Discovering you are carrying twins is often a moment of mixed emotions. You may feel two babies rather than just one is a blessing. You may worry just how you are going to accommodate and afford your doubled joy.  There is likely to be a plethora of questions and thoughts swimming in your head in the early days. No doubt you’ll soon start to wonder what it is like giving birth to twins.

It is true that in every birth there are many variables. However, giving birth to twins carries with it increased risks which may limit the birth choices available to you. The way in which you decide 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. You must decide what is best and safest for you and your children.

The onset of labour

Around 50% of twins are born prior to 36 weeks gestation. In some cases, preterm labour occurs naturally, and cannot be halted. This is 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 mean that the labour is induced.

If your labour begins prior to 34 weeks gestation your doctor or midwife will generally recommend you give birth in a large hospital. This will also be the case if you have any complications during the pregnancy. A large hospital will have a fully equipped neonatal intensive care unit. Here there will be specialists in ultrasound, twin pregnancies and neonatology. They 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 women carrying twins, irrespective of a medical necessity. However, a vaginal twin birth is now thought to be as safe as a caesarean if there are no complications.

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. This is 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. They will 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. This is 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. This could occur 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 transverse. 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.

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

Epidurals

In the past it was common practice to recommend a mandatory epidural block for women giving birth to twins. This was recommended in case twin two needed assistance or an emergency caesarean was necessary. The pain relief would then already be in place and this could in some cases also avoid the need for a general anaesthetic.

Some physicians and midwives actually prefer that mothers giving birth to twins not have an epidural. This is so that the mother 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 once common for all labouring woman, this practice is no longer routine. The rationale behind inserting an IV was to assist in hydrating the woman. It was also 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 or 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 and/or vaginal examination can also help confirm this. In some cases, the second twin may have altered position, which may facilitate or hinder the 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 mainly depend on the wellness of mother and baby. It will also depend on 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:

• fetal distress;
• the cord of the second twin coming out before they are born; or
• either placenta separating from the uterine wall prior to the second baby’s birth.

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 born by caesarean, your second baby will be born surprisingly quickly after the first. Again, if your babies and you are well, you can hold them 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 busy with your new babies.

The third stage

Where your babies are born vaginally, you will birth the placentas after both babies have arrived. You will generally have synthetic oxytocin to help with contractions and minimise bleeding after birth. Note that the risk of excessive bleeding increases with twins. If you prefer to have a physiological third stage, where the placentas are delivered 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 are necessary, you are within your rights to request that unnecessary spectators, such as students or trainees, are not present.

References

• multiples.about.com/od/pregnancy/tp/Why-Twins-are-Born-Early.htm
• www.birth.com.au/Twins-triplets-or-more/Twin-positions
• www.ncbi.nlm.nih.gov/pmc/articles/PMC1481670/
• www.ivillage.com/must-i-have-epidural-when-i-give-birth-my-twins/6-n-145601
• healthy-mother.com/in-a-twin-birth-how-long-to-wait-for-the-second-twin
• Article Twins ‘Double the trouble and twice the fun’ by Dr Hannah Dahlen

Article written and published 15th January 2012