This document provides guidelines for the management of twin pregnancies and deliveries. It discusses increased prenatal care needs including nutrition, activity restrictions, and screening. Ultrasound scans are recommended at various gestational ages. Prenatal diagnosis of anomalies may require procedures like amniocentesis or selective feticide. Delivery is recommended in a fully equipped hospital between 37-38 weeks. Vaginal delivery of the first twin is possible if it is vertex presenting, while the second twin requires assessment and may need procedures like internal version for breech extraction. Caesarean section is indicated if vaginal delivery is not possible. Close monitoring and precautions against postpartum hemorrhage are essential.

1. APARNA P
2009 MBBS

3. 1.Prenatal care
 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
pregnancy.
 Restriction of activity and increased
rest at home.
 Prophylactic steroids – risk for
preterm labour or IUGR.

4. 2.Ultrasound scan
 At 9-11 wks :
confirmation,
chorionicity
determination,
assessment of
gestational age and
nuchal translucency.
 anomaly scan at 20 wks
 4 weekly scans in 3rd
trimester to assess fetal
growth, diagnose
complications like TTS

5. 3.Prenatal diagnosis

Screening for aneuploidy

Mid trimester amniocentesis

Chorionic villous sampling

Serum screening

Management of anomalies-

Selective feticide kcl injection

Ultrasound guided doppler
coagulation

6. 4.Multifetal and
selective pregnancy
reduction

Selective fetal reduction-one fetus in
a multiple gestation is abnormal

Multifetal reduction-in higher order
pregnancy

Iatrogenic fetal death –us guided
fetal heart puncture or inj kcl

One member of monochorionic pair

8. 1.Place of deliveryFully equipped hospital
having intensive neonatal
care unit.
2.Timing of delivery
RCOG recommends
elective termination of
pregnancy at 37-38
weeks
 Monochorionic
pregnancy best delivered
at 36-37 weeks


9. Maternal indications
Fetal indications
Placenta previa
Ist fetus noncephalic
Severe preeclampsia
Twins with
complications IUGR
Previous cs
Monoamniotic twins
Cord prolapse is baby
Abnormal uterine
contractions,CPD
Monochorionic twins
with severe TTTS

10. Vaginal Deliveryprerequisites

First twin presents as vertex,no other
indications for CS.

Facilities for operative delivery,
careful fetal monitoring,neonatal unit
available.

Portable US & preferably a
cardiotocography machine with dual
channel monitoring.

Second obstetrician(atleast one
obstetrician should be experienced in
breech extraction)

Anesthetist, Neonatologist

11. 
Internal examination soon after
rupture of membranes to r/o cord
prolapse.

Women should be counseled about
chances of operative interference.

She is restricted to taking sips of
clear fluids and antacids can be
given.

All precautions to combat PPH
should be ready like cross matched
blood and oxytocics.

12. Liberal episiotomy under local
infiltration with 1% lignocaine.
First baby delivered in the usual
manner as if it were a singleton.
Cord is clamped immediately at
both fetal & placental ends to
prevent acute intrapartum
transfusion.
IV oxytocics shouldn’t be given at
this point as it can cause
entrapment and asphyxia of
second twin.

13. •
Palpate abdomen immediately
to ensure lie,presentation.
•
If required-ultrasound
examination done.
•
Vaginal examination is also
done to exclude cord prolapse.
•
Acceptable interval between
deliveries – 30 mins

14. Vertex or breech is presenting,& is
in pelvis,good contractionsARM
done,second fetus descends
rapidly.
If contractions are
inadequate,oxytocin given for
augmentation, then amniotomy done.
IF VERTEX is low donforceps can be
applied
High up-r/o CPD, hydrocephalusafter
excluding these,internal version & breech
extcn under GA
BREECH-delivery compltd by
breech extraction

15. 
Indications are : -

Severe vaginal bleeding

Cord prolapse of second
baby

Inadvertent use of iv
ergometrine with the
delivery of anterior
shoulders of first baby

Appearance of fetal distress

16. 2
options

External version

Internal podalic
version and breech
extraction

18. 
Internal podalic version is used only
for second twin when it is lying
transversely.

Useful when immediate delivery of
second fetus is needed as in cord
prolapse or abruption.

Performed in operation theatre under
GA

PrerequisitesMembranes intact
Uterus relaxing between pains
Cervix completely dilated
Under GA
1.
2.
3.
4.

19.  Contraindications
 Obstructed
labour
 Membranes ruptured with all
liquor drained
 Previous CS
 Contracted pelvis
 Complications
Rupture uterus
 Anaesthetic risks
 Atonic pph due to use of uterine
relaxants
 Birth asphyxia & birth trauma


20. Gen anaesthesia-hand
ruptures membranes &
introduced into uterine
cavity
This hand identifies and grasps
the foot and gives traction
Other hand kept on the uterine
fundus to provide assistance
from above
Manual removal of placenta, iv
ergometrine, episiotomy
suturing

21. Twin
1st twin
non vertex
1st twin vertex
Caesarean section
vaginal delivery of first twin
assess lie of second twin
Vertex
Vaginal delivery
Vertex
Vaginal
delivery
breech
assisted breech
delivery
transverse lie
external version
breech
assisted breech
delivery
unsuccessful
intact membrane
IP version & breech
extraction
ruptured
membrane
CS

22. 
Cross matched blood should be
readily available.

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
completeness, confirm
chorionicity.