19.9 Multiple pregnancies

You can deliver most twins vaginally, and only do a Caesarean section on the same indications as for a singleton pregnancy (22.5). 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 32–37 weeks, at home if possible, or at a hospital or health centre. You will usually have to admit a mother at 34–35weeks 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 (21.3). 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.

Figure 19.7: HOW TWINS PRESENT. In 40% of cases both twins are cephalic. In 21% the second twin is a breech. In 14% the first twin is a breech. In 10% of cases both twins are breeches. In all remaining cases one or other twin, or occasionally both, are transverse.