Multiple pregnancy

Multiple pregnanciy is a pregnancy with two or more fetuses. Or the term multiple
pregnancy is used to describe the development of more than one fetus in utero at the same
time. Names for these include the following:

Twins - 2 fetuses
Triplets - 3 fetuses
Quadruplets - 4 fetuses
Quintuplets - 5 fetuses
Sextuplets - 6 fetuses
Septuplets - 7 fetuses

Multiple births occur when multiple fetuses are carried during one pregnancy. Twins are
the most common type of multiple pregnancies. But worldwide,( Since 1970 ), the
incidence of multiple pregnancies of all types - twins, triplets, quadruplets, quinteplets,
sextets, and more - is increasing because of more widespread use of assisted reproductive
technologies to treat infertility.
Multifetal pregnancies are high-risk pregnancies with numerous associated fetal and
neonatal complications. The largest multiple pregnancies on record led to the birth of
nine offspring.
The clafication of multiple pregnancy is based on:
Number of fetuss twins, triplets, quadruplets etc
Number of placenta - chorionicity
Number of fertilized ova - zygosity
Number of amniotic cavities - amnionicity

Incidence: While multiples account for only a small percentage of all births
(about 3 %), the multiple birth rates are rising.
Sign and symptoms of multiple pregnancy
The following are the most common symptoms of multiple pregnancy. However, each
woman may experience symptoms differently. Symptoms of multiple pregnancy may
include:

uterus is larger than expected (> 4 cm) for the dates in pregnancy
increased morning sickness
increased appetite
excessive maternal weight gain, especially in early pregnancy
fetal movements felt in different parts of abdomen at same time

Polyhydramnios, manifested by uterine size out of proportion to the calculated

duration of gestation, is almost 10 times more common in multiple pregnancy.

History of assisted reproduction.

Outline or ballottement of uterus more than one fetus.

Simultaneous recording of different fetal heart rates, each asynchronous with the
mothers pulse and with each other and varying by at least 8 beats per minute.
(The fetal heart rate may be accelerated by pressure or displacement.)

Palpation of one or more fetuses in the fundus after delivery of one infant.

Diagnosis

Laboratory Findings

Alpha-fetoprotein
Levels of a protein released by the fetal liver and found in the mother's blood may be high when
more than one fetus is making the protein. The majority of multiple pregnancies are

currently identified by using maternal serum alpha-fetoprotein (MSAFP)

screening.
The hematocrit and hemoglobin values and the red cell count usually are
considerably reduced, in direct relationship to the increased blood volume

Glucose tolerance tests demonstrate that both gestational diabetes

mellitus and gestational hypoglycemia are much higher in multiple
gestations compared with findings in singleton pregnancy. Glucose screening is
the standard of care in multiple pregnancy.

Pregnancy blood testing: Levels

Ultrasound Findings: Ultrasonography is the preferred imaging modality for

diagnosis of multiple gestations, and is potentially able to differentiate multiple
gestations as early as 4 weeks (by intravaginal probe).

of human chorionic gonadotrophin (hCG) may be

quite high with multiple pregnancy.

Causes multiple pregnancy

There are many factors related to having a multiple pregnancy. Naturally occurring
factors include the following:

Heredity
A family history of multiple pregnancy increases the chances of having twins.

Older age
Women over 30 have a greater chance of multiple conceptions. Many women
today are delaying childbearing until later in life, and may have twins as a result.

High parity
Having one or more previous pregnancies, especially a multiple pregnancy,
increases the chances of having multiples.
Race
African-American women are more likely to have twins than any other race. Asian
and Native Americans have the lowest twinning rates. Caucasian women,
especially those over age 35, have the highest rate of higher-order multiple births
(triplets or more).

Other factors that have greatly increased the multiple birth rates in recent years include
reproductive technologies, including the following:

Ovulation-stimulating medications such as clomiphene citrate and follicle

stimulating hormone (FSH) help produce many eggs, which, if fertilized, can result
in multiple babies.

Assisted reproductive technologies such as in vitro fertilization (IVF) and other

techniques help couples conceive. These technologies often use ovulationstimulating medications to produce multiple eggs which are then fertilized and
returned to the uterus to develop.

How does multiple pregnancy occur?

