LABOR IN CASE OF TWINS.
Whatever the presentation, however, external version is not possible as long as the twins are still within the uterine cavity. After the birth or the extraction of the first foetus, if the second presents by the shoulder, external version may be resorted to, although podalic version is usually an easy matter, and a large number of authorities immediately resort to it. As a rule, we are frequently obliged to interfere in twin labors, and the following tables show the frequency of such interference, compared with that necessary in general labor.
Ordinarily, after the birth of the first child, the pains cease for an in terval whioh may vary from a few minutes to a few hours, or even dap, and authorities differ as to the proper course to pursue, some being in favor of active intervention, and in this we agree, others being guided by the position of the foetus, or the reappearance of uterine contractions.
Kleinwiichter favors the immediate extraction of the second fcetus by version, except where: 1st. The head or breech is engaged. 2. There is pronounced contraction, absolute or relative, of the pelvis, and the fcetal head is above the superior strait. 3. There exists a double chorion; one fcetus is born before term, and immediate extraction would result in birth before term of second fcetus.
Reuss is opposed to these views of Kleinwitchter, and is guided in his action entirely by circumstances, under the same rules which govern natural labor. In 74 labors, he gives the following data as to the inter val elapsing between the birth of the first and the second fcetus: From 5 minutes to 1 hour79 per cent. " 1 hour to 6 hours .15 if . .
Over " "6 " • Kleinwachter, on the other hand, gives the following figures for 262: From 5 minutes to 1 hour. 89.41 per cent.
" 6 hours .9.22 " . .
Over " " .2.67 ,, . .
In twin pregnancies, premature labor is frequent enough, and, strange to say, oftener in multiparse than in primiparw. In 143 cases of prema
ture collected from various sources, the following are the data: Hoffman. 29 nulliparse.' 28 multiparze.
Reuss 45 " Q8 " .
.
. .
Sinclair and Johnston73 ,, 160 " Bleinwachter. 45.9 per cent. 54.9 per cent.
It is further to be noted that the mortality in case of twins is high, viz.: Reuss 10.4 per cent.; Collins 11.6 per cent.; Churchill 25 per cent. ; Hugenberger 19 per cent. Chiari, Braun and Spaeth give a lower rate, 4 per cent.
The folio wing tables show the relative frequency of various presenta tions, and the sex of the twins: This table justifies, in a measure, the current opinion that the children are usually of the same sex, but this opinion is not absolute by any means; for, on careful sifting of statistics, it is seen that the reverse is very fre quently the case. Thus: At Wurzburg, In 57 per cent. same sex. In 43 per cent. not. Spaeth • " 70 " " 30 " 4C Veit . • " 64 " C, " 36 " Churchill . 62 CC 4C 44 37.5 Collins ? " 60 " " 40 " t‘ What now should be the rule in case of twin labor ? We resume, in a few words, our own practice, which is none other than that of our teacher, Depaul: If the two fcetuses present well, if the first labor has been nor mal, we wait. If, at the expiration of fifteen minutes to one half an hour, contractions do not recur, then make friction over the uterus, and gently stimulate the cervix. If these means do not suffice, then rupture the membranes, and again wait. Extract in case of urgency. If, on the other hand, the presentation of the second fcetus be faulty, in case of the breech, wait, in case of the shoulder, version, external or internal accord ing to the case. Whatever the presentation, interfere at once if the in terests of mother or child demand it.