Multiple Pregnancy / Twin Pregnancy – Labour Management

Place of delivery – as the twin pregnancy is considered a ‘high risk’, the patient should be confined in an equipped hospital preferably having an intensive neonatal care unit.

First stage:

Usual conduction of the first stage as outlined for a singleton fetus is to be followed with additional precautions.

1. Patient should be kept in bed and the enema with held. These are to prevent early rupture of the membranes.
2. Use of analgesic drugs is to be limited as the babies are small and rapid delivery may occur. Epidural analgesia is preferred as it facilitates manipulation of second fetus should it prove necessary.
3. Careful fetal monitoring is to be done with available gadgets.
4. Internal examination should be done soon after the rupture of the membranes to exclude cord prolapse.
5. An intravenous line with ringer’s solution be set up for any urgent intravenous therapy, if required.
6. One unit of compatible and cross matched blood should be made reality available.
7. Neonatologist should be present at the time of delivery.

Delivery of the 1^st stage

      As the baby is usually small, the delivery does not usually pose any problem. (i) liberal episiotomy under local infiltration with 1% lignocaine saves both the fore coming or the after coming head of the premature baby from intracranial damages. (ii) forceps delivery, if needed, should be done preferably under pudental block anesthesia. (iii) do not give intravenous ergometrine with the delivery of the anterior shoulder of the first baby. (iv) clamp the cord at two places and cut in between. (v) at least 8-10cm of cord is left behind for administration of any drug or transfusion, if required.

• Blood transfusion if necessary
• The patient is to be carefully watched for about 2hrs after delivery.

Conduction of labour after the delivery of the baby

Principle:

The principle is to expedite the delivery of the second baby.

Steps of management:

Step-1: put two clamps on the cord and cut in between to prevent exsanguinations of the second baby.

Step-2: following the birth of the first baby, the lie presentation size of the baby and FHS of the second baby should be ascertained by abdominal examination. Vaginal examination also done to exclude the cord prolapse.

 

Longitudinal

Step-1:  low rupture of the membranes is done after fixing the presenting part on the brim. Syntocinon may be added to the infusion bottle to achieve this. Internal examination is once more to be done to exclude cord prolapse. More vigilance is employed to watch the fetal condition.

Step-2: if the uterus contraction is poor, 5 units of oxytocin is added to the infusion bottle.

Step-3: if there is still a delay (say 15 minutes), interference is to be done.

Vertex:

• Low down- forceps are applied
• High up- if the first baby is too small and the second one seems bigger, cephalo-pelvic disproportion should be ruled out. The possibility of hydrocephalic head should also be kept in mind. If these are excluded, internal version followed by breech extraction is performed under general anesthesia. Ventouse may be an effective alternative.

Breech: the delivery should be completed by breech extraction.

Transverse:  If the lie is transverse, it should be corrected by external version in to a longitudinal lie preferably cephalic, if fails, podalic. If the external version fails, internal version under general anesthesia should be done forth with. As the fetus is small there is no difficulty in performing internal version and it is the only accepted indication of internal version.