Twin birth

 

Emergency — rare in remote context but may happen if woman hasn't had antenatal care or can't get to hospital in time

Complications include

  • Preterm labour
  • Breech presentation (one or both babies not coming head first)
  • Cord prolapse (cord comes before either baby)
  • Foetal distress, especially of second baby
  • Postpartum haemorrhage (woman bleeds heavily after birth )
  • If not known to be twin pregnancy and oxytocin is given after first twin is born the cervix may close before the second twin is born

Do first

  • Call for help — get midwife/doctor/obstetrician on speaker phone, if none locally
  • Find support people — if possible female ATSIHP or older women familiar with birthing
  • Reassure woman and explain what is happening. Have someone stay with her for support
  • Get ready to send to hospital
  • Do first check in labour — see Labour and birth

Ask helper to get equipment

  • 1–2 people to look after each baby
  • 2 sets of birth and resuscitation equipment
  • 2 oxygen sources
  • 2 suction attachments
  • 2 sets of 2 cord clamps labelled 'Baby 1 and Surname' and 'Baby 2 and Surname'
  • 2 sets of 2 name bands, labelled 'Baby 1 and Surname' and 'Baby 2 and Surname'
  • Oxytocin IM — 10 international units single dose
  • Oxytocin infusion — 40 international units in 1L normal saline, infusion pump if available — Do not start oxytocin until after second baby born and placenta/s delivered

If in early stages of labour

  • Medical consult about stopping labour
  • Make sure woman has emptied her bladder
  • If membranes rupture — check for cord prolapse​
    • If cord seen at vulva or felt just inside vagina — see Cord prolapse straight away

If labour continues

  • Follow Labour and birth AND
    • Put in second IV cannula — largest possible
    • Give normal saline at 125mL/hr
    • Do not let woman eat or drink anything — may need operation

The birth

Birth of first baby
  • If baby coming head first — see Birthing baby
  • If baby is coming bottom or foot first — see Breech birth THEN continue with this protocol
  • Do not give oxytocin until after second baby born
  • Do not deliver placenta/s until after second baby born
  • Clamp and cut cord
    • Some cultures like a long cord left on baby. Ask mother or support person
    • Clamp cord on first twin within 1 minute — risk of losing blood to other twin if only 1 placenta (monochorionic)
    • Put 2 metal clamps ('Baby 1') on cord 5cm apart, at least 10cm from baby’s abdomen — Figure 1.50
    • Cut cord between the 2 clamps with sterile blunt-end scissors
    • Do not take clamps off after cutting

Figure 1.50   

Check — after birth of first baby

  • Woman’s pulse ​and BP
  • Vaginal blood loss ​
  • Colour of liquor ​
  • Try to work out position of second baby by palpating uterus, if skilled — head or bottom first
  • Feel for contractions ​— often stop for up to 5 minutes after first birth

Do

Midwife/obstetrician consult about

  • Findings and further management
  • IV fluids
  • Whether to do vaginal exam, if skilled

Urgent medical/obstetrician consult if

  • Woman bleeding heavily

If no contractions ​after 5 minutes

  • Check vaginal blood loss at least every 5 minutes
  • Keep woman on her left side, reassure her and keep her comfortable
  • If vaginal blood loss ​small — wait for evacuation to hospital
  • Consider asking mother to breastfeed Baby 1 to stimulate contractions​

If labour ​continues

  • If baby coming head first — see Birthing baby
  • If baby coming bottom or foot first — see Breech birth
  • If another part of baby felt — urgent medical consult
  • If membranes rupture check for cord prolapse —​
    • If cord seen at vulva or felt just inside vagina — put/keep fingers in vagina and push baby away from cord — see Cord prolapse straight away

After birth of second baby
  • Clamp and cut cord 
    • Cut the same length as for first twin
    • Wait at least 1 minute and until cord stops pulsating if possible
    • Put 2 metal clamps ('Baby 2') on cord 5cm apart, at least 10cm from baby’s abdomen — Figure 2.44
    • Cut cord between the 2 clamps with sterile blunt-end scissors
    • Do not take clamps off after cutting
  • Dry and wrap baby and give to helper to assess,  resuscitate, keep warm as needed — see Labour and birth Immediate care of baby and follow rest of care for baby
  • Check there isn’t a third baby
  • If no more babies — give oxytocin IM — 10 international units single dose in thigh
  • Deliver placenta or if 2 placentas deliver both together
  • After placenta/s delivered start oxytocin infusion — 40 international units in 1L normal saline at 250mL/hr
    • If no infusion pump — monitor carefully
    • Medical consult about how long to continue
  • Collect cord blood from both cords and label 'Baby 1 and Surname' and 'Baby 2 and Surname'
  • While waiting for evacuation — see Newborn care and Care of mother — first 24 hours after birth