Varities of twins

1.Dizygotic twins-it is the most common (80%)

and results from the fertilization of two or more
ova.
2.Monozygotic twins- (20%) results from the
fertilization of a single ovum.

10/13/2020 3
GENESIS OF TWINS
 Dizygotic twins
It is also known as binovular or fraternal twins
develop from two separate ova that are
fertilized by two different spermatozoa, and are
often referred to as non- identical twins.

10/13/2020 4
CONTD…
 They are no more alike than any brother or
sister and can be the same or different sex.
Because in any pregnancy there is a 50:50
chance of girl or boy, half of the dizygotic
twins will be boy-girl pairs.

10/13/2020 5
CONTD…
 Sometimes a twin pregnancy just happens. In
other cases, specific factors are at play.
For example, a twin pregnancy is more likely
as women get older because hormonal
changes can cause more than one egg to be
released at a time.
 Use of assisted reproductive technologies —

such as in vitro fertilization — also boosts the

odds of twins or other multiples.

10/13/2020 6
10/13/2020 7
Monozygotic twins
 It is also known as uniovular twins as
‘identical twins.
 They develop from the fusion of one ovum
and one spermatozoon, which after
fertilization spills into two.
 These twins will be the same sex and have
same genes, blood groups, and physical
features such as eye and hair color, ear
shapes and palm creaases.

10/13/2020 8
10/13/2020 9
Contd…

On the rare occasion, the following possibilities

may occur:

If the divisions takes within 72 hours after

fertilization (prior to morula stage) the resulting
embryo will have two separate placenta, chorion
and amnnons (diamniotic- dichorionicm30 %)

10/13/2020 10
10/13/2020 11
 Contd…
If the divisions takes place between the 4th
and 8th day after the formation of inner cell
mass when chorion has already developed –
diamniotic monochorionic twins develop(66 %).

10/13/2020 12
10/13/2020 13
Contd…
 If the division occurs after 8th day of fertilization,
when the amniotic cavity has already formed, a
monoamniotic- monochorionic twin develops (3
%).

10/13/2020 14
10/13/2020 15
Contd…
 on extremely rare occasions, division occurs
after 2 weeks of the development of
embryonic disc resulting in the formation of
conjoined twin (1%) called – Siamese twin.

10/13/2020 16
Four types of fusion
 a. Thoracopagus (most common),

 b. Pyopagus (posterior fusion)

 c. Craniopagus (cephalic) and

 d. Dischopagus (caudal).

10/13/2020 17
Zygosity and chorionicity
 Zygosity refers to the genetic makeup of twin
pregnancy and chrorionicity refers the
placenta's membrane status.
chrorionicity is determined by the timing of
embryo division.
 Chorionnicity is diagnosed by

ultrasonography in the 1st trimester by

counting the number of gestation sac and
evaluating the thickness of the dividing
membranes.

10/13/2020 18
 Diagnosis of zygosity
Examining fetal gender
 (different genders=dizygotic), placenta

(monochorionic monozygotic) and by

genetic testing

10/13/2020 19
Examination of placenta and membrane

 Dizygotic twins:

 i) There are two placentae, either completely

separated or more commonly fused at the
margin appearing to be one (9 out of 10).
There is no anastomosis between the two
fetal vessels.
 ii) Each fetus is surrounded by a separate

amnion and chorion.

10/13/2020 20
Contd…
 Monozygotic twins:
 i) the placenta is single.
 There is varying degree of free anastomosis

between the two fetal vessels.

 ii) Each fetus is surrounded by a separate

amniotic sac with chorionic layer common to

both (diamniotic - monochorionic)

10/13/2020 21
Contd…
 iii) As such the intervening membranes
consist of two layers of amnion only.

 However, on rare occasions, the uniovular

twins may be diamniotic – dichorionic or
monoamniotic – monochorionic.
 sex: while twins having opposite sex are

almost always binovular and twins of the

same sex are not always uniovular but the
uniovular twins are always of the same sex.

