multiple pregnancy nursing pregnancy

1. MULTIPLE
PREGNANCY
Advisor : Respected Dr. Mrs. Molly Babu, H.O.D.
Obstetrics And Gynecological Nursing
Speaker : Suparna Mill

2. DEFINITION
When more than one fetus
simultaneously develops in the
uterus, it is called multiple
pregnancy.
• Two fetuses (twins)
• Three fetuses (triplets)
• Four fetuses (quadruplets)
• Five fetuses (quintuplets)
• Six fetuses (sextuplets)

3. TWINS
• Dizygotic twins—It is the most
common (80%) and results from the
fertilization of two ova

4. • (2) Monozygotic twins (20%)
results from the fertilization of a
single ovum

5. Monozygotic twins (syn:
Identical, uniovular):
• Upto 3 days - diamniotic-
dichorionic
• Between 4th & 7th day -
diamniotic monochorionic -
most common type
• Between 8th & 12th day-
monoamniotic-monochorionic
• After 13th day - conjoined /
Siamese twins.

7. Twin placenta.
Dizygotic twins (A, B) have two placentae (D/D): (A) separated and (B) fused
without any vascular communications; intervening membranes consist of 4 layers
(D/D).
Monozygotic twins; (B) two placentae (D/D); (C) one placenta with free internal
vascular anastomosis; the intervening membranes consist of 2 layers (D/M); (D)
same as (C) but without any intervening membranes (M/M)

10. Conjoined twins
Ventral:
1) Omphalopagus
2) Thoracopagus
3) Cephalopagus
4) Caudal/ ischiopagus
Lateral:
1) Parapagus
Dorsal:
1)Craniopagus,
2)Pyopagus

12. DETERMINATION OF ZYGOSITY:
• Examination of placenta and membranes
• 2) Sex
• 3) If the fetuses are of the same sex and
have the same genetic features
• 4) A test skin graft—Acceptance of
reciprocal skin graft is almost a certain
proof of monozygosity.
• 5) DNA microprobe technique

13. Placent
a
Communi
cating
vessels
Intervening
membranes
Sex Genetic
features
(dominant
blood
group)
DNA
finger
printing
Skin
grafting
(Reciproc
al)
Follow
up
Monozyg
otic
One Present 2 (amnions) Always
identic
al
Same Acceptan
ce
Usuall
y
identic
al
Dizygotic Two
(most
often
fused)
Absent 4 (2 amnions
2 chorions)
May
differ
Differ Rejection Not
identic
al

14. INCIDENCE
Hellin’s Law:
Twins: 1:89
Triplets: 1:892
Quadruplets: 1:893
Quintuplets: 1:894
Conjoined twins: 1 : 60,000
Worldwide incidence of monozygotic - 1 in
250
Incidence of dizygotic varies & increasing

15. ETIOLOGY:
• Race
• Hereditary
• Advancing age of the mother
• Influence of parity
• Nutritional status
• Iatrogenic
• ART
• Conception after stopping OCP( oral
contraceptive pills)

16. MATERNAL
PHYSIOLOGICAL CHANGES
(1) There is increase in weight gain and
cardiac output.
(2) Plasma volume is increased by an
addition of 500 mL. There is no
corresponding increase in red cell volume
resulting in exaggerated hemodilution and
anemia.
(3) There is increased a fetoprotein level,
tidal volume and glomerular filtration rate.

17. LIE AND PRESENTATION
• Longitudinal lie (90%)
• both vertex (40%)
• Vertex + breech (28%)
• breech + vertex ( 9%)
• both breech ( 6%)
• Others
• vertex + transverse
• breech + transeverse
• both transeverse

19. DIAGNOSIS
• HISTORY:
I. History of ovulation inducing drugs specially
gonadotrophins
II. Family history of twinning (maternal side).
• SYMPTOMS:
i. Hyperemesis gravidrum
ii. Cardio-respiratory embarrassment - palpitation or
shortness of breath
iii. Tendency of swelling of the legs,
iv. Varicose veins
v. Hemorrhoids
vi. Excessive abdominal enlargement
vii. Excessive fetal movements.

20. GENERAL EXAMINATION:
I. Prevalence of anemia is more than in
singleton pregnancy
II.Unusual weight gain, not explained by pre-
eclampsia or obesity
III.Evidence of preeclampsia(25%)is a
common association.
ABDOMINALEXAMINATION:
Inspection:
• The elongated shape of a normal pregnant
uterus is changed to a more "barrel shape”
and the abdomen is unduly enlarged.

