The course and management of delivery at twins

The management of the first stage of labor at multiple pregnancy is determined by term of gestation, condition of fetuses, and character of labor pains. If labor pains began prematurely (in term of 28-36 weeks), amniotic membranes are not ruptured, the dilatation of the cervical canal is not more than 4 cm, it is possible to prolong pregnancy. In this case a strict bed regimen, sedative therapy, tocolytic therapy, beta-adrenomimetics (adrenoceptor agonists), magnesium preparations for controlling premature labor pains should be administered.

In case of non-effective tocolytic therapy, labor should be conducted by a principle of premature labor: spasmolitic agents, analgesics by indications should be administered. For acceleration of ripening of surfactant in fetal lungs, glucocorticoids (100 mg of hydrocortisone or 60 mg of prednisolone) should be prescribed.

At minor outflow of amniotic fluid or doubt in safety of bag of membranes, it is possible to prolong pregnancy with the purpose of acceleration of ripening of surfactant in fetal lungs. Thus, the development of ascending endometritis and infection of intrauterine fetuses are a basic danger. The pregnant woman should be placed in a ward of intensive therapy for diagnostics of possible complication; leukocytosis, ESR are determined three times a day. Body temperature should be measured every three hours.

Prophylactic antibiotic therapy is proposed. With the purpose of prevention of respiratory disorders at birth of immature fetuses, glucocorticoids for ripening of surfactant are usually administered: dexametazon — 4 mg a day during 3-7 days. Simultaneously the therapy directed at improvement of feto-placental microcirculation and prophylaxis of intrauterine hypoxia of the fetus should be prescribed.

For the necessity of delivery and unreadiness of cervix of uterus, the hormonal-energetic treatment is usually prescribed: 60 mg of castor oil orally, and in 2 hours a cleansing enema should be done. In 3-4 hours after the hormonal-energetic treatment, labor induction and stimulation with prostaglandins intravenously by drops (or mixed prostaglandin and oxytocin according to the scheme) start. Delivery should be conducted carefully, preferably under cardiomonitoring, with adequate analgesia, prevention of anomalies of uterus contractility and intrauterine hypoxia of the fetus.

In the first stage of labor (stage of cervical dilation) the condition of mother and fetus should be controlled carefully. When simultaneously with twins, there is hydramnios, amniotomy should be done if the opening of the cervical canal is not less than 4 cm. Amniotic fluid flows out very slowly in order to prevent prolapse of small parts of the fetus and umbilical cord, premature separation of normally located placenta, and other complications. After discharge of amniotic fluid the tension of uterus decreases, labor pains become stronger, regular and less painful.

For prophylaxis of head injury in the second stage of labor, pudendal anesthesia with novocain and perineotomy or episiotomy are performed.

After birth of first newborn the fetal and maternal end of umbilical cord is carefully bandaged, because in case of monochorionic twins the second fetus can be lost from bleeding through non-bandaged umbilical cord of the first fetus. Immediately after birth of the first twin it is necessary to examine the mother carefully to find out her general condition. At the same time it is necessary to determine the position of the second fetus in the uterus and his condition (if there are any signs of beginning asphyxia).

At a good condition of mother, absence of signs of asphyxia and longitudinal lying of the second fetus, in 5-10 minutes after birth of the first child the bag of membranes of the second fetus should be opened (ruptured) and under the control of hand the fluid is slowly let out. In what follows the delivery should be conducted carefully, depending on obstetrical situation.

For this time the organism of mother gradually adapts to new conditions, uterus restores its normal tonus, clasps the fetus and develops a good contractile activity, due to which the second twin is rather soon also born. If within 30 minutes the second twin is not born, the bag of membranes should be opened and, having made sure, that the head or buttocks are inserted into the pelvic cavity, delivery takes its eventual course. At such conducting of the second stage of labor, the second twin is usually born in not later than one hour.

If the second twin appears in transverse or oblique lying, in 20-30 minutes after birth of the first fetus, the second bag of membrane should be opened; the internal version of the fetus and extraction by the leg should be performed. At occurrence of premature separation of placenta, bleeding from the uterus and increasing of intrauterine asphyxia of the fetus, the urgent intervention — version of the fetus on legs and extraction together with placenta is necessary.

In all cases, when the urgent termination of delivery is necessary, resort to operative delivery: at head presentation — applying forceps, at breech — extraction by podalic end, at transverse and oblique lying — a classical version of the fetus on legs and its extraction.

Each of these operations can be made at presence of necessary conditions. In case of operative removal of the first fetus, the second fetus should be removed operatively too, but not earlier than 10-15 minutes after the first, if there are no indications to the immediate termination of delivery.

Recently, in connection with high traumatism of operation of fetus version and extraction by podalic end in transverse lying, a cesarean section according to plan has been preferred, i.e. before the beginning of labor.

After the birth of the second fetus, the mother continues to remain under persistent supervision in case of danger of profuse bleeding in placental stage of labor and in early puerperal period. If hemorrhage happens at separated placenta, it should be removed from the uterus by external maneuvers and at non-separated placenta — a manual removing should be done. After delivery of placenta it is necessary to make sure of its wholeness and to determine, whether there are two-egg or one-egg twins. For prophylaxis of atonic hemorrhage, 1 ml of methylergometrine should be done subcutaneously.

The twins, having lived for 2-3 weeks, further develop in the same way as children, born at single pregnancy. However, in some newborns (13 %) physical and mental retardation may develop. It is more often manifested in premature infants, and also in children, delivered by mothers with complications of pregnancy (severe preeclampsia, feto-placental insufficiency, threatened interruption of pregnancy in different terms of gestational process).

Thus, gestation and labor at multiple pregnancy are connected with a high risk of development of maternal and fetal pathology, that demands rapt attention to them from both obstetrician-gynaecologist and neonatalogist.