Delivery in twin-to-twin transfusion syndrome at Genesis Dnipro, Dnipro Alternate: Childbirth for twin-to-twin transfusion syndrome at Genesis Dnipro, Dnipro (Ukraine)

Delivery in twin-to-twin transfusion syndrome (TTTS) refers to childbirth management in a complicated multiple pregnancy that requires intensified fetal monitoring and preparedness for specific interventions.

This approach may be relevant when transfusion syndrome is confirmed in twins and it is necessary to plan in advance the timing, location, and strategy for delivery.

Important issues to discuss with your doctor and obstetrician include:

the condition of each fetus
the possible need for preterm delivery
organization of neonatal care
options for pain relief/anaesthesia

Decisions are made individually based on the evolving health of the mother and fetuses and may change during labor, since the priority is the safety of the mother and the babies.

What this delivery approach means

Delivery for fetofetal (twin‑to‑twin) transfusion syndrome is managed with intensified monitoring of both fetuses and the mother, with predefined tactics and preparedness for different scenarios. This approach is used in multiple (often twin) pregnancies with confirmed transfusion syndrome and requires coordination between obstetrics and neonatology. Before delivery it is important to discuss with your doctor and the obstetric team the condition of the fetuses, possible delivery options, and organizational issues. The decision on the method and timing of delivery is made individually and can change during the course of labor.

Intensified monitoring of both fetuses and the mother during labor.
Planning the timing and mode of delivery according to the clinical course.
Availability of a prepared neonatal team and equipment for resuscitation.
Discussion of possible scenarios with the doctor and obstetrician, including emergency cesarean section.
Limitation: a plan for vaginal delivery may be changed if the fetuses’ condition worsens.
Preliminary discussion of analgesia/anesthesia and logistics of admission/staying in the maternity hospital.

It is important to come to the discussion with questions and your antenatal records, but understand that the final decision depends on the current condition of the mother and infants.

The priority is the safety of the mother and the newborns.

Who this delivery format may be suitable for

This delivery format is intended for pre-planned management of multiple pregnancies and increased risk of complications, including twin-to-twin transfusion syndrome (TTTS). It is relevant when tactics need to be coordinated, neonatal care prepared, and a contingency plan put in place. Discussing details before birth helps clarify possible scenarios and limitations. Final decisions are made based on the current condition of the mother and the fetuses.

A woman who wishes to discuss possible scenarios and a birth plan in advance.
Presence of a partner, which needs to be coordinated with the medical team.
The need to discuss pain-relief options and to consult an anesthesiologist ahead of time.
A desire to understand who will manage the delivery and how responsibilities are allocated.
A high-risk pregnancy that requires a coordinated delivery plan.
A patient who wishes to remain active during labor when clinically appropriate.
Previous birth experiences that should be taken into account when choosing tactics and support.
A need for a calmer, clearer, and pre-agreed delivery plan.

Discuss expectations and questions with your doctor and obstetrician to determine possible options. Remember that the plan may change in the interest of the safety of the mother and the newborns.

## When this delivery format may require restrictions

In the context of delivery with twin‑to‑twin (feto‑fetal) transfusion syndrome, a previously agreed delivery plan may become unacceptable or need to be changed. This can occur if monitoring reveals changes in the condition of the mother or fetuses that require a rapid response. The plan is discussed before delivery, but priority is given to safety and timely decision‑making.

- Obstetric complications requiring urgent intervention, for example massive hemorrhage.
- Signs of fetal distress detected on monitoring that require a change of plan.
- Need for an emergency cesarean section because of deterioration in the condition of the mother or fetus.
- Contraindications to the chosen method of analgesia as confirmed by the anesthesiologist.
- Infectious or organizational restrictions that prevent a partner from being allowed in the delivery room.
- Maternal conditions in which safety is more important than maintaining the original delivery plan.
- Lack of necessary resources or equipment for the planned mode of delivery.

Such restrictions are a normal part of the clinical process and do not imply an error.

The doctor and midwife will explain the reasons for changes and offer safe alternatives.

Who decides on the mode of delivery

The decision on the mode of delivery is made jointly and is based on clinical data, the patient's preferences, and the team's readiness for different scenarios. In twin-to-twin transfusion syndrome (TTTS) it is especially important to consistently assess the condition of both fetuses and the mother. The patient states her expectations, and the team explains which options are safe in her situation. The final decision may be adjusted as the clinical picture changes.

