CLINICAL OBSTETRICS AND GYNECOLOGY

Volume 58, Number 3, 690702

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Multifetal Gestation:
Mode of Delivery
MARTHA MONSON, MD, and ROBERT M. SILVER, MD
Department of Obstetrics and Gynecology, University of Utah
Health Care, Salt Lake City, Utah
Abstract: The incidence of twin, triplet, and higherorder multifetal gestations, has increased dramatically
in the recent years. Rates of cesarean delivery for
multiple gestations also have risen, largely due to the
perception that cesarean delivery improves neonatal
outcomes. Until recently, data to support the best
mode of delivery for multifetal gestations was lacking.
However, recent high-quality retrospective studies
and a prospective randomized trial now offer the
obstetrician guidance as to the optimal intrapartum
management of women with multiple gestations.
Key words: multiple gestation, cesarean delivery,
breech delivery, TOLAC, twin delivery, triplet
delivery

Introduction
The advent of assisted reproductive
technology has brought about a significant increase in the number of multifetal
gestations in the United States. Concomitantly, there has been an increase in the
number of cesarean deliveries performed
in the United States including those performed for multiple gestations.1 Indeed,
there has been a steady rise in the cesarean
delivery rate for twins, which increased
Correspondence: Robert M. Silver, MD, Department of
Obstetrics and Gynecology, Division of Maternal Fetal
Medicine, University of Utah Healthcare, Room
2B200, Salt Lake City, UT. E-mail: bob.silver@hsc.
utah.edu
The authors declare that they have nothing to disclose.
CLINICAL OBSTETRICS AND GYNECOLOGY

from 53.4% in 1995 to 75% in 2008.2 In

addition, the overall rate of cesarean delivery in the United States for triplets is
estimated to be approximately 95%.3 The
reason for the increase in cesarean deliveries for multiple gestations is unclear but
appears to be due, in part, to a perception
that vaginal delivery increases the risk of
adverse outcomes, particularly for the
after-coming twin or multiple. In turn,
as the rate of vaginal delivery of twins
decreases, newer providers are not being
adequately trained in techniques such as
breech extraction, furthering the trend
toward cesarean delivery.
Cesarean delivery, however, has considerable short-term and long-term risks.
Short-term maternal risks include infection, hemorrhage, venous thromboembolism, increased recovery time compared
with vaginal delivery, and even death.4
Neonates delivered by cesarean have an
increased rate of respiratory problems
including transient tachypnea of the newborn. Long-term risks affect the mother
and fetus in subsequent pregnancies. The
most important are risks associated with
trial of labor after cesarean delivery and
the risk for morbidly adherent placentation (eg, placenta accreta) in subsequent
pregnancies. The incidence of placenta
accreta has increased from 0.8 per 1000
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NUMBER 3

SEPTEMBER 2015

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Multifetal Gestation
to 3 per 1000 over the past 20 years in the
setting of an increased cesarean rate.4
This diagnosis carries with it the need
for cesarean hysterectomy, probable and
possibly massive blood transfusion, and a
marked risk for maternal morbidity and
even mortality.4 Each cesarean delivery
exponentially increases the chance for
abnormal placentation in later pregnancies.4 Finally, cesarean delivery is considerably more expensive than vaginal
delivery.
Accordingly, it is worthwhile to determine the optimal route of delivery for
multifetal gestations. Until recently, relatively few studies evaluated the safety of
vaginal delivery for the second twin. In
the past 20 years, numerous retrospective
studies and a recent randomized-controlled trial (RCT) provided valuable data
and guidance for determining the appropriate mode of delivery. We will examine
the intrapartum risks associated with
multiples including twins and higher-order multifetal gestations. We will then
evaluate available data regarding optimal
modes of delivery for multiple gestations
and provide a framework for clinicians to
use in their counseling and decision
making.

Twin Gestation
INTRAPARTUM RISKS: GENERAL
CONSIDERATIONS

Intrapartum management of twins poses

multiple challenges including difficulty in
continuous monitoring of each fetal heart
rate. In addition, there are considerable
risks at the time of delivery, particularly
for the after-coming twin during the interval between delivery of the first and
second twin. These include placental
abruption before delivery of the second
twin and increased risk for malpresentation or compound presentation with cord
prolapse or occlusion. These complications may result in the need for an urgent

691

or emergent operative vaginal or cesarean

delivery. To optimally manage these
problems, it is now considered the standard of care in high-income countries to
deliver twins in an operating room setting
with the capacity to perform an emergent
operative delivery. Maternal risks include
exhaustion from having a prolonged the
second stage, the need for operative delivery for the after-coming twin, and postpartum hemorrhage.
In addition, there may be an increased
risk associated with breech extraction of
the second twin. Vaginal breech deliveries
may lead to increased fetal or neonatal
morbidity through 2 mechanisms. First,
there is an increased risk of cord occlusion
as noted previously. In theory, this is
ameliorated by the relatively rapid delivery of the second twin as delivery is not
dependent upon maternal expulsive efforts. Second, and most worrisome, is
the risk for delivery of the fetal body with
entrapment of the after-coming head.
This may lead to hypoxia and in severe
cases, stillbirth, neonatal death, and/or
hypoxic ischemic encephalopathy.
MODE OF DELIVERY

