This document summarizes key information about multiple pregnancies from a medical student presentation. It defines multiple pregnancy as more than one fetus developing simultaneously in the uterus. Twin pregnancies are most common, though higher-order multiples can also occur. Multiple pregnancies are classified based on zygosity into either monozygotic or dizygotic twins. Labor and delivery procedures for multiples aim to expedite delivery of the second twin to avoid complications from reduced placental function after the first birth. C-section is often recommended due to risks of vaginal delivery for multiples.

1. Uzhhorod National University
Medical Faculty No: 2
Department of Obstetrics & Gynaecology
Multiple Pregnancy.
Presented by
Kolappa Pillai Ainkareswar
4th Course.
Presented to
Prof./Dr. Ibadova Tunzale
Department of O&G, UzhNU.

2. Introduction.
• When more than one fetus simultaneously develops in the uterus, it
is called multiple pregnancy.
• Simultaneous development of two fetuses (twins) is the most
common; although rare, development of three fetuses (triplets), four
fetuses (quadruplets), five fetuses (quintuplets) or six fetuses
(sextuplets) may rarely occur.
• In terms of statistics, approximately the chances of multiple
pregnancy is about 2.5%.
• Influence due to Ethinicity, maternal age , hereditary and maternal
environmental factors.

3. A classic case of Multiple Pregnancy.

4. Classification.
Multiple pregnancy can be classified on the basis of Zygosity.
• Monozygotic.
• Polyzygotic.
It is more common to find Dizygotic (Polyzygotic) multiple pregnancy
(about 80%) than monozygotic multiple pregnancy.

5. Monozygotic Multiple Pregnancy.
• Develop from single fertilized egg after division of inner cell mass of
blastocyst.
• Rarely two chorion present in monozygotic multiple pregnancy.
• Presence of two amnions.
• Each fetus is surrounded by a separate amniotic sac with the
chorionic layer common to both (diamniotic—monochorionic).
• Only one placenta present.
• Identical gender of the fetuses.

6. Ultrasound of Monozygotic Multiple Pregnancy.

7. Dizygotic Multiple Pregnancy.
• Result from fertilization of two ova and by two sperms during a single
ovarian cycle.
• The babies bear only fraternal resemblance to each other and hence
called fraternal twins.
• There are two placentae, either completely separated or more
commonly fused at the margin appearing to be one.
• Each fetus is surrounded by a separate amnion and chorion.
• Gender is not always identical.

9. Types of Multiple Pregnancy.
• Superfecundation can be explained as the fertilization of two different
ova released in the same cycle, by separate acts of coitus within a
short period of time
• Superfetation can be defined as the fertilization of two ova released
in different menstrual cycles. The implantation and development of
one fetus over another fetus is possible until the decidual space is
obliterated by 12 weeks of pregnancy.

10. Labor in Multiple Pregnancy.
• Most of multiple pregnancy patients are considered to be at high risk
during labor due to variety of maternal and labor complications.
• So it is important to hospitalize patient in the neonatal intensive care
unit, if signs of labor are expressed.
• Vaginal delivery is preferred if and only if at least one of the fetus is in
cephalic presentation,else cesarean section is the preferred.
• In countries like India, cesarean section is the most preferred as there
are little risks to maternal and fetal health during labor.
• Vaginal examination is done in order to examine the risk of cord
prolapse.

11. Indication for C-Section in Multiple
Pregnancy.
• Obstetric causes.
• For twins.
For twins:
1) Both the fetuses or even the first fetus with
noncephalic (breech or transverse) presentation
2) Twins with complications: , conjoined twins.
3) Monoamniotic twins
4) Collision of both the heads at brim preventing
engagement of either head.
5)Monochorionic twins with TTTS
Obstetric indication:
1) Severe preeclampsia
2) Previous cesarean section
3) Cord prolapse of the first baby
4) Abnormal uterine contractions
5) Contracted pelvis.

12. Delivery of the first baby.
The delivery should be conducted in the same guidelines as mentioned
In normal labor. As the baby is usually small, the delivery does not usually pose any problem.
(i) Liberal episiotomy under local infiltration with 1% lignocaine.
(ii) Forceps delivery, if needed, should be done preferably under pudendal block anesthesia. General anesthesia is
better avoided, as the second baby may be subjected to the effects of prolonged anesthesia.
(iii) Not to give intravenous ergometrine with the delivery of the first baby.
(iv) Clamp the cord at two places and cut in between, to prevent exsanguination of the second baby through
communicating placental circulation in monozygotic twins (of course, it is an usual procedure even in singleton birth).
(v) At least, 8–10 cm of cord is left behind for administration of any drug or transfusion, if required.
(vi) The baby is handed over to the nurse afterlabeling it as number 1

13. Delivery of the second twin.
• 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
• 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 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.

14. Delivery of the second twin.
If the Lie of the fetus is longitudinal:
Step 1: Low rupture of the membranes is done after fixing the presenting part on the brim. Internal
examination is once more to be done to exclude cord prolapse.
Step 2: 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 3: If there is still a delay , interference is to be done.
Vertex:
• Low down : Forceps are applied.
• High up : Brech extraction is performed under general anesthesia.
Breech: The delivery should be completed by breech extraction.

15. Delivery of the second twin,
If the lie of the fetus is transverse, it should be corrected by external
version into a longitudinal lie preferably cephalic. 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.

16. Delivery of the second twin.
Management.
In all these conditions, the baby should be delivered quickly. A rational scheme is
given below which depends on the lie, presentation and station of the head.
A. Head
• If head is low down, delivery by forceps
• If head is high up, delivery by internal version under general anesthesia
B. Breech should be delivered by breech extraction
C. Transverse lie—internal version followed by breech extraction under general anesthesia.
If, however, the patient bleeds heavily following the birth of the first baby, immediate low rupture of
the membranes usually succeeds in controlling the blood loss.

17. 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.
• Conjoined twins are often diagnosedduring 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 suggests conjoined twins.
• Presence of a bridge of tissue between the fetuses on vaginal
examination confirms the diagnosis.
• Possibility of surgical seperation depending upon the anatomy.

18. THANK YOU!