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Prenatal Behavior of Multiples: Implications for Families and Nurses
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PRINCIPLES & PRACTICE
Prenatal Behavior of Multiples: Implications for Families and Nurses Linda G. Leonard, RN, MSN
Each twin and higher order multiple leads an extraordinary life before birth. The literature has revealed that the intrauterine environment differs for every multiple fetus and helps to shape the individuality of each multiple-birth child. From early in pregnancy, it appears that a multiple develops his or her own temperament and each set of multiples establishes an individualized pattern of tactile communication between or among themselves. The same behaviors, traits, and intermultiple interactions seen in pregnancy also have been observed in infancy and beyond. Intermultiple communication continues after birth, and preliminary evidence suggests that co-bedding assists the majority of newborns to make the transition from intrauterine to extrauterine life. The response of a multiple to the death of a co-multiple during pregnancy or after birth may be influenced by the relationship they shared in utero. Nurses and other health care providers have a role to play in informing multiple-birth parents about the latest knowledge, thereby assisting parents with the attachment process and specific parenting issues. In addition, nurses now have a solid foundation on which to create and implement care strategies that promote the healthy development of each multiple-birth infant and the intermultiple relationship. JOGNN, 31, 248–255; 2002. Keywords: Attachment—Co-bedding— Death—Higher order multiples—Prenatal relationship—Twins Accepted: October 2001
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. . . you all are active and it makes me feel so blessed and alive to put my hands against my skin and feel your movements. (Sather & Zwelling, 1998, p. 324) The miracle of the developing human fetus became known to us through the magnificent photography of Lennart Nilsson (1965) in A Child Is Born and through ultrasound technology. Fetuses react to sounds and light, kick, twist their bodies, somersault, startle, stroke their faces, hang on to the umbilical cord, suck their fingers, breathe, swallow, stretch, yawn, and even jump off the uterine wall (Arabin, Mohnhaupt, & van Eyck, 1998). Our fascination now extends to the prenatal lives of twins and higher order multiples. Each year, more than 126,000 multiple-birth infants are born in the United States (Martin, Hamilton, Ventura, Menacher, & Park, 2002) and 9,100 are born in Canada (Statistics Canada, 2001). Even though multiples share the intrauterine environment, that environment is constantly changing and is not the same for each twin or higher order multiple fetus (Piontelli, Bocconi, Boschetto, Kustermann, & Nicolini, 1999). In the vast majority of multiple pregnancies, each fetus has its own placenta, umbilical cord, and amniotic fluid. Multiples develop in different locations within the uterus and do not receive an equal share of blood, nutrients, and stimuli. When they do share a placenta, it is not shared equally. It is now realized that an important part of the environment of a multiple fetus is the tactile stimulation received from a co-multiple (Arabin,
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Gembruch, & van Eyck, 1995; Piontelli, 1999). Thus, each multiple-birth newborn, whether monozygotic (“identical”) or dizygotic (“fraternal”), is shaped not only by his or her genetic makeup but also by a highly individualized prenatal experience. An extensive review of the ultrasonography, maternalfetal medicine, fetal/child development, and nursing literature was conducted. The findings arising from the
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win fetuses engage in intrapair stimulation by 15 weeks gestation.
research lend support to and suggest ways that caregivers can provide developmentally and therapeutically supportive care to multiple-birth children and their families during the prenatal and childrearing years. Not only is the intermultiple relationship fascinating, but this knowledge enables multiple-birth parents and health professionals to better understand the uniqueness of each multiple-birth prenate (fetus) and the way in which multiples interact with one another.
Historical Beginnings Several researchers became curious about electronic fetal monitoring data elicited during the 3rd trimester of twin pregnancies. They determined that there was a significant amount of synchrony (simultaneity) within twin pairs regarding fetal heart rate accelerations, breathing motions, and body movements (Ohel, Samueloff, Navot, & Sadovsky, 1985; Sherer, Nawrocki, Peco, Metlay, & Woods, 1990; Zimmer, Goldstein, & Alglay, 1988). Behavioral patterns, similar to those seen after birth, were detected in sets of twins who were 28 to 39 weeks gestation (Gallagher, Costigan, & Johnson, 1992). Each twin pair was found to be synchronous 95% of the time regarding the amount of time a twin and co-twin spent in each of the four sleep-awake states (quiet sleep, active sleep, quiet awake, active awake). Monochorionic-diamniotic twins were synchronous 100% of the time, and dichorionic twins 92% of the time. Same-gender twins were more synchronous (98%) than unlike-gender pairs (90%). Evidence mounted that a notable portion of the heart rate accelerations and breathing and body movement patterns of twin fetuses was likely due to tactile communication between the pair (Sherer et al., 1990). Monochorionic-diamniotic twins share one chorion (membrane closest to the uterus), and each twin has his or her own amnion (membrane surrounding the amniotic May/June 2002
fluid). Found in separate amniotic sacs, the twins are monozygotic (identical) and always the same gender. Monochorionic-monoamniotic twins share the same amnion and chorion and are in one chorioamniotic sac. They are monozygotic and always the same gender. Dichorionic twins have a separate chorion and amnion and are in separate chorioamniotic sacs. They may be monozygotic or dizygotic (fraternal) and are of the same or different genders.
Temperament and Fetal Twins Real-time ultrasound, using transvaginal and transabdominal sonography, has made it possible to observe fetal motility and to make intermultiple comparisons. Two independent research teams headed by Arabin and Piontelli, respectively, painstakingly analyzed hours of videotaped ultrasounds of twin and triplet pregnancies. Arabin, a perinatologist, and her colleagues focused on documenting the onset and type of movements seen in twin/triplet prenates as well as the nature of responses elicited during their contacts. Piontelli, a psychologist, and her coworkers focused on the differences and similarities in a twin pair, the intertwin relationship, and the indications that prenatal life provides a glimpse of future temperament and the intertwin relationship. Intertwin differences in behavioral traits or temperament have been detected prenatally (Piontelli, 1989; Piontelli et al., 1999). Piontelli and coworkers noted that in the first part of pregnancy, a pair of monozygotic twins behaves more similarly than differently, but as the pregnancy progresses, the pair become as dissimilar as dizygotic twins. A co-twin behaves differently from his or her sibling with regard to the amount and quality of movements, the amount of stimulation required to elicit activity, preferred activities and positions, and the rhythm of sleep-awake cycles. It has been observed that the twin in each pair who is more active during one ultrasound observation continues to be more active during future observations (Piontelli et al., 1999). Behavioral differences between twins may persist throughout pregnancy and continue after the births into infancy and beyond (Holditch-Davis, Roberts, & Sandelowski, 1999; Piontelli, 1989; Piontelli et al., 1999). Sherer and colleagues (1992), using electronic monitoring, were unable to determine if one fetal twin is more dominant than the other. Preliminary ultrasound evidence suggests that one twin may be more dominant than the other and that dominance should be regarded only as one twin being more active than the other (Piontelli, 1999). Piontelli clarifies that an actively moving fetus is not awake but in a different phase of “sleep.” Brief episodes of wakefulness have only been detected close to term. As pregnancy moves closer to term and the living space becomes more crowded, the amount of activity between
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the twin fetuses decreases, especially large body movements such as startles. Fetal body movements continue during labor in twin and triplet pregnancies (Arabin et al., 1995). If a twin or triplet prenate has a health problem such as a major malformation, the quality and quantity of movements may be affected. The affected fetus will likely conserve energy and may progress to intermultiple contacts at a later gestational age or not at all; the result will be less intermultiple communication in utero (Arabin et al., 1998; Piontelli et al., 1999).
Intrauterine Twin Communication The entire behavior of unborn twins can be captured on one ultrasound screen until only 16 to 22 weeks gestation (Arabin et al., 1998; Piontelli, 1999). Active movements of a fetus begin around 7 completed weeks of pregnancy and progress from being somewhat jerky to slow and harmonious by 16 weeks gestation (Arabin et al., 1998). In the last half of pregnancy, the heads and small body parts become the focus of intertwin studies. The first touches in utero start with slow initiatives from the twin and slow responses from the co-twin; the speed of initiatives and reactions were noted to be greater in male pairs than in female or mixed pairs of twins. Differences in testosterone levels might have an effect on early intrauterine development (Arabin et al., 1998). Tactile contacts between monochorionic-monoamniotic twins occur at approximately 9 weeks gestation (Arabin, Bos, Rijlaarsdam, Mohnhaupt, & van Eyck, 1996); contacts for these prenates are the easiest because they share the same amniotic sac. Between 10 and 12 weeks gestation, monochorionic twins begin to stimulate each other, whereas dichorionic twins engage in intertwin stimulation at 12 to 15 weeks gestation (Arabin et al., 1996; Piontelli, 1999). Monochorionic twins have more opportunities than dichorionic twins for intertwin communication because they are more proximate to one another, share the same placenta, and are separated by no or thinner intertwin membranes (Arabin et al., 1998). By 15 weeks gestation, intrapair stimulation occurs in all twin pregnancies (Piontelli, 1999). Arabin et al. (1995) observed via ultrasound “twins approaching each other continuously with their hands or faces” (p. 342). Female pairs seem to develop full-body contacts (parents refer to them as embraces) or mouth contacts (parents call them kissing) earlier than male pairs (Arabin et al., 1996). Male and female pairs engage equally in less complex body contacts such as touching a cotwin with a leg, arm, or head. Twin prenates experience more tactile stimuli than unborn singletons. Arabin et al. (1996) contended that this stimulation may accelerate and improve the development of twin children on specific neurologic and physical maturity measures.
