The multiple birth explosion: implications for nursing practice

Multiple Gestation: Side Effects of Antepartum Bed Rest

The birth rate for higher order multiples has dramatically increased in recent decades. Multiple gestation pregnancies are considered to be at high obstetric risk. Antepartum bed rest is often prescribed to offset complications despite the lack of evidence for its effectiveness in preventing complications. This longitudinal repeated-measures study identified side effects of antepartum bed rest treatment for 31 hospitalized women with twin or triplet gestation. Maternal weight gain and infant birth weight were recorded. Antepartum stressors were measured by the Antepartum Stressors Hospital Inventory, and depressive symptoms were measured by the Center for Epidemiologic Studies Depression Scale (CES-D). Antepartum and post-partum side effects of bed rest were also assessed by the Antepartum and Postpartum Symptom Checklists. The weekly rate of maternal weight gain during hospitalization was significantly less than recent recommendations for multiple gestation weight gain (t =– 2.14,p = .04). Infant birth weights were appropriate for gestational age. There were fewer than expected small-for-gestational-age infants. Concerns regarding family status and separation from family were the major antepartum stressors. Women reported a high number of symptoms during bed rest (M= 22), which did not significantly change across 2 weeks. CES-D scores for depressive symptoms were high on antepartum hospital admission. Postpartum symptoms were initially high but had significantly declined by 6 weeks: F(1, 27)= 15.68, p = .00. These findings suggest that interventions are needed to reduce antepartum maternal weight loss, stress, physiologic and psychosocial symptoms, and depressive symptoms, as well as reduce postpartum symptoms of maternal morbidity.

Correlates of negative and positive mood state in mothers of twins

Relationships between parenting distress, social support, and sense of competence and negative and positive maternal mood were assessed in 162 mothers with twins younger than 2 years. Women with lower satisfaction scores on the sense of competence scale reported higher negative mood (adjusted R(2) = 21.7%, p < .001). Women with lower parenting distress and higher efficacy scores on the sense of competence scale reported higher positive mood (adjusted R(2) = 39.4%, p < .001). Neither instrumental nor subjective social support contributed to variance in maternal mood. Interventions should be aimed at decreasing parenting distress and increasing sense of competence for mothers of twins.

Sleep patterns and fatigue in parents of twins

OBJECTIVE

To examine patterns of postpartum parental sleep and levels of fatigue at 2, 12, and 20 weeks following hospital discharge of newborn twins.

DESIGN

Descriptive longitudinal pilot study.

SETTING

Recruitment from 2 hospital postpartum units. Data collected in parents' homes.

PARTICIPANTS

Eight primiparous parents caring for twins delivered at 33 to 38 weeks gestation.

METHODS

Home visits to deliver and retrieve study equipment: wrist actigraphy and sleep diaries to measure sleep, standardized instrument to measure fatigue, and an investigator-developed form to measure demographics and related variables.

RESULTS

Fathers had significantly less night sleep (5.4 hours) and less 24 hour sleep (5.8 hours) than mothers (6.2 and 6.9 hours, respectively) at 2 weeks after twins were discharged. Sleep efficiency increased significantly over time in a linear fashion for both parents. Morning and evening fatigue levels were not significantly different between parents and remained constant over time.

CONCLUSION

Pilot data suggest that mothers and especially fathers of twins experience sleep disturbances after discharge of their twins. Further study is needed to more fully describe the evolution of sleep patterns and clarify factors that influence sleep in parents of twins.

Together or apart? A behavioural and physiological investigation of sleeping arrangements for twin babies

OBJECTIVE

the pros and cons of co-bedding for healthy twin babies on the postnatal ward and in the home are issues with which midwives need to be familiar; however, little objective research has been conducted on which to base policies and recommendations. In this two-part study, I explore the behaviour and physiology of twin babies sleeping separately and together.

DESIGN, SETTING AND PARTICIPANTS

in part one, 10 twin baby pairs aged between 1 and 3 months were videoed sleeping together at home in head to head and side by side configurations. In part two, 14 twin pairs under 3 months of age participated in a two-condition trial with behavioural and physiological monitoring while sleeping together and apart in the sleep lab.

FINDINGS

in part one, sleep variables were unaffected by co-bedding configuration. Babies positioned side by side were observed to occasionally impinge on, but not obstruct, one another's airways, with an arm across the other's face. In part two, no difference was found in their duration of sleep, frequency of waking, core temperature or head covering in the two conditions; co-bedded twins showed synchronous sleep states.

CONCLUSIONS

the co-bedding of term twin babies less than 3 months of age does not seem to be associated with the negative attributes that concern some parents. There may also be advantages of sleep synchrony and ease of care. These results can be used by health professionals in formulating guidance for parents of twins.

The seeking of baby-feeding information by Canadian women pregnant with twins

OBJECTIVE

To analyse baby-feeding information needs and seeking described by Canadian women pregnant with twins.

DESIGN

Qualitative; data were collected by in-depth semi-structured interviews. Transcripts provided the data for discourse analysis of the use of two interpretative repertoires.

SETTING

Ontario, Canada.