Twin gestation in isolation is not an indication for cesarean delivery. The classic
generally accepted indications for cesarean delivery for singleton pregnancies
should apply for multifetal gestations as
well (eg, placenta previa, abnormal fetal
heart rate tracings, and maternal contraindication to labor). In the setting of twin
gestation, a trial of labor is relatively
contraindicated for monoamniotic twin
gestation given the risk for cord entanglement, and many elect cesarean delivery
for the breech presenting first twin. In the
absence of the aforementioned clinical
scenarios and in the setting of twin A with
a vertex presentation, a trial of labor may
be considered. Indeed, this includes most
twins:
 Cephalic/cephalic: 40%
 Cephalic/noncephalic: 32%
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692

Monson and Silver

 Breech/any position: 8%
 Noncephalic presentations of both
twins increase with decreasing gestational age.
RISK OF ADVERSE PERINATAL
OUTCOMES: ROUTE OF DELIVERY

When evaluating available data regarding

route of delivery and twins, several issues
deserve consideration. First, the presentation of each twin has tremendous influence on the safety of vaginal delivery.
Gestational age, parity, fetal size, and
comorbid conditions are other important
variables. Second, it is crucial (when possible) to compare intended vaginal delivery with intended cesarean delivery. In
many cases, intended vaginal deliveries
may result in cesareans. Thus, comparing
actual vaginal and cesarean deliveries
may mistakenly attribute to risk associated with vaginal delivery to cesarean.
Several retrospective studies supported
the notion that cesarean delivery decreases the risk of intrapartum complications, in particular, for the second twin.
Two large retrospective cohorts of twins
from Scotland evaluated the risk for perinatal death and other intrapartum complications, based on the route of delivery.
The first cohort included twin deliveries
>24 weeks gestation between 1992 and
1997.5 There was no difference in intrapartum or neonatal death between the
first and second twin among 1438 twins
delivered before 36 weeks gestation.5
However, results differed for the 2436
twins delivered after 36 weeks gestation.
No deaths occurred in the first twin, but
there were 9 deaths of the second twin
(P = 0.004). Of these, 7 were due to anoxia and 5 were associated with mechanical problems at the time of delivery.
There were no deaths among the 454
scheduled cesarean deliveries.5 The second study focused on perinatal death
among twins born at >36 weeks gestation in Scotland between 1985 and 2001.6
Outcomes of the first and second twin

were compared with mode of delivery

assessed with linear regression. Of 8076
subjects, there were 6 deaths of the first
twin and 30 deaths of the second twin
generating an odds ratio (OR) for death
in the second twin of 5.0 [95% confidence
interval (CI), 2.0-14.7] and OR for death
of the second twin due to anoxia of 21.0
(95% CI, 3.4-868.5). In contrast, there
was no association between birth order
and death in twins delivered by planned
cesarean delivery (1472/8076; 18.2%).
Smith et al6 estimated that 264 cesarean
sections would need to be performed to
prevent a single neonatal or perinatal
death. Deaths due to fetal anomaly, antepartum stillbirth, or twin to twin transfusion syndrome were excluded in both of
these cohorts. These data strongly suggest
that cesarean delivery improves outcomes
for the second twin in term gestations.
However, relatively few details were available regarding each case and data were
not assessed by intention-totreat.
Another retrospective cohort study
based in Denmark evaluated 1175 twin
deliveries at >36 weeks gestation from
2004 to 2006, and assessed pregnancy
outcomes according to chorionicity and
mode of delivery.7 Primary outcomes included 5-minute Apgar score r7, umbilical artery pH<7.10, neonatal intensive
care unit admission of >3 days, and death.
These outcomes were evaluated separately and pooled together as poor outcome. Dichorionic twins with planned
vaginal delivery (n = 689) compared with
dichorionic twins with planned cesarean
delivery (n = 371) exhibited an increased
risk of poor neonatal outcome [OR =
1.47 (95% CI, 1.02-2.13), P = 0.037].
Conversely, there was no difference in
outcomes with monochorionic twins
when comparing delivery modes. Nulliparity and birthweight discordance of
>300 g increased the risk of poor outcome
in dichorionic and monochorionic twins
[OR = 1.5 (95% CI, 1.0-2.0), P = 0.032
and OR = 4.0 (95% CI, 1.2-14.0),

