MULTIPLE BLESSINGS

The birth of a baby is an exhilarating experience. The birth of more than one baby at once is positively electrifying!

Karen* was my first ever multiple birth experience. She waddled into the labour ward at about one o’clock in the morning declaring she was in labour. She was infectiously cheerful for someone in pain. She had been attending out antenatal clinic and she was very well prepared for delivery. This was a great learning experience for me as a young intern doctor in the labour ward.

As the nurse settled Nancy in bed, I prepared to review her even as we waited for her file to arrive from the record department. Karen was a breath of fresh air. At that hour of the morning, she was very bubbly. She informed me of all the key things I needed to know in one sentence. She knew she was carrying twins who’s due date was in two days’ time, and that they were both positioned head first and so she was scheduled for a normal delivery.

It was refreshing to meet a patient who was so involved in her care and privy to all her relevant medical information. She noted that she had been woken up about an hour before by what felt like labour pains but noted that despite the short duration, her contractions were quite regular and only about three minutes apart.

As I started to jot all this down, she had a contraction that interrupted the conversation. It was a big one that got me concerned. I suspended taking the medical history to examine her first. My decision was well informed because her babies were ready to come there and then. The race to wheel her bed to the delivery suit was by all means hilarious. I was shouting to the midwife to bring the delivery tray while everyone scattered out of our way.

We did make it to the delivery suite but certainly not onto the delivery couch. The babies were well on their way. The first twin arrived without much effort. Mummy needed no encouragement. She gave a single push and the little fellow came out yelling lustily as he took his first breath. I never even got a chance to wear the sterile delivery gown.

Barely had we cut the umbilical cord and settled him in the resursitare (the receiving bed for newborns) that his brother quickly made his entry into the world. He was equally loud and assertive. The two came out minutes apart, identical in every way except for their birth weights. At 3700g and 3900g, they were really big for a twin pregnancy. Karen was ecstatic.

Worldwide, monozygotic (identical) twins occur at a rate of 4 per 1000 birth. They result from fertilization of one egg by one ovum. Once the fertilized egg starts to divide into many cells that form the eventual baby, somewhere along the way they cleave into two separate entities, each independently developing into a baby. The babies are same gender and will look very much alike.

Fraternal (non-identical, dizygotic) twins on the other hand result from two separate eggs that are fertilized at the same time and develop into two separate babies who are not identical and may even be different sexes. The incidence rate varies for these twins, and is dependent on age of mother, race and interventions such as assisted fertility. The rate is about 10-40 per 1000 births in blacks, 7-10 per 1000 births in whites, and approximately 3 per 1000 births in Asians. It is also more common in the older women.

The excitement of the double blessings is not without its downside. Multiple pregnancies, twins, triplets and other high order births come with increased complications. There is associated higher rate of neonatal morbidity and mortality, risk of preterm delivery, low birth weight, congenital abnormalities and other high-risk morbidities. Maternal morbidity and mortality are also increased with complications such as anemia, pre-eclampsia and post-partum hemorrhage.

With each extra baby in the womb, the pregnancy duration is reduced by approximately two weeks. Therefore, the higher the number of multiples, the higher the expected rate of prematurity and resultant low birth weight.

The large placenta to cater for the multiple babies increases the risk of the mother developing pregnancy-induced hypertension, pre-eclampsia and eclampsia. This sets in earlier in the pregnancy, increasing the need to deliver earlier, hence setting up the vicious cycle of prematurity.

The excessive stretch on the uterus makes it difficult to contract after the babies come out, hence allowing for heavy bleeding that could be life threatening. Mothers delivering twins are marked from the outset as high alert for bleeding and their management is aggressively geared towards preventing postpartum hemorrhage. They are more likely to undergo a caesarian section especially because of the position of the babies in the womb.

Karen’s babies may certainly have avoided prematurity and low birth weight, much to our relief, but Karen wasn’t so lucky. Within the first hour of delivery, she got an attack of eclampsia that sent her straight to the intensive care unit for three days.

It is not always easy adjusting to motherhood and the demands a new baby brings. The demands are even more so increased in the case of multiple babies and this can be difficult for the new mother. This leads to increased risk of post-natal depression in the new mother.

Our double bundles of joy certainly serve an extra portion of happiness despite the uncertainties they come with!