10/13/2020 22
 Contd…
 If the fetus are of the same sex and have the
same genetic features (dominant blood
group), monozygosity is likely.
 A skin graft: Acceptance of reciprocal skin

graft is almost a certain proof of

monozygocity.
 Follow –up study between 2 and 4 years

showing almost similar physical and

behavioral features suggestive of
monozygosity.

10/13/2020 23
 INCIDENCE
 The incidence of monozygotic twins is
constant worldwide, approximately four per
1000 births.

 The incidence of multiple zygotic pregnancies

varies in relation to maternal age, the use of
assisted reproductive technology (ART), and
ethnicity.

10/13/2020 24
Contd…
 The incidence of multiple births increased
significantly in the late 20th century in the
United States and worldwide.

 A combination of factors contributed to this,

the two most prominent of these being the
use of ART and advanced maternal age at the
time of conception

10/13/2020 25
Contd…
 As previously stated, the incidence of
monozygotic twins is constant worldwide
(approximately 4 per 1000 births).

 Approximately two thirds of twins are dizygotic.

Birthrates of dizygotic twins vary by race (10-40
per 1000 births in blacks, 7-10 per 1000 births
in whites, and approximately 3 per 1000 births
in Asians) and maternal age (ie, the frequency
has risen with increasing maternal age ≤40
years).

10/13/2020 26
Contd…
 Dizygotic-twin birthrates are also influenced by
other factors, such as parity and mode of
fertilization (i.e. most artificially conceived twins
are dizygotic; however, 6-10% are monozygotic).

 Naturally occurring triplet births occur in

approximately 1 per 7000-10,000 births;
naturally occurring quadruplet births occur in
approximately 1 per 600,000 birth.

10/13/2020 27
 Etiology

 The cause of twining is not non known. The

frequency of monozygotic twins remains
constant throughout the globe and is
probably related to maternal environmental
factors.

 It is the wide variation in the prevalence of

binovular twins which is responsible for
fluctuation in the overall incidence of twins in
different populations.

10/13/2020 28
Contd…
 1. Race: The frequency is highest amongst
Negroes, lowest amongst Mongols and
intermediate amongst Caucasians.

 2. Hereditary: Hereditary predisposition likely

to be more transmitted through the female.
(Maternal side).

 3. Advancing age of mother: maximum age

between 30 and 35 years.

10/13/2020 29
Contd…
 4. Influence of parity: The incidence is
increased with increasing parity, especially
from 5th gravida onward.

 5. Iatrogenic: Drugs used for induction of

ovulation may produce multiple fetuses to the
extent of 20-40% following gonadotropin
therapy, although to a lesser extent (5-6%)
following clomiphene citrate.

10/13/2020 30
Contd…
 6. Superfetation: it is the fertilization of two
ova released in different menstrual cycles.
The nidation and development of one fetus
over another fetus is theoretically possible
until the decidual space is obliterated by 12
weeks of pregnancy.

 7.Superfecundation: is the fertilization of two

different ova released in the same cycle, by
separate act of coitus within a short period.

10/13/2020 31
MATERNAL PHYSIOLOGICAL CHANGES

 1. There is increase in weight gain and

cardiac output.

 2. Plasma volume is increased by an addition

of 500 ml.

 3. There is increased alpha fetoprotein level,

tidal volume, and GFR.

10/13/2020 32
LIE AND PRESENTATION

 The most common fetus lie is longitudinal(90%)

but malpresentations are quite common.
 The combination of presentation of the fetuses
are

1.Both vertexes (60%)

2.First vertex and second breech (30%)

3.First breech and second vertex (10%)

10/13/2020 33
Contd…

 5. Both breech (10%)

 6. First vertex and second transverse and so

on, but rarest one, being both transverse
when the possibility of conjoined twins
should be ruled out.