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Multifetal Gestation
P = 0.021 for nulliparity in dichorionic
and monochorionic twins, respectively,
OR = 1.5 (95% CI, 1.1-2.2), P = 0.019
and OR = 6.0 (95% CI, 1.8-19.8),
P = 0.002 for birthweight discordance in
dichorionic and monochorionic twins, respectively]. For dichorionic twins there was
a significantly higher risk of poor outcome
for the second born twin compared with the
first (OR = 1.64, P = 0.001).
Another important study was conducted
by Armson et al8 from 1988 to 2002 in
Nova Scotia. They also evaluated twin
deliveries and assessed neonatal outcomes
for second twins, stratified by mode of
delivery. Their results were similar to the
Denmark cohort, with a higher risk of poor
outcomes for second born twin compared
with the first. A total of 1542 twin pair
deliveries at >37 weeks were evaluated
with a composite outcome of perinatal
mortality, birth asphyxia, respiratory distress syndrome, birth trauma, and infection. Monoamniotic twins, conjoined or
anomalous twins, and antepartum stillbirth were excluded. Relative risk (RR)
for the composite adverse outcome in the
second twin was noted to be 1.62 (95% CI,
1.381.9) and was associated with planned
vaginal delivery, birthweight discordance,
and prolonged interdelivery interval. Risk
appeared to be independent of chorionicity, presentation or fetal sex. In this study,
the term second twin encountered less risk
when delivered by elective cesarean with an
RR = 1.0 (95% CI, 0.14-7.10) compared
with planned vaginal delivery (RR = 3.0;
95% CI, 1.47-6.11). Birth asphyxia and
respiratory distress syndrome were major
contributors to the neonatal morbidity in
the second twin. Armson et al8 estimated
that 33 cesarean deliveries would need to be
performed to prevent a single adverse perinatal outcome. This study further supports
improved outcomes for the second twin
with cesarean delivery. However, these
studies are hampered by small numbers
and the bias inherent in retrospective
analyses.

693

Recently, Peaceman et al9 used United

States Vital Statistics data to address the
safety of vaginal delivery in a very large
cohort of twins between 1995 and 2000,
albeit retrospectively. A total of 450,504
infants at >30 weeks gestation and
weighing >1500 g were identified for
analysis, after excluding higher-order
multifetal gestation, maternal complications such as pregnancy-induced hypertension, diabetes, placenta previa,
abruption, and fetal distress. The analysis
was stratified by presentation (vertex/
vertex and vertex/nonvertex-presenting
twins) and mode of delivery (eg, vaginal
vs. cesarean delivery). Vertex/vertex and
vertex/nonvertex groups were then evaluated for infant outcome including Apgar
score, ventilation requirement, birth
injury, seizure, and infant death during
the first year of life. Composite adverse
outcome was defined as Apgar score r3
at 5 minutes, seizure, birth injury, or infant death (Table 1).
There was no increase in the composite
adverse outcome for vertex/vertex-presenting twins when comparing vaginal to
cesarean delivery. Vaginal delivery was
associated with a small increase in the
incidence of a few specific adverse neonatal outcomes such as 5-minute Apgar
score r3, ventilation for <30 minutes,
and birth injury. However, it was not
associated with seizure or infant death.
The subgroup of infants delivered at Z34
weeks gestation also was assessed, and
were largely consistent with the results for
the entire group (Table 2); thus the overall
study findings do not appear to be dependent on gestational age. The authors
also evaluated outcomes for discordant
twin growth, with a focus on cases where
the second twin was larger than the presenting twin. Importantly, there was no
increase in adverse neonatal outcomes
when the birthweight of the second twin
surpassed that of the presenting twin by
Z25% in vertex/vertex and vertex/nonvertex presentations.9
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Monson and Silver

TABLE 1.

Infant Outcomes by Presentation of Twin Set and Method of Delivery

Vertex/Vertex

Vertex/Nonvertex

Vaginal
Both Cesarean Vaginal Delivery Both Cesarean Delivery
(n = 129,340) (n = 179,480)
(n = 18,060)
(n = 27,088)

Outcomes (%)

Apgar score r3 at 5 min

Ventilation, <30 min
Ventilation, Z30 min
Birth injury
Seizure
Infant death
Composite of Apgar score r3 at 5 min,
birth injury, seizure, or infant death

0.1
2.6
1.9
0.1
0
0.6
0.7

0.2
2.9*
1.6*
0.1*
0
0.5w
0.8

0.1
4.5
3.2
0.1
0.1
0.5
0.6

0.3*
5.2*
2.8w
0.5*
0.1
0.6
1.3*

*P<0.001.
w P<0.01.
Used with permission from Peaceman et al.9

Another recent retrospective cohort

trial evaluated delivery outcomes in New
York in a single busy practice between
2005 and 2009 in twin pregnancies undergoing planned labor with active management of the second stage compared with
planned cesarean delivery.10 Standardized protocols for second stage management were used including breech
extraction of the second nonvertex twin
and internal podalic version followed by
breech extraction of the second twin
should the twin be vertex but unengaged
following delivery of the presenting twin.
TABLE 2.

