[Management of second twin delivery].
OBJECTIVE
To determine the optimal mode of delivery of the second twin according to his presentation.


METHODS
The PubMed data base has been consulted.


RESULTS
Considering longer intertwin intervals are correlated with poorer umbilical artery blood gas results and are associated with greater rates of cesareans for the second twin after vaginal birth of the first twin and increased neonatal morbidity of the second twin, second twin delivery should be actively managed for reducing this interval (EL3). In case of non cephalic presentation of the second twin, immediate total breech extraction, after internal version in case of transverse lie, could be associated with lower rates of cesareans for the second twin (EL3). In these situations, external version might be deleterious (EL3). In case of cephalic presentation above a 0 station, and if the obstetrical team is trained in obstetrical maneuvers, internal version followed by immediate total breech extraction could be preferred to the association of maternal pushing efforts, oxytocin infusion and artificial rupture of the membranes, because this first strategy might be associated with less cesareans for the second twin (EL4). In case of cephalic presentation at or below a 0 station, management of second twin delivery should consist in the association of maternal pushing efforts, oxytocin infusion and artificial rupture of the membranes (EL3). All the obstetrical maneuvers for second twin delivery should be performed in first intent with intact membranes (EL5).


CONCLUSIONS
Second twin delivery should be actively managed and largely depends on the knowledge of specific obstetrical maneuvers. Training residents to these maneuvers remains a priority.
Hôpital Cochin, AP-HP, Maternité Port-Royal, 123, boulevard de Port-Royal, 75014 Paris, France. thomas.schmitz@cch.aphp.fr
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D003663:Decision Trees; D036861:Delivery, Obstetric / Q000379:methods*; D005260:Female; D006801:Humans; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D059285:Pregnancy, Twin; D013997:Time Factors