Multiple pregnancy usually occurs when more than one egg is fertilized and implants in
the uterus. This is called fraternal twinning and can produce boys, girls, or a combination
of both. Fraternal multiples are simply siblings conceived at the same time. However, just
as siblings often look alike, fraternal multiples may look very similar. Fraternal multiples
each have a separate placenta and amniotic sac.
Sometimes, one egg is fertilized and then divides into two or more embryos. This is called
identical twinning and produces all boys, or all girls. Identical multiples are genetically
identical, and usually look so much alike that even parents have a hard time telling them
apart. However, these children have different personalities and are distinct individuals.
Identical multiples may have individual placentas and amniotic sacs, but most share a
placenta with separate sacs. Rarely, identical twins share one placenta and a single
amniotic sac.
Complication
Being pregnant with more than one baby is exciting and is often a happy event for
many couples. However, multiple pregnancy has increased risks for complications. The

effects of multiple pregnancy on the patient include earlier and more severe pressure in
the pelvis, nausea, backache, varicosities, constipation, hemorrhoids, abdominal
distention, and difficulty in breathing. A large pregnancy may be indicative of
twinning (distended uterus).
The most common complications include the following:

Preterm labor and birth

About half of twins and nearly all higher-order multiples are premature (born
before 37 weeks). The higher the number of fetuses in the pregnancy, the greater
the risk for early birth. Premature babies are born before their bodies and organ

systems have completely matured. These babies are often small, with low
birthweights (less than 2,500 grams or 5.5 pounds), and they may need help
breathing, eating, fighting infection, and staying warm. Very premature babies,
those born before 28 weeks, are especially vulnerable. Many of their organs may
not be ready for life outside the mother's uterus and may be too immature to
function well. Many multiple birth babies will need care in a neonatal intensive
care unit (NICU).

Pregnancy-induced hypertension
Women with multiple fetuses are more than three times as likely to develop high
blood pressure of pregnancy. This condition often develops earlier and is more
severe than pregnancy with one baby. It can also increase the chance of placental
abruption (early detachment of the placenta).
Anemia
Anemia is more than twice as common in multiple pregnancies as in a single birth.
Birth defects
Multiple birth babies have about twice the risk of congenital (present at birth)
abnormalities including neural tube defects (such as spina bifida), gastrointestinal,
and heart abnormalities.
Miscarriage
A phenomenon called the vanishing twin syndrome in which more than one fetus
is diagnosed, but vanishes (or is miscarried), usually in the first trimester, is more
likely in multiple pregnancies. This may or may not be accompanied by bleeding.
The risk of pregnancy loss is increased in later trimesters as well.
Twin-to-twin transfusion syndrome
Twin-to-twin syndrome is a condition of the placenta that develops only with
identical twins that share a placenta. Blood vessels connect within the placenta
and divert blood from one fetus to the other. It occurs in about 15 percent of
twins with a shared placenta.

In TTTS, blood is shunted from one fetus to the other through blood vessel
connections in a shared placenta. Over time, the recipient fetus receives too much
blood, which can overload the cardiovascular system and cause too much amniotic
fluid to develop. The smaller donor fetus does not get enough blood and has low
amounts of amniotic fluid.

Abnormal amounts of amniotic fluid

Amniotic fluid abnormalities are more common in multiple pregnancies, especially
for twins that share a placenta.

Cesarean delivery
abnormal fetal positions increase the chances of cesarean birth.
Postpartum hemorrhage
The large placental area and over-distended uterus place a mother at risk for
bleeding after delivery in many multiple pregnancies.

Management of multiple pregnancy:

Specific management for multiple pregnancy will be determined by your physician based
on:

pregnancy, overall health, and medical history

the number of fetuses
your tolerance for specific medications, procedures, or therapies
expectations for the course of the pregnancy
your opinion or preference

Management of multiple pregnancy may include the following:

Increased nutrition
Mothers carrying two or more fetuses need more calories, protein, and other
nutrients, including iron. Higher weight gain is also recommended for multiple
pregnancy. The American College of Obstetricians and Gynecologists recommends
women carrying twins gain at least 35 to 45 pounds.