The primary outcome was 5-minute Apgar score <7 for the second twin. Secondary outcomes included 5-minute Apgar
score <7 for the first twin, and 1-minute
Apgar score <7 and arterial cord
pH<7.2 for either twin. A total of 287
twin pregnancies were evaluated, 130
(45.3%) of which underwent a planned
trial of labor. There were no significant
differences in outcomes between delivery
groups. Cesarean delivery rate for the
planned trial of labor group was 15%. It
is noteworthy that no cesarean deliveries
were performed for the second twin

Infant Outcomes for Infants Delivered at Z34 Weeks Gestation

Vertex/Vertex

Outcomes (%)

Apgar score r3 at 5 min

Ventilation, <30 min
Ventilation, Z30 min
Birth injury
Seizure
Infant death
Composite of Apgar score r3 at 5 min,
birth injury, seizure, or infant death

Vertex/Nonvertex

Vaginal
Both Cesarean Vaginal Delivery Both Cesarean Delivery
(n = 116,820) (n = 163,565)
(n = 15,969)
(n = 24,335)

0.1
2.4
1.1
0.1
0
0.4
0.6

0.2*
2.8*
1.1
0.1*
0
0.4
0.7*

0.0
4.1
2.0
0.1
0.1
0.4
0.5

0.2*
5.0*
1.8
0.5*
0.1
0.4
1.2*

*P<0.001.
Used with permission from Peaceman et al.9

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Multifetal Gestation
following vaginal delivery of the first
twin. Young maternal age and prior vaginal delivery were patient factors associated with successful vaginal delivery.
PLANNED VAGINAL OR CESAREAN
DELIVERY: RCT

As stated previously, few RCTs have been

conducted to determine the safest mode of
delivery for the multifetal gestation. One
small, prospective RCT was conducted in
Israel from 1983 to 1985 for twin pregnancies >35 weeks with vertex/non
vertex-presenting twins.11 Thirty-three
women were randomized to a planned
vaginal delivery and 27 to a planned
cesarean. The primary outcome included
maternal and fetal morbidity and mortality. Four vaginal births occurred in the
planned cesarean delivery group due to
the second twin spontaneously converting
to vertex presentation. Two cesareans
were performed for the vaginal delivery
group. Ultimately there were no differences in adverse neonatal outcomes for
the second twin regardless of delivery
mode. However, the first twin had fewer
low Apgar scores compared with the second twin with both routes of delivery.
There was an increase in maternal febrile
morbidity in the cesarean compared with
the vaginal delivery group (40.5% vs.
11.1%, P<0.05). Of course the study
had insufficient sample size to assess
meaningful morbidity associated with
vaginal delivery.
A recent, large, prospective multicenter, multinational RCT conducted by
Barrett et al12 from 2003 to 2011 (Twin
Birth Study) sought to answer the same
clinical question regarding safest mode of
delivery for twin gestations. A total of
1398 women with 2795 fetuses between
32 and 38 6/7 weeks gestation were
randomized to a planned vaginal or cesarean delivery. The presenting twin was
required to be in the cephalic presentation
with estimated fetal weight for each twin
of 1500 to 4000 g. Primary outcomes

695

included a composite of fetal or neonatal

death, or serious neonatal morbidity defined as birth trauma, Apgar of <4 at
5 minutes, coma (abnormal level of consciousness), seizures, need for ventilation,
sepsis, necrotizing enterocolitis, bronchopulmonary dysplasia, grade III or IV
intraventricular hemorrhage, or cystic
periventricular leukomalacia. Cesarean
delivery rate was 90.7% in the planned
cesarean delivery group and 43.8% in the
planned vaginal delivery group. Women
in the planned cesarean group delivered
earlier than those in the planned vaginal
delivery group (12.4 vs. 13.3 d from
randomization, P = 0.04). Planned subgroup analysis was also performed, with
stratification by parity, gestational age at
time of randomization, presentation of
the second twin, maternal age, chorionicity, and national perinatal mortality rate
in the mothers country of residence.
There was no significant difference in
the primary composite outcome between
planned cesarean or vaginal delivery
[2.2% vs. 1.9%, respectively, with OR of
1.16 for planned cesarean delivery (95%
CI, 0.77-1.74), P = 0.49] (Table 3). Maternal composite outcome also was similar between the planned cesarean and
vaginal delivery groups (7.3% vs. 8.5%,
P = 0.29). Planned subgroup analysis revealed no significant interactions for the
primary outcome between treatment
group and the aforementioned variables.
Of note, as shown in other studies, the
second twin was more likely to have the
primary outcome compared with the presenting twin [OR = 1.90 (95% CI, 1.342.69), P<0.001], but this was not related
to treatment group (OR for presenting
twin 1.3, OR for second twin 1.09,
P = 0.63). Ultimately, there was no benefit of planned cesarean delivery for twins
delivered between 32 and 38 weeks gestation with a vertex first twin. An important limitation of this study is the
relatively limited number of term infants
included (just under half of the study
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Monson and Silver

TABLE 3.

