Issue

Vol. 2 No. 2 (2025)

Date Log

Submitted
January 20, 2026
Published
December 31, 2025

Copyright (c) 2025 Samar Hussein Altoukhi, Sattam Ali Alenazi, Ali Hussain Qasem Alnami, Sarah Alafaleq, Adel Hassan Yahya Mashufi, Abdoilah Muteb Jazaa Alharbi, Turki Ahmed Alasmari, Mohammed Abdullah Saleh Alamri, Obaid Abed Obaidallah Alabsi, Ibrahim Khalaf I. Alghamdi

Creative Commons License

This work is licensed under a Creative Commons Attribution 4.0 International License.

Clinical Management and Public Health Implications of Multiple Birth Deliveries: An Interdisciplinary Approach Integrating Gynecology, Family Medicine, Radiology, and Anesthesia

https://doi.org/10.64483/202522546
Samar Hussein Altoukhi
King Fahad Medical City – KFMC, Ministry of Health, Saudi Arabia
Sattam Ali Alenazi
Ministry of Health, Saudi Arabia
Ali Hussain Qasem Alnami
Riyadh Second Health Cluster, Saudi Arabia
Sarah Alafaleq
Ministry of Health, Saudi Arabia
Adel Hassan Yahya Mashufi
Sabya General Hospital, Ministry of Health , Saudi Arabia
Abdoilah Muteb Jazaa Alharbi
Health Control Center – Prince Mohammad bin Abdulaziz International Airport, Madinah Health Cluster, Saudi Arabia
Turki Ahmed Alasmari
Imam Abdulrahman Al-Faisal Hospital, Riyadh, Ministry of Health , Saudi Arabia
Mohammed Abdullah Saleh Alamri
Imam Abdulrahman Al-Faisal Hospital, Riyadh, Ministry of Health , Saudi Arabia
Obaid Abed Obaidallah Alabsi
Farasan General Hospital – Jazan – Ministry of Health, Saudi Arabia
Ibrahim Khalaf I. Alghamdi
Al-Baha – Ministry of Health, Saudi Arabia

Corresponding Author(s) : Samar Hussein Altoukhi

Dr.samartoukhi@gmail.com

Saudi Journal of Medicine and Public Health, Vol. 2 No. 2 (2025)

Abstract

Background: Multiple birth deliveries, particularly twin and higher-order gestations, are associated with substantially increased maternal and perinatal risks compared with singleton pregnancies. These risks necessitate specialized antenatal surveillance, individualized delivery planning, and coordinated intrapartum management. Despite advances in obstetric care, optimal timing and mode of delivery in multifetal pregnancies remain complex and dependent on several clinical factors.


Aim: This article aims to review and synthesize current evidence on the clinical management of multiple birth deliveries, with emphasis on delivery timing, mode of birth, multidisciplinary preparation, and intrapartum techniques to optimize maternal and neonatal outcomes.


Methods: A narrative, evidence-based review was conducted integrating data from randomized controlled trials, observational studies, and professional guidelines. The analysis focused on twin gestations stratified by chorionicity and amnionicity, as well as higher-order multiple pregnancies, addressing indications, preparation, personnel requirements, delivery techniques, and complications.


Results: Evidence supports a risk-stratified approach to multiple birth delivery. Planned vaginal delivery is safe in carefully selected twin pregnancies where the leading twin is cephalic and no contraindications exist, while cesarean delivery is generally favored for monochorionic monoamniotic and higher-order gestations. Intensive antenatal surveillance, intrapartum ultrasound, and multidisciplinary readiness are critical to favorable outcomes.


Conclusion: Individualized planning grounded in placental characteristics, fetal presentation, and institutional expertise is central to safe and effective multiple birth delivery.