more frequent prenatal visits (to check for complications and to monitor
nutrition and weight gain)
Referrals
Referral to a maternal-fetal medicine specialist, called a perinatologist, for special
testing or ultrasound evaluations, and to coordinate care of complications, may be
necessary.
Increased rest
Some women may also need bedrest - either at home or in the hospital depending
on pregnancy complications or the number of fetuses. Higher-order multiple
pregnancies often require bedrest beginning in the middle of the second trimester.
Maternal and fetal testing
Testing may be needed to monitor the health of the fetuses, especially if there are
pregnancy complications.
tocolytic medications
Tocolytic medications may be given, if preterm labor occurs, to help slow or stop
contractions. These may be given orally, in an injection, or intravenously. Tocolytic
medications often used include terbutaline and magnesium sulfate.
Corticosteroid medications
Corticosteroid medications may be given to help mature the lungs of the fetus.
Lung immaturity is a major problem of premature babies.
cervical cerclage
Cerclage (a procedure used to suture the cervical opening) is used for women
with an incompetent cervix. This is a condition in which the cervix is physically
weak and unable to stay closed during pregnancy. Some women with higher-order
multiples may require cerclage in early pregnancy.

Twins pregnancy
When two fetuses simultaneously develop in the uterus, it is called twins
pregnancy. It is commonest variety of multiple pregnancy.
Types of twins
1. Dizygotic twins: Dizygotic or binovular twins develop from two separate
ova that are fertilized by two different spermatozoa, and are often referred
to as non identical twins.
2. Monozygotic or uniovulartwinsare also referred to as identical twins.
They develop from the fusion of one ovum and one spermatozoa
, which after fertilization splits in to two identical structures.
Determination of zogocity
S.N

Feature

Uniovular

Binovular

1.
2.

Placenta

One

Membrane

2amnion, one
chorion

Two
2 amnion, two
chorion

3.

Sex

Always same

May differ(either
same or
different
sex)

Genetic feature

Same

Differ

Follow up

Usually identical

Not identical

Causes
Idopathic
Heridity
Multiparity
Advancing age of the mother (Above 30)

 Assisted reproductive technologies

Iatrogenic (drug used for inductionof ovulation)
Sign and symptoms (Same as multiple pregnancy)
Diagnosis
Abdominal examination
Inspection: abdomen is unduly enlarged
Palpation:
The height of the uterus is more than the period of amenorrhoea,
Palpation of too many fetal parts,
Fetal bulkseems disproportionately larger in relation to the size of the fetal
head,
The girth of the abdomen at the level of umbilicus is more than the normal
average at term.
Auscultation: FHS wil be heard in two different areas and difference of heart rate
is at least 10 beats/m.
General examination:
Prevalance of anaemia is more
Unusual weight gain
Evidence of preeclampsia (25%) is common association.
Internal examination
In some cases, one head is felt deep in the pelvis, while the other one is located by
abdominal examination.
Ultrasound or X-ray
Management
Antenatal management

Diet: Increased diatery supplement is needed for increased energy supply to the extent
of 300kcal/day
Increased rest
Supplement therapy eg iron therapy additional vitamins, calcium etc
ANC visit: More frequent

Management during labour

First stage
Skilled obstetrician should be present
Use of analgesic drugs
Careful fetal monitoring
An intravenous line with RL solution should be set up for any urgent therapy, if
required.
Obstetrician an pediatrician should be informed.
Avoid early rupture of membrane.
Second stage
Delivery of first baby
The delivery should be conducted in the same guideline as normal delivery and
give episiotomy if necessary
Check presentation
If a vertex presentation, allow labour to progress as for a single vertex
presentation.
If breech presentation, apply the same guidelines as for a single breech
presentation.
If transverse lie, deliver by CS.
Delivery of second baby
Following the birth of the first baby, the lie ,presentation, size and FHS of
second baby should be ascertained by examination.

