Multiple pregnancies present numerous healthcare and medical risks to the mother and the babies. Multiple births occur following multiple pregnancies. Multiple pregnancies occur when more than one ova is fertilized (Murray et al., 2018). It can also occur when a fertilized egg splits into two or more embryos. The aim of the task is to conduct a literature review on the safe delivery of multiple births. The literature review will focus on various areas. Firstly, statistics of multiple births and pregnancies will be highlighted. Secondly, existing evidence-based literature will elaborate on the association between multiple births and certain complications. Thirdly, research articles will be used to explore the safest mode of delivery in multiple births. The analysis will involve cesarean section, assisted deliveries, and vaginal delivery. Fourthly the literature will highlight complications related to multiple pregnancies post-delivery and how to prevent them. Finally, evidence-based articles will be used to assess interventions or factors that can ensure the safe delivery of high-order pregnancies.
Multiple Births And Pregnancy
Multiple births refer to the delivery of more than one baby. Statistics indicate that the most common type of multiple births in twin deliveries. Cases of octuplets, sextuplets, septuplets, quintuplets, quadruplets and triplets have been widely reported across the globe (Dias et al., 2019). According to statistics, multiple pregnancies make up to three in every a hundred births (CDC, 2019). However, current statistics indicate that the rate of multiple births is rising. In the United States, 120291 twin births were made in 2019. In the same year, the number of triplet births recorded was 3136. The number of Quadruplets and other high order deliveries was 150. The twin birth rate was around 32.1 in every a thousand live births. Similarly, the birth rate for triplets and other high order births was 87.7 per 100,000 live births.
Various factors are linked to multiple pregnancies. The factors can be natural or artificial (Mariet et al., 2018). It is believed that multiple pregnancies may be running in the family. Genetics plays a crucial role in multiple pregnancies. It is believed that having identical twins is not genetic. However, fraternal twins can run in the family. Studies indicate that a woman who has a fraternal twin sibling is up to three times more likely to have twins (Tsakiridis et al., 2020). A history of multiple pregnancies in previous pregnancies can also predispose one to have multiple pregnancies. Other natural factors linked to multiple pregnancies include old age and race. Artificial factors such as reproductive technologies have increased the number of multiple births over the past years. The technologies include assisted reproductive technologies and hormonal replacement therapies (Lei et al., 2019). The methods that help other couples to get pregnant such as invitro-fertilization, have been linked with the high number of multiple pregnancies in the United States. Similarly, hormonal replacement therapy, such as ovulation stimulating drugs like clomiphene citrate and follicle-stimulating hormones, can increase the number of eggs produced. The fertilization of the eggs can result in multiple babies.
Causes Of Multiple Births
Multiple pregnancies can happen in various ways. Firstly it can occur if more than one ovum is fertilized and implants in the uterus (Mackie et al., 2019). This phenomenon is known as fraternal twinning. It results in a girl or boy or a combination of both. Fraternal twins are simply babies conceived at the same time. The twins will have a separate placenta and amniotic sac.
In some cases, one egg can be fertilized then split into two embryos (Hawkins et al., 2020). This results in identical twins. The sex of these twins is normally similar. They are either all boys or girls. These babies normally share a placenta and have separate sacs. High order multiples and twins can be a combination of fraternal and identical twins.
Complication Of Multiple Births And Management
Preterm Labour And Birth
Healthcare practitioners should understand the various complications of multiple births and their management. Multiple births come with numerous complications that can increase the mortality and morbidity in the mother and the baby or fetus. Multiple pregnancies have an increased risk of complications. The first complication is preterm labor and preterm birth. Preterm labor occurs when there is an onset of regular contractions before week 37 of pregnancy (Suff et al., 2019). When not managed effectively, it can lead to preterm birth. The births result in the delivery of preterm babies. The earlier the preterm delivery, the higher the risks for certain neonatal complications. Preterm delivery poses numerous health risks to the mother and the baby (Medley et al., 2018). The risks that can occur to the baby include low birth weight, underdeveloped organs, vision problems, and poor vision. The children often have a higher risk of developing behavioral problems, learning disabilities, and cerebral palsy.
