Care during labour and birth
The Twin Birth Study has clearly shown that routine planned elective caesarean section is not advantageous for the fetuses, and this finding applies to both dichorionic and MCDA twins (107).
It is, however, important to emphasize that to optimize outcomes, deliveries should be carried out by skilled clinicians, particularly in vaginal breech delivery (if the second twin is non-vertex), and there is access to facilities for emergency caesarean section without delay. The evidence to guide the mode of delivery for preterm twins less than 32 weeks' gestation is not robust and conflicting. There is some evidence to support caesarean section when the fetal weight range is 500-1500 g; however, vaginal delivery is an acceptable practice if the first twin is vertex until more robust data come available (109).When in labour, there should be one- to- one care with an attending midwife. It is important to ascertain separate fetal heart monitoring, ideally using a cardiotocography machine with twin tracing functions. Indications for delivery by caesarean section when a woman in labour would include usual indications as per NICE intrapartum care guidance for singletons; however, failure to adequately monitor twin 2 or fetal distress would need offering delivery by caesarean section. When in the second stage, the obstetrician and the neonatal team (if there are any concerns about gestation) should be informed. There should be two resuscitaires in the proximity (checked for functioning prior to delivery and switched on and warm). An ultrasound machine should be available, as it would be needed to check the presentation of the second twin after the delivery of the first, and to stabilize fetal lie. Adequate arrangements including oxytocin for the third stage need to be made beforehand as women with multiple pregnancies are at a higher risk of postpartum haemorrhage.