Multiple Pregnancy- obstetrics and gynaecology nursing

Obstetrics nursing

1. MULTIPLE PREGNANCY
PRESENTED BY:-
Shivanshita Patel
Roll No.:-40

2. ☆Definition:-
●The pregnancy in which a woman carries more than one
foetus in her uterus, is known as multiple pregnancy.
OR
●The pregnancy in which two or more foetuses
simultaneously develop in the woman’s uterus, is
known as multiple pregnancy.

3. ●Simultaneous development of two foetuses (twins) is
the commonest; although rare development of
○Three foetuses (triplets)
○Four foetuses (quadruplets)
○Five foetuses (quintuplets) or
○Six foetuses (sextuplets), may also occur.

4. ☆Varieties:-
◇Dizygotic twins:-It is the most common (80%)
and results from the fertilization
of two ova.
◇Monozygotic twins:-(20%) Results from the
fertilization of a single ovum.

5. 1) Dizygotic Twins:-(80%) (Fraternal, Binovular)
●Results from the fertilization of two ova, most likely
ruptured from two distinct Graafian follicles usually
of the same or one from each ovary, by two sperms
during a single ovarian cycle.
●Their subsequent implantation and development differ
little from those of a single fertilized ovum.

6. ●The babies bear only Fraternal resemblance to each other
(that of brothers and sisters from different births)
andhence called Fraternal Twins.

7. 2) Monozygotic twins:-(20%) (Identical, Uniovular)
●This type of twin pregnancy occurs as a result of
fertilization of one ovum by one sperm.
●As identical twins are formed when a single fertilized
ovum is divided into two halves. Each half is genetically
identical so the babies share the same DNA. It means that
the babies will share many physical and mental
characteristics. However, sometimes identical twins can
look quite different because there appearance is
influenced by environment also as well as by the genes.

8. ●After fertilization, cleavage of the fertilized ovum occurs
and as a result two foetuses developed simultaneously.
●In this type of twin pregnancy, number of placenta is one
and number of
intervening membranes
are 2 (only two layers
of amnion).

9. ☆Possibilities:-
■If the division takes place within 72 hours after fertilization
(prior to morula stage); the resulting embryos will have to
separate placenta, chorions and amnions (diamniotic –
dichorionicor D/D) (25-30%).
■Is the division takes place within the 4
th
-7
th
days After the
formation of inner cell mass when chorionic has already
developed diamniotic monochorionictwins develop (D/M)
(70-75%).

10. ■If the division occurs within 8-12 days after fertilization,
When the amniotic cavity has already formed,
monoamniotic monochorionictwin develops (M/M) (1–
2%).
■On extremely rare occasions, division occurs after 2 weeks
of the development of embryonic disc resulting in the
formation of Conjoined Twin(<1%) called Siamese twin.

11. ○Fusions that occur are of the following five types:-
a) Craniopagus:-Twins that are fuse that the cranium.
b) Thoracopagus:-Twins that are fused at the chest. It is the
commonest type of conjoined twins.
c) Pyopagus:-Twins that are fused at the back.
d) Ischiopagus:-Twins that are fused at caudal part.
e) Omphalopagus:-Twins that are fused at anterior
abdominal wall.

12. ☆Terms:-
a) Superfecundation:-It is the fertilization of two
different ova released in the same cycle, by separate act
of coitus within short period of time.
b) Superfetation:-It is the fertilization of two ova
released in different menstrual cycles. The nidation and
development of one foetus over is theoretically possible
until the decidual space is obliterated by 12 weeks of
pregnancy coitus within a short period of time.

13. c) Foetus papyraceous or compressus:-It is a state which
occurs if one of the foetus dies early. The dead foetus is
flattened, mummified and compressed between the membrane
of the living foetus and uterine wall. It may occur in both
varieties of twins, but is more common in monozygotic twins.
d) Foetus acardius:-It occurs only in monozygotic twins.
Part of one fetus remains amorphous and becomes
parasitic without a heart.

