Multifetal Gestations: Twin, Triplet, and Higher-Order Multifetal Pregnancies

Publication Date: October 1, 2016
Last Updated: March 14, 2022

Recommendations and Conclusions

The following recommendations and conclusions are based on good and consistent scientific evidence.

  • There is no role for the prophylactic use of any tocolytic agent in women with multifetal gestations, including the prolonged use of betamimetics for this indication.
  • Progesterone treatment does not reduce the incidence of spontaneous preterm birth in unselected women with twin or triplet gestations and, therefore, is not recommended.

The following recommendations and conclusions are based on limited or inconsistent scientific evidence.

  • Because of the increased rate of complications associated with monochorionicity, determination of chorionicity by late first trimester or early second trimester in pregnancy is important for counseling and management of women with multifetal gestations.
  • Interventions, such as prophylactic cerclage, prophylactic tocolytics, prophylactic pessary, routine hospitalization, and bed rest, have not been proved to decrease neonatal morbidity or mortality and, therefore, should not be used in women with multi-fetal gestations.
  • Magnesium sulfate reduces the severity and risk of cerebral palsy in surviving infants if administered when birth is anticipated before 32 weeks of gestation, regardless of fetal number.
  • Women with one previous low transverse cesarean delivery, who are otherwise appropriate candidates for twin vaginal delivery, may be considered candidates for trial of labor after cesarean delivery.
  • Women who underwent pregnancy reduction from triplets to twins, as compared with those who continued with triplets, were observed to have lower frequencies of pregnancy loss, antenatal complications, preterm birth, low-birth-weight infants, cesa-ean delivery, and neonatal deaths, with rates similar to those observed in women with spontaneously conceived twin gestations.
  • Unless a contraindication exists, one course of ante-natal corticosteroids should be administered to all patients who are between 24 weeks and 34 weeks of gestation and at risk of delivery within 7 days, irrespective of the fetal number.

The following recommendations and conclusions are based primarily on consensus and expert opinion.

  • Women with uncomplicated monochorionic–monoamniotic twin gestations can undergo delivery at 32–34 weeks of gestation.
  • In diamniotic twin pregnancies at 32 0/7 weeks of gestation or later with a presenting fetus that is vertex, regardless of the presentation of the second twin, vaginal delivery is a reasonable option and should be considered, provided that an obstetrician with experience in internal podalic version and vaginal breech delivery is available.
  • All women with multifetal gestations, regardless of age, are candidates for routine aneuploidy screening.
  • The administration of neuraxial analgesia in women with multifetal gestations facilitates operative vaginal delivery, external or internal cephalic version, and total breech extraction.
  • Women with monoamniotic twin gestations should be delivered via cesarean.

Recommendation Grading




Multifetal Gestations: Twin, Triplet, and Higher-Order Multifetal Pregnancies

Authoring Organization

Publication Month/Year

October 1, 2016

Last Updated Month/Year

January 5, 2023

Document Type


External Publication Status


Country of Publication


Inclusion Criteria

Female, Adolescent, Adult

Health Care Settings


Intended Users

Physician, nurse midwife, nurse, nurse practitioner, physician assistant



Diseases/Conditions (MeSH)

D011247 - Pregnancy, D059285 - Pregnancy, Twin, D059286 - Pregnancy, Triplet, D014310 - Triplets, D011272 - Pregnancy, Multiple, D059288 - Pregnancy, Quintuplet, D059287 - Pregnancy, Quadruplet


multifetal gestations, twins, triplets