Download Effects of pregnancy

Effects of pregnancy
Exacerbation of common
disorders
• The presence of more than one fetus in
utero and the higher levels of circulating
hormones ohen exacerbate the common
disorders of pregnancy.
• - Sickness, nausea and heartburn may be
more persistent and more troublesome
than in a singleton pregnancy.
Anaemia
• -Iron and folic acid deficiency anaemias are
common in twin pregnancies.
• Early growth and development of the uterus and
its contents make greater demands on the
maternal iron stores; in later pregnancy (aher
the 28th week), fetal demands may lead to
anaemia.
• Routine oral iron supplementation remains a
controversial issue), but all pregnant women are
advised to take folic acid daily
Polyhydramnios
• This is also common and is particularly
associated with monochorionic twins and
with fetal abnormalities.
• -Polyhydramnios will add to any discomfort
that the woman is already experiencing.
• - If acute polyhydramnios occurs, it can
lead to miscarriage or preterm labour.
Pressure symptoms
• -The increased weight and size of the uterus
and its contents may be troublesome.
• -Impaired venous return from the lower limbs
increases the tendency to varicose veins and
oedema of the legs.
• -Backache is common and the increased uterine
size may also lead to marked dyspnoea and
indigestion.
Other
• There can be an increase in complications
of pregnancy such as obstetric
cholestasis, and pelvic girdle pain (PGP)
Labour and the birth
• Onset
• -The more fetuses the woman is carrying, the earlier labour is likely
to start.
• - Twins are usually born around 37 weeks rather than 40 weeks,
• -approximately 60% of twins are born spontaneously before 37
weeks' gestation.
• -In addition to being preterm, the babies may be small for
gestational age (SFGA) and therefore prone to the associated
complications of both conditions.
• - If spontaneous labour begins before 24 weeks, the chances of
survival outside the uterus are very small, but it is possible the
woman can be given drugs to inhibit uterine activity.
• Causes of preterm labour must, if at all possible, be
diagnosed and treated quickly; for example, urinary tract
infection should be treated with antibiotics.
• Antenatal corticosteroids are usually given to all women
of multiple pregnancies before 36 weeks' gestation
• Evidence shows that aher 38 weeks' gestation there is
increased risk of higher mortality in babies
• most obstetricians advise induction of labour by 38
weeks for dichorionic twins and between 36 and 37
weeks for monochorionic twins .
• In dichorionic pregnancies,
• if the first twin is a cephalic presentation,
labour is usually allowed to continue to a
vaginal birth, but if the first twin is
presenting in any other way, an elective
caesarean section (CS) is usually
recommended
• For uncomplicated monochorionic twin
pregnancies women are generally offered
a vaginal birth,
• for complicated monochorionic
pregnancies birth is by elective CS.
• For triplets and above, the mode of birth is
almost always by CS.
ca se hist o r y 1
• C
A 34-year-old primigravida was diagnosed with DCDA twins,
no family history, so it was a complete shock. At the ultrasound
department, a leaflet with local twin organizations and contacts
was given to the mother. Through the hospital specialist, multiple
birth midwife and twins club the mother started to come to terms
with the prospect of twins.
• She knew she was expecting two boys and began to wonder if they
were identical or not, but would have to wait until they were born and
have DNA tests if they looked alike.
• She had a straightforward birth with her first child, so she was keen
to have a vaginal birth again, but felt there was pressure on her to
have an elective caesarean section.
• The pregnancy progressed normally and with support from the
specialist midwife, she wrote her birth plan. The presenting baby
was cephalic, and at 38 weeks labour was induced.
• The woman had an epidural and progressed to birth both babies
vaginally aher a short labour.
• Both babies were put to her breast in the labour suite; twin one
sucked well but twin two was not interested.
• As establishing
•
feeding was more problematic than she expected and she felt she
needed a lot of help from the midwives, the mother stayed in
hospital until day 5. Both babies were sucking well on return home,
although twin two did occasionally need a ‘top up’ from the bottle.
