Editing Multiple birth (section)

==Management==
[[Bed rest]] has not been found to change outcomes and therefore is not generally recommended outside of a research study.<ref>{{Cite journal |last1=McCall |first1=CA |last2=Grimes |first2=DA |last3=Lyerly |first3=AD |date=June 2013 |title="Therapeutic" bed rest in pregnancy: unethical and unsupported by data. |journal=Obstetrics and Gynecology |volume=121 |issue=6 |pages=1305–8 |doi=10.1097/aog.0b013e318293f12f |pmid=23812466 |s2cid=9069311}}</ref>

===Selective reduction (procedure)===
[[Selective reduction]] is the practice of reducing the number of fetuses in a multiple pregnancy; it is also called "multifetal reduction".<ref>{{Cite web |date=September 2017 |title=Opinion Number 719: Multifetal Pregnancy Reduction |url=https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Ethics/Multifetal-Pregnancy-Reduction |publisher=American College of Obstetricians and Gynecologists' Committee on Ethics.}}</ref>

The procedure generally takes two days; the first day for testing in order to select which fetuses to remove, and the second day for the procedure itself, in which [[potassium chloride]] is injected into the heart of each selected fetus under the guidance of ultrasound imaging.<ref>{{Cite journal |last1=Evans |first1=MI |last2=Andriole |first2=S |last3=Britt |first3=DW |date=2014 |title=Fetal reduction: 25 years' experience. |journal=Fetal Diagnosis and Therapy |volume=35 |issue=2 |pages=69–82 |doi=10.1159/000357974 |pmid=24525884 |doi-access=free}}{{open access}}</ref>  Risks of the procedure include bleeding requiring transfusion, rupture of the uterus, [[retained placenta]], infection, a miscarriage, and [[prelabor rupture of membranes]]. Each of these appears to be rare.<ref>{{Cite journal |last1=Legendre |first1=Claire-Marie |last2=Moutel |first2=Grégoire |last3=Drouin |first3=Régen |last4=Favre |first4=Romain |last5=Bouffard |first5=Chantal |year=2013 |title=Differences between selective termination of pregnancy and fetal reduction in multiple pregnancy: A narrative review |journal=Reproductive BioMedicine Online |volume=26 |issue=6 |pages=542–54 |doi=10.1016/j.rbmo.2013.02.004 |pmid=23518032 |doi-access=free}}{{open access}}</ref> There are also ethical concerns about this procedure, since it is a form of [[abortion]], and also because of concerns over which fetuses are terminated and why.<ref>{{Cite news |date=13 January 2012 |title="Selective Reduction Abortions" On the Rise. |url=https://www.christian.org.uk/news/selective-reduction-abortions-on-the-rise/}}</ref><ref>{{Cite news |date=31 August 2011 |title=US article exposes trend to abort half a twin pregnancy |url=https://www.christian.org.uk/news/us-article-exposes-trend-to-abort-half-a-twin-pregnancy/}}</ref>

Selective reduction was developed in the mid-1980s, as people in the field of assisted reproductive technology became aware of the risks that multiple pregnancies carried for the mother and for the fetuses.<ref>{{Cite news |last=Mundy |first=Liza |date=May 20, 2007 |title=Too Much to Carry? |url=https://www.washingtonpost.com/wp-dyn/content/article/2007/05/15/AR2007051501730_pf.html |archive-url=https://web.archive.org/web/20150405010648/http://www.washingtonpost.com/wp-dyn/content/article/2007/05/15/AR2007051501730_pf.html |archive-date=April 5, 2015 |newspaper=[[The Washington Post]] Magazine}}</ref><ref>{{Cite magazine |last=Padawer |first=Ruth |date=August 10, 2011 |title=The Two-Minus-One Pregnancy |url=https://www.nytimes.com/2011/08/14/magazine/the-two-minus-one-pregnancy.html |magazine=New York Times Magazine}}</ref>

===Care in pregnancy===
Women with a multiple pregnancy are usually seen more regularly by midwives or doctors than those with singleton pregnancies because of the higher risks of complications.<ref name="Dodd-2015">{{Cite journal |last1=Dodd |first1=JM |last2=Dowswell |first2=T |last3=Crowther |first3=CA |date=6 November 2015 |title=Specialised antenatal clinics for women with a multiple pregnancy for improving maternal and infant outcomes. |journal=The Cochrane Database of Systematic Reviews |volume=11 |issue=11 |pages=CD005300 |doi=10.1002/14651858.CD005300.pub4 |pmc=8536469 |pmid=26545291}}</ref> However, there is currently no evidence to suggest that specialised antenatal services produce better outcomes for mother or babies than 'normal' antenatal care.<ref name="Dodd-2015" /> Women with a multiple pregnancy are also encouraged after 24 weeks to be on bed rest. This recommendation is not a requirement for women with a multiple pregnancy, but it has been used as a method to prevent complications. Some doctors may prescribe this method to be on the safe side and if they believe it is necessary.