Various studies have indicated the association of preterm delivery and birth with multiple pregnancies. Mulualem et al. (2019) conducted a systemic review and a meta-analysis to evaluate the effect of multiple pregnancies and pregnancy-induced hypertension on preterm births in healthcare settings in Ethiopia. The analysis collected statistics on the prevalence of preterm births and the effect multiple pregnancies play. The articles selected included case-control studies, cross-sectional studies, and cohort studies. The articles that showed the association between preterm births and multiple pregnancies and pregnancy-induced hypertension were selected. Most of the studies selected were conducted in Ethiopia’s healthcare and community settings. The articles were located from reputable electronic databases. These databases included Google Scholar, web of science, EMBASE, and PubMed. The following key terms were used to locate the articles: preeclampsia, hypertension, multiple pregnancy, pregnancy-induced hypertension, multiple pregnancy, twin pregnancy, predictors, prevalence, indicators, preterm delivery, preterm birth, low gestational age, and preterm. The data collected was organized into percentages. The findings indicated that preterm birth is one of the major problems in Ethiopia. The determinants factors of preterm birth included multiple pregnancies and pregnancy-induced hypertension. Therefore mothers with multiple pregnancies should be managed effectively to minimize the complications of preterm labor and delivery.
Wagura et al. (2018) conducted a similar study to investigate the prevalence and factors associated with preterm deliveries in a national hospital in a developing country. The study aimed to determine the prevalence of preterm birth and the factors associated with preterm delivery in Kenya. The study was a cross-sectional descriptive study. A total of 322 mothers were selected for the study. The results indicated the prevalence of preterm delivery was around eighteen percent. From the study, preterm birth was related to parity, multiple pregnancies, pregnancy-induced hypertension, urinary tract infections, and prolonged premature rupture of membranes. Like other studies, the research article confirmed that preterm labor and delivery are associated with multiple pregnancies.
Healthcare practitioners can provide certain health education and interventions to prevent preterm delivery in mothers with multiple pregnancies. The first intervention is to advise them to seek regular prenatal care. Prenatal visits enable the identification of various risk factors and precursors to preterm labor (Medley et al., 2018). The healthcare providers can also assess the health status of the mother and the baby. Secondly, the mothers need to be advised to eat a healthy diet. Good pregnancy outcomes in multiple pregnancies are associated with good nutrition. Various studies also indicate that a diet high in polyunsaturated fatty acids is associated with a reduced risk of preterm labor. Thirdly, the mothers are advised to avoid smoking, alcohol, and taking other harmful substances. Drugs and other substances can affect the health and the wellbeing of the developing baby. Additionally, they can trigger preterm labor. Other interventions that can reduce preterm delivery include managing co-existing conditions such as diabetes, hypertension, and heart conditions, being cautious when using assistive reproductive technology, and considering pregnancy spacing. Healthcare providers can also do a cervical cerclage. It is a procedure that involves inserting synthetic tape or sutures to reinforce the cervix in pregnancy, especially in women with a shorter cervix. The procedure will reduce premature deliveries in women with incompetent or shorter cervical os.
The other complication of multiple pregnancies is anemia. Statistics indicate that anemia is highly common in mothers with multiple pregnancies compared to those with single pregnancies. Iron deficiency anemia is very common in pregnancies. Statistics indicate that it affects around eighteen percent of all women during the three trimesters. In twin and other high order pregnancies, the maternal iron demand increases due to the greater expansion of plasma volume and maternal red blood cells. The increased fatal and placental requirement further increases the demand. Studies indicate that the maternal hemoglobin in twin pregnancies is lower in the entire trimesters than singleton gestations.
