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The midwife, upon discovering a twin or multiple birth while the woman is in labor and delivering should contact the client's health care provider, alerting her/him to the situation. Consultation and emergency transport may be necessary, depending upon the client and her health care provider.
Discuss with the client the dangers of twin births. Twin births may go well, but they can be more difficult or dangerous than a single birth. Twins are more than 3 times as likely to die than other babies, for these reasons:
- Twins are more likely to be born early, and to be small and weak. If you can get your client to at least 37 weeks gestation before delivering, this is optimal. Twins are considered full term by obstetricians at 38 weeks gestation. The closer to full term they become, the fewer the problems associated with prematurity.
- The cord (especially of the second twin) is more likely to come down in front of the baby (cord prolapse).
- The placenta of the second twin may start coming off the wall of the uterus after the first twin is born. This can cause bleeding.
- The mother is more likely to bleed heavily after the birth for 2 reasons: (1) Her uterus gets over-stretched, and (2) the place where the placentas were attached to the uterus is very large. This will cause a large open wound after the placentas separate.
- If the second twin is not born soon, the uterus may get infected. The second twin may also be infected.
- One or both twins are more likely to be in a difficult or impossible to deliver position. Or the twins may get in each other's way, becoming "locked", and making it impossible for them to be born.
For these reasons, twins are recommended to be born in a hospital. If the journey is very difficult or will occur before arriving at the hospital, feel (palpate) the mother's tummy to determine the position of the babies. This will help you to know how many problems to expect at the birth.
1. The midwife should get extra help as quickly as possible. Having a second skilled midwife at the birth is optimal. If the baby is breech, avoid a rapid breech delivery. Allow time for the cervix to completely dilate 10+ cm before permitting the baby's body to be born. Check for prolapse of cord for the presenting first baby if the amniotic bag has broken. Deliver the first baby as you would any single baby.
2. The midwife should double clamp or tightly tie off and cut cord between the clamps immediately following birth of baby #1, paying special attention to the length of cord coming out of the mother. This is to prevent the second twin of a monozygotic pregnancy from partially exsanguinating through the first cord (twin babies sometimes share the same placenta, and the second baby could bleed through the cord of the first baby). This should be done with the cord as far outside the vagina as possible. The cord can then hang loose to permit vaginal examination or manipulation. This also eliminates inadvertent cord traction on the placenta.
3. The first baby should be "identified" as baby #1 with a label, bracelet, skin marking or anything else that will not accidentally fall off or be removed right away. The umbilical cord for baby #1 should also be labeled.
4. The midwife should perform a vaginal exam immediately after the birth of the first infant to ascertain the presentation of the second amniotic sac, baby and the possibility of a cord prolapse or entanglement. The midwife should determine the fetal position of the 2nd baby. If the second baby is in a transverse presentation, the midwife should do an external version and a slow, gentle delivery when the cervix is fully dilated again. A vertex presentation is preferred. Again, she should prepare to deliver a breech, if necessary.
5. The midwife should be monitoring the fetal heart tones (FHT) regularly and as necessary.
6. The midwife and client should be prepared to transport for 2nd birth, if necessary.
7. The midwife should be prepared for maternal hemorrhage and take necessary preventive and corrective actions. Do not give any oxytocic tinctures or medications to the client until after the birth of the second twin. If this is done before the birth of the second twin, reduction of the utero-placental circulation will jeopardize the second twin.
8. The second baby should be born within 15 to 20 minutes. Deliver it as you would any other baby. If the mother does not start to have contractions within 15 minutes of the birth of the first twin, you may consider trying to get the labor going again by letting the first baby breastfeed. You can also use nipple stimulation. If the baby is head down or breech, try breaking the amniotic bag with a sterile hemostat or clamp. But do not break the bag if the second baby is sideways.
If you wait longer than 15 minutes, the placenta may start coming off the wall of the uterus, the cervix may start to close or, if you wait a few hours, the second baby and the uterus may develop an infection.
Again, if these methods do not work, seek medical help as soon as possible. Again, do not give any oxytocic injections or medications to get labor started again.
THE SECOND BABY SIDEWAYS
If possible, transport to the hospital. If at all possible, a sideways (transverse) baby should be born by cesarean section in the hospital. If it is too far away, try to find a skilled midwife to assist you in turning the baby. You will have to make a decision whether to turn the baby head down (vertex) or bottom down (breech). This will depend on how easily the baby moves into one position or the other. If you are alone, try the following:
1. Try to turn the baby's head down by massaging the mothers tummy. Some sideways babies will turn easily, with just a gentle push. This is especially true if the mother has had other babies. It is always best if a skilled person does this. If there is any resistance... Stop immediately. Do not force it.
2. If you cannot move the baby to a head down position, massage the belly and try to move it to the breech position.
3. If you cannot move the baby to either of these positions, the baby must be born in the hospital! Caution: Pushing on the uterus will tear it. Only turn the baby if it goes easily.
THE MOTHER BLEEDS BEFORE THE SECOND BABY IS BORN
(Or the first placenta is born before the second twin)
Bleeding after the birth of one twin and before the second means that there may be early separation of the placenta. The mother and the second baby may bleed heavily. Get the second baby out as fast as you can. Caution: If you put your hand inside the mother to help with the birth, or if she bleeds a lot, the mother is in great danger of infection. Use sterile technique if you must put your hand inside the mother for any reason. Antibiotics will need to be given after the birth.
TWINS & MULTIPLE PREGNANCIES LINKS
MoonDragon's ObGyn Pregnancy Information: Twins & Multiple Pregnancies
MOONDRAGON'S BREECH LINKS
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