Were you hoping to have a vaginal birth, only to find out you were expecting twins? You’re not alone, but expecting twins does not usually rule out vaginal birth. The greatest things you can do to ensure a positive outcome with your twin birth are actually best done during the pregnancy! After all, if you can avoid setting yourself up for pregnancy complications that can make birth difficult or encourage preterm labor, you’ve won half the battle! Of course, not all complications ruling out natural birth can be prevented. However, you greatly increase your chances of a natural, healthy birth if you and your babies are well-nourished, well-hydrated, and well-rested.
Other than taking good care of yourself during your twin pregnancy, the next thing you can do to make a positive birth experience more likely is choose a provider who suits your needs and desires. If it is important to you to have a vaginal birth, you’ll want to choose a provider who has plenty of experience with vaginal twin birth. Ask your provider how many vaginal twin births s/he has attended, and also what his or her cesarean rate for twin pregnancies is. Not all twins can or should be born vaginally, but if you don’t have a provider with experience attending vaginal twin births, your chances of having a vaginal birth, even if it is a possibility in your case, decrease dramatically.
You may also want to have a provider who has experience attending breech births, as well. Almost all of the research supports a vaginal birth as long as baby A (the one closest to the cervix at the onset of labor, born first) is head-down, or “vertex.” Studies have shown that outcomes are similar with a vertex baby A even if baby B is breech or transverse. There have even been some studies that suggest that a trial of labor is indicated for some women (particularly those with prior vaginal birth) even if baby A is breech. This is a case in which you’ll want to ask your provider what his or her philosophy is about the presentation of the babies. What if you have a breech baby B? What if you have a breech baby A?
Sometimes during birth, after baby A is out, baby B will change position. A baby B who had been persistently vertex might flip to transverse (lying sideways) or breech, or a baby B who had been breech might flip to transverse. You can anticipate this and account for it in your birth planning. Depending on how comfortable you are with birth intervention, you might have birth assistants help hold a vertex baby B in place until the head is firmly engaged in the birth canal, or have an provider experienced with external version turn a breech baby B after baby A is born (if there is time). Some doctors will do a “breech extraction” with a breech or transverse baby B, and reach into the birth canal to pull the baby out by his or her feet. Many natural birth advocates, however, feel that the best approach to breech vaginal birth is “hands off the breech,” or not pulling to avoid neck injury to the baby. Do your research on breech birth, and come to an understanding of what your comfort level is; ask your provider questions about his or her approach.
Many twin moms fear the “double whammy”– or having a vaginal birth for baby A, followed by an unexpected Cesarean birth for baby B. Realize that this happens in fewer than 5% of twin births, and that studies have shown it is overused. While there are definite instances in which an emergency Cesarean for baby B might be required, having a provider who is comfortable and experienced with vaginal birth of a breech baby B can improve your odds of avoiding a vaginal-Cesarean birth. Additionally, many of the small handful of moms who have had a vaginal-Cesarean birth report no regrets, and are thankful that even one of their twins was able to experience the benefits of vaginal birth.
One other question to ask your provider is whether or not s/he has a routine for inducing or performing a Cesarean at a certain gestational age for twins. Most providers agree that the majority of twins can be safely born at 36 weeks. This has led a disturbingly large number of providers to tell mothers that their twins are “term” at 36 weeks, and “postdates” at 38 weeks. While there has been some research that shows no improvement in outcomes after 38 weeks and worse outcomes past 40 weeks, there is also other research that shows no benefit to routinely inducing twins before 40 weeks. Quite simply, this is a gray area – undecided – in the research. Research has, however, been clear in showing worse outcomes, including higher rates of Cesarean, as well as higher rates of fetal distress, associated with inductions; for this reason, you must carefully weigh your options with regard to inductions. Obviously, if there is a medical reason for induction, such as pre-eclampsia or intrauterine growth retardation (IUGR), the benefits outweigh the risks. However, in a healthy twin pregnancy, with a well-nourished mother and no other complications, it is usually not warranted to have an induction or scheduled Cesarean for gestational age alone. Find out where your potential provider stands on this before making your final decision on a provider, and if your provider later suggests an induction for gestational age alone, remember that there are tests that can be done to monitor the condition of the babies to give a better indication of if they are still doing well in utero. Many twin moms have safely given birth to their babies at 40, 41, and even 42 weeks gestational age! Remember that <b>babies born early, babies who have been induced, and babies that have been born via Cesarean tend to have more problems establishing breastfeeding</b>, and that not having to worry about making bottles may lead to a more restful recovery for mom.
