A maneuver for head entanglement in term breech/vertex twin labor

Journal of Case Reports and Images in Obstetrics and Gynecology, Vol. 4, 2018.

J Case Rep Images Obstet Gynecol 2018;4:100042Z08SF2018.

www.edoriumjournals.com/case-reports/jcrog

Fischbein SJ 1

CASE REPORT OPEN ACCESS

A maneuver for head entanglement in term breech/vertex

twin labor

Stuart J. Fischbein

ABSTRACT

Whether planned or precipitous, some women

will present in advanced labor with a breech

first twin. We present a rare case of interlocking

heads in a woman with a term breech/vertex

pregnancy who strongly desired a vaginal birth.

A simple vaginal maneuver is described that led

to safe delivery of both twins.

Keywords: Breech, Complication, Inter-locking,

Twin

How to cite this article

Fischbein SJ. A maneuver for head entanglement in

term breech/vertex twin labor. J Case Rep Images

Obstet Gynecol 2018;4:100042Z08SF2018.

Article ID: 100042Z08SF2018

*********

doi: 10.5348/100042Z08SF2018CR

INTRODUCTION

When a first twin presents as breech a cesarean

section is generally recommended [1]. When twin A is

breech and twin B is vertex there is the concern for the

Stuart J. Fischbein

Affiliations: Birthing Instincts, Inc. 10309 Santa Monica

Blvd, Los Angeles, CA 90025, USA.

Corresponding Author: Stuart J. Fischbein, M.D., FACOG,

Birthing Instincts, Inc. 10309 Santa Monica Blvd, Los An-

geles, CA 90025, USA; Email: [email protected]

Received: 05 December 2018

Accepted: 16 December 2018

Published: 31 December 2018

rare complication of interlocking heads [2]. There is also

evidence that supports the vaginal delivery of breech

first twins and confirms the rarity of this complication

[3]. As with all aspects of pregnancy and labor, informed

consent is an integral part of the process. Mode of

delivery will often depend on the desire of the mother

in conjunction with the resources available to her. The

will and expertise to assist women with singleton or

twin breech birth, either A or B, is rapidly diminishing

leading to increasing cesarean rates for all breech and

twin births.

We present a case of diamniotic-dichorionic twins in

which twin A presented as complete breech and twin B

as vertex at 37 6/7 weeks. Descent of twin A arrested in

left sacrum transverse position with the feet and lower

body protruding. A diagnosis of head entanglement

was suspected and confirmed by vaginal exploration. A

fulcrum-like maneuver using the left hand internally

to elevate twin B’s head while freeing twin A led to

subsequent vaginal delivery of both twins.

Vaginal birth of many twin pregnancies is a reasonable

and evidence supported option. Fetal head entanglement

is a rare complication of breech/vertex twin births. For

women who choose to labor or present precipitously with

a breech first twin we present a successful maneuver for

resolving head entanglement.

CASE REPORT

A 32-year-old gravid 1, para 0 woman presented with

a diamniotic-dichorionic pregnancy by intrauterine

insemination for prenatal care at 11 weeks gestation.

There was no other pregnancy or health concerns.

Non-Invasive Prenatal Testing (NIPT and structural

ultrasound at 20 weeks were both normal. Babies were

concordant throughout. From approximately 26 weeks

on twin A was on maternal left and remained in complete

breech position. Twin B, on maternal right, was also in

breech position until 36 weeks at which point it became

vertex. Twin B was noted to have a dolicocephalic head

shape early on. During limited ultrasounds at 36 1/7 and

37 2/7 weeks it was determined that twin B’s head was

slightly lower in the pelvis than twin A’s head. There

was normal fluid and concordant growth. The mother

strongly desired a vaginal birth and was well informed

CASE REPORT PEER REVIEWED | OPEN ACCESS

Journal of Case Reports and Images in Obstetrics and Gynecology, Vol. 4, 2018.

J Case Rep Images Obstet Gynecol 2018;4:100042Z08SF2018.

www.edoriumjournals.com/case-reports/jcrog

Fischbein SJ 2

in all her options, preferred to wait for labor to arrive

and see how labor progressed.

In the early morning hours labor began becoming

active around noon. A vaginal exam at 1:15PM confirmed

complete breech at 5-6cm/100%/0 station and intact

membranes. By 4:55PM she was completely dilated with

bulging membranes. She was feeling an urge to push with

rectal pressure and began the second stage at 5:10PM.

Pushing was initiated on hands and knees. After about

40 minutes she changes to a semi-reclined position

due to fatigue on her arms and shoulders. At 5:50PM

the feet were seen to protrude from the introitus still

inside an intact sac. Contractions continued every 2 to 3

minutes and the Fetal Heart Rate (FHR) of both babies

via intermittent monitoring remained in the normal

range without decelerations. By 6:09PM the legs and

rump had appeared still inside the intact amniotic sac

(Figure 1). There was good tone and capillary filling. At

6:12, the membranes were artificially ruptured releasing

watery meconium stained fluid. Twin A did not descend

any further and remained in the left sacrum transverse

position. Attempts at rotation (Loveset maneuver) were

unsuccessful in achieving any descent. The arms were

then swept down over the chest without much resistance

but still no descent and the head of twin B was evident

in the right lower quadrant. Abdominal manipulation

attempting to elevate twin B was unsuccessful in shifting

the positions. A diagnosis of head entanglement was made

(Figure 2A). The practitioner’s left hand was inserted up

along twin A’s body cupping its head in the palm while

using the back of the hand to elevate twin B’s head out of

the pelvis in a fulcrum like manner (Figure 2B-C). This

immediately freed twin A, who was then delivered easily

with use of the Mauriceau–Smellie–Veit maneuver at

6:15PM weighing 5 pounds 10 ounces with Apgar scores

of 7 & 9.

