Abstract
In France, the rate of twin deliveries is estimated at 1.6% of all births. These recommendations address the gestational age at delivery and the mode of delivery for twin pregnancies. They were developed using the GRADE methodology, with questions formulated according to the PICO framework. Regarding gestational age at delivery, in cases of uncomplicated dichorionic diamniotic pregnancies, it is recommended to plan delivery between 37 weeks and 0 days and 38 weeks and 6 days of gestation (weak recommendation, very low-quality evidence). In cases of uncomplicated monochorionic diamniotic pregnancies, it is recommended to plan delivery between 36 weeks and 0 day and 37 weeks and 6 days of gestation (weak recommendation, very low-quality evidence). Finally, in cases of uncomplicated monochorionic monoamniotic pregnancies, it is recommended to plan delivery between 33 weeks and 0 day and 34 weeks and 6 days of gestation (weak recommendation, very low-quality evidence). Regarding the mode of delivery for diamniotic twin pregnancies, when the first twin is in cephalic presentation and the gestational age is 32 weeks or more, a planned vaginal birth is recommended (strong recommendation, high-quality evidence). When the first twin is in breech presentation and the gestational age is 32 weeks or more, it is recommended to offer either a trial of vaginal birth or a scheduled cesarean section; the expert group suggests favoring a trial of vaginal birth when all eligibility criteria are met (weak recommendation, low-quality evidence). In monoamniotic twin pregnancies, the available data are insufficient in both quantity and quality to issue a recommendation regarding a trial of vaginal birth compared with a scheduled cesarean section (no recommendation, very low-quality evidence). It is recommended to offer labor induction rather than a scheduled cesarean section when delivery is indicated at 32 weeks or more and the first twin is in cephalic presentation (weak recommendation, very low-quality evidence). Regarding the delivery of the second twin, in vaginal births at 32 weeks or more with the second twin in cephalic presentation, it is recommended to perform either internal version or resumption of pushing efforts, with artificial rupture of membranes with or without oxytocin (weak recommendation, low-quality evidence). When the second twin is in breech presentation, total breech extraction is recommended rather than resumption of pushing efforts (weak recommendation, very low-quality evidence). In diamniotic twin pregnancies with spontaneous labor before 32 weeks and with the first twin in cephalic presentation, it is recommended to offer a trial of vaginal birth rather than systematic cesarean section (weak recommendation, low-quality evidence). The available data are insufficient in both quantity and quality to issue a recommendation regarding a trial of vaginal birth compared with systematic cesarean section in cases of spontaneous labor before 32 weeks with the first twin in breech presentation (no recommendation, very low-quality evidence). It is recommended not to take growth discordance into account when choosing the mode of delivery (weak recommendation, very low-quality evidence). The available data are insufficient in both quantity and quality to issue a recommendation regarding the usefulness of pelvimetry when the first twin is in cephalic presentation (no recommendation, very low-quality evidence).