With regard to choosing your provider, it is important to realize that different kinds of providers have different approaches to birth. You might choose a perinatologist, an obstetrician, a certified nurse-midwife (CNM), or a direct-entry midwife (certified professional [CPM] or licensed midwife [LM]), or some combination of the above, to attend your birth. Perinatologists and obstetricians attend births in hospitals, CPMs and LMs attend births in birth centers and in homes, and CNMs may work in a hospital, birth center, or in homes. Your state may have regulations that prohibit midwives from attending out-of-hospital twin births. If you live in one of those states and, after doing your research and considering your options, you still feel that an out-of-hospital birth with a midwife is the right choice for you and your babies, you may want to explore alternative options. Some midwives travel and mothers will bring them in for the period before the birth; other mothers have gone out of state for their twin births. Things to consider when choosing your birth location will include the chorionicity of your babies (whether or not they share a sac), your provider’s experience with twin vaginal birth, proximity to a hospital for transport in case of emergency, whether or not your provider is equipped to treat a postpartum emergency (such as having medications on hand for a postpartum hemorrhage, which is more likely after twin birth), and the overall health of the pregnancy up to the date of birth (including monitoring for twin-to-twin transfusion syndrome (TTTS) for twins who share a placenta). Availability of options in choosing the location and provider for the births of multiples is of paramount importance, as many mothers who have no options for skilled providers for an out-of-hospital birth are forced to consider unassisted birth, even when it is not their ideal. Even advocates of unassisted birth generally agree that no woman should give birth unassisted simply because all her other safe, natural options have been taken from her.
If you are planning on an unmedicated birth, you may want to consider hiring professional labor support. Studies have shown that women who give birth supported by a doula have shorter labors, less use of medications, and a more positive experience of their birth. They are also more likely to be breastfeeding at six weeks postpartum, and to have better confidence in their parenting abilities. Particularly with the added efforts of giving birth twice in a short period of time, doula support can prove invaluable.
There are several factors that will influence your birth planning. There are factors surrounding your individual pregnancy history and situation, pre-birth complications that might alter your birth planning at any point during the pregnancy, and complications that can arise during the births themselves that can alter your birth plan. While it is important to maintain your focus on your hopes for your birth during your pregnancy (as they can give you strength to make it through some of the less pleasant aspects of twin pregnancy), it is also important to stay flexible, and to remember that the safe births of the babies are the number one priority. Many of the factors influencing birth options will be the same as for singleton pregnancies, and will include monitoring for gestational diabetes and pre-eclampsia, among other diagnoses. Many moms who have conceived their twins via fertility assistance feel obligated to an overly medicalized birth, as they feel they owe their pregnancy itself to the medical community. In an otherwise healthy pregnancy, even one brought about by fertility treatment, there is no reason for a change in birth planning; many moms who conceived their twins with fertility assistance go on to have wonderful, natural births. Women hoping for a vaginal birth after Cesarean (VBAC) can be reassured, as well; while twin moms may be less likely to try for a VBAC, they are no more likely than singleton VBAC mothers to have a rupture or other complication, and are no more likely than other twin moms (without a prior Cesarean) to have a complication during a vaginal birth.
Certain situations that might affect your twin birth planning can include whether or not your twins share a sac or are at risk for TTTS. Twins who share a sac (monoamniotic twins) are at significantly higher risk for cord entanglement, cord compression, TTTS, and preterm birth; they will require additional monitoring throughout the pregnancy and most experts recommend a scheduled cesarean for this kind of birth. Monoamniotic twins are extremely rare; however, even the most naturally-minded mothers expecting twins support having at least one ultrasound to determine the number of amniotic sacs and placentas. Identical (“monozygotic,” or MZ) twins can be at risk for twin-to-twin transfusion syndrome (TTTS), a situation in which the flow of blood to the babies becomes (for lack of a better description) rewired, causing one twin (the donor twin) to not get enough, and the other twin (the recipient) to get too much. Twins at risk for TTTS should be monitored throughout the pregnancy; if it is determined that the pregnancy has become too risky for the babies, an induction or Cesarean may be encouraged. It is important to note that there have been acute cases of TTTS that present during labor itself; ask your provider about this risk.
