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Triplets with conjoined twins
TRIPLETS WITH CONJOINED TWiNS A Nigerian Midwife’s Case Report
Rachel 0. Iroku, CNM,
MSN,
A 29.year-old grewida 3 pam 2 Nigetian woman received prenatal care from a local midwife beginning at four months’ aestation. Her last menstial period began on Febmay 27. 1987. m&no her excected date or confinement &cemb& 6.1987. No fertility drags were taken by the patient Apart from edema of the legs at the seventh month and enormous abdominal girth, the pregnancy v/es uneventful. In the eighth month of pregnency, due to large fetal size (for gestational age), fundal helghf and abdominal &&ton of two heads, the mother we5 diagnosed with multiple g&ation. When informed of this. she decided to return to the village of her
and May Anah, Midwife
childhood home, where she hoped to obtain helo from both her mother ind mother-m-law after delivery. She arrived in the village on November 14, 1937. et 37 weeks’ gestetion. The folIotins dav she went into labor, and rep&ted io the local Lucv Udo Matemiht Home. where she-had previousI; delivered her second child. This local maternity was owned and operated by a mldtie and her three auxlliazy nurses. After two hours of labor and fo!lowing spontaneous rupture of the membranes. Baby A’s head was delivered. Dellvejof her body proceeded up to the umbilicus, where further descent ceased. The attending midwife sought e reason. Vaglnel examlnatian revealed e&nsion of Baby A’s legs, as well es her attachment to Baby B. The midwife flexed and delivered the legs. The legs were followed by delivery of
conjoined butt&. carried out wi!h caution and carelully guided maternal effort Baby B’s legs, body, and head oroceeded in that order. The fen& hbies were joined back to back et their buttocks [pywpagusj. as depicted In ~&we3 1 and 2. Their etways were cieaxed with E auction bulb. They tied soon after birth. &by A ~5 kept warm with a hot-water bottle, as she was sltghdy cvanosed Memwhlle, Baby C’s membranes were atllicieliy ruptured. She was deilvered as a breech, Ien minutes after the blrtb of her slstem The entire second stege of !&xx bsted 45 minutes. The third steoe toteled l+ze minutes aad wee un&ntftd. EIQIm&tr~ f!.5 reg GZ adrMtered Intmmusculady to the mother to aid utEdne contmctlon and lessen the posslblllty of postpartum hemor
Mother and t&let were takeo to the neaby Cottage Hospital in stable condition within one hour of delivery. From there. they were referred to tbe University Teaching Hospital 70 km (44 miles) away, where they u’ere admltted the following day. The conjoined tins had a combined weight of 3.8 kg (8 lb 6 02). They were nutwed for 51 days with breast milk and formula supplements to raise their weight to e level that would enable them to withstand SWoav. This oedod allowed for investigative pro&dures. It also gave the operating team, made up of 28 pedtakic surgecns, nurses. and anesthesiol@sts, time to plan for the tins separation and the reconstruction necessaryfor independent existence. Successful separation and reconebuction of the conjoined twins was carded out during a six-hour operation on January 8, 1988. At that time, their combined weight was 6.8 kg (14 lb 15 021. The huins had: (1) a common anal opening but separate rectllms; (2) separate vaginal apnings; (3) separate urethral openings; (4) postedody fused vestibules; and I.51 sideby-side fusion of the bunocks and coccygealregions. In additin, Baby A had her two kidneys fused, a shorter left lower limb, and abnormalities of the toes and spine. The tripI& were nurt.~red iii the hospilzl &a the operation for hue months and three weeks by the family and health-care team. The general care of the conjoined twins becameeasier after the successful surgery. The
_~_
Rechellmtw is e lecturerin the llepertmentof NursingSciencesat the Oniirenityo/Nige&a,Etuyu Campus, Nigetia. Maw Anoh is the propnefor of the Lucy Udo MatemhrHome wherethe birth desotbedI,, this articleto& piece She else carriedout tie dehuey.Ms. Anah has pmtied rumI mldwifey in Nigeria for35 yeon.
108
Figure 1. Conjoined twins. with side-to-side @on
of the butkk
and mecygeal re@ms.
Figure 2. A mmmon anal opening and v&bule are sharedby the conjoined twins Iurethral and vaginal openingsand rechunsare sqarate).
giax+mothcr was permitted to be with the infants throughout their hosp~talizaton to assist with the care of the Mplets. Prolonged breast-feedingis widely acceptedin Nigaia, and this mother successfuUybreast-fed her tipleh for one year. Breast milk was initially supplemented with NAN (a European formulaI. which was gradually replacedwith solid food. Public health nurses made a series of tistts to the home in preparation
dwmaf
for the tr!p’kLFI bomauifig. The infants were discharged hame on March 31,1988.
