8 lbs. individually. cerebral palsy cerebral palsy is more common among multiple births than single births, being 2.3 per 1,000 survivors in singletons, 13 in twins, and 45 in triplets in north west england. this is likely a side effect of premature birth and low birth weight. behavioural issues premature birth is associated with a higher risk for a breadth of behavioral and socioemotional difficulties that begin in childhood and continue through teenagehood and often into adulthood. conditions where the risk is greatest include attention deficit hyperactivity disorder, autism spectrum disorder and anxiety disorders. incomplete separation further information: twin § degree of separation multiples may be monochorionic, sharing the same chorion, with resultant risk of twin-to-twin transfusion syndrome. monochorionic multiples may even be monoamniotic, sharing the same amniotic sac, resulting in risk of umbilical cord compression and nuchal cord. in very rare cases, there may be conjoined twins, possibly impairing function of internal organs. mortality rate (stillbirth) multiples are also known to have a higher mortality rate. it is more common for multiple births to be stillborn, while for singletons the risk is not as high. a literary review on multiple pregnancies shows a study done on one set each of septuplets and octuplets, two sets of sextuplets, 8 sets of quintuplets, 17 sets of quadruplets, and 228 sets of triplets. by doing this study, hammond found that the mean gestational age (how many weeks when birthed) at birth was 33.4 weeks for triplets and 31 weeks for quadruplets. this shows that stillbirth happens usually 3–5 weeks before the woman reaches full term and also that for sextuplets or higher it almost always ends in death of the fetuses. though multiples are at a greater risk of being stillborn, there is inconclusive evidence whether the actual mortality rate is higher in multiples than in singletons. prevention in ivf today many multiple pregnancies are the result of in vitro fertilisation (ivf). in a 1997 study of 2,173 embryo transfers performed as part of in vitro fertilisation (ivf), 34% were successfully delivered pregnancies. the overall multiple pregnancy rate was 31.3% (24.7% twins, 5.8% triplets, and .08% quadruplets). because ivfs are producing more multiples, a number of efforts are being made to reduce the risk of multiple births- specifically triplets or more. medical practitioners are doing this by limiting the number of embryos per embryo transfer to one or two. that way, the risks for the mother and fetuses are decreased. the appropriate number of embryos to be transferred depends on the age of the woman, whether it is the first, second or third full ivf cycle attempt and whether there are top-quality embryos available. according to a guideline from the national institute for health and care excellence (nice) in 2013, the number of embryos transferred in a cycle should be chosen as in following table: ageattempt no.embryos transferred <37 years1st1 2nd1 if top-quality 3rdno more than 2 37–39 years1st & 2nd1 if top-quality 2 if not top-quality 3rdno more than 2 40–42 years2 also, it is recommended to use single embryo transfer in all situations if a top-quality blastocyst is available. management bed rest has not been found to change outcomes and therefore is not generally recommended outside of a research study. selective reduction (procedure) selective reduction is the practice of reducing the number of fetuses in a multiple pregnancy; it is also called "multifetal reduction". the procedure generally takes two days; the first day for testing in order to select which fetuses to remove, and the second day for the procedure itself, in which potassium chloride is injected into the heart of each selected fetus under the guidance of ultrasound imaging. risks of the procedure include bleeding requiring transfusion, rupture of the uterus, retained placenta, infection, a miscarriage, and prelabor rupture of membranes. each of these appears to be rare. there are also ethical concerns about this procedure, since it is a form of abortion, and also because of concerns over which fetuses are terminated and why. selective reduction was developed in the mid-1980s, as people in the field of assisted reproductive technology became aware of the risks that multiple pregnancies carried for the mother and for the fetuses. care in pregnancy women with a multiple pregnancy are usually seen more regularly by midwives or doctors than those with singleton pregnancies because of the higher risks of complications. however, there is currently no evidence to suggest that specialised antenatal services produce better outcomes for mother or babies than ‘normal’ antenatal care. nutrition as preterm birth is such a risk for women with multiple pregnancies, it has been suggested that these women should be encouraged to follow a high-calorie diet to increase the birth weights of the babies. evidence around this subject is not yet good enough to advise women to do this because the long term effects of the high-calorie diets on the mother are not known. cesarean section or vaginal delivery a study in 2013 involving 106 participating centers in 25 countries came to the conclusion that, in a twin pregnancy of a gestational age between 32 weeks 0 days and 38 weeks 6 days, and the first twin is in cephalic presentation, planned cesarean section does not significantly decrease or increase the risk of fetal or neonatal death or serious neonatal disability, as compared with planned vaginal delivery. in this study, 44% of the women planned for vaginal delivery still ended up having cesarean section for unplanned reasons such as pregnancy complications. in comparison, it has been estimated that 75% of twin pregnancies in the united states were delivered by cesarean section in 2008. also in comparison, the rate of cesarean section for all pregnancies in the general population varies between 40% and 14%. fetal position (the way the babies are lying in the womb) usually determines if they are delivered by caesarean section or vaginally. a review of good quality research on this subject found that if the twin that will be born first (i.e. is lowest in the womb) is head down there is no good evidence that caesarean section will be safer than