Multiple pregnancy

Question 1

What is the definition of a multiple pregnancy?

Answer 1

A pregnancy that involves the presences of two or more fetuses

Question 2

What are the incidences of Multiple pregnancies?

Answer 2

twins is 1 in 90 pregnancies

Triplets are 1 in 8,100 pregnancies

multiple pregnancy accounts for 3% of live births

Question 3

What are women with multiple pregnancy at an increased risk of?

Answer 3

Anaemia
•Pre eclampsia / PIH
•Gestational Diabetes
•Prematurity
•Placental Insufficiency
•Placenta praevia
•PPH
•Trauma associated with fetal manipulation

Question 4

What is the role of the midwife and the obstetric team?

Answer 4

./, Provide guidance regarding expected pregnancy
•Discuss physical and emotional changes
•Describe measures to alleviate backache, round ligament pain, leg ache or oedema, breathlessness, constipation
•Encourage attendance at TAMBA meetings, local twins club, bespoke parentcraft classes for parents expecting multiples

Question 5

What is Dizygotic twinning

Answer 5

dizygotic multiple pregnancies, each fetus has its own placenta (either separate or fused), amnion and chorion.

Question 6

What is Monozygotic twinning

Answer 6

The situation is more complex depending on the timing of the division of the ovum:
–embryo splits at 3 days - two chorions, two amnions
–embryo splits at 4-7 days - single placenta, one chorion, two amnions
–embryo splits at 8-12 days - single placenta, one chorion and one amnion (rare)
–embryo splits at 13 days - conjoined or Siamese twins (very rare)

Question 7

What can happen in monochorionic twinning

Answer 7

–one twin can receive a reduced blood supply and have a slower growth rate (twin-twin transfusion).
–Sometimes, one fetus dies and forms a mummified fetus papyraceous or is reabsorbe

Question 8

‘Monozygotic is Non-identical’

true or false?

Answer 8

False

Question 9

‘Dizygotic is Non-identical’

true or false?

Answer 9

True

Question 10

What does super-fecundation mean?

Answer 10

Twins resulting from two coital acts in the same menstrual cycle

Question 11

What does Superfetation mean?

Answer 11

Twins resulting from two coital acts in different cycle

Question 12

What steps would take in Initial diagnosis of twins?

Answer 12

• News should be given sensitively;
• Avoid any delay in interpreting an US Scan;
• Explain ‘vanishing twin syndrome’ (20% of early twin pregnancies);
• Provide information re local and national support organization

Question 13

As a midwife, what should be your key priorities of childbirth

Answer 13

–Antenatal and postnatal mental health and wellbeing
–Antenatal nutrition
–The risks, symptoms and signs of preterm labour and the potential need for corticosteroids for fetal lung maturation
–Likely timing and possible modes of delivery
–Breastfeeding
–Parenting

Question 14

What would your provide within antenatal care as a midwife?

Answer 14

Glucose Tolerance Test (GTT) at 28 weeks (ALL)
•Regular BP monitoring and urinalysis
•Antenatal steroids should be considered in all cases if other risk factors for a preterm pregnancy occur
•Routine cervical cerclage / oral tocolytics / bed rest / progesterone should not be used to prevent preterm labour
•Labour and Mode of Delivery Discussed

Question 15

What are the indications for referral to a FMC

Answer 15

Seek a consultant opinion:
–Monochorionic monoamniotic twin pregnancies
–Monochorionic monoamniotic triplet pregnancies
–Monochorionic diamniotic triplet pregnancies

–Pregnancies complicated by any of the following
•Poor fetal growth
•Fetal anomaly
•Discordant fetal death
•Feto-fetal transfusion syndrome

Question 16

If twins had congenital anomalies what would u explain to the parents ?

Answer 16

The nature of the anomaly;
–Implications for pregnancy;
–Implications for the child in the long and short term;
–Options available;
–Implications for future pregnancies

Question 17

What can Twin-Twin Transfusion cause for the recipient?

Answer 17

polyycythemia, circulatory overload, polyhydramnios (recipient)

Question 18

What can Twin-Twin Transfusion cause for the Donor?

Answer 18

Anemia, oedema, growth retardation, oligohydramnios (donor)

Question 19

What would u be looking for an abdominal examination

Answer 19

•On Inspection
 Size of uterus larger than per weeks
 – after 20/40Multiplicity of movements
 –Broad uterus
 –Polyhydramnios
 –Excess Striae Gravidarum

•On Palpation
 –Fundus larger than dates
 –Two fetal poles
•Auscultation
 –Simultaneous auscultation – Difference of 10 beats

Question 20

What is the optimal timing of birth for uncomplicated diamonitic twins?

Answer 20

37-38weeks

Question 21

What is the optimal timing of birth for Monochorionic twins?

Answer 21

should have timing of birth discussed and be offered elective delivery from 36/40 with the administration of antenatal steroids, unless there is an indication to deliver early

Question 22

What is the optimal timing of birth for monochorionic diamniotic (MCDA) twins

Answer 22

appropriate to aim for a vaginal birth.

Question 23

What are the incidences of presentation of twins?

Answer 23

Both Vertex 50%
One vertex, one breech 40%
Both Breech 8%
Others 2%

Question 24

What 4 main things would u need to Labour and delivery

Answer 24

–The obstetric registrar on-call is responsible for the management of labour and birth
–Paediatrician
–Two resuscitaires
–US machine outside of room

Question 25

If both babies vertex what would u do?

Answer 25

aim for a vaginal delivery

Question 26

If first baby vertex and second baby breech or transverse what would you do?

Answer 26

vaginal delivery attempted with an external or internal version of Twin 2 (Use of Syntocinon)

Question 27

If both twins breech

what would u do?

Answer 27

recommend C-section

Question 28

What are the 11 things you would consider during Labour and delivery?

Answer 28

•Premature Rupture of Membranes
•Prolapsed Cord
•Delay in Birth of Second Twin
•Prevention of Asphyxia
•Premature Separation of the placenta
•Sepsis
•Premature Expulsion of the Placenta
•PPH
•If relevant Check Premature Delivery Policy
–Group B Strep Prophylactic antibiotics
–Magnesium Sulphate to prevent cerebral palsy should be considered

Question 29

What are the 11 things you would advice parents on?

Answer 29

• Written information re support (TAMBA, MBF)
• Topics for Classes
• Facts and figures
• Prenatal complications
• Labour and delivery
• Possible preterm birth (Visit to NNU)
• Feeding
• Zygosity
• Prams, car seats etc
• Coping with twins
• Developing individuality