CONdOlNED
WINS
vaginal delivq of fullterm conjoined twins is a rare and fascinating event. Coniofned twins occur when a ftilized ovum that is dividing to form identical hvins fails to divide completely. Conjoined twins occw approxiSpontanecus
of Nurse-Midwifery
. Vol. 35. No. 2. MerchlAprtl1990
mately once in 50,3x births.’ Diai and Fummn estimated the incidence to be one in 50,000 to ZGO,OOO births in the United States, with higher rates in Africa, jndla, Pakist:m. and Thailand (which range from one in 14,OKl to one in 25,0+X births).* Reason for the higher in& dence of conjoined twins in developing countlies has not been determined. Ir. 1982 there were sppmximately 600 reported cases of conjoined twins worldwide.3 Seventy percent of conjoined twins are fema1e.l Conjoined twins can be joined anywhere from the head to the leg.* The most frequent site is the thorax (40%); the least frequent is the skull 12%).* The frequency of hvins conjoined at the buttocks. as described in this case, is 18%. TfiE RURALNIGERfANhUDWlFE AND HIGH-RISKDELf”EffY It is VitaUy important for the Nigedan midwife to be able to recognize and refer high-risk dlents for s&&lied obstetrical care. She must also be able to intite care in emergency tituatfons to save the life of mother or child in the absence of a physician. Although these hvo functions are expected of any midwife throughout the world, the rural Nigerian midwife faces special circumstances, which make t&e abilities very important in her practice. One speclil circumstance is that diagnostic eaujpment such as ujtraso&d IS not i&dily available in rural Nioerln. When a rural Niserian w&an is referred for dw&osUc tests, she might need to travel far from her community to obtain them. She might not make the ]oumey due to lack of tnnspixtatjon or money. fgnorance concerning the need for
test
could be another reason for noncompliance. A woman might beUeve that because her grandmother and mother delivered safely without any tats. so can she. There also exists I general belief that any misfortune is the work of providence and cannot be awidrd. Thus, the Nigerian midwife &are to function in emergency situations knowing that a negative outcome will be regarded as an act of God and that she therefore will not be liable in a lawwt. The rural Nigerian midwife must assume a high level of responsibffity for complicated casesbecause backup obstetrtdansmay not be available during emergendes. Although each maternity or health center has an obstetrician who visits on scheduled days, there is no guarantee that he will be available during a high&k bmh. Thus the mral midwife I” Nigeria Hidens her scope of practice through experience, by managing compjicated casesthat a midwife in a larger hospital would definitely refer. The midwife working in a maternity or health center also encourages he; clients to re&.ter at a iarger herpital in case of wmplications. The hospital is usually the nearest one, which can be as near as 1 km 10.62 miles) or 3s far a5 80 km (50 t&s.). If coripliuiions arise, the woman is refened to that hospital. If the case cannot be handled there, she is ageln referred to a tertiary-care center, as in this case of conjoined twins.
the
The midwife who performed the delivery described here had three yean of formal midwifey training. backed up by 35 years of pm&e. Multiple gestation ulas not a criterion for referral from her maternity center. Five sets oj iive triplets and
~urnmous hvlns had been delivered It thtsmatemi$ center during the 33 wars of its extstence. However, i!!osis of conjoined twins before :he second stage of labor would ,ave led to referral of thir, mother to L ho@tal The utilization of ultnsound would have made wssible ~renataf d&onosis of the’cojoined twins. The enormous abdominal olrth of this mother (also noted by-hiends and nejghbors) was an indication for 2’ Insound investigetta. but ti was not done because the technology was not IocaUy available. If diagnosed prenativ. conjoined twins are usually delivered by ekxwe cesareansection. jt is fascinating that this delivety of conjoined twins was canted out v@aEy by a midwife with no ep~otomy. no lacerations. and no complications! Obviously, va@l?Lldeiiwy of this case by a less skilled practitioner could have jeopardized the iives of both mother and b&&s. No wonder the parents of Ibe.% cbxdren r!amed the triplets Chidinma. Chioma, and Chiamaka, names that mean. iiteraUy+ “God is kind,“--possibly for sending the molber to this midwife. REFERENCES 1. M&r 0, ColombaniP, BuckJR, et al: New techniqw in the diagnosis and operaduemaMgement of Siamese twins d Pediatr surg 18(4):373 ., 176, 1983. 2. Dlar JH. Furman fBz Petioperctivemanagement of conjoinedtwins.An&h&logy 67(6j%L973, 1987. 3. GoUaday IS. WIlllams GD. SebeTtu et al: rnce,*l!&5 &puscowned Iwlne a almical LLoalawJ”and reviewof prmA.usly r-&c&c&es. 2 PedlaUab Sow 17lwS9-263.15a2. 4. KenQsbPm, R Harper R: Sepam Yen of ompbalopaguotwins. J Pediak surg 17(3):255-257. 1982.
