In the Trenches

Vaginal Delivery of the SecondNonvertex TwinAvoiding a Poor Outcome When the Presenting PartIs Not Engaged

Birgit Arabin, MD, PhD, and Ioannis Kyvernitakis, MD

PROCEDURES FOR DELIVERING THESECOND NONENGAGED NONVERTEX TWINModel 1: Dichorionic Diamniotic TwinPregnancy: Vertex–Transverse PositionA gravida 1 woman with dichorionic diamniotic twinswas admitted at 36 weeks of gestation for rupture ofmembranes of the first twin (Fig. 1A). Informedconsent was obtained and the patient opted for vagi-nal delivery and epidural analgesia. After spontane-ous delivery of the first twin, ultrasonography con-firmed the second twin in a transverse position withintact membranes (Fig. 1B). By inserting one handbetween the membranes and the uterine wall untilreaching the fetal hips and slowly turning the fetusinto breech position, under cardiotocographic andultrasonographic control, the second twin was deliv-ered (Fig. 1 C–E). Rupture of membranes occurredduring the foot extraction (Fig. 1F).

Model 2: Monochorionic Diamniotic TwinPregnancy: Vertex–Breech PositionA gravida 2 para 1 woman with monochorionicdiamniotic twins was admitted in labor with the firsttwin in vertex and the second in breech position at36 weeks of gestation (Fig. 2A). She was informedabout risks of a vaginal delivery, mainly the small

chance of acute intertwin transfusion, but opted forvaginal delivery with epidural analgesia. Immedi-ately after the delivery of the first twin the umbilicalcord was clamped. Because the second twin was notengaged but presented with forelying feet, theobstetrician decided to insert the hand betweenmembranes and uterine wall, verifying hips, thighs,and feet under cardiotocographic and ultrasono-graphic guidance (Fig. 2 B–C). The second twin wasdelivered 3 minutes after the birth of the first.Rupture of membranes occurred during the footextraction (Fig. 2D).

QUESTIONS FOR THE SPECIALISTWhat Is the Distribution of Positions of Twinsat the End of Pregnancy?Twin pregnancies and consequently their deliveryhave increased by 50–80% in Western countries sincethe 1970s, owing to higher maternal age and use offertility treatments. No evidence suggests that vaginaldelivery is contraindicated neither in dichorionic norin monochorionic diamniotic twins. Mainly in casesof monochorionic diamniotic twins the time intervalbetween delivery of the first twin and second twinshould be short and intense surveillance is manda-tory.1 Twin sets fall into three categories (Box 1).2

Pairs with the first twin in transverse or in breechposition should be scheduled for a planned cesarean.Controversies relate to the delivery of twins with thefirst twin in vertex position (in total more than 80%),mainly if the second twin is in nonvertex position(38.4%). Independent of the position, monochorionicmonomaniotic twins should be delivered by cesarean.This advice is supported by expert opinion ratherthan by results from randomized trials, which arehardly to be performed.

From the Departments of Prenatal Medicine and Perinatal Medicine, Center forMother and Child, University of Marburg, Marburg, Germany, in cooperationwith the Clara Angela Foundation, Witten, Germany.

Corresponding author: Prof. Birgit Arabin, Department of Prenatal Medicine,Center for Mother and Child, University of Marburg, Germany Baldinger Str.1 35033 Marburg, Germany; e-mail: bine.clara.angela@gmail.com.

Financial DisclosureThe authors did not report any potential conflicts of interest.

© 2011 by The American College of Obstetricians and Gynecologists. Publishedby Lippincott Williams & Wilkins.ISSN: 0029-7844/11

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How Do Guidelines “Guide” Us in DecisionMaking?Guidance related to delivery of twins is poor andlacks uniformity. The American College of Obstetri-cians and Gynecologists’ guidelines state: “The routeof delivery should be determined by the position, theease of fetal heart rate (FHR), maternal and fetalstatus. Data are insufficient to determine the bestroute of delivery.”3 European guidelines do not sup-

ply us with more details; even worse, in Germanythere are no guidelines at all. Only the recent Frenchguidelines use professional consensus and evidencelevels and state that, “… the immediate and perma-nent availability of an obstetrician with experience inthe vaginal delivery of twins is required and epiduralanesthesia is desirable” and “… that studies on themode of delivery lack of power. However, activemanagement of the second twin and in cases ofnonvertex position, breech extraction, possibly afterinternal maneuvers is recommended as opposed tooxytocin infusion, pushing or artificial rupture ofmembranes.”4

What Are the Risks of a “Prophylactic”Cesarean Delivery?No study shows maternal advantages of a prophylac-tic cesarean, but many series demonstrate an in-creased maternal morbidity and higher risks for sub-sequent pregnancies.

