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Complexities in Midwifery Care > Multiple Pregnancy and Birth > Flashcards

Multiple Pregnancy and Birth Flashcards

1
Q

What increases the chance of multiple pregnancy

A

Maternal Age
High Parity
Family History
PCOS
Ethnicity
Assisted reproduction

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2
Q

Does the rate of multiple birth increase by maternal age

A

Yes (ONS, 2023)
A steady increase until 40-45 and then a spike at >45
(See Flashcard)

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3
Q

What campaign did HFEA launch in 2007 and what was the aim of this?

A

The collaborative ‘One at a time’ campaign in 2007 to reduce high multiple births from IVF in the UK.

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4
Q

According to HFEA, 2022 how has the average UK multiple birth rate from IVF treatment changed?

A

Has decreased from around 28% in the 1990s to 6% in 2019.

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5
Q

What are the characteristics of monozygotic twins?

A

Identical twins
From one oocyte and spermatozoon that splits into two after fertilisation
1/3 of all twins
Non-hereditary

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6
Q

What are the characteristics of Dizygotic twins?

A

Non-identical twins
Two separate oocytes that are fertilised by two separate spermatozoa
2/3 of all twins
Hereditary

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7
Q

What is the difference between the chorion and amnion?

A

Chorion- The outer membrane
Amnion-Inner membrane
See photo

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8
Q

What does Dichorionic mean?

A

Two placentae (may be fused)
Two chorions
Two amnions
These twins can either be dizygotic or monozygotic

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9
Q

What does monochorionic mean?

A

One placenta
One chorion
Two amnions (One amnion in monoamniotic twins is very rare)
These twns can only be monozygotic.

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10
Q

What is meant by dichorionic diamniotic by Brewester and Turier, 2020

A

Most common- 2/3 of twin pregnancies
Both babies have there own placenta
2 chorion 2 amnion
Usually non-identical- can occasionally be identical
Diagnosed by presence of lambda sign on scan (see photo)
Chronicity and amnioicity determined at dating scan (if not, needs to be determined by 14 weeks)

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11
Q

Why dos chorionicity and amnioicity need to be determined at dating scan or by 14 weeks?

A

Differences between two types of placentation are more pronounced in first trimester.

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12
Q

What are monochorionic twins according to Brewster and Turier, 2020?

A

usually Monochorionic Diamniotic (MCDA)
Monochorionic Monoamniotic (MCMA) rare about 8:100,000
Always Identical
MC twin pregnancies have a higher risk of complications in pregnancy; perinatal morbidity and mortality
If unable to tell on USS, treat as monochorionic until proven otherwise.

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13
Q

What are Trichorionic triaminotic triplets?

A

Each baby has a separate placenta and amniotic sac.

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14
Q

What are Dichorionic triamniotic triplets

A

One baby has a separate placenta and 2 baby’s share a placenta.
All 3 babies have a separate amniotic sacs.

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15
Q

What are Dichorionic Diamniotic triplets

A

One baby has a separate placenta and amniotic sac
Two of the babies share a placenta and amniotic sac.

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16
Q

What are Monochorionic triamniotic triplets?

A

All 3 babies share a placenta
All 3 babies have separate amniotic sacs

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17
Q

What are Monochorionic Diamniotic triplets

A

All 3 babies share 1 placenta
One baby has a separate amniotic sac and two babies share 1 sac

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18
Q

What are Monochorionic monoamniotic triplets?

A

All 3 babies share a placenta and amniotic sac.

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19
Q

What is the management of care for multiple pregnancies according to NICE 2024 guidelines?

A

Consultant led care- Core team of specialist obstetricians, specialist midwives and monographers, all of whom have knowledge of managing twin/triplet pregnancies.
Co-ordinate care to:
Minimise number of hospital visits
Provide care as close to home as possible
Provide continuity of care within and between hospitals and the community.

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20
Q

What is the schedule of care from DCDA twins according to NICE, 2024 guidelines?