14. e) Hydatidiform mole:- (from one placenta) and a normal fetus
and placenta (from the other conceptus) have been observed
ultrasonographically.
f) Vanishing twin:-Serial ultrasound imaging revealed
occasional death of one fetus and continuation of pregnancy
with the surviving one. The dead fetus simply vanishes' by
resorption.

15. ☆CLINICAL MANIFESTATION:-
●There is increase in weight gain and cardiac output.
●Plasma volume is increased by an addition of 500 mL.There
is no corresponding increase in red cell volume resulting in
exaggerated hemodilution and anemia.
●There is increased a fetoprotein level, tidal volume and
glomerular filtration rate.
●Increased nausea and vomiting in early months.
●Constipation.

16. ●Problem of fatigue, backache, indigestion etc. is more.
●Swelling of the legs.
●Cardiorespiratory embarrassment which is evident in the
later months such as palpitation or shortness of breath
●Abdominal enlargementis more.
●Excessive fetal movements.
●Varicose veins and haemorrhoids may also appear.
●Problem in walking later months.

17. ☆LIE AND PRESENTATION:-
□The most common lie of the fetuses is longitudinal (90%) but
malpresentationsare quite common.
●The combination of presentation of the fetuses are:-
1) both vertex (50%)
2) first vertex second breech (30%)
3) first breech and second vertex (10%)
4) both breech (10%)
5) first vertex and second transverse and so on, but rarest one,
being both transverse when the possibility of conjoined twins
should be ruled.

18. ☆DIAGNOSTIC EVALUATION
¤ History collection.
¤ Abdominal examination
A) Inspection:- The elongated shape of a normal pregnant uterus is
changed to a more "barrel shape" and the abdomen is unduly
enlarged.
B) Palpation:-
(i) The height of the uterus is more than the period of
amenorrhea. This discrepancy may only become evident from mid-
pregnancy onwards.
(ii) The girth of the abdomen at the level of umbilicus is more
than the normal average at term (100 cm).

19. iii) Fetal bulk seems disproportionately larger in relation to the
size of the fetal head.
iv) Palpation of too many fetal parts.
v) Finding of two fetal heads or three fetal poles make the clinical
diagnosisalmost certain.
C) Auscultation:-
Simultaneous hearing of two distinct fetal heart sounds located at
separate spots with a silent area in between by two observers, gives
a certain clue in the diagnosis of twins, provided the difference in
heart rates is at least 10 beats per minute.

20. ¤ Internal Examination:-
▪︎In some cases, one head is felt deep in the pelvis, while
the other one is located by abdominal examination.
¤ Investigations:-
▪︎Sonography
▪︎Chorionicity of the placenta
▪︎Biochemical tests

21. ☆ANTENATAL MANAGEMENT:-
●Early Diagnosis.
●Ultrasound Examination.
●The woman should be advised to visit antenatal clinic
regularly and more frequently. Close examination should be
done and identification of associated complication, if present
should be treated or managed in early stage.
●Continuous monitoring of maternal and fetal well being.
●Prevention and treatment of exaggerated minor ailments.

22. ●As there is more risk of anaemia, Hb level and general
health status should be assessed during every visit.
●The women should be advised to take Iron Folic Acid
(IFA) tablets daily and along with that should be encourage
to take iron rich foods in adequate quantity.
●And also should be advised to take Vitamin C rich food
items such as amla, lemon, orange, and guava etc.
●The woman should be encouraged not to take tea, coffee
or milk within 1 hour after a meal as this interfere with the
absorption of iron.

23. ●After 24 weeks of pregnancy the women should be advised
for bed rest as it improves Utero-Placentalblood circulation
and reduces the risk of preeclampsia.
●The woman and her family maybe anxious for the health
status of women and her babies so emotional support should
be provided.
●During the third trimester of pregnancy cereal sonography
we should be employed.
●During multiple pregnancy, the woman maybe restless due
to more heaviness of the uterus so she should be advised to
wear Maternity Beltduring later months.

