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APARNA P
2009 MBBS
1.Prenatal care
 More frequent antenatal visits.
 prophylactic iron 60-100mg and

folic acid 1mg daily should be
given.
...
2.Ultrasound scan
 At 9-11 wks :

confirmation,
chorionicity
determination,
assessment of
gestational age and
nuchal tran...
3.Prenatal diagnosis


Screening for aneuploidy



Mid trimester amniocentesis



Chorionic villous sampling



Serum ...
4.Multifetal and
selective pregnancy
reduction


Selective fetal reduction-one fetus in
a multiple gestation is abnormal
...
1.Place of deliveryFully equipped hospital
having intensive neonatal
care unit.

2.Timing of delivery
RCOG recommends
elec...
Maternal indications

Fetal indications

Placenta previa

Ist fetus noncephalic

Severe preeclampsia

Twins with
complicat...
Vaginal Deliveryprerequisites


First twin presents as vertex,no other
indications for CS.



Facilities for operative d...


Internal examination soon after
rupture of membranes to r/o cord
prolapse.



Women should be counseled about
chances ...
Liberal episiotomy under local
infiltration with 1% lignocaine.

First baby delivered in the usual
manner as if it were a ...
•

Palpate abdomen immediately
to ensure lie,presentation.

•

If required-ultrasound
examination done.

•

Vaginal examin...
Vertex or breech is presenting,& is
in pelvis,good contractionsARM
done,second fetus descends
rapidly.

If contractions a...


Indications are : -



Severe vaginal bleeding



Cord prolapse of second
baby



Inadvertent use of iv
ergometrine ...
2

options



External version



Internal podalic
version and breech
extraction


Internal podalic version is used only
for second twin when it is lying
transversely.



Useful when immediate delivery...
 Contraindications
 Obstructed

labour
 Membranes ruptured with all
liquor drained
 Previous CS
 Contracted pelvis
 ...
Gen anaesthesia-hand
ruptures membranes &
introduced into uterine
cavity

This hand identifies and grasps
the foot and giv...
Twin
1st twin
non vertex

1st twin vertex

Caesarean section

vaginal delivery of first twin
assess lie of second twin

Ve...


Cross matched blood should be
readily available.



Risk of atonic PPH is more.



Oxytocin infusion & i/v
ergometrin...
Multiple pregnancy – management
Multiple pregnancy – management
Multiple pregnancy – management
Multiple pregnancy – management
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Multiple pregnancy – management

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Multiple pregnancy – management

  1. 1. APARNA P 2009 MBBS
  2. 2. 1.Prenatal care  More frequent antenatal visits.  prophylactic iron 60-100mg and folic acid 1mg daily should be given.  Nutritional advice-calorie req is 300kcal/day more than that recommended for uncomplicated pregnancy.  Restriction of activity and increased rest at home.  Prophylactic steroids – risk for preterm labour or IUGR.
  3. 3. 2.Ultrasound scan  At 9-11 wks : confirmation, chorionicity determination, assessment of gestational age and nuchal translucency.  anomaly scan at 20 wks  4 weekly scans in 3rd trimester to assess fetal growth, diagnose complications like TTS
  4. 4. 3.Prenatal diagnosis  Screening for aneuploidy  Mid trimester amniocentesis  Chorionic villous sampling  Serum screening  Management of anomalies-  Selective feticide kcl injection  Ultrasound guided doppler coagulation
  5. 5. 4.Multifetal and selective pregnancy reduction  Selective fetal reduction-one fetus in a multiple gestation is abnormal  Multifetal reduction-in higher order pregnancy  Iatrogenic fetal death –us guided fetal heart puncture or inj kcl  One member of monochorionic pair
  6. 6. 1.Place of deliveryFully equipped hospital having intensive neonatal care unit. 2.Timing of delivery RCOG recommends elective termination of pregnancy at 37-38 weeks  Monochorionic pregnancy best delivered at 36-37 weeks 
  7. 7. Maternal indications Fetal indications Placenta previa Ist fetus noncephalic Severe preeclampsia Twins with complications IUGR Previous cs Monoamniotic twins Cord prolapse is baby Abnormal uterine contractions,CPD Monochorionic twins with severe TTTS
  8. 8. Vaginal Deliveryprerequisites  First twin presents as vertex,no other indications for CS.  Facilities for operative delivery, careful fetal monitoring,neonatal unit available.  Portable US & preferably a cardiotocography machine with dual channel monitoring.  Second obstetrician(atleast one obstetrician should be experienced in breech extraction)  Anesthetist, Neonatologist
  9. 9.  Internal examination soon after rupture of membranes to r/o cord prolapse.  Women should be counseled about chances of operative interference.  She is restricted to taking sips of clear fluids and antacids can be given.  All precautions to combat PPH should be ready like cross matched blood and oxytocics.
  10. 10. Liberal episiotomy under local infiltration with 1% lignocaine. First baby delivered in the usual manner as if it were a singleton. Cord is clamped immediately at both fetal & placental ends to prevent acute intrapartum transfusion. IV oxytocics shouldn’t be given at this point as it can cause entrapment and asphyxia of second twin.
  11. 11. • Palpate abdomen immediately to ensure lie,presentation. • If required-ultrasound examination done. • Vaginal examination is also done to exclude cord prolapse. • Acceptable interval between deliveries – 30 mins
  12. 12. Vertex or breech is presenting,& is in pelvis,good contractionsARM done,second fetus descends rapidly. If contractions are inadequate,oxytocin given for augmentation, then amniotomy done. IF VERTEX is low donforceps can be applied High up-r/o CPD, hydrocephalusafter excluding these,internal version & breech extcn under GA BREECH-delivery compltd by breech extraction
  13. 13.  Indications are : -  Severe vaginal bleeding  Cord prolapse of second baby  Inadvertent use of iv ergometrine with the delivery of anterior shoulders of first baby  Appearance of fetal distress
  14. 14. 2 options  External version  Internal podalic version and breech extraction
  15. 15.  Internal podalic version is used only for second twin when it is lying transversely.  Useful when immediate delivery of second fetus is needed as in cord prolapse or abruption.  Performed in operation theatre under GA  PrerequisitesMembranes intact Uterus relaxing between pains Cervix completely dilated Under GA 1. 2. 3. 4.
  16. 16.  Contraindications  Obstructed labour  Membranes ruptured with all liquor drained  Previous CS  Contracted pelvis  Complications Rupture uterus  Anaesthetic risks  Atonic pph due to use of uterine relaxants  Birth asphyxia & birth trauma 
  17. 17. Gen anaesthesia-hand ruptures membranes & introduced into uterine cavity This hand identifies and grasps the foot and gives traction Other hand kept on the uterine fundus to provide assistance from above Manual removal of placenta, iv ergometrine, episiotomy suturing
  18. 18. Twin 1st twin non vertex 1st twin vertex Caesarean section vaginal delivery of first twin assess lie of second twin Vertex Vaginal delivery Vertex Vaginal delivery breech assisted breech delivery transverse lie external version breech assisted breech delivery unsuccessful intact membrane IP version & breech extraction ruptured membrane CS
  19. 19.  Cross matched blood should be readily available.  Risk of atonic PPH is more.  Oxytocin infusion & i/v ergometrine 0.25mg or methergine 0.2mg given following delivery of anterior shoulder of second baby.  Prostaglandins-15 methyl PG F2alpha can also be used.  Placenta examined for completeness, confirm chorionicity.

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