Rachel 0. Iroku, CNM,
MSN,
A 29.year-old grewida 3 pam 2 Nigetian woman received prenatal care from a local midwife beginning at four months’ aestation. Her last menstial period began on Febmay 27. 1987. m&no her excected date or confinement &cemb& 6.1987. No fertility drags were taken by the patient Apart from edema of the legs at the seventh month and enormous abdominal girth, the pregnancy v/es uneventful. In the eighth month of pregnency, due to large fetal size (for gestational age), fundal helghf and abdominal &&ton of two heads, the mother we5 diagnosed with multiple g&ation. When informed of this. she decided to return to the village of her
and May Anah, Midwife
childhood home, where she hoped to obtain helo from both her mother ind mother-m-law after delivery. She arrived in the village on November 14, 1937. et 37 weeks’ gestetion. The folIotins dav she went into labor, and rep&ted io the local Lucv Udo Matemiht Home. where she-had previousI; delivered her second child. This local maternity was owned and operated by a mldtie and her three auxlliazy nurses. After two hours of labor and fo!lowing spontaneous rupture of the membranes. Baby A’s head was delivered. Dellvejof her body proceeded up to the umbilicus, where further descent ceased. The attending midwife sought e reason. Vaglnel examlnatian revealed e&nsion of Baby A’s legs, as well es her attachment to Baby B. The midwife flexed and delivered the legs. The legs were followed by delivery of
conjoined butt&. carried out wi!h caution and carelully guided maternal effort Baby B’s legs, body, and head oroceeded in that order. The fen& hbies were joined back to back et their buttocks [pywpagusj. as depicted In ~&we3 1 and 2. Their etways were cieaxed with E auction bulb. They tied soon after birth. &by A ~5 kept warm with a hot-water bottle, as she was sltghdy cvanosed Memwhlle, Baby C’s membranes were atllicieliy ruptured. She was deilvered as a breech, Ien minutes after the blrtb of her slstem The entire second stege of !&xx bsted 45 minutes. The third steoe toteled l+ze minutes aad wee un&ntftd. EIQIm&tr~ f!.5 reg GZ adrMtered Intmmusculady to the mother to aid utEdne contmctlon and lessen the posslblllty of postpartum hemor
Mother and t&let were takeo to the neaby Cottage Hospital in stable condition within one hour of delivery. From there. they were referred to tbe University Teaching Hospital 70 km (44 miles) away, where they u’ere admltted the following day. The conjoined tins had a combined weight of 3.8 kg (8 lb 6 02). They were nutwed for 51 days with breast milk and formula supplements to raise their weight to e level that would enable them to withstand SWoav. This oedod allowed for investigative pro&dures. It also gave the operating team, made up of 28 pedtakic surgecns, nurses. and anesthesiol@sts, time to plan for the tins separation and the reconstruction necessaryfor independent existence. Successful separation and reconebuction of the conjoined twins was carded out during a six-hour operation on January 8, 1988. At that time, their combined weight was 6.8 kg (14 lb 15 021. The huins had: (1) a common anal opening but separate rectllms; (2) separate vaginal apnings; (3) separate urethral openings; (4) postedody fused vestibules; and I.51 sideby-side fusion of the bunocks and coccygealregions. In additin, Baby A had her two kidneys fused, a shorter left lower limb, and abnormalities of the toes and spine. The tripI& were nurt.~red iii the hospilzl &a the operation for hue months and three weeks by the family and health-care team. The general care of the conjoined twins becameeasier after the successful surgery. The
_~_
Rechellmtw is e lecturerin the llepertmentof NursingSciencesat the Oniirenityo/Nige&a,Etuyu Campus, Nigetia. Maw Anoh is the propnefor of the Lucy Udo MatemhrHome wherethe birth desotbedI,, this articleto& piece She else carriedout tie dehuey.Ms. Anah has pmtied rumI mldwifey in Nigeria for35 yeon.
108
Figure 1. Conjoined twins. with side-to-side @on
of the butkk
and mecygeal re@ms.
Figure 2. A mmmon anal opening and v&bule are sharedby the conjoined twins Iurethral and vaginal openingsand rechunsare sqarate).
giax+mothcr was permitted to be with the infants throughout their hosp~talizaton to assist with the care of the Mplets. Prolonged breast-feedingis widely acceptedin Nigaia, and this mother successfuUybreast-fed her tipleh for one year. Breast milk was initially supplemented with NAN (a European formulaI. which was gradually replacedwith solid food. Public health nurses made a series of tistts to the home in preparation
dwmaf
for the tr!p’kLFI bomauifig. The infants were discharged hame on March 31,1988.
