A 35-year-old gravida 6, para 5 mother who is 38-week pregnant from last normal menstrual period has presented to Tercha General Hospital (a rural hospital in Southern Ethiopia). The patient is referred from a health center 60 kms far from this hospital for suspected "big baby" in labor. The patient was an illiterate housewife. In terms of past obstetrics history, all previous deliveries occurred at home vaginally with live birth with no major complication. During the index pregnancy, she had antenatal care visits at a nearby health center without ultrasound examination. She reports that the current pregnancy is heavier than previous ones and associated with significant discomfort than her previous pregnancy experiences. Otherwise, she has no self or family history of twinning in the past.
Examination shows a stable gravida with normal vital signs. Abdominal examination shows big for date uterus with two cephalic poles in the lower abdomen and positive fetal heartbeat. Standard ultrasound examination confirmed twin pregnancy with both in cephalic presentation and adequate amniotic fluid; single placenta with no visible dividing membrane; fetal heartbeat is visible at two sites and is in a normal range. Upon pelvic examination, the cervix is 8cm dilated with left occiput-anterior position at a station 0. Fetal membrane is ruptured with clear liquor passing. With diagnosis of twin pregnancy (both cephalic presenting), in active phase of first stage of labor patient is admitted to labor ward and management of labor started in the standard way.
In the next few hours labor progressed well and the first baby is crowning. Duty midwives are attending the delivery. Subsequently, with maternal effort the head and upper extremities of the first baby are delivered and the remaining part of the fetus is delivered by 'gentle' traction by the midwives. But after delivery of the whole body, baby 1 remained 'attached' to the mothers' perineum, though the baby is crying vigorously (Figure 1). The midwives started to shout for help and senior obstetrician arrived.
On reevaluation, we noticed the same and we found that the anterior abdomen of baby 1 from xiphisternum to the site of umbilical cord insertion is continuous into the uterine cavity. This led to sudden and unexpected consideration of the possibility of conjoined twins. Bedside ultrasound showed alive remaining fetus with fetal heart rate of 76 and in a transverse lie with the head in the right iliac fossa and fetal dorsum anterior. Initial attempt to access the extremities and aid delivery of the remaining fetus vaginally is not possible due to failure to reach the extremities for intrauterine manipulation. Emergency laparotomy is decided.
Emergency laparotomy under general anesthesia with midline subumbilical abdominal incision and lower uterine segment vertical hysterotomy is performed. We corrected the lie of the born baby such that it is parallel to that of the unborn baby; with deep vaginal examination along with the caudal end of the attachment and managed to manipulate the lower extremities of the intrauterine fetus to vagina and after grasping those with the right hand vaginally, we brought it to the perineum. Then there is careful manipulation to bring those extremities posterior to the born baby with a second assistant holding and manipulating the born baby away from the area of manipulation. Progressive delivery of the second baby of the conjoined pairs is affected by total breech extraction with minimal difficulty.
Both newborns were depressed at completion of the procedure and recovered after aggressive resuscitation for 10 minutes (Figure 2). Both are male and their combined weight is 5800 gm. Ultrasound examination of the twins shows shared liver with no other organs shared. Latter the second baby passed away after 1 hour of stay at the NICU. The second baby died after 20 hours of stay, during transportation to higher center for possible emergency separation. The mother was discharged to home on her sixth post-op day after counseling.