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OB Guideline 22: Management of Twins


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The clinician and the patient should have a discussion about the delivery options during the antenatal period and that discussion should be documented in the medical record. An example of a specific written consent is available in Appendix F.

Timing of Delivery

Dichorionic twin pregnancies should usually be delivered after the end of the 37th week, and not later than their due date. Monochorionic diamniotic twins should be delivered no later than 37 weeks gestation. Prior assessment of fetal lung maturity is not required for such cases.1

Intrapartum Considerations

  1. The obstetrical care provider should evaluate and document fetal presentations.
  2. Continuously monitor (via EFM) both fetuses throughout active labor and delivery.
  3. Intravenous access should be established.
  4. Pain relief remains the patient’s choice.
  5. Sufficient personnel should be available to care for the mother and each baby.
  6. An ultrasound should be available throughout the delivery to confirm presentation and, if necessary, to document the fetal heart rate.
  7. Cesarean delivery is indicated for twin pregnancies with a non-vertex presenting twin unless vaginal delivery is imminent.

After Vaginal Delivery of the First Twin

  1. When monitoring indicates a Category I or II intrapartum fetal heart rate, there is no urgency to deliver the second twin (delivery interval does not appear to affect perinatal outcome).
  2. If the second twin is not in a vertex presentation, an obstetrician skilled in vaginal breech delivery should be available.
  3. Total breech extraction, assisted breech delivery, cesarean delivery, and attempted external cephalic version are all acceptable approaches to the delivery of a breech second twin. Vaginal breech delivery is not recommended in the presence of significant discordance (i.e., second twin larger than first). Previous ultrasound (within 2–4 weeks of labor) can be valuable in determining discordance.

  1. Multiple gestation: complicated twin, triplet, and high-order multifetal pregnancy. ACOG Practice Bulletin No. 56. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2004;104:869–83.


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May 1, 2014
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