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All stimulation emanating from a multiple, such as a punch or kick, will not necessarily result in a response from a co-multiple. If the receiving prenate is in a period of rest, motor inhibition, or has become accustomed to a stimulus such as his mother’s bowel sounds, there will likely be no reaction (Arabin et al., 1995; Piontelli et al., 1997). This may explain why most newborn twins are not disturbed by a co-twin’s punches or loud crying, or when the household vacuum cleaner is operating. Some multiples seem to seek contact during the pregnancy and show a preference for touch or physical nearness, whereas others appear to avoid contact with their co-multiple. Piontelli (1989) describes one set of unborn twins in which the male would reach out through the inter-twin membranes and touch his sister’s face; the twin responded by turning her face toward him and the two engaged in a gentle cheek-to-cheek motion of stroking. At age 1, they played a favorite game of using a curtain as a type of membrane to separate themselves; the male put his hand through the curtain and his sister put her cheek forward and they began their mutual stroking. A second set of fetal twins enjoyed a different relationship: when the female tried to make contact with her brother, he would cover his face with his hands, withdraw, and bury his face in the placenta. If she continued to seek him out, he would punch her back, sometimes quite violently. At age 1, the same behavior continued between the two, with the placenta being replaced by the mother’s lap or other soft object.
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etal movements enable a woman expecting multiples to relate to her unborn children, affirm that each one is alive and healthy, and attach to them individually and as a unit.
Woodward (1998), a lone twin herself, an attachment therapist, and founder of The Lone Twin Network in Britain, noted that some form of attachment may occur between twin pairs prior to and around the time of birth. Piontelli (1999) cautioned that one must not assume that unborn twins are attaching psychologic or social meaning to the contacts with their co-twin or that they are expressing the more complex feelings of love, jealousy, longing, or rejection. She noted that once twins are born, they do not show signs of “social recognition” toward each other. Instead, they may seek physical closeness because of the need for warmth, touch, security, and the other kinds of stimulation that the co-twin can provide. The link between
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behavior before and after the births requires clarification; co-bedding studies present such an opportunity.
Co-bedding of Twins and More Co-bedding first came to the attention of parents and health professionals in North America in 1995 when the Worcester Telegram & Gazette (MA) published a story and photograph of preterm twins bedded together in the neonatal intensive-care unit (Sheehan, 1995). Co-bedding is a continuation of the closeness and shared intrauterine experiences of multiples. It is theorized that multiple-birth newborns may have the unique ability to support each other during their transition to extrauterine life (Nyqvist & Lutes, 1998). Research is under way in several centers to determine whether and how co-bedding is advantageous to multiple-birth newborns requiring neonatal intensive care (Walker, 2000). The purported physiologic advantages of co-bedding as compared to individual bedding are improved heart rate, temperature, and respiratory control (including fewer apneic periods [Walker, 2000]); lower oxygen requirements; greater weight gain; and improved motor development, coregulation (balancing and supporting of one another), and facilitation of state control such as sleep and alertness (Nyqvist & Lutes, 1998). Other benefits of co-bedding may include improved infant growth and development, faster movement from isolettes to open
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urses and other health professionals can assist parents before and after the births to learn about their multiples’ temperaments, similarities and differences in behavior, and responses to one another.
cribs, a shorter hospital stay, decreased hospital costs, improved parent-nurse communication (one nurse usually cares for the twin pair), more consistent care, a decrease in the number of rehospitalizations, enhanced parent-infant attachment, and easier transition to home. Co-bedding may be problematic for a few twin pairs, as one or both infants may become physiologically unstable (heart rate, breathing, temperature control, for example) or may disturb one another, resulting in more crying, restlessness, less sleep, and added stress (Gannon, 1999; Lutes, 1996a). It is unknown if these are the same infants who “fought” or retreated when stimulated by their cotwin during pregnancy.
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Parent reaction to co-bedding generally has been highly positive, with reports of twins moving closer to each other, touching, holding, hugging, looking at, smiling at, and sucking on one another (Moreau, 1999; Nyqvist & Lutes, 1998). In addition, parents have noted that multiples when co-bedded were calmer after caregiving and feeding than when individually bedded. In a few instances, parents have requested that their twins be separated because the twins were incompatible or the parents wanted to treat the infants individually. Whether or not a multiple-birth infant’s response to his or her co-multiple is at some level of social recognition or constitutes attachment remains to be determined. A neonatal nurse and a physiotherapist commented on the cobedding of triplets and the reunion of two of a threesome: “I’m sure that Justin recognized Rebecca. He was so wide-eyed and alert, almost hyperalert. He reached out and touched her face and her hair. . . . Justin stroked Rebecca’s face and she turned and rooted and sucked on his fingers. Rebecca had never been interested in a soother” (Moreau, 1999, p. 150). Prior to co-bedding, both newborns were tachycardic; when co-bedded, their heart rates fell noticeably.
The Surviving Multiple(s) The loss of a multiple before or after birth is shattering for parents and family and heartbreaking for health care professionals. Parents and families are faced with the paradoxical task of grieving the loss and welcoming a new life (Netzer & Arad, 1999). But what is the impact on a surviving multiple when a co-multiple dies before or shortly after birth? Piontelli (1999) believes that only after intrapair stimulation has become a regular feature of the intrauterine life of twins (after the 1st trimester) should we presume that the surviving twin fetus feels “some kind of sense of ‘loss’ . . .” (p. 13). She states that what a twin fetus might miss is not a complete person but the stimulation arising from and the comfort provided by the co-twin. It is unknown if the stimulation between the pair becomes “forever embedded in the subconscious of the surviving twin” (Piontelli, 1999, p. 13). There are anecdotal accounts from various therapists of emotionally aggrieved survivors when a twin miscarries, such as occurs in “vanishing twin syndrome.” When a twin is stillborn or dies shortly after birth, the emotional impact on the surviving twin may (or may not) be profound (Bryan, 1995; Woodward, 1998). Woodward (1988, 1998) conducted an extensive study of lone twins and discovered that the distress felt by the twin whose co-twin died at or around birth may occur even when the survivor is unaware of being a twin. Some multiple-birth survivors, especially those who lose a monozygotic or dizygotic multiple of the same gender, report a pervasive feeling that
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something is missing or has been lost, endlessly searching for an attachment that cannot be found, intense and constant loneliness, and guilt (Bryan, 1995; Segal, 1999; Woodward, 1988, 1998). Whether or not the fetus has a psychic memory is controversial (Pector, 2001).
Implications for Nursing The existing research provides considerable direction for community and hospital-based nurses and other health care professionals who provide care to the multiple-birth family during the antepartum, postpartum, and infancy periods.