24. ☆Management During Intranatal Period:-
■The delivery should we conducted in a hospital with well
equipped Labour room, Operation theatreand Neonatal ICU.
■At the time of delivery Obstetrician, Anaesthetistand
Paediatricianshould be readily available so that any
complication if arises, can be handled properly.
■In case of multiple pregnancy, usually labour process starts
before EDD.

25. ♧Management during first stage:-
•Assess the maternal and fetal well being frequently.
•Monitor the progress in labour process.
•Provide emotional support to the woman.
•Encourage the patient for complete.
•The woman should be closely observed for cord prolapse, early
rupture of membrane, prolonged labour etc.
•Partograph should be plotted essentially.
•For pain management, give epidural analgesic drugs if required.

26. •Avoid to give enema during first stage as it may cause early
rupture of membranes.
•Blood transfusion products should be kept ready.
•Following articles should be kept ready in extra quantity:-
○Cord clamps
○Scissors
○Cord ligatures
○Mucus extractor
○Blanket, Tray, Towel, Identification tag, etc.

27. • Prevent the labour process from being complicated. In
case of prolonged labour, administer IV Ringer Lactate for
preventing dehydration and ketoacidosis.
•If there is no satisfactory progress in the labour process
then perform ARM with or without oxytocin drip.

28. ♧Management during second stage:-
• Closely monitor the maternal wellbeing, fetal wellbeing and
progress in labour process.
•In case of multiple pregnancy the possibility of Caesarean
Section is always present so all the preparation should be kept
ready in the operation theatre.
A) Delivery of the first baby:-
• The delivery of the first baby is done according to the normal
process in the normal pregnancy.
• Avoid to give IV ergometrine following delivery of the anterior
shoulder of the first baby.

29. • Umbilical cord should be clamped at two places and cut in
between.
•After delivery of the first baby, time of delivery and sex of the
baby should be noted.
•The baby should be labelled as baby number 1.
B) Delivery of the second baby:-
•It is advisable to conduct the delivery of the second baby
within 30 minutes of the expulsion for the first baby.
•After delivery of the first baby abdominal examination should
be done to identify the lie, presentation and position of the
second baby.

30. • IV fluid should be kept continue and women should be given
emotional support continuously.
•As there is risk of cord prolapse, vaginal examination should be
done to exclude it.
• If the lie of second baby is longitudinal (either vertex or breech
presentation) amniotomy should be done with or without
Oxytocin drip soon after fixing of fetal head or breech in the pelvic
brim.
• If the lie of the second baby is transverse then it should be
changed into longitudinal by either external cephalic or podalic
version. Then delivery should be done after amniotomy with or
without Oxytocin drip.

31. • Time of delivery and sex of the baby should be noted.
• After delivery of the anterior shoulder of the second baby 0.2
mg Methargin should be given by IV route and the baby should
be labelled as baby number 2.
• After delivery of both the babies Placenta should be expelled
by controlled cord traction.
• If there is a delay in the expulsion of the baby in longitudinal
lie or if the external version fails in the transverse lie then the
following procedure should be done according to condition:-

32. ◇Condition 1:-
If presentation is vertex and presenting part is low then-
Forceps Delivery.
◇Condition 2:-
If presentation is vertex and presenting part is high then-
Internal Podalic Version and Breech Extraction.
◇Condition 3:-
If presentation is breech-Breech Extraction.

33. ☆INDICATIONS OF CESAREAN SECTION :-
a) Obstetric Indications
▪︎Placenta Previa
▪︎CPD
▪︎Severe preeclampsia
▪︎Cord prolapse of the first baby
▪︎Abnormal uterine contractions
▪︎Previous cesareansection.

34. b) Twins:-
●Monoamniotic twins
●Monochorionic twins
●IUGR
●Collision of the heads
●Conjoint twins.