a vaginal birth for the mother or babies. monoamniotic twins (twins that form after the splitting of a fertilised egg and share the same amniotic fluid sac) are at more risk of complications than twins that have their own sacs. there is also insufficient evidence around whether to deliver the babies early by caesarean section or to wait for labour to start naturally while running checks on the babies’ wellbeing. the birth of this type of twins should therefore be decided with the mother and her family and should take into account the need for good neonatal care services. cesarean delivery is needed when first twin is in non cephalic presentation or when it is a monoamniotic twin pregnancy. neonatal intensive care multiple-birth infants are usually admitted to neonatal intensive care or a special care nursery in the hospital immediately after being born. the records for all the triplet pregnancies managed and delivered from 1992 to 1996 were looked over to see what the neonatal statistics were. kaufman found from reviewing these files that during a five-year period, 55 triplet pregnancies, which is 165 babies, were delivered. of the 165 babies 149 were admitted to neonatal intensive care after the delivery. society and culture a woman bearing 9 or 11 children, prodigiorum ac ostentorum chronicon, 1557, by conrad lycosthenes united states a study by the u.s. agency for healthcare research and quality found that, in 2011, pregnant women covered by private insurance in the united states were older and more likely to have multiple gestation than women covered by medicaid. cultural aspects certain cultures consider multiple births a portent of either good or evil. mayan culture saw twins as a blessing, and was fascinated by the idea of two bodies looking alike. the mayans used to believe that twins were one soul that had fragmented. in ancient rome, the legend of the twin brothers who founded the city (romulus and remus) made the birth of twin boys a blessing, while twin girls were seen as an unlucky burden, since both would have to be provided with an expensive dowry at about the same time. beatrix with her seven swan-children, from the knight of the swan romance (talbot shrewsbury book) in greek mythology, fraternal twins castor and polydeuces, and heracles and iphicles, are sons of two different fathers. one of the twins (polydeuces, heracles) is the illegitimate son of the god zeus; his brother is the son of their mother's mortal husband. a similar pair of twin sisters are helen (of troy) and clytemnestra (who are also sisters of castor and polydeuces). the theme occurs in other mythologies as well, and is called superfecundation. in certain medieval european chivalric romances, such as marie de france's le fresne, a woman cites a multiple birth (often to a lower-class woman) as proof of adultery on her part; while this may reflect a widespread belief, it is invariably treated as malicious slander, to be justly punished by the accuser having a multiple birth of her own, and the events of the romance are triggered by her attempt to hide one or more of the children. a similar effect occurs in the knight of the swan romance, in the beatrix variants of the swan-children; her taunt is punished by giving birth to seven children at once, and her wicked mother-in-law returns her taunt before exposing the children. ethics of multiple births medically assisted procreation in vitro fertilization: in vitro fertilization (ivf) was first successfully completed in the 1970s as a form of assisted reproductive technology. out of all the assisted reproductive technology available that is currently in practice, in vitro fertilization has the highest chance of producing multiple offspring. per each female egg, ivf currently has a 60-70% chance of conceiving. fertilization is made possible by administering a fertility drug to the eggs or by directly injecting semen into the eggs. there is an increased chance for women over the age of 35 to have multiple births. ivf is a common genetic and ethical topic. through ivf individuals can produce offspring successfully when natural procreation is not viable. however, in vitro can become genetically specific and allow for the selection of particular genes or expressible traits to be dominantly present in the formed embryo. ethical dilemmas arise when determining health care coverage and the deviation from natural selection and gene variations. in regards to multiple births different ethical concerns arise from the use of in vitro fertilization. overall, multiple pregnancies can cause potential harm to the mother and children due to potential complications. such complications can include uterine bleeding and children not receiving equal nutrients. ivf has also revealed some pre term deliveries and lower birth weights in babies. while some view medically assisted procreation as a saving grace to have children, others consider these procedure to be unnatural and costly to the community. multifetal pregnancy reduction multifetal pregnancy reduction is the reduction of one or more embryos from the bearing woman. selective reduction usually occurs for pregnancies assisted by assisted reproductive technology (art). the first multifetal pregnancy reductions to occur in a clinical setting took place in the 1980s. the procedure aims to reduce pregnancies down to approximately one to two fetuses. the overarching purpose of the procedure is not primarily to simply terminate life, but to increase the survival and success of the mother and babies. however, multifetal pregnancy reduction raises some ethical questions. the main argument is similar to abortion ethics (abortion debate) in reduction of fetus versus fetus life. the protection of maternal well being versus harm of newly formed fetal life is an extension of the aforementioned ethical question. it can be viewed that all life is important and that no life should be terminated without consent from the life that is being terminated. a polar opposite viewpoint advocates for the right of choice, that being the choice to terminate a pregnancy due to desire or pregnancy risks. overall, most multifetal pregnancy reductions that occur as a result of art are being done for the protection of the child-bearer's health and to maximize the health of the remaining fetuses.