Facilitating Attachment Pregnancy is the beginning of a long and complex process for parents of getting to know and forming an attachment toward the multiples as a unit and as individuals (Anderson & Anderson, 1990; Gromada, 1999; Holditch-Davis et al., 1999; Robin, Kheroua, & Casati, 1992; Sather & Zwelling, 1998; Van der Zalm, 1995a). Fetal movements play a vital role in the attachment process. Van der Zalm (1995a) discovered that for women to relate to their unborn twins and to continually affirm the presence of two living fetuses, they relied on detecting and eliciting fetal activity. The women perceived that fetal activity was “the only reciprocal method of relating to their unborn twins” (p. 123). An expectant mother of triplets wrote to her unborn children: “I could feel all of you moving and kicking inside me. . . . The more I can feel different body parts . . . the more I want to touch them and feel your soft skin” (Sather & Zwelling, 1998, pp. 323, 326). Fetal movements also serve as powerful reminders of an expectant woman’s achievement: “I feel you three moving inside and realize that you are what I’m accomplishing” (Sather & Zwelling, p. 323). Theroux and Tingley (1995) reported that 66% of expectant mothers of twins were able to identify the individual movement patterns of their twins; Damato (2000) indicated that almost 95% of women were able to distinguish between their twin fetuses by position, obstetric labeling, gender, activity, or through a combination of these methods. The recent advent of 3-D ultrasound enables parents to gain a detailed, colored, and threedimensional “portrait” of their unborn children’s faces and body parts, complete with movement. Arabin and colleagues (1998) commented that parents are truly amazed at the existence of intertwin contacts in utero and raise questions about such contacts. Ultrasonographers, fetal monitoring personnel, childbirth educators, midwives, nurse specialists, and antepartum nurses can encourage expectant mothers to observe their unborn children’s movements and patterns. They can also assist 252 JOGNN
the expectant family to differentiate between individual multiples, identify behavioral similarities and differences, recognize intermultiple contacts (during ultrasound examinations and fetal monitoring), and take an active role through questioning and clarification during fetal assessment sessions. Parents may wish to keep a journal and to discuss their observations with family members and other expectant multiple-birth families. It is important for parents to realize that their newborns are not blank slates at birth, but that the groundwork for certain behaviors, temperament, preferences, and the relationship between their multiples is likely taking shape during pregnancy. Care providers need to recognize that women may feel closer to or have a preference for one or more of the unborn multiples (Damato, 2000), and as a result, some women may feel distressed or guilty (Theroux & Tingley, 1995). Expectant women may need help in acknowledging their preferences or fears about the outcome for their unborn multiples.
Developing Parenting Skills The unceasing demands of parenting more than one infant of the same age are compounded when the children are born preterm or experience medical problems. Approximately 50% of twins and 90% of triplets are born both preterm and low birth weight (Ventura, Martin, Curtin, Mathews, & Park, 2000). Certain behaviors or traits of preterm and full-term multiple-birth infants such as irritability, crying, jerky body movements, and difficulty adapting to environmental change may also be expressions of temperament. These traits may leave parents feeling that they are the cause of the behaviors, that they prefer one infant to another, and that they are inadequate as parents. When parents are ready, it can be informative and reassuring to learn more about each infant’s behavioral communication, preferences, abilities, and the nature of the intermultiple interaction. Parents may need to be cautioned about over- or misinterpreting specific intermultiple behaviors. It is satisfying for parents to believe that their children love one another and that they show that love through embraces, kisses, and sucking on one another’s hands. However, when an infant withdraws from the touch of the co-multiple or becomes agitated in his or her presence, parents need to know that this is not an indication of one twin socially rejecting the other. Multiple-birth parents usually welcome the opportunity to participate in the planning and implementation of developmentally and medically supportive care approaches. One such care model is the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) developed by Als (1995). Attention can be directed toward building on the parents’ knowledge of their unborn multiples and neonates, thereby increasing multiple-birth parenting skills, parent confidence, and satisfaction. Volume 31, Number 3
Bedding Multiples Together Co-bedding in hospital and at home is one component of developmentally supportive care and one way to foster the continuity between the intrauterine and extrauterine life of multiple-birth infants (DellaPorta, Aforismo, & Butler-O’Hara, 1998; Nyqvist & Lutes, 1998). Lutes (1996b) warned that we must consider the impact of separating multiple-birth infants, especially if by separating them, we affect their development or long-term mental health. It may become necessary for health care professionals to advocate for the infants and their parents regarding the practice of co-bedding during the infants’ hospitalization. If the infants need to be separated because of incompatibilities or clinical reasons, communication with parents is paramount (DellaPorta et al., 1998; Gannon, 1999).
Supporting Parents and Multiples When a Multiple Dies Parents who have lost one or more of their multiplebirth children require support to deal with their grief and to attach to the surviving multiple(s). However, effective support from health care professionals, families, and society is not always forthcoming (Netzer & Arad, 1999). Sather’s heartrending account of her triplet pregnancy drives home the need for nurses to respond sensitively and appropriately to an expectant parent’s fears of losing one or more of their multiple prenates (Sather & Zwelling, 1998). The importance of assisting parents to get to know their unborn multiples, even when the outcome for one or more is precarious, is captured by Van der Zalm’s (1995b) account of perinatal attachment and detachment. Parents who undergo multifetal pregnancy reduction (or the termination by medical intervention of an abnormal fetus in a continuing pregnancy) generally report high levels of stress, fear, emotional pain, and grief, with some reporting feelings of guilt; the emotional pain may take 1 month to 2 years to resolve (Garel et al., 1997). The parents are often unable to share their decision with family members or friends and may not tell the surviving multiple(s) about it. Such parents need a nonjudgmental attitude and empathetic support from nurses. Parents may require assistance from nurses regarding how to communicate with and support their multiplebirth child(ren) after the death of a multiple as “raising a twinless twin is more difficult than people imagine” (Sorensen, 1998). One study found that the survivors who made the best adjustment to the loss of a co-twin were raised in situations where the parents genuinely wanted and accepted the surviving multiple for herself or himself; parents and the lone twin openly acknowledged, respected, and discussed the intense feelings generated by the loss; and the survivor had access to tangible evidence of May/June 2002
the deceased twin’s existence (Woodward, 1998). Nurses can serve as role models in acknowledging and helping parents express their emotional pain. They can also help parents understand that the survivor(s) may not have conscious memories of the sibling who died at or around birth but that the child will likely experience feelings, perhaps intensely, that are consistent with losing a co-multiple. A surviving infant multiple may want to be cuddled and held more often or may assume sleep and cuddling positions that mimic prenatal life (Pector, 2001). Some lone multiples may be afraid of being abandoned again, fear being alone, or have difficulties attaching to others, including to a co-multiple. The children whose co-multiple died in utero or shortly thereafter may need assurance that they were not responsible for the death. Parents who are overly protective of the survivor(s) may require assistance in dealing with their fears of losing the child and with learning how to nurture the survivor’s development (Woodward, 1998). A referral to a therapist familiar with the complexities of multiples’ loss may benefit certain parents and multiple-birth children. The development of an individual identity is a complex process for a multiple-birth child as it is built on the concept of being part of a pair (Woodward, 1998), trio, or more. When, for example, a twin dies prenatally or postnatally, the lone twin is faced with establishing a separate sense of self, but without the presence of the co-twin. Each survivor needs concrete information about the deceased co-multiple(s); this is illustrated by an 8-year-old lone triplet who frequently asked his mother questions about the prenatal life that he and the other two shared and always informed her “of his loneliness for them” (Gossett, 1998). Nurses can aid parents, through suggestions and actions, to amass a treasury of the deceased multiple’s life that can be viewed and discussed by the parents and survivor(s) over the ensuing years. Tangible evidence may include journal entries made by the mother during pregnancy, naming the deceased baby, copies of ultrasound and fetal monitoring records, a lock of hair, hand and footprints, clothing worn by the baby, photographs of the multiples together and apart, a death certificate, and a gravestone. With perceptive support, the vast majority of surviving multiples “will prove to be normal, talented, and sensitive individuals” (Pector, 2001, p. 6). Parents, older multiple-birth children, and nurses may wish to contact bereavement resources and support networks specific to multiple-birth loss. Resources include the following: Center for Loss in Multiple Birth (CLIMB), P.O. Box 1064, Palmer, AK 99645; telephone: (907) 7452706; e-mail: [email protected]; online: http:// www.climb-support.org; and Multiple Births Canada, Box 234, Gormley, ON L0H 1G0 Canada; telephone: (905) 888-0725; e-mail: [email protected]; online: http://www.multiplebirthscanada.org. Other resources are The Lone Twin (Woodward, 1998), Living
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Without Your Twin (Case, 2001), and Pector’s informative web site, Multiplicity, at http://www.geocities.com/ synspectrum/multiplicity.html.