Fetal or Neonatal Outcomes

Planned
Cesarean
Delivery

Outcomes

Fetal or neonatal death or serious neonatal morbidity

No. fetuses or infants included in analysis
2783
Composite primary outcomes [n (%)]*
60 (2.2)
Gestational age at randomization [n/N (%)]
32 wk 0 d to 33 wk 6 dw
32/948 (3.4)
34 wk 0 d to 36 wk 6 d
26/1358
(1.9)
37 wk 0 d to 38 wk 6 d
2/477 (0.4)
Death [n (%)]z
24 (0.9)
Fetal death
13 (0.5)
Before the onset of labor
11 (0.4)
During delivery
0
Unknown
2 (0.1)
Neonatal death
11 (0.4)
Serious neonatal morbidity [n (%)]z
36 (1.3)
Neonatal morbidity, excluding death of either twin
No. infants included in the analysis
2759
Birth trauma [n (%)]
Long-bone fracturez
0
Other bone fracture
1 (<0.1)
Facial-nerve injury at 72 h of age or at
0
dischargez
Intracerebral hemorrhagez
3 (0.1)
Apgar score <4 at 5 min [n (%)]z
2 (0.1)
Abnormal level of consciousness [n (%)]
Comaz
0
Stupor or decreased response to painz
2 (0.1)
Hyperalert, drowsy, or lethargic
9 (0.3)
Z2 seizures within 72 h after birth [n (%)]z
3 (0.1)
27 (1.0)
Assisted ventilation for Z24 h by means of
endotracheal tube, inserted within 72 h after birth
[n (%)]z
Neonatal sepsis within 72 h after birth [n (%)]z
1 (<0.1)
Necrotizing enterocolitis [n (%)]
1 (<0.1)
Cystic periventricular leukomalacia [n (%)]z
2 (0.1)

Planned
Vaginal
Delivery

Odds Ratio
(95% Confidence
Interval)

2782
52 (1.9)

1.16 (0.77-1.74)

0.49

26/956 (2.7) 1.25 (0.70-2.24)

19/1326
1.34 (0.71-2.54)
(1.4)
7/500 (1.4) 0.30 (0.06-1.43)
17 (0.6)
9 (0.3)
8 (0.3)
1 (<0.1)
0
8 (0.3)
35 (1.3)
2765
4 (0.1)
1 (<0.1)
1 (<0.1)
1 (<0.1)
7 (0.3)
1 (<0.1)
0
7 (0.3)
3 (0.1)
17 (0.6)
2 (0.1)
3 (0.1)
0

*The composite primary outcome was fetal or neonatal death or serious neonatal morbidity. The probabilities of interaction
between treatment group and baseline variables for the composite primary outcome were as follows: parity (0 vs. Z1, P = 0.23);
gestational age at randomization (32 wk 0 d to 33 wk 6 d, 34 wk 0 d to 36 wk 6 d, or 37 wk 0 d to 38 wk 6 d, P = 0.18); maternal age
(<30 vs. Z30 y, P = 0.63); presentation of second twin (cephalic vs. noncephalic, P = 0.51); chorionicity (dichorionic vs.
monochorionic, P = 0.15); and national perinatal mortality in the mothers country of residence (<15 deaths per 1000 births, 15
to 20 deaths per 1000 births, or >20 deaths per 1000 births, P = 0.50). There were no infants with spinal cord injury, basal or
depressed skull fracture, subdural hematoma, meningitis, grade 3 or 4 intraventricular hemorrhage, or bronchopulmonary
dysplasia in either group.
w Two infants (from 1 pregnancy) whose mother underwent randomization at 31 weeks of gestational age were included in the
gestational age category of 32 to 33 weeks.
z This outcome was a component of the composite primary outcome.
Used with permission from Barrett et al.12

population was comprised of preterm infants). Additional caveats include the fact
that all deliveries were performed at an
institution where an emergent cesarean

could be performed within 30 minutes,

and all participating obstetric providers
were trained in vaginal breech extraction.
Nonetheless, these data are some of the

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Multifetal Gestation
TABLE 4.

Ingredients for Successful Trial

of Labor of Multiple Gestation

Delivery in operating room

Continuous electronic fetal monitoring
Intravenous access for administration of medicine
Experienced obstetric provider and assistants
Uterine relaxant agents (eg, nitroglycerin,
terbutaline)
Operating room team available to perform
immediate abdominal delivery
Bedside ultrasound to assess fetal position of
after-coming twin
Multidisciplinary team immediately available:
neonatology, anesthesia, nursing staff
Instrumentation for operative vaginal delivery
(eg, vacuum, Piper forceps, etc.)
Broken down bed allowing dorsal lithotomy
position and adequate room for obstetricians
Regional anesthesia (if desires)

highest quality information available and

can provide reassurance that planned vaginal delivery is a reasonable option for
many, if not most, women with twins after
32 weeks gestation if the first twin is in the
vertex presentation. Suggested criteria for
safe vaginal delivery of multiple gestations are shown in Table 4.
VERTEX/NONVERTEX TWINS:
EXTERNAL CEPHALIC VERSION (ECV)
OF TWIN B