In the only randomized controlled trial Rabi-novici et al5 stated that, “… a cesarean deliveryincreased maternal febrile morbidity but did notimprove neonatal outcome of either twin.”5 Stressincontinence is not increased by vaginal delivery of

Box 1. Distribution of Different Positions inTwin Pregnancies Before Delivery

Twin A vertex with twin B vertex: 42.5%Twin A vertex with twin B nonvertex: 38.4%

• With twin B breech: 26%• With twin B transverse: 11.3%• With twin B oblique: 1.1%

Twin A nonvertex: 19.1%• Breech–vertex: 6.9%• Breech–breech: 6.1%• Breech–transverse: 4.7%• Breech–oblique: 0.3%• Transverse–vertex: 0.6%• Transverse–transverse: 0.5%

Fig. 1. Delivery of twins in vertex–dorsoanterior transverse position(A). After the delivery of the firsttwin, ultrasonography is performedimmediately by an assistant or theobstetrician. After diagnosing thenonengaged twin in transverse posi-tion, one hand is moved slowly be-tween membranes and uterine wallto the fetal hips (B), the hips aresoftly pushed down (C), and, underultrasonographic guidance, thehand is moved to the thigh and thefeet (D, E), all in a relaxed uterus—eventually with the aid of tocolytics.Only when it is certain that the handof the obstetrician can grip the feet,a total extraction is performed pos-sibly with some support by an assis-tant (F). In case of spontaneous rup-ture before or during the maneuver,the procedure is performed morerapidly. Reprinted with permissionfrom the Clara Angela Foundation,copyright 2011.Arabin. Delivery of Vertex-FirstNonengaged Second Twins. ObstetGynecol 2011.

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twins compared with cesarean delivery. Only totalintrauterine weight, fundal pressure, or symptoms ofprenatal or postnatal incontinence increase this riskfor permanent stress incontinence.6

It has been proven that the downstream risks forfurther pregnancies increase with each cesarean de-livery: Clark et al have demonstrated that the rate ofplacenta previa, placenta accreta, placenta increta,and placenta percreta increases with the number ofprior (0–4) cesarean deliveries from 0.6 to 10% forplacenta previa and from 0.06% to 6.7%, respectively,for placenta accreta, placenta increta, or placentapercreta. The risk in patients with previous placentaprevia of having an additional placenta accreta, pla-centa increta, or placenta percreta increases from 5%to 67% in patients with either no or four cesareandeliveries, respectively, in previous pregnancies.7

Two recent, large multicenter studies address themode of twin deliveries: Vendittelli et al analyzed acohort of 2,597 deliveries at 34 weeks of gestationwith the first twin in cephalic presentation by anintention-to-treat analysis (evidence level II). Neona-tal complications were lower after vaginal deliverycompared with scheduled cesarean delivery (26.5%compared with 31.7%, P�.005) even if only thesecond twin was considered (27.6% compared with32.7%, P�.005). The authors concluded that thepolicy of a planned cesarean delivery for pregnanciesafter 34 weeks of gestation cannot be supported.8

Similarly, Rossi et al found in a meta-analysis of

39,571 twin pregnancies that neonatal morbidity waslower after vaginal delivery (1.1%) than after sched-uled cesarean delivery (2%) (P�.01, odds ratio [OR]0.40, 95% confidence interval [CI] 0.2–0.81) for twinA and without significant differences between the twoplanned delivery modes for twin B. When outcomeswere stratified for presentation and delivery mode,mortality was lower after vaginal delivery (0.6%) forboth vertex and nonvertex twin B compared withcesarean delivery (0.8%, P�.008, OR 1.25, 95% CI1.06–1.47).9

What Are the Potential Risks of a CombinedDelivery?Cesarean delivery for the second twin is regarded asthe least desirable mode of delivery as the mothersuffers from a tiring labor in addition to the risksderiving from a major operation. In retrospectiveaudits, the indications were classified as follows10: Theemergency situation could not be predicted, such asabruption, cord prolapse, or cervical spasm, or could bepredicted but the obstetrician thought that vaginal de-livery would be too risky.

Furthermore, there were failures to diagnose thesituation before; such as dorsoinferior transverse po-sition with legs not reachable. We admit, that it maybe more difficult in a dorsoinferior compared with adorsosuperior transverse position to reach the feet.However, it is not obsolete to perform a version andextraction in a dorsoinferior position in a relaxed

Fig. 2. Delivery of twins in vertex–breech position (A). After the delivery of the first twin, ultrasonography is performedimmediately by an assistant or the obstetrician. After diagnosing the nonengaged breech, possibly with fore lying feet, the handslowly moves between membranes and uterine wall to the hips and the thigh (B, C), all in a relaxed uterus- eventually with theaid of tocolytics. Only when it is certain that the hand of the obstetrician can grip the feet, a total extraction is performed possiblywith some support by an assistant (D). In case of spontaneous rupture before or during the maneuver the procedure is performedmore rapidly. Reprinted with permission from the Clara Angela Foundation, copyright 2011.Arabin. Delivery of Vertex-First Nonengaged Second Twins. Obstet Gynecol 2011.

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uterus combining ultrasonography and manual expe-rience to grasp the posterior-most foot so that thesecond twin will rotate the back anteriorly. Theanesthesia team and adequate nursing and pediatricstaff should be present in case that the maneuver fails.

