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									 VAGINAL DELIVERY                                                      Objectives
     OF TWINS                                             1.   To argue in favor of vaginal delivery of

    Edward R. Yeomans, M.D.                               2.   To present the prerequisites for
                                                               accomplishing objective #1.
   Texas Tech University Health
                                                          3.   To review several unique complications
         Sciences Center                                       of twins and discuss their impact on
         December 2010                                         route of delivery.

• Fascinating subject
                                                           • Epidemiology
• Fixed names
                                                           • Biology
  • Taiuro -- “he who has the first taste of the world”
  • Kainde -- “he who lags behind”                         • Ultrasound

• Romulus/Remus                                            • Maternal/Perinatal Outcome

• Castor/Pollux                                            • Labor and Delivery
                                                           • Unique complications

                 Twins                                  Twins
       Epidemiology                                  Biology
Incidence 3.2%                         DZ = 2 eggs, Dichorionic Diamniotic
   50% spontaneous, 50% ART            MZ = 1 egg and a later division:
   DZ to MZ = 2-3 to 1
              2-          MZ = 1/250        0-
                                        Day 0-3    Dichorionic Diamniotic
   MC/MA = 1% of MZ                         4-
                                        Day 4-8    Monochorionic Diamniotic
   PNM = 4x singleton                   > Day 8    Monochorionic Monoamniotic
   Hellin’s Law (for higher order)      > Day 13 Conjoined

          DZ Factors
• Age (up to 37)

• Parity (up to 5-6)

• Race (B>C>A)

• Maternal Family History

• Gonadotropins/ART

                     Twins                                      Twins
            Ultrasound                         Maternal Complications
• Diagnosis                                     • Hypertension
• Chorionicity – 20% Monochorionic              • Hemorrhage
• Anomaly detection                             • Hydramnios
• Guide invasive procedures                     • Hyperemesis
• Fetal growth
                                                • Protracted labor
• Confirm presentation
                                                • Frequent cesarean delivery
• ? Assist in delivery

                     Twins                                      Twins
Perinatal Complications                                    BEWARE!
• Low birth weight                            Undiagnosed twins – an LBJ phenomenon!
   Growth restriction                         • Be alert in triage – abdominal exam
   P    t it
                                              • Careful ultrasound
• Increased perinatal mortality
                                              • Danger – one twin completely unmonitored
   2% of births, 10% of deaths
                                               during labor
• Increased abortion – vanishing twin
                                              • Delivery may occur in an unfavorable setting
• Increased rate of malformations (MZ > DZ)

                 Twins                              Vaginal Delivery of Twins
                Labor                                  Specific Issues
  • Often protracted
                                              • Influence of presentation
  • Confirm presentation
                                              • Extremes of birth weight
  • Estimate weight
                                              • Prematurity
  • OK to augment
                                              • Intertwin interval
  • Monitor both fetuses
                                              • External cephalic version
  • Epidural anesthesia

     Vaginal Delivery of Twins                                    Twins
Influence of Presentation                    Changing Mode of Delivery
• Vertex/vertex – most (including ACOG)       • Cesarean rate for twins is rising rapidly in the
 recommend vaginal delivery.                    USA!

• Vertex/nonvertex – results from vaginal     • Fewer breech singletons deliver vaginally
 delivery are comparable to cesarean.           loss of experience for breech twins

• Nonvertex twin A – vaginal delivery safe    • Practice of defensive medicine
 but experience limited.

                                       N = 466
                                    Vertex/Vertex = 232 (50%)
                                    Vertex/Nonvertex = 124 (27%)
                                    Nonvertex Twin A = 110 (23%)

                                                                        OG 4/06

                                       Basic Philosophy of
            Delivery                      Twin Delivery
     c/s 1999      71%
                                   • Try to deliver both twins by the same route
     c/s 2004      95%
                                    (preferably vaginally)
                                   • Optimize maternal and neonatal outcomes
     c/s 1999      38%
     c/s 2004      68%
                         OG 4/06

Undesirable Outcome:                                Cesarean Delivery
 Cesarean Delivery of                              for the Second Twin
    Twin B Only                              • Secondary analysis of MFM network data

• Failure of descent                                C-
                                             • 1028 C-sections for twins after onset of labor

• Persistent malpresentation                 • 179 Combined vaginal/cesarean deliveries

• Cord prolapse                              • No difference in neonatal adverse outcomes
• Hemorrhage                                 • Conclusion: Don’t forego attempting vaginal
• FHR abnormalities                           delivery for fear of cesarean of second twin
• Incredible shrinking cervix                                                         OG 10/08

                                                Residents Must Acquire
         My Question
                                                    Specific Skills
                                                 • Forceps delivery
What about the mother?                           • Intrauterine manual dexterity

                                                 • Total breech extraction

                                                 • Internal podalic version
                                April 2009       • Piper forceps to the aftercoming head

  Vaginal Delivery of Twins
• Try to avoid ECV – increased cesarean risk

• No benefit of c/s over vaginal delivery, so why
 not try to avoid an unnecessary cesarean?
• Delay increases risk of combined delivery, so
 delivery of twin B
• Internal podalic version is an essential skill
                                       Carroll, Yeomans
                                       Clin OG 3/06

