Mode d’accouchement des grossesses gémellaires

Abstract

The assessment of optimal delivery for twin gestations is complex due to the relatively high frequency of obstetrical complications and to the heterogeneity of delivery management in these conditions. The extern validity of the Anglo-Saxon studies is limited in particular because delivery management of the second twin (approach of external cephalic version) differs from the French one (approach of internal version and/or total breech extraction) in cases of non-vertex second twin. Anglo-Saxon studies suggest that a planned vaginal delivery is associated to an increased risk of neonatal morbidity for second twin compared to first twin at term, in particular in cases of combined vaginal-cesarean birth. To reduce the interval twin-to-twin delivery interval and the number of combined vaginal-cesarean births, in our opinion, one must stop to perform external cephalic version and recommend a routinely active management for the second non-vertex twin delivery. With this active management, there is no evidence to support planned cesarean section for twins. Nevertheless, active management requires training as internal version might be difficult to perform, and therefore it is essential to pursue to teach junior obstetrician these obstetric maneuvers. There is limited role for trial of labor after cesarean delivery in twin gestation with a policy of active management.