Monoamniotic twinning is a rare event with an incidence of 1% of all monozygotic twins and associated with a high fetal morbidity and mortality. Confident early diagnosis is possible, but optimal management is not yet established. This article presents the experience of a single centre in managing all monoamniotic twins diagnosed during 1994–2000. Seven pairs of monoamniotic twins were identified for analysis. All were managed in accord with a unit protocol that involved early diagnosis, serial ultrasound examination and elective early delivery. In four cases, the detection of monoamnionicity was made during a first trimester nuchal scan. Discordance for structural abnormality was found in three cases where the co-twin was normal. Cord entanglement was detected antenatally in four cases. Two pairs of twins died before 20 weeks. One of these had early onset twin–twin transfusion syndrome. In five cases, the pregnancy continued beyond 20 weeks. A live birth rate of 90% and intact survival of 70% were achieved in this group. We believe that ultrasound is reliable in diagnosing monoamniotic twins and the detection of cord entanglement. Timing of elective delivery is a balance between the risks of preterm birth at a specific gestational age in an individual centre compared with the unquantifiable risks of fetal death if an expectant policy were pursued. The decision to deliver and at which gestational age should combine input from the parents, neonatologist, fetal medicine consultant and the obstetrician.