10/13/2020 34
 DIAGNOSIS

1. HISTORY:
 i. History of ovulation including drugs

specially gonadotropins, for infertility or use

of ART.

 ii. Family history of twining (more often

present in the maternal side).

10/13/2020 35
 2. SYMPTOMS

 i. Increased nausea and vomiting in early

months,

 ii. Cardiorespiratory embarrassment which is

evident in the later months such as
palpitation or shortness of breath.

10/13/2020 36
Contd…

 iii. Tendency of swelling of the legs, varicose

veins and hemorrhoids is greater

 iv. unusual rate of abdominal enlargement

and excessive fetal movements may be
noticed by an experienced parous mother.

10/13/2020 37
3. GENERAL EXAMINATION

 1. Prevalence of anemia is more than in

singleton pregnancy.

 2. Unusual weight gain, not explained by pre-

eclampsia or obesity

 3. Evidence of pre-eclampsia(25%) is a
common

10/13/2020 38
4. ABDOMINAL EXAMINATION

Inspection: The elongated shape of a normal

pregnant uterus is changed to a more "barrel
shape" and abdomen is unduly enlarged.

Palpation: The height of the uterus is more

than the period of amenorrhea. This
discrepancy may only become evident from
mid pregnancy onwards.

10/13/2020 39
Contd…
 The height of the abdomen at the level of
umbilicus is more than the normal average
term (100 cm).
 Fetal bulk seems disproportionately larger in

relation to the size of the fetal head.

 Palpation of too many fetal parts.
 Findings of two fetal heads or three fetal

poles make the clinical diagnosis almost

certain.

10/13/2020 40
Contd…
Auscultation:
Simultaneous hearing of two distinct fetal heart
sound located at separate spots given a certain
clue in diagnosis of twins, provided the
difference in heart rates is at least 10 beats per
minute.
 The abdominal palpation and auscultation

may not be carried out so easily, as described

because of the presence of hydramnious.

10/13/2020 41
5.Internal examination
 In some cases, one head is felt deep in the
pelvis, while the other one is located by
abdominal examination.

 On occasion, the clinical method fails to

detect twins prior to the delivery of the first
baby.

10/13/2020 42
6. Investigations

Sonography: In multifetal pregnancy, it is done

to obtain the following information:
1. Confirmation of diagnosis of early as 10th
week of pregnancy.
 2. Variability of fetuses, vanishing twins in

the second trimester.

 3. Chorionicity ( lambda or twin peak sign ).
 4. Pregnancy dating.

10/13/2020 43
Contd…
 5. Fetal abnormalities.
 6. Fetal growth monitoring ( at every 3-4

weeks intervals ) for IUGR.

 7. Presentation and lie of the fetus.
 8. Twin transfusion ( doppler studies ).
 9. Placental localization.
 10. Amniotiuc fluid volume.

10/13/2020 44
Chorionicity of the placenta
 It is the best diagnosed by ultrasound at 6-9
weeks of gestation.
 In dichorionic twins there is a thick septum

between the chorionic sacs.

 It is best identified at the base of the

membrane, where a triangular projection is

seen.

10/13/2020 45
Contd…
This is known as Lambda or twin peak signs.
Presence of lambda or twin peak sign indicates
dichorionic placenta.

Radiography: It is done less in these days. Two

fetal head and spines could be seen. Triplet or
conjoined diagnosed accidently.

10/13/2020 46
Contd…
Biochemical tests:

 Maternal serum chorionic gonadotrophin,

alpha feto-protein and unconjugated oestrol
are approximately double than in singletone
pregnancy.

10/13/2020 47
 Differential diagnosis

 Hydramnious

 Big baby

 Fibroid or ovarian with pregnancy

 Ascitis with pregnancy.

10/13/2020 48
 COMPLICATIONS
Maternal
During pregnancy:
Nausea and vomiting occurs with increased
frequency and severity.

Anemia is more due to increased iron and

folate requirement by the two fetuses.
Deficiency of folic and leads to increased
incidence of megaloblastic anemia.

