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.

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), do a Caesarean section, unless he is very small (<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. Insert an IV line, and have ergometrine and oxytocin in easy reach.

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 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 the membranes. (2) The second twin may be larger than the first one. If you are unskilled, a timely Caesarean section 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. However, be cautious: CPD is unusual with twins.

If the second twin is lying longitudinally, rupture the 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 the 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, or if this fails by Caesarean section.

THIRD STAGE

Manage this actively to minimize blood loss. Start IV ergometrine with oxytocin 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 add 10 units of oxytocin in 500 ml of fluid at 10 drops/min.

PARTICULAR METHODS FOR MULTIPLE PREGNANCIES

INTERNAL PODALIC VERSION can often be done without general anaesthesia. It is kinder however under sedation.

Put the patient 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, 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 Løvset’s manoeuvre and his head by the Mauriceau–Smellie–Veit manoeuvre (23.7).

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 do a Caesarean section, 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—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 <11 cm, or a true conjugate <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 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 IV oxytocin, of concentration 2.5 units to 500 ml, at 60 drops/min. Try to deliver the second twin within 20 minutes of the first, or preferably less.

If, after the delivery of the first twin, you feel the head or breech of the second twin, but her CERVIX IS ONLY 7–8 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 sedation, but if it doesn’t, do a Caesarean section.

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 (23.7).