22. Palpation:
• Fundal height more than the period of
amenorrhoea
• girth more than normal
• Palpation of too many fetal parts
• Palpation of two fetal heads
• Palpation of three fetal poles
• Auscultation:
Two distinct fetal heart sounds with
Zone of silence
10 beat difference per minute

23. INVESTIGATIONS
• Sonography: In multi fetal pregnancy it
is done to obtain the following
information:
i. Suspecting twins – 2 sacs with fetal
poles and cardiac activity
ii. Confirmation of diagnosis
iii. Viability of fetuses, vanishing twin
iv. Chorionicity – 6 to 9 wks ( single or
double placenta, lamda or twin peak
sign in d /d gestation or Tsign in m/d )
v. Pregnancy dating,

25. Sonography ( ctd )
vi. Fetal anomalies
vii. Fetal growth monitoring (at every
3-4 weeks interval) for IUGR
viii. Presentation and lie of the fetuses
ix. Twin transfusion (Doppler studies)
x. Placental localization
xi. Amniotic fluid volume

26. • Biochemical tests: raised but
not diagnostic
Maternal serum chorionic
gonadotrophin,
Alpha fetoprotein
Unconjugated oestriol

27. DIFFERENTIAL DIAGNOSIS
Hydramnios
Big baby
Fibroid or ovarian tumor with
pregnancy
Ascites with pregnancy

28. COMPLICATIONS
• Maternal
– Pregnancy
– Labour
– Puerperium
• Fetal
• MATERNAL: During pregnancy:
- miscarriages
– Hyperemesis gravidrum
– Anaemia
– Pre-eclampsia (25%)
– Hydramnios ( 10 % )

29. • GDM ( 2 – 3 times)
• Antepartum hemorrhage – placenta
previa and placental abruption
• Malpresentations
• Preterm labour (50%) twins – 37
weeks, triplets – 34 weeks,
quadruplets – 30 weeks
• Mechanical distress such as
palpitation, dyspnoea, varicosities
and haemorrhoids

30. During Labour:
• Prelabour rupture of the membranes
• Cord prolapse
• Incoordinate uterine contractions
• Increased operative interference
• Placental abruption after delivery of 1st baby
• Postpartum haemorrhage
• (i) Atony of the uterine muscle
• (ii) A longer time taken by the big placenta to separate
• (iii) Bigger surface area of the placenta
• (iv) Implantation of a part of the placenta in the lower
segment which is less retractile.

31. During puerperium:
• Subinvolution
• Infection
• Lactation failure

32. FETAL – more with monochorionic
• Spontaneous abortion
• Premature rate (80%)
• Discordant twin growth (20%)
• Intrauterine death of one fetus
Vanishing twin – before 10 weeks
 Fetus papyraceous/compressus – 2nd trim
neurological, renal lesions
anaemia, DIC
hypotension and death

33. • Congenital anomalies – conjoined
twins, neural tube defects –
anencephaly, hydrocephaly,
microcephaly, cardiac anomalies,
Downs syndrome, talipes, dislocation
of hip
• Asphyxia – cord complication,
abruption
• Still birth – antepartum or
intrapartum cause

34. FETAL COMPLICATIONS (ctd)

38. FETAL COMPLICATIONS (ctd)
• TRAP -Twin reversed arterial perfusion
syndrome or Acardiac twin - absent heart in
one fetus with arterio-arterial communication in
placenta, donor twin also dies

40. Monoamniotic twins
• high perinatal morbidity,
mortality.
• Causes : cord entanglement
 congenital anomaly
 preterm birth
 twin to twin transfusion syndrome

41. Antenatal Management
1) Early diagnosis
2) Diet: additional 300 K cal per day,
increased proteins, 60 to 100 mg of iron and
1 mg of folic acid extra
3) Increased rest
4) Supplement therapy:
• (i) Iron therapy is to be increased to the extent
of 100–200 mg per day.
• (ii) Additional vitamins, calcium and folic acid
(5 mg) are to be given, over and above those
prescribed for a singleton pregnancy.

42. • Frequent and regular antenatal visit
• Fetal surveillance by USG – every 4 weeks
Hospitalisation not as routine
Strict bed rest from 24 wks onwards
• Corticosteroids -only in threatened preterm
labour , same dose
• Birth preparedness

43. Management During Labour
• Place of delivery: tertiary level hospital
• FIRST STAGE:
• A skilled obstetrician should be present.
• Presence of ultrasound in the labor ward is helpful.
• The patient should be in bed to prevent early
rupture of the membranes.
• Use of analgesic drugs
• Careful fetal monitoring
• Internal examination

44. • • An intravenous line with ringer’s
solution should be set up for any
urgent intravenous therapy, if
required.
• • One unit of compatible and cross
matched blood should be made
readily available.
• • Neonatologist should be present
at the time of delivery.