The patient's preferences, expressed in advance and discussed with the medical team.
Assessment by the obstetrician and midwife of tests, ultrasound, and the current condition of the fetuses.
Involvement of an anesthesiologist to discuss options and contraindications for analgesia/anesthesia.
Participation of a neonatologist, if necessary, to plan neonatal care and resuscitation.
Organizational factors and the availability of necessary equipment affect the acceptable delivery options.
Willingness to change the birth plan during labor if the condition of the mother or fetuses worsens.

The decision is made in the interest of the safety of the mother and the babies and is based on the professional judgment of the team.

Discuss your preferences in advance so the team can take them into account when planning and explain possible changes.

What to discuss with your doctor before childbirth

Before delivery, it’s helpful to prepare a short list of questions to clarify the plan and possible changes. Especially with twin-to-twin transfusion syndrome (TTTS), it’s important to discuss key management points and emergency scenarios in advance. Below are questions for your consultation with your obstetrician and midwife to help get clarity.

Ask whether your desired mode of delivery is possible given our condition and associated risks.
Discuss whether a birth partner can be present and any restrictions.
Ask about pain relief options and whether an anesthesiologist consultation is necessary.
Inform them about previous births, cesarean sections, or complications and ask how these affect the plan.
Disclose any chronic conditions and ask how they will influence the delivery plan.
Review ultrasound and test results, and ask which changes would affect decisions about delivery.
Ask what the action plan is if the condition of the fetuses or the mother worsens.
Find out when to go to the hospital if symptoms appear or labor begins.
Clarify which documents and items to bring to the maternity hospital, and what the postnatal stay conditions are.
Discuss who will attend the delivery (obstetrician and midwife) and the neonatologist’s role if needed.

Write down the answers and save contact information so you can act quickly if things change. If anything is unclear, ask them to explain in simple terms.

How preparation for delivery is carried out in twin-to-twin transfusion syndrome

Preparation for delivery is a stepwise process that simplifies decision-making and reduces uncertainty at critical moments. In twin-to-twin transfusion syndrome (TTTS), coordination between obstetrics, anesthesiology, and neonatology is essential. During preparation the clinical picture, delivery plan and organizational details are discussed.

Consultation with the obstetrician-gynecologist to assess the pregnancy and plan management.
Review of the maternity record, ultrasound and the most recent laboratory results.
Agreement on the delivery plan: possible scenarios and criteria for emergency intervention.
Consultation with the anesthesiologist to discuss analgesia/anesthesia options and contraindications.
Preparation of the neonatal team and discussion of neonatal support measures.
Discussion of the partner’s role, the order of their presence and possible restrictions.
Preparation of paperwork and a short list of items needed for the stay in the maternity hospital.
Instructions on warning signs and when to seek immediate medical attention.

These steps make the plan clearer and help the team act faster if the situation changes. Final decisions remain with the medical team, taking into account the current condition of the mother and the fetuses.

How labor proceeds in this context

Labor in cases of twin-to-twin transfusion syndrome (TTTS) is usually conducted according to a prearranged plan with enhanced monitoring of both fetuses. The process includes admission to the labor ward, an initial assessment, continuous monitoring, and readiness for different management options. The team discusses possible actions and criteria for interventions before labor, but the plan may change if the clinical situation changes. Below are the main stages that patients typically go through in this scenario.

Admission to the labor ward: registration, vital signs and measurements, confirmation of the plan.
Initial examination and assessment of the mother and both fetuses, cardiotocography (CTG).
Monitoring contractions: tracking frequency, intensity, and progression; encouraging mobility as appropriate.
Continuous fetal monitoring with periodic interpretation of results by the team.
Labor managed by the obstetrician and midwife according to the agreed plan and criteria for intervention.
Pain relief (analgesia/anesthesia) if needed; options discussed in advance with the anesthesiologist.
Conversion to operative delivery (cesarean section) if the condition of the mother or fetuses deteriorates.
Second stage (pushing): support, instructions on pushing, partner involvement if arranged.
Birth of the baby and initial assessment by a neonatologist; immediate resuscitation if necessary.
First hours after birth: monitoring of the mother and newborns, arrangements for early postnatal care.

This plan gives an idea of the typical course of events, but the priority in the clinic remains the safety of the mother and babies.

If the situation changes, the team will explain the reasons and propose the optimal course of action.

Analgesia during labor

Discussion of pain relief is held in advance at a consultation to take into account the mother's condition, monitoring data, and possible contraindications. In cases of twin-to-twin (fetofetal) transfusion syndrome, the choice of method is coordinated with the anesthesiologist, considering the safety of both fetuses. During labor the decision may be adjusted as the clinical situation evolves.

