Twin Delivery

Women who are pregnant with twins will usually have be given the choice to deliver vaginally, if certain criteria are met, or by C-section. Twin labours are managed differently from singleton gestations.

Preterm delivery is much more likely, and the median time of delivery for twins is about a month before the due date (36 weeks). The management of preterm labour in twins before 34-36 weeks will be individualized. The following labour protocol applies to pregnancies that have reached a minimum of about 34 weeks.

A vaginal delivery will typically be possible when the presenting twin (Twin A) is head first. When Twin A is breech, a C-section will usually be advised. If the second twin (Twin B) is much larger than Twin A, a C-section might also be recommended.

Women can follow the flowchart above to determine when to come to the hospital in labour, but should err on the side of coming early. Once admitted, they will labour in the high-risk LDR area in TACC. Because delivery of Twin B may require manipulations or the assistance of instruments, it is recommended that women have an epidural placed when they are in active labour.

Continuous fetal monitoring by EFM is advised. When there is difficulty in differentiating between the two fetal heart rates, a scalp electrode or FECG may need to be placed on the head of Twin A.

Delivery might take place in our specialized twin delivery room, or in the OR, depending on the circumstances.

Delivery of Twin A is usually quite similar to delivery of a singleton. After Twin A is born, there is some urgency for Twin B to be born. This is because complications can happen between delivery of the twins (eg. placental separation, umbilical cord compression). If there has been too much time in between, the cervix may no longer be fully dilated, and an emergency C-section for the second twin could become necessary. To avoid this situation, most OBs will actively manage the second twin. If Twin B is head first, this may involve oxytocin to increase contractions, rupture of Twin B’s membranes, and on-going active pushing by the mother. Once Twin B’s head is low enough, assistance with forceps or the vacuum can be provided where necessary. If Twin B is breech or lying sideways, it will be pulled out by the feet (breech extraction). Special forceps (Piper forceps) are available in case Twin B’s head gets stuck. This is unlikely to happen when Twin B is similar in size or smaller than Twin A.

The placentas will come out after both twins have been born. Women with twins are at higher risk for postpartum hemorrhage, and active measures will be taken to mitigate this risk.