Pregnancy, Birth and Beyond

http://www.pregnancy.com.au/pregnancy-information/twins-pregnancy/twin-articles/giving-birth-to-twins.shtml

Giving birth to twins

Discovering you are carrying twins is often a moment of mixed emotions. Among the plethora of questions and thoughts swimming in your head in the early days after this discovery, no doubt you’ll start to wonder what it is like giving birth to twins.

Giving birth to twins
Twin breech girls born naturally

Discovering you are carrying twins is often a moment of mixed emotions. You may feel overjoyed that you are being blessed with two babies rather than just one, and you may worry just how you are going to accommodate and afford your doubled joy.  Among the plethora of questions and thoughts swimming in your head in the early days after this discovery, no doubt you’ll start to wonder what it is like giving birth to twins.

While in every birth there are many variables, giving birth to twins carries with it increased risks which in some cases limit the birth choices available to you. While the options available may differ, the manner in which you make your decisions about these choices will be the same as that of a woman carrying a single infant. At the end of the day you must weigh the variables – the risks and benefits – and determine what is best and safest for you and your children.

The onset of labour

It is estimated that 50% of twins are born prior to 36 weeks gestation. In some cases, preterm labour occurs naturally, and cannot be halted, often as a result of the woman’s enlarged uterus and the strain this places on her cervix. In other situations, risks to the mother and/or babies result in the decision to induce labour.

If your labour begins prior to 34 weeks gestation, or you have any complications during the pregnancy, your doctor or midwife will generally recommend you give birth to twins in a large hospital which has a fully equipped neonatal intensive care unit. Here specialists in ultrasound, twin pregnancies and neonatology can work together with you and your partner to ensure the best outcome for your babies.

In the past an elective caesarean was often recommended for many woman carrying twins, irrespective of a medical necessity. There is no evidence, however, that it is safer to have a caesarean than a vaginal birth when giving birth to twins, where there are no complications evident.

Home births of twins do occur, but are generally rare in Australia. Most doctors and many midwives discourage woman from giving birth to twins at home due to the risk factors, particularly for the second twin. If you are considering a home birth, discuss your wishes with your medical professionals to carefully consider the possible risks and benefits.

The impact of positioning

As with carrying one baby, your two babies will enjoy moving around freely within your uterus in the early months of pregnancy, and become quite cramped towards the end of it. However unlike a pregnancy with a single baby, the relative position of each twin, both to your uterus and to its sibling, can impact positively or negatively on the birth.

Both Headfirst: In approximately 45% of cases, both twins will be positioned with their heads pointing downwards towards the mother’s pelvis. This position offers the greatest chance of giving birth to twins vaginally.

One Headfirst/One Breech: The next most common position is that of one baby being head down with the other breech, sometimes referred to as the Ying and Yang position. This occurs in approximately 40% of twin pregnancies. A vaginal birth is possible if a skilled midwife or doctor is available who can assist breech births.

If the first twin is in the breech position, there is potential for the first baby's head to be become locked chin on chin, with the head of the second twin as the first twin decends into the birth canal. This will effectively prevent the first twin from being born. As a result of this rare but serious complication, a caesarean may be recommended for babies presenting in this position.

Both Breech: The final position most commonly seen in a twin pregnancy occurs when both babies are breech. This accounts for around 10% of pregnancies. In these cases, a caesarean is often recommended due to the loss of medical skills in assisting breech birth. If you can find the right midwife or doctor a vaginal birth is still possible.

Transverse combinations: In the remaining 5% (approximately) of cases, one or both twins will be positioned transversely. Again the possibility for a natural birth hinges on the position of the first twin. Where this twin is head down or bottom down, a natural birth may be possible. Where both babies are positioned transversely, a caesarean will be necessary. However this is extremely rare, accounting for only 0.5% of twin pregnancies.

Complications and Interventions

Fetal distress

Twins are at an increased risk of becoming distressed during labour. As a result, most women are encouraged to have their babies’ heart rates continuously electronically monitored. The choice of whether or not to have continuous fetal monitoring during labour, though, remains with you. As a middle ground, you can choose to have your babies' heart rates monitored intermittently.

