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CLINICAL STUDY OF LABOUR IN TWIN PREGNANCY

OBJECTIVES: The objective of the present study is to analyse the incidence of preterm labour, intrapartum complications, incidence of operative delivery both vaginal and cesarean and indications for such interventions. METHODOLOGY: A total of 150 cases of twin pregnancy were analyzed between the period of September 2012 to February 2014. These cases were studied with respect to period of gestation at the onset of labour, fetal presentations at the onset of labour, route and mode of delivery, indications in cases of cesarean delivery, intrapartum complications and delivery interval between twins. OBSERVATIONS AND RESULTS: In the present study there was increased incidence of preterm labour (52.6%), fetal malpresentations (43.3%), operative vaginal delivery (29.5%), cesarean delivery (17.3%). CONCLUSION: In this study it is observed that above mentioned labour events and complications double up in the event of a twin pregnancy. Regular antenatal visits, planned delivery and anticipation and identification of complications will help for better pregnancy outcome.


INTRODUCTION:
Twin pregnancy is the simultaneous development of two embryos in the uterus at the same time. The incidence of twins is on rise as a result of increasing use of ovulation induction and assisted reproductive technology. Twin pregnancy is associated with greater maternal and fetal complications than singleton pregnancy. 1 The incidence of preterm delivery is comparatively high in twins than singleton pregnancy. As compared to vaginal singleton birth, there is an increased likelihood of operative delivery for one or both twins, with the associated maternal risks of trauma, infection and haemorrhage. 2 Twins are more frequently delivered by cesarean section than singletons, either as an elective procedure or as an emergency before or after the delivery of first twin. 3 This study intends to know the period of gestation at the onset of labour and incidence of vaginal delivery, operative vaginal delivery, cesarean section rate and indications for cesarean delivery in twin pregnancy and management of labour. When the pregnant lady went into labour, the duration of gestation was recorded. At the onset of labour, detailed per vaginal examination was done to note the cervical dilatation, presentation, position, the level of the presenting part and the type of the pelvis. Complications during labour such as hand prolapse, cord prolapse, postpartum hemorrhage etc. were noted. Necessary precautions were taken to prevent complications during labour. Labour was accelerated by oxytocin whenever indicated. In cases where there was contraindication for vaginal delivery, they were taken up for cesarean section. Careful intrapartum monitoring was done. Third stage of labour was managed carefully. Mother and babies were followed till discharge.

RESULTS:
The following data was obtained from the present study.
The incidence of twin pregnancy is about 1.4%. Among the total 150 cases, 34.2% were booked rest were unbooked cases.
From table no 1 it can be seen that 79(52.6%) had delivered before 37 completed weeks.
In the present series 85(56.7%) cases presented by vertex -vertex and rest had malpresentations. one case of fetus papyraceus and one case of acardiac twin constitute missing cases as shown in table no 2.
In present study 122(81.3%) cases had vaginal delivery, 26(17.3%) had cesarean delivery where as in 2(1.4%) cases first baby delivered by vaginal route and second baby by cesarean delivery.
As shown in table no 3, in the present series in 124(82.7%) cases first twin delivered vaginally, among which 11(7.3%) were instrumental deliveries.
Vaginal delivery rate for second twin was 81.3% (122 cases) and instrumental delivery rate was 18% (27 cases).
All assisted and operative deliveries were more common in twin deliveries especially so for the second twin.
In the present study cesarean section rate in the present series is 17.3% and cesarean section rate for only second fetus was 18.7%. Here cesarean section was done for second fetus because of failed internal podalic version in 2 cases. Indications for cesarean delivery are shown in table no 4.
In 126(84%) cases second twin was delivered within 15 minutes of delivery of the first twin. In 18(12%) cases the delivery interval between I and II twins was 16-30 min; 4(2.7%) cases between 30-60 min and 2(1.3%) cases it was more than one hour, both resulting in fetal loss.

DISCUSSION:
Incidence of preterm labour in present study is 52.6%. Incidence is slightly higher compared to other studies as shown in table no 6. Main reason might be due to the high number of unbooked cases referred to us, ours being a tertiary care Centre. In the present series, out of 79 cases of preterm delivery 65(89.3%) were unbooked cases and 6(10.7%) were booked cases.
In table no 7 the incidence of various combinations of presentations in this study is compared with those of other authors.
The results of study of route of delivery are comparable with that of Farouqui et al. (8) series and Shola Purkar (9) series as shown in table no. 8.
As shown in table no 9, regarding mode of delivery the results of the present series are comparable with that of Pandole A (4) series.
All assisted and operative deliveries were more common for the second twin. The only exception was assisted breech delivery which was more common in the first twin (15.3%) compared to the second twin (13.3%).
The delivery interval between two twins is compared with other studies in table no. 10. In the present series in majority of cases (84%) delivery interval was less than 15 minutes. Out of 150 cases, one patient had come with history of having delivered the first baby at home. The interval between the delivery of the first and second baby was 480 minutes.
The incidence of postpartum hemorrhage is 5.3% which is lower than other studies. The reduced incidence of PPH is due to the prophylactic measures taken in anticipation, especially prophylactic methergine given during the delivery of anterior shoulder of second twin.

CONCLUSION:
In this study it is observed that above mentioned labour events and complications double up in the event of a twin pregnancy. Regular antenatal visits, planned delivery and anticipation and identification of complications will help for better pregnancy outcome.