Intrapartum management of twin gestation.

The intrapartum management of the patient with a multiple gestation should begin in the antenatal period. With the present widespread use of ultrasound, the number of multiple gestations diagnosed early in pregnancy has now increased, permitting determination of placentation and monitoring of fetal growth. When a patient with a twin gestation presents in labor, ultrasound should be used to establish fetal presentation and size. The fetal well-being should be evaluated with fetal heart monitoring, and assessment of potential maternal complications, such as anemia, hypertension, and polyhydramnios, should be accomplished. With more than two fetuses, cesarean delivery is recommended. The principal controversy in intrapartum management of twin gestation relates to the planned route of delivery, particularly because this consideration is influenced by malpresentation and prematurity. There is general agreement favoring vaginal delivery for vertex-vertex twin pairs. With dual fetal heart rate monitoring and appropriate delivery room preparation for emergency cesarean section, recent evidence supports planned vaginal delivery of the mature nonvertex second twin. Elective cesarean section for the nonvertex second twin estimated as weighing less than 1800 gm is advised.