10/13/2020 49
Contd…
Pre eclampsia (25%) is increased 3 times over
singletone pregnancy.

Hydamnios (10%) is more common in

monozygotic twins and and usually involves
the second sac.
It is perhaps due to increased renal perfusion
with consequent increased urinary output
which may accompany the hypervolemia in the
large vein.

10/13/2020 50
Contd…
Antepartum hemorrhage may occur with slight
increased frequency.
The increased incidence of placenta previa is due to
the bigger size of the placenta encroaching on to
the lower segment.

The separation of normally situated placenta may

be due to
i. Increased incidence of pre eclampsia
ii. Sudden escape of liquor following upture of
membrane of the hydram.niotic sac

10/13/2020 51
Contd…
iii. Deficiency of folic acid
iv. Following delivery of the 1st baby due to sudden
shrinkage of the uterine wall adjuncent to the
placental attachment.

Malpresentation is quite common in twins

compared to singleton pregnancy. In labor,70%
cases the 1st baby is presented by vertex and 50%
both presented by vertex.
Malpresentation is more more common in 2nd
baby.

10/13/2020 52
Contd…
Pre term labor(50%) frequently occurs and the
mean gestational period for twins is 37 weeks.
overdestension of the uterus, hydramnios,and
PROM are responsible for pre term labor.
Mechanical distress
palpitation,
dyspnea,
vercisities and
hemorrhoids

10/13/2020 53
 During labor
 Early ROM and cord prolapse are increased
due to increased prevalence of
malpresentation.

 Cord prolapse is 5 times more common

 It is more common inn 2nd baby.

10/13/2020 54
Contd…
 Prolonged labor it is theoritically expected, is
not practically met.
 This is because of parous women with smaller
baby.
 Increased operative interference is due to high
prevalence of malpresentation with its
associated compliations.
 Bleeding (intrapartum) following the birth of the
1st baby may at times be almaring and is due to
separation of placenta following reduction of
placental site.

10/13/2020 55
Contd…
Postpartum hemorhage is due to:
i. Atony of the uterine muscle due to
overdistension of the uterus
ii. Longer time taken by the big placenta to
separate
iii. Bigger surface area of the placenta
exposing more uterin sinuses
iv. Implantation of a part of the placenta in
the lower segment

10/13/2020 56
 During pueperium
 Subinvolution of uterus , because of bigger
size of uterus
 Infection because of increased operative

delivery, preexisting anemia and blood loss

during delivery.
 Lactaion failure this is minimized by

reassurance and giving her additional

support.

10/13/2020 57
 Fetal
 Miscarriage is increased especially with
monozygotic twins
 Premature rate (80%)
 Discordant twin growth (25%)
 IUD of one fetus is more in monozygotic one.
 Fetal anomalies increased by 2-4%
 Asphyxia and still birth are common due to
increased prevalence of pre eclampsia
malpresentation placental abruption and
increased prevalence of operative interfrance.

10/13/2020 58
 PROGNOSIS
Maternal mortality is increased in twin than in
singleton pregnancy.

 Death is mostly due to hemorrhage (before,

during and after delivery), pre eclampsia and
anemia.

 Increased maternal morbidity is due to

prevalence of complications and operative
interference.

10/13/2020 59
Contd..
Perinatal mortality is markedly increased
mainly due to prematurity.

It is 4-5 times higher than in a singleton

pregnancy.

It is extremely high in monoamniotic mono

zygotic twins due to cord entanglement.

10/13/2020 60
Contd…
 One third loss is due to still birth and two
third due to neonatal death.

 During delivery the 2nd baby is more at risk

(50%) than the first one due to:
i. Retraction of uterus leading to placental
insufficiency.
ii. Increased operative interference and
iii. Increased interference of cord prolapse.

