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  • Maternal and neonatal morbidity is increased in these scenarios when compared with singleton vertex vaginal delivery
  • Vaginal delivery is preferred in appropriate patients when obstetrical expertise is available, backed up by adequate hospital facilities including presence and expertise of an anesthesiologist


  • Favorable presentations:
    • First twin has to be vertex
    • Version or breech extraction may be necessary if presentation is not vertex–vertex
  • Preterm delivery common:
    • Sixty percent of twin pregnancies are delivered by Cesarean section in the United States
  • Intrapartum fetal heart rate monitoring may be difficult
  • Intrapartum complications may necessitate conversion to Cesarean section:
    • Nonreassuring fetal heart rate
    • Failed delivery of second twin
    • Cord prolapse
    • Abruption of placenta
  • Delivery is often in the OR or in designated labor room with easy access to the OR
  • Epidural analgesia is strongly recommended:
    • Good labor analgesia
    • Augmentation of analgesia for version or breech extraction (8–10 mL 3% chloroprocaine or 2% lidocaine with 1:200,000 epinephrine)
    • Conversion to surgical anesthesia if urgent Cesarean delivery is indicated (15–20 mL 3% chloroprocaine)
    • Administer supplemental oxygen during second stage of labor
  • Presence of an anesthesiologist for delivery is recommended:
    • Provide continued analgesia
    • Intervene with IV medications if necessary
    • Uterine relaxation
    • Uterotonics
    • Induce general anesthesia if fetal emergency


  • The deciding factor in the choice of vaginal or Cesarean delivery is most commonly the experience and skill of the obstetrician
  • Facilities for emergent Cesarean delivery must be immediately available
  • Urgent conversion to Cesarean delivery:
    • Nonreassuring fetal heart rate
    • Cord prolapse
    • Failed second stage (pushing past 30 minutes)
    • Fetal head entrapment
  • Epidural analgesia is strongly recommended
  • Anesthesiologist should be immediately available in case of emergency obstetrical intervention


  • The risk of uterine rupture during TOLAC is estimated at about 1%
  • ACOG guidelines recommend TOLAC in facilities with staff present or immediately available to perform emergency care
  • Most women with low transverse incision are candidates for TOLAC:
    • Induction of labor and oxytocin augmentation are allowed; prostaglandins are not recommended
  • Uterine rupture should be suspected if:
    • Acute onset, severe abdominal pain
    • Sudden fetal bradycardia
    • Sudden change in shape of abdomen
    • Maternal circulatory shock
    • Vaginal bleeding
  • Epidural analgesia is strongly recommended:
    • Epidural analgesia may ameliorate pain of uterine rupture
    • Premature urge to push is diminished by good labor analgesia; this reduces pressure on uterine scar
    • Conversion to surgical anesthesia is possible
  • General anesthesia is often necessary in frank rupture of the uterus and delivery of fetus in abdominal cavity
  • Associated maternal hemorrhage is often significant

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