The rules of practice in twin cases, after the birth of the first child, are plain and not at all ambiguous, as some authors would have them. After the expulsion of the first child, one of two things must happen; first, that pretty severe pains will quickly ensue, and if the position be natural, quickly cause the birth; or second, there will be an entire suspension of pain. In the first case the labor must be conducted in all respects the same as if it were an original one; nor is it at all to be interfered with so long as there is any reasonable prospect that nature will prove adequate to relieve herself; and this she is generally able to do. When pains follow the expulsion of the first child, there is every reason to believe that they will in proper time accomplish the birth of the second, because it will receive the whole influence of the expulsive efforts of the uterus, whereas before it was expended upon both fetuses, and because the subsequent pains will be more powerful, since the uterus is now smaller, and its contractions consequently more perfect; and lastly, because the parts have been already dilated by the passage of the first child.
But if there is a suspension of pain, the rule of practice is equally plain as in the former case; if there should be flooding—which will seldom happen—we are to proceed as we would in any other case of hemorrhage preceding the birth of the child; we are to endeavor to arrest the hemorrhage, and if this cannot be accomplished—which I think it usually may be—we are driven to the necessity of delivering the child by means of art. If there be no hemorrhage present, we are to solicit the contraction of the uterus by frictions and kneading on the abdomen, by cold, wet compresses freely used, by general ablutions; the cold hip-bath, perhaps, in some cases, the frequent drinking of very cold water, taking small pieces of ice into the stomach, and by cold injections in the bowels. But we may safely allow nature to rest herself somewhat before we enter upon these means. A meddlesome midwifery, we should remember, is always bad. As things have been in the healing art, nature has been hindered in her processes, probably scores of times, by manual operations, where she has been really aided once!
The Placenta.—Usually in twin cases, each child has its own placenta, but this is not always the case.
When there are two placentæ, they are usually connected together; sometimes, also, they are entirely separated.
The number of placentæ is usually in proportion to the number of children. To this rule there are also exceptions. A single placenta and a single cord has been found in a case of twins, the cord branching off into two, some distance from the after-birth. In some rare instances, likewise, the cords are found so closely twined together, that they have the appearance of one.
Before any attempt is made to deliver the placenta, when we have reason to suspect there is another child in the womb, or where we have ascertained such to be the case, we should, at the proper time, separate the cord of the first child, and place a ligature on the part next the mother. The cut extremity of the cord, in such cases, is supposed to yield a more than usual quantity of blood, even to the exhaustion of the second child.
When the placentæ are separate, that of the first child should not be delivered before the birth of the second child. Should it be so delivered, there must necessarily follow a considerable discharge of blood, which might amount to a profuse or fatal hemorrhage. But in some instances the after-birth has been expelled by the natural efforts, without any considerable effusion of blood. In some cases of hemorrhage, when there is only one child, the placenta is thrown off first, and yet without any detriment or danger, such as is usually looked for in such cases.
In cases where it is necessary to extract the child by art, it is also generally looked upon as necessary to deliver the placenta by the same means; but such is not necessarily the case. If there is no hemorrhage, or other cause of alarm, there is no more reason for giving assistance to deliver the placenta than if only one child had been present; we ought either to wait for the spontaneous operation of nature, or, at most, give very little assistance, precisely as we would in a case of single birth.
Whenever it is found necessary to give assistance in the matter of removing the after-births, we are to recollect that the two placentæ should be extracted together, or in quick succession, as the patient would not be freed from the peril of her situation if we did not proceed in this way. If the hand is to be introduced into the uterus, it should not be withdrawn till both the placentæ are detached, and ready to come away. If we are to give assistance by making traction at the cord or cords, we must be careful that each shall bear an equal proportion of the force we think it advisable to use.
We are not to be alarmed if more blood is lost in twin cases than is usual at single births. The discharge is commonly greater in the former cases, and longer continued than in the latter.