A

At least 8 AN appts with a healthcare professional from the core
professional team:
○ At least 2 of these appointments should be with the specialist obstetrician
● Scans and appointments - dating scan then 4 weekly between 20 and 36
weeks
● Offer additional appointments without scans at 16 and 34 weeks

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21
Q

what is the schedule of care for MCDA (NICE, 2024)

A

At least 11 AN appts with a healthcare professional from the core
professional team
○ At least 2 of these appointments should be with the specialist obstetrician
● 2 weekly scans between 16 and 34 weeks
● All scans performed by fetal medicine consultant

22
Q

What is the schedule of care for TCTA (NICE, 2024)

A

At least 9 AN appts with a healthcare professional from the core
professional team
○ At least 2 of these appointments should be with the specialist obstetrician
● Scans and appointments - dating scan, 20, 24 then 2 weekly until 34 weeks
● Offer an additional appointment without a scan at 16 weeks

23
Q

what is the schedule of care for DCTA or MCTA (NICE, 2024)

A

At least 11 AN appts with a healthcare professional from the core
professional team
○ At least 5 of these appointments should be with the specialist obstetrician
● 2 weekly scans between 16 and 34 weeks

24
Q

Schedule of care for MA triplets (NICE, 2024)

A

Offer women with a twin or triplet pregnancy involving a shared amnion
individualised care from a consultant in a tertiary level fetal medicine centre

