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I’ll never forget the look on the
face of a father during a delivery, when the
midwife, instead of producing a placenta,
delivered the head of a second baby
and exclaimed, “Oh, there’s another
one!” He seemed absolutely shocked.Thirty years ago, half of twin pregnancies were not
diagnosed until the mother was in labor. Back then,
few data on the subject were available, and parent sup-
port organizations, such as the National Organization
of Mothers of Twins Clubs, Inc. (NOMOTC), were in
their infancy—if they existed at all.
Elizabeth Bryan, MD, FRCP, FRCPCH
140 AWHONN Lifelines Volume 10 Issue 2
Since the advent of routine ultrasound scanning in devel-
oped countries, the situation has changed dramatically. Many
multiple pregnancies are diagnosed in the first trimester, and
nearly all of them are identified by 20 weeks. These days, the
diagnosis may be no less of a shock for the expectant parents,
but at least they have time to prepare themselves and learn all
they can about how to care for two or more babies at the same
time. As health care providers, we can help make sure that this
extra time is used to its full advantage.
There is clearly a need. In the past, mothers had difficulty
getting information from their doctors, nurses and midwives
(Spillman, 1992), and there was a dearth of literature on the
subject. Too few maternity units catered to the special needs of
these parents. Once the babies were born, parents often didn’t
receive practical advice on the care of multiple-birth children,
such as the need for individual attention and the promotion of
language development.
Multiple Births on the RiseThroughout the developed world, there has been a steady
rise in the incidence of twin births since the early 1980s
(Imaizumi, 2003; Kiely & Kiely, 2001) (see Box 1). In the
United States, twin births have increased 65 percent from 18.9
twins per 1,000 births in 1980 to 31.1 twins per 1,000 births in
2002. Triplet births have increased from 37 triplets per 100,000
live births in 1980 to 184 per 100,000 in 2002 (Martin et al.,
2003). In the United Kingdom, the rate of twin births has
increased from 9.0 per 1,000 births in 1980 to 14.67 per 1,000
in 2003. The incidence of triplets escalated even faster through
1998, quadrupling in 15 years. The rate of triplet births has
now started to decline again. (It is important to note that in the
United Kingdom, twin births are reported by number of births,
whereas in the United States, statistics reflect the number of
twin infants and therefore appear to be double those of the
United Kingdom.) The multiple-birth rate in Canada was 2.3
percent of the 380,342 live and stillbirths that were recorded in
1995 (Health Canada, 2000).
The increase in multiple births is known to be largely due to
the widespread use of poorly monitored ovulation induction
and to multiple embryo transfer following in vitro fertilization
(IVF) (Loos, Derom, Vlietinck, & Derom, 1998). In Canada in
2002, 35 percent of IVF treatment cycles resulted in live birth of
multiples (CFAS, 2004). In the United States, 56 percent of in-
fants born as a result of IVF were multiples in 1998 (CDC,
2002). Also, to a lesser extent, the phenomenon may be due to
Elizabeth Bryan, MD, FRCP, FRCPCH, is a medical consultant to
the Multiple Births Foundation at Queen Charlotte’s and Chelsea
Hospital in West London.
DOI: 10.1111/j.1552-6356.2006.00020.x
the rise in average maternal age (Kiely & Kiely, 2001) as an in-
creasing number of women delay childbearing. Spontaneous
twinning is known to increase until the late 30s (MacGillivray,
Sampier, & Little, 1988).
In most countries, accurate data on conception are only
available for multiple births that occur following IVF or gamete
donation; those due to ovulation induction alone are not
Box 1.
Vital Statistics
• Throughout the developed world, there has been a steady rise in the incidence of twin births since the early 1980s due, in part, to the increase in the number of women undergoing IVF.
• In the United States, twin births have increased from 18.9 twins per 1,000 births in 1980 to 31.1 twins per 1,000 births in 2002. Triplet births have increased from 37 triplets per 100,000 births in 1980 to 184 per 100,000 in 2002.
• Practices and protocols for screening in multiple pregnancy still vary between individual practitioners, and uniform protocols are lacking.
• Perinatal mortality is nearly five times higher in twins and eight times higher in triplets than in singletons.
April | May 2006 AWHONN Lifelines 141
recorded. The 2003 figures from the United Kingdom’s Human
Fertilisation and Embryology Authority (HFEA) report a mul-
tiple-birth rate of 24.1 percent following IVF, of which 23.6
percent was twins and 0.5 percent was triplets (HFEA, 2005).
Most of the multiple pregnancies resulting from ovulation
induction and multiembryo transfer are multizygotic (MZ); it
is the increase in dizygotic (DZ) twinning that is largely re-
sponsible for the current upward trends in twin births.