Management of iron deficiency anemia in multiple pregnancies involves supplementation of iron beyond a typical prenatal vitamin. Experts recommend that healthcare providers should double the multivitamins provided to mothers during pregnancy containing thirty milligrams of elemental iron during the third and second trimesters in twin pregnancies (Govindappagari et al., 2019). Proper nutrition is crucial in preventing iron-deficiency anemia. The mothers can be educated to increase their dietary intake of more animal foods with high iron levels, such as dairy products, meat, and eggs.
Birth defects are critical, common, and costly conditions that affect one in every thirty-three babies born in the United States. This relates to nearly one hundred and twenty thousand babies (Mai et al., 2019). They are structural changes noted at birth affecting any part or parts of the body. They may affect how the body works, looks, or both. Birth defects can be mild or severe depending on the part of the body affected. Common birth defects include cleft palate or lip, heart defects, neural tube defects, and abnormal limbs (Beames et al., 2020). The birth defects often lead to various functional or structural limitations, including brain or nervous system problems, sensory problems, metabolic disorders, and degenerative disorders. Studies indicate that the risks of congenital malformations or birth defects are increased in multiple pregnancies.
Primary prevention is key in reducing the causes of birth defects in multiple pregnancies. Various approaches can be implemented to reduce the incidences of congenital malformations in twin or high-order pregnancies (Botto et al., 2018). Firstly the mothers should start prenatal care as soon as possible. This allows for the monitoring and administering of various supplements to reduce birth defects. In prenatal care and counseling, the mother can be educated on lifestyle changes that could reduce the risks of birth defects in their babies. Secondly, the mothers should take folic acid supplementation. This reduces the development of neural tube defects. Thirdly, the mothers should be advised on alcohol and substance use cessation. Fourthly they should discuss the medications they are taking when pregnant. Certain medications can result in the development of birth defects. Other preventive approaches include preventing infections during pregnancy, identifying and treating fever, and managing co-existing medical conditions.
Miscarriage is the unplanned or spontaneous expulsion of fetuses from the womb before it is fully developed and can survive independently postuterine. In multiple pregnancies, it is often referred to as the vanishing twin syndrome. Studies indicate that the spontaneous loss of one fetus occurs in around twenty percent of twin pregnancies. The spontaneous loss increases in higher quadruplets or triplet pregnancies. Findings indicate that a fetus is lost within the first trimester at the rate of forty percent in triplets and other high order pregnancies. When a fetus is lost during the first pregnancy, the other fetuses continue to grow normally. However, it may result in vaginal bleeding. The risk of pregnancy loss following the loss of a fetus in the first trimester is increased.
Healthcare providers can provide various interventions and health education to prevent miscarriages in multiple pregnancies and ensure safe multiple births. Some factors causing miscarriages are unavoidable. These factors include fatal developmental problems and chromosomal abnormalities (Colley et al., 2019). Women with multiple pregnancies can reduce the risk of miscarriages. Firstly women can take folic acid supplementation. Studies recommend the administration of 400 mcg of folic acid daily to reduce the risk of congenital malformations that can result in miscarriages. Secondly, the individuals are required to follow a healthy lifestyle. They can do this by avoiding smoking, secondhand smoke, alcohol use, and drug use. Additionally, the mothers can engage in regular exercises, get adequate sleep, and eat a healthy and well-balanced diet.
Thirdly, the mothers can maintain a healthy weight. Studies indicate that being obese, overweight, and underweight predisposes the risks of complications in the antepartum period (Magnus et al., 2019). Fourthly, mothers can take precautions against infections, including urinary tract infections. The women should protect themselves against common infections such as pneumonia and flu, which spread easily. Women can ensure their immunization status is up to date. This includes having a flu shot. The fifth approach is the management of chronic conditions such as hypertension, diabetes, and other autoimmune disorders. Certain medical conditions such as high blood pressure have been associated with the high incidence of miscarriages. These conditions should be managed effectively to minimize the risk. Women should control their blood sugar and blood pressure during pregnancy. Finally, women should practice safe sex. Safe sex reduces the risks of getting certain sexually transmitted infections such as gonorrhea and syphilis. Studies indicate that gonorrhea and syphilis can cause miscarriages. The safe sex approaches include using barrier methods during sexual encounters, both oral and anal.
