MULTIPLE PREGNANCY

The term ‘multiple pregnancy’ is used to describe the devel-

opment of more than one fetus in utero at the same time.
Twin pregnancy
Types of twin pregnancy
 Twins will be either monozygotic (MZ) or dizygotic (DZ).
 Monozygotic or uniovular twins are also referred to as
‘identical twins’.
 They develop from the fusion of one oocyte and one sper-
matozoon, which after fertilization splits into two.
 These twins will be of the same sex and have the same
genes, blood groups and physical features, such as eye
and hair colour, ear shapes and palm creases.
 Dizygotic or binovular twins develop when two separate
oocytes are fertilized by two different spermatozoa; they
are often referred to as fraternal or non-identical twins.
Determination of zygosity and chorionicity
 Determination of zygosity means determining whether or
not the twins are monozygotic (identical) or dizygotic (non-
identical). .
 If the babies have a single outer membrane, the chorion,
they must be monochorionic and so monozygotic.
 In one-third of monozygotic twins, the placenta will have
two chorions and two amnions (DCDA), and either fused
placentas or two separate placentas (dichorionic), which is
indistinguishable from the situation in dizygotic twins.

Relationship between zygosity and chorionicity

Dichorionic Monochorionic
Two placentae (may be fused) One placenta
Two chorions One chorion
Two amnions Two amnions (one amnion in monoamniotic twins
is very rare)
These twins can be either dizygotic or monozygotic These twins can only be monozygotic
Pregnancy
A multiple pregnancy tends to be shorter than a single
pregnancy. The average gestation for twins is 37 weeks, tri-
plets 34 weeks and quadruplets 32 weeks.

Diagnosis of twin pregnancy

Antenatal screening
Screening for Down syndrome is by the combined test:
 Amniocentesis can be performed in twin pregnancies,
usually between 15 and 20 weeks.
 Chorionic villus sampling (CVS

Ultrasound examination
 Monochorionic twin pregnancies should be scanned every
 2 weeks from 16 to 24 weeks to check for lack of harmony
in fetal growth and signs of twin-to-twin transfusion syn-
drome (TTTS).
 A detailed cardiac scan should be included with the
anomaly scan due to increased incidence of cardiac prob-
lems with MZ twins.
 Dichorionic twin pregnancies should be scanned monthly
from 16 weeks, with the anomaly scan between 18+0 to
20+6 weeks.

Antenatal care and preparation

 Women expecting an uncomplicated monochorionic twin
pregnancy should be offered at least nine antenatal ap-
pointments with health- care professionals from the core
team.
 At least two of these should be with the specialist obste-
trician.
 Women with uncomplicated dichorionic twin pregnancies
should be offered at least eight antenatal appointments
with a healthcare professional from the core team, and
two of these with the specialist obstetrician.

Parent education
 Facts and figures on twins and twinning
 Diet and exercise
 Parental anxieties about obstetric complications
 Labour, pain relief and the birth
 Possibilities of premature labour and birth the outcome
 Visit to the special care baby unit
 Breastfeeding and bottle-feeding
 Zygosity
 Equipment (prams and buggies, car seats, etc.)
 Coping with newborn twins or more
 Development of twins including individuality and identi-
 ty

Preparation for breastfeeding

Support needed by the breastfeeding mother of twins
or more
 Consistent professional advice
 Reassurance of her ability to produce enough milk to
satisfy her babies
 Encouragement from professionals and family in her
ability to cope with feeding two or more
 Support from her partner
 Help at home with household chores
 Help with older siblings.
 A high calorie and high protein diet Abdominal examina-
tion

Abdominal examination
1. Inspection
 On inspection, the size of the uterus may be larger than
expected for the period of gestation.
 The uterus may look broad or round and fetal movements
may be seen over a wide area.
 Fresh striae gravidarum may be apparent.
 Up to twice the amount of amniotic fluid is normal in a
twin pregnancy but polyhydramnios is not an uncommon
complication of a twin pregnancy, particularly with mono-
chorionic twins.
2. Palpation
 On palpation, the fundal height may be greater than ex-
pected for the period of gestation.
 The presence of two fetal poles (head or breech) in the
fundus of the uterus may be revealed on palpation and
multiple fetal limbs may also be palpable.
 The head may be small in relation to the size of the uterus
and may suggest that the fetus is also small and therefore
 there may be more than one present.
 Lateral palpation may reveal two fetal backs, or limbs on
both sides.
 Pelvic palpation may give findings similar to those on
fundal palpation, although one fetus may lie behind the
other and make detection difficult.
 Location of three poles in total is diagnostic of at least two
fetuses.
3. Auscultation
 Two fetal heart may be heard.
 If simultaneous comparison over one minute of the heart
rates reveals a difference of at least 10 bpm, it may be as-
sumed that two hearts are being heard beating

