More frequent antenatal visits.
prophylactic iron 60-100mg and
folic acid 1mg daily should be
Nutritional advice-calorie req is
300kcal/day more than that
recommended for uncomplicated
Restriction of activity and increased
rest at home.
Prophylactic steroids – risk for
preterm labour or IUGR.
At 9-11 wks :
gestational age and
anomaly scan at 20 wks
4 weekly scans in 3rd
trimester to assess fetal
complications like TTS
Selective fetal reduction-one fetus in
a multiple gestation is abnormal
Multifetal reduction-in higher order
Iatrogenic fetal death –us guided
fetal heart puncture or inj kcl
One member of monochorionic pair
1.Place of deliveryFully equipped hospital
having intensive neonatal
2.Timing of delivery
elective termination of
pregnancy at 37-38
pregnancy best delivered
at 36-37 weeks
Ist fetus noncephalic
Cord prolapse is baby
with severe TTTS
First twin presents as vertex,no other
indications for CS.
Facilities for operative delivery,
careful fetal monitoring,neonatal unit
Portable US & preferably a
cardiotocography machine with dual
Second obstetrician(atleast one
obstetrician should be experienced in
Internal examination soon after
rupture of membranes to r/o cord
Women should be counseled about
chances of operative interference.
She is restricted to taking sips of
clear fluids and antacids can be
All precautions to combat PPH
should be ready like cross matched
blood and oxytocics.
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
IV oxytocics shouldn’t be given at
this point as it can cause
entrapment and asphyxia of
Palpate abdomen immediately
to ensure lie,presentation.
Vaginal examination is also
done to exclude cord prolapse.
Acceptable interval between
deliveries – 30 mins
Vertex or breech is presenting,& is
in pelvis,good contractionsARM
done,second fetus descends
If contractions are
inadequate,oxytocin given for
augmentation, then amniotomy done.
IF VERTEX is low donforceps can be
High up-r/o CPD, hydrocephalusafter
excluding these,internal version & breech
extcn under GA
BREECH-delivery compltd by
Indications are : -
Severe vaginal bleeding
Cord prolapse of second
Inadvertent use of iv
ergometrine with the
delivery of anterior
shoulders of first baby
Appearance of fetal distress
version and breech
Internal podalic version is used only
for second twin when it is lying
Useful when immediate delivery of
second fetus is needed as in cord
prolapse or abruption.
Performed in operation theatre under
Uterus relaxing between pains
Cervix completely dilated
Membranes ruptured with all
Atonic pph due to use of uterine
Birth asphyxia & birth trauma
ruptures membranes &
introduced into uterine
This hand identifies and grasps
the foot and gives traction
Other hand kept on the uterine
fundus to provide assistance
Manual removal of placenta, iv
1st twin vertex
vaginal delivery of first twin
assess lie of second twin
IP version & breech
Cross matched blood should be
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