Keywords

Multiple pregnancy, twin delivery, chorionicity, vaginal delivery, cesarean section, obstetric management
Altoukhi, S. H., Sattam Ali Alenazi, Ali Hussain Qasem Alnami, Sarah Alafaleq, Adel Hassan Yahya Mashufi, Abdoilah Muteb Jazaa Alharbi, … Ibrahim Khalaf I. Alghamdi. (2025). Clinical Management and Public Health Implications of Multiple Birth Deliveries: An Interdisciplinary Approach Integrating Gynecology, Family Medicine, Radiology, and Anesthesia. Saudi Journal of Medicine and Public Health, 2(2), 3139–3151. https://doi.org/10.64483/202522546
Download Citation
Endnote/Zotero/Mendeley (RIS)
BibTeX
References
  1. Horon I, Martin JA. Changes in Twin Births in the United States,2019-2021. National vital statistics reports : from the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System. 2022 Dec:71(9):1-11
  2. Multifetal Gestations: Twin, Triplet, and Higher-Order Multifetal Pregnancies: ACOG Practice Bulletin, Number 231. Obstetrics and gynecology. 2021 Jun 1:137(6):e145-e162. doi: 10.1097/AOG.0000000000004397.
  3. Aviram A, Lipworth H, Asztalos EV, Mei-Dan E, Melamed N, Cao X, Zaltz A, Hvidman L, Barrett JFR. Delivery of monochorionic twins: lessons learned from the Twin Birth Study. American journal of obstetrics and gynecology. 2020 Dec:223(6):916.e1-916.e9. doi: 10.1016/j.ajog.2020.06.048.
  4. Barrett JF, Hannah ME, Hutton EK, Willan AR, Allen AC, Armson BA, Gafni A, Joseph KS, Mason D, Ohlsson A, Ross S, Sanchez JJ, Asztalos EV, Twin Birth Study Collaborative Group. A randomized trial of planned cesarean or vaginal delivery for twin pregnancy. The New England journal of medicine. 2013 Oct 3:369(14):1295-305. doi: 10.1056/NEJMoa1214939.
  5. Sharshiner R, Silver RM. Management of fetal malpresentation. Clinical obstetrics and gynecology. 2015 Jun:58(2):246-55. doi: 10.1097/GRF.0000000000000103.
  6. Chibber R, El-Saleh E, Al Fadhli R, Al Jassar W, Al Harmi J. Uterine rupture and subsequent pregnancy outcome--how safe is it? A 25-year study. The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians. 2010 May:23(5):421-4. doi: 10.3109/14767050903440489.
  7. ACOG Committee on Practice Bulletins. ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. No. 82 June 2007. Management of herpes in pregnancy. Obstetrics and gynecology. 2007 Jun:109(6):1489-98
  8. Gill P, Lende MN, Van Hook JW. Twin Births. StatPearls. 2023 Jan
  9. Glinianaia SV, Rankin J, Khalil A, Binder J, Waring G, Sturgiss SN, Thilaganathan B, Hannon T. Prevalence, antenatal management and perinatal outcome of monochorionic monoamniotic twin pregnancy: a collaborative multicenter study in England, 2000-2013. Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology. 2019 Feb:53(2):184-192. doi: 10.1002/uog.19114.
  10. Van Mieghem T, Abbasi N, Shinar S, Keunen J, Seaward G, Windrim R, Ryan G. Monochorionic monoamniotic twin pregnancies. American journal of obstetrics & gynecology MFM. 2022 Mar:4(2S):100520. doi: 10.1016/j.ajogmf.2021.100520.
  11. Madsen C, Søgaard K, Zingenberg H, Jørgensen FS, Rosbach H, Hoseth E, Pedersen LH, Petersen OB. Outcomes of monoamniotic twin pregnancies managed primarily in outpatient care-a Danish multicenter study. Acta obstetricia et gynecologica Scandinavica. 2019 Apr:98(4):479-486. doi: 10.1111/aogs.13509.
  12. Patient Safety and Quality Committee, Society for Maternal-Fetal Medicine. Electronic address: smfm@smfm.org, Hoskins IA, Combs CA. Society for Maternal-Fetal Medicine Special Statement: Updated checklists for management of monochorionic twin pregnancy. American journal of obstetrics and gynecology. 2020 Nov:223(5):B16-B20. doi: 10.1016/j.ajog.2020.08.066.
  13. MONOMONO Working Group. Inpatient vs outpatient management and timing of delivery of uncomplicated monochorionic monoamniotic twin pregnancy: the MONOMONO study. Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology. 2019 Feb:53(2):175-183. doi: 10.1002/uog.19179.
  14. Anselem O, Mephon A, Le Ray C, Marcellin L, Cabrol D, Goffinet F. Continued pregnancy and vaginal delivery after 32 weeks of gestation for monoamniotic twins. European journal of obstetrics, gynecology, and reproductive biology. 2015 Nov:194():194-8. doi: 10.1016/j.ejogrb.2015.09.014.
