Multiple pregnancy which is clearly and fully uploaded.

1. MULTIPLE PREGNANCY
Presentation by,
Mr. Manish kannake

2. CONTENT
• Introduction
• Definition
• Incidence
• Varieties
• Factor affecting
• Sign and symptoms
• Diagnostic evaluation
• Investigation
• Managment
• Nursing diagnosis

3. Introduction
• When more then Fetus simultaneously develop in the uterus
It is called multiple pregnancy.
Simultaneously development of two Fetus most common a
through
Rare development of tree Fetus (triplets), four (quadruplets),
five (quintuplets) or six (sextuplets).

4. Definition
When more then one Fetus simultaneously develop in the
uterus is called multiple pregnancy.

5. INCIDENCE
• Helen’s rule (1895) the mathematical frequency to multiple
birth is twins 1 in 80 pregnancies.
• The actual incidence of multiple pregnancy has increased
significantly
At present .
Highest in Nigeria being 1 in 20
Lowest in far eastern countries being 1 in 200 pregnancies.

7. Varieties
1. Diazygotic twins- it is most common (80%) results from the
fertilization of two ova.
2. Monozygotic twins- (20%) results from the fertilization of a
single ovam

8. • 1》 Dizygotic twins – (binovular)
• Result from fertilization of two ova most likely ruptured
from two distinct graafian follicles usually of the same or one
from each over, by two sperms during a single ovarian cycle.
• Implantation and development differ little from these of a
single fertilized ovam.
• The babies bear only fraternal resemblance to each other
and called fraternal twins
2. Monozygotic twins- (Uniovular)
• The twinning may occur at diffrent periods after fertilization
and this markedly influences the process of implantation and
the formation of the fetal membrane..

9. Monozygotic twins Dizygotic Twins

10. FACTOR AFFECTING
1. Age :- more then 30 years
2. Heredity :- family history in mother
3. Maternal age :- twinning peaks at age of 37 years ( increase weight
gain)
4. Multigravida :- more the 5 times
5. Nutritional factor :- taller,heavier women twinning rate 25 to 30 %
greater.

11. Sign and symptoms
• Enlargement of uterus
• Rapid weight gain
• Large fungal height
• Multiple heart beats
• Increase morning sickness
• Severe breast tendrness
• Increase appetite
• Excessive fetal movement
• Swelling of leg
• Increase of nausea and vomiting

12. DIAGNOSTIC EVALUATION
1. History taking :-
• family history of twinning.
2. General examination :-
• More prevalence of anemia
• Unusual weight gain
Chances of pre-eclampsia
3. Abdominal examination :-
A) Inspection:-
• in the elongated shaped of normal pregnant uterus is
changed to a more “barrel shape the abdomen is enlarged.

13. • B) palpation :-
• Height of uterus more then period of amenorrhea.
- Girth of abdomen more then normal range at term
- palpation may fetal parts
-fetal sometime two fetal head can be palpated easily.
C) Auscultation:-
• Two distinct FHS at separate parts diffrence heart rate is at
least 10 beats/ min.

14. INVESTIGATION
1. Sonography :-
-To detect gestational sac as early as 10 week.
- Repeated sonography is helpfull.
-Pregnancy date
- fetal anomalies
- fetal growth monitoring presentation.
- amniotic fluid volume
●Complication :-
1) Maternal :-
A) During pregnancy :-
- Nausea and vomiting
-Anemia
-Hydraminos
-Antepartum hemorrhage (APH) pto.

15. • Preterm labour
• Malpresentation
• Mechanical distress
B) during labour :-
•
• Premature rupture of membranes
• Cord prolapse
• Bleeding
• Peuperium
• Chances of infection
• Lactation failure
C) Fetal :-
• Miscarriage
• congenital malformation
• Premature birth and asphyxia.

16. Complication of multiple pregnancy
• Twin to twin transfusion syndrome
• Dead Fetus syndrome
• Monoamniotic Conjointed twins
● MANAGMENT ●
1) Antenatal managment:-
-Early diagnosis to detect fetal growth pattern and congenital
malformation.
-careful Antenatal supervision throughout pregnancy.
2) Diet :- Increase Dietary supplement Is needed for increase
energy Supply to the extent of 300k/ day.

17. 3) Rest:-
at home and early cassation Of work form 24 week Onword is
advised to prevent preterm labour and other Complication.
4) Supplement therapy :-
Sonography at every 3 4 week interval or earlier If need
assessment of fetal growth And Antenatal visit.
(ex. Iron and multivitamin supplement)
5)During the first stage of labour :-
• The women should be kept in bed and enema with the held
to prevent early rupture of membranes
• Use analgesics Is limited as the babies are small And rapid
delivery may occur.
• Vaginally examination should be done Soon after the
ruptured of membranes to exclude Cord prolapse.

18. • Iv line with ringers lactate should be stop for any urgent iv
therapy if required one unit of cross matched blood should be
made readily available.
• In case of poor uterine contraction start oxytocin drip once the
membranes have been ruptured.
• Midwife should provide physical and emotional support to
mother.
●During the second stage :-
• Delivery of first twin should be conducted in the same manner
as in normal labour If it present vertex.
• Clamp the Cord at the two places and cut it in middle.
• At least 8-10 cm Of Cord is left Behind for administration of any
drug Or transfusion if required.
• The baby should be labeled one.

19. • Uterine contraction are not effective Oxytocin drip should be
started to stimulated contraction.
• When the presenting part of twins become visible mother should
encourage to push with contraction to deliver second twin.
• Delivery will be proceed if the presentation in vertex.
• Following the delivery anterior shoulder Of second twin
methargin should be given at 0.2 mg Intravenously.
●Managment of third stage :-
• The placenta is delivered by Cord control traction .
• Oxytocin drip should be continue for at least one hour following
the delivery of second twin.
• Mother and baby should be carefully watched for 2 hours
following delivery.

20. • If blood loss is more then avarage it should be replaces by blood
transfusion.
• Placental membrane and Cord should be examined Carefully
for any abnormalities.
●Indication for cesarean section :-
• Contracted pelvis
• Placent previa
• Severe pre eclampsia
• Previous history of cesarean section
• Cord prolapse of first baby
• Abnormal uterine contraction.

21. • Fetal causes:-
• Both babies are first Baby in transverse lie.
• non vertex twins with weight 2000gm or less
• Conjoined twins
●Postnatal Managment :-
• After the delivery of twins Sure that airway should be clear
the temperature must be maintained.
• Advice the mother for breastfeeding either simultaneously
as separately to both babies.

22. Nursing Diagnosis
1 ) imbalance nutrition less then body requirement related to
Increased physiological demands as evidenced by Increase morning
sickness.
2 ) acute pain related to multiple pregnancy as evidenced by pain
scale.
3) Deficient fluid volume As related to Nausea and Vomiting as
evidence by dehydration.
4) Risk for fetal injury related to multiple pregnancy as evidence by
Excessive fetal movement.
5) Knowledge deficit related to multiple pregnancy as evidence by
asking irrelevant questions.