Management of labour
• -During antenatal classes the couple must be warned
that a multiple birth is less common and therefore, for
educational purposes in the hospital setting, a number of
professionals may ask to observe the birth.
• If the woman has any objection to this, her wishes must
be respected and a record made in her notes that she
wants only those concerned with her care to be present.
• Home births are not advisable with a multiple pregnancy,
but some women may still request one, in which case
every effort should be made to support her decision with
an uncomplicated pregnancy.
• This will require meticulous risk assessment and
planning, including the involvement of midwifery
supervision in order that a plan of care for labour
is clearly articulated and documented in the
woman's records.
• A skilled team of midwives with confidence to
deliver intrapartum care to women with twin
•
pregnancies at home will need to be identified to
be on call.
• The majority of women expecting twins will
go into labour spontaneously.
• Theoretically the duration of the first stage
of labour should be no different from that
of a single pregnancy.
• However, there is an increased incidence
of dysfunctional labour in twin
pregnancies, possibly because of
overdistension of the uterus.
reasons for earlier induction of
labour
•
•
•
•
•
as pregnancy-induced hypertension
obstetric cholestasis
, intrauterine growth restriction (IUGR)
twin-to-twin transfusion syndrome
high risk and continuous electronic fetal heart
monitoring (EFM) of both fetuses is advocated.
• This can be achieved either with two external
transducers or, once the membranes are
ruptured, a scalp electrode on the presenting
twin and an external transducer on the second.
• If a ‘twin monitor’ is available, both heartbeats
can be monitored simultaneously to give a more
reliable reading.
• Uterine activity will also need to be monitored.
• If cardiotocography (CTG) is not available (e.g. a
home birth), use of hand-held Dopplers may be
more pragmatic for structured intermifent fetal
heart rates (FHRs) auscultation than a Pinard's
stethoscope.
• -If the lafer has to be used, two people must
auscultate simultaneously, so that the two
distinct FHRs are counted over the same
minute.
• While in labour, the woman should be
encouraged to adopt whichever position she
finds most comfortable.
• -A foam rubber wedge under the side of the
mafress will help to prevent supine hypotensive
syndrome by giving a lateral tilt.
• - It may be preferable for her to adopt a leh lateral
position, well supported by pillows or a beanbag.
• -A birthing chair or a reclining chair, if available, may be
more comfortable than a conventional labour suite
birthing bed.
• -Regional epidural block provides excellent analgesia,
and if necessary, allows easier instrumental births and
also manipulation of the second twin.
• The use of Entonox analgesia may be helpful, either
before the epidural is in situ or during the second stage,
if the effect of the epidural is wearing off.
• The woman should be encouraged to use
whatever form of relaxation she finds helpful.
• If she chooses to use pharmacological means of
analgesia only aher non-pharmacological
methods are no longer effective, her wishes
should be respected.
• The midwife should explain that, if
complications arise, intervention and the use of
pharmacological analgesia might be necessary.
• Ideally this should be discussed with the woman
antenatally so that the physiology of labour is not
disturbed with new information
• If fetal compromise occurs during labour, the
birth will need to be expedited, usually by CS.
Action may also need to be taken if the woman's
condition gives cause for concern.
• -If uterine activity is poor, the use of intravenous
oxytocin may be required once the membranes
have been ruptured.
• -Artificial rupture of the membranes (ARM) may
be
•
sufficient to stimulate good uterine activity
• it may need to be used in conjunction with intravenous
oxytocin.
• The CTG will give a good indication of the pafern of
uterine activity, whether the labour is induced or
spontaneous.
• The response of the fetal hearts to uterine contractions
can be observed on the CTG.
• If the babies are expected to be preterm, low birth
weight, or known to have any other problems, the
neonatal intensive care unit (NICU) must be informed
that the woman is in labour so they can make the
necessary preparations to receive the babies.
• -When birth is imminent, the paediatric
team should be summoned.