Nursing and Collaborative Research Further exploration by nurses and other researchers of the intermultiple relationship has the potential to enrich nursing practice and the lives of multiple-birth families. Additional research is needed to further illuminate the nature and significance of the early intermultiple relationship, especially that experienced by higher order multiples. Nursing and collaborative research initiatives are also needed that focus on the development and evaluation of strategies designed to (a) promote parental attachment to multiples during the perinatal period; (b) provide developmentally supportive care to multiple-birth families, including co-bedding; and (c) foster healthy identity development in children whose co-multiple died. Hospital and community-based nurses have the privilege of making a valuable contribution to the health of multiple-birth families. All evidence points toward the importance of nursing strategies that foster parent attachment before and after the births, promote the development of each multiple-birth child, and enhance the unique relationship that multiple-birth children share. REFERENCES Als, H. (1995). Manual for the naturalistic observation of the newborn (preterm and fullterm) (rev. ed.). Boston: Children’s Hospital. Anderson, A., & Anderson, B. (1990). Toward a substantive theory of mother-twin attachment. American Journal of Maternal Child Nursing, 15, 373-377. Arabin, B., Bos, R., Rijlaarsdam, R., Mohnhaupt, A., & van Eyck, J. (1996). The onset of inter-human contacts: Longitudinal ultrasound observations in early twin pregnancies. Ultrasound in Obstetrics and Gynecology, 8(3), 166-173. Arabin, B., Gembruch, U., & van Eyck, J. (1995). Intrauterine behavior. In L. Keith, E. Papiernik, D. Keith, & B. Luke (Eds.), Multiple pregnancy: Epidemiology, gestation, and perinatal outcome (pp. 331-349). New York: Parthenon. Arabin, B., Mohnhaupt, A., & van Eyck, J. (1998). Intrauterine behavior of multiplets. In A. Kurjak (Ed.), Textbook of perinatal medicine (Vol. 1, pp. 1506-1531). London: Parthenon. Bryan, E. (1995). Twins, triplets and more: Their nature, development, and care. London: Multiple Births Foundation. Case, B. (2001). Living without your twin (rev. ed.). Portland, OR: Tibbutt. Damato, E. (2000). Maternal-fetal attachment in twin pregnancies. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 29, 598-605. DellaPorta, K., Aforismo, D., & Butler-O’Hara, M. (1998). Cobedding of twins in the neonatal intensive care unit. Pediatric Nursing, 24(6), 529-531.
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Gallagher, M., Costigan, K., & Johnson, R. (1992). Fetal heart rate accelerations, fetal movement, and fetal behavior patterns in twin gestations. American Journal of Obstetrics and Gynecology, 167(4, Pt. 1), 1140-1144. Gannon, J. (1999). So happy together: Co-bedding multiples boosts growth and development, enhances bonding. Neonatal Network, 18(8), 39-40. Garel, M., Stark, C., Blondel, B., Lefebvre, G., VauthierBrouzes, D., & Zorn, J. (1997). Psychological reactions after multifetal pregnancy reduction: A 2-year follow-up study. Human Reproduction, 12(3), 617-622. Gossett, B. (1998). Jeffrey, Jason, and Jessie . . . Nothing is that simple. Parents of Multiples (POMS) Forever. Retrieved August 12, 2001, from http://www.erichad.com/pom/jjj.htm. Gromada, K. (1999). Mothering multiples: Breastfeeding & caring for twins or more!!! (rev. ed.). Schaumburg, IL: La Leche League International. Holditch-Davis, D., Roberts, D., & Sandelowski, M. (1999). Early parental interactions with and perceptions of multiple birth infants. Journal of Advanced Nursing, 30(1), 200-210. Lutes, L. (1996a). Bedding twins/multiples together. Neonatal Network, 15(7), 61-62. Lutes, L. (1996b). Co-bedding of twins and multiples. Retrieved May 6, 2001, from http://www.parentsplace.com/family/ multiples/gen/0,3375,11533,00.html. Martin, J., Hamilton, B., Ventura, S., Menacher, F, & Park, M. (2002, February 12). Births: Final data for 2002. National Vital Statistics Reports, 50(5). Atlanta, GA: Centers for Disease Control and Prevention. Retrieved February 15, 2002, from http://www.cdc.gov/nchs/data/nvsr/nvsr50/ nvsr50_05.pdf. Moreau, J. (1999). Co-bedding twins in a neonatal intensive care unit: A descriptive case study. Unpublished masters thesis, University of British Columbia School of Nursing, Vancouver, British Columbia, Canada. Netzer, D., & Arad, I. (1999). Premature singleton versus a twin or triplet infant death: Parental adjustment studied through a personal interview. Twin Research, 2(4), 258-263. Nilsson, L., Ingelman-Sundberg, A., &Wirsen, C. (1965). A child is born. New York: Delta. Nyqvist, K., & Lutes, L. (1998). Co-bedding twins: A developmentally supportive strategy. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 27, 450-456. Ohel, G., Samueloff, A., Navot, D., & Sadovsky, E. (1985). Fetal heart rate accelerations and fetal movements in twin pregnancies. American Journal of Obstetrics and Gynecology, 152(6, Pt 1), 686-687. Pector, E. (2001). Raising survivors of multiple birth loss: What can parents expect? Retrieved October 2, 2001, from http://www.geocities.com/synspectrum/survivors3.doc. Piontelli, A. (1989). A study on twins before and after birth. International Review of Psycho-Analysis, 16(4), 413-426. Piontelli, A. (1999). Twins in utero: Temperament development and intertwin behavior before and after birth. In A. Sandbank (Ed.), Twin and triplet psychology (pp. 7-18). London: Routledge. Piontelli, A., Bocconi, L., Boschetto, C., Kustermann, A., & Nicolini, U. (1999). Differences and similarities in the intra-uterine behavior of monozygotic and dizygotic twins. Twin Research, 2(4), 264-273.
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Piontelli, A., Bocconi, L., Kustermann, A., Tassis, B., Zoppini, C., & Nicolini, U. (1997). Patterns of evoked behavior in twin pregnancies during the first 22 weeks of gestation. Early Human Development, 50(1), 39-45. Robin, M., Kheroua, H., & Casati, I. (1992). Effects of early mother-twin relationships from birth to age 3, on twin bonding. Acta Geneticae Medicae et Gemellologiae, 41, 143-148. Sather, S., & Zwelling, E. (1998). A view from the other side of the bed. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 27, 322-328. Segal, N. (1999). Entwined lives: Twins and what they tell us about human behavior. New York: Plume. Sheehan, N. (1995, November 19). Sisters kept close: Twins do better in crib together. Worcester Telegraph & Gazette, pp. 1, A10. Sherer, D., Nawrocki, M., Abramowicz, J., Peco, N., Metlay, L., & Woods, J. (1992). Is there a “dominant twin” in utero? American Journal of Perinatology, 9(5-6), 460-463. Sherer, D., Nawrocki, M., Peco, N., Metlay, L., & Woods, J. (1990). The occurrence of simultaneous fetal heart rate accelerations in twins during nonstress testing. Obstetrics and Gynecology, 76(5, Pt. 1), 817-821. Sorensen, R. (1998). In memory of James. Parents of Multiples (POMS) Forever. Retrieved August 12, 2001, from http://www.erichad.com/pom/james.htm. Statistics Canada. (2001, December 10). Births: 1999. The Daily. Retrieved February 15, 2002, from http://www. statcan.ca/daily/english/011210/d011210b.htm. Theroux, R., & Tingley, J. (1995). Bonding and attachment. In L. Keith, E. Papiernik, D. Keith, & B. Luke (Eds.), Multiple pregnancy: Epidemiology, gestation, and perinatal outcome (pp. 563-571). New York: Parthenon. Van der Zalm, J. (1995a). Accommodating a twin pregnancy: Maternal processes. Acta Geneticae Medicae et Gemellologiae, 44(2), 117-133.
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Van der Zalm, J. (1995b). The perinatal death of a twin: Karla’s story of attaching and detaching. Journal of NurseMidwifery, 40(4), 335-341. Ventura, S., Martin, J., Curtin, S., Mathews, T., & Park, M. (2000, March 28). Births: Final data for 1998. National Vital Statistics Reports, 48(3). Atlanta, GA: Centers for Disease Control and Prevention. Retrieved February 9, 2001, from http://www.cdc.gov/nchs/data/nvs48_3.pdf. Walker, A. (2000, June). Multiple birth, pre-term babies should share bed. Medical Post, 36(23). Retrieved May 6, 2001, from http://www.medicalpost.com/mdlink/english/ members/medpost/data/3623/02A.HTM. Woodward, J. (1988). The bereaved twin. Acta Geneticae Medicae et Gemellologiae, 37, 173-180. Woodward, J. (1998). The lone twin: Understanding twin bereavement and loss. London: Free Association Books. Zimmer, E., Goldstein, I., & Alglay, S. (1988). Simultaneous recording of fetal breathing movements and body movements in twin pregnancy. Journal of Perinatal Medicine, 16(2), 109-112.
Linda G. Leonard is an associate professor in the School of Nursing at the University of British Columbia and a multiplebirths specialist. She developed and operates an outreach support program for multiple-birth families and is an advisor to Multiple Births Canada (MBC), the national organization located near Toronto, ON. MBC aims to improve the quality of life for Canadian multiple-birth families and individuals through support, education, research, and advocacy. Address for correspondence: Linda G. Leonard, RN, MSN, School of Nursing, University of British Columbia, T 201 2211 Wesbrook Mall, Vancouver, British Columbia, V6T 2B5 Canada. E-mail: [email protected].