                                                             Neonatal Outcomes of
                                                                Twin Pregnancy
                                                          N=758 Consecutive sets of twins ≥ 35 weeks
                                                            Twin A : all cephalic
                                                            Pl    d    i l 657
                                                            Planned vaginal: 6       Delivered vaginal: 515
                                                                                     D li    d    i l 1
                                                           Cesarean after labor: 142
                                                            Planned cesarean: 101
                                                            Cesarean for B only: 3
                                                                                                   OG 3/08

 Neonatal Outcomes of
    Twin Pregnancy
Mean intertwin delivery intervals = 4.9 ± 3.2
Composite neonatal morbidity for twin B
  5% for planned cesarean
  4.7% for planned vaginal
                                       OG 3/08

 Twins: February Green                           Accompanying Editorial
N=287                                            • “Recommended” (Schmitz) vs “offer” (Fox)

• Active second stage management                 • In the Fox study, >50% underwent planned
• No combined deliveries
                                                   How were women counseled?
                                                 • H                    l d?
• Residents NEVER the primary operator
                                                 • Prerequisite: Obstetrician skilled in
• Did not report number of IPV                     intrauterine manipulation
• Allowed women to choose elective C/S           • “If future generations of obstetricians are not
                                                   trained…C/S rate will increase”
                                   Fox et al                                          D’Alton
                                   OG Feb 2010                                        OG Feb 2010

Infant Morbidity and Mortality with
     Vaginal Delivery of Twins                     There is NO diagnosis of twins

• 71% of twins delivered by C/S in 2005            • There are only monochorionic or dichorionic
  (was 54% in 1995)                                    twins
      y                               (1995-
• Analyzed all twin births > 30 weeks (1995-              g                      g
                                                   • RCOG guidelines call for diagnosis of
  2000)                                                chorionicity by first trimester ultrasound
• Conclusion: M+M similar for vaginal and          • Monochorionic twins are high risk –
  cesarean                                             ultrasounds every two weeks
• Morbidity does not correlate with birth                                             Moise
  weight discordance.                                                                 AJOG Jul 2010
                                      AJOG 4/09

          Management of                                                 Twins
           MC-DA Twins                                 Unique Complications
N = 236   Ongoing pregnancies at 24 wks EGA        •     Weight discordance
                   pp             preterm
• Results do NOT support elective p
                                                   •     Discordance for anomalies
 delivery to prevent IUFD in uncomplicated
 MC-DA twins
 MC-                                               •     IUFD of one fetus
• BUT…no data on route of delivery                 •     PPROM

                                   Smith et al     •     Delayed delivery of one twin
                                   AJOG Aug 2010

Unique Complications
• Monoamniotic twins

• Conjoined twins

• Twin-Twin Transfusion

• Acardiac twin (TRAP sequence)

• Fetus/Complete mole

                                  Vidaeff AC, Delu AN, Silva JB, Yeomans ER: Monoamniotic Twin Pregnancy Discordant for Body Stalk Anomaly.  J Ultrasound Med 2005; 24:1739‐1744.

                                                                                                                                                                 Body Stalk Anomaly                                  Limb-Body Wall Complex
                                                                                                                                                     Craniofacial defects not present                        Craniofacial defects present

                                                                                                                                                     Limb defects, if present, are non-band related (such    Limb malformations, associated with amniotic
                                                                                                                                                     as clubfeet, abnormal rotation, flexion contractures,   bands or ring constrictions, are characteristic
                                                                                                                                                     and hypoplasias)

                                                                                                                                                     Abnormal umbilical cord (shortening, complete           Umbilical cord may be present
                                                                                                                                                     cord absence, or absence of one umbilical artery)

                                                                                                                                                     Defective abdominal wall, with abdominal organs
                                                                                                                                                     outside the peritoneal cavity covered by an
                                                                                                                                                     amnioperitoneal membrane adherent to the
                                                                                                                                                     chorionic plate

                                                                                                                                                     Kyphoscoliosis, neural tube defects, increased
                                                                                                                                                     nuchal translucency in 1st trimester

                                                                                                                                                     Cases are sporadic, no risk of recurrence,
                                                                                                                                                     karyotype normal

                                                                                                                                                     Endogenous embryonic disturbance with                   Primary amnion rupture and vascular disruption is
                                                                                                                                                     persistence of the extraembryonic coelomic cavity       likely pathogenesis
   Vidaeff AC, Delu AN, Silva JB, Yeomans ER: Monoamniotic Twin Pregnancy Discordant for Body Stalk Anomaly.  J Ultrasound Med 2005; 24:1739‐1744.
                                                                                                                                                     is likely pathogenesis

    Monoamniotic Twins
• May be discordant for anomalies (as in the
 case just discussed)
• Timing and route of delivery - controversial

• Remember the picture of the intertwined
• Fortunately rare – 1/10,000

• Start with the major texts

• Develop a filing system – include your own
• Be ready for your opportunity

• Acquire/maintain skills


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