Twin pregnancy: Labor and delivery

INTRODUCTION

Twin pregnancies are at increased risk of intrapartum complications, such as fetal heart rate abnormalities and complications related to malpresentation. This topic will review issues related to the delivery of twins, such as timing and route of delivery, fetal monitoring, maternal analgesia/anesthesia, and management of delivery. Antepartum assessment and neonatal management of these pregnancies, and monoamniotic twin pregnancy, are discussed separately. (See "Twin pregnancy: Prenatal issues" and "Monoamniotic twin pregnancy" and "Neonatal outcome, complications, and management of multiple births".)

TIMING

Spontaneous or medically indicated preterm birth complicates over 50 percent of twin pregnancies, thus scheduling the timing of delivery is not subject to the discretion of the obstetrician in most cases [1]. However, in the absence of a spontaneous or medically indicated preterm delivery, when should ongoing twin pregnancies be delivered?

In general, we agree with expert consensus guidelines for timing of delivery of twin gestations. A consensus opinion from a workshop held by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and the Society for Maternal-Fetal Medicine (SMFM) suggested delivery at 38 weeks for uncomplicated dichorionic twins and 34 to 37 weeks for uncomplicated monochorionic diamniotic twins [2]. The National Institute for Health and Clinical Excellence (NICE) recommends elective delivery of dichorionic twin pregnancies from 37 weeks of gestation and monochorionic twin pregnancies from 36 weeks (after a course of corticosteroids) [3]. The American College of Obstetricians and Gynecologists (ACOG) recommends delivery of uncomplicated dichorionic twins at 380/7ths to 386/7ths weeks and uncomplicated monochorionic twins at 340/7ths to 376/7ths weeks of gestation [4,5]. Twin pregnancies complicated by fetal growth restriction are delivered earlier, with timing depending on the clinical scenario.

Dichorionic/diamniotic twin pregnancy — For normal uncomplicated dichorionic/diamniotic twin pregnancies, we suggest elective delivery between 38 and 40 weeks of gestation.

There are no high quality data from randomized trials on which to base a recommendation for the optimum timing of delivery of dichorionic/diamniotic twins. Based on our experience and the data presented below, we and others avoid elective delivery (ie, in the absence of usual maternal or fetal indications for delivery) of dichorionic/diamniotic twins prior to 38 weeks of gestation [5-8]. Assessment of fetal lung maturity should be performed if elective delivery is considered prior to 38 weeks [9].

                            

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Literature review current through: Nov 2014. | This topic last updated: Dec 16, 2014.
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