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Over the last 30 years there has been a gradual decrease in the vaginal delivery of twins. This may have led to a loss of obstetric intrapartum skills and confidence in some accoucheurs. Leading professional organizations recommend that all women with a cephalic presenting twin be counseled about the availability and safety of vaginal delivery. There are a number of different techniques for delivering twins and the accoucheur should be adept at all, and tailor their practice to the clinical situation in the moment, rather than relying on a single technique. Techniques for vaginal birth in multiple pregnancy have evolved in an anecdotal fashion and there is wide variation in practice throughout the world. None of the techniques are a challenge to a person of average dexterity and an Obstetrics department can safely increase the rate of vaginal delivery of twins through a program of needs assessment, education, simulation, and clinical backup. Some still advocate for the vaginal delivery of triplets, but such practice is rare and as a consequence questionable. The delivery of quadruplets and greater is by caesarean delivery.
The rate of structural malformations in monozygotic twins is higher than in dizygotic twins or singletons. The mechanical process of the embryo splitting may precipitate structural abnormalities leading to this higher incidence. Despite being genetically identical, monozygotic twins can be discordant for structural abnormality. Among the most common structural malformations in twin pregnancies are cardiac anomalies, neural tube and brain malformations, gastrointestinal and abdominal wall defects. Congenital heart disease is more prevalent in monochorionic twins, a proportion of which is caused in response to the abnormal physiology of twin-twin transfusion syndrome. First trimester ultrasound can identify those twin pregnancies at a higher risk of structural malformations and therefore lead to earlier detailed anatomy ultrasound and earlier prenatal diagnosis.
Multiple pregnancies are associated with higher risks for both mother and babies. Women with multiple pregnancies have an increased risk of miscarriage, anemia, hypertensive disorders, haemorrhage, and postnatal illness. These pregnancies are more likely to need an operative delivery, and maternal mortality is generally 2.5 times that of singleton births. Fetuses are at increased risk for anatomic and genetic anomalies, growth abnormalities, prematurity, and several physiological problems related to monochorionicity. This book provides a much needed, up-to-date guide to the management of multiple pregnancies. Presented with a uniform approach to all chapters, information is easily navigable, evidence-based, and highly practical. Heavily illustrated, particularly with ultrasound images – the cornerstone of management of multiple pregnancies - this book will appeal to obstetricians and specialists in maternal-fetal medicine, midwives and ultrasonographers and will improve outcomes for mothers and babies.