Many women with twin pregnancies will undergo cesarean delivery. In the US, approximately 75% of all twin births are born via cesarean delivery. However, with the use of breech extraction of the second twin, more twins can be delivered vaginally, and safely.
In the setting of a breech (bottom first) or transverse presenting first twin, cesarean delivery is recommended. In the setting of a cephalic-presenting (head-first) first twin, vaginal delivery may be a reasonable delivery option. In our practice, all women with twin pregnancies also have the option of elective cesarean delivery, regardless of fetal position.
Retrospective studies comparing planned vaginal delivery to planned cesarean delivery in twins have been mixed in regards to neonatal outcomes. However, these studies are limited due to selection bias and poor data collection.
A recent well-designed, international, multicentered, prospective, randomized clinical trial examining delivery mode for twin pregnancies showed no difference in severe neonatal morbidity at 28 days of life-based on planned mode of delivery (Barrett et al NEJM 2013). This study included 2,804 women with dichorionic or monochorionic twins with a cephalic-presenting (head-first) first twin. This study supports the safety of vaginal delivery of twins.
For women attempting vaginal delivery of twins, there is a risk of cesarean delivery during labor. There is also the risk of a vaginal delivery of Twin A followed by a cesarean delivery of Twin B. This risk is usually approximately 5-10%, but with doctors experienced with twin deliveries and breech extraction of the second twin, it can be as low as less than 1%, which is what we have published from our own series of patients.
We recommend that all twins have regional anesthesia (epidural) and continuous fetal monitoring during their labor and delivery. It is our practice to deliver all twins in an operating room. All twin pregnancies, regardless of the mode of delivery, have an increased risk of postpartum hemorrhage and preeclampsia, which may delay transfer off of the labor floor after delivery.
Maternal Fetal Medicine blogs are intended for educational purposes only and do not replace certified professional care. Medical conditions vary and change frequently. Please ask your doctor any questions you may have regarding your condition to receive a proper diagnosis or risk analysis. Thank you!