a)Twin pregnancy is a high risk pregnancy and the Consultant Obstetrician-on-call,Anaesthetist-on-call,and the Paediatric team should be informed of the admission.Site the venous cannula and collect blood samples for Full blood count and Group and save.Check that the CTG is reactive of both twins.Vaginal examination should be done to know the dilatation of the cervix, effacement, position of the vertex and station.Presence or absence of membranes and colour of the liqour is noted.Applying Fetal scalp electrode helps in the monitoring of the first twin.Continuous fetal monitoring should be organised.Partogram should be commenced and vaginal examination should be repeated in 4hrs,unless suboptimal CTG warrants it earlier.Pain relief should be discussed and as twins are more likely to need manoeuvres or emergency Caesarean section, she should consider epidural for pain relief.She should be looked after by a seniour midwife.
b)Fetal morbidity increases after 3hrs of full dlatation of the cervix.If the CTG is normal,and she is bearing down well, shecan be encouraged.Bearing down in lithotomy position can help.If she is exhausted, she should be transferred to Theatre for delivery.If CTG is normal, she should be considered for Ventouse delivery.The incidence of maternal perineal tears is low and the soft silastic cup is kinder to the baby.The disadvantage is the incidence of slipping of the cup is higher.The chignon on the fetal head because of the cup usually settles in 24-48hrs.Forceps is quicker to apply and deliver the baby.If CTG is suboptimal,forceps should be preferred to ventouse.The other advantage is that it does not slip.The disadvantage is the incidence of perineal and 3degree tears is higher.This is low forceps so the morbidity to the baby from tentorial tears will be low.
c)Call for help from seniour midwife like shift leader and on-call Anaesthetist .Check airway breathing and vital signs.Site 2 large bore cannulas and collect samples for FBC and cross-matching of 6 units(if not collected previously) Start IV fluids, crystalloids followed by colloids if required.Commence Oxygen by mask.Check if uterus is contracted.,if not ask midwife to give ergometrine 0.5mgIV/IM andprepare 40units syntocinon in 500mls of Hartmann\'s.,and rub up a contraction. Ifthe bleeding is heavy do bimanual compression of the uterus and try to roughly estimate the loss.If uterus has still not contracted give prostaglandinF2 (caboprst)250mcg every 15mins. to a maximum of 8doses.Rule out any cervical tear or deep fornicial vaginal tear.Inform Consultant Obstetrician and send blood samples to the lab for APTT, PT and Fibrinogen degradation products and inform the Haematologist.Request for Rh negative blood if her blood pressure continues to be low.Follow the local guideline for PPH.Inform Intervention Radiologist if facility is available in the hospital for consideration of uterine artery embolisation.Consider Rusch catheter intrauterine, prior to any invasive procedure.