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PRINCIPLES & PRACTICE
Prenatal Behavior of Multiples: Implications for Families and Nurses Linda G. Leonard, RN, MSN
Each twin and higher order multiple leads an extraordinary life before birth. The literature has revealed that the intrauterine environment differs for every multiple fetus and helps to shape the individuality of each multiple-birth child. From early in pregnancy, it appears that a multiple develops his or her own temperament and each set of multiples establishes an individualized pattern of tactile communication between or among themselves. The same behaviors, traits, and intermultiple interactions seen in pregnancy also have been observed in infancy and beyond. Intermultiple communication continues after birth, and preliminary evidence suggests that co-bedding assists the majority of newborns to make the transition from intrauterine to extrauterine life. The response of a multiple to the death of a co-multiple during pregnancy or after birth may be influenced by the relationship they shared in utero. Nurses and other health care providers have a role to play in informing multiple-birth parents about the latest knowledge, thereby assisting parents with the attachment process and specific parenting issues. In addition, nurses now have a solid foundation on which to create and implement care strategies that promote the healthy development of each multiple-birth infant and the intermultiple relationship. JOGNN, 31, 248–255; 2002. Keywords: Attachment—Co-bedding— Death—Higher order multiples—Prenatal relationship—Twins Accepted: October 2001
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. . . you all are active and it makes me feel so blessed and alive to put my hands against my skin and feel your movements. (Sather & Zwelling, 1998, p. 324) The miracle of the developing human fetus became known to us through the magnificent photography of Lennart Nilsson (1965) in A Child Is Born and through ultrasound technology. Fetuses react to sounds and light, kick, twist their bodies, somersault, startle, stroke their faces, hang on to the umbilical cord, suck their fingers, breathe, swallow, stretch, yawn, and even jump off the uterine wall (Arabin, Mohnhaupt, & van Eyck, 1998). Our fascination now extends to the prenatal lives of twins and higher order multiples. Each year, more than 126,000 multiple-birth infants are born in the United States (Martin, Hamilton, Ventura, Menacher, & Park, 2002) and 9,100 are born in Canada (Statistics Canada, 2001). Even though multiples share the intrauterine environment, that environment is constantly changing and is not the same for each twin or higher order multiple fetus (Piontelli, Bocconi, Boschetto, Kustermann, & Nicolini, 1999). In the vast majority of multiple pregnancies, each fetus has its own placenta, umbilical cord, and amniotic fluid. Multiples develop in different locations within the uterus and do not receive an equal share of blood, nutrients, and stimuli. When they do share a placenta, it is not shared equally. It is now realized that an important part of the environment of a multiple fetus is the tactile stimulation received from a co-multiple (Arabin,
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Gembruch, & van Eyck, 1995; Piontelli, 1999). Thus, each multiple-birth newborn, whether monozygotic (“identical”) or dizygotic (“fraternal”), is shaped not only by his or her genetic makeup but also by a highly individualized prenatal experience. An extensive review of the ultrasonography, maternalfetal medicine, fetal/child development, and nursing literature was conducted. The findings arising from the
T
win fetuses engage in intrapair stimulation by 15 weeks gestation.
research lend support to and suggest ways that caregivers can provide developmentally and therapeutically supportive care to multiple-birth children and their families during the prenatal and childrearing years. Not only is the intermultiple relationship fascinating, but this knowledge enables multiple-birth parents and health professionals to better understand the uniqueness of each multiple-birth prenate (fetus) and the way in which multiples interact with one another.
Historical Beginnings Several researchers became curious about electronic fetal monitoring data elicited during the 3rd trimester of twin pregnancies. They determined that there was a significant amount of synchrony (simultaneity) within twin pairs regarding fetal heart rate accelerations, breathing motions, and body movements (Ohel, Samueloff, Navot, & Sadovsky, 1985; Sherer, Nawrocki, Peco, Metlay, & Woods, 1990; Zimmer, Goldstein, & Alglay, 1988). Behavioral patterns, similar to those seen after birth, were detected in sets of twins who were 28 to 39 weeks gestation (Gallagher, Costigan, & Johnson, 1992). Each twin pair was found to be synchronous 95% of the time regarding the amount of time a twin and co-twin spent in each of the four sleep-awake states (quiet sleep, active sleep, quiet awake, active awake). Monochorionic-diamniotic twins were synchronous 100% of the time, and dichorionic twins 92% of the time. Same-gender twins were more synchronous (98%) than unlike-gender pairs (90%). Evidence mounted that a notable portion of the heart rate accelerations and breathing and body movement patterns of twin fetuses was likely due to tactile communication between the pair (Sherer et al., 1990). Monochorionic-diamniotic twins share one chorion (membrane closest to the uterus), and each twin has his or her own amnion (membrane surrounding the amniotic May/June 2002
fluid). Found in separate amniotic sacs, the twins are monozygotic (identical) and always the same gender. Monochorionic-monoamniotic twins share the same amnion and chorion and are in one chorioamniotic sac. They are monozygotic and always the same gender. Dichorionic twins have a separate chorion and amnion and are in separate chorioamniotic sacs. They may be monozygotic or dizygotic (fraternal) and are of the same or different genders.
Temperament and Fetal Twins Real-time ultrasound, using transvaginal and transabdominal sonography, has made it possible to observe fetal motility and to make intermultiple comparisons. Two independent research teams headed by Arabin and Piontelli, respectively, painstakingly analyzed hours of videotaped ultrasounds of twin and triplet pregnancies. Arabin, a perinatologist, and her colleagues focused on documenting the onset and type of movements seen in twin/triplet prenates as well as the nature of responses elicited during their contacts. Piontelli, a psychologist, and her coworkers focused on the differences and similarities in a twin pair, the intertwin relationship, and the indications that prenatal life provides a glimpse of future temperament and the intertwin relationship. Intertwin differences in behavioral traits or temperament have been detected prenatally (Piontelli, 1989; Piontelli et al., 1999). Piontelli and coworkers noted that in the first part of pregnancy, a pair of monozygotic twins behaves more similarly than differently, but as the pregnancy progresses, the pair become as dissimilar as dizygotic twins. A co-twin behaves differently from his or her sibling with regard to the amount and quality of movements, the amount of stimulation required to elicit activity, preferred activities and positions, and the rhythm of sleep-awake cycles. It has been observed that the twin in each pair who is more active during one ultrasound observation continues to be more active during future observations (Piontelli et al., 1999). Behavioral differences between twins may persist throughout pregnancy and continue after the births into infancy and beyond (Holditch-Davis, Roberts, & Sandelowski, 1999; Piontelli, 1989; Piontelli et al., 1999). Sherer and colleagues (1992), using electronic monitoring, were unable to determine if one fetal twin is more dominant than the other. Preliminary ultrasound evidence suggests that one twin may be more dominant than the other and that dominance should be regarded only as one twin being more active than the other (Piontelli, 1999). Piontelli clarifies that an actively moving fetus is not awake but in a different phase of “sleep.” Brief episodes of wakefulness have only been detected close to term. As pregnancy moves closer to term and the living space becomes more crowded, the amount of activity between
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the twin fetuses decreases, especially large body movements such as startles. Fetal body movements continue during labor in twin and triplet pregnancies (Arabin et al., 1995). If a twin or triplet prenate has a health problem such as a major malformation, the quality and quantity of movements may be affected. The affected fetus will likely conserve energy and may progress to intermultiple contacts at a later gestational age or not at all; the result will be less intermultiple communication in utero (Arabin et al., 1998; Piontelli et al., 1999).
Intrauterine Twin Communication The entire behavior of unborn twins can be captured on one ultrasound screen until only 16 to 22 weeks gestation (Arabin et al., 1998; Piontelli, 1999). Active movements of a fetus begin around 7 completed weeks of pregnancy and progress from being somewhat jerky to slow and harmonious by 16 weeks gestation (Arabin et al., 1998). In the last half of pregnancy, the heads and small body parts become the focus of intertwin studies. The first touches in utero start with slow initiatives from the twin and slow responses from the co-twin; the speed of initiatives and reactions were noted to be greater in male pairs than in female or mixed pairs of twins. Differences in testosterone levels might have an effect on early intrauterine development (Arabin et al., 1998). Tactile contacts between monochorionic-monoamniotic twins occur at approximately 9 weeks gestation (Arabin, Bos, Rijlaarsdam, Mohnhaupt, & van Eyck, 1996); contacts for these prenates are the easiest because they share the same amniotic sac. Between 10 and 12 weeks gestation, monochorionic twins begin to stimulate each other, whereas dichorionic twins engage in intertwin stimulation at 12 to 15 weeks gestation (Arabin et al., 1996; Piontelli, 1999). Monochorionic twins have more opportunities than dichorionic twins for intertwin communication because they are more proximate to one another, share the same placenta, and are separated by no or thinner intertwin membranes (Arabin et al., 1998). By 15 weeks gestation, intrapair stimulation occurs in all twin pregnancies (Piontelli, 1999). Arabin et al. (1995) observed via ultrasound “twins approaching each other continuously with their hands or faces” (p. 342). Female pairs seem to develop full-body contacts (parents refer to them as embraces) or mouth contacts (parents call them kissing) earlier than male pairs (Arabin et al., 1996). Male and female pairs engage equally in less complex body contacts such as touching a cotwin with a leg, arm, or head. Twin prenates experience more tactile stimuli than unborn singletons. Arabin et al. (1996) contended that this stimulation may accelerate and improve the development of twin children on specific neurologic and physical maturity measures.