Twin to twin transfusion syndrome
Twin to twin transfusion syndrome is a rare syndrome that may affect identical twins or other multiples. The syndrome occurs when twins share one placenta and a network of blood vessels that supply oxygen molecules and nutrients essential for fetal uterine development (Bamberg et al., 2019). It occurs in monochorionic pregnancies. In some cases, the disorder occurs due to uneven distribution of blood vessels connections to the fetuses. This may lead to an imbalance in the fetuses’ blood exchange and nutrient supply. One twin may give away more blood than it receives to the other twins leading to malnourishment and organ failure. The recipient twin may receive too much blood and nutrients which may cause heart and other cardiac complications. The donor twin experiences hypovolemia or progressive blood loss. As a result, its kidneys do not filter more fluid from the blood, reducing urination. This may affect the development of the kidney and the urinary system. It can result in reduced levels of amniotic fluid. Low amniotic fluid levels may diminish its ability to cushion the womb. In conclusion, the donor is placed at risk for death due to multiple organ failure and underdevelopment.
On the other hand, the recipient twin is at risk of hypervolemia. Hypervolemia will result in increased urination, production of a high amount of urine, and more bladder filling. The resultant condition is polyhydramnios (Bamberg et al., 2019). This is the abnormal increase in the volume of amniotic fluid. The persistent state of hypervolemia affects the functioning of the cardiac muscles. This can often result in cardiovascular dysfunction, heart failure, and death. Healthcare practitioners need to assess the severity of the syndrome to help in its management. A Quintero staging system can be utilized to assess the severity. This will indicate the disease severity and the potential for worsening the condition. The result of the staging can be used to make crucial decisions on whether to terminate the pregnancies. When one twin is severely affected, the pregnancy can be terminated to allow the other twin to reach term.
The other complications of multiple pregnancies include an abnormal amount of amniotic fluid, postpartum hemorrhage, pregnancy-induced hypertension, and diabetes. The woman may also require a cesarean section (Santana et al., 2018). Polyhydramnios is common in multiple pregnancies, especially in twins sharing one placenta. Polyhydramnios can increase the heart’s workload and even result in cardiovascular and other heart complications. Amniocentesis can reduce the excessive volume of amniotic fluid in the womb. Postpartum hemorrhage is common in multiple pregnancies. Several maternal and peripartum factors are associated with postpartum hemorrhage in twin pregnancies. Multiple pregnancies result in an overdistended uterus, putting the mother at risk for bleeding following delivery. Cesarean delivery is common in multiple pregnancies. This may be due to the malpresentation, making vaginal delivery impossible. Finally, diabetes has been associated with a sudden rise in blood pressure. This is due to increased blood volume to meet the demands of the growing placenta. Pregnancy-induced hypertension may result in preterm deliveries and other complications. Healthcare providers need to manage pregnancy-induced hypertension to increase the chances of safe delivery in multiple births.
Conclusions and Recommendations
Safe delivery in multiple births should be a priority of healthcare providers around the globe. Healthcare providers need to understand the risk factors of multiple deliveries. The risk factors of multiple deliveries include the use of assistive reproductive technologies, high parity, family history of fraternal twins, race, and age. Healthcare providers should educate patients on various risk factors and reduce their chances of having multiple pregnancies. Multiple pregnancies come with numerous healthcare complications responsible for the high morbidity and mortality rate among mothers and babies. The complications associated with multiple pregnancies include preterm labor and delivery, postpartum hemorrhage, cesarean delivery, abnormal amounts of amniotic fluid, twin to twin transfusion syndrome, miscarriage, pregnancy-induced hypertension, gestational diabetes, birth defects, ad anemia. Healthcare workers should diagnose and manage these common complications to ensure good healthcare outcomes for the mother and the babies.
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