AN UP-TO DATE LOOK AT THE MODE OF DELIVERY IN DIAMNIOTIC TWIN PREGNANCIES
Keywords:
twins, vaginal delivery of second twinAbstract
After the introduction of assisted reproduction methods more than fourty years ago, the incidence of twin pregnancies has increased significantly worldwide. This makes the issues related to childbirth in these patients extremely relevant. The mode of delivery in twin pregnancy depends on multiple factors and is very controversial in the literature. The most important factors to be considered on deciding the delivery mode are the fetus presentation, especially the first twin, fetal weight, weight difference between the fetuses, gestational weight and maternal clinical conditions. Nulliparity and non-vertex presentation of the second twin were found to be independently associated with cesarean delivery for both twins. It is important to consider that indications for a cesarean section in singleton pregnancies should also be applied in multiple pregnancies. The decision on mode of delivery must consider the best neonatal and maternal outcomes. The biggest risk in a vaginal delivery is for the second twin, as complications can occur after the delivery of the first twin, including placental abruption or umbilical cord prolapse. According to some studies vertex-first twins born between 32 and 37 gestational weeks by planned caesareans as compared to vaginal deliveries had higher neonatal mortality and morbidity rates, while other randomized trials has proven, that in twin pregnancy between 32 weeks 0 days and 38 weeks 6 days of gestation, with the first twin in the cephalic presentation, planned cesarean delivery did not significantly decrease or increase the risk of fetal or neonatal death or serious neonatal morbidity, as compared with planned vaginal delivery. The American College of Obstetricians and Gynecologists also recommends that in diamniotic twin pregnancies at 32 0/7 weeks of gestation or later with a presenting fetus that is vertex, regardless of the presentation of the second twin, vaginal delivery is a reasonable option and should be considered, provided that an obstetrician with experience in internal podalic version and vaginal breech delivery is available. Unfortionately, because of the rising rate of cesarean deliveries in twin pregnancies combined with decline in operative obstetrics, the number of obstetricians skilled in vaginal deliveries of twins is constantly decreasing. Most obstetricians would prefer a cesarean delivery when the second twin is not in a cephalic presentation. Efforts are needed to improve the skills of obstetricians in conducting normal deliveries in twins in order to change the trend of excessive use of cesarean section as a method of delivery in twin pregnancies
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