 Correct the longitudinal lie by external version

Check FHS
Perform vaginal examination to determine if:
The cord has prolapsed
The membranes are intact or ruptured
Presentation of other baby
From impact
3rd stage
To minimizethe risk of PPH, follow active management of third stage of labour
Continue the oxytocin drip for at least one hour, following delivery of the
second baby
The mother is to be care fully watch for about 2 hours after delivery

MECHANISM OF LABOR

The ability of the fetus to successfully negotiate the pelvis during labor involves changes
in position of its head during its passage in labor. The mechanisms of labor, also known
as the cardinal movements, are described in relation to a vertex presentation, as is the
case in 95% of all pregnancies.
Definition- The series of movements that occur on the head in the process of adaptation
during its journey through narrow and long twisted birth canal and the pelvis is called
mechanism of labour.
The ability of the fetus to successfully negotiate the pelvis during labor involves changes
in position of its head during its passage in labor. The mechanisms of labor, also known
as the cardinal movements, are described in relation to a vertex presentation, as is the
case in 95% of all pregnancies. There is mechanism for every presentation and position
which can be delivered vaginally. During vaginal delivery the fetal presentation and
position will govern the exact mechanism as the fetus responds to external pressures.

There is overlap of these mechanisms. The fetal head, for example, may continue to flex
or increase its flexion while it is also internally rotating and descending.
Principles common to all mechanisms are:

Descent takes place throughout.

Whichever part leads and first meets the resistance of the pelvic floor will rotate
forwards until it comes under the symphysis pubis

Whatever emerges from the pelvis will pivot around the pubic bone.

At the onset of labour, the commonest presentation is the vertex and the most common
position either left or right occipitoanterior; therefore it is this mechanism, which will be
described. When these conditions are met, the way that the fetus is normally situated can
be described as follows:

The lie is longitudinal.

The presentation is cephalic.

The position is right or left occipitoanterior.

The attitude is one of good flexion.

The denominator is the occiput.

The presenting part is posterior area of the parietal bone.

Although labor and delivery occurs in a continuous fashion, the cardinal movements are
described as 9 (different) discrete sequences, as discussed below.2
Engagement
The widest diameter of the presenting part (with a well-flexed head, where the largest
transverse diameter of the fetal occiput is the biparietal diameter) enters the maternal
pelvis to a level below the plane of the pelvic inlet.Or the fetal head is said to have
engaged when the greatest transverse diameter, biparital diameter that is 9.5cm and
anterioposterior diameter which varies with the degree of flexion or extension of the
head, have crossed the plane of pelvic brim. On the pelvic examination, the presenting
part is at 0 station, or at the level of the maternal ischial spines.In primigravida,
engagement occurs in a signiment number of cases before the onset of labour while in
multiparae, the same may occur in late first with rupture of the membranes.
Descent

It is the downward passage of the presenting part through the pelvis. Descent of the fetal
head in to the pelvis often begins before the onset of labour. In primigravida it usually
occurs during the latter weeks of pregnancy when engagement of the head provides
confirmation that vaginal delivery is probable. Through out labour this occurs
intermittently with contractions and retraction. The rate is greatest during the second
stage of labor. The head generally enters the pelvis in the transverse and oblique position.
The degree of descent is measured by stations.
Factors facilitating descent are uterine contraction and retraction, bearing down efforts
and the pressure of amniotic fluid.

Flexion
It is bending movement of fetal head which is normal attitude of the fetus in utero. As the
fetal vertex descents, it encounters resistance from the bony pelvis or the soft tissues of
the pelvic floor, resulting in passive flexion of the fetal occiput. The chin is brought into
contact with the fetal thorax, and the presenting diameter changes from occipitofrontal
(11.0 cm) to suboccipitobregmatic (9.5 cm) for optimal passage through the pelvis. This
functionally creates a smaller structure to pass through the maternal pelvis. When flexion
occurs, the occipital (posterior) fontanel slides into the center of the birth canal and the
anterior fontanel becomes more remote and difficult to feel. The fetal position remains
occiput transverse.

Internal rotation
During a contraction the leading part is driven downwards onto the pelvic floor.The
resistance of this muscular diaphrgm brings about rotation. As the contraction fedes the
pelvic floor rebounds, causing the occiput to glide forwards. Resistance is therefore an
important diterminant of rotation.The slope of the pelvic floor determines the direction of
rotation.In a well flexed vertex presentation the occiput leads and meets the pelvic floor
first and rotates anteriourly through one eight of a circle. This causes a slight tuist in the
neck of the fetus as the head is no longer in direct alignment with the shoulders. The

anterioposterior diameter of the head now lies in the widest (anterioposterior) diameter of
the pelvic outlet, facilitating an easy escape. The occiput slips beneath the sub-pubic arch
and crowning occurs when the head no longer recedes between contractions and the
widest transverse diameter (Biparital ) is born.