CONdOlNED
WINS
vaginal delivq of fullterm conjoined twins is a rare and fascinating event. Coniofned twins occur when a ftilized ovum that is dividing to form identical hvins fails to divide completely. Conjoined twins occw approxiSpontanecus
of Nurse-Midwifery
. Vol. 35. No. 2. MerchlAprtl1990
mately once in 50,3x births.’ Diai and Fummn estimated the incidence to be one in 50,000 to ZGO,OOO births in the United States, with higher rates in Africa, jndla, Pakist:m. and Thailand (which range from one in 14,OKl to one in 25,0+X births).* Reason for the higher in& dence of conjoined twins in developing countlies has not been determined. Ir. 1982 there were sppmximately 600 reported cases of conjoined twins worldwide.3 Seventy percent of conjoined twins are fema1e.l Conjoined twins can be joined anywhere from the head to the leg.* The most frequent site is the thorax (40%); the least frequent is the skull 12%).* The frequency of hvins conjoined at the buttocks. as described in this case, is 18%. TfiE RURALNIGERfANhUDWlFE AND HIGH-RISKDELf”EffY It is VitaUy important for the Nigedan midwife to be able to recognize and refer high-risk dlents for s&&lied obstetrical care. She must also be able to intite care in emergency tituatfons to save the life of mother or child in the absence of a physician. Although these hvo functions are expected of any midwife throughout the world, the rural Nigerian midwife faces special circumstances, which make t&e abilities very important in her practice. One speclil circumstance is that diagnostic eaujpment such as ujtraso&d IS not i&dily available in rural Nioerln. When a rural Niserian w&an is referred for dw&osUc tests, she might need to travel far from her community to obtain them. She might not make the ]oumey due to lack of tnnspixtatjon or money. fgnorance concerning the need for
test
could be another reason for noncompliance. A woman might beUeve that because her grandmother and mother delivered safely without any tats. so can she. There also exists I general belief that any misfortune is the work of providence and cannot be awidrd. Thus, the Nigerian midwife &are to function in emergency situations knowing that a negative outcome will be regarded as an act of God and that she therefore will not be liable in a lawwt. The rural Nigerian midwife must assume a high level of responsibffity for complicated casesbecause backup obstetrtdansmay not be available during emergendes. Although each maternity or health center has an obstetrician who visits on scheduled days, there is no guarantee that he will be available during a high&k bmh. Thus the mral midwife I” Nigeria Hidens her scope of practice through experience, by managing compjicated casesthat a midwife in a larger hospital would definitely refer. The midwife working in a maternity or health center also encourages he; clients to re&.ter at a iarger herpital in case of wmplications. The hospital is usually the nearest one, which can be as near as 1 km 10.62 miles) or 3s far a5 80 km (50 t&s.). If coripliuiions arise, the woman is refened to that hospital. If the case cannot be handled there, she is ageln referred to a tertiary-care center, as in this case of conjoined twins.
the
The midwife who performed the delivery described here had three yean of formal midwifey training. backed up by 35 years of pm&e. Multiple gestation ulas not a criterion for referral from her maternity center. Five sets oj iive triplets and
~urnmous hvlns had been delivered It thtsmatemi$ center during the 33 wars of its extstence. However, i!!osis of conjoined twins before :he second stage of labor would ,ave led to referral of thir, mother to L ho@tal The utilization of ultnsound would have made wssible ~renataf d&onosis of the’cojoined twins. The enormous abdominal olrth of this mother (also noted by-hiends and nejghbors) was an indication for 2’ Insound investigetta. but ti was not done because the technology was not IocaUy available. If diagnosed prenativ. conjoined twins are usually delivered by ekxwe cesareansection. jt is fascinating that this delivety of conjoined twins was canted out v@aEy by a midwife with no ep~otomy. no lacerations. and no complications! Obviously, va@l?Lldeiiwy of this case by a less skilled practitioner could have jeopardized the iives of both mother and b&&s. No wonder the parents of Ibe.% cbxdren r!amed the triplets Chidinma. Chioma, and Chiamaka, names that mean. iiteraUy+ “God is kind,“--possibly for sending the molber to this midwife. REFERENCES 1. M&r 0, ColombaniP, BuckJR, et al: New techniqw in the diagnosis and operaduemaMgement of Siamese twins d Pediatr surg 18(4):373 ., 176, 1983. 2. Dlar JH. Furman fBz Petioperctivemanagement of conjoinedtwins.An&h&logy 67(6j%L973, 1987. 3. GoUaday IS. WIlllams GD. SebeTtu et al: rnce,*l!&5 &puscowned Iwlne a almical LLoalawJ”and reviewof prmA.usly r-&c&c&es. 2 PedlaUab Sow 17lwS9-263.15a2. 4. KenQsbPm, R Harper R: Sepam Yen of ompbalopaguotwins. J Pediak surg 17(3):255-257. 1982.