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All stimulation emanating from a multiple, such as a punch or kick, will not necessarily result in a response from a co-multiple. If the receiving prenate is in a period of rest, motor inhibition, or has become accustomed to a stimulus such as his mother’s bowel sounds, there will likely be no reaction (Arabin et al., 1995; Piontelli et al., 1997). This may explain why most newborn twins are not disturbed by a co-twin’s punches or loud crying, or when the household vacuum cleaner is operating. Some multiples seem to seek contact during the pregnancy and show a preference for touch or physical nearness, whereas others appear to avoid contact with their co-multiple. Piontelli (1989) describes one set of unborn twins in which the male would reach out through the inter-twin membranes and touch his sister’s face; the twin responded by turning her face toward him and the two engaged in a gentle cheek-to-cheek motion of stroking. At age 1, they played a favorite game of using a curtain as a type of membrane to separate themselves; the male put his hand through the curtain and his sister put her cheek forward and they began their mutual stroking. A second set of fetal twins enjoyed a different relationship: when the female tried to make contact with her brother, he would cover his face with his hands, withdraw, and bury his face in the placenta. If she continued to seek him out, he would punch her back, sometimes quite violently. At age 1, the same behavior continued between the two, with the placenta being replaced by the mother’s lap or other soft object.
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etal movements enable a woman expecting multiples to relate to her unborn children, affirm that each one is alive and healthy, and attach to them individually and as a unit.
Woodward (1998), a lone twin herself, an attachment therapist, and founder of The Lone Twin Network in Britain, noted that some form of attachment may occur between twin pairs prior to and around the time of birth. Piontelli (1999) cautioned that one must not assume that unborn twins are attaching psychologic or social meaning to the contacts with their co-twin or that they are expressing the more complex feelings of love, jealousy, longing, or rejection. She noted that once twins are born, they do not show signs of “social recognition” toward each other. Instead, they may seek physical closeness because of the need for warmth, touch, security, and the other kinds of stimulation that the co-twin can provide. The link between
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behavior before and after the births requires clarification; co-bedding studies present such an opportunity.
Co-bedding of Twins and More Co-bedding first came to the attention of parents and health professionals in North America in 1995 when the Worcester Telegram & Gazette (MA) published a story and photograph of preterm twins bedded together in the neonatal intensive-care unit (Sheehan, 1995). Co-bedding is a continuation of the closeness and shared intrauterine experiences of multiples. It is theorized that multiple-birth newborns may have the unique ability to support each other during their transition to extrauterine life (Nyqvist & Lutes, 1998). Research is under way in several centers to determine whether and how co-bedding is advantageous to multiple-birth newborns requiring neonatal intensive care (Walker, 2000). The purported physiologic advantages of co-bedding as compared to individual bedding are improved heart rate, temperature, and respiratory control (including fewer apneic periods [Walker, 2000]); lower oxygen requirements; greater weight gain; and improved motor development, coregulation (balancing and supporting of one another), and facilitation of state control such as sleep and alertness (Nyqvist & Lutes, 1998). Other benefits of co-bedding may include improved infant growth and development, faster movement from isolettes to open
N
urses and other health professionals can assist parents before and after the births to learn about their multiples’ temperaments, similarities and differences in behavior, and responses to one another.
cribs, a shorter hospital stay, decreased hospital costs, improved parent-nurse communication (one nurse usually cares for the twin pair), more consistent care, a decrease in the number of rehospitalizations, enhanced parent-infant attachment, and easier transition to home. Co-bedding may be problematic for a few twin pairs, as one or both infants may become physiologically unstable (heart rate, breathing, temperature control, for example) or may disturb one another, resulting in more crying, restlessness, less sleep, and added stress (Gannon, 1999; Lutes, 1996a). It is unknown if these are the same infants who “fought” or retreated when stimulated by their cotwin during pregnancy.
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Parent reaction to co-bedding generally has been highly positive, with reports of twins moving closer to each other, touching, holding, hugging, looking at, smiling at, and sucking on one another (Moreau, 1999; Nyqvist & Lutes, 1998). In addition, parents have noted that multiples when co-bedded were calmer after caregiving and feeding than when individually bedded. In a few instances, parents have requested that their twins be separated because the twins were incompatible or the parents wanted to treat the infants individually. Whether or not a multiple-birth infant’s response to his or her co-multiple is at some level of social recognition or constitutes attachment remains to be determined. A neonatal nurse and a physiotherapist commented on the cobedding of triplets and the reunion of two of a threesome: “I’m sure that Justin recognized Rebecca. He was so wide-eyed and alert, almost hyperalert. He reached out and touched her face and her hair. . . . Justin stroked Rebecca’s face and she turned and rooted and sucked on his fingers. Rebecca had never been interested in a soother” (Moreau, 1999, p. 150). Prior to co-bedding, both newborns were tachycardic; when co-bedded, their heart rates fell noticeably.
The Surviving Multiple(s) The loss of a multiple before or after birth is shattering for parents and family and heartbreaking for health care professionals. Parents and families are faced with the paradoxical task of grieving the loss and welcoming a new life (Netzer & Arad, 1999). But what is the impact on a surviving multiple when a co-multiple dies before or shortly after birth? Piontelli (1999) believes that only after intrapair stimulation has become a regular feature of the intrauterine life of twins (after the 1st trimester) should we presume that the surviving twin fetus feels “some kind of sense of ‘loss’ . . .” (p. 13). She states that what a twin fetus might miss is not a complete person but the stimulation arising from and the comfort provided by the co-twin. It is unknown if the stimulation between the pair becomes “forever embedded in the subconscious of the surviving twin” (Piontelli, 1999, p. 13). There are anecdotal accounts from various therapists of emotionally aggrieved survivors when a twin miscarries, such as occurs in “vanishing twin syndrome.” When a twin is stillborn or dies shortly after birth, the emotional impact on the surviving twin may (or may not) be profound (Bryan, 1995; Woodward, 1998). Woodward (1988, 1998) conducted an extensive study of lone twins and discovered that the distress felt by the twin whose co-twin died at or around birth may occur even when the survivor is unaware of being a twin. Some multiple-birth survivors, especially those who lose a monozygotic or dizygotic multiple of the same gender, report a pervasive feeling that
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something is missing or has been lost, endlessly searching for an attachment that cannot be found, intense and constant loneliness, and guilt (Bryan, 1995; Segal, 1999; Woodward, 1988, 1998). Whether or not the fetus has a psychic memory is controversial (Pector, 2001).
Implications for Nursing The existing research provides considerable direction for community and hospital-based nurses and other health care professionals who provide care to the multiple-birth family during the antepartum, postpartum, and infancy periods.