PARTICIPANTS

19 women pregnant with twins.

MEASUREMENTS AND FINDINGS

The first interpretative repertoire represented caring for twins as fundamentally distinct from caring for singly born babies, and therefore emphasised the commonality of mothers of twins regardless of their background or situation. The second highlighted the uniqueness and individuality of each person. These repertoires intersect with discourses of baby feeding and good mothering, resulting in a complex discursive interplay of similarity and difference, commonality and individuality, information seeking, baby feeding and good mothering. Participants used the two interpretative repertoires to (1) frame information needs; (2) construct complex accounts of the biomedical, experiential and personalised authority of information sources; (3) describe the helpfulness of information sources independent of their authority; and (4) describe the barriers encountered in the finding appropriate sources of baby-feeding information in pregnancy.

IMPLICATIONS

Understanding and respecting the discursive constructions of pregnancy and mothering can help practitioners understand the complex discursive interplay underlying participants' baby-feeding decisions, and may facilitate more sensitive support for women's individual needs and understandings.

Duration of Breastfeeding for Mothers of Twins

OBJECTIVE

To describe the incidence and duration of breastfeeding for mothers of twins and identify factors that affected this duration.

DESIGN

Secondary analysis of data from a larger longitudinal predictive study of maternal attachment in mothers of twins.

SETTING

Paper and pencil questionnaires once during pregnancy and twice in the first 6 months postpartum.

PARTICIPANTS

123 women recruited from a national support group for mothers of twins.

MAIN OUTCOME MEASURES

Mothers' Information Tool, Edinburgh Postnatal Depression Scale, Rosenberg Self-Esteem Scale, and the Index of Breastfeeding Status.

RESULTS

110 (89.4%) of the sample initiated breastfeeding or initiated a milk supply by pumping. Percentage of breast milk feedings at time 2 predicted whether or not a woman was still breastfeeding at time 3 (odds ratio = 3.63, p < .001).

CONCLUSION

A high percentage of breastfeeding initiation was found despite the increased care burden that has been described for mothers of twins. Mothers who continued to breastfeed at time 3 provided a high percentage of the twins' milk feedings as breast milk. The results suggest that mothers who are able to persist with the difficulties of establishing a milk supply for twins and feeding two infants are able to continue providing a high percentage of the infants' feedings as breast milk.

Prenatal attachment and other correlates of postnatal maternal attachment to twins

PURPOSE

To determine the relationship of prenatal attachment and other selected perinatal contextual variables (method of delivery, maternal self-reported health, depression, infant birthweight, need for neonatal intensive care unit [NICU] admission) to postnatal attachment in mothers of twins.

SUBJECTS

Two hundred fourteen women were initially recruited from a national mothers of twins support group for a study of maternal prenatal attachment. Of the 168 women who agreed to be contacted after delivery, 142 returned completed questionnaires (82.7% response rate), with 139 study-eligible women included in the analysis for this report.

STUDY DESIGN

Correlational design with longitudinal follow-up at 1 month after expected delivery date.

METHODS

Self-administered, mailed questionnaires completed by women with twin gestations prenatally and postnatally 1 month after their expected delivery dates. Descriptive analysis, correlations, and regression equations were performed.

MAIN OUTCOME MEASURES

The Maternal Attachment Inventory.

PRINCIPLE RESULTS

A modest correlation was found between prenatal and postnatal attachment ( r = 0.38, P < 0.001). Prenatal attachment and postpartum depression explained 26.1% of the variance in postnatal attachment ( F = 5.06, P < 0.001). Depression, method of delivery, and need for admission to the NICU had moderator effects on the relationship between prenatal attachment and postnatal attachment. The addition of these interaction terms nominally increased the adjusted R 2 to explain 27.9% to 29.6% of the variance in postnatal attachment.

CONCLUSIONS

Although the study findings support a modest relationship between prenatal and postnatal attachment in mothers of twins, maternal depression was also significant in explaining postnatal attachment. Postpartum depression, having a cesarean delivery, and the experience of a NICU admission for 1 or both twins further influenced the relationship between prenatal attachment and postnatal attachment. When fostering attachment in mothers of twins, nurses should assess for symptoms of depression and pay particular attention to those women who have an infant requiring a NICU admission.

Breast Milk Feeding Rates of Mothers of Multiples Compared to Mothers of Singletons

OBJECTIVE

Over 3% of infants born annually in the United States are from a multiple gestation pregnancy, yet there is little data published about the feeding practices of their mothers. The objectives of this study were to determine and compare the rates of breast milk feeding of mothers of multiples and mothers of singletons.

METHODS

Stratified random sampling (n = 686) on the basis of plurality of pregnancy and gestational age at delivery was performed on a 1999 birth certificate database in the greater Cincinnati area. We collected information about infant feeding during the first 6 months of life using a retrospective, self-administered questionnaire and phone interview from mothers of term singletons (TS), preterm singletons (PS), term multiples (TM), and preterm multiples (PM). Data were analyzed using chi-square and logistic or multiple regression.