45. DELIVERY OF THE FIRST BABY
• Liberal episiotomy
• Forceps delivery, if needed
• Do not give intravenous ergometrine with the
delivery of the anterior shoulder of the first baby
• Clamp the cord at two places and cut in
between
• At least, 8–10 cm of cord is left behind for
administration of any drug
• The baby is handed over to the nurse after

46. CONDUCTION OF LABOR AFTER
THE DELIVERY OF THE FIRST BABY
• Principles: The principle is to expedite
the delivery of the second baby. The
second baby is put under strain due
to placental insufficiency caused by
uterine retraction following the birth of
the first baby.

47. STEPS OF MANAGEMENT:
• Step – I: Following the birth of the first
baby, the lie, presentation, size and FHS
of the second baby should be ascertained
by abdominal examination or if required by
real time ultrasound. 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.

48. 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. More
vigilance is employed to watch the fetal
condition.

49. • 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 (say 30
minutes), interference is to be done.
• • Vertex: • Low down — Forceps are
applied.

50. • High up — If the first baby is too small
and the second one seems bigger,
cephalopelvic disproportion should
be ruled out. The possibility of
hydrocephalic head should be
excluded by ultrasonography. If these
are excluded, internal version
followed by breech extraction is
performed under general anesthesia.
Ventouse may be an effective
alternative.
• • Breech: The delivery should be
completed by breech extraction.

51. LIE TRANSVERSE
• If the lie is transverse, it should be
corrected by external version into a
longitudinal lie preferably cephalic, if fails,
podalic. If the external version fails, internal
version under general anesthesia should
be done forthwith. As 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
obstetric practice).

52. • Indications of urgent delivery of
the second baby: (1) Severe
(intrapartum) vaginal bleeding
(2) Cord prolapse of the second
baby (3) Inadvertent use of
intravenous ergometrine with
the delivery of the anterior
shoulder of the first baby (4)
First baby delivered under
general anesthesia (5)
Appearance of fetal distress.

53. Management During Labour
• Delivery of second twin – problems & interventions
-inadequate contraction- augmentation – ARM,
oxytocin
-transverse lie – ECV, IPV
-fetal distress, abruption, cord prolapse- expedite
delivery – forceps, ventouse, breech extraction
• THIRD STAGE
- continue oxytocin drip
- 10 un oxytocin IM
- monitor for 2 hours

55. POSTNATAL PERIOD
1) Care of the babies
2) Breastfeeding
3) Nutrition
4) Care of the mother

56. INDICATIONS OF
CAESAREAN
• Non cephalic presentation of first twin
• Monoamniotic twins
• Conjoined twins
• Locked twins
• Other obstetric conditions
• Second twin – incorrectible lie, closure of
cervix

57. • Interlocking: The mostcommon one being the
aftercoming head of the first baby getting
locked with the forecoming head of the second
baby. Vaginal manipulation to separate the
chins of the fetuses is done, failing which
cesarean section is necessary.
• Decapitation of the first baby if already dead,
pushing up the decapitated head, followed by
delivery of the second baby and lastly, delivery
of the decapitated head, at least saves one
baby.

58. CONJOINED TWINS
• It is extremely rare. Incidence
varies from 1: 100,000 to 1:
50,000 births. In twin
pregnancies the incidence is
from 1: 900 to 1: 650.

59. • Diagnosis: Unfortunately conjoined
twins are often diagnosed during
delivery when there is obstruction in
the second stage. Failure of traction
to deliver the first twin in the second
stage or inability to move one twin
without moving the other suggest
conjoined twins. Presence of a
bridge of tissue between the fetuses
on vaginal examination confirms the
diagnosis. Antenatal diagnosis is
important.

60. TRIPLETS, QUADRUPLETS,
ETC
Triplets may develop from
fertilization of a single ovum or
two or even three ova; similarly
with quadruplets and
quintuplets. Female are joined
at the anterior abdominal wall
from xiphi sternum to the level
of umbilicus.

61. NURSING DIAGNOSES
• • Anxiety
• • Deficient Knowledge Regarding
High-risk Situation/Preterm Labor
• • Risk for Imbalanced Nutrition:
Less/More than Body Requirements
• • Risk for Fetal Injury
• • Risk for Maternal Injury
• • Risk for Deficient Fluid Volume
• •

62. • Risk for Impaired Gas Exchange
• • Risk for Activity Intolerance
• • Risk for Ineffective/Compromised
Family Coping
• • Risk for Interrupted Family
Process.

63. • For Cesarean Delivery
• • Deficient Knowledge Regarding
Surgical Procedure, and Postoperative
Regimen
• • Anxiety
• • Powerlessness
• • Risk for Acute Pain
• • Risk for Infection
• • Risk for Impaired Fetal Gas Exchange
• • Risk for Maternal Injury
• • Risk for Decreased Cardiac Output

64. Thank You