If clinicians are uncomfortable with

breech extraction, another acceptable option in cases of nonvertex twin B is ECV of
twin B. This procedure was popular in the
1980s and has about 50% to 70% success
rate.13,14 As with all twin deliveries, it is
typically performed in an operating room
setting with the capacity to do an emergent cesarean delivery. However, in
addition to frequent failure, it often is
associated with complications such as cord
prolapse/occlusion, malpresentation, compound presentation, and abruption.13,14
Because of higher success and lower complication rates,13,14 breech extraction is
strongly preferable to ECV of twin B.
Nonetheless, it may allow for reasonably

697

safe vaginal delivery if breech extraction is

not an option.
OTHER CONSIDERATIONS

Most authorities agree that if twin A is not

vertex, cesarean delivery is preferred. This
is because of the theoretical risk of
locked twins, if twin A is breech and
twin B is vertex. Although data proving
the superiority of cesarean are lacking,
there are too few cases of successful vaginal delivery to recommend a trial of labor
if twin A is anything other than vertex.
If twins are born prematurely, there is a
theoretical increase in the risk of head
entrapment. Infants <32 weeks gestation may deliver through an incompletely
dilated cervix, even in the vertex presentation. In turn, this increases the risk of
head entrapment of a nonvertex twin B.
This has not been proven in appropriate
trials, but the reasoning is sound enough
so that most authorities advise cesarean
delivery if the twins are <1500 g. As there
is considerable error in the sonographic
estimation of fetal weight, most experts
advise allowing a trial of labor only if the
twins are >1800 g. Figure 1 depicts an
algorithm for determining the optimal
route of delivery of twins.
PREDICTION OF SAFE VAGINAL
DELIVERY WITH TWINS

Good clinical judgment is desirable when

selecting candidates for trial of labor in
the setting of a cephalic presenting first
twin. A prospective multicenter cohort
study conducted in Ireland from 2007 to
2009 evaluated 971 twin pairs to determine factors that may predict a successful
vaginal delivery.15 Monoamniotic twins,
anomalous twins, and twins with evidence
of aneuploidy were excluded from the
trial. A total of 441 of the 971 twin pairs
considered a trial of labor, 338 (76.6%) of
which had successful vaginal deliveries of
the first twin (4% cesarean rate for the
second twin). Successful vaginal delivery
and failed trial of labor groups were
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698

Monson and Silver

Non-Vtx A

Twins

Planned CD

No emergency
CD possible

Planned CD

Appropriate
Facility

TOL

Twin A < 2000

grams

Planned CD

Twin A > 2000

grams

No emergency
CD / trained
provider

Vtx B

Vtx A

Non-Vtx B
Planned CD
Appropriate
facility / trained
provider

TOL

FIGURE 1. Algorithm to determine the optimal route of delivery for twins. CD indicates
cesarean delivery; TOL, trial of labor; Vtx, vertex presentation.

compared. Multiparity and spontaneous

conception predicted a successful vaginal
delivery. Factors that did not influence a
successful trial of labor included advancing gestational age, vertex presentation of
the second twin, and concordant growth
(even with >20% growth discordance
between the second and presenting twin).
TWIN-TWIN DELIVERY TIME

Apart from carefully selecting candidates

for a trial of labor in the setting of multifetal gestation and ensuring that appropriately trained personnel are available
for the delivery and capable of performing
an emergent cesarean in a timely manner.
Investigators have worked to identify other modifiable delivery factors that may
favorably impact neonatal outcomes. One
of these factors is the intertwin delivery
interval or twin to twin delivery time
(TDT). There are inherent intrapartum
risks for morbidity for the second twin
after delivery of the initial twin (eg, risk of
premature placental abruption, cord prolapsed, and occlusion). It has been speculated that a prolonged intertwin delivery
interval may increase the risk for adverse
neonatal outcomes and perinatal morbidity. Breech extraction and operative vaginal delivery have been used historically to
shorten the TDT, but data supporting a

validated safe or recommended TDT

has been lacking.
Leung et al16 conducted a retrospective
cohort study in Hong Kong over approximately 4.5 years at a single institution.
Twins >34 weeks gestation with vaginal
delivery of twin A were included and cases
with antepartum stillbirth, significant
growth discordance of >20%, preeclampsia, twin to twin transfusion syndrome, or fetal anomalies were excluded.
A total of 118 twin deliveries were included and TDT was assessed and correlated with umbilical cord blood gases. A
negative correlation was observed between arterial and venous pH, base excess
of the second twin, and TDT (P<0.05). A
positive correlation was also noted between arterial and venous partial pressure
of CO2 and TDT (P<0.05). Essentially,
as the TDT lengthened, the pH went
down and base excess and the CO2 both
rose for the second twin. It was noted that
the arterial pH was <7.0 in 0 cases with
TDT<15 minutes, 5.9% with TDT of 16
to 30 minutes, and 27% with TDT>30
minutes. In addition, for TDT>30 minutes, 73% had an abnormal fetal heart
rate tracing requiring operative delivery.
These authors concluded that the risks for
fetal acidosis and fetal distress were highest
for the second twin when the TDT interval

