Multiple pregnancies

You can deliver most twins vaginally, and only section their mother on the same indications as for a singleton pregnancy (18.4). Twins do however have problems: (1) Labour is more often premature, which puts them at risk. (2) Uterine inertia is more common; this delays the first and second stages of labour, and makes postpartum haemorrhage more likely. (3) Malpresentations are more common, especially with the second twin. (4) Prolapse of the cord is also more common. (5) When the first twin has been born, the second may suffer as the uterus retracts and constricts the placental site.

As soon as you diagnose twins plan for: (1) Hospital delivery. (2) Rest from 32 to 37 weeks, at home if possible, or at a hospital or health centre. You will usually have to admit a mother at 34[nd]35 weeks to the mother's waiting area. (3) A clinical pelvic assessment at 36 weeks. She is more likely to become anaemic, so be sure she is on iron and folic acid. Watch for gestational hypertension (17.4). She should not labour for longer with twins than she would with a single pregnancy. If you do decide to use oxytocin, use it with the greatest care. Deliver triplets (or quadruplets) as you would twins. Expect the same problems as with twins, but expect them more often.

Mr PRINTER. Please take in ''After You, No After you'' No caption, not in series.

MULTIPLE PREGNANCIES FIRST STAGE. As soon as a mother is admitted in labour, determine the lie and presentation of the first twin by abdominal palpation. Confirm this by examining her vaginally, and at the same time assess her pelvis, if this has not already been done at 36 weeks. Manage her as for a singleton pregnancy and use a partogram. If there is delay during the active stage, manage this as for a singleton pregnancy, and apply the same criteria for the use of oxytocin and Caesarean section (see below).

If the first twin is cephalic, or a fully-flexed breech, manage the first stage as an ordinary trial of labour, unless he is very big, or her pelvis is very contracted.

If the first twin has a transverse lie, or is a footling (one leg flexed and one extended), section her, unless he is very small (less than 1.5 kg). He is likely to slip through an undilated cervix, and runs an increased risk of cord prolapse.

SECOND STAGE. Find an assistant who will be ready to look after the first twin, while you deliver the second. Be prepared for an operative delivery of the second twin, and for a postpartum haemorrhage. Have equipment for a drip ready, and ergometrine and oxytocin in easy reach. Preferably, have a drip up routinely.

Deliver the first twin as usual for a cephalic or breech presentation. Immediately he has been born, divide his cord between clamps, and then replace the maternal one by a tie.

CAUTION ! As soon as the first twin is born, look at the clock. Deliver the second twin as soon as possible, but without undue hurry. 20 minutes is a reasonable time.

Feel her abdomen through a sterile towel to find the lie, presentation, and level of the presenting part of the second twin. Then do a vaginal examination to feel how it fits her pelvis. Use 4 fingers or even your whole hand, instead of the usual two; there will always be room for them immediately after delivery of the first twin. The head of the second twin is likely to be high, and you may not be able to reach it with it with two fingers.

If you have a skilled assistant, ask her to do the abdominal palpation and external version of the second twin, and to hold his head steady, while you rupture the patient's membranes.

Listen for the fetal heart, but don't waste too much time doing this; it may be difficult to hear and you will have to deliver him promptly anyway.

CAUTION ! (1) Be sure you know what the presenting part is before you rupture her membranes. (2) The second twin may be larger than the first one. If you are unskilled, a timely section (rarely necessary) is better than the vacuum extraction of a high head, or pulling down the leg of a high-sitting breech. But, if you are expert, a vaginal delivery will always be quicker. Don't be too keen on section: CPD is unusual with twins.

If the second twin is lying longitudinally, rupture his membranes, and deliver him as a vertex or a breech. If he is a vertex, ask your assistant to push his head into her pelvic brim, as you rupture his membranes (to avoid prolapse of the cord).

If the second twin is transverse, correct his lie by manipulating him through a towel on her abdomen, so that his head presents (external cephalic version). The external version of a second twin is usually easy, provided you do it without delay, immediately after the first twin has been delivered, while the membranes remain intact, and before uterine contractions restart. Your assistant can usually do the version, while you check vaginally that he has turned correctly.

If immediate delivery of the second twin in the labour ward by external cephalic version is not possible, try to keep her membranes intact. Rupturing them while he is transverse risks obstructed labour and rupture of her uterus. Arrange for speedy delivery in the theatre by internal podalic version so that you can bring down a leg (see below), or if this fails by Caesarean section.

Fig. 19-8. IF THE SECOND TWIN IS TRANSVERSE, first try external cephalic version. If you succeed, rupture his membranes. If you fail, bring down a leg so as to make him into a breech presentation. This is internal podalic version. Keep the membranes intact if you can, until you have found a foot. In C, and D, they have been broken.