Effects of pregnancy
Exacerbation of common disorders
 The presence of more than one fetus in utero and the
higher levels of circulating hormones often 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 con-
tents make greater demands on the maternal iron
stores; in later pregnancy fetal demands may lead to
anaemia.

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 con-
tents 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 la-
bour is likely to start.
 Twins are usually born around 37 weeks rather than 40
weeks, and approximately 60% of twins are born sponta-
neously before 37 weeks’ gestation.
 Ante- natal corticosteroids are usually given to all women
of multiple pregnancies before 36 weeks’ gestation
 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 oth-
er way, an elective caesarean section (CS) is usually rec-
ommended.

Management of labour
 Labour for women expecting twins must be recognized as
high risk and continuous electronic fetal heart monitoring
(EFM) of both fetuses is recommended.
 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 helpful for
intermittent fetal heart rates (FHRs) auscultation than a
Pinard’s stethoscope.
 If the Pinard’s stethoscope has to be used, two people
must auscultate simultaneously, so that the two distinct
FHRs are counted over the same minute.
 A foam rubber wedge under the side of the mattress will
help to prevent supine hypotensive syndrome by giving a
lateral tilt.
 It may be preferable for her to adopt a left lateral position,
well supported by pillows or a beanbag.
 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 be-
fore the epidural is in situ or during the second stage, if
 the effect of the epidural is wearing off.
 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 rup-
tured.
 Artificial rupture of the membranes (ARM) may be suffi-
cient to stimulate good uterine activity but it may need to
be used in conjunction with intravenous oxytocin.
 The CTG will give a good indication of the pattern of uter-
ine activity, whether the labour is induced or spontane-
ous.
 If the babies are expected to be preterm, low birth weight,
or known to have any other problems, the neo-natal in-
tensive care unit (NICU) must be informed that the wom-
an is in labour so they can make the necessary prepara-
 tions to receive the babies.
 When birth is imminent, the paediatric team should be
summoned.
Management of the birth
 The onset of the second stage of labour should be con-
firmed by a vaginal examination.
 In the hospital setting, 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 sin-
 gleton 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’ immedi-
ately.
 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 skin-to-skin con-
tact and encouraged to go to the breast as sucking stimu-
lates uterine contractions.
 After 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 attempt may be made to
correct it by external cephalic version (ECV).
 If it is longitudinal, a vaginal examination is made to con-
firm the presentation.
 If the presenting part is not engaged it should be gently
guided into the pelvis and kept in place until it firmly en-
gages.
 ARM must not be performed on the second sac of mem-
branes 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 re-
commence, intravenous oxytocin may be used.
 When the presenting part becomes visible, the mother
should be encouraged to birth her second twin with con-
tractions.
 The midwife should always be aware there is a risk the
 placenta may start to separate before the birth of the se-
cond twin, causing oxygen deprivation.
 The birth will proceed as normal if the presentation is ver-
tex, but if the fetus presents by the breech and the mid-
wife 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 expe-
dited 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 lo-
cal policy, after 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.
 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.
 If the babies are of different sexes, they are dizygotic.
 If the placenta is mono-chorionic (MCDA), they must be
monozygotic.
 If they are of the same sex and the placenta is dichorionic
(DCDA), then further tests will be needed.
 The umbilical cords should also be examined and the
number of cord vessels and the presence of any abnor-
malities noted.
COMPLICATIONS ASSOCIATED WITH MULTIPLE PREG-
NANCY
Polyhydramnios
 It may be associated with fetal abnormality but is more
likely to be due to twin-to- twin transfusion syndrome
(TTTS), which can also be known as feto-fetal transfusion
syndrome (FFTS).
Twin-to-twin transfusion syndrome
 Twin-to-twin transfusion syndrome (TTTS) can be acute or
chronic.
 The acute form usually occurs during labour and is the
result of blood transfusing from one fetus (donor) to the
other (recipient) through vascular anastomosis in a mono-
chorionic placenta.
 Both fetuses may die of cardiac failure if not treated ur-
gently.
Fetal malformations
 This is particularly associated with monochorionic twins.
Conjoined twins
 This extremely rare malformation of monozygotic twinning
results from the incomplete division of the fertilized oo-
cyte;
Twin reversed arterial perfusion
 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.
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
 Although the uterus is large and distended, the fetuses
 are less mobile than may be supposed. They can restrict
each other’s movements, which may result in malpresen-
tations, particularly of the second twin.
 After the birth of the first twin, the presentation of the se-
cond twin may change.
Preterm rupture of the membranes
 Malpresentations due to polyhydramnios may predispose
to preterm rupture of the membranes.
Cord prolapse
 This too is associated with malpresentations and polyhy-
dramnios and is more likely if there is a poorly fitting pre-
senting part.
 The second twin is particularly at risk of cord prolapse.
Prolonged labour
 Malpresentations are a poor stimulus to good uterine ac-
tion and a distended uterus is likely to lead to poor delay
 in the birth of the second twin.
Monoamniotic twins
 Approximately 1% of MZ twins share the same amniotic
sac. Monoamniotic (MCMA) twins risk cord entanglement
with occlusion of the blood supply through the umbilical
cords to one or both fetuses.
Locked twins
 There are two types. One occurs when the first twin pre-
sents by the breech and the second by the vertex;
 the other when both are vertex presentations.
 In both instances, the head of the second twin prevents
the continued descent of the first.
Delay in the birth of the second twin
 Poor uterine action as a result of malpresentation may be
the cause of delay.
 The risks of such delay are intrauterine hypoxia, birth as-
phyxia following premature separation of the placenta and
 sepsis as a result of ascending infection from the first
umbilical cord, which lies outside the vulva. .
Premature expulsion of the placenta
 The placenta may be expelled before the birth of the se-
cond twin.
 The risks of severe asphyxia and death of the second twin
are very high. .
Postpartum haemorrhage
 Poor uterine tone as a result of overdistension or hypo-
tonic activity is likely to lead to postpartum haemorrhage
There is also a much larger placental site to contract
down.
Delayed interval birth of the second twin
 There have been several reported cases where the first
twin has been born, often very prematurely, and then a
long gap before labour recommences; it can be days or
 even weeks before the second twin is born.
 This opportunity can be used to give antenatal cortico-
steroids to the mother to help mature the lungs of the se-
cond twin.
Undiagnosed twins
 The possibility of an unexpected, undiagnosed second ba-
by 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.