  15. Chitrit Y, Korb D, Morin C, Schmitz T, Oury JF, Sibony O. Perinatal mortality and morbidity, timing and route of delivery in monoamniotic twin pregnancies: a retrospective cohort study. Archives of gynecology and obstetrics. 2021 Mar:303(3):685-693. doi: 10.1007/s00404-020-05782-1.
  16. Lewi L. Monochorionic diamniotic twin pregnancies. American journal of obstetrics & gynecology MFM. 2022 Mar:4(2S):100501. doi: 10.1016/j.ajogmf.2021.100501.
  17. Lewi L, Jani J, Blickstein I, Huber A, Gucciardo L, Van Mieghem T, Doné E, Boes AS, Hecher K, Gratacós E, Lewi P, Deprest J. The outcome of monochorionic diamniotic twin gestations in the era of invasive fetal therapy: a prospective cohort study. American journal of obstetrics and gynecology. 2008 Nov:199(5):514.e1-8. doi: 10.1016/j.ajog.2008.03.050.
  18. American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice, Society for Maternal-Fetal Medicine. Medically Indicated Late-Preterm and Early-Term Deliveries: ACOG Committee Opinion, Number 831. Obstetrics and gynecology. 2021 Jul 1:138(1):e35-e39. doi: 10.1097/AOG.0000000000004447.
  19. Roberts D, Brown J, Medley N, Dalziel SR. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. The Cochrane database of systematic reviews. 2017 Mar 21:3(3):CD004454. doi: 10.1002/14651858.CD004454.pub3.
  20. Gyamfi-Bannerman C, Thom EA. Antenatal Betamethasone for Women at Risk for Late Preterm Delivery. The New England journal of medicine. 2016 Aug 4:375(5):486-7. doi: 10.1056/NEJMc1605902.
  21. . Indications for Outpatient Antenatal Fetal Surveillance: ACOG Committee Opinion, Number 828. Obstetrics and gynecology. 2021 Jun 1:137(6):e177-e197. doi: 10.1097/AOG.0000000000004407.
  22. Bernal Claverol M, Ruiz Minaya M, Aracil Moreno I, Tizón SG, Pintado Recarte P, Alvarez-Mon M, Arribas CB, Ortega MA, De Leon-Luis JA. Maternal, Perinatal and Neonatal Outcomes of Triplet Pregnancies According to Chorionicity: A Systematic Review of the Literature and Meta-Analysis. Journal of clinical medicine. 2022 Mar 28:11(7):. doi: 10.3390/jcm11071871.
  23. Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstetrics and gynecology. 2017 Oct:130(4):e168-e186. doi: 10.1097/AOG.0000000000002351.
  24. Patel K, Zakowski M. Enhanced Recovery After Cesarean: Current and Emerging Trends. Current anesthesiology reports. 2021:11(2):136-144. doi: 10.1007/s40140-021-00442-9.
  25. Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin No. 199: Use of Prophylactic Antibiotics in Labor and Delivery. Obstetrics and gynecology. 2018 Sep:132(3):e103-e119. doi: 10.1097/AOG.0000000000002833.
  26. . Practice Bulletin No. 199: Use of Prophylactic Antibiotics in Labor and Delivery: Correction. Obstetrics and gynecology. 2019 Oct:134(4):883-884. doi: 10.1097/AOG.0000000000003499.
  27. Tita AT, Szychowski JM, Boggess K, Saade G, Longo S, Clark E, Esplin S, Cleary K, Wapner R, Letson K, Owens M, Abramovici A, Ambalavanan N, Cutter G, Andrews W, C/SOAP Trial Consortium. Adjunctive Azithromycin Prophylaxis for Cesarean Delivery. The New England journal of medicine. 2016 Sep 29:375(13):1231-41. doi: 10.1056/NEJMoa1602044.
  28. Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, Reinke CE, Morgan S, Solomkin JS, Mazuski JE, Dellinger EP, Itani KMF, Berbari EF, Segreti J, Parvizi J, Blanchard J, Allen G, Kluytmans JAJW, Donlan R, Schecter WP, Healthcare Infection Control Practices Advisory Committee. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA surgery. 2017 Aug 1:152(8):784-791. doi: 10.1001/jamasurg.2017.0904.
  29. Caissutti C, Saccone G, Zullo F, Quist-Nelson J, Felder L, Ciardulli A, Berghella V. Vaginal Cleansing Before Cesarean Delivery: A Systematic Review and Meta-analysis. Obstetrics and gynecology. 2017 Sep:130(3):527-538. doi: 10.1097/AOG.0000000000002167.
  30. Liao JB, Buhimschi CS, Norwitz ER. Normal labor: mechanism and duration. Obstetrics and gynecology clinics of North America. 2005 Jun:32(2):145-64, vii
