When one twin comes out and the other stays in the womb

We all have that quirky friend we cannot live without.

The one who wakes you up at four o’clock on a Wednesday morning to tell you her tent is flooding and you wonder what she is doing in a tent in the middle of a working week when you know she should be at work.

You will assume she needed a break so urgently, she drove out of town on a Tuesday evening to commune with nature, even if for one night. On Wednesday afternoon, she will be calmly seated on her desk providing her services to the infirm without missing a heartbeat.

This is how I describe my completely non-conforming friend, an amazing gynaecologist, fitness freak and talented writer who prefers solitude but still finds a way to accommodate us.

Every once in a while, we bond over a quiet dinner and catch up with each other’s lives. It was during one of these moments that she calmly narrated to me one of the craziest cases she had ever come across.

This case made me question whether sometimes Mother Nature over-indulges in mind-altering substances and decides to cause great confusion, just for the sake of it.

Labour disappeared

Doc calmly leaned back into her seat and mentioned in passing, that she had discharged Lucy* at last. I gave her a blank look because I had no idea who Lucy was. It turns out she thought we had discussed Lucy previously. Lucy was a patient under her care, pregnant with twins as a first time mom.

At 29 weeks, Lucy checked into the hospital at 10 o’clock in the night with preterm labour. She was distraught because she knew her twins were not ready to be born. She was excited to meet her babies but not this early. Doc quickly admitted her to the ward, ordered all the necessary investigations and started Lucy on an infusion to try and knock off the labour and buy the little ones some more time.

By four in the morning, it was clear they were losing the battle and Lucy was transferred to the delivery couch. The first twin came quickly, a tiny 1.1kg baby girl, who was hurriedly transferred to the newborn unit. 

Under normal circumstances, twins are generally born within minutes of each other. However, in 24 per cent of cases, a delay of over 30 minutes may occur, constituting an obstetric emergency termed ‘retained second twin’. This retained twin faces a great risk of death and for this reason, interventions are necessary to improve the outcomes.

However, in this case, the second twin did not come out. Even more uncharacteristic is that the cervix closed and labour contractions disappeared.

Up to this point, I was just a curious listener. I was waiting for the punchline. When it came, it was nothing that I expected.
My very brave friend decided to let Mother Nature show off and do her thing. She did not disappoint. Lucy was transferred back to the ward, with one baby in her womb and the other fighting for her life in the newborn unit.

Lucy was watched like a hawk, with tests every 72 hours to ensure she was not developing an infection and that baby was just fine. Her other little one in the newborn unit was all on her own, fighting for survival as mom was not allowed out of bed.

Long-term effects

Six weeks later, Lucy went into labour yet again, and this time round, a healthy little boy made his grand entrance at 2.1kg with a lusty cry. It took another two weeks before the three were let home but they all made it to the finish line safely. By this time, my long-forgotten ice cream desert was a soggy puddle. I was gawking at my friend.

Over the next few weeks, I went back to my books, almost demanding that my graduate school refund part fees for never taking me through this class. I reconsidered the demand when I found out just how few documented cases of ‘Delayed Interval Twin Delivery’ there are world over.

In these cases, however, the first twin was commonly delivered in the second trimester, mostly around the 20th or 21st week of gestation and they generally did not make it. The mother then had a purse-string stitch inserted in her cervix, to hold it closed and buy time for the remaining twin to mature.

This rare event happens only in the case of fraternal twins with clearly separate placentae and amniotic bags, such that one twin would come out with all their paraphernalia and leave the other completely intact.

The risks to the mother and baby are immense, most especially infection. Further, none of the studies had followed up the babies born under these circumstances long enough to know what the long-term effects were.

I am still crushed at how my friend failed to imprint this extremely rare phenomenon in the annals of obstetric medical publications. If only to help Lucy’s twins understand why they are considered twins when they do not share a birthday.