Twins & Breech – Breech Birth San Diego

Pregnant with twins? Seeking resources to help turn your baby or babies? Learn how to encourage your baby or babies to turn and be sure to consult your care provider for individual recommendations.

What presentation variations are there?

Baby A head down and Baby B head down
Baby A head down and Baby B breech (or transverse)
Baby A breech (or transverse) and Baby B breech (or transverse)
Baby A breech (or transverse) and Baby B head down

Balancing & Pregnancy Support

Spinning Babies has wonderful resources (here and here) explaining many options and techniques available for breech position during a twin pregnancy.

Twin Pregnancy Nutritional Support

Note: homebirth midwives can do co-care for twins at the hospital and body balancing can be done earlier and for comfort.

Evidence for Induction

Coming soon!

Type of Twin Pregnancy and the Research

Much of the research for breech twins is lacking. For quality research, large numbers or sample sizes are needed and most of the twins studies lack large numbers. When smaller numbers are used, data are not reliable and less generalizable to the greater population. It is important to also note the lack of evidence regarding the rare cases of interlocking twins.

Twin Births: Vaginal Delivery Safer than Cesarean.
Schmitz, Thomas MD, PhD; Prunet, Caroline MSc; Azria, Elie MD, PhD; Bohec, Caroline MD; Bongain, André MD; Chabanier, Pierre MD; D’Ercole, Claude MD; Deruelle, Philippe MD, PhD; De Tayrac, Renaud MD, PhD; Dreyfus, Michel MD; Dupont, Corinne PhD; Gondry, Jean MD; Graesslin, Olivier MD, PhD; Kayem, Gilles MD, PhD; Langer, Bruno MD, PhD; Marpeau, Loïc MD; Morel, Olivier MD, PhD; Parant, Olivier MD, PhD; Perrotin, Franck MD, PhD; Pierre, Fabrice MD; Poulain, Patrice MD; Riethmuller, Didier MD; Rozenberg, Patrick MD; Rudigoz, René-Charles MD; Sagot, Paul MD; Sénat, Marie-Victoire MD, PhD; Sentilhes, Loïc MD, PhD; Vayssière, Christophe MD, PhD; Venditelli, Françoise MD, PhD; Verspyck, Eric MD, PhD; Winer, Norbert MD, PhD; Lecomte-Raclet, Laurence PhD; Ancel, Pierre-Yves MD, PhD; Goffinet, François MD, PhD; for the JUmeaux MODe d’Accouchement (JUMODA) Study Group and the Groupe de Recherche en Obstétrique et Gynécologie (GROG)
Obstetrics & Gynecology 129:974-975, 986-995, 2017.

“The findings of this study are similar to those obtained in the Twin Birth Study conducted in Canada, Dr. Rouse adds. Both trials have shown that, when the first twin has a cephalic presentation, and the appropriate equipment and personnel are available, “at least from 32 weeks of gestation onward, an attempt at vaginal delivery should be the default plan, regardless of the presentation of the second twin.”

Mode of birth in twins: data and reflections.
A. Reitter, B. A. Daviss, M. J. Krimphove, K. C. Johnson, R. Schlößer, F. Louwen & A. Bisits
Journal of Obstetrics & Gynecology 0(0), 1-9, 2018.

“There are good grounds to encourage vaginal birth for low-risk twin pregnancies. The trend of rising caesarean rates in low-risk twin pregnancies worldwide will erode important skills for the conduct of vaginal births without any clear benefit for mothers or babies. The current situation demands careful thought about implementing innovative training opportunities for younger obstetricians. Finally, we need intelligent responses to many non-evidence-based factors which can drive clinical practice.”

Mode of delivery in non-cephalic presenting twins: a systematic review.
Steins Bisschop, C.N., Vogelvang, T.E., May, A.M., and Schuitemaker, N.W.E.
Archives of Gynecology and Obstetrics 286(1), July 2012.

“Our results do not suggest benefit of caesarean over vaginal delivery for selected twin gestations with twin A and/or twin B in non-cephalic presentation. However, no final conclusion can be drawn. Randomized studies with sufficient power are required to make a strong recommendation.”

Delivery of the second twin: Influence of presentation on neonatal outcome, a case controlled study.
Bogner, G., Wallner, V., Fazelnia, C., Strobl, M., Volgger, B., Fischer, T., and Jacobs, V. R.
BMC Pregnancy and Childbirth 18(176), May 2018.