Facilitating Attachment Pregnancy is the beginning of a long and complex process for parents of getting to know and forming an attachment toward the multiples as a unit and as individuals (Anderson & Anderson, 1990; Gromada, 1999; Holditch-Davis et al., 1999; Robin, Kheroua, & Casati, 1992; Sather & Zwelling, 1998; Van der Zalm, 1995a). Fetal movements play a vital role in the attachment process. Van der Zalm (1995a) discovered that for women to relate to their unborn twins and to continually affirm the presence of two living fetuses, they relied on detecting and eliciting fetal activity. The women perceived that fetal activity was “the only reciprocal method of relating to their unborn twins” (p. 123). An expectant mother of triplets wrote to her unborn children: “I could feel all of you moving and kicking inside me. . . . The more I can feel different body parts . . . the more I want to touch them and feel your soft skin” (Sather & Zwelling, 1998, pp. 323, 326). Fetal movements also serve as powerful reminders of an expectant woman’s achievement: “I feel you three moving inside and realize that you are what I’m accomplishing” (Sather & Zwelling, p. 323). Theroux and Tingley (1995) reported that 66% of expectant mothers of twins were able to identify the individual movement patterns of their twins; Damato (2000) indicated that almost 95% of women were able to distinguish between their twin fetuses by position, obstetric labeling, gender, activity, or through a combination of these methods. The recent advent of 3-D ultrasound enables parents to gain a detailed, colored, and threedimensional “portrait” of their unborn children’s faces and body parts, complete with movement. Arabin and colleagues (1998) commented that parents are truly amazed at the existence of intertwin contacts in utero and raise questions about such contacts. Ultrasonographers, fetal monitoring personnel, childbirth educators, midwives, nurse specialists, and antepartum nurses can encourage expectant mothers to observe their unborn children’s movements and patterns. They can also assist 252 JOGNN
the expectant family to differentiate between individual multiples, identify behavioral similarities and differences, recognize intermultiple contacts (during ultrasound examinations and fetal monitoring), and take an active role through questioning and clarification during fetal assessment sessions. Parents may wish to keep a journal and to discuss their observations with family members and other expectant multiple-birth families. It is important for parents to realize that their newborns are not blank slates at birth, but that the groundwork for certain behaviors, temperament, preferences, and the relationship between their multiples is likely taking shape during pregnancy. Care providers need to recognize that women may feel closer to or have a preference for one or more of the unborn multiples (Damato, 2000), and as a result, some women may feel distressed or guilty (Theroux & Tingley, 1995). Expectant women may need help in acknowledging their preferences or fears about the outcome for their unborn multiples.
Developing Parenting Skills The unceasing demands of parenting more than one infant of the same age are compounded when the children are born preterm or experience medical problems. Approximately 50% of twins and 90% of triplets are born both preterm and low birth weight (Ventura, Martin, Curtin, Mathews, & Park, 2000). Certain behaviors or traits of preterm and full-term multiple-birth infants such as irritability, crying, jerky body movements, and difficulty adapting to environmental change may also be expressions of temperament. These traits may leave parents feeling that they are the cause of the behaviors, that they prefer one infant to another, and that they are inadequate as parents. When parents are ready, it can be informative and reassuring to learn more about each infant’s behavioral communication, preferences, abilities, and the nature of the intermultiple interaction. Parents may need to be cautioned about over- or misinterpreting specific intermultiple behaviors. It is satisfying for parents to believe that their children love one another and that they show that love through embraces, kisses, and sucking on one another’s hands. However, when an infant withdraws from the touch of the co-multiple or becomes agitated in his or her presence, parents need to know that this is not an indication of one twin socially rejecting the other. Multiple-birth parents usually welcome the opportunity to participate in the planning and implementation of developmentally and medically supportive care approaches. One such care model is the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) developed by Als (1995). Attention can be directed toward building on the parents’ knowledge of their unborn multiples and neonates, thereby increasing multiple-birth parenting skills, parent confidence, and satisfaction. Volume 31, Number 3
Bedding Multiples Together Co-bedding in hospital and at home is one component of developmentally supportive care and one way to foster the continuity between the intrauterine and extrauterine life of multiple-birth infants (DellaPorta, Aforismo, & Butler-O’Hara, 1998; Nyqvist & Lutes, 1998). Lutes (1996b) warned that we must consider the impact of separating multiple-birth infants, especially if by separating them, we affect their development or long-term mental health. It may become necessary for health care professionals to advocate for the infants and their parents regarding the practice of co-bedding during the infants’ hospitalization. If the infants need to be separated because of incompatibilities or clinical reasons, communication with parents is paramount (DellaPorta et al., 1998; Gannon, 1999).
Supporting Parents and Multiples When a Multiple Dies Parents who have lost one or more of their multiplebirth children require support to deal with their grief and to attach to the surviving multiple(s). However, effective support from health care professionals, families, and society is not always forthcoming (Netzer & Arad, 1999). Sather’s heartrending account of her triplet pregnancy drives home the need for nurses to respond sensitively and appropriately to an expectant parent’s fears of losing one or more of their multiple prenates (Sather & Zwelling, 1998). The importance of assisting parents to get to know their unborn multiples, even when the outcome for one or more is precarious, is captured by Van der Zalm’s (1995b) account of perinatal attachment and detachment. Parents who undergo multifetal pregnancy reduction (or the termination by medical intervention of an abnormal fetus in a continuing pregnancy) generally report high levels of stress, fear, emotional pain, and grief, with some reporting feelings of guilt; the emotional pain may take 1 month to 2 years to resolve (Garel et al., 1997). The parents are often unable to share their decision with family members or friends and may not tell the surviving multiple(s) about it. Such parents need a nonjudgmental attitude and empathetic support from nurses. Parents may require assistance from nurses regarding how to communicate with and support their multiplebirth child(ren) after the death of a multiple as “raising a twinless twin is more difficult than people imagine” (Sorensen, 1998). One study found that the survivors who made the best adjustment to the loss of a co-twin were raised in situations where the parents genuinely wanted and accepted the surviving multiple for herself or himself; parents and the lone twin openly acknowledged, respected, and discussed the intense feelings generated by the loss; and the survivor had access to tangible evidence of May/June 2002
the deceased twin’s existence (Woodward, 1998). Nurses can serve as role models in acknowledging and helping parents express their emotional pain. They can also help parents understand that the survivor(s) may not have conscious memories of the sibling who died at or around birth but that the child will likely experience feelings, perhaps intensely, that are consistent with losing a co-multiple. A surviving infant multiple may want to be cuddled and held more often or may assume sleep and cuddling positions that mimic prenatal life (Pector, 2001). Some lone multiples may be afraid of being abandoned again, fear being alone, or have difficulties attaching to others, including to a co-multiple. The children whose co-multiple died in utero or shortly thereafter may need assurance that they were not responsible for the death. Parents who are overly protective of the survivor(s) may require assistance in dealing with their fears of losing the child and with learning how to nurture the survivor’s development (Woodward, 1998). A referral to a therapist familiar with the complexities of multiples’ loss may benefit certain parents and multiple-birth children. The development of an individual identity is a complex process for a multiple-birth child as it is built on the concept of being part of a pair (Woodward, 1998), trio, or more. When, for example, a twin dies prenatally or postnatally, the lone twin is faced with establishing a separate sense of self, but without the presence of the co-twin. Each survivor needs concrete information about the deceased co-multiple(s); this is illustrated by an 8-year-old lone triplet who frequently asked his mother questions about the prenatal life that he and the other two shared and always informed her “of his loneliness for them” (Gossett, 1998). Nurses can aid parents, through suggestions and actions, to amass a treasury of the deceased multiple’s life that can be viewed and discussed by the parents and survivor(s) over the ensuing years. Tangible evidence may include journal entries made by the mother during pregnancy, naming the deceased baby, copies of ultrasound and fetal monitoring records, a lock of hair, hand and footprints, clothing worn by the baby, photographs of the multiples together and apart, a death certificate, and a gravestone. With perceptive support, the vast majority of surviving multiples “will prove to be normal, talented, and sensitive individuals” (Pector, 2001, p. 6). Parents, older multiple-birth children, and nurses may wish to contact bereavement resources and support networks specific to multiple-birth loss. Resources include the following: Center for Loss in Multiple Birth (CLIMB), P.O. Box 1064, Palmer, AK 99645; telephone: (907) 7452706; e-mail: [email protected]; online: http:// www.climb-support.org; and Multiple Births Canada, Box 234, Gormley, ON L0H 1G0 Canada; telephone: (905) 888-0725; e-mail: [email protected]; online: http://www.multiplebirthscanada.org. Other resources are The Lone Twin (Woodward, 1998), Living
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Without Your Twin (Case, 2001), and Pector’s informative web site, Multiplicity, at http://www.geocities.com/ synspectrum/multiplicity.html.
