Second twin transverse after birth of twin 1 — emergency management station

Team-based emergency station: transverse second twin with fetal bradycardia after vaginal birth of twin 1. Tests the interval drill, decision-making between internal podalic version and caesarean, the technique of version and breech extraction, prevention of combined delivery, anticipation of postpartum haemorrhage, and team communication. Includes assessor timeline, marking domains and assessor key.

Prompt

A 34-year-old G3P1 with a dichorionic diamniotic twin pregnancy labours spontaneously at 37+3 weeks. Twin 1 is born vaginally in cephalic presentation at 02:14. Two minutes later the midwife tells you twin 2's heart rate has fallen to 90 beats per minute and the abdomen feels broad and low. Bedside ultrasound shows twin 2 in a transverse lie with the back down and the membranes intact. She has a working epidural. You are the registrar; the consultant is in the building.

Station brief

Format. Emergency management station, approximately 12 minutes. You are the obstetric registrar in a birth suite room with a midwife, a second midwife caring for twin 1, an anaesthetist and two neonatal staff. The assessor runs the clock and feeds you findings. ^[1]

Candidate instruction. Lead the management of a transverse second twin with a fetal bradycardia. Verbalise your actions, your decisions and the reasons behind them, and your communication with the woman and the team. ^[2]^[5]

References6Show

[1]Barrett JF, Hannah ME, Hutton EK, et al. A randomized trial of planned cesarean or vaginal delivery for twin pregnancy N Engl J Med, 2013.PMID 24088091
[2]Aviram A, Lipworth H, Asztalos EV, et al. The worst of both worlds-combined deliveries in twin gestations: a subanalysis of the Twin Birth Study, a randomized, controlled, prospective study Am J Obstet Gynecol, 2019.PMID 31254526
[3]Smith GC, Fleming KM, White IR Birth order of twins and risk of perinatal death related to delivery in England, Northern Ireland, and Wales, 1994-2003: retrospective cohort study BMJ, 2007.PMID 17337456
[4]Leung TY, Tam WH, Leung TN, et al. Effect of twin-to-twin delivery interval on umbilical cord blood gas in the second twins BJOG, 2002.PMID 11843376
[5]American College of Obstetricians and Gynecologists Multifetal Gestations: Twin, Triplet, and Higher-Order Multifetal Pregnancies: ACOG Practice Bulletin, Number 231 Obstet Gynecol, 2021.PMID 34011891
[6]Royal College of Obstetricians and Gynaecologists (RCOG) Management of Monochorionic Twin Pregnancy: Green-top Guideline No. 51 BJOG, 2017.PMID 27862859

Second twin transverse after birth of twin 1 — emergency management station

Station brief

References6Show

[1]Barrett JF, Hannah ME, Hutton EK, et al. A randomized trial of planned cesarean or vaginal delivery for twin pregnancy N Engl J Med, 2013.PMID 24088091
[2]Aviram A, Lipworth H, Asztalos EV, et al. The worst of both worlds-combined deliveries in twin gestations: a subanalysis of the Twin Birth Study, a randomized, controlled, prospective study Am J Obstet Gynecol, 2019.PMID 31254526
[3]Smith GC, Fleming KM, White IR Birth order of twins and risk of perinatal death related to delivery in England, Northern Ireland, and Wales, 1994-2003: retrospective cohort study BMJ, 2007.PMID 17337456
[4]Leung TY, Tam WH, Leung TN, et al. Effect of twin-to-twin delivery interval on umbilical cord blood gas in the second twins BJOG, 2002.PMID 11843376
[5]American College of Obstetricians and Gynecologists Multifetal Gestations: Twin, Triplet, and Higher-Order Multifetal Pregnancies: ACOG Practice Bulletin, Number 231 Obstet Gynecol, 2021.PMID 34011891
[6]Royal College of Obstetricians and Gynaecologists (RCOG) Management of Monochorionic Twin Pregnancy: Green-top Guideline No. 51 BJOG, 2017.PMID 27862859