This document discusses multiple pregnancies, also known as twin or higher order pregnancies. It defines types of multiple pregnancies including twins, triplets, quadruplets, etc. It describes the two types of twin pregnancies - monozygotic (identical) and dizygotic (fraternal) twins. It discusses the incidence, duration, etiology, lie and presentation, physiological changes in the mother, diagnosis, complications, and nursing management of multiple pregnancies.

1. Multiple pregnancy
SUBMITTED TO: SUBMITTED BY:
Mrs.Snehlata Parashar Avdhesh Singh
(Lecturer,OBG) (BSc.Nsg.4th Yr.)

2. INTRODUCTION:-
 When more than one foetus simultaneously developes
in the uterus ,called MULTIPLE PREGNANCY.
 Two foetuses – Twins (most common)
 Three foetuses - Triplets
 Four foetuses - Quadruplets
 Five foetuses – Quintuplets
 Six foetuses - sextuplets

3. Types of twin pregnancy
 Monozygotic (Mz) or uniovular twins or identicle
twins
 Dizygotic (Dz) or biovular twins or non-identicle twins
1) Monozygotic (Mz) twins :-Monozygotic twins
develop from fusion of one ovum and one
spermatozoa.
• after fertilization it split into two
• it is found cases (20%)
• Most often division occur’s between 04 - 08 days
after fertilization
• These twins will be of the same sex and have same
gene’s blood group and physical feature’s such as
eye’s,hair’s colour,ear shape

4. Dizygotic (Dz) twins :- Dizyggotic twins develop from
two separate ova that are fertilized by two differnt
spermatozoa.
 Most common (80% cases )
 There is 50-50 chances of agirl or a boy. It may found
both girls and boys.

5. INCIDENCE:-
In india and bangladesh is generally 01 casess into 70-100
pregnancies.

6. DURATION OF PREGNANCY:-
A multiple pregnancy is shorter than a single pregnancy.
The average gestational period is .......
 Twins is 37 weeks
 Triplets is at 34 weeks
 Quadruplets is at 33 weeks

7. ETIOLOGY:-
The cause of twin is not known.
But the frequency of uniovular twins is related to:
a) Maternal environmental factors and the prevelence
of biovular twins is related to:
 Race : highest among negros
 Hereditory : most transmitted through maternal side
 Advancing age of mother : (30-35 years)
 Influence of parity :- specially from 5th gravida
 Iatrogenic :- drugs used for induction of ovulation may
produce multiple fetuses to the extent of 20 – 40%

8. a) Super fecundation :- it is the fertilization of two
different ova released in the same cycle by separate act of
coitus within a short period of time.
b) Superfetation :- it is the fertilization of two ova release
in different menstrual cycle
c) Fetus papyraceouas or compressus :- it is a state which
occrs if one of the fetus dies early. The dead fetus
is flattened and compressd between the membrane’s of
the living fetus and the uterine wall
d) Fetus acardiacus :- it occur,s in uniovular twins
e) Vanishing twins :- it includes death of one fetus and
continuation of pregnancy with the surviving one.
The dead fetus simply “vanishes” by resorption.

9. LIE & PRESENTATION :-
 LIE :- commonest lie of the fetus is longitudinal
( 90%) but malpresentation are quite common.
 PRESENTATION :-
1. Both vertex (commonest) – 50%
2. First vertex & second breech – 30%
3. First breech & second vertex – 10%
4. Both breech – 10%
5. First vertex & second transverse – 5%
6. Both transverse – (Rare)

10. PHYSIOLOGICAL CHANGES IN MOTHER:-
1. Weight gain
2. Increase cardiac output
3. Increase plasma volume by an additional of 500 ml.
4. Increase alpha fetoprotein level
5. Increase tidal volume
6. Increase GFR Rate

11. DIAGNOSIS OF MULTIPLE PREGNANCY
1. History taking :- family history of twinning
2. Noting symptoms :- enlargement of uterus.
– nausea & vomiting in early month.
- cardio- respiratory – palpitation & SOB
- swelling in legs , vericose vein and hemorrhoids
- fetal movement may be noticed
3. General examination : -
- anemia is more prevalent.
- unusual weight gain
- evidence of pre- eclampsia

12. 4. Abdomonal examination :-
- Inspection :- Elongated shape of a normal
pregnant uterus is changed to a more “ Barrel” shape
– palpation:- fundal height may be greater.
- multiple fetal limbs may be felt.
- the girth of the abdomen at the level of umblicus is
more than the normal average at term ( 100 cm. )
- Auscultation :- hearing of two distinct fetal heart
sounds located at separate spots with a silent area.
- different heart rate is at least 10 beats / min.
5. Investigations :-
(a) sonography :- it is confirmation test.
- pregnancy date.
- fetal anomalies.

13. - Presentation & lie’s of foetuses
- placental localization
- Amniotic fluid volume
(b) Biochemical test – maternal serum chorionic
gonadotrophin
- alpha foetoprotein

14. COMPLICATION
1. Maternal complication –
a) During pregnancy
b) During labour
c) During puerperium
During pregnancy- Nausea & vomiting
- Anemia – more common in twin preggnancy
- pre – eclampsia
- Hydramnious is more common
- Antipartum hemorrhage
- Preterm labour
- malpresentation – more common in second baby

15. During labour –
- Early rupture of membrane & cord prolapse
- Prolong labour
- Increase operation interferences
- Bleeding
- Post – partum hemorrhage
- During puerperium-
- Subinovulation
- Infection
- Failing lactations

16. (2) Fetal complication –
- Abortion rate is increase
- Prematurity is seen
- Growth problem appear like IUGR
- Intra uterine death of one fetus
- Fetal anomalies (Eg. Hydrocephalus, down
syndrome,encephaly etc.)
- Asphyxia and still birth

17. NURSING MANAGEMENT
1. Proper care and advice
2. Hospitalization
3. Management during labour
4. Indication for cesarean section

18. Indication’s for cesarean
section/LSCS
 Associated causes :-
- contracted pelvis
- placenta praevia
- sever pre – eclampsia
- previous history of LSCS
- cord prolapse of 1st baby
- abnormal uterine contraction’s
 For twins :-
- both babies / first born with transverse lie
- Non – vertex twins with weight 2 kg or less
- Conjoined twins

19.  Management during labour :-
Place of delivery – as the twin pregnancy is considered
a high risk the patient should be confined in an
equiped hospital prefarably having an intensive
neonatal care unit.
Vaginal delivery is allowed – when both the twins are
atleast the first twin is with vertex presentation.

20.  FIRST STAGE :- A skilled obstetrician should be
present.
- Neonatologist
- Presence of USG machine in labour room
- Use of analgesic drugs
- Careful foetal monitoring
- Internal examination should be done
- An I/V line prepared
- Arranged 01 unit blood (if needed).