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Complications associated with multiple pregnancy
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The higher perinatal mortality associated with
twinning is largely due to complications of
pregnancy, such as the premature onset of
labour, intrauterine growth restriction and
complications at birth.
 -The management of multiple pregnancy is
concerned with the prevention, early detection
and treatment of these complications.
Polyhydramnios
Acute polyhydramnios may occur as
early as 16 weeks.
 -It may be associated with fetal
abnormality but is more likely to be due
to TTTS
 -which can also be known as fetofetal
transfusion syndrome (FFTS).
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Twin-to-twin transfusion syndrome
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-Twin-to-twin transfusion syndrome (TTTS) can be
acute or chronic.
-The acute form usually occurs during labour
- the result of blood transfusing from one fetus (donor)
to the other (recipient) through vascular anastomosis
in a monochorionic placenta.
- Both fetuses may die of cardiac failure if not treated
urgently.
-Chronic TTTS occurs in about 15% of monochorionic
twin pregnancies
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The placenta in TTTS transfuses blood from one twin
fetus to the other.
-This results in anaemia and growth restriction in the
donor twin (the term ‘stuck twin’ may be used)
- polycythaemia with circulatory overload in the
recipient twin (hydrops).
-The fetal and neonatal mortality is high but infants
may be saved by early diagnosis and prenatal
treatment
- amnioreduction, which may have to be repeated
regularly as fluid can reaccumulate rapidly.
- or laser ablation therapy of communicating placental
vessels, or septostomy
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-The midwife should always be alerted to the
mother who complains of a rapid increase in
her abdominal girth in the second trimester
 - a uterus that feels hard and uncomfortable
continuously, due to polyhydramnios and if not
treated urgently can cause premature labour.
 - This usually occurs in women who have a
monochorionic pregnancy
Fetal abnormality
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-associated with monochorionic twins.
1-Conjoined twins
-rare malformation of monozygotic twinning
- results from the incomplete division of the
fertilized oocyte;
 -it occurs once in 50 000 births and over half
the cases are stillborn.
 -Delivery has to be by caesarean section.
 - Separation of the babies is sometimes
possible and will depend on how they are
joined and which internal organs are involved.
Thoracopagus is the commonest form of
fusion (over 70% of cases).
 -Many conjoined twins can now be
successfully separated.
 -Others pose major ethical dilemmas –
particularly if one can be saved at the
expense of the other.
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2-Twin reversed arterial perfusion
Twin reversed arterial perfusion (TRAP)
 -In TRAP, one twin presents without a
well-defined cardiac structure and is kept
alive through placental anastomoses to
the circulatory system of the viable fetus
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3-Fetus-in-fetu
-In fetus-in-fetu (endoparasite)
- parts of a fetus may be lodged within another
fetus
- this can happen only in MZ twins
Malpresentations
- malpresentations, particularly of the second
twin.
- After the birth of the first twin, the
presentation of the second twin may change.
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Premature rupture of the membranes
-Malpresentations due to polyhydramnios may
predispose to pre-term rupture of the membranes.
Prolapse of the cord
-associated with malpresentations and
polyhydramnios, with a poorly fitting presenting part.
- The second twin is particularly at risk of cord
prolapse.
Prolonged labour
-Malpresentations are a poor stimulus to good uterine
action
- a distended uterus is lead to poor uterine activity and
prolonged labour.
Monoamniotic twins
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-Approximately 1% of twins share the same
sac.
-(MCMA) twins risk cord entanglement with
occlusion of the blood supply through the
umbilical cords to one or both fetuses.
- treated with sulindac taken by the mother to
reduce amniotic fluid levels
- delivered at around 32–34 weeks
-by elective caesarean section
Locked twins
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-a very rare but serious complication.
-There are two types
1- the first twin presents by the breech and the
second by the vertex
2- when both are vertex presentations In both
instances, the head of thesecond twin
prevents the continued descent of the first.
-Primigravidae are more at risk than
multiparous women.
Delay in the birth of the second twin
-After the birth of the first twin, uterine
activity should recommence within 5 min.
 -Ideally the birth of the second twin
should be completed within 45 min of the
first twin being born
 - Poor uterine action as a result of
malpresentation may be the cause of
delay.
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-The risks of such delay are
1-intrauterine hypoxia
2- birth asphyxia
3- premature separation of the placenta
4- sepsis as a result of ascending infection
from the first umbilical cord, which lies outside
the vulva.
- After the birth of the first twin the lower
uterine segment begins to reform and the
cervical canal may have to dilate fully again.
-The midwife may need to ‘rub up’ a
contraction
 - put the first twin to the breast to
stimulate uterine activity.
 - a caesarean section may be necessary
if obstructed labor occur
 -If there is no obstruction, oxytocin
infusion may be commenced or forceps
delivery considered.
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Premature expulsion of the placenta
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-The placenta may be expelled before the birth
of the second twin.
- In dichorionic twins with separate placentae,
-in monochorionic twins the shared placenta
may be expelled.
- The risks of severe asphyxia and death of the
second twin are very high.
-Haemorrhage is also likely if one twin is
retained in utero as this prevents adequate
retraction of the placental site.
