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 About 40% of twins present as cephalic/cephalic. The remainder pose some abnormal
presentation of one or both twins. Because of the abnormal presentations and the
complexities of delivering twins, many are delivered by cesarean section.
Some physicians favor cesarean delivery for all twins feeling that
this is probably a little safer for the babies and not appreciably
more dangerous for the mother. Others offer vaginal delivery on a
selective basis. Factors that can contribute a greater degree of
safety to vaginal delivery of twins include:
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Experience of the operator
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Cephalic/cephalic presentation
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Previous vaginal deliveries of the mother
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Not too big and not too small
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No large discrepancy in twin sizes.
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Normal electronic fetal monitoring pattern
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Normal progress in labor
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Resources for quickly changing to a cesarean section for one or
both twins in the event of unfavorable occurrences.
One special circumstance requiring a cesarean section is a
mono-amniotic sac with breech/cephalic twins. In this case, the
opportunity of "interlocking twins" during delivery is too great and
cesarean section is normally chosen.
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If vaginal delivery is chosen, remember that following delivery of the first twin, there is a period of time during which
contractions slow or stop. Both placentas remain inside the uterus and attached.
It is usually safest to make no attempt to speed up this process, but to await the
resumption of contractions. This could take a few minutes or many minutes. While waiting,
monitor the second twin's heart beat and if normal, continue to observe the patient.
If contractions do not promptly resume, it is acceptable to stimulate the uterus with
oxytocin.
With your hand in the vagina, feel the fetal presenting part. If it is not engaged, try
to guide it down to the pelvic inlet. Avoid rupturing membranes until the fetal presenting
part is engaged in the birth canal.
As the presenting part descends, ask the mother to bear down and usually
the second twin will deliver as easily as the first twin. 
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