Prior to delivery of twin A the FHR of twin B was 160

with good variability. Three minutes post-delivery of twin

A the FHR of twin B was at 80-90bpm and vaginal exam

confirmed a cephalic presentation at -1 station. At 6:19

the membranes were artificially ruptured releasing clear

fluid. Mother was able to push twin B to +2 station but

baby was in the direct occiput posterior (OP) position

and FHR remained in the 90s. Uterine contractions had

diminished at this point and maternal pushing remained

ineffective. Low Tucker-McLane forceps were applied

with delivery of twin B, direct OP at 6:22PM. Apgar scores

were also 7 & 9 and the weight was 6 pounds 1 ounce. A

second degree laceration was noted and repaired.

DISCUSSION

In our case report we describe a well-informed woman

and her partner aware of the possibility of interlocked

or entangled heads but the rarity of this complication

made it a minor consideration. To insist, by coercion or

skewed counseling on a cesarean section for such a rare

occurrence against the wishes of the mother would not be

sound ethical practice. Labor progressed normally and

there was a normal second stage for twin A until descent

arrested. Breech delivery is facilitated on all fours and

shortens the second stage and expands the pelvis [4]. That

was evident here although the mother’s arms and legs got

tired and she had to switch to a semi-reclining position.

We do not think the position change contributed to the

head entanglement. More likely twin B’s dolicocephaly

prevented twin A’s head from passing by and both heads

descended in tandem. When descent and rotation of

a breech baby arrests it may be a signal the baby needs

assistance. The ineffectiveness of the usual maneuvers

Figure 1: Twin a still in caul remains left sacrum transverse.

Figure 2: (A) Entangled fetal heads result in arrest of descent for

Twin A. (B)Practitioner inserts hand vaginally. (C) Fulcrum-like

maneuver elevates Twin B releasing obstruction.

Journal of Case Reports and Images in Obstetrics and Gynecology, Vol. 4, 2018.

J Case Rep Images Obstet Gynecol 2018;4:100042Z08SF2018.

www.edoriumjournals.com/case-reports/jcrog

Fischbein SJ 3

to deliver twin A and the antenatal knowledge of the

position and shape of the head of twin B facilitated the

diagnosis of head entanglement. Intrapartum ultrasound

may assist if the diagnosis is in question but may consume

valuable time if not readily available. We present a novel

vaginal maneuver to elevate the head of the second twin

and facilitate passage of the breech twin. Using the back

of the hand to elevate the vertex of twin B while gently

cupping the head of twin A in a fulcrum-like fashion you

can release the obstruction and successfully complete the

vaginal breech delivery. If twin B is on mother’s right you

would use your left hand. If twin B is on the mother’s left

the practitioner would use the right hand.

The frequency of twin pregnancy in the U.S. in 2009

is about 1 in 30 pregnancies [5]. Vertex/vertex accounted

for 44%. Vertex/breech presentation occurred in 27%,

while breech/breech and breech/vertex occurred in 13%

each [6]. There is ongoing discussion about the best way

for term twins to deliver [7, 8, 9]. But no matter what the

studies may conclude the science is uncertain and women

may choose to exercise their right of informed consent

and refusal to choose any alternative. There is enough

evidence in the literature to support, as reasonable, the

choice of attempting vaginal birth with breech first twins.

When time is of the essence, use of stilled hands may

provide resolution before resorting to a surgical approach.

CONCLUSION

While no one has expertise in head entanglement

resolution, the skills acquired from hands on training

in breech delivery assist the practitioner with the spatial

relationships useful for problem solving in a highly

intense setting. We encourage the re-teaching of breech

and twin skills for just those rare moments such as this.

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preferable in twin pregnancies at >=36 weeks

gestation? PLoS One 2016;11(5):e0155692.

8. Barrett JF, Hannah ME, Hutton EK, et al. A randomized

trial of planned cesarean or vaginal delivery for twin

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Author Contributions

Stuart J. Fischbein – Substantial contributions to

conception and design, Acquisition of data, Analysis

and interpretation of data, Drafting the article, Revising

it critically for important intellectual content, Final

approval of the version to be published

Guarantor of Submission

The corresponding author is the guarantor of submission.

Source of Support

None.

Consent Statement

Written informed consent was obtained from the patient

for publication of this case report.

Conflict of Interest

Author declares no conflict of interest.

Data Availability

All relevant data are within the paper and its Supporting

Information files.

under the terms of Creative Commons Attribution

License which permits unrestricted use, distribution

and reproduction in any medium provided the original

author(s) and original publisher are properly credited.

Please see the copyright policy on the journal website for

more information.

Journal of Case Reports and Images in Obstetrics and Gynecology, Vol. 4, 2018.

J Case Rep Images Obstet Gynecol 2018;4:100042Z08SF2018.

www.edoriumjournals.com/case-reports/jcrog

Fischbein SJ 4

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