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Multifetal Gestation
exceeded 30 minutes based on cord blood
gases. However, neonatal outcomes and
thus clinical relevance was not evaluated
in this trial. In turn, it is hard to make
definitive clinical recommendations based
on these data. Conversely, the data indirectly support the use of breech extraction
to reduce the TDT.
A subsequent retrospective cohort
study performed in Austria from 1993 to
2002 by Schneuber et al17 also examined
the effect of TDT on neonatal outcomes
for the second twin. This study was conducted at a single institution and evaluated 207 otherwise uncomplicated twin
pairs at >34 weeks gestation following
vaginal delivery of the first twin. TDT and
neonatal outcomes for the second twin
(eg, umbilical artery pH, Apgar scores,
need for neonatal intensive care) were
assessed. The study population was divided into vertex/vertex presentation with
vaginal delivery of both twins (n = 151)
and vertex presentation with vaginal or
operative vaginal delivery of the first twin,
and breech or transverse presentation of
the second twin followed by vaginal
breech or cesarean delivery (n = 56).
There was no association between TDT
and neonatal outcomes for the vertex/
vertex vaginal delivery. In addition, there
were no significant associations between
TDT and adverse neonatal outcomes for
the latter group. There was, however, a
trend toward lower arterial pH and Apgar
score with increasing TDT. The authors
concluded that increased TDT was not
associated with increased adverse neonatal outcomes. Limitations of this study
include its small sample size, but it is
noteworthy that increased TDT was not
associated with adverse outcomes. A rational clinical approach using these studies would be to not place a ceiling on
TDT if the fetal heart rate tracing is
normal and there are no other complications. However, clinicians should be prepared for the unexpected onset of an
abnormal fetal heart rate tracing and

699

other complications in the setting of increased TDT. Having a low threshold for
intervention in those circumstances may
decrease the risk of a low cord pH.

Triplet Gestation
MODE OF DELIVERY: IS CESAREAN
THE STANDARD OF CARE?

Triplet pregnancies are the most common

type of higher-order multiple gestations.
Cesarean delivery is the most commonly
employed mode of delivery for triplets,
due to the concerns outlined previously
for twins. Indeed, over 95% of triplets are
delivered by cesarean in the United
States.3 However, data to support cesarean delivery as the only safe mode of
delivery has not been clearly established
and this should not be accepted as a
dogma. Unfortunately, quality data regarding the optimal route of delivery for
triplets are lacking and most information
is derived from small case series and retrospective cohorts.
Vintzileos et al3 used data from the
United States matched multiple birth
data file from 1995 to 1998 to assess the
cesarean delivery rate for triplet pregnancies in the United States, and to evaluate
the relationship between delivery mode
and stillbirth, neonatal and infant mortality rates in these pregnancies. A total of
21,201 fetuses (7067 triplet pregnancies)
>24 weeks gestation at the time of delivery were included in the analysis. The
cesarean delivery rate among triplets was
95% (6680/7067 pregnancies). However,
data were unavailable regarding the intended route of delivery. Vaginal delivery for all triplet fetuses was associated
with an increased risk for stillbirth (RR =
5.7; 95% CI, 3.83-8.49), neonatal death
(RR = 2.83; 95% CI, 1.91-4.19), and infant death (RR = 2.29; 95% CI, 1.613.25). There was no association between
birth order and neonatal or infant mortality rates, regardless of the delivery mode
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700

Monson and Silver

employed. The authors noted that missing

data and the study design did not allow
for determination of whether stillbirths
occurred antepartum rather than intrapartum, precluding definitive conclusions
regarding the optimal mode of delivery.
For example, clinicians may have elected
to perform a vaginal delivery as all or
some of the infants had died. Nonetheless,
the authors concluded that cesarean delivery is the preferred mode of delivery in
for triplets.
Available studies regarding mode of
delivery for triplets are sparse in number,
and include case series and retrospective
cohorts. This is likely due to the relatively
infrequent incidence of triplet gestations.
Most of these case series conclude that a
trial of labor for triplet pregnancies is a
reasonable and viable option in the wellcounseled individual. For example, Grobman et al18 reported outcomes in 33 sets of
triplets who underwent a trial of labor,
matched with triplets delivered by
planned cesarean. There were no differences in neonatal outcomes between
groups, but triplets delivered by cesarean
had a higher rate of neonatal respiratory
distress syndrome (P = 0.09).
Another cohort included 39 triplet
pregnancies who desired vaginal delivery
(87% of whom were successful) compared
with 30 women who desired a planned
cesarean delivery.19 Cesarean delivery
was associated with a higher perinatal
mortality rate (P = 0.02) and higher neonatal complication rate (P = 0.03).19
However, the study was biased as women
in each group received care in separate
institutions. Another case series included
93 triplet pregnancies, with 78 undergoing
a trial of labor, and 66 successfully delivering vaginally.20 The remaining women
underwent cesarean delivery during labor
or had a planned cesarean section. Neonatal and maternal outcomes were evaluated and no differences were noted
between groups. Finally, no differences
were noted in neonatal mortality or

