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delivery of second twin

delivery of second twin Posted by Jonathan N.

Just done some MCQs and came across some questions about delivery of the 2nd twin. My understanding (and clinical practice that I have seen and used myself in the UK) is that internal podalic version is acceptable management, especially with fetal distress to expedite delivery. The MCQ I copied below says this is false. In fact there was a TOG article on this in 2011 (Webster SNE, Loughney AD, Internal podalic version with breech extraction. The Obstetrician & Gynaecologist 2011; 13:7-14.)

Also, textbooks do describe the use of a ventouse with the station in the midpelvis or at the pelvic brim for the 2nd twin if bradycardia. (Munro-Kerr's Operative Obstetrics, 2007, p.198) Again this is something I have been taught in modern UK O&G practice and used myself.

Any thoughts?

Internal podalic version is no longer an acceptable procedure



Your answer: False

Correct answer: True



1) Conditions for vaginal operative delivery must be met and the head must be engaged

2) ECV should be considered if twin 2 is breech. Internal podalic version for a non-longitudinal lie however carries significant risks and should not be undertaken

3) The fetal heart should be monitored continuously

Posted by Jonathan N.

I agree with many of the comments you have made and I am a junior registrar who is yet to face many bad outcomes / litigation etc,.

I do think it is still 'acceptable' practice though to perform an internal podalic version for a 2nd twin in appropriate circumstances (maybe the example of a bradycardia was not best, but a breech extraction can be used to expidite delivery). There will be a body of consultants who feel it is 'unacceptable' to revert to LSCS of a 2nd twin without trying an internal podalic version.

It is clearly a skill which is rarely performed. There are aspects of it that we do perform more regular though - for example at a breech LSCS or transverse lie we often perform the breech extraction portion of this delivery in order to be prepared for when it might be appropriate in a 2nd twin. There is the morbidity from the delay of going to theatre and the maternal morbidity from a FD LSCS to consider too.