Labor and Birth with Twins

Giving birth is always amazing. The process for giving birth to twins is doubly amazing. Here are some of the things that a twin mom will need to consider when giving birth to her twins.

Babies Positions

The position of the babies will largely determine how the twins are born - vaginally or by cesarean. About 40% of twins are both head down (vertex) at term, another approximately 30% see the first baby (Twin A) vertex and Twin B breech. Both of these positions are acceptable to consider a vaginal birth.

Other positions of the babies like two breeches, two transverse or Twin A breech and Twin B vertex are usually delivered via cesarean surgery. This is usually known ahead of time with ultrasound technology. However, even twins can change positions late in the game and even into labor. This is particularly true of Twin B after the birth of Twin A.

Vaginal Birth

More than half of twins will be born vaginally. Whether this option is the right one for you and your babies is a discussion that should be discussed with your doctor or midwife. The good news is that even though you have two babies - you only have to labor once!

Once the cervix is open, each baby will have it's own pushing stage (second stage). This means you will have to push twice, but the majority of the time the second twin is born much more easily than the first. This is because the first twin has paved the way, so to speak.

The average time between the birth of the first and second baby is generally about 17 minutes. However, as long as the second baby is doing well (they will still be monitoring this baby), there isn't much need to speed things along. Sometimes during this phase of waiting, you will have an ultrasound to confirm the position of the second twin and your practitioner will decide how it is best to deliver him or her.

Sometimes, the second twin simply comes down head first like Twin A, this is handled in exactly the same manner. If Twin B is breech, your practitioner may decide to allow the baby to deliver breech, to turn the baby externally or internally or even do something called a breech extraction (pulling baby out by the feet).

Cesarean Birth

While having twins does increase the risk of you having a cesarean, fewer than half of twins are born this way. While positioning of your babies will play a large part in the decision as to what type of birth you will have, there are also all of the normal reasons for cesareans. These include, placenta previa, placental abruption, maternal indications like PIH, active herpes, and labor complications like fetal distress, etc.

If you give birth by cesarean prior to labor, the date will most likely be set between 37-40 weeks. If you go into labor prior to the scheduled date, your cesarean will likely happen then. There is no real difference in the surgery or recovery from a cesarean with twins.

Combined Vaginal/Cesarean Birth

This is actually not as common as you might believe. One baby being born vaginally with the second twin being born via cesarean occurs in only about 3-4% of all twin births. Usually this is done for an emergency with Twin B, like a cord prolapse (This is where the cord comes out with or before the baby, thereby cutting off the baby's oxygen supply.), severe malpresentation (like a transverse baby that cannot be moved by internal or external forces), placental abruption (This is where the placenta tears away from the wall of the uterus prematurely.), etc.

Prematurity

More than half of twins will be born prior to 37 weeks. This can also impact how your babies are delivered. Talk to your practitioner about staying healthy and maintaining adequate hydration, rest and nutrition to care for your growing babies and body.

Hospital Concerns

Some hospitals require that all twin mothers give birth in the operating room, even if they have a vaginal birth. You might also ask about the use of epidural anesthesia, as it is also sometimes a requirement, even if there are no medications placed inside the tubing. This allows immediate anesthesia should it become necessary. There may be other concerns you have like rooming-in or breastfeeding two babies. Be sure to talk to your hospital at length about issues you may be concerned about with your babies.

No matter how your twins come into the world, be prepared for a sudden change. Be willing to accept help when offered and take the time to get to know each of your new little bundles.

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Twin Pregnancy

People are very fascinated with twins and other multiples. 

It seems mysterious how one pregnancy can result in more than one baby.

Multiple pregnancies are on the rise in recent years with more and more twins and other types of multiples being born. 

The majority of the reason for this rise is the increased use of fertility drugs.

There are a couple of ways that multiples are conceived:

• Multiple eggs are released or there is more than one ovulation. Both (or more) eggs are fertilized and you have fraternal twins. This can happen with or without fertility drugs.
• One egg is release but splits in two. Identical twins are made. This can happen with or without fertility drugs.
• In cases of IVF, there are usually 3 or more fertilized eggs put back into the uterus. The rationale is that not all of these will implant, though sometimes they do.

Once conceived you have a lot of possibilities on placentas, implantation locations, number of amniotic sacs. For example, you can have two babies, two placentas, and two sacs. You can have two babies one placenta, two sacs. It will be important to know exactly what you are dealing with, particularly when it comes to amniotic sacs.

How Multiples Are Discovered

Many people learn about their multiples at an early ultrasound. Although some critics say that before twelve weeks gestation there is still a high risk of Vanishing Twin Syndrome (VTS), where one baby stops growing and is either absorbed back into the mother's body or is still born when the other twin is born.

Some people find a rapid rate of grow in their uterus which leads some to suspect twins. I will say, for all of you second timers out there, that your bellies will grow faster than with your first pregnancy, so don't automatically assume twins.

Sometimes multiple heart beats are heard, leading your practitioner to believe that there is more than one bundle of joy in your uterus.

Some women find out when they have abnormally high levels on the AFP test that multiples are on the way, since multiple babies would increase the levels of these hormones. It's also sometimes possible to detect multiples with serial hCG levels in early pregnancy. The more babies the faster the rate of rise in the hCG which should nearly double every 48 hours with a singleton.

About 3% of all twin pregnancies are undetected until birth. It is possible to have an ultrasound and not see the other baby, though rare.

Multiple Pregnancy

Being pregnant with multiples is not necessarily a high risk situation, except when dealing with higher order multiples or specific problems. Someone on the bulletin board phrased it as being "high need." I really think that this is a positive shift away from the technical side. Find a practitioner who is experienced with multiples births, but one who will not panic at every corner.

In general you need to increase the amount of protein that you eat. Protein is the building block of every cell in your body and your babies' bodies. It will help you build a good placenta and a strong amniotic sac. A healthful diet will also help fight against infection.

You will probably see your practitioner more frequently towards the end of pregnancy. You may have more testing than most women during pregnancy, but not always. Some of these might include: non-stress testing, more ultrasounds, etc.

Complications

There can be a higher risk for complications. You will be monitored for the normal complications of pregnancy like high blood pressure, and fetal growth. However, twins and other multiples can have higher incidences of things such as Intrauterine Growth Restriction (IUGR), Twin to Twin Transfusion (TTTS), and others. Remember to keep your appointments, watch your diet and do your Fetal Kick Counts.

Multiple Birth

In years past cesarean became popular for multiple births. Now that rate is about 50% for twins, and declining. We've found that vaginal birth is usually very safe for multiples, who frequently need the stimulation 

and rise in hormones levels associated with labor.

Whether or not you will have a vaginal birth will depend on many factors, including the position of the babies, and how the babies tolerate labor.

If your babies are in a position where neither can move, they are said to be locked. These babies will have to be born via cesarean.

Breech babies really depend on the size of the baby and the skill of the practitioner. Usually if baby A (The first baby in the pelvis.) is head down a vaginal birth will be attempted. If Baby B is breech or transverse an internal or external version may be attempted to help facilitate the birth, or that baby may be allowed to be born breech.

Monoamniotic twins will also be born via cesarean, due to the added risk of cord entanglement.

No matter how your twins were conceived, or how they were born, babies are delightful. Parenting multiples has its special challenges, but it also yields special rewards.

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