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MS WordPerinatologist Corner - C.E.U/C.M.E. Modules
Twins: Antepartum assessment and Intrapartum management
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11 Twin Pregnancy: Double Trouble?
Step 11. Labor Management: Vagominal delivery risks
Let’s discuss vaginal delivery, but be aware of the risks that a vaginal delivery can be immediately followed by an abdominal delivery, or the neologist’s colloquialism, vagominal delivery.
If the A twin is a cephalic, and the B twin is a non-cephalic (~38% of twin pairs), many would allow a trial of vaginal delivery
for the pair. Since A is in cephalic presentation, it will usually deliver in a fairly standard fashion as such. Following delivery of A, twin B should be examined with ultrasound in the delivery room to see how it may descend.
If it is still non-cephalic, some authorities would recommend doing an external version under ultrasound guidance.
The problem here is that it may turn to a general “head down” presentation, but be poorly applied to the cervix, and cord or extremities may come forth when the membranes rupture…. Others would recommend letting B deliver as a breech, needling the membranes to allow safe descent of the buttocks without cord prolapse, and allowing maternal efforts to deliver it as such, keeping the head well flexed. A has “opened the way” so to speak, allowing an easier breech delivery.
Total breech extraction is to be discouraged as it usually deflexes the head and is often traumatic. The availability of intra-partum ultrasound monitoring, and cesarean readiness,
are of course prerequisites for this management plan. (Hogle)
If at any point along this continuum of different presenting parts you detect a non-reassuring fetal heart tracing, prolapsed cord, abruption placenta, persistent transverse lie, etc….then the patient may require urgent cesarean delivery of the second twin. It is this situation that has been euphemistically called the ‘vag’ + ‘ominal’ or vagominal delivery.
Remember to be prepared for uterine atony and post partum hemorrhage as a result of uterine over distention after any form of twin delivery.
Twins are always exciting to deliver and fun to take care of, but are often “double trouble”. Be sure you feel comfortable taking on their care. Decide on the best facility for them to be managed depending on their chorionicity, and the availability of surgical intervention and neonatal intensive care should those become necessary, as they often do.