“Even though elective cesarean means reduced stress for second twins this seems not to be clinically relevant. Non-cephalic presentation of the second twin does not significantly influence the perinatal outcome of the second twin but might be a risk factor for vaginal-cesarean birth.“

Vaginal Delivery of Twins.
Carroll, MA & Yoemans, E.R.
Clinical Obstetrics and Gynecology 49(1), 2006.

“Historically, concern for interlocking of twins has motivated the choice of cesarean delivery in this group. Locking is a rare condition, reported in as few as one in 500 to 1000 twin deliveries. Rydhstrom reported the results of a review of the world literature (1958–1987) for locked twins. In this series, the risk for interlocking was reported as one in 645 twin deliveries (0.15%).25 Whereas the mortality associated with interlocking is high (30–40% in published reports), given the rarity of this event and the ready availability of ultrasound during delivery to assist in diagnosis of this condition, the concern for interlocking as an indication for cesarean delivery may be overstated. Rather, appropriate selection of patients for vaginal breech delivery is preferable to automatic cesarean delivery for this group.

Oettinger reported retrospective data on nonvertex first twin deliveries during 2 time periods in which large differences in the rate of cesarean delivery for breech first twins were noted (20.9% vs. 94.9%).21 Neonatal and maternal morbidities were compared between these 2 cohorts. Neonatal morbidity was unrelated to the mode of delivery. Maternal fever was statistically more likely in the cesarean delivery group. There were no cases of interlocking twins. Birth trauma was equally likely if the patient was delivered by cesarean or vaginal delivery (8.9% vs. 8.2%, respectively), suggesting that cesarean delivery did not improve neonatal outcome. Birth trauma and neonatal death with cesarean delivery of twins have also been reported in other series.7,15 In an article describing his experience of vaginal delivery of nonvertex second twins, Chervenak wrote, ‘‘It must be emphasized that cesarean section is not a panacea and does not preclude the possibility of birth injury.’’7″

An Evidence-based Approach to Determining Route of Delivery for Twin Gestations.
Christopher, D., Robinson, B.K., and Peaceman, A.M.
Review in Obstetrics and Gynecology 4(3-4), 2011.

“The best method by which to deliver pregnancies in which only the presenting twin is cephalic remains controversial. Evidence supports a vaginal trial of labor in late preterm and term twins. Routes of delivery for preterm twins lighter than 1500 g remains unclear, with compelling data for both planned cesarean and planned vaginal delivery. No data support planned cesarean for birthweight discordance alone. Risks of TOLAC for women with twins appear similar to risks for women with singletons-particularly for those who successfully undergo VBAC. For each of the clinical scenarios above, however, two major factors remain constant: (1) obstetricians need to be prepared for, and skilled in, breech extraction of the second twin; and (2) individualized patient counseling with regard to mode of delivery is important when offering a vaginal trial of labor to women with a twin gestation.”

Article describing the Twin Birth Study.

A Randomized Trial of Planned Cesarean or Vaginal Delivery for Twin Pregnancy.
Barrett, Jon F.R., Mary E. Hannah, Mary E., Hutton, Eileen K., Willan, Andrew R., Allen, Alexander C., Armson, B. Anthony, Gafni, Amiram, Joseph, K.S., Mason, Dalah, Ohlsson, Arne, Ross, Susan, Sanchez, J. Johanna, and Asztalos, Elizabeth V.
New England Journal of Medicine 369(14), 2013.

“In twin pregnancy between 32 weeks 0 days and 38 weeks 6 days of gestation, with the first twin in the cephalic presentation, planned cesarean delivery did not significantly decrease or increase the risk of fetal or neonatal death or serious neonatal morbidity, as compared with planned vaginal delivery.”

Twin pregnancy outcomes after increasing rate of vaginal twin delivery: Retrospective cohort study in a Hong Kong regional obstetrical unit.
Hiu Tung Tang, Ah Lai Liu, Sum Yee Chan, Chin Ho Lau, Wai Kuen Yung, Wai Lam Lau, and Wing Cheong Leung
The Journal of Maternal-Fetal & Neonatal Medicine, 2015.

“With proper counseling, significantly more women who were suitable for vaginal twin delivery would opt to do so.”