Crowning
After internal rotation of the head , further descent occers until the subocciput lies
underneath the pubic areh.At this stage, the maximum diameter of the head (biparital
diameter) stretches the vulval outlet without any recessionof the head even after the
contraction is over, called crowning of the head.
Extension of head
Once crowning has occurred the fetal head can extend, pivoting on the suboccipital
region around the pubic bone.Or With further descent and full flexion of the head, the
base of the occiput comes in contact with the inferior margin of the pubic symphysis.
Upward resistance from the pelvic floor and the downward forces from the uterine
contractions cause the occiput to extend and rotate around the symphysis. This release the
sinciput, face and chin which sweep the perineum and are born by a movement of
extension.The curve of the hollow of the sacrum favors extension of the fetal head as
further descent occurs. This is the means that the fetal chin is no longer touching the fetal
chest.)

Restitution
It is visible passive movement of the head due to untuisting of the neck sustained during
internal rotation. Movement of restitution occurs rotating the head through 1/8 of circle in
the direction opposite to that of internal rotation. (When the fetus' head is free of

resistance, it untwists about 45 left or right, returning to its original anatomic position in
relation to the body.)
It is themovement of rotationof head visible externally due to internal
rotation of shoulders. As the anterior shoulder rotate towards the symphysis pubis from
the oblique diameter, it carries the head in a movement of external rotation through 1/8 th
circle in the same direction as restitution. The shoulders now lie in the anterior-posterior
diameter.
External Rotation:

Expulsion
After the fetus' head is delivered, further descent brings the anterior shoulder to the level
of the pubic symphysis. The anterior shoulder is then rotated under the symphysis,
followed by the posterior shoulder and the rest of the fetus.
Usually, labor progresses in this fashion, if the fetus is of average size, with a normally
positioned head, in a normal labor pattern in a woman whose pelvis is of average size and
gynecoid in shape
Internal rotation
As the head descends, the presenting part, usually in the transverse position, is rotated
about 45 to anteroposterior (AP) position under the symphysis. Internal rotation brings
the AP diameter of the head in line with the AP diameter of the pelvic outlet.
Extension
With further descent and full flexion of the head, the base of the occiput comes in contact
with the inferior margin of the pubic symphysis. Upward resistance from the pelvic floor
and the downward forces from the uterine contractions cause the occiput to extend and
rotate around the symphysis. This is followed by the delivery of the fetus' head.
Restitution and external rotation
When the fetus' head is free of resistance, it untwists about 45 left or right, returning to
its original anatomic position in relation to the body.
Expulsion (Birth of shoulders and trunk)

After the fetus' head is delivered, further descent brings the anterior shoulder to the
level of the pubic symphysis. The anterior shoulder is then rotated under the
symphysis, followed by the posterior shoulder and the rest of the fetus. After the
shoulder are potioned in anterioposterior diameter of the outlet, further descent takes
place until the anterior shoulder escapes below the symphysis pubis first. by a
movement of lateral flexion of the spine, the posterior shoulder sweeps over the
perineum. Rest of the trunk is then expelled out by lateral flexion.

Pathophysiology
Multiple births include twins and higher-order multiples (eg, triplets, quadruplets). The 2 types of twins
are monozygotic and dizygotic.
Dizygotic twins, which sometimes are called fraternal twins, are produced when 2 sperm fertilize 2 ova.
Separate amnions, chorions, and placentas are formed in dizygotic twins (see Media file 1). The
placentas in dizygotic twins may fuse if the implantation sites are proximate. The fused placentas can
be easily separated after birth.