RESULTS

We obtained feeding information from 346 mothers (n = 81 TS, 80 PS, 90 TM, and 95 PM). By 3 days postpartum, PM provided breast milk less often than all other groups: TS = 69%, PS = 66%, TM = 73%, PM = 57% (P =.035). Among mothers who initiated breast milk feeding, the geometric mean duration of at least some breast milk feeding was significantly shorter for PM than for all other groups: TS = 23 weeks, PS = 19 weeks, TM = 24 weeks, and PM = 12 weeks (P =.002).

CONCLUSIONS

Further evaluation of the potential causes for the lower breast milk feeding rates among PM is needed to develop effective intervention strategies and increase the number of preterm multiple gestation infants receiving breast milk.

Correlates of Depressive Symptoms in Mothers of Preterm Infants

Purpose: To identify factors related to depressive symptoms in mothers of preterm infants and to changes in depressive symptoms between hospitalization and when the infant was six months corrected age and to determine whether these factors differentiate mothers at high risk for depression from mothers at low risk for depression.

Design: Correlational.

Sample: During hospitalization, 39 mothers of preterm infants and, at six months corrected infant age, 34 mothers of preterm infants.

Main Outcome Variable: Depressive symptoms as measured on the Center for Epidemiological Studies Depression scale.

Results: At enrollment, 19 mothers (48.7 percent) had elevated depressive symptom scores. When the infants were six months corrected age, mean scores had decreased by 36 percent, and only 20 percent of the mothers had elevated scores. During hospitalization, the correlates of depressive symptoms were similar to the factors that differentiated between mothers at high risk and those at low risk for depression. However, the correlates of depressive symptoms during hospitalization were different from correlates of changes in depressive symptoms between hospitalization and six months corrected infant age. Identifying correlates of maternal depressive symptoms may lead to earlier identification and treatment of women at risk for depression, thereby decreasing the negative effects on infant development.

Releasing the pause button: mothering twins during the first year of life

The purpose of this grounded theory study was to investigate the basic social psychological problem mothers of twins experience during the first year after delivery and the process they use to resolve this fundamental problem. Life on hold was the basic social psychological problem that mothers of twins experienced during the first year of their twins' lives. Releasing the pause button was the four-stage process mothers progressed through as they attempted to resume their own lives. These four phases were (a) draining power, (b) pausing own life, (c) striving to reset, and (d) resuming own life. The most vulnerable period for mothers of twins is the first 3 months postpartum. Intensive interventions need to be in place to support women during this time.

Maternal-fetal attachment in twin pregnancies

OBJECTIVE

To describe maternal attachment to twin fetuses and determine whether such attachment differs between the twins.

DESIGN

A descriptive, correlational, nonexperimental design was used to collect data on a convenience sample of high-risk and low-risk women pregnant with twins.

SETTING

Questionnaires were distributed or mailed by presidents of parents of multiples clubs to interested participants. Participants mailed the questionnaires back to the researcher via stamped return envelope.

PARTICIPANTS

During a 14-month period, 214 eligible women from 41 states and the District of Columbia completed the survey instruments.

MAIN OUTCOME MEASURE

The Prenatal Attachment Inventory.

RESULTS

Pregnant women reported greater attachment to Twin B than to Twin A.

CONCLUSION

Pregnant women may be more attached to Twin B (typically the nonpresenting fetus) because this twin may be easier to see and touch. While the mean attachment scores between twins differed, the size of the difference was small. Further study is needed to determine the predictive value and clinical significance of this finding for future mother-infant relationships.

[Breast feeding and birth of twins]

OBJECTIVES

To investigate the breast-feeding (BF) situation after birth of twins and find what factors affect the decision to breast-feed, its length and the reasons for stopping it.

DESIGN

Retrospective, observational study.

SETTING

Sabadell Hospital, Barcelona.

PARTICIPANTS

All the women who gave birth to twins between January 1994 and June 1997 (n = 72).

MAIN RESULTS

64 women (88.9%) began BF. It was exclusive in 37 cases (57.8%) and mixed in the other 27 (42.2%). The main reason for choice was "better feeding" (100% of cases). The age of mothers, the type of birth, the weight of the children, admissions to the New-born Baby Department, work situation, mother's educational qualifications and the existence of domestic help affected neither initial breast-feeding nor its length. Women with prior counselling started BF in greater numbers than those not counselled (p = 0.026). Almost half of them received the information through the matron or nurse. Mean length of BF was 102 days. After two months, half of those who began BF were still breast-feeding; and at four months, 26.5%.

CONCLUSIONS

We observed a high level of starting breast-feeding after twin births, almost the same as for single births. Women with previous knowledge of the question are more likely to breast-feed. The length of BF is slightly greater in the studies reviewed. Adequate prenatal, postnatal and puerperal support from health-workers can have a positive effect on the success of BF after twin births.

Prenatal care and multiple pregnancy

Prenatal care of multiple pregnancy presents a variety of nursing challenges. Specialized care, beginning in early pregnancy, can have a significant impact on the outcome for mothers and neonates. Dramatically increasing roles for advanced technology in the care of multifetal pregnancies must be balanced with families' needs for education and support.