10/13/2020 61
COMPLICATIONS OF MONOCHRIONIC
TWINS
Twin- twin transfusion syndrome (TTTS)
 It is clinicopathological state, exclusively met

with in monozygotic twins, where one twin

appears to bleed into the other through some
kind of placental vascular anastomosis.

 Clinical manifestation of twin transfusion

syndrome occur when there is hemodynamic
imbalance due to unidirectional deep
arteriovenous anastomosis.

10/13/2020 62
Contd…
 As a result of receptor twin becomes larger
with hydramnios , polycythemic,
hypertensive, and hypervolemic,at the
expense of the donor twin which becomes
smaller with oligohydramnios,
anemic,hypotensive and hypovolemmic.

10/13/2020 63
Contd…
 The donor twin may appear “stuck” due to
severe oligohydramnios.

 Difference of hemoglobin concentration

between the two, usually exceeds 5gm% and
estimated fetal weight discrepancy is 25% or
more.

10/13/2020 64
 MANAGEMENT
 Antenatal diagnosis is made by ultrasound with
Doppler blood flow study in the placental
vascular bed.
a. Repeated amniocentesis to control
polyhydramnios in the recipient twin is done.

b. Septostomy (making a hole in the dividing

amnniotic membrane).
c. Laser photocoagulation to interrupt the
anastomotic vessels on the chorionic plate can give
some success.

10/13/2020 65
Conntd…
d. Selective reduction(feticide) of one twin is
done when survival of both the fetuses is at
risk.

The smaller twin generally has got better

outcome.

The plethoric twin runs the risk of congestive

cardiac failure and hydrops.

10/13/2020 66
Contd…
 Congenital abnormalities (neural tube
defects, holorosencephaly) are high (2-3
times).
 Perinatal mortality in TTTS is about 70%.

10/13/2020 67
DEAD FETUS SYNDROME
 Death of one twin (2-7%) is associated with
poor outcome of the co-twin (25%) specially
in monochorionic placenta.

 The surviving twin runs the risk of cerebral

palsy, microcephaly, renal cortical necrosis
and DIC.
 This is due to thrmboplastin liberated from

the dead twin that crosses via placental

anastomosis to the living twin.

10/13/2020 68
 TWIN REVERSEED ARTERAL
PERFUSION(TRAP)
It is characterized by an ‘acardiac perfused
twin’ having blood supply from a normal co-
twin via large arterio-arterial or vein to vein
Anastomosis.

In majority the co-twin dies (in the perinatal

period) due to high output cardiac failure.
The arterial pressure of the donor twin being
high the recipient twin receives the used blood
from the donor.

10/13/2020 69
Contd…
 The perfused twin is often chromosomally
abnormal.
 The anomalous twin may appear an

amorphous mass.
 Management of TRAP is controversial.

Ligation of the umbilical cord of the acardiac

twin under fetoscopic guidance has been
done.

10/13/2020 70
Monoamniocity(2% of all twins)
 In monochorionic twins leads to high
perinatal mortality due to cord
problems(entanglement).

 Sulindac,a prostaglandin synthase inhibitor

has been used to reduce fetal urine output,
creating borderline oligohydramnios and
reduce excessive movements.

10/13/2020 71
 Conjoined twins
 It is rare (1.3 per 100,000 births).

 Perinatal survival depends upon the type of

joint.

 Major cardiovascular connection leads to high

mortality.

10/13/2020 72
 Management

Antenatal management:

 Early diagnosis of a twin pregnancy and of

chorionicity is extremely important in order
to prepare the parents by giving them the
specialist support and advice they will need.

10/13/2020 73
Contd…
Advice on following points;
Diet:

Increased dietary supplement is needed for

increased energy to the extent of 300 Kcal per
day, over and above that needed in the
singletone pregnancy.

 The increased protein demand is to be met

with.

10/13/2020 74
Contd…
Increased rest: Increased rest at home and early
caesarean section is advised to prevent preterm labor
and other complications.

Supplement therapy:
 Iron therapy is to be increased to the extent of 60-100

mg per day.