• -Throughout labour, the emotional and
general physical condition of the woman
must be considered.
• - She requires the presence of her birthing
partner and one-to-one care from the
midwife.
Management of the birth
• -The onset of the second stage of labour should be confirmed by a
vaginal examination.
• -In the hospital sefing, the obstetrician, paediatric team and
anaesthetist should be present for the birth as there is a risk of
complications.
• • Epidural analgesia may need to be ‘topped up’ prior to the birth.
• The possibility of emergency CS is ever present and the operating
theatre should be ready to receive the mother at short notice.
• Monitoring of both FHRs should continue until birth.
• Provided that the first twin is presenting by the vertex, the birth can
be expected to proceed normally, as with a singleton pregnancy.
• When the first twin is born, the time of birth and
the sex are noted.
• This baby and cord must be labelled as ‘twin
one’ immediately.
• The identity tags should be checked with the
mother or father before they are applied to the
baby in accordance with local policy.
• The baby may be given to the mother for skinto-skin contact and encouraged to go to the
breast as sucking stimulates uterine contractions
• Aher the birth of the first twin, abdominal
palpation is made to ascertain the lie,
presentation (in the event of doubt a
portable ultrasound machine should be
available) and position of the second twin
and to auscultate the FHR to ensure
continuous EFM.
• An assistant may need to stabilize the lie
of the second twin.
• If the lie is not longitudinal, an afempt may
be made to correct it by external cephalic
version (ECV)
• ECV in this context in the UK should only
be performed or supervised by a senior
obstetrician).
• ECV is less invasive than internal podalic
version, and will often be the default
manoeuvre employed by obstetricians
• -If it is longitudinal, a vaginal examination is made to
confirm the presentation.
• -If the presenting part is not engaged it should be gently
guided into the pelvis and kept in place until it firmly
engages.
• -ARM must not be performed on the second sac of
membranes until the presenting part engages, as risk of
cord prolapse is ever present.
• -The FHR must be auscultated again;
• -a scalp electrode might be required following ARM if
external monitoring of the FHR is of poor quality
• -If uterine activity does not recommence,
intravenous oxytocin may be used.
• -When the presenting part becomes visible, the
mother should be encouraged to birth
• after second twin with contractions.
• -The midwife should always be aware there is a
risk the placenta may start to separate before
the birth of the second twin, causing oxygen
deprivation.
• -The birth will proceed as normal if the
presentation is vertex, but if the fetus presents
by the breech and the midwife is not
experienced in breech births she will need a
doctor's assistance.
• -The birth of the second twin should ideally be
completed within 45 minutes of the first twin but,
as long as there are no signs of fetal
compromise in the second twin, it may be
allowed to continue longer.
• -If there are signs of compromise, the birth must
be expedited and the second twin may need to
be born by CS.
• -An uterotonic drug (Syntometrine or oxytocin) is
usually given intramuscularly or intravenously,
depending on local policy, aher the birth of the
anterior shoulder as with a singleton pregnancy.
• This baby and cord are labelled as ‘twin two’.
• The time of birth and sex of child must be noted.
• If either twin needs to be transferred to the NICU
for observation, the mother should have a
chance to see and hold the baby whenever
possible.
• -Once the uterotonic drug has taken effect,
controlled cord traction is applied to both cords
simultaneously to aid birth of the placentas
without delay.
• -Emptying the uterus enables bleeding to be
controlled and postpartum haemorrhage
prevented.
• -The placenta(s) should be examined not only to check
completion but the number of amniotic sacs, chorions
and placentas noted (see Fig. 14.2).
• -If the babies are of different sexes, they are dizygotic.
• - If the placenta is monochorionic (MCDA), they must be
monozygotic.
• -If they are of the same sex and the placenta is
dichorionic (DCDA), then further tests will be needed
(see Zygosity).
• - The umbilical cords should also be examined and the
number of cord vessels and the presence of any
abnormalities noted.
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