Postnatal period
Care of the babies
 Immediate care after the birth is the same as for a single
baby.
 The babies may need to be admitted to the NICU from the
labour suite, otherwise they can be encouraged to have
 skin-to-skin contact, and go to the breast if they are to be
breastfed before being transferred to the postnatal ward
with their mother.
Temperature control
 Maintenance of a thermoneutral environment is essential,
particularly for babies in the NICU.
 Clothing should be light but warm, and allow air to circu-
late.
Feeding
 With breastfeeding, both babies may be breastfed sepa-
rately or simultaneously.
Separate feeding
 It allows her to give one-to-one attention to each ba-
by, something mothers of twins feel they have very lit-
tle time for.
 It is easier for the mother, as she has both hands
 free
 to position and attach one baby at a time.
 If she does feed separately, it is recommended that
she adopts a routine where whichever baby wakes first
is fed and the second one is woken straight afterwards
so keeping her feeds together.
Simultaneous feeding
 It saves time as both babies are feeding together,
though the mother will need to be organized, and will
need help in the early days to get both babies attached
to the breast.
 If the mother does want to feed the babies together, it
is advisable to try this before going home from hospi-
tal, where a midwife can stay with her

Care of the mother

 Involution of the uterus will be slower because of its in-
creased bulk. ‘After pains’ may be more troublesome and
analgesia should be offered.
 A good diet is essential and if the mother is breastfeeding
she requires a high protein, high calorie diet.
 It is quite common for breastfeeding mothers to feel hun-
gry between meals and they should be encouraged to keep
sensible snacks to hand for such times.
 A dietician may be able to offer help.
 The physiotherapist or midwife should instruct the moth-
er in her postnatal exercises.
 The midwife must give the mother of twins extra support.
Teaching her simple parenting skills and encouraging her
to carry them out with increasing assurance will build up
her confidence.