 Additional vitamins, calcium and folic acid 1 mg are to

be given, over and above those prescribed in singleton
pregnancy.

10/13/2020 75
Contd…
Interval of antenatal visit
It should be more frequent to detect at the
earliest, the evidence of anemia, preterm labor
or pre eclampsia.
Fetal surveillance
It is maintained by serial sonography at every
3-4 weeks interval.
Assessment of fetal growth, amniotic fluid
volume and AFI, non stress test and doppler
velocimetry are carried out.

10/13/2020 76
Fetal surveillance

 It is maintained by serial sonography at every

3-4 weeks interval.

 Assessment of fetal growth, amniotic

volume,and AFI,non stress test and Doppler
velocimetry are carried out.

10/13/2020 77
 Hospitalization
 Routine : routine hospital admission only for
bed rest is not essential.
 Bed rest even at home from 24 weeks

onwards, not only ensures physical and

mental rest but also improve utero-placental
circulation.
 This result in: i. increased birth weight of

babies
 ii. Decreased frequency of pre eclampsia
 iii. Prolongation of the duration of pregnancy

10/13/2020 78
Contd…
 Use of corticosteroid to accelerate fetal lung
maturation is given to women with pre term
labor less than 34 weeks.

 Twins develop pulmonary maturity 3-4 weeks

earlier than singleton.
Emergency development of complicating
factors necessitates urgent admission
irrespective of the period of gestation.

10/13/2020 79
Mangement during labor
Place of delivery:
As twin pregnancy is considered as ‘high risk’,
the patient should be confined in an equipped
hospital preferably having an intensive
neonatal care unit.

Vaginal delivery is allowed when both the twins

are or at least first twin is with vertex
presentation.

10/13/2020 80
 First stage
 A skilled obstetrician should be present.
 An around experienced anesthesist should be

made available.
 Presence of ultrasound in the labor ward is

helpful.
 The patient should be in bed to prevent early

rupture of membranes.
 Use of analgesic drugs is to be limited as the

babies are small and rapid delivery may occur.

Epidural anesthesia is preferred as it facilitates
manipulation of 2nd fetus should it prove necessary.

10/13/2020 81
Contd…
 Careful fetal monitoring (preferably electronic) is
to be done.
 Internal examination should be done soon after
rupture of membranes to exclude cord prolapse.
 An intravenous line with ringer’s solution should
be made readily available.
 Neonatologist should be present at the time of
delivery.
 Throughout the labor the emotional as well as the
general physical condition of the mother must be
considered.

10/13/2020 82
Delivery of the first baby
Check presentation

 If vertex presentation, allow labor to progress

as for a single vertex presentation and
monitor progress in labor using a partograph.
 If breech presentation, apply the same

guidelines for a singleton breech presentation

and monitor progress of labor using a
partograph.
If transverse lie, delivery by caesarean section.

10/13/2020 83
Contd…
 The delivery should be conducted as same in the
normal delivery
 As the baby is usually small, the delivery does

not usually pose any problem.

 Deliver the first baby and follow the following

points:
i. Episiotomy under local infiltration with 1%
lignocaine.
ii. Perform instrumental delivery, if needed,
should be done preferably under pudendal
block anesthesia.

10/13/2020 84
Contd…
iii. Clamp the cord at two places and cut in
between to prevent exsanguination of the second
baby through communicating placental circulation
in the monozygotic twins.
Do not attempt to deliver the placenta until the
last baby is required.
iv. At least, 8-10 cm of cord is left behind for
administration of any drugs or transfusion, if
required.
v. The baby is handed over to the circulating
nurse after labeling as number one.

10/13/2020 85
Conduction of the labor after delivery
of 1st baby
Principles:
The principle is to expedite the delivery of the
second baby is put under strain due to placental
insufficiency caused by uterine retraction
following the birth of the first baby.
Steps of management:
Step i: following the birth of the 1st baby, the lie,
presentation, size and FHS of the second baby
should be ascertained by abdominal examination
or if required by real time ultrasound.