Monozygotic twins develop when a single fertilized ovum splits during the first 2 weeks after
conception. Monozygotic twins are also called identical twins. An early splitting (ie, within the first 2 d
after fertilization) of monozygotic twins produces separate chorions and amnions (see Media file 1).
These dichorionic twins have different placentas that can be separate or fused. Approximately 30% of
monozygotic twins have dichorionic/diamniotic placentas.
Later splitting (ie, 3-8 d after fertilization) results in monochorionic/diamniotic placentation (see Media
file 2). Approximately 70% of monozygotic twins are monochorionic/diamniotic. If splitting occurs even
later (ie, during 9-12 d after fertilization), monochorionic/monoamniotic placentation occurs (see Media
file 3). Monochorionic/monoamniotic twins are rare; only 1% of monozygotic twins have this form of
placentation. Monochorionic/monoamniotic twins have a common placenta with vascular
communications between the 2 circulations. These twins can develop twin-to-twin transfusion
syndrome (TTTS). If twinning occurs more than 12 days after fertilization, then the monozygotic pair
only partially split, resulting in conjoined twins.
Triplets can be monozygotic, dizygotic, or trizygotic. Trizygotic triplets occur when 3 sperm fertilize 3
ova. Dizygotic triplets develop from one set of monozygotic cotriplets and a third cotriplet derived from
a different zygote. Finally, 2 consecutive zygotic splittings with one split results in a vanished fetus and
monozygotic triplets.
Although the evaluation of the placenta or placentas after the birth is important in all multifetal
pregnancies, the examination may not always help determine zygosity, as in the case of monozygotic
twins, in which 30% have a dichorionic/diamniotic placentation.

Mortality/Morbidity
Multifetal pregnancies are high-risk pregnancies. The fetal mortality rate for twins is 4 times the fetal
mortality rate for single births. The neonatal mortality rate for twins is more than 5 times greater than
the neonatal mortality rate for single births. Higher-order multiple births have even greater mortality
rates than twin and single births.
A high prevalence of low birth weight infants, due to prematurity and intrauterine growth retardation
(IUGR) and their associated complications, contribute to this problem. Twins have increased frequency
of congenital anomalies, placenta previa, abruptio placenta, preeclampsia, cord accidents, and
malpresentations, as well as asphyxia/perinatal depression, group B streptococcal (GBS) infections,
hyaline membrane disease (HMD), and TTTS.

Management of multiple pregnancy:

Specific management for multiple pregnancy will be determined by your physician based
on:

your pregnancy, overall health, and medical history

the number of fetuses
your tolerance for specific medications, procedures, or therapies
expectations for the course of the pregnancy
your opinion or preference

Management of multiple pregnancy may include the following:

increased nutrition
Mothers carrying two or more fetuses need more calories, protein, and other
nutrients, including iron. Higher weight gain is also recommended for multiple
pregnancy. The American College of Obstetricians and Gynecologists recommends
women carrying twins gain at least 35 to 45 pounds.

more frequent prenatal visits (to check for complications and to monitor
nutrition and weight gain) Multiple pregnancy increases the risk for complications. More
frequent visits may help detect complications early enough for effective treatment or management.
The mother's nutritional status and weight should also be monitored more closely.

referrals
Referral to a maternal-fetal medicine specialist, called a perinatologist, for special
testing or ultrasound evaluations, and to coordinate care of complications, may be
necessary.
increased rest
Some women may also need bedrest - either at home or in the hospital depending
on pregnancy complications or the number of fetuses. Higher-order multiple
pregnancies often require bedrest beginning in the middle of the second trimester.
maternal and fetal testing
Testing may be needed to monitor the health of the fetuses, especially if there are
pregnancy complications.
tocolytic medications
Tocolytic medications may be given, if preterm labor occurs, to help slow or stop
contractions. These may be given orally, in an injection, or intravenously. Tocolytic
medications often used include terbutaline and magnesium sulfate.
corticosteroid medications
Corticosteroid medications may be given to help mature the lungs of the fetus.
Lung immaturity is a major problem of premature babies.
cervical cerclage
Cerclage (a procedure used to suture the cervical opening) is used for women
with an incompetent cervix. This is a condition in which the cervix is physically
weak and unable to stay closed during pregnancy. Some women with higher-order
multiples may require cerclage in early pregnancy.

How are multiple pregnancies delivered?