Frequently iatrogenic measures can lead to un-necessary combined delivery. Artificial rupture ofmembranes or liberal use of oxytocin without engage-ment of the leading part and prolonged intervalbetween delivery of both twins cause fetal distress,uterine contraction around a malpresented fetus, oreven cervical spasm, leading to difficulties in deliver-ing the second twin vaginally and also during asubsequently indicated cesarean delivery. It is notsurprising that apart from maternal risks associatedwith an unplanned operation, a cesarean delivery forthe second twin is combined with a high neonatalmorbidity: 19.8% (2,331/11,716) compared with 9.5%(10,873/115,005) in the vaginal delivery group(P�.001, OR 0.55, 95% CI 0.41–0.74) and comparedwith 9.8% (11,278/114,369) in a planned cesareandelivery group (P�.001, OR 0.47, 95% CI 0.43–0.53),respectively.9

Another important issue is the experience of theobstetrician. Some hospitals cannot provide patientswith a 24-hour specialist in high-risk pregnancies.There is a linear correlation between the frequency ofcombined deliveries and the frequency of plannedcesarean deliveries in the same department. If special-ists have less experience in vaginal deliveries of twinsthey more often resort to a cesarean delivery in asecond twin.10 Two-thirds of combined deliveries areperhaps avoidable, and they have an increased riskfor immediate maternal complications such as hem-orrhage or infection as well as later complicationssuch as adhesions, uterine rupture, and abnormalplacentation.10

What Are the Advantages Delivering aNonengaged Nonvertex Second Twin WithIntact Membranes?The described techniques have not only been per-formed in these two single patients but in series oftwin pregnancies with comparable combinations, allby an experienced obstetrician and a resident intraining. A logical consequence from the cited studiesis to deliver vertex-first twins vaginally even if thesecond twin is in nonvertex position and to avoidcombined delivery. Many studies supporting prophy-lactic cesarean in twin pregnancies with the first invertex position lack any prospective or retrospectiveaudit related to the operator’s skill and experience,subsets of different positions (eg, foot lying breech or

breech), comorbidity, and chorionicity, which allinfluence the results.

Ultrasonography is capable of differentiatingwhether membranes of the second twin are still intactor not. A few publications already support maneuverswith intact membranes in the second twin.8,11 Stan-dard obstetric texts rarely describe techniques relatedto a nonengaged second twin in either position butsometimes even recommend rupture of membranesbefore performing version or extraction. Rates ofcomplications of maneuvers with either intact orruptured membranes cannot be compared and wewould not support randomized trials related to thisdifference because the risks of uterine contractionaround a nonengaged twin, cord prolapse, and fetaldistress after rupture of the second membranes areobvious. Oxytocin is only indicated if the second twinis in vertex position with some contact to the birthcanal, fetal heart rate (FHR) monitoring is normal,and spontaneous contractions are not effective. In allcases where a manual version or extraction are sched-uled, oxytocin should be avoided, tocolytics may beindicated and antibiotics should be applied in caseswith internal maneuvers.

In patients where membranes of the second twinrupture before or during birth of the first twin, thetechniques would be the same, but should be per-formed immediately after delivery of the first twin ina relaxed uterus. The patient should not push andpain relief should be assured to perform these maneu-vers rapidly but without panic. Waiting too long maynot only increase the risk of prolapsed cord but also ofacidemia in the second twin even if FHR pattern isreassuring.12

Why Do Obstetricians Presently ResistPerforming Intrauterine Maneuvers?Historically, midwives and physicians have deliveredtwins vaginally from complicated positions with littlemedical or technical support. Meanwhile, fetal ultra-sonography, intrapartum monitoring and medicationduring delivery have been introduced, all of whichare particularly useful for the delivery of the secondtwin. Nevertheless, many obstetricians have lost theintention or capability to actively deliver the secondnonengaged nonvertex twin. Cruikshank has statedthat, “… physicians trained after the 1970s have noidea how to perform internal maneuvers.”13 How canwe allow this ignorance as maternal-fetal specialists?

Wisdom derives from looking to the past and thefuture in the same time. This is an appeal to ourprofessional integrity to teach residents and specialiststo combine old techniques with modern achieve-

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ments. Randomized trials about different modes ofdelivery in vertex-first twin pregnancies and a nonen-gaged nonvertex second twin will hardly be possiblebecause this situation is frequently only diagnosedafter the delivery of the first twin, which is not a goodmoment to ask for participation apart from otherbiases such as skills of the operator, FHR pattern, anduterine relaxation. Evidence of large observationaltrials and beneficence toward all three patients doesnot necessarily support a scheduled cesarean deliveryin vertex-first nonvertex second twin pregnancies butrather a nuanced approach, where patients should beencouraged to deliver vaginally in perinatal centerswith sufficient expertise and all described facilities.Studies should not be content with immediate out-comes, but also include results from retrospectiveaudits and long-term follow up before making tooearly conclusions.

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