10/13/2020 86
Contd…
 A vaginal examination is also to be made not
only to confirm the abdominal findings but to
note the status of the membranes and to exclude
cord prolapse, if any.
Lie longitudinal:
step i: low rupture of the membranes is done after
fixing the presenting part on the brim.
Syntocinon may be added to the infusion bottle to
achieve this.
Internal examination is once more to be done to
exclude cord prolapse.

10/13/2020 87
Contd…
Step ii: if the uterine contraction is poor, 5
units of oxytocin is added to the infusion
bottle.
 The interval between deliveries should ideally

be less than 30 minutes.

Step iii. If there is still a delay, interference is

to be done.

10/13/2020 88
Contd…
 Vertex: low down- forceps are applied
High up- if the 1st baby is too small and the 2nd
one seems bigger, ruled out CPD.
 The possibility of the hydrocephalic head

should excluded by ultrasonography.

 if these are excluded, internal version

followed by breech extraction is performed

under G.A.
 Ventouse may be an effective alternative.

10/13/2020 89
Contd…
 Breech: the delivery should be completed by breech
extraction.
 Lie tranverse:
 It should be corrected by external version into
longitudinal lie, preferably cephalic, if fails, podalic
 If the external version fails, cx. Is fully dilated and
membranes is still intact attempt internal podalic
version.
 If the fetus is small there is no difficulty in
performing internal version and it is the only
accepted indication of internal version in present day
of obstetric practice.

10/13/2020 90
Indication of urgent delivery of the
2nd baby
 Severe (intrapartum) vaginal hemorrhage.

 Cord prolapse of the 2nd baby

 Apperance of fetal distress.

 First baby is delivered under G.A.

10/13/2020 91
 Management
 In all these conditions, the baby should be
delivered quickly.
 A rational scheme is given below which

depends on the lie, presentation and station

of the head.
a. head: if low down, delivery by forceps.
If high up delivery by internal version under
G.A.
b. Breech should be delivered by breech
extractiion

10/13/2020 92
Contd…
 C. Transverse lie: internal version followed by
breech extraction under G.A.

 If however patient bleeds heavily following

the birth of the 1st baby, immediate low
rupture of membranes usually suceeds in
controlling the blood loss.

10/13/2020 93
Management of 3rd stage of labor
 The risk of PPH can be minimized by routine
administration of 0.2 mg methargin or 10
unit oxytocin IM with the delivery of the
anterior should of the 2nd baby.
 The placenta should be delivered by CCT.
 It is a sound practice to continue the oxytocin

drip for at least one hour, following the

delivery of the 2nd baby.
 The patient is to be carefully watched for

about 2 hrs. after delivery.

10/13/2020 94
Contd…
 The placenta should be examined and the
number of amnion sacs, chorions and
placenta are noted.

Multiple birth puts an additional stress and

strain on the mother as well as on the family
members.
Mother should be given additional support at
home to look after both the babies.

10/13/2020 95
Indication of caesarean section
1. Obstetric cause

 Placenta previa
 Severe pre eclampsia
 Previous caesarean section
 Cord prolapse of the 1st baby
 Abnormal uterine contraction
 Contracted pelvis

10/13/2020 96
Contd…
2. For twins:

 Both the fetus or even the 1st with non-

 cephalic(breech or transverse) presentation.

 Twins with complications: IUGR, conjoined

twin

 Monozygotic twins

10/13/2020 97
 Dutta,DC: Text Book of Obstetrics,Central
Book agency 8th ed.
 Marshall. J and Raynor Myles Textbook for

midwifes, 16th ed.

 Subedi, Durga: Midwifery nursing Madhavi

publication 2nd ed.
 Pillitteri A. Maternal and Child Health Nursing,Care of

child bearing and child rearing family. 6TH

Edition.China: Lippincott Williams and wilkins; 2010

10/13/2020 98