Delivery of multiples depends on many factors including the fetal positions, gestational
age, and health of mother and fetuses. Generally, in twins, if both fetuses are in the
vertex (head-down) position and there are no other complications, a vaginal delivery is
possible. If the first fetus is vertex, but the second is not, the first fetus may be delivered
vaginally, then the second is either turned to the vertex position or delivered breech
(buttocks are presented first). These procedures can increase the risk for problems such
as prolapsed cord (when the cord slips down through the cervical opening). Emergency
cesarean birth of the second fetus may be needed. Usually, if the first fetus is not vertex,
both babies are delivered by cesarean. Most triplets and other higher-order multiples are
born by cesarean.
Vaginal delivery may take place in an operating room because of the greater risks for
complications during birth and the need for cesarean delivery. Cesarean delivery is
usually needed for fetuses that are in abnormal positions, for certain medical conditions
of the mother, and for fetal distress.

Care of multiple birth babies:

Because many multiples are small and born early, they may be initially cared for in a
special care nursery called the neonatal intensive care unit (NICU). Once babies are able
to feed, grow, and stay warm, they can usually be discharged. Other babies, that are
healthy at birth, may need only a brief check in a special care nursery.
Breastfeeding multiples is certainly possible and many mothers of twins and even triplets
are successful in breastfeeding all of their babies. Lactation specialists can help mothers
of multiples learn techniques for breastfeeding their babies separately and together, and
to increase their milk supply. Mothers whose babies are unable to breastfeed because
they are sick or premature can pump their breast milk and store the milk for later
feedings.
Families with more than one baby need help from family and friends. The first two
months are usually the most difficult as everyone learns to cope with frequent feedings,
lack of sleep, and little personal time. Having help for household chores and daily tasks
can allow the mother the time she needs to get to know her babies, for feedings, and for
rest and recovery from delivery.

Care and Management of Multiple Pregnancy

Care and Management of Multiple Pregnancy

Management of multiple pregnancy:

Specific management for multiple pregnancy will be determined by your physician
based on:

your pregnancy, overall health, and medical history

the number of fetuses
your tolerance for specific medications, procedures, or therapies
expectations for the course of the pregnancy
your opinion or preference

Management of multiple pregnancy may include the following:

increased nutrition
Mothers carrying two or more fetuses need more calories, protein, and
other nutrients, including iron. Higher weight gain is also recommended for
multiple pregnancy. The American College of Obstetricians and
Gynecologists recommends women carrying twins gain at least 35 to 45
pounds.
more frequent prenatal visits
Multiple pregnancy increases the risk for complications. More frequent
visits may help detect complications early enough for effective treatment or
management. The mother's nutritional status and weight should also be
monitored more closely.
referrals
Referral to a maternal-fetal medicine specialist, called a perinatologist, for
special testing or ultrasound evaluations, and to coordinate care of
complications, may be necessary.
increased rest
Some women may also need bedrest - either at home or in the hospital
depending on pregnancy complications or the number of fetuses. Higherorder multiple pregnancies often require bedrest beginning in the middle of
the second trimester.
maternal and fetal testing
Testing may be needed to monitor the health of the fetuses, especially if
there are pregnancy complications.
tocolytic medications
Tocolytic medications may be given, if preterm labor occurs, to help slow or
stop contractions. These may be given orally, in an injection, or
intravenously. Tocolytic medications often used include terbutaline and
magnesium sulfate.
corticosteroid medications
Corticosteroid medications may be given to help mature the lungs of the
fetus. Lung immaturity is a major problem of premature babies.
cervical cerclage
Cerclage (a procedure used to suture the cervical opening) is used for
women with an incompetent cervix. This is a condition in which the cervix is
physically weak and unable to stay closed during pregnancy. Some women
with higher-order multiples may require cerclage in early pregnancy.

How are multiple pregnancies delivered?

Delivery of multiples depends on many factors including the fetal positions,
gestational age, and health of mother and fetuses. Generally, in twins, if both fetuses
are in the vertex (head-down) position and there are no other complications, a
vaginal delivery is possible. If the first fetus is vertex, but the second is not, the first
fetus may be delivered vaginally, then the second is either turned to the vertex
position or delivered breech (buttocks are presented first). These procedures can
increase the risk for problems such as prolapsed cord (when the cord slips down
through the cervical opening). Emergency cesarean birth of the second fetus may be
needed. Usually, if the first fetus is not vertex, both babies are delivered by
cesarean. Most triplets and other higher-order multiples are born by cesarean.