It is a very uncommon occurrence for the human uterus to contain more children than two, though a few well-authenticated cases are recorded in which three, four, and even five, have been detected within its cavity.
From the returns of the London and Southwark Midwifery Institution, it appears that twin cases have occurred in the proportion of about one in eighty labours; and, although that Institution has been in active operation for the last eight years, no case of triplets has been recorded.
Twin labour. Certain symptoms have been mentioned by authors to enable us to detect, even before the delivery of the first child, the existence of a plurality within the womb. These signs are, however, so exceedingly equivocal, that time would be wasted in enumerating them, especially as it would conduce to no useful purpose; the rules applicable to single births being equally so where there are two or more children in utero.
After the first child is born, the hand being placed upon the female's abdomen, the parietes will feel tense and hard, and there will appear to he but little diminution in size; and when an internal examination is made, the bag containing the second child will generally be easily felt.
Treatment. The delivery of the first child is to be conducted upon the usual principles. With regard to the second, two methods have been recommended: the one to trust the case entirely to nature, the other to interfere immediately for the purpose of hastening the birth. In general, the best practice lies between these two extremes, for the patient is frequently somewhat exhausted after the expulsion of the first child, and consequently requires a little time to recruit herself. Under these circumstances nourishment should be administered, and, if the pains are not then renewed, the membranes may be ruptured, and the os uteri gently stimulated by passing the finger round it; when the uterine efforts will soon be repeated. If dangerous symptoms manifest ilium selves, such as hemorrhage, convulsions, &C, of course no time must be lost, hut the child extracted as speedily as possible. Where the position of the second foetus requires to be rectified, it can be effected with the utmost ease, in consequence of the already dilated state of the parts. There is sometimes only one large placenta, with which the two funes communicate; at other times there are two distinct placentae, connected however to each other by the membranes; and occasionally, though not very frequently, the vascular structures unite through the medium of one or more vessels, which pass from the one to the other.
The same general rules apply to the management of the placenta; as in single births. They are usually expelled together after the birth of both children, and it is of great consequence that they are not too suddenly hurried away. When, from any cause, it may be considered right to assist in their removal, (as, for example, where they are lying in the vagina,) both cords are to be laid hold of, and the same extracting efforts will then be made use of to each.
In the management of twin labours, great care must be taken gradually to tighten the bandage around the abdomen, as, in consequence of the exertion the uterus must necessarily undergo, there is more than the usual risk of hemorrhage; and, when this occurrence takes place, it is apt to be more profuse in consequence of the large extent of uterine surface which is occupied by the two placentae. This is the reason why the discharges after delivery are greater than in single births, as they flow from the whole of that surface.
Where the uterus contains more children than two, the labour will require the same management.
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From Charles Waller
Elements of Practical Midwifery: Or, Companion to the Lying-in Room, 1829
