A trial of labor and vaginal delivery are usually indicated in vertex-vertex twins. For vertex-nonvertex twins, vaginal birth is preferred, with the second twin being delivered by breech extraction, unless it is significantly larger than the first. Cesarean delivery is indicated if the first twin is nonvertex and for all cases of monoamniotic or potentially viable conjoined twins. There is a limited role for trial of labor after cesarean delivery in twin gestations. In my opinion, combined vaginal-cesarean birth is the riskiest method for mother and infants and should be avoided if possible.
The route of delivery of twins is determined by presentation and operator skill, and combined vaginal-cesarean deliveries should be avoided whenever possible.
From the Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin.
Corresponding author: Dwight P. Cruikshank, MD, 9200 West Wisconsin Avenue, Milwaukee, WI 53226; e-mail: firstname.lastname@example.org.