Classification of twin pregnancy:

1. Dizygotic/fraternal/binovulartwins (80%): Result from fertilization of two ovum. 
2. Monozygotic/indentical/uniovular twins (20% ) : Result from fertilization of a single ovum.

Diagnose a case of twin pregnancy

History:

• History of ovulation inducing drug
• Family history of twin pregnancy.

Symptoms of twin pregnancy :

• Increased nausea and vomiting
• Palpitation, shortness of breath
• Tendency of swelling of legs, varicose veins andhaemorroids. 
• Unusual rate of abdominal enlargement.

Signs of twin pregnancy:

a) General examination:

1. Anaemia is more than single pregnancy. 
2. Unusual weight gain.
3. Evidence of pre-eclampsia.

b) Abdominal examination: 

  Inspection :  nusual enlargement of the abdomen with tense and shiny

  Palpation:

Height of uterus is more than the period of amenorthoca.

Girth of abdomen at the level of umbilicus.

Palpation of too many fetal parts.

Finding two fetal heads or three fetal poles make the clinical diagnosis almost certain 

  Auscultation: Simultaneous hearing of two distinct fetal heart sound.

Vaginal examination: In some cases one head is felt deep in the pelvis, while other is located by abdominal examination Reference DC Dutta edition, page 201-210.

Management of twin pregnancy during labour:

1st stage:

1. A skilled obstetrician should be present.
2. A neonatologist should be present at the time of delivery
3. Patient should be in the bed to prevent at the time of delivery.
4. Careful fetal monitoring
5. Per vaginal examination should be done after rupture of the membranes.
6.  Opening of an IV channel with Hartman’s solution
7. One unit of compatible and cross-matched blood should be made readily available.

2 stages:

Delivery of the 1″ baby:

1. As the baby is usually small, the delivery does not usually pose any problem.
2.  Episiotomy sometimes needed.
3. Should not given I/V Ergometrine with the delivery of the anterior shoulder.
4. Clamping of the cord at two places & cut in between 5. At least 8-10cm of cord is left behind for administration of any drug or transfusion, if required.
5. The baby is handed over the nurse after labeling it as number 1. 

3rd stage:

1. The risk of PPH can be minimized by routine use of 0.2 mg delivery of the anterior shoulder of the 2 baby.Ergometrine I/V with the delivery of the anterior shoulder of the 2nd baby.
2. The placenta should be delivered by controlled cord traction
3. It is a sound practice to continue the oxytocin drip for at least one hour.
4. Careful monitoring for at least one hour.

Complications of twin pregnancy:

Maternal complications:

A. During pregnancy:

1.  Nausea and vomiting
2. Anaemia
3. Pre eclampsia
4. Polyhydramnios
5. APH ( Antepartum haemorrhage).
6. Malpresentation.
7. Preterm labour.
8. Increased mechanical distress.

B. During labour : 

1. Early rupture of membrane.

2. Cord prolapse.

3. Prolonged labour

4. Increased operative interference 

5. Postpartum haemorrhage.

Fetal complications:

1. Abortion.

2. Intrauterine death. 3. Congenital malformation.

4. Asphyxia and still birth.