Delivery of Multiple Gestations
Catherine Finnegan
Fergal Malone
GENERAL PRINCIPLES
Nonoperative Management
Vaginal Delivery of Multiple Gestations
Prerequisites for Vaginal Delivery
Planned vaginal birth and planned cesarean delivery are both safe choices for delivery of multiple gestations. To plan for a vaginal delivery, however, the following must apply:
The pregnancy remains uncomplicated.
There are no obstetric contraindications to labor.
The first fetus is in a cephalic presentation.
If growth discordance is present such that the first fetus, in a cephalic presentation, is the larger one and the subsequent fetuses are smaller.
Vaginal Delivery of Higher Order Multiple Gestations
Some groups have looked at outcomes following vaginal delivery for these pregnancies. A multicenter U.S. cohort found that vaginal delivery of triplets was associated with increased risk of maternal transfusion and need for neonatal mechanical ventilation and therefore they recommend elective prelabor cesarean delivery (1). However, a recent large cohort study in the Netherlands of 386 triplet pregnancies found that cesarean delivery did not significantly reduce perinatal morbidity or mortality (2). Other smaller cohorts reported similar findings and did not advocate for elective cesarean delivery because there was no significant difference in outcomes (3,4). Cesarean delivery is generally recommended, however, for the delivery of higher order multiple gestations, owing to the difficulty in monitoring multiple fetuses in labor.
Delivery of the Presenting Fetus—Cephalic Presentation
If the presenting fetus is cephalic, the delivery proceeds as it does for the vaginal delivery of a singleton. This should follow the standard management of the institution for the first and second stage of labor, with similar indications for the requirement of operative vaginal delivery and episiotomy.
Delivery of the Presenting Fetus—Breech Presentation
Vaginal delivery of multiple gestations is not recommended in the setting of the first fetus having a breech presentation. This is due to the potential, although rare, complication of interlocking chins, which may occur when the first fetus is breech and the second is cephalic and the fetal faces are aligned in such a way as to allow “locking.”
However, should a case arise where a woman presents in advanced labor with the first fetus in a breech presentation, the following can be implemented.
If at all possible, regional anesthesia should be instituted— this allows for immediate cesarean delivery if needed, and also diminishes the patient’s anxiety and involuntary pushing efforts. In most cases, uterine contractions alone will result in spontaneous descent of the breech to a point that a few maternal pushing efforts will complete the delivery. Asking the mother to push too soon will tire her out at best, and, at worst, may lead to premature efforts to deliver the breech with resultant failure and need for emergent cesarean section.
As long as both babies are stable, watchful waiting is indicated, allowing the presenting breech to distend the perineum and “crown” unaided. It is important to avoid pulling the breech before it crowns and delivers spontaneously because traction efforts can cause a nuchal arm or arms and an obstructed delivery.
Once the presenting breech is visible, if not already known from an ultrasound examination, the type of breech can be established—frank (extended), flexed, or footling.
If a frank breech is found, the buttocks are first delivered in the same manner as the vertex of a cephalic presenting fetus—essentially simply watching the presenting part deliver. If the breech is presenting in a sacrum posterior position, once it has crowned and is delivering, gentle rotation of the breech to a sacrum anterior will help with the rest of the delivery.
If a footling or flexed breech position is found, at least one foot is grasped by the operator and delivered to the buttocks.
If the lower limbs are extended and the feet are presenting, watchful waiting until the buttocks spontaneously deliver is advised. When the trunk has been delivered to the level of the umbilicus, a loop of cord can be pulled down, and fetal heart rate can be monitored simply by feel. If it is not possible to pull down a loop of the cord, this may indicate
a severely shortened umbilical cord, in which case the cord may need to be divided and the delivery expedited.
The operator may use their fingers to exert pressure on the back of the knee (Pinard maneuver) and guide the thigh away from the trunk as it is rotated in the opposite direction (Figure 4.3.1). This causes the knee to flex and allows extraction of the leg and foot. This can be repeated to deliver the other leg and foot. Traction on the trunk should be gentle and allow expulsive effort to come from maternal effort.
Once delivered to the level of the shoulders, assistance of delivery of the arms can happen. Holding the fetus by the hips or bony pelvis, the fetus is rotated through 180 degrees to deliver the first arm and shoulder and then in the opposite direction to deliver the other. This is the Løvset maneuver (Figure 4.3.2). Failure of the shoulders and arms to deliver with simple rotation of the trunk is managed by sliding an index finger into the antecubital fossa. The elbow and forearm are swept in front of the face and toward the chest so that the arm delivers. This procedure is repeated for the other arm. Gentle rotation of the fetal trunk at the same time, keeping the back anterior (i.e., toward the ceiling), will assist the operator.
Delivery of the head may occur spontaneously at this point or require assistance. The Mauriceau-Smellie-Veit maneuver is favored by some obstetricians for routine delivery of the head. The fetal trunk lies along the operator’s right forearm, with legs straddling the forearm. The middle finger of the right hand is placed on the maxilla, and the second and fourth fingers on the malar eminences to promote flexion and descent while counterpressure is applied to the occiput with the middle finger of the left hand (Figure 4.3.3). Alternatively, Piper forceps can be applied to aid delivery of the after-coming head. Piper forceps were designed with a perineal curve to allow for safe extraction of the after-coming head. The fetus is held upward, but with care not to overextend the neck. The feet can be grasped and held by an assistant, using a towel for aid, while the operator applies the blades.
If Piper forceps are not available, Kielland forceps can be used—all the while taking care not to hyperextend the fetal back and neck.
Delivery of the Second Fetus
Following the delivery of the first fetus, an infusion of oxytocin may need to be started to maintain adequate uterine contractions.
Once the cord of the first fetus has been clamped and cut (in an identifiable manner using clamps), it is time to repeat the process for the second fetus. If the membranes are intact around the second fetus, the operator should assess the fetal presentation.
Figure 4.3.1. Pinard maneuver. Pressure on the back of the knee allows the knee to flex (A) and allows delivery of leg and foot (B).
If cephalic presentation is confirmed, delivery can proceed as for the first fetus.
If breech presentation is confirmed, then a foot must first be identified and grasped. When the grasped foot has been brought to the level of the introitus, the membranes may rupture spontaneously. If they do not, the operator can choose to rupture them, or leave them intact, delivering the fetus en caul. The remainder of the delivery is then completed as described earlier for breech delivery.
Delivery of Any Subsequent Fetus
The delivery of any subsequent fetus will take place as for the second fetus outlined earlier, with the initial step being correct identification of fetal lie and presentation. With each delivery and cord being cut, each cord should be identified by way of clamps for later examination.
IMAGING AND OTHER DIAGNOSTICS
Ultrasound is widely used in the antenatal care of a multiple gestation, and is extremely useful during labor and delivery as well. Ultrasound can be utilized during vaginal delivery, where available, to check presentation and position of both twins. It is most useful during delivery of the second twin where the presentation can change following delivery of the first twin owing to the intrauterine space that becomes available. In addition, the fetal heart rate can be monitored as the baby changes orientation during internal podalic version and descent through the birth canal.
PREOPERATIVE PLANNING
Timing of Elective Delivery for Multiple Gestations
It is important to carefully consider the timing of elective delivery for a mother with a multiple gestation, both for elective cesarean delivery and for induction of labor if vaginal delivery is the goal. The timing of delivery is based on the chorionicity of the pregnancy, assuming that it is otherwise uncomplicated. Issues such as preeclampsia, fetal growth discordance, and maternal medical disorders are outside the scope of this chapter, but would necessitate different plans for timing of delivery.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
