This document provides guidelines for the delivery of twins, including: - Spontaneous twins occur in 1 in 90 pregnancies and reproductive technology has increased twin rates. - Vaginal delivery is recommended when possible, with an obstetrician in attendance and extra staff on hand. Delivery in the hospital is advised. - Different guidelines are provided for vertex-vertex, vertex-breech, breech-breech, and other twin positions. C-section may be recommended depending on positions and other risk factors. - Close monitoring of both fetal heart rates is important during labor and delivery to ensure fetal well-being.

2.  Spontaneus twins occur in approximately 1 in
90 pregnancies
 Increased use of reproductive technology has
significantly increased this rate

3.  Discussed and planned in advance
 Consultation with patient, family attending
physician and obstetrician
 Recommended delivery in hospital

4.  Obstetrician in attendance for labour, if
possible
 Same resources as required for singleton with
extra staffing
 Consider transfer of labouring patient if
resources unavailable locally

5.  Discussed and planned in advance
 Consultation with patient, family attending
physician and obstetrician
 Recommended delivery in hospital

6.  Obstetrician in attendance for labour, if
possible
 Same resources as required for singleton with
extra staffing
 Consider transfer of labouring patient if
resources unavailable locally

7.  Consider the lie and presentation of each
fetus
 Vaginal delivery is the goal unless there are
specific contraindications
 Placenta should not be drained and cord
bloods not taken untill after delivery of
second twin

10. Vertex- Vertex
 Vaginal delivery, interval between twins not to exceed
20 minutes.
Vertex- Breech
Vaginal delivery by senior obstetrician
Breech- Vertex
 Safer to delivery by CS to avoid the rare interlocking
twins
Breech-Breech
 Usually by CS.

11.  First twin cephalic : vaginal
 Second Twin :
 Cephalic : vaginal
 Breech : vaginal
▪ Breech extraction acceptable
 Other :
▪ Prompt internal or external version
▪ If fails perform caesarean

12.  Selection for labour and vaginal delivery similar
to singleton breech
 Consider risk of “locked” twins if twin B is
cephalic
 Second twin (if first twin delivered vaginally)
 Cephalic : vaginal
 Breech : vaginal
▪ Breech extraction acceptable
 Other
▪ Prompt internal or external version
▪ If fails perform caesarean

13. Intrapartum
Pervaginam
- Vertex – vertex
- Vertex – breech
(extraction
acceptable)
CS
Malpresentation (vertex – non vertex, non vertex -
vertex atau non vertex – non vertex, locking twins)
weight < 2 kg,
discordant growth ( i.e.: IUGR or twin-twin transfusion,
or disproportionate twins, twin B larger than A,
twin A: is non-vertex.
Conjoined Twins
Cord prolapse
placenta previa
Interlocking occurs in the fetus
During Labor: if delayed progress, fetal distress, or if
twin B transverse and cervix is thickened (retained
second twin).

15. a. Collision, impaction,compaction:
- Avoid strong traction and fundal pressure
- push the second twin out of the pelvis under
deep anesthesia
- Then delivery the first and second twin in the
usual way
- if the method fail and babies are alive do CS

16.  b. Chin to chin interlocking
▪ avoid traction of the first twin
▪ unlock the chin under anesthesia and the second
win is pushed out of the way
▪ delivery of the second baby and delivery of the
head of the first baby by traction

17. Management of Labour – Fetal Well Being
 Intermittent auscultation of both fetal heart rates
 No absolute time limit on duration between delivery
of twins if second twin is well
 In the twin delivery should always be available blood
to cope with postpartum bleeding
 Monitoring of postpartum hemorrhage and uterine
contractions