What is the recommended mode of delivery for a twin pregnancy where the first twin is in cephalic presentation and the second twin is in transverse lie?

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Twin Delivery: Cephalic First Twin with Transverse Lie Second Twin

For twin pregnancies with the first twin in cephalic presentation and the second twin in transverse lie, planned vaginal delivery with active management of the second twin is recommended, utilizing internal podalic version followed by breech extraction when the team is appropriately trained. 1

Mode of Delivery Decision

The presentation of the first twin is the primary determinant of delivery mode, not the second twin's position. 2, 1

  • When the first twin is cephalic (vertex), attempt vaginal delivery regardless of the second twin's presentation. 2, 1
  • The landmark Twin Birth Study (2013) demonstrated no significant difference in fetal/neonatal death or serious morbidity between planned cesarean and planned vaginal delivery when the first twin is cephalic (2.2% vs 1.9%, OR 1.16,95% CI 0.77-1.74). 2
  • Chorionicity alone should not dictate the mode of delivery; base the decision on standard obstetric indications and fetal presentation. 3

Active Management of the Transverse Second Twin

When the first twin delivers vaginally and the second twin is in transverse lie, immediate active intervention reduces complications and cesarean rates. 1

Recommended Technique: Internal Podalic Version with Breech Extraction

  • Perform internal podalic version followed by total breech extraction for the transverse second twin. 1
  • This approach is associated with the lowest cesarean rates for second twins compared to expectant management. 1
  • Begin the maneuver while membranes are still intact whenever possible to maintain uterine volume, facilitate version, and prevent cord prolapse. 4
  • Internal version with breech extraction is superior to a strategy of resuming pushing, oxytocin augmentation, and artificial rupture of membranes, which increases cesarean rates for the second twin. 1

Technical Considerations

  • The procedure requires an experienced obstetrician skilled in internal version and breech extraction. 1
  • Epidural analgesia is highly desirable for twin delivery to facilitate these maneuvers. 1
  • Inability to successfully perform internal podalic version and extraction accounts for 52% of cesarean deliveries for the second twin. 5

Critical Risk: Transverse Lie with Back Down

  • When the second twin is transverse with the back down, inability to turn and extract is the most common reason for cesarean (9/14 cases in one series). 5
  • This configuration presents the highest technical difficulty for internal version. 5

Timing Between Twin Deliveries

  • Active management should minimize the interval between delivery of the twins. 1
  • Time interval between twin deliveries has not been associated with adverse outcomes when active management is employed. 6

Alternative: External Cephalic Version

  • External cephalic version of the transverse second twin is an option, with success rates of approximately 71% for transverse presentations. 6
  • Success is associated with the mode of anesthesia and size disparity between twins. 6
  • However, internal podalic version with breech extraction remains the preferred approach in most guidelines due to higher success rates and lower cesarean rates. 1

When Cesarean Is Required for the Second Twin

Cesarean delivery of the second twin after vaginal delivery of the first occurs in approximately 5% of all twin deliveries and 14.4% of all twin cesareans. 5

Primary indications include:

  • Inability to perform internal podalic version and extraction (52% of cases). 5
  • Cord prolapse (26% of cases, particularly when attempting vaginal delivery of vertex-vertex twins). 5
  • Fetal distress of the second twin. 5
  • Placental abruption. 5

Essential Prerequisites

  • Immediate availability of a gynecologist-obstetrician experienced in vaginal twin delivery and internal version techniques. 1
  • Rapid access to blood products at the delivery facility. 1
  • Capability for emergency cesarean delivery if internal version fails or complications arise. 1
  • Epidural analgesia in place before delivery of the first twin. 1

Common Pitfalls to Avoid

  • Do not routinely perform cesarean section for transverse lie of the second twin when the first twin is cephalic and the team is skilled in internal version. 1
  • Avoid rupturing membranes of the second twin before attempting version, as this increases the risk of cord prolapse and makes version more difficult. 4
  • Do not delay active management of the second twin; prolonged intervals without intervention increase complications. 1
  • The "safest" configuration (vertex-vertex) paradoxically accounts for 96% of cesarean deliveries for the second twin because these are the cases allowed to labor, making cord prolapse the leading complication. 5
  • Recognize that the rising cesarean rates for twins correlate with declining skills in internal version and breech extraction among obstetricians. 4

References

1
Research

Twin pregnancies: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians (CNGOF).

European journal of obstetrics, gynecology, and reproductive biology, 2011

3
Guideline

Ultrasound Surveillance and Intervention in Twin Pregnancies

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

4
Research

Vaginal delivery of the second twin in unengaged cephalic presentation.

The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians, 2021

5
Research

Cesarean section for the second twin.

The Journal of reproductive medicine, 1997

6
Research

Intrapartum external version of the second twin.

Obstetrics and gynecology, 1983

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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