Approach to delivery of the second twin after birth of the first twin

There is no maximum time interval between birth of the first and second twin as long as the FHR pattern is reassuring. Electronic FHR monitoring and real-time ultrasound enable identification of second twins who would benefit from expedited delivery, while allowing most cases to be managed expectantly.

ROM: rupture of membranes; FHR: fetal heart rate.

* Refer to UpToDate content on breech extraction of the second twin for procedural guidance (eg, ultrasound, uterine relaxation, maternal analgesia).

¶ Refer to UpToDate content on ECV of the second twin for procedural guidance. Membranes should be left intact. Data confirming the safety of an attempt at version with ruptured membranes are not available, though with fetal monitoring and the capability to perform breech extraction or cesarean birth immediately, we consider it an option.

Δ When the head is engaged, we perform artificial rupture of membranes during a contraction to facilitate delivery. One approach used by some providers when the head is not engaged is to perform a controlled needle puncture of the amniotic sac between contractions to allow slow leaking of amniotic fluid and facilitate descent while reducing the risk of umbilical cord prolapse.

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Approach to delivery of the second twin after birth of the first twin