Finding out you're pregnant with twins can be simultaneously the most exciting and the most stressful news an expectant parent can receive.
There’s so much to consider – will your car be big enough, how will you manage to breastfeed two babies, and what sort of birth will you end up having?
Twins are more likely to be born earlier than a singleton baby, so it’s really important to know your birth options early.
Less than half of all twin pregnancies continue beyond 37 weeks.
It’s common for twins to be born by 38 weeks, and roughly 60% of twins are born via c-section.
However, a recent study has shown planning an elective c-section does not maximise your chances for a safe birth.
When you mention you’re expecting twins, it isn’t uncommon for others to ask when your c-section is scheduled – leading you to assume a c-section must be the norm for twin birth. While some twin pregnancies necessitate a c-section birth, vaginal birth is an option for many.
There are a number of important factors to think about when you are considering a vaginal birth for your twins.
Here are 6 factors to consider:
#1 How Is Twin A Positioned?
Vaginal birth for twins depends a lot on the position of the babies. If both twins are in the vertex (head down) position, then the risk is roughly the same as a single baby. There can be a slightly increased chance of cord prolapse (where the umbilical cord slips down before the baby) after the birth of Twin A.
When Twin A is breech or in an unfavourable position, c-section is usually the most common option.
#2. How Is Twin B Positioned?
If Twin B is in the same vertex position, then your chances of a vaginal birth are excellent.
It’s still possible to birth vaginally if Twin B is breech or in another position. Once Twin A is born, your care provider can turn Twin B to be ready for birth. In some cases, for example when Twin B is in the transverse (sideways) position, sometimes he or she can drop into to a vertex position after Twin A is born. If Twin B is in a breech position and your care provider has the experienced and knowledge, the baby can be born in that position.
In some situations, patience is all that is needed. Once Twin A is born, Twin B may have plenty of space to turn into the vertex position. It isn’t uncommon for Twin B to be born several minutes later or even more than an hour after Twin A during an uncomplicated, normal physiological vaginal birth. Being able to patiently wait for Twin B can be dependent upon many factors including mother’s wellbeing, Twin B’s wellbeing, and your care provider’s training and skill level for supporting vaginal twin birth.
If your care provider is not confident in delivering breech babies, c-section for the second twin is the result when Twin B isn’t easily turned into the vertex position. Vaginal-plus-c-section birth only happens in about 4% of twin births.
#3. How Big Are The Twins?
It’s common for twins to be slightly different sizes during pregnancy. However if the difference in size becomes too large, your care provider may be concerned about the smaller twin’s ability to cope with labour.
If you wish to naturally birth your twins and one is smaller, consider the differences between natural and induced labour and how this may affect your babies.
#4. One Placenta Or Two?
There are three types of twins:
- Dichorionic diamniotic (DCDA) twins: separate placenta with its own separate inner membrane (the amnion) and outer membrane (the chorion).
- Monochorionic diamniotic (MCDA) twins: share a single placenta with a single outer membrane and two inner membranes.
- Monochorionic monoamniotic (MCMA) twins: share a single placenta and share both the inner and outer membranes.
If your twins share a placenta (MCDA or MCMA) then your chances of having a vaginal birth are slim. Delivering the placenta after Twin A but before the birth of Twin B would be risky and potentially dangerous.
#5. Do I Need To Be Induced?
If you haven’t gone into labour by 38 weeks your care provider may recommend induction. The main reason given for the early birth of twins is to avoid complications such as preeclampsia, fetal growth restriction or placental failure. Large population studies have shown the stillbirth risk increases slightly after 38-40 weeks.
Your care provider’s experience with twin births may impact their recommendations for induction or waiting for labor to begin spontaneously. Some providers will recommend regular non-stress tests (NST) and/or biophysical profiles as you near the end of pregnancy, and especially if your pregnancy continues after 38 weeks. The type of twin pregnancy you have will also impact your risk level and recommendation to induce or wait for spontaneous labor.
Methods of induction most commonly used are amniotomy (artificial rupture of membranes), prostaglandin gel, or synthetic oxytocin. Continuous monitoring will be required to make sure the babies are coping with the artificially stimulated contractions. You’re likely to be restricted in your ability to move and required to lie down or sit reclining on a bed.
#6. Where Will I Give Birth?
Most women who are pregnant with twins will give birth in a hospital. This will mean a far higher level of medical management as a twin pregnancy is treated as high risk.
Most obstetricians have quite strict management policies for multiple births, which protects them from potential litigation if something goes wrong. They may want you to have an epidural in place, be induced by 37 weeks, or labour in the operating theatre in case previous interventions lead to c-section.
If you want to birth vaginally, it will take a care provider who is experienced in and supports natural birth for multiples. Some women are happy to go with their obstetrician’s recommendations, others want to be supported in having a vaginal birth.
It’s possible to have twins in birth centres or at home, with consideration to the health of your babies and their positions. Finding qualified and experienced care providers outside a hospital setting may be a challenge but is possible. Planned homebirth is rare but when it happens it takes place under a team of midwives experienced in twin birth.
How Do I Avoid A C-Section?
If you are keen to avoid a c-section, the first and best decision you can make is to choose a care provider who supports natural twin birth. Stay as healthy as possible by eating well during pregnancy in order to avoid issues like gestational diabetes and encourage your babies to settle into an optimal birth position.
If you decide to birth in hospital, do your research on inductions and interventions and the link to increased risk of c-section. Hire a doula to provide continuous support during pregnancy and labour.
Finally, remember there are always diminished expectations from the moment you find out you are having twins. Most people and health professionals will begin to treat you as though you are having a high-risk pregnancy with a c-section the inevitable outcome. It can be difficult to face all the challenges of pregnancy and the birth of your babies, plus parenting twins in the future, without positive support. Check if there is multiple birth associations in your area or online for continuous support from other experienced parents of multiples.