In reply

Abstract

I read with interest the recent article by Carvalho and colleagues 1 and the accompanying editorial 2 regarding anaesthetists' presence for multiple births. This is a controversial issue and as the articles point out there is no consensus as to either the optimal route for twin delivery or what our involvement should be in attempted vaginal twin delivery.The authors showed that in California 64% of hospitals perform vaginal twin delivery in the operating room and that in 55% an anaesthetist is present. In the authors' own hospital these numbers are even greater with 100% of vaginal twin deliveries taking place in the operating room and all with an anaesthetist present. The authors found in their survey that the hospital type, location, delivery volume per year and presence of dedicated obstetric anaesthesia coverage were not associated with an anaesthetist's presence during vaginal twin delivery.In my own hospital, which has a delivery rate of over 5000/year and dedicated obstetric anaesthetic cover, our guidelines for the management of labour in a multiple pregnancy include the presence of an anaesthetist in the labour ward (but not in the room) at the time of delivery. Vaginal twin delivery is attempted in the delivery room rather than in the operating theatre. We have regular ward rounds attended by both the obstetric team and the anaesthetist on duty, who is therefore aware of any problems. Our guidelines, however, do not specifically state that the obstetric team must inform us when the woman is in the second stage of labour, and as a result the anaesthetist may be involved in the care of another patient.Given the difference between practice at my hospital and that at Stanford University, I carried out a small e-mail survey of consultant obstetricians in the South-West of England to establish current practice. This revealed that vaginal twin delivery was attempted in the delivery room in the vast majority. Only one hospital routinely performs vaginal twin delivery in theatre with an anaesthetist present. One hospital has a twin room that can easily be transformed into a theatre and one hospital conducts vaginal twin delivery in theatre if the second twin is breech. In no hospital is an anaesthetist present in the delivery room during the second stage but all confirmed anaesthetic presence in the labour ward.Anaesthetic interventions were needed 27% of the time according to Carvalho's chart review. In a significant number of deliveries therefore an anaesthetist was present for the second stage but no further intervention was required. Although this could be seen to represent wasted time on the part of the anaesthetist, it ensures that involvement with another patient is avoided when a woman with twins enters the second stage of labour.There are several important points brought out by this survey. All women undergoing attempted vaginal twin delivery should have early anaesthetic assessment with encouragement towards epidural placement. Good communication between obstetricians and anaesthetists during labour is...