Although DZ twinning rates vary greatly in different parts of
the world (Imaizumi, 2003), the trends are similar wherever
new infertility treatment techniques are practiced. In general,
women of African origin have the highest rates of spontaneous
DZ twins, and women of Far Eastern origin have the lowest
(Bowers, 1998); rates among East Indians and Caucasians lie
between these two extremes.
Although the majority of “iatrogenic” twins are DZ, there
appears to be a higher than expected incidence of MZ twinning
following ovulation induction with or without embryo transfer
than there is for spontaneous conceptions. Until recently, and
unlike DZ twinning, the prevalence of MZ twin births had re-
mained constant in all societies worldwide at 3.5 per 1,000
pregnancies. Since the early 1990s, there has been a small in-
crease (Imaizumi, 2003).
Although health care providers now appreciate the impor-
tance of determining the chorionicity in a multiple pregnancy,
there may be some practitioners who unwittingly misinform
parents by telling them that their twins are definitely DZ be-
cause they have a dichorionic placenta (Ooki, Yokoyama, &
Asaka, 2004). In actuality, approximately one-third of MZ
twins also have dichorionic placentae (Derom & Derom, 2005)
The Implications of a Multiple PregnancyPrenatal screening of the fetuses in a multiple pregnancy
presents special problems, and parents often receive inadequate
information about potential problems. One particular dilemma
may occur when one fetus has an anomaly and the other is
normal. Practices and protocols for screening in multiple preg-
nancy still vary among individual practitioners, and uniform
protocols are lacking (Multiple Births Foundation, 2004).
Multiple pregnancies are more likely to bring complications
such as hypertension, pre-eclampsia and anemia, as well as
general discomfort and preterm labor. Women pregnant with
multiples may also find it harder to travel to appointments.
Prenatal classes should be started earlier than for a singleton
pregnancy—at least by 20 weeks.
Multiple-birth babies may experience complications from
being born preterm and/or of low-birth-weight (Alexander &
Salihu, 2005). There is indeed the consequent risk of death or
long-term disability. They may also suffer from specific com-
plications related to monochorionic placentation, such as the
twin-twin transfusion syndrome, cord complications in mono-
amniotic twins, the damaging effect of a fetal death on the co-
twin survivor and the higher incidence of lethal malformations,
such as acardia (or the twin reversed arterial perfusion se-
quence), in which one twin fetus has no heart and is therefore
dependent for survival on the other twin’s circulation. Perinatal
mortality is nearly five times higher in twins than in singletons
and eight times higher in triplets (Macfarlane & Mogford,
2000). There is also a 3- to 7-fold higher incidence of cerebral
palsy in twins and more than 10-fold higher incidence in trip-
lets (Topp et al., 2004).
Less appreciated than these potential physical hazards are
the problems that may arise when otherwise healthy twins have
to share attention from parents and other caregivers (see Box
2). Language development is commonly delayed (Hay, Prior,
Collett, & Williams, 1987; Thorpe, Rutter, & Greenwood,
2003), and this is often associated with later difficulties with
reading (Levy, Hay, McLaughlin, Wood, & Waldman, 1996).
Behavioral and disciplinary problems are common. Depression
in mothers of twins has been noted to be more common than
in mothers of singletons (Thorpe, Golding, MacGillivray, &
Greenwood, 1991) and is often associated with fatigue and
isolation combined with behavior problems in the twins’
siblings (Hay, McIndoe, & O’Brien, 1987). All these factors
increase the risk of child abuse in multiple-birth families
(Groothuis et al., 1982).
Where one or more of the children has special needs, the
problems concerning practical care and emotional stress are
clearly greater still. These sometimes include disturbed behav-
ior in the healthy child who may be jealous of the extra atten-
tion given to the sibling with special needs (Bryan, 1999).
If one twin dies, bereaved parents may face unusual and
complex difficulties in coping with the contradictory emotions
of grieving for one baby while celebrating the life of the other,
who, furthermore, constantly reminds them of the dead child
(Lewis & Bryan, 1988).
Box 2.
Some potential developmental, behavioral and mental health issues facing multiple-birth children and their families
Delayed language development and difficulty readingBehavioral and disciplinary problemsDepression and fatigue in parentsJealousy in siblings (who may be jealous that multiple-birth children are receiving extra attention)Increased risk of child abuseIncreased complexity of grief if one twin dies and one survives
142 AWHONN Lifelines Volume 10 Issue 2
Helping Parents of MultiplesWith practical help and early intervention from professionals,
many of the potential longer term problems can be prevented
or lessened. It’s important for nurses caring for these families
to keep in mind the considerable practical, emotional and
financial stresses these families are likely to experience, all of
which are likely to be magnified in situations of higher birth
order (Botting, Macfarlane, & Price, 1990).