Discuss pain relief in advance at the preparatory consultation.
An anesthesiologist consultation to assess indications and possible contraindications.
Choose a method taking into account the condition of the mother, the fetuses, and the results of examinations.
Possible options, including epidural anesthesia, when indicated and in the absence of contraindications.
Decision made jointly: the patient, the obstetrician, and the anesthesiologist when necessary.
Possibility to change the pain-relief plan during labor for medical reasons.
Restrictions in certain conditions; the final decision rests with the medical team.

Discuss your expectations and questions in advance with your doctor and anesthesiologist so you have a clear plan on admission. The priority is the safety of the mother and newborns, not adherence to a predetermined scenario.

Safety and monitoring during labor

Monitoring and ensuring safety are routine parts of intrapartum care; with twin-to-twin transfusion syndrome (TTTS) attention is paid to both fetuses and the mother. The team relies on monitoring data and clinical observations to respond promptly to changes. CTG (cardiotocography) and other methods are used as indicated, depending on the situation.

Assessment of the mother's condition: blood pressure, pulse, bleeding, and overall wellbeing.
Assessment of each fetus's heart rate using CTG or intermittent auscultation.
Continuous or intermittent monitoring depending on the clinical situation.
Monitoring the progress of labor: strength of contractions, cervical dilation, and frequency of maternal bearing-down efforts.
Team readiness to change management and, if necessary, perform operative intervention.
Involvement of a neonatologist and availability of equipment to support newborns.
Open communication: explaining the reasons for any change in the plan and the next steps.

Monitoring is a way to maximize safety, not a sign of an inevitable problem.

The team will always explain changes in the plan and offer the best options for the mother and babies.

If labor doesn't go according to plan

A birth plan is a guideline, not a rigid instruction; the team is ready to change tactics quickly if necessary. With twin-to-twin transfusion syndrome, such adjustments may be required more quickly and more often than in a typical pregnancy. It is more important not to follow the plan at all costs, but to choose the safest option for the mother and the babies.

- Reconsideration of the partner's presence: for medical reasons, they may be asked to leave the delivery room.
- Switching from a spontaneous vaginal birth to labor induction/augmentation or to a cesarean section if indications change.
- Epidural anesthesia may be impossible if there are contraindications, and alternative pain-relief options will be sought.
- Changing from an upright birthing position to a more controlled approach if clinical parameters worsen.
- Adjusting the plan with the least invasive intervention when a fetal risk appears.
- Involving a neonatologist and preparing equipment for emergency newborn care.
- Prompt communication: the doctor and midwife explain the reasons for changes and the next steps.

Changes to the plan are a normal part of clinical care aimed at safety. Whenever possible, the team informs and supports the patient in advance while decisions are being made.

Which risks and limitations to consider

Any mode of delivery has its limits, and this is especially important to consider in twin-to-twin transfusion syndrome (TTTS). Decisions about management are based on the current condition of the mother and both fetuses, not just on initial preferences. Describing possible limitations helps prepare for the fact that the plan may change in the interests of safety.

- Decisions depend on the condition of the mother and both fetuses.
- Possibility of emergency interventions if parameters deteriorate suddenly.
- The delivery plan may be changed during labor if medical indications arise.
- Contraindications to certain forms of pain relief or anesthesia in a specific patient.
- Organizational or infection-related restrictions that can affect partner-supported births.
- Inability to rely solely on others’ experiences when choosing the mode of delivery.
- The safety of the mother and baby takes precedence over a preselected scenario.

Discuss possible limitations with your doctor in advance so you understand the criteria for changing the plan. The care team will explain the reasons for any adjustments and offer safe alternatives if needed.

What happens immediately after birth

The first hours after a baby is born are devoted to assessing the condition of both the mother and the newborn and establishing initial contact. In the clinic these procedures are carried out according to an established protocol, which is adapted to the current situation. The team explains what is happening and helps with the first breastfeeding attempt, involving a neonatologist if necessary. The final course of action depends on the condition of the mother and the newborn(s) at the time of delivery.

Maternal cardiotocography (CTG) and the neonatologist’s initial examination of the newborn are always performed.
Assessment of the mother’s condition: bleeding, blood pressure, pain, and general well‑being.
Skin‑to‑skin contact and assistance with the first breastfeeding attempt when possible.
Additional examinations by the neonatologist and provision of urgent care if necessary.
Monitoring in the first hours: regular checks of the mother and monitoring of the baby.
Transfer to the postnatal ward after stabilization and completion of necessary paperwork.
Explanation of next steps by the doctor and midwife, with answers to the family’s questions.
Arrangement of feeding and newborn care consultations in the first hours after birth.

