Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content ++ Maternal and neonatal morbidity is increased in these scenarios when compared with singleton vertex vaginal deliveryVaginal 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 vertexVersion or breech extraction may be necessary if presentation is not vertex–vertexPreterm delivery common:Sixty percent of twin pregnancies are delivered by Cesarean section in the United StatesIntrapartum fetal heart rate monitoring may be difficultIntrapartum complications may necessitate conversion to Cesarean section:Nonreassuring fetal heart rateFailed delivery of second twinCord prolapseAbruption of placentaDelivery is often in the OR or in designated labor room with easy access to the OREpidural analgesia is strongly recommended:Good labor analgesiaAugmentation 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 laborPresence of an anesthesiologist for delivery is recommended:Provide continued analgesiaIntervene with IV medications if necessaryUterine relaxationUterotonicsInduce 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 obstetricianFacilities for emergent Cesarean delivery must be immediately availableUrgent conversion to Cesarean delivery:Nonreassuring fetal heart rateCord prolapseFailed second stage (pushing past 30 minutes)Fetal head entrapmentEpidural analgesia is strongly recommendedAnesthesiologist 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 careMost women with low transverse incision are candidates for TOLAC:Induction of labor and oxytocin augmentation are allowed; prostaglandins are not recommendedUterine rupture should be suspected if:Acute onset, severe abdominal painSudden fetal bradycardiaSudden change in shape of abdomenMaternal circulatory shockVaginal bleedingEpidural analgesia is strongly recommended:Epidural analgesia may ameliorate pain of uterine rupturePremature urge to push is diminished by good labor analgesia; this reduces pressure on uterine scarConversion to surgical anesthesia is possibleGeneral anesthesia is often necessary in frank rupture of the uterus and delivery of fetus in abdominal cavityAssociated maternal hemorrhage is often significant Your Access profile is currently affiliated with [InstitutionA] and is in the process of switching affiliations to [InstitutionB]. Please select how you would like to proceed. Keep the current affiliation with [InstitutionA] and continue with the Access profile sign in process Switch affiliation to [InstitutionB] and continue with the Access profile sign in process Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Error: Incorrect UserName or Password Username Error: Please enter User Name Password Error: Please enter Password Sign in Forgot Password? Forgot Username? Download the Access App: iOS | Android Sign in via OpenAthens Sign in via Shibboleth You already have access! Please proceed to your institution's subscription. Create a free profile for additional features.