Twin delivery

The incidence of twin pregnancy has increased worldwide over the past 10 years largely as a consequence of the assisted reproductive technologies. Issues such as intrapartum monitoring and operative interventions, especially with regard to the second twin, provide a unique challenge in labour and delivery. Epidemiological data suggest that the term twin has a threefold higher mortality rate than the singleton. It is the authors' view that many aspects of twin delivery deserve as much import as those features of twin gestations such as pre-term birth and intrauterine growth restriction that, to date, have received much of the research and clinical interest in this area. Indications for elective Caesarean section are presented, incorporating new data derived from the delivery of the term singleton breech, and implications on the timing thereof are discussed. Vaginal delivery of both twins presenting by the vertex is recommended as safe as long as guidelines for the conduct of such delivery are followed. The recommended time interval between twins as well as the use of epidural, fetal monitoring and ultrasound in the delivery room are discussed. The second twin presenting as a non-vertex presents an urgent dilemma for accoucheurs. Data suggest that internal version and breech extractions are safer than external cephalic version provided that the appropriate techniques are applied. It is revealed, however, that the use of elective Caesarean section in this group of babies has not been subject to randomized controlled studies of sufficient power to determine the best method of delivery of the second twin - particularly in the low-birth-weight baby.