25
What is the test of choice for twin pregnancies according to NHS England 2024 for screening for chromosomal conditions?
Combined Test
26
What is the chance result reported for in monochorionic twin pregnancy and then dichorionic for screening for chromosomal conditions (NHS England, 2024)
M- The chance result is the same for each baby and one 'pregnancy' chance result is reported. D- The chance result is reported for each baby
27
How do we screen for chromosomal conditions in triplets and what are the difficulties with this? (NICE, 2024)
Greater likelihood of Down's syndrome, Edward's syndrome and Patau's syndrome in triplet pregnancy. Increased false positive rate of screening tests in triplet pregnancy Use of nuchal translucency and maternal age to screen Chance of Down's syndrome, Edwards' syndrome and Patau's syndrome calculated for each fetus Refer women with a triplet pregnancy who want to have screening to a tertiary level fetal medicine center.
28
How do we monitor growth in multiple pregnancies?
At dating USS- Estimate GA from the largest baby in a twin or triplet pregnancy to avoid the risk of estimating it from a baby with early growth pathology At dating USS- Assign nomenclature (Upper/lower or left/right) to babies in a twin or triplet pregnancy, and document this clearly in the woman's notes to ensure consistency throughout pregnancy. Fundal height measurements should not be performed Allow 30 mins for growth scans.
29
How do we screen for dichorionic or trichorionic for fetal growth restriction and when are higher risks associated. (NICE, 2024)
At each USS from 24 weeks, offer pregnancy diagnostic monitoring for fetal weight discordance. Higher risks associated with a difference of greater than 25% or if any of the babies are below the 10th centile.
30
At every USS what do we offer women simultaneous monitoring for? (NICE, 2024)
Feto-fetal transfusion syndrome FGR Advance stage twin anemia polycythemia sequence (TAPS)
31
How and why should we screen for Pre term birth according to NICE, 2019
Approx 60% of twins will result in spont pre-term birth Approx 75% of triplets will result in spont birth before 35 weeks Offer a single cervical length scan between 16 and 20 weeks to women or pregnant people with a twin or triplet pregnancy (NICE, 2024)
32
What antental discussions should we be having with women about risk of pre term birth? (NICE, 2019)
Having a higher risk of spont preterm birth than women with a singleton pregnancy The risks, symptoms and signs of preterm labour and the potential need for corticosteroids for fetal lung maturation.
33
What is feto-fetal transfusion- which pregnancies, effects for both twins and treatment
twin-to-twin transfusion MC pregnancies only The placenta transfuses blood from one twin to another Donor twin- anaemia and growth restriction Recipient twin- Polythaemia and hydrops Treatment- amnioreduction, septostomy or laser ablation therapy (see photo)
34
What is Twin anemia polycythemia sequence (TAPS)- which pregnancies, effects for both twins and treatment
MC pregnancies only Imbalance in RBC's Donor twin- anaemia Recipient twin-Polythaemia No imbalance of amniotic fluid Often undiagnosed Treatment- Expectant management, expidite brith, Intrauterine transfusion or laser surgery (see photo)
35
What is the timing of birth for DCDA twins? (NICE, 2024)
Offer planned delivery at 37 weeks to women with uncomplicated DCDA twin pregnancy
36
What is the timing of birth for MCDA twins? (NICE, 2024)
Offer planned birth as follows, after a course of antenatal corticosteroids has been considered at 36 weeks for women with an uncomplicated MCDA twin pregnancy.
37
What is the timing of birth for MCMA twins? (NICE, 2024)
Offer planned birth as follows, after a course of antenatal corticosteroids has been considered between 32+0 and 33+6 weeks for women with an uncomplicated MCMA twin pregnancy.
38
What is the timing of birth for triplets? (NICE, 2024)
Offer planned birth at 35 weeks to women with an uncomplicated TCTA or DCTA triplet pregnancy Individualised care plan for MCTA triplet pregnancy that involves a shared amnion.
39
What is the mode of birth for women with an uncomplicated pregnancy and what are the restrictions?
Both vaginal birth and a planned LSCS are safe choices if all of the following apply: The pregnancy remains uncomplicated beyond 32 weeks There are no obstetric complications The first baby is cephalic There is no sig size discordance
40
What is the mode of birth offered for MCMA twins?
Offer CS to women with MCMA pregnancy.
41
What does the cochrane review (Hofymer et al, 2015) say about the difference in mortality, morbidiy, BF and postnatal depression between women for planned vaginal birth or planned LSCS?
No significant difference.
42
What is the mode of birth offered for triplets?
ELCS
43
What should intrapartum care for the first stage look like according to NICE 2024?
Advise birth in consultant led unit Advise continuous fetal monitoring IV access in labour and blood taken for FBC/ G&S Observations as per NICR intrapartum guidelines USS to be performed in birthing room to confirm fetal lie FSE can be used after 34 weeks Offer an epidural and explain this is likely to: -Improve the chance of success and optimal timing of assisted vaginal delivery of both babies -Enable quicker birth by EMCS if required.
44
What should intrapartum care look like for second stage? (NICE, 2024)
As per normal guidance Inform MDT at the beginning of second stage- obstetrician, anaesthetist, paediatrician Midwife can perform birth but obstetrician should be made available.
45
What equipment should be made available in second stage of twin birth?
Resusitaire x2 Ventouse/ Forceps trolley Amnihook Cord clamps x5 Oxytocin infusion- prepared and ready to use after birth of first twin Portable scanning machine.
46
What are the guidelines following the birth of twin 1?
Clamp and cut the cord (Don not initiate delayed cord clamping in MCDA twins, can be undertaken with DCDA twins) Identify twin 1 by using labels/ 1 cord clamp Ascertain presentation of twin 2 +/- ECV Continue CTG and wait for head to descend into pelvis +/- fundal pressure If no contractions after 5-10 minutes start oxytocin infusion Aim to birth within 45 minutes Identify twin 2 with labels/ 2 cord clamps
47
Which type of twins can you initiate delayed cord clamping?
Do not initiate in MCDA twins, but can be undertaken with DCDA twins
48
What are the guidelines for intrapartum care in the third stage?
Do not offer physiological management Offer active management immediately following the birth of the last baby.
49
What are some potential birth complications multiple pregnancies are at risk of?
Premature placenta birth Locked twins Cord entanglement Cord prolapse Malpresentations PROM PPH Prolonged labour Delay of the 2nd twin
50
What are some post-natal care considerations?
Slower involution of the uterus Greater after pains Emotional and practical support Infant feeding support.

Complexities in Midwifery Care (8 decks)

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