The sequence of actions may change depending on the condition of the mother and the newborn(s); the team will always explain the reasons and the next steps. If anything causes concern, don’t hesitate to ask questions.

Role of the physician and the team

The role of the physician and the team is to coordinate the labor process and ensure the safety of the mother and the babies at every stage. In deliveries complicated by twin-to-twin transfusion syndrome, special attention is paid to the condition of both fetuses and to being ready to change tactics quickly. The team explains what is happening to the patient and involves the necessary specialists as needed.

Risk assessment by the obstetrician-gynecologist, taking into account the condition of the mother and both fetuses.
Continuous monitoring of labor progress and interpretation of monitoring data.
Explaining the current situation and the available options to the patient in clear, understandable language.
Coordination of actions between the physician and the obstetrician/midwife, as well as other specialists.
Involvement of an anesthesiologist when planning pain relief and assessing contraindications.
Calling a neonatologist and preparing equipment for receiving newborns when necessary.
Organizing the operating room team and a rapid transition to surgical interventions when indicated.

The team works together to make well-founded decisions and to inform you promptly of any change in approach. If you have questions, ask for clarification at any time.

How this format benefits the patient

This approach to delivery provides a more predictable structure and clearer decision-making in a complex multiple pregnancy. A prepared plan reduces uncertainty and allows key points to be discussed with the team in advance. This is especially important in twin-to-twin transfusion syndrome, when coordination between specialists is required. Below are practical advantages often noted by patients.

A clear birth plan with defined scenarios and thresholds for interventions.
The ability to discuss and record personal wishes and limitations in advance.
Less uncertainty thanks to pre-agreed action criteria.
The option to choose and arrange for the presence of a specific physician.
The option for partner presence, subject to medical and organizational conditions.
Availability of pain relief options in consultation with the anesthesiologist.
Continuous monitoring of the mother and both fetuses during labour.
The team’s readiness to quickly switch to an alternative scenario if indications change.

These conveniences help patients feel more informed and calmer, but they do not remove the clinical necessity to change the plan for safety.

Discuss your expectations with the team in advance so they can take them into account during preparation.

How a pre-delivery consultation goes

A pre-delivery consultation is a structured meeting to review the current situation and agree on a plan of action. In twin-to-twin transfusion syndrome (TTTS) such a consultation is especially important to assess the condition of both fetuses. During the appointment the doctor and the midwife review the maternity (antenatal) record, test results, and discuss your preferences. Often clarification or additional testing is required before a final decision is made.

Medical history taking: discussing the course of the pregnancy and previous deliveries.
Review of the maternity record and previous antenatal notes.
Review of current ultrasound scans and available laboratory results.
Discussion of your preferences and expectations regarding the mode of delivery.
Explanation of limitations and the criteria under which the plan may change.
Joint assessment of safety and help in choosing acceptable options.
Discussion of warning signs that require immediate contact and when to go to the hospital.
Answers to questions and agreement on next steps for preparation.

Write down key questions and come with your maternity record and test results. If anything remains unclear, ask for further clarification at the next appointment.

Please note that online consultations are available for patients from other cities. We often receive requests from Zaporizhzhia, Pavlohrad, Kamenskoye (Dniprodzerzhinsk), Novomoskovsk (Samar), Kryvyi Rih, Nikopol, Marganets, Sinelnikovo, Pokrov, Zhovti Vody, and other cities.

Preparation for admission to the maternity/delivery unit

In twin-to-twin transfusion syndrome (TTTS), it is especially important to gather key documentation and information in advance so the team can quickly assess the situation. Preparation makes admission to the delivery unit easier and helps coordinate actions immediately after arrival.

Bring everything you need in a convenient folder or bag.

Documents: ID, insurance and contact information.
Maternity/antenatal record with notes from pregnancy monitoring.
Most recent ultrasound and laboratory results.
Items for the mother: basic personal items for comfort during the hospital stay.
Items for the baby: simple items for initial needs and transport.
Items for the partner, if their presence is planned and permitted by hospital rules.
Regular medications with dosage information — discuss taking them with your doctor in advance.

Clarify at your consultation which documents and tests will be specifically needed in your case.

Keep everything in one place so you don’t waste time in an emergency.

Maternity ward conditions

The maternity ward is organized to manage planned and emergency deliveries, taking into account the needs of the mother and the newborn. In high‑risk situations, such as twin‑to‑twin transfusion syndrome, special attention is paid to monitoring and coordination among specialists. Before delivery, it is advisable to clarify at a consultation which services and conditions are available in your case.