THIRD STAGE. Manage this actively to minimize blood loss. Give her intravenous ergometrine with oxytocin (''Syntometrine') with the birth of the anterior shoulder of the second twin, and then deliver the placentas by controlled cord traction. If bleeding continues or her uterus is lax, also give her 10 units of oxytocin in 500 ml of fluid at 10 drops a minute.

PARTICULAR METHODS [s7]FOR MULTIPLE PREGNANCIES INTERNAL PODALIC (''foot') VERSION can often be done without general anaesthesia. It is kinder however to give her diazepam 10 mg and pethidine 50 mg intravenously.

Put her into the lithotomy position. Make sure her bladder is empty. Prepare her vulva as usual, and preferably her abdominal wall also (sterile sheets are a nuisance, and you want to feel what you are doing).

Wait until she is relaxed between contractions, then put your gloved right hand through her vagina and fully dilated cervix into her uterus, until you can feel her intact membranes. Keep them intact if you can. Often, you have to rupture them before you can get a grip on a foot. Feel her abdomen with your left hand. Grope around for a foot, which you will recognize by its heel. If this is difficult (unusual), work out which way he is lying, and then feel in the direction of his buttocks. Find a leg and follow this down. Use your other hand if this seems easier. When you have found a foot, bring this down. Hold his ankle between your index and middle finger, with your thumb on the dorsum of his foot. Gently pull his foot, so as to bring one of his legs over her pelvic brim, and down her vagina as far as you can, if possible as far as her vulva. His buttocks and other leg will follow. At the same time push his head towards her fundus.

Only now rupture her membranes. Keep pulling on his leg in the direction of the floor. If necessary squat to do this. As more leg appears, hold it higher along its length. When his anterior buttock appears on her perineum, pull horizontally, and then upwards (breech extraction). When his buttocks are out, deliver his shoulders by Lovset's manoeuvre and his head by the Mauriceau[nd]Smellie[nd]Veit manoeuvre (19.8).

Occasionally, it is enough to pull down a leg into her vagina, and let her do the pushing (an assisted breech delivery); but don't rely on this, and be ready to assist her if she is uncooperative or exhausted.

CAUTION ! (1) Internal podalic version is only for the second twin with intact or recently ruptured membranes, during a delivery which you have been supervising. It is not suitable if she is admitted with a transverse second twin and ruptured membranes. If so, manage her as a neglected transverse lie: if he is alive section her, if he is dead, do a destructive operation. (2) Make quite sure it is a foot, and not a hand that you are feeling. Don't, in exasperation, bring down any limb[md]it is sure to be an arm! (3) If you don't know what is presenting, don't waste time waiting for the presenting part to come down. While you wait, her membranes will probably rupture spontaneously, and the presenting part may be an arm!

CAESAREAN SECTION is indicated if she has: (1) A contracted pelvis with a diagonal conjugate of [lt]11 cm, or a true conjugate [lt]9.5 cm. (2) A major malpresentation of the leading baby, such as a transverse lie or an incomplete breech. (3) Lack of progress in labour. (4) A second twin with a transverse lie which you cannot correct. The scar from a previous Caesarean section is a relative contraindication to vaginal delivery.

DIFFICULTIES [s7]WITH MULTIPLE PREGNANCIES If there is DELAY IN THE FIRST STAGE, you can use oxytocin, provided there is no CPD. Rupture the membranes of the first twin.

If CONTRACTIONS STOP after delivery of the first twin, and your are sure the presentation of the second is

cephalic or breech, rupture her membranes. If contractions don't start immediately, put up an oxytocin drip at 2.5 units to 500 ml, and run this at 60 drops a minute. Try to deliver the second twin within 30 minutes of the first, or preferably less.

If, when you do a vaginal examination after the delivery of the first twin, you feel the head or breech of the second twin, but her CERVIX ONLY SEEMS TO BE 7 OR 8 CM DILATED, rupture her membranes and make her push. Her cervix will dilate again, as soon as the presenting part of the second twin comes down. Contraction of her cervix will not delay delivery of the second twin, and is no reason for waiting.

If the SECOND TWIN IS SO HIGH IN HER BIRTH CANAL, that you cannot reach him with your whole hand, and her cervix only admits two fingers, she has a CONTRACTION RING. It may go if you give her pethidine and diazepam, but if it doesn't section her.

If she BLEEDS HEAVILY BEFORE THE DELIVERY OF THE SECOND TWIN, the placenta of the first one has probably separated. Deliver the second twin quickly, and then deliver both placentas together.

If either twin is a BREECH, and she pushes well and the breech descends well, it will be an assisted breech delivery. If there is fetal distress, or delay, or poor pushing, don't hesitate to apply more traction, and turn delivery into a breech extraction (19.8).