Mar 10, 1962
British Medical Journal
SIR,-It is a pity that in his most valuable paper on the " Management of the Second Twin" (February 24, p. 518) Dr. R. R. Macdonald omits any mention of the significance of its size relative to the first twin. Bitter experience has taught me that routine operative delivery by the clock will sooner or later involve the obstetrician in a traumatic extraction of a larger baby through a cervix dilated only to accommodate a smaller foetus. I would commend the operator to consider this possibility in every case after rupturing the membranes of the second sac, which I do as soon as I have brought a pole over the brim. Should it seem possible that a larger baby remains to be born it is prudent to allow labour to proceed until adequate obliteration of the cervix and advance of the presenting part has taken place for the delivery to be safely completed. For the reasons so clearly explained by Dr. Macdonald this should not be unnecessarily delayed. If contractions have not started five minutes after rupture of the second sac it is therefore my practice to give 1 unit of oxytocin diluted in I ml. of water subcutaneously. If ineffective this small dose may be repeated in 10 minutes, though this is not often necessary. Local anaesthesia being the rule, it is seldom these days that one is tempted to rush into a possibly traumatic operative delivery of the second twin simply because the patient is under a general anaesthetic, though other considerations may force one's hand.-I am, etc., Tyrone County Hospital, J. H. PATTERSON. N. Ireland.