Postpartum haemorrhage
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-Poor uterine tone as a result of over
distension or hypotonic activity is likely to lead
to postpartum haemorrhage.
 -There is also a much larger placental site to
contract down.
 Undiagnosed twins
 -The possibility of an unexpected,
undiagnosed second baby (though this is
unlikely with ultrasound scanning) should be
considered if the uterus appears larger than
expected after the birth of the first baby or if
the baby is surprisingly smaller than expected.
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-If an uterotonic drug has been given after the
birth of the anterior shoulder of the first baby
 - the second baby is in great danger of birth
asphyxia and his birth should be expedited.
 -The midwife must break the news of
undiagnosed twins gently to the parents.
 - These parents will require special support
and guidance during the postnatal period.
Delayed interval delivery of the
second twin
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can be used to give betamethasone to the
mother to help mature the lungs of the second
twin.
 Careful observations of the mother's condition
must be made during this time for signs of
infection and fetal compromise.
 The mother will need additional support from
the midwives to cope with her anxieties for her
premature baby, time to grieve if the baby has
died.
Postnatal period
Care of the babies
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is the same as for a single baby.
Maintenance of body temperature is vital
use of overhead heaters will help to prevent heat loss.
Identification of the babies should be clear
The babies may need to be admitted to the neonatal
unit
-transferred to the postnatal ward with their mother
Temperature control
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-Maintenance of a thermo neutral environment
is essential, particularly for babies in the
neonatal unit.
Nutrition
-The mother may choose to feed her babies by
breast or with formula milk
- may be breastfed separately or
simultaneously.
-In the immediate postnatal days, it is
recommended the mother breastfeeds her
twins separately,
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-this give her time to get to know each baby and to feel
confident in her ability to cope.
 -If the babies are small for gestational age or pre-term,
the paediatricians may recommend that the babies be
‘topped up’ after a breastfeed.
 -Expressed breast milk is best for these babies.
 -If the babies are not able to suck ,the mother should
be encouraged to express her milk regularly.
 - human milk bank can be used; this is preferable for
pre-term babies,and reduces the risk of necrotizing
enterocolitis (NEC)
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-As twin babies are more likely to be pre-term
or small for gestational age, their ability to
coordinate the sucking and swallowing
reflexes may be poor.
 -need to be fed intravenously or by
nasogastric tube, or cup-fed ,depending on
their size and general condition.
 -Careful monitoring of weight gain is required.
 - Hypoglycemia may occur and regular
capillary blood glucose estimations may be
needed.
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mother think of insufficient milk, the midwife should
reassure her that lactation responds by the babies
sucking .
- At feeding times, the midwife must be with the
mother to offer support and advice on positioning and
fixing the babies
- encouraging her to breastfeed two babies.
Breastfeeding
-The advantages of breastfeeding are
the same as for single babies
 - twins have a higher tendency to be
born prematurely and small for
gestational age, it is even more
important that they should be breastfed.
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-advantages of breast milk
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-It is cheaper
- breast milk is available 24 hrs a day
- at the correct temperature.
-There are no bottles to wash, no sterilizing to
organize or feeds to make up,
- less take time.
-Twins can be breastfed together or
separately.
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- If the babies are to be fed together, then the
feeds will take only a little longer than with a
single baby.
 -Mothers of twins always complain that there is
never enough time for cuddling.
 -breastfeeding together is the only way for her
to hold and feed both babies together at the
same time.
 - to coping with two or more babies. It may
take 4–6 weeks for a feeding to get
established
Mother–baby relationships
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it more difficult to bond with both babies
equally.
 the mother should be encouraged to spend as
much time as possible with the baby on the
NNU and to visit as soon after the birth as she
feels able.
 help the mother to divide her attention
between both babies and to give plenty of
reassurance that she is not the first mother to
feel the same way
Mother–partner relationships
In some cases her partner may feel that
she is devoting too much time to the
babies and not enough to him, thus
making him feel excluded.
 The midwife should always encourage
the father to be involved in the daily care
of the babies, either in hospital or at
home.
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Care of the mother
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-involution of the uterus will be slower
- ‘After pains’ is more so analgesia should be offered.
-A good diet is essential
- a high protein, high calorie diet.
- It is quite common for breastfeeding mothers to feel
hungry between meals and they should be encouraged
to keep snacks to hand for such times.
-A dietician may be able to offer help.
-The physiotherapist or midwife should instruct the
mother in her postnatal exercises .
- The mother may feel ‘in the way’ if the babies are in the
neonatal unit
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-She may also have feelings of guilt
 - let her to express her feeling
 -keep her up-to-date with the care and condition of her
infants.
 -If one infant is very ill or dies, the mother will
experience additional psychological problems.
 -included partner ,relatives & friends in support.
 -The community midwife will contact the mother after
discharge from hospital to arrange home visits.
 - encouraged to rest and sleep during the day
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- eat a well-balanced diet
- discourage visitors in the first week at home
-The father should be encouraged to help as
much as possible.
-Isolation can be a real problem for new
mothers.
- the incidence of postnatal depression to be
significantly higher in mothers of twins
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Stress, isolation and exhaustion are all
significant precipitants of depression;
mothers of twins are therefore more
vulnerable.