Delivery rooms equipped for monitoring the mother and fetus(es).
Postpartum rooms offering rooming‑in for mother and baby.
Availability of a neonatologist and equipment for the initial assessment and care of the newborn.
Access to an anesthesiologist consultation and agreement on pain‑relief/analgesia options.
The possibility to arrange a partner’s presence, subject to compliance with medical and organizational rules.
Personal support by one team member by prior arrangement.
Coordination among obstetricians, neonatologists, and anesthesiologists when management tactics change.

Clarify the details and any possible limitations at your pre‑delivery consultation. The team will explain which options are appropriate and safe for your situation.

When to seek urgent medical attention

If you notice one or more worrying symptoms, do not delay contacting the maternity ward or emergency services. During pregnancy—and especially with twin-to-twin (feto‑fetal) transfusion syndrome—timely assessment can be decisive. When in doubt, it is better to consult a doctor.

Bloody or active vaginal bleeding
Your waters have broken or you suspect leaking of amniotic fluid
Regular contractions that intensify and do not stop
Severe, atypical abdominal or pelvic pain
Noticeable decrease or absence of fetal movements
Sudden rise in blood pressure or a very fast heartbeat
Intense headache not relieved by usual measures
Vision changes: blurring, dimming, or the appearance of spots
Marked weakness, confusion, or fainting
Fever with accompanying signs of infection
Any sudden, unusual changes in how you feel or behave

If you notice any of these signs, contact your clinic or go to the maternity/delivery ward immediately. In emergency situations, call emergency services.

Frequently Asked Questions

Question: Can the mode of delivery be chosen in advance for twin-to-twin transfusion syndrome?
Answer: You can and should discuss your preferred mode of delivery in advance, but the final decision depends on the current condition of the mother and both fetuses.
Question: Is this type of delivery suitable for everyone?
Answer: No — the choice of mode depends on the clinical picture, test results, and the physician’s assessment of risks.
Question: Can the birth plan be changed during labor?
Answer: Yes, the plan can and often is adjusted for medical reasons in the interest of safety.
Question: Can the mode be discussed before labor so we can prepare?
Answer: Yes, a consultation covers options, criteria for changing the plan, and required tests.
Question: Can I have my partner present during labor?
Answer: Often yes, but partner presence must be agreed with the medical team and depends on organizational and infection-control restrictions.
Question: How do I prepare my partner for the birth?
Answer: Discuss visiting rules, their role in the delivery room, and basic instructions with the obstetrician and team in advance.
Question: Is epidural anesthesia possible in this delivery setting?
Answer: Epidural anesthesia is possible when indicated and if there are no contraindications; the decision is discussed with the anesthesiologist.
Question: Who decides about pain relief?
Answer: The decision is made jointly by the patient, the obstetrician, and the anesthesiologist, taking into account the clinical situation and contraindications.
Question: What happens if the chosen method of pain relief is not suitable?
Answer: The anesthesiologist will offer alternatives or adjust the analgesia plan during labor depending on the situation.
Question: When should I go to the hospital?
Answer: Go when you have regular contractions, your waters break, there is bleeding or other worrying symptoms, or as instructed by your doctor.
Question: What should I take to the maternity hospital?
Answer: Bring identification, your maternity record (antenatal record), recent test results, and basic items for your stay; check the clinic’s specific list.
Question: Do I need my maternity record and tests when admitted?
Answer: Yes — the maternity record and up-to-date tests help quickly assess the situation and speed up admission.
Question: Can I come with tests that are already done?
Answer: Yes — current ultrasound scans and laboratory results are helpful for decision-making at the consultation.
Question: What happens if a cesarean section is needed?
Answer: The team will explain the indications and prepare you for surgical delivery; in an emergency, immediate operative care will be provided.
Question: What if the previously chosen delivery mode no longer seems possible?
Answer: Discuss the change with your doctor — the team will propose a safe alternative and explain the reasons for the adjustment.
Question: Can I get a second opinion on the planned management?
Answer: Yes — you may request an additional consultation with another specialist to clarify management options.
Question: Can I meet the doctor in advance and discuss the plan?
Answer: Yes — schedule a consultation to discuss scenarios, pain-management questions, and organizational details.
Question: What should I discuss if I had previous deliveries or a cesarean?
Answer: Inform the team about prior deliveries, complications, and any surgical interventions — this affects risk assessment and choice of management.