While in the past continuous monitoring would have resulted in a woman being forced to remain in bed, the advent of the wireless fetal monitor means that women can remain active, stand under a shower, be in the bath and change position more readily, while still having their babies’ heart rates monitored.

Epidurals

In the past it was common practice to recommend a mandatory epidural block for women giving birth to twins. The rationale behind doing so was that, in the event of the need for assistance with the birth of the second twin or an emergency caesarean, having an epidural already in place would provide pain relief and/or avoid the need for a general anaesthetic.

Some physicians and midwives actually prefer that mothers giving birth to twins not have an epidural, so that they can better respond to what they're feeling and push more effectively. Whether or not to opt for an arbitrary epidural is a decision to make in consultation with your midwife or doctor.

Intravenous drips

Again, while the insertion of an intravenous (IV) drip during labour was common for all labouring woman, this practice is no longer routine. The rationale behind inserting an IV was to assist in hydrating the woman, and to speed the administration of drugs such as synthetic oxytocin to control any excessive bleeding after birth.

It is generally accepted nowadays that encouraging a woman to drink water during her labour provides effective hydration without the mobility issues an IV can cause. However, because the risk of bleeding after birth is higher with twins, your doctor or midwife may recommend an IV be inserted. A valid compromise may be to request the IV be inserted when birth is imminent, to allow freedom of movement beforehand.

The births

The arrival of the first baby

In the case of a vaginal birth where your babies are not preterm, the first is in good condition, and the second appears well, you should be offered your first baby immediately to hold until you are ready to birth your second baby. You may, however, prefer to instead accept a first cuddle and then pass your baby to your partner or support person to focus on birthing your second child.

In the case of a caesarean, if your first baby is well and not preterm you may be able to have a little skin to skin contact and a cuddle with your first born while waiting for the second. Operating room protocols differ from hospital to hospital but generally if not given to you to hold, your partner will be encouraged to hold your first child. Again the ability to do so is determined by the wellness and maturity of your babies.

Once born, whether by caesarean of vaginally, a name tag will be attached to your baby’s wrist or ankle bearing the words ‘Twin One’ in addition to the traditional ‘Baby of…’ This enables both you and your health professionals to know which baby was born first.

The arrival of the second baby

In the case of a vaginal birth, once the first baby has been born, the midwife or doctor will feel the mother’s abdomen and determine what position the second twin is in. An ultrasound may and/or vaginal examination can also help confirm this. In some cases, the second twin may have altered position, which may facilitate or hinder a vaginal birth of this baby.

It can take anywhere from minutes to hours for a second twin to be born vaginally. If this time becomes protracted, how long you choose to wait before accepting intervention will largely be determined by the wellness of mother and baby, and also the preferences of your attending midwife or doctor. That said, medical professionals generally prefer not to let too much time elapse between births, due in part to the possibility of complications such as:

If complications or concerns arise the birth of the second twin may need to be hastened using forceps or vacuum delivery, or occasionally a caesarean.

Where both twins are being delivered by caesarean, your second baby will be born surprisingly quickly after the first. Again, if your babies and you are well, they should be given to you immediately to promote skin to skin contact and bonding. Once your babies, and their placentas, have been born your surgeon will commence closing your incision. This can be an odd feeling but you will likely be preoccupied with your new babies.

The third stage

Where your babies are born vaginally, the placentas will be born after both babies have arrived. Synthetic oxytocin will generally be administered to aid contraction of the uterus and minimise bleeding after birth, the risk of which is increased with twins. If you prefer to have a physiological third stage, where the placentas are allowed to deliver in their own time, discuss your wishes and the potential risk factors with your doctor or midwife.

Where the second or both babies have been delivered via caesarean section, the placentas will be removed by the surgeon prior to closing your incision.

Bow for the audience

Women giving birth to twins often comment on the number of people present in the room for the birth of their babies. Generally speaking, hospitals and medicos prefer to have a couple of extra people on hand during the birth of twins. For the birth you will usually have a couple of midwives, an obstetric doctor, and a neonatologist or paediatrician. If the babies are born very prematurely there will be a neonatologist for each child. While these staff may be considered necessary, you are within your rights to request that unnecessary spectators, such as students or trainees, be excluded.

Photo by Holly Priddis Photography.

References


Article written and published 15th January 2012