6.2 Twin pregnancy

Simultaneous development of two foetuses in the uterine cavity.
More than two foetus can exceptionally develop in the uterine cavity.  

6.2.1 Diagnosis

– The diagnosis is suspected in the second half of pregnancy when the uterus is abnormally large.
– Two poles of the same type (e.g., two heads) or three poles are felt.
– Two distinct foetal heart tones are heard.
– The diagnosis can be confirmed by ultrasound.

6.2.2 Management during pregnancy

Close monitoring, more frequent antenatal consultations, screening for and management of complications such as anaemia, placenta praevia, prematurity, and pre-eclampsia.

6.2.3 Management during delivery

Twin deliveries (and all multiple deliveries) should take place in a CEmONC facility, if possible.

Delivering the first twin

– Insert an IV line before expulsion starts.
– Deliver the first twin in the same way as a singleton.
– When the cord is cut, leave a clamp on the placenta side, as there may be an anastomosis with the second twin's circulation.
– Never administer oxytocin for active management of the third stage of labour before the second twin is delivered.
– Vaginal delivery is possible when the first twin is breech. Twins who are locked at the chin is a rare complication, seen when the first twin is breech and the second vertex. If this occurs, attempt to continue the vaginal delivery. The mortality and morbidity among such twins is high.

– External version is contra-indicated.
– If the first twin is in a transverse lie (unusual): schedule a caesarean section.

Rest period

– Usually 15 minutes; should not exceed 30 minutes. Take advantage of the pause in contractions to study the presentation of the second twin.
– Immediately after delivery of the first twin, an assistant should hold the second twin in a vertical position by placing hands laterally on either side of the uterus. This is done to prevent the foetus from assuming a transverse lie, in the now too large uterus.
– Continue heart rate monitoring of the second twin. In the event of abnormal heart rate, expedite delivery of the second twin.
– If the presentation is normal, as well as the foetal heart rate, await spontaneous delivery.

– If contractions have not resumed after 15 to 30 minutes, administer an escalating-dose oxytocin infusion (Chapter 7, Section 7.4) to speed up the birth of the second twin.

Delivering the second twin

– If presentation of the second twin is longitudinal (vertex or breech): proceed as with a normal vertex or breech delivery. Delivery of the second twin is usually faster. 
– For a transverse lie, attempt external version (Chapter 7, Section 7.7) or perform internal version (Chapter 7, Section 7.8) if conditions are favourable (full dilation, soft uterus) to bring the foetus to a breech position, then perform total breech extraction (Section 6.3).
Note: in case of multiple pregnancies with more than two fetuses, proceed as with second twin.  

Delivering the placenta

– After the second twin is born, administer:
• oxytocin routinely: 5 to 10 IU by IM or slow IV
• cefazolin or ampicillin slow IV1 : 2 g single dose if internal manoeuvres were performed.
– There is a significant risk of haemorrhage due to uterine atony. If there is any doubt, perform manual removal of placenta and/or uterine cavity exploration.

Ref Notes

For patients with a history of immediate hypersensitivity reaction to penicillin (urticaria, respiratory problems or oedema): clindamycin IV 900 mg single dose + gentamicin IV 5 mg/kg single dose.