These issues have led to the development of a declaration of
rights and statement of needs of twins and higher order multi-
ples adopted by the Council of Multiple Birth Organizations of
the International Society for Twin Studies (Multiple Births
Canada, 2005). Supporting statements outlining key consider-
ations for care of twin pregnancies have been released by the
Association of Obstetricians and Gynecologists in the United
States (American College of Obstetricians and Gynecologists,
1999) and the Society of Obstetricians and Gynaecologists of
Canada (Barrett & Bocking, 2000a, 2000b).
The Multiple Births Foundation: A Case Study in Caring for Families of MultiplesThe Multiple Births Foundation (MBF) was established in
London in 1988 as the first organization worldwide to offer
support and resources to families of multiples and the health
care professionals who care for them. Among the resources the
MBF offered were “Twins Clinics” (Bendefy, Elliman, Prior, &
Bryan, 1994), which were run in three centers in the United
Kingdom and concentrated on problems that are caused or
increased by twinship, such as extreme rivalry, language delay,
difficulties over identity and behavior problems in older sib-
lings. The clinics also helped resolve uncertainty over zygosity.
Counselors and psychotherapists treated parents and older
twins needing psychological support. For families with more
than just twins, there were “Supertwins Clinic,” in which ex -
perienced volunteers—all parents of multiples themselves—
provided practical advice, support and reliable childcare
(Linney, Higgins, & Hallett, 1993).
The MBF also provided a telephone advisory service (Read,
Bryan, & Higgins, 1996), literature, and additional meetings in
the evenings, which focused on topics such as prenatal prepa-
ration, language, behavior, individuality and schooling. In ad-
dition to parents, grandparents and other caregivers were
encouraged to attend. The telephone advisory service provided
scheduled consultations of up to 30 minutes for both parents
and health care professionals. Many couples considering treat-
ment for infertility telephoned for information on the risks
and implications of a multiple pregnancy. Those who had al-
ready conceived sometimes wished to discuss the option of a
multifetal pregnancy reduction. Others who knew that one of
their fetuses had an anomaly wanted more information on se-
lective feticide. The Telephone Service was run by a counselor
who, when necessary, would refer cases to a pediatrician or
midwife. Much of the advice given could be supplemented by
an MBF booklet on the specific topic.
It soon became clear that one small charitable organization
could not provide sufficient support to all the families con-
cerned and that it was more appropriate for the health care
providers to give advice and support. The MBF, therefore, de-
cided to concentrate on the education of professionals. It shares
the services described as models for other professionals and
groups to follow. It also offers seminars and study days, and its
staff members lecture widely.
MBF staff have traveled worldwide to help other coun-
tries establish twin clinics and other services for families with
multiple-birth children. Many programs have now been es-
tablished on the MBF model, notably in Australia, Canada and
various European countries.
A network of midwives and community nurses in the
United Kingdom with a particular interest and expertise in
the care of multiple-birth families is being developed, includ-
ing regular seminars and free access to MBF staff and their
resources.
It has been shown that many parents do not have realistic
expectations of how the birth of twins will affect their family
(Hay et al., 1990), and many suffer weeks of unnecessary con-
fusion and anxiety. All hospitals should have a protocol and
Box 3.
Resources for Professionals and Patients
American College of Obstetricians and Gynecologists: http://www.acog.orgCenter for the Study of Multiple Birth: http://www.multiplebirth.com/index/htmlMedical University of South Carolina, Multiple Pregnancy Program: http://www.muschealth.com/women/services/multipregMultiple Births Canada: http://www.multiplebirthscanada.org/english/index.phpMultiple Births Foundation: http://www.multiplebirths.org.ukNational Organization of Mothers of Twins Clubs: http://www.nomotc.orgSunnybrook and Women’s College Health Sciences Centre, Multiple Births Pregnancy Health Centre: http://www.womenshealthmatters.ca/centres/pregnancy/multiples/index.htmlThe Triplet Connection: http://www.tripletconnection.orgTwins and Multiple Births Association (TAMBA): http://www.tamba.org.uk/html/home.htm
April | May 2006 AWHONN Lifelines 143
guidelines on the management of multiple pregnancies. Those
published by the MBF advise on the care of multiple-birth
families from before conception through adolescence (Bryan,
Denton, & Hallett, 2001).
Parent Support OrganizationsSeveral countries, including the United States, most European
countries, Japan, Australia, New Zealand, Sri Lanka, Nigeria,
South Africa, Indonesia, South Korea, Russia and India, now
have some sort of organization that provides information and
support to parents of twins and for twins themselves. While no
centralized organization similar to the MBF currently exists in
the United States, some regional tertiary medical centers have
developed specialized programs providing prenatal care and ser-
vices for multiple-birth families (Luke et al., 2003; Ruiz, Brown,
Peters, & Johnston, 2001) (see Box 3 for examples of these and
other organizations for both patients and professionals).