===Nutrition===
As preterm birth is such a risk for women with multiple pregnancies, it has been suggested that these women should be encouraged to follow a high-calorie diet to increase the birth weights of the babies.<ref>{{Cite journal |last1=Kwok |first1=Man Ki |last2=Yeung |first2=Shiu Lun Au |last3=Leung |first3=Gabriel M. |last4=Mary Schooling |first4=C. |date=2016-03-01 |title=Birth weight and adult cardiovascular risk factors using multiple birth status as an instrumental variable in the 1958 British Birth Cohort |journal=Preventive Medicine |volume=84 |pages=69–75 |doi=10.1016/j.ypmed.2015.12.016 |issn=0091-7435 |pmid=26748345}}</ref> Evidence around this subject is not yet good enough to advise women to do this because the long term effects of the high-calorie diets on the mother are not known.<ref>{{Cite journal |last1=Bricker |first1=L |last2=Reed |first2=K |last3=Wood |first3=L |last4=Neilson |first4=JP |date=24 November 2015 |title=Nutritional advice for improving outcomes in multiple pregnancies. |journal=The Cochrane Database of Systematic Reviews |volume=2015 |issue=11 |pages=CD008867 |doi=10.1002/14651858.CD008867.pub3 |pmc=7133547 |pmid=26599328}}</ref>

===Cesarean section or vaginal delivery===
A study in 2013 involving 106 participating centers in 25 countries came to the conclusion that, in a twin pregnancy of a [[Gestational age (obstetrics)|gestational age]] between 32 weeks 0 days and 38 weeks 6 days, and the first twin is in [[cephalic presentation]], planned [[Cesarean section]] does not significantly decrease or increase the risk of [[Perinatal mortality|fetal or neonatal death]] or serious neonatal [[disability]], as compared with planned vaginal delivery.<ref>{{Cite journal |last14=Twin Birth Study Collaborative Group |vauthors=Barrett JF, Hannah ME, Hutton EK, Willan AR, Allen AC, Armson BA, Gafni A, Joseph KS, Mason D, Ohlsson A, Ross S, Sanchez JJ, Asztalos EV |year=2013 |title=A Randomized Trial of Planned Cesarean or Vaginal Delivery for Twin Pregnancy |journal=New England Journal of Medicine |volume=369 |issue=14 |pages=1295–1305 |doi=10.1056/NEJMoa1214939 |pmc=3954096 |pmid=24088091}}</ref> In this study, 44% of the women planned for vaginal delivery still ended up having Cesarean section for unplanned reasons such as [[pregnancy complication]]s. In comparison, it has been estimated that 75% of twin pregnancies in the United States were delivered by Cesarean section in 2008.<ref>{{Cite journal |vauthors=Lee HC, Gould JB, Boscardin WJ, El-Sayed YY, Blumenfeld YJ |year=2011 |title=Trends in Cesarean Delivery for Twin Births in the United States |journal=Obstetrics & Gynecology |volume=118 |issue=5 |pages=1095–101 |doi=10.1097/AOG.0b013e3182318651 |pmc=3202294 |pmid=22015878}}</ref> Also in comparison, the rate of Cesarean section for all pregnancies in the general population varies between 40% and 14%.<ref>{{Cite web |last=Gallagher |first=James |date=23 November 2011 |title=Women can choose Caesarean birth |url=https://www.bbc.co.uk/news/health-15840743 |url-status=live |archive-url=https://web.archive.org/web/20120819201245/http://www.bbc.co.uk/news/health-15840743 |archive-date=2012-08-19 |website=BBC}}</ref>

Fetal position (the way the babies are lying in the womb) usually determines if they are delivered by caesarean section or vaginally. A review of good quality research on this subject found that if the twin that will be born first (i.e. is lowest in the womb) is head down there is no good evidence that caesarean section will be safer than a vaginal birth for the mother or babies.<ref>{{Cite journal |last1=Hofmeyr |first1=GJ |last2=Barrett |first2=JF |last3=Crowther |first3=CA |date=19 December 2015 |title=Planned caesarean section for women with a twin pregnancy. |journal=The Cochrane Database of Systematic Reviews |volume=12 |issue=12 |pages=CD006553 |doi=10.1002/14651858.CD006553.pub3 |pmc=4110647 |pmid=26684389}}</ref>

[[Monoamniotic twins]] (twins that form after the splitting of a fertilised egg and share the same amniotic fluid sac) are at more risk of complications than twins that have their own sacs. There is also insufficient evidence around whether to deliver the babies early by caesarean section or to wait for labour to start naturally while running checks on the babies' wellbeing.<ref name="Shub-2015">{{Cite journal |last1=Shub |first1=A |last2=Walker |first2=SP |date=23 April 2015 |title=Planned early delivery versus expectant management for monoamniotic twins. |journal=The Cochrane Database of Systematic Reviews |volume=4 |issue=4 |pages=CD008820 |doi=10.1002/14651858.CD008820.pub2 |pmc=8947902 |pmid=25906204}}</ref> The birth of this type of twins should therefore be decided with the mother and her family and should take into account the need for good neonatal care services.<ref name="Shub-2015" />

Cesarean delivery is needed when first twin is in non cephalic presentation or when it is a monoamniotic twin pregnancy.

===Neonatal intensive care===
Multiple-birth infants are usually admitted to neonatal intensive care or a special care nursery in the hospital immediately after being born. The records for all the triplet pregnancies managed and delivered from 1992 to 1996 were looked over to see what the neonatal statistics were. Kaufman found from reviewing these files that during a five-year period, 55 triplet pregnancies (i.e. 165 babies) were delivered. Of the 165 babies 149 were admitted to neonatal intensive care after the delivery.<ref>{{Cite journal |vauthors=Kaufman GE, Malone FD, Harvey-Wilkes KB, Chelmow D, Penzias AS, D'Alton ME |year=1998 |title=Neonatal morbidity and mortality associated with triplet pregnancy |journal=Obstet Gynecol |volume=91 |issue=3 |pages=342–8 |doi=10.1016/s0029-7844(97)00686-8 |pmid=9491857 |s2cid=12722478}}</ref>