I have copied two articles which may be of some help to you.
All the best,
Leanne.
Investigating the inter-twin interval
Issue 11: 30 May 2005
Source: American Journal of Obstetrics and Gynecology 2005; 192: 1420-2
The length of time between the birth of the first and second twin has no
significant effect on the immediate neonatal outcome of the younger twin,
according to the results of a new study.
Specialists in maternal-fetal medicine at the Saint Joseph Mercy Hospital in
Ypsilanti, Michigan, USA, reviewed the hospital’s medical records concerning
the neonatal outcomes of all live-born viable vaginal twin deliveries over a
6-year period: a total of 144 sets of twins.
They used statistical analyses to identify factors significantly associated
with immediate neonatal outcomes of the second twin: the umbilical arterial
pH, the umbilical venous pH, the 1-minute Apgar score and the 5-minute Apgar
score.
Overall, the inter-twin time interval for the twins studied ranged from a
few minutes to an extreme of about 130 minutes.
The 1- and 5-minute Apgar scores were significantly predicted only by
gestational age and birth weight, while umbilical arterial and venous pH
were significantly predicted only by the inter-twin interval. For every
extra minute of the inter-twin interval, the arterial pH fell linearly by
0.00063 units, and the venous pH by 0.00081 units.
Second twins born more than 45 minutes after the first twin typically had an
arterial or venous pH that was 0.07 units lower than that of second twins
born within 15 minutes of the first twin.
Not clinically relevant?
The researchers say their study confirms that a longer inter-twin interval
is associated with a “continuous slow decline” in umbilical cord pH. But
they add: “However, although these pH differences may be of note from a
physiologic standpoint, we do not believe that they are of a magnitude great
enough to influence clinical management.”
They continue: “We believe our data support the view that expectant
management of the second twin birth is appropriate and do not support
arbitrary intervention based solely on time.”
The second-twin delivery dilemma
Issue 08: 22 Apr 2002
Source:
European Journal of Obstetrics & Gynecology and Reproductive Biology 2002;
In press (lead author Pons J-C)
The first twin has been delivered successfully, but what is the optimal
method for delivering the second? The two main options are active and
expectant management, a choice that has been the subject of debate among
specialists for many years. That debate is now furthered by a new study
comparing the two approaches.
Specialists in Grenoble and Paris, France, carried out a retrospective study
investigating twin births at two maternity units over a 2-3 year period: a
total of 78 pairs of twins at the Port-Royal unit in Paris, and 113 pairs at
the Antoine Beclere unit in Clamart. All the first twins had been delivered
vaginally.
The expectant approach
At the Antoine Beclere, the obstetrics team generally applied the expectant
approach to delivering the second twin. This is based on respect for the
natural process of twin delivery: the delivery of the first twin (twin A),
then an interval of 10-15 minutes marked by a halt to uterine contractions,
then resumption of contractions and delivery of the second twin (twin B),
followed by the afterbirth. As the researchers point out in their paper, the
role of the medical team is to accompany this process, with "watchful
waiting, fetal heart rate monitoring, external version of the second twin in
a transverse lie towards the longitudinal, and patience." An objective is to
avoid maneuvers considered traumatizing (such as total breech extraction) or
alternatives such as cesarean delivery of twin B.
The average delay between the birth of two twins at this unit was 9 minutes.
A total of 51 percent of deliveries were spontaneous, with intra-uterine
manipulation applied to only 2 percent of the second twins. It was necessary
to perform a cesarean to deliver the second twin in five of the 113 cases.
The active approach
In contrast, the team at the Port-Royal largely applied the active approach
to delivering twin B, based on the view that time spent in utero after the
birth of twin A is harmful. "The difficulty of fetal monitoring and the risk
of acute fetal distress and of retraction of the cervix may make the second
twin's delivery very difficult, if not impossible," the researchers note.
The active approach aims to limit the duration of the interval between the
two births. After the birth of twin A, the artificial rupture of the
membranes must be followed by twin B's birth, either spontaneously or
assisted by obstetric maneuvers.
At the Port-Royal, the average time between the two births was 5 minutes,
and 43 percent of twin B births involved substantial intra-uterine
manipulations to assist vaginal delivery. Only 27 percent of the deliveries
were spontaneous. No cesarean deliveries were performed.
The Apgar assessment scores of the newborns, at both 1 and 5 minutes after
birth, were identical at the two units. The proportions of second twins
transferred to the neonatal intensive care unit were also similar at both
units, at 18-19 percent.
"Equivalent" outcomes
After reviewing these and many other indicators of health, the researchers
conclude: "The neonatal results were similar in both groups, even though
both the rate of obstetric maneuvers and the interbirth interval differed
significantly. The two methods therefore appear to be equivalent when judged
by the second twin's neonatal indicators."
They call for further research to verify whether an active approach helps to
avoid or reduce the risk of cesarean delivery.
The researchers finish by making an important observation about a risk
associated with the expectant approach that could not be quantified in the
study: "This risk is the unfamiliarity or loss of clinical experience with
the obstetric maneuvers involved in version by intra-uterine manipulations
and total extraction, and thus to be unequipped to perform them on the day
they are indispensable." They therefore suggest that tertiary maternity
units promote the active approach to second-twin delivery, to ensure
adequate training of interns, residents and student midwives.
From: "Lindsay & Yvette" <[EMAIL PROTECTED]>
Reply-To: ozmidwifery@acegraphics.com.au
To: <ozmidwifery@acegraphics.com.au>
Subject: Re: [ozmidwifery] RE Twins
Date: Thu, 2 Jun 2005 10:54:38 +1000
Thanks for your reply Lieve. What state are you in?
I'm certainly not keen to let them induce if I get to 38 weeks. They say
there is no way of telling the condition of the placenta, and that there's
evidence or studies to show significant increase in worse outcomes after 38
weeks or something like that, but I don't know yet what studies/evidence
they're relying on re this. I will be asking for details as soon as they
let me see someone.
I see with the second one you described there was 1/2 hour between babies
for monochorionic diamniotic twins. I'm not convinced about the 10 minute
thing either, and they'll have to give me details of what evidence they're
relying on if they want me to consider this seriously as well.
I'm starting to think I should place the onus more on them to prove to me
why I should adhere to their "recommendations" rather than the other way
around. If they can let me see the info myself I can consider it, but I
don't think I should just take their word for it.
I met another pregnant mum yesterday, same type of twins as me and in a
public hospital in Melbourne too. She's having the same issues as me. She
doesn't want an epidural and has been told she has to have one. She waits
up to 2 hours for a rushed 10 minute appointment with an Ob, then doesn't
get to ask any questions. We'll be staying in touch; she's due a few weeks
before me.
Yvette
(pg with monochorionic diamniotic twins due 5th Sept).
Hello Yvette,
I just want to tell you my excperience. I accompagned two twin births
this year in the hospital. We have there very good supporting obs, that
are very confident with breech and twin births.
Lieve
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Leanne Wynne
Midwife in charge of "Women's Business"
Mildura Aboriginal Health Service Mob 0418 371862
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