outcome between first, second, and third

triplets in 8 triplet pregnancies that delivered vaginally.21
Taken together, these data support the
notion that vaginal delivery is a reasonable option in well-counseled and carefully selected women with triplet gestation
(eg, vertex first twin and >32 wk gestation and weighing >1500 g). It is important to note that the case series described
included carefully selected and motivated
patients and physicians, and the numbers
included were too small to exclude rare
but serious adverse events. Clear proof
of equivalence for planed vaginal and
planned cesarean delivery is lacking.
Nonetheless, serious adverse events are
rare and these observations are useful in
counseling families.
MULTIFETAL GESTATION: TRIAL OF
LABOR AFTER CESAREAN DELIVERY

As stated previously, the risks for repeat

cesarean delivery, and especially multiple
repeat cesareans are considerable. Accordingly, it is desirable for appropriate
patients with prior cesareans to have the
opportunity to have a trial of labor after
prior cesarean (TOLAC). Current rates of
TOLAC are relatively low in the United
States due to concern for uterine rupture
and rare but serious sequelae. In theory,
TOLAC in the setting of twins may be
even riskier due to the increased uterine
volume possibly increasing the risk for
rupture. However, this has not been observed with TOLAC and twins. Although
no randomized control trials have been
performed evaluating the safety of trial of
labor after cesarean for multiple gestations, several good prospective observational studies have been performed.
Varner et al22 performed a prospective
observational case-control study comparing TOLAC success and complication
rates in women with 1 prior cesarean
and with multifetal compared with singleton pregnancies. A total of 556 of 944
cases (multiple gestations) attempted a

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Multifetal Gestation
TOLAC, 85.6% of which were successful.
A total of 13,923 of 29,329 controls (singleton gestations) attempted TOLAC,
73.1% of which were successful. Cases
that underwent a TOLAC had no increased risk for complications (both maternal and perinatal) when compared with
their singleton counterparts (controls). Of
note, cases with a successful vaginal birth
after cesarean section (VBAC) were more
likely to have a history of a successful
VBAC. The authors of this report concluded that in the setting of 1 prior cesarean delivery, a TOLAC for multifetal
gestations is a reasonable option, with a
complication rate similar to singleton
pregnancies undergoing a TOLAC.
Although good outcomes have been reported, there are too few cases of vaginal
delivery of twins in women with 2 prior
cesareans to make meaningful recommendations regarding safety.
THE NEXT GENERATION

It also is important to consider the decreasing number of providers who are

well trained in and comfortable with vaginal delivery of multiple gestations. Thus,
it is critical to make efforts to increase
training of residents and fellows in these
procedures. Potential solutions include
simulation exercises and practicing the
technique of breech extraction at the time
of vaginal delivery. In addition, obstetricians caring for women who desire a
vaginal delivery with a multiple gestation,
but who do not perform the procedure,
should consider transfer of care to providers who do, especially if they practice
in a teaching institution. This will allow
the woman to have the type of delivery
that she desires and will ensure that such
women have the same option in the
future.

Conclusions
Considerable evidence supports a planned
vaginal delivery as being a reasonable (and

701

perhaps best) option for most twin pregnancies at >32 weeks in the setting of a
cephalic presenting twin. A trial of labor
should ideally be accomplished in a hospital with the capability of performing an
emergent cesarean delivery, 24-hour availability of obstetric anesthesia, and while
utilizing continuous electronic intrapartum
fetal monitoring. This is a safe and acceptable option in the hands of an experienced
obstetric provider with skills to perform a
vaginal breech extraction of the after-coming twin, possibly preceded by an internal
podalic version (eg, active management of
the second stage). It is noteworthy that a
trial of labor is still appropriate even if the
second twin is larger than the first, as long
as the first twin is large enough so as not be
able to deliver through an incompletely
dilated cervix (typically over 1800 g). In
addition, a history of 1 prior low transverse
cesarean delivery is not a contraindication
to attempting a trial of labor with twins in a
well-counseled individual that otherwise
meets criteria for a trial of labor. Finally,
vaginal delivery of triplets also is a reasonable option in well-counseled women at
>32 weeks gestation and >1500 g with
triplet A in a cephalic presentation.

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