Obstetrics and Gynecology - A.M. Hromova 2000

Multiple pregnancy
Management of labor

Delivery in Multiple Pregnancy is generally considered a threshold between physiological and pathological processes due to a significantly higher rate of complications.

Labor management must be carried out under continuous electronic fetal monitoring, including the Prevention and Treatment of intrauterine Fetal Hypoxia, as well as timely correction of labor dystocia.

Managing such deliveries requires utmost care and patience. It is essential to closely monitor the condition of the mother and fetuses, the progression of labor, and the descent of the fetuses through the birth canal.

Once labor is established at term with progressive cervical dilation up to complete effacement and intact membranes, amniocentesis with a large-bore needle or Amniotomy is performed to relieve excessive uterine overdistension and stimulate uterine activity. Fluid is released slowly to prevent potential complications, such as umbilical cord prolapse, herniation of small fetal parts, or premature placental abruption. During the first stage of labor, pain relief and fetal hypoxia prevention are administered every 2–4 hours. If necessary, medical induction or augmentation of labor is prescribed.

The Second Stage of labor is managed with an " intravenous line in place." Active interventions are reserved for complications. Following the delivery of the first twin, the fetal and maternal ends of the umbilical cord are promptly clamped and ligated to prevent Hemorrhage in the second twin, particularly in monozygotic cases. The presentation, position, variety, and lie of the remaining fetus in utero are immediately assessed, and its heartbeat is auscultated. After 10–15 minutes, a vaginal examination and amniotomy are performed. If the second fetus presents longitudinally, labor is managed conservatively. In case of a transverse lie of the second twin, internal podalic version followed by Breech Extraction is performed. To avoid complications, a Cesarean Section may be indicated.

Indications for cesarean section in multiple pregnancy include:

— unripe cervix after 38 weeks of gestation accompanied by fetal distress;

— breech presentation of the First and Second fetuses, particularly in primiparas;

— history of Infertility, recurrent Miscarriage, or stillbirth;

— primiparas over the age of 28;

— breech presentation of the first fetus;

— transverse lie of the first fetus;

— failure to respond to labor induction or augmentation within three hours;

— preterm pregnancy.

The Third Stage of labor in multiple pregnancy is managed with an "intravenous line in place," through which a 5% glucose solution with oxytocin is infused via an IV drip. It is crucial to closely monitor the mother's condition and Blood loss. In the event of hemorrhage, manual removal of the separated Placenta or Manual Exploration of the uterine cavity should be performed, along with bimanual uterine massage.

The delivered placenta must be thoroughly inspected to ensure its integrity and to determine whether the multiple pregnancy was monozygotic or dizygotic.

In the postpartum period, especially during the first few hours after delivery, measures to prevent excessive blood loss must be implemented, such as applying an ice pack to the lower abdomen, monitoring regular urination, performing Therapeutic Exercises to tone the anterior abdominal wall Muscles, and administering uterotonic medications like injectable oxytocin or oral quinalgin.

The discharge of mothers with twins from the maternity hospital may be delayed due to potential complications in the postpartum period or the neonatal period. Following discharge, mothers with twins require heightened medical supervision from both antenatal clinics and pediatric care providers.

Review Questions

1. What is defined as a multiple pregnancy?

2. Enumerate the causes of multiple pregnancy.

3. How do monozygotic and dizygotic twins develop?

4. What are the differences between monozygotic and dizygotic twins?

5. Diagnosis of Multiple Pregnancy.

6. What are the specific Clinical Features of multiple pregnancy?

7. What does the prevention of complications in multiple pregnancy involve?

8. What complications most frequently arise during labor?

9. What are the Specific features of labor progression in multiple pregnancies?

10. How is The First stage of labor managed in multiple pregnancies?

11. Features of management during the second (expulsion) stage.

12. How should the postpartum period be managed in multiple pregnancies?