Midwifery and the diseases of women

by Joel Shew

Signs of Twins.—A vast deal of thought and investigation have been put forth on the subject of ascertaining twin cases before birth. The physician is often consulted on this subject; but, it need hardly be said that the wisest and most experienced can hardly do more than guess upon so important a matter. Dr. Dewees tells us, we should always answer the question in the negative, and for two reasons, especially; first, because it is impossible to decide it positively; and, secondly, if it could be so decided, it never should be, as much mischief might arise from the uneasiness and fear it might produce.

It may not, however, be wholly uninteresting to our readers to know something of the signs which have been supposed to indicate the presence of more than one child in the uterus. Women who are more than ordinarily large, are apt to suspect themselves pregnant with twins; we very often see such cases, and yet, in few instances, comparatively, the surmises of such patients prove true; they are in general happily disappointed, for no mother, I think, would prefer to run the greater risk of bearing twins.

If a woman be unusually large in the early part of pregnancy, and increase proportionably to the full period, there is some reason, as Dr. Denman regards, that she will have twins; but people will vary very much in regard to what constitutes “large,” and what “small,” in reference to the size of the abdomen in pregnancy: a few will suppose themselves very large when they are, in fact, only of common or moderate size. Particularly in cases of first pregnancy patients are apt to be misled on this subject; there can be no surprise if conjectures on the subject of twins often prove fallacious.

The abdomen of all women with child is in general uniformly distended, without any inequality. It sometimes, however, happens that the tendons, which form what is called the linea alba, which leads from the navel to the middle of the ossa pubis, being less distensible than the sides of the abdomen, which are muscular, divide the abdomen, as it were, into two equal parts by a raphé or indentation through its inferior part. This presumed sign of twins is as ancient as the time when the human uterus, like that of quadrupeds, was supposed to be divided into cornua, a child being thought to be contained in each horn. But as the form of the human uterus is now well understood and known to be equally distensible to its contents, whatever the form of the abdomen may be, unless it is constrained by external means, even less regard is paid to the form of this than to its degree of distention, when we are judging whether it be probable that a woman is pregnant with more than one child.

Women with child—those who have passed through one or more previous pregnancies—are sometimes apprehensive that they have twins, from a greater, a more distant, or other peculiar motion they feel during the period. But sensations of this kind, it hardly need be said, are generally fallacious, as affording any probable evidence of there being more than one child in the uterus. Besides, it is to be remembered, that women never experience the same sensations during any two pregnancies.

Tardiness of labor has sometimes been considered a sign of twins; but this may be occasioned by so great a variety of circumstances, it cannot be at all relied on as an evidence of compound pregnancy. It is true, however, that when two or more children are to be born at a time, the labor of the first is almost universally slow; and this slowness is to be attributed to the greater distention of the womb.

There is one method of which I should speak, that some, in modern times, place much reliance upon in ascertaining the presence of twins in the uterus. Dr. Kennedy, of Dublin, and others, have affirmed that the motion of two fetal hearts may be ascertained by means of auscultation; others again have less confidence in this matter, so that on the whole, it is doubtful whether much reliance is to be placed upon this method. It would be difficult, I apprehend, in most instances, for two practitioners to agree upon this point.

Management of Twin Cases.—The labor of a woman pregnant with two or more children begins, in all respects, like that in which there is but one; its progress, however, is not in general so regular or rapid. The reason why labor is more tedious in these cases is, that neither child can be subjected so well to the expulsive force of the uterus as when there is but one fetus in its cavity.

It is inculcated as a rule among physicians, to keep a patient as long as possible ignorant of there being more than one child, when this is known. But in almost every conceivable instance, the physician is not aware that he is encountering a case of twins until the first child has been born. After the first child is expelled, we may suspect the presence of another from the following circumstances: first, when the child is small in comparison with the abdomen of the mother; and second, when we find the uterus still large, extending high in the abdomen, and not contracted into a comparatively small and hard tumor, as is usually the case at single birth.

It happens in the greater number of twin cases, that while the physician is waiting for the pulsation in the umbilical cord to cease, or is employed in tying it, or waiting for a pain to expel the placenta, the patient complains with more than ordinary earnestness; on examination it is then found that there is a second child on the point of being born, or the bag of waters may be protruding with more than ordinary firmness, so that almost instantly on their breaking, the child is expelled, and this not unfrequently before there is time to give either the mother or friends notice that a second child is to be born; and fortunately it happens in the great majority of cases that, save the exception of the labor being more protracted and severe in the beginning of those cases, the ultimate births are effected with as little danger and trouble as in the average of single cases.