ROBERTS, VATANI,
RALLIS,CROWLEY !!

SEEN IT DONE IT !!!

DELOS