In addition to pre-birth factors that affect birth planning, there are special situations that may arise during the birth itself that may require intervention or a Cesarean. One complication, more common with baby B and in breech births, is cord prolapse, which is when the umbilical cord comes into the birth canal before the baby. With a cord prolapse, the cord may become pressed between the birth canal and the baby’s body, causing a decrease of blood flow, and thus oxygen, to the baby. Occasionally, and particularly if baby B is significantly bigger than baby A in a first time mom, the second twin may require an operative birth (forceps or vacuum) or Cesarean; this is extremely rare. Some studies have shown best outcomes when the time between the babies’ births is not that great, and for this reason many providers set a time limit for the second twin to come; it is unsure as to whether or not these studies accounted for any negative effect of active management of the second twin. Often, a mother’s contractions may slow or stop after the birth of baby A, only for labor to resume after a while. It is not unusual in this kind of situation for there to be a time period of an hour or more between births, and the condition of baby B can be monitored during this time. For the most part, many of the complications that can come up during a twin birth are the same as the complications that can occur during any birth.
Almost always, the placenta(s) come out after both babies have been born; two placentas may be fused together and come out in one large piece. As mentioned earlier, postpartum bleeding is typically more intense for twin moms: you will have a larger area of the uterus left raw after the detachment of the placenta(s). Some of this can be controlled prenatally by eating a diet rich in iron and greens, taking supplemental iron if warranted, and monitoring your hemoglobin and hematocrit levels. It can also usually be handled by the administration of herbs, Pitocin, Methergine, or other anti-bleeding medication. Even in homebirths, some midwives can administer intravenous or intramuscular shots or drips of Pitocin; ask your provider before the birth how s/he would handle a postpartum hemorrhage, as they can frequently be handled with skill and ease, whatever your birthing location.
If you and your provider decide on an induction, remember that there are natural ways you can encourage labor to begin, including nipple stimulation, sex, evening primrose oil, and other herbs. Ask your provider if these are appropriate for you. Sometimes, a foley catheter may be used to begin dilation without medications. If a medical induction becomes necessary, remember that prostaglandins (while not recommended for vaginal birth after Cesarean) can help prepare the cervix before beginning Pitocin, and can decrease the chances of your induction ending in a Cesarean. A form of prostaglandins that can be removed by a string if complications occur is best; Cytotec is not FDA approved for beginning labor, and has many significant risks.
If it becomes clear that you will need a Cesarean, there are things you can do to make it a more positive experience for you and your babies. Check out the web site of the International Cesarean Awareness Network (http://www.ican-online.org) for more information on how to have a more mother-friendly Cesarean. It might also be good, even if you are planning on a vaginal birth, to make sure you have a provider who supports mother-friendly Cesarean practices, just in case.
As always, if your birth does not go the way you anticipated, it is important to process any unexpected feelings you might have. Speaking with a doula, childbirth educator, friend, or a counselor can help you avoid anxiety, depression, or additional trauma related to the birth. Solace (http://www.solaceformothers.org/about-solace.html) is an organization devoted to helping mothers recover from challenging childbirth. If you need help processing your feelings about your birth, you are not alone. Seek out the support and help you need.
The greatest gift you can give yourself and your babies, when it comes to planning your twin births, is knowledge. Research, read, and ask questions, both of professionals and of other twin moms who have had (or planned) vaginal births with their own babies. Take independent childbirth education classes from a childbirth educator with a birth philosophy similar to your own; some hospitals even offer special childbirth education classes for parents of multiples. Preparing for Multiple: The Family Way (http://www.thefamilyway.com/multiplespage.html) is one such program. Surround yourself with supportive people, and ignore the negative comments. You don’t have to be a doctor or midwife to be an active participant in your own birth planning. While I have no degrees in a birth-related field, the research I did during my own twin pregnancy proved valuable when it came to knowing the right questions to ask. While no book or web site can be a substitute for proper maternity care, armed with research and information, you can ask better questions, make better choices, and be empowered to work toward the births you envision for your babies. There are no guarantees in birth, just as there are no guarantees in life; that shouldn’t stop us from putting one foot in front of the other, moving forward in the best way we can, planning for things to go according to plan, and having a backup plan just in case they don’t.