A 28-year-old woman, gravida 1 para 0, at 37 weeks gestation comes to the emergency department due to leakage of fluid and painful uterine contractions that occur every 2-5 minutes. The patient has a spontaneous dichorionic/diamniotic twin gestation; her pregnancy has otherwise been uncomplicated. Serial ultrasounds throughout the pregnancy have consistently shown concordant growth of the twins. The patient has no chronic medical conditions and has had no surgery. She takes a daily prenatal vitamin. Examination confirms rupture of membranes; on digital examination the cervix is 5 cm dilated. Bedside ultrasound reveals that both twins are in vertex presentation. The patient is admitted to the hospital for labor, and epidural analgesia is administered. Twin A is delivered vaginally 8 hours after admission, with Apgars of 8 and 9 at 1 and 5 minutes, respectively. The patient is reexamined and the cervix has contracted to 9 cm, 100% effaced, with the vertex of twin B at −2 station. The amniotic membranes are intact. Fetal heart tracing is category 1. Tocometry shows contractions every 2-3 minutes. Which of the following is the best next step in management of this patient?

Question

A 28-year-old woman, gravida 1 para 0, at 37 weeks gestation comes to the emergency department due to leakage of fluid and painful uterine contractions that occur every 2-5 minutes.  The patient has a spontaneous dichorionic/diamniotic twin gestation; her pregnancy has otherwise been uncomplicated.  Serial ultrasounds throughout the pregnancy have consistently shown concordant growth of the twins.  The patient has no chronic medical conditions and has had no surgery.  She takes a daily prenatal vitamin.  Examination confirms rupture of membranes; on digital examination the cervix is 5 cm dilated.  Bedside ultrasound reveals that both twins are in vertex presentation.  The patient is admitted to the hospital for labor, and epidural analgesia is administered.  Twin A is delivered vaginally 8 hours after admission, with Apgars of 8 and 9 at 1 and 5 minutes, respectively.  The patient is reexamined and the cervix has contracted to 9 cm, 100% effaced, with the vertex of twin B at −2 station.  The amniotic membranes are intact.  Fetal heart tracing is category 1.  Tocometry shows contractions every 2-3 minutes.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c02d_f3ec_8f63_c1a4a8dc32a5_MD0005_00 The delivery of a second twin is associated with an increased risk of umbilical cord prolapse, abruptio placentae, malpresentation, and neonatal death. To minimize these risks, vaginal delivery of twin gestations is offered selectively. In patients with dichorionic/diamniotic twins, mode of delivery is dictated by fetal presentation. When dichorionic/diamniotic twins are in a vertex/vertex presentation, a vaginal delivery can be attempted. dichorionic/diamniotic twins After delivery of twin A (ie, the first twin), the cervix often constricts (ie, cervical dilation decreases) due to a lack of engagement (ie, high station) of twin B. The cervix typically returns to complete dilation quickly when the presenting part of twin B descends into the pelvis. After the delivery of twin A and prior to the descent of twin B, an ultrasound is used to reconfirm the presentation of twin B. If twin B still has a vertex presentation and a reassuring fetal heart rate tracing (ie, normal baseline, moderate variability, accelerations, no decelerations), twin B is expectantly managed. no decelerations (Choice A) Indications for cesarean delivery of twins include monoamnioticity, malpresentation of twin A, and a nonreassuring fetal heart rate tracing of either twin during labor. (Choice C) A forceps-assisted vaginal delivery is indicated for an arrested second stage of labor, fetal heart rate tracing abnormalities, or maternal contraindications to Valsalva (eg, cardiac or neurologic disease). However, criteria for operative vaginal delivery include complete cervical dilation (10 cm) and at least +2 fetal station. fetal station (Choice D) Internal podalic version is used to facilitate delivery of a nonvertex twin B that is still a candidate for vaginal delivery. It entails the intrauterine manipulation of the fetus from a transverse or oblique lie to a breech presentation, thereby expediting delivery. In this patient, twin B is in vertex presentation and these maneuvers are not indicated. transverse breech presentation (Choice E) Oxytocin administration is indicated for labor protraction due to inadequate uterine contractions. This patient is contracting every 2-3 minutes and therefore is likely having adequate contractions. Educational objective: Vaginal delivery is indicated for dichorionic/diamniotic twins in a vertex/vertex presentation. If, after delivery of twin A (the first twin), twin B is in vertex presentation and has a normal fetal heart tracing, labor is managed expectantly. References: Management of twins: vaginal or cesarean delivery? (http://www.ncbi.nlm.nih.gov/pubmed/25851847) Multifetal festation: mode of delivery. (http://www.ncbi.nlm.nih.gov/pubmed/26165179)

A 28-Year-Old Woman, Gravida 1 Para 0, at 37 Weeks