The development of three or more babies in the uterus as a multiple pregnancy is treated separately from twin pregnancy because the use of the fertility drug in recent years has greatly increased the number of multiple births. Several years ago the production of quads or even triplets was worthy of a place on the front page of the newspaper. Today, however, less than five or six babies do not attract much publicity. In any case, publicity in childbirth is something which most people would rather avoid.
Why do Multiple Births occur ?
Multiple births occur for exactly the same reason as do twins. Either one egg divides into two or more at a very early stage in its development, or more than one egg is produced. When more than two babies are present both these factors can occur together. In triplets two babies may be identical, that is arising from a single ovum, and the third non-identical, arising from a completely different ovum. The non-identical baby has its own placenta whereas the identical babies share a placenta. It is possible for the three babies to be identical and to share a single placenta and for their circulations to mix as they do in identical twins.
The production of an ovum from each ovary, or the early division of the fertilized egg, seems to be an inherited factor since twinning tends to run in families. Until recently very little was known about ovulation and its mechanism; however, it is now known that the ovaries are stimulated to ovulate by follicle stimulating hormone which is produced normally by the pituitary gland. If follicle stimulating hormone is given artificially to a woman it will promote the formation of follicles within the ovaries and, however careful the doctors may be, the ovaries occasionally become hypersensitive and produce more than one follicle and more than one ovum. They may sometimes produce five, six or even more eggs, all of which may be fertilized, and hence a large number of foetuses begin to develop.
Just as twins may develop at an unequal rate, so may triplets or quadruplets develop so that they are different sizes. It is also possible for one baby, or perhaps even more than one baby, to die in the uterus while the others continue to grow normally.
Multiple pregnancy is not usually diagnosed until after the 20th week when the uterus may be noticed to be particularly large for the dates and there may be an excessive amount of movement ‘all over the place’. Nowadays it is possible to confirm the presence of a multiple pregnancy, which has been clinically suspected, either by using an ultrasound scan or, later in pregnancy, by taking a single abdominal X-ray picture. In nearly every instance the signs and symptoms all point to a twin pregnancy and there is general consternation when three or more babies are discovered. A multiple pregnancy is undoubtedly more difficult to handle than a single pregnancy. There is a greater incidence of pre-eclampsia, raised blood pressure, oedema, anaemia, excessive weight gain and, of course, premature labour, which is a hazard of every multiple pregnancy.
During a multiple pregnancy very special attention is paid to the blood count and to iron and vitamin supplements. Diet must be very carefully controlled to prevent too much gain in weight, but if quads are expected it is almost impossible to avoid an excessive weight gain unless the woman adheres very rigidly to a light diet containing protein, vegetables and fruit. Rest and relaxation are the other main factors that are of paramount importance in a multiple pregnancy. However difficult it may be, an adequate amount of rest is absolutely essential, since this is the only real way in which premature labour can be avoided.
One of the most troublesome things about a multiple pregnancy is the abdominal enlargement. The uterus and the abdomen get bigger and bigger so that not only does moving around tend to be clumsy, awkward and quite an effort, but breathing also becomes difficult. It is extremely difficult to breathe when lying down flat, so that even when she goes to sleep a woman should sit in a semi-upright position, propped up with plenty .of pillows or against a special foam-rubber backrest.
Because multiple babies tend to be premature it is essential that everything should be prepared for their arrival long before the expected date. There is an old-fashioned superstition that too much preparation should not be made, but a certain amount of work and preparation must be undertaken. This is especially important since it may be necessary to go into hospital for rest when the abdomen becomes too uncomfortable or it is difficult to manage satisfactorily at home. When a woman is feeling particularly uncomfortable towards the end of a multiple pregnancy she may also suffer from fairly severe indigestion and heartburn and will find that small, frequent meals are a great help.
The main problem with triplets and quads is to keep them in the uterus sufficiently long to enable them to grow large enough. They invariably arrive early and labour is usually easy, smooth and straightforward. Labour begins in exactly the same way as any other labour. The first baby is nearly always a head presentation. It is usually much smaller than a single baby so that the cervix does not have so far to dilate, but as the overdistended uterus will not contract as efficiently as a uterus containing only one baby, labour is usually about the same length as a singleton labour. When the first baby has been delivered, uterine contractions cease for a short time. The doctor carefiilly ascertains the position of the second baby and may manoeuvre it into the correct ppsition if it is lying obliquely or transversely. If contractions have not commenced in 10 or perhaps 20 minutes, he may very gently break the bag of water surrounding the baby so that its head can descend into the pelvis, and then with one or two expulsive contractions the next baby is delivered. The third baby follows in exactly the same way.
It is an almost invariable rule in the delivery of multiple pregnancies that an episiotomy is performed to protect the babies’ heads and not because there is insufficient room. This is done under a local anaesthetic usually just as the first baby is being delivered.
The babies are always smaller than usual but the actual size is relatively unimportant. The really important factor is maturity. For instance, a 2.2 kg. baby who is 3 7 weeks mature is much stronger and fitter and will get on much better than a 3.2 kg. baby who is only 34 weeks mature. Therefore if babies are sufficiently mature, their size is of secondary importance. The babies are resuscitated in the normal manner and nearly always put into incubators. The practice of putting all small babies into incubators is rapidly increasing.
This is because it is much easier to look after and nurse them in an incubator where their whole condition can be seen at a glance and where they are kept at the correct temperature and humidity, and not necessarily because they require oxygen or some other form of high-powered treatment.