  31. Fieni S, Di Ilio C, Kiener AJO, Scebba D, D'Amario P, Dall'Asta A, Ghi T. Real-time ultrasound to assist during a vaginal breech delivery. American journal of obstetrics and gynecology. 2023 Apr 8:():. pii: S0002-9378(23)00152-7. doi: 10.1016/j.ajog.2023.03.007.
  32. Christopher D, Robinson BK, Peaceman AM. An evidence-based approach to determining route of delivery for twin gestations. Reviews in obstetrics & gynecology. 2011:4(3-4):109-16
  33. Gregorić A, Benčić A, Habek D. Mode of vaginal delivery in breech presentation and perinatal outcome. Ginekologia polska. 2022:93(9):728-734. doi: 10.5603/GP.a2021.0183.
  34. Desai NM, Tsukerman A. Vaginal Delivery. StatPearls. 2023 Jan
  35. Sung S, Mahdy H. Cesarean Section. StatPearls. 2023 Jan
  36. Tanigaki S, Takemori S, Osaka M, Watanabe M, Kitamura A, Ueyama S, Tanaka K, Matsushima M, Kobayashi Y. Caesarean Section of Multifetal Pregnancy. Surgery journal (New York, N.Y.). 2020 Jul:6(Suppl 2):S92-S97. doi: 10.1055/s-0040-1712924.
  37. Day MC, Barton JR, O'Brien JM, Istwan NB, Sibai BM. The effect of fetal number on the development of hypertensive conditions of pregnancy. Obstetrics and gynecology. 2005 Nov:106(5 Pt 1):927-31
  38. Weissman A, Drugan A. Glucose tolerance in singleton, twin and triplet pregnancies. Journal of perinatal medicine. 2016 Oct 1:44(8):893-897. doi: 10.1515/jpm-2016-0186.
  39. di Marco G, Bevilacqua E, Passananti E, Neri C, Airoldi C, Maccarrone A, Ciavarro V, Lanzone A, Familiari A. Multiple Pregnancy and the Risk of Postpartum Hemorrhage: Retrospective Analysis in a Tertiary Level Center of Care. Diagnostics (Basel, Switzerland). 2023 Jan 26:13(3):. doi: 10.3390/diagnostics13030446.
  40. Lindroos L, Elfvin A, Ladfors L, Wennerholm UB. The effect of twin-to-twin delivery time intervals on neonatal outcome for second twins. BMC pregnancy and childbirth. 2018 Jan 19:18(1):36. doi: 10.1186/s12884-018-1668-6.
  41. Korb D, Deneux-Tharaux C, Goffinet F, Schmitz T. Severe maternal morbidity by mode of delivery in women with twin pregnancy and planned vaginal delivery. Scientific reports. 2020 Mar 18:10(1):4944. doi: 10.1038/s41598-020-61720-w.
  42. Borah T, Das A. Locked twins: a rarity. Annals of medical and health sciences research. 2012 Jul:2(2):204-5. doi: 10.4103/2141-9248.105676.
  43. . Operative Vaginal Birth: ACOG Practice Bulletin, Number 219. Obstetrics and gynecology. 2020 Apr:135(4):e149-e159. doi: 10.1097/AOG.0000000000003764.
  44. Barnes AC. Piper forceps for the aftercoming head. American journal of obstetrics and gynecology. 1972 Aug 15:113(8):1146
  45. Ramin SM, Little BB, Gilstrap LC 3rd. Survey of forceps delivery in North America in 1990. Obstetrics and gynecology. 1993 Feb:81(2):307-11
  46. Shekhar S, Rana N, Jaswal RS. A prospective randomized study comparing maternal and fetal effects of forceps delivery and vacuum extraction. Journal of obstetrics and gynaecology of India. 2013 Apr:63(2):116-9. doi: 10.1007/s13224-012-0282-1.
  47. Mounsey D. Kielland-Barton-Laufe (K.B.L.) forceps with Luikart modification in the management of transverse and posterior positions of the fetal head. The Australian & New Zealand journal of obstetrics & gynaecology. 1979 Aug:19(3):139-42
  48. Burke N, Field K, Mujahid F, Morrison JJ. Use and safety of Kielland's forceps in current obstetric practice. Obstetrics and gynecology. 2012 Oct:120(4):766-70
  49. Bogner G, Wallner V, Fazelnia C, Strobl M, Volgger B, Fischer T, Jacobs VR. Delivery of the second twin: influence of presentation on neonatal outcome, a case controlled study. BMC pregnancy and childbirth. 2018 May 18:18(1):176. doi: 10.1186/s12884-018-1815-0.
  50. Dufour P, Vinatier D, Puech F. The use of intravenous nitroglycerin for cervico-uterine relaxation: a review of the literature. Archives of gynecology and obstetrics. 1997:261(1):1-7
  51. Klufio CA, Amoa AB. Breech presentation and delivery. Papua and New Guinea medical journal. 1991 Dec:34(4):289-95
Read More
Author biographies is not available.
Download
PDF
Statistic
Read Counter : 60 Download : 61