a. Description.

(1) Multiple pregnancy is the presence of two or more fetuses in the uterus at the same time.

(2) High-risk conditions may be associated with and include premature delivery, hemorrhage, hypertensive disorders, abnormal presentation and position, hydramnios (an excess of amniotic fluid), and uterine dysfunction.

(3) Uncomfortable symptoms experienced by the mother during the last trimester are the same as for the mother with a single fetus. However, the symptoms occur earlier and are more intense. The symptoms are:

(a) Heaviness of the lower abdomen.

(b) Back pains.

(c) Swelling of the feet and ankles.

(d) Difficulty in sleeping that is due to abdominal distention.

(e) Woman tires easily.

b. Labor and Delivery Process.

(1) The first stage of labor for the mother is essentially the same as for the woman with a single fetus. Effacement and dilatation occur the same if there is an adequate labor pattern.

(2) Possible complications during labor and delivery include the following.

(a) Possible prolapsed cord. Babies of multiple births tend to be smaller than single fetus and may not fill the pelvis completely. The cord may drop when the membranes rupture.

(b) Possible fetal respiratory distress that is due to analgesia. Analgesia is administered very conservatively. The infant’s size normally prevents them form metabolizing analgesia from their systems prior to birth. Withholding it avoids respiratory difficulties following delivery.

(c) Entanglement of fetuses during delivery. Presentation of all fetuses should be known prior to delivery. If the first fetus is not vertex, cesarean section is normally done. This prevents the first fetus from becoming entangled with other fetuses. More than two fetuses indicate cesarean section for control and quick access to the infants.

c. Nursing Interventions.

(1) Monitor the patient and fetuses continuously. Internal monitoring is applied to the presenting fetus. External monitoring is applied to the second fetus. Additional fetuses should be monitored at least every 15 minutes during the first stage with a Doppler and recorded. The mother’s vital signs should be checked and recorded frequently.

(2) Start intravenous infusion with at least an 18-gauge as soon as the patient presents to labor and delivery.

(3) Type and cross-match the patient for blood (at least 2 units) on admission for possible administration or as stated in the unit SOP.

(4) Notify appropriate personnel to be present for actual delivery.

(a) An anesthesiologist or anesthetist should be notified in case an emergency cesarean becomes necessary. Anesthesia may be required for the delivery of the subsequent fetuses.

(b) A physician and a nurse team should be notified for each fetus. The nurse should be skilled in resuscitative measures. The physician should be a pediatrician.

(5) Have enough equipment available to accommodate the number of fetuses to be delivered.

(6) Identify and care for each fetus immediately at delivery.

(a) The first fetus born is A or twin I.

(b) The second fetus is B or twin II. and so on.

(c) Tag the infant prior to leaving the delivery room. Do not depend on memory.

(7) Keep the mother informed of each infant’s status.

(a) Identify the sex of the infant.

(b) Allow the mother to see the infant prior to being transferred from the delivery room if at all possible.

(8) Administer Pitocin® as soon as all placentas are delivered and upon physician’s order. Massage the fundus to stimulate contractility. Excessive blood loss is common with multiple pregnancy during the third stage of labor.