Nursing and Collaborative Research Further exploration by nurses and other researchers of the intermultiple relationship has the potential to enrich nursing practice and the lives of multiple-birth families. Additional research is needed to further illuminate the nature and significance of the early intermultiple relationship, especially that experienced by higher order multiples. Nursing and collaborative research initiatives are also needed that focus on the development and evaluation of strategies designed to (a) promote parental attachment to multiples during the perinatal period; (b) provide developmentally supportive care to multiple-birth families, including co-bedding; and (c) foster healthy identity development in children whose co-multiple died. Hospital and community-based nurses have the privilege of making a valuable contribution to the health of multiple-birth families. All evidence points toward the importance of nursing strategies that foster parent attachment before and after the births, promote the development of each multiple-birth child, and enhance the unique relationship that multiple-birth children share. REFERENCES Als, H. (1995). Manual for the naturalistic observation of the newborn (preterm and fullterm) (rev. ed.). Boston: Children’s Hospital. Anderson, A., & Anderson, B. (1990). Toward a substantive theory of mother-twin attachment. American Journal of Maternal Child Nursing, 15, 373-377. Arabin, B., Bos, R., Rijlaarsdam, R., Mohnhaupt, A., & van Eyck, J. (1996). The onset of inter-human contacts: Longitudinal ultrasound observations in early twin pregnancies. Ultrasound in Obstetrics and Gynecology, 8(3), 166-173. Arabin, B., Gembruch, U., & van Eyck, J. (1995). Intrauterine behavior. In L. Keith, E. Papiernik, D. Keith, & B. Luke (Eds.), Multiple pregnancy: Epidemiology, gestation, and perinatal outcome (pp. 331-349). New York: Parthenon. Arabin, B., Mohnhaupt, A., & van Eyck, J. (1998). Intrauterine behavior of multiplets. In A. Kurjak (Ed.), Textbook of perinatal medicine (Vol. 1, pp. 1506-1531). London: Parthenon. Bryan, E. (1995). Twins, triplets and more: Their nature, development, and care. London: Multiple Births Foundation. Case, B. (2001). Living without your twin (rev. ed.). Portland, OR: Tibbutt. Damato, E. (2000). Maternal-fetal attachment in twin pregnancies. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 29, 598-605. DellaPorta, K., Aforismo, D., & Butler-O’Hara, M. (1998). Cobedding of twins in the neonatal intensive care unit. Pediatric Nursing, 24(6), 529-531.
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Gallagher, M., Costigan, K., & Johnson, R. (1992). Fetal heart rate accelerations, fetal movement, and fetal behavior patterns in twin gestations. American Journal of Obstetrics and Gynecology, 167(4, Pt. 1), 1140-1144. Gannon, J. (1999). So happy together: Co-bedding multiples boosts growth and development, enhances bonding. Neonatal Network, 18(8), 39-40. Garel, M., Stark, C., Blondel, B., Lefebvre, G., VauthierBrouzes, D., & Zorn, J. (1997). Psychological reactions after multifetal pregnancy reduction: A 2-year follow-up study. Human Reproduction, 12(3), 617-622. Gossett, B. (1998). Jeffrey, Jason, and Jessie . . . Nothing is that simple. Parents of Multiples (POMS) Forever. Retrieved August 12, 2001, from http://www.erichad.com/pom/jjj.htm. Gromada, K. (1999). Mothering multiples: Breastfeeding & caring for twins or more!!! (rev. ed.). Schaumburg, IL: La Leche League International. Holditch-Davis, D., Roberts, D., & Sandelowski, M. (1999). Early parental interactions with and perceptions of multiple birth infants. Journal of Advanced Nursing, 30(1), 200-210. Lutes, L. (1996a). Bedding twins/multiples together. Neonatal Network, 15(7), 61-62. Lutes, L. (1996b). Co-bedding of twins and multiples. Retrieved May 6, 2001, from http://www.parentsplace.com/family/ multiples/gen/0,3375,11533,00.html. Martin, J., Hamilton, B., Ventura, S., Menacher, F, & Park, M. (2002, February 12). Births: Final data for 2002. National Vital Statistics Reports, 50(5). Atlanta, GA: Centers for Disease Control and Prevention. Retrieved February 15, 2002, from http://www.cdc.gov/nchs/data/nvsr/nvsr50/ nvsr50_05.pdf. Moreau, J. (1999). Co-bedding twins in a neonatal intensive care unit: A descriptive case study. Unpublished masters thesis, University of British Columbia School of Nursing, Vancouver, British Columbia, Canada. Netzer, D., & Arad, I. (1999). Premature singleton versus a twin or triplet infant death: Parental adjustment studied through a personal interview. Twin Research, 2(4), 258-263. Nilsson, L., Ingelman-Sundberg, A., &Wirsen, C. (1965). A child is born. New York: Delta. Nyqvist, K., & Lutes, L. (1998). Co-bedding twins: A developmentally supportive strategy. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 27, 450-456. Ohel, G., Samueloff, A., Navot, D., & Sadovsky, E. (1985). Fetal heart rate accelerations and fetal movements in twin pregnancies. American Journal of Obstetrics and Gynecology, 152(6, Pt 1), 686-687. Pector, E. (2001). Raising survivors of multiple birth loss: What can parents expect? Retrieved October 2, 2001, from http://www.geocities.com/synspectrum/survivors3.doc. Piontelli, A. (1989). A study on twins before and after birth. International Review of Psycho-Analysis, 16(4), 413-426. Piontelli, A. (1999). Twins in utero: Temperament development and intertwin behavior before and after birth. In A. Sandbank (Ed.), Twin and triplet psychology (pp. 7-18). London: Routledge. Piontelli, A., Bocconi, L., Boschetto, C., Kustermann, A., & Nicolini, U. (1999). Differences and similarities in the intra-uterine behavior of monozygotic and dizygotic twins. Twin Research, 2(4), 264-273.
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Piontelli, A., Bocconi, L., Kustermann, A., Tassis, B., Zoppini, C., & Nicolini, U. (1997). Patterns of evoked behavior in twin pregnancies during the first 22 weeks of gestation. Early Human Development, 50(1), 39-45. Robin, M., Kheroua, H., & Casati, I. (1992). Effects of early mother-twin relationships from birth to age 3, on twin bonding. Acta Geneticae Medicae et Gemellologiae, 41, 143-148. Sather, S., & Zwelling, E. (1998). A view from the other side of the bed. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 27, 322-328. Segal, N. (1999). Entwined lives: Twins and what they tell us about human behavior. New York: Plume. Sheehan, N. (1995, November 19). Sisters kept close: Twins do better in crib together. Worcester Telegraph & Gazette, pp. 1, A10. Sherer, D., Nawrocki, M., Abramowicz, J., Peco, N., Metlay, L., & Woods, J. (1992). Is there a “dominant twin” in utero? American Journal of Perinatology, 9(5-6), 460-463. Sherer, D., Nawrocki, M., Peco, N., Metlay, L., & Woods, J. (1990). The occurrence of simultaneous fetal heart rate accelerations in twins during nonstress testing. Obstetrics and Gynecology, 76(5, Pt. 1), 817-821. Sorensen, R. (1998). In memory of James. Parents of Multiples (POMS) Forever. Retrieved August 12, 2001, from http://www.erichad.com/pom/james.htm. Statistics Canada. (2001, December 10). Births: 1999. The Daily. Retrieved February 15, 2002, from http://www. statcan.ca/daily/english/011210/d011210b.htm. Theroux, R., & Tingley, J. (1995). Bonding and attachment. In L. Keith, E. Papiernik, D. Keith, & B. Luke (Eds.), Multiple pregnancy: Epidemiology, gestation, and perinatal outcome (pp. 563-571). New York: Parthenon. Van der Zalm, J. (1995a). Accommodating a twin pregnancy: Maternal processes. Acta Geneticae Medicae et Gemellologiae, 44(2), 117-133.
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Van der Zalm, J. (1995b). The perinatal death of a twin: Karla’s story of attaching and detaching. Journal of NurseMidwifery, 40(4), 335-341. Ventura, S., Martin, J., Curtin, S., Mathews, T., & Park, M. (2000, March 28). Births: Final data for 1998. National Vital Statistics Reports, 48(3). Atlanta, GA: Centers for Disease Control and Prevention. Retrieved February 9, 2001, from http://www.cdc.gov/nchs/data/nvs48_3.pdf. Walker, A. (2000, June). Multiple birth, pre-term babies should share bed. Medical Post, 36(23). Retrieved May 6, 2001, from http://www.medicalpost.com/mdlink/english/ members/medpost/data/3623/02A.HTM. Woodward, J. (1988). The bereaved twin. Acta Geneticae Medicae et Gemellologiae, 37, 173-180. Woodward, J. (1998). The lone twin: Understanding twin bereavement and loss. London: Free Association Books. Zimmer, E., Goldstein, I., & Alglay, S. (1988). Simultaneous recording of fetal breathing movements and body movements in twin pregnancy. Journal of Perinatal Medicine, 16(2), 109-112.
Linda G. Leonard is an associate professor in the School of Nursing at the University of British Columbia and a multiplebirths specialist. She developed and operates an outreach support program for multiple-birth families and is an advisor to Multiple Births Canada (MBC), the national organization located near Toronto, ON. MBC aims to improve the quality of life for Canadian multiple-birth families and individuals through support, education, research, and advocacy. Address for correspondence: Linda G. Leonard, RN, MSN, School of Nursing, University of British Columbia, T 201 2211 Wesbrook Mall, Vancouver, British Columbia, V6T 2B5 Canada. E-mail: [email protected].
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