ConclusionsTwins and triplets can and do bring great joy to families. But
they are also at greater risk of both medical and psychosocial
complications. Before undergoing treatment that increases the
chances of a multiple pregnancy, parents should be given care-
ful counseling on the potential implications of having twins or
triplets. For those who conceive more than one baby, appropri-
ate and ongoing advice and support should be provided during
the pregnancy and throughout childhood.
Nurses in both the hospital and the community have a cru-
cial role from the start. They are vital to assessing the needs of
multiple-birth families, coordinating various services and
providing ongoing support. Although some nurses may have
limited experience with the special needs of such families,
fortunately, there are more resources than ever before for
caring with multiple-birth families.
References
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Bendefy, I., Elliman, A., Prior, S., & Bryan, E. M. (1994). Is there a role for a Twins Clinic? An evaluation of parents’ responses. Acta Paediatrica Scandinavica, 83, 40-45.
TEN YEARS AGO.. .
The recommended serial assessment for twin pregnancies is described as beginning in the second trimester and comprising ultrasound observation on a regular basis with the addition of Doppler velocimetry and nonstress testing in the third trimester. Estimated fetal weight was regarded as the best discriminator for discordant growth.
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A case report of delayed interval delivery of quadruplets reported that after the first baby was born at 26 weeks gesta-tion, ultrasound showed that the remaining three fetuses were in separate amniotic sacs. With bed rest and tocolysis, the second infant remained in utero until eight days later and after a further 36-hour delay, the remaining two babies were deli -vered. The first baby died at seven months; however, the other three were well at 1 year of age and developing normally.
Source: Olatunbosun, O., Turnell, R., Sankaran, K., & Ninan, A. (1995). Delayed interval delivery in quadruplets. Inter national Journal of Gynaecology and Obstetrics, 50(3), 287-290.
TEN YEARS FROM NOW.. .
IVF techniques will allow for the successful implantation of a single embryo that is healthy with a resultant decrease in the number of multiple pregnancies and compromised neonates. Twin pregnancies will be a natural and happy occurrence for most parents rather than an iatrogenic effect. We will have effective interventions for delaying preterm labor and delivery of multiple pregnancies, and most twins or triplets will be born at or close to 40 weeks gestation.
144 AWHONN Lifelines Volume 10 Issue 2
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Read, B., Bryan, E., & Higgins, R. (1996). Time to talk: A telephone service for families. London: Multiple Births Foundation.
Ruiz, R. J., Brown, C. E., Peters, M. T., & Johnston, A. B. (2001). Specialized care for twin gestations: Improving newborn outcomes and reducing costs. Journal of Obstetric, Gynecologic & Neonatal Nursing, 30, 52-60.
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Topp, M., Huusom, L. D., Langhoff-Roos, J., Delhumeau, C., Hutton, J. L., & Dolk, H. (2004). Multiple birth and cerebral palsy in Europe: A multicenter study. Acta Obstetrica Gynecologiae Scandinavica, 83, 548-553.
Joseph Schulman, USA
April 2004 / 160 pp / PB / 0727918338$32.00 / £20.00
Contents
PART 1: Systems
Systems and our work
The work of the NICU
Working with process mapping: an example
Activity without value: Muda
Diagnostic testing and Muda
Needless complexity in our care process
More tools for "drilling down"
PART 2: Data
Measuring outcomes: What? How?
Characterising variation in our measurements
Understanding variation in our measurements
PART 3: Action
Benchmarks and benchmarking
Keeping track of what you decided tomeasure
Change and people
The gap is never closed completely
Joseph Schulman, USA
April 2004 / 160 pp / PB / 0727918338$32.00 / £20.00
Contents
PART 1: Systems
Systems and our work
The work of the NICU
Working with process mapping: an example
Activity without value: Muda
Diagnostic testing and Muda
Needless complexity in our care process
More tools for "drilling down"
PART 2: Data
Measuring outcomes: What? How?
Characterising variation in our measurements
Understanding variation in our measurements
PART 3: Action
Benchmarks and benchmarking
Keeping track of what you decided tomeasure
Change and people
The gap is never closed completely
Evaluating theProcesses of NeonatalIntensive CareThinking Upstream to Understand Downstream Processes
Evaluating theProcesses of NeonatalIntensive CareThinking Upstream to Understand Downstream Processes
• Practical "how to" book on evaluation and quality improvement
• Written by a neonatologist with an understanding of the needsof those in the specialty
• Based on sound outcomes research
• Practical "how to" book on evaluation and quality improvement
• Written by a neonatologist with an understanding of the needsof those in the specialty
• Based on sound outcomes research
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