Previous history of twinning; high parity
Older maternal age > 37yrs
History of ovulation induction or pregnancy
Family history of twinning
• Exaggerated pregnancy symptoms.
• Fetal activity is greater and more persistent in
twinning than in singleton pregnancy.
• (1) Uterus > dates of amenorrehea .
• (2) Excessive maternal weight gain that is not explained
by edema or obesity.
• (3)palpation of 2 fetal heads/presence of three fetal
• 4) Simultaneous recording of different fetal heart rates,
each asynchronous with the mother’s pulse and with
each other and varying by at least 8 beats per minute.
Ultrasound Determination of Chorionicity
• Number of sacs. [ before 10 weeks ]
2 sacs – dichorionic
Single sac - monochorionic
• Intertwin membrane
thicker and more echogenic in dichorionic
Ideal time for assessing of chorionicity is before 14 weeks
More frequent antenatal visits.
prophylactic iron 60-100mg and folic
acid 1mg daily should be given.
Nutritional advice-calorie req is
300kcal/day more than that
recommended for uncomplicated
Restriction of activity and
increased rest at home.
Prophylactic steroids – risk for
preterm labour or IUGR.
At 9-11 wks :
assessment of gestational
age and nuchal
anomaly scan at 20 wks
4 weekly scans in 3rd
trimester to assess fetal
complications like TTS
the gold standard
CTG with dual monitoring capability
Forceps or vacuum
Tocolytic agent for uterine relaxation
Methergin, 15-methyl PGF2 alpha
Immediate availability of blood
Access for emergency C/S
1.Place of delivery-
2.Timing of delivery
of pregnancy at 37-
delivered at 36-37
Mode of delivery
Depend on presentation of 1st twin
Both vertex / 1st twin vertex –
Indication for Elective LSCS
-More than 2 fetuses
-1st twin malpresentation, CPD
-IUGR in dichorionic twin
Delivery of 1st twin twin
Deliver the first baby vaginally
Cord is divided in between 2 clamps to prevent acute
No methergin is given at this point as it can cause
entrapment and asphyxia of second twin.
Delivery Of Second Twin
• Palpate abdomen
immediately to ensure
• If required-ultrasound
• Vaginal examination is
also done to exclude
• Acceptable interval
between deliveries – 30
A.R.M + oxytocin if necessary…. If delay
Vertex- Low down->forceps or ventose;
High up->internal version
Breech- breech extraction
External version- cephalic or IF FAILS
Internal version under G.A
Internal podalic version
To do or not to do ??
EFW > 1500 gm
Available anesthesia for
• effective uterine relaxation
• for emergency C/S
Rapid Delivery BY emergancy CS
Severe vaginal bleeding
Cord prolapse in second twin
Inadvertent use of IV ergometrine with
delivery of anterior shoulders of first
2nd twin is transverse, version failed
after delivery of 1st twin
Cross matched blood should be
Risk of atonic PPH is more.
Oxytocin infusion & i/v
ergometrine 0.25mg or
methergine 0.2mg given
following delivery of anterior
shoulder of second baby.
Prostaglandins-15 methyl PG
F2alpha can also be used.
Placenta examined for
Selective fetal reduction-one
fetus in a multiple gestation is
Multifetal reduction-in higher
Iatrogenic fetal death –us
guided fetal heart puncture or
One member of monochorionic
pair should never be selected
Multifetal and selective pregnancy reduction