Friday, October 26, 2012

Advice for Twin Births

I am happy to present this information written by Kimberly Amato, a doula with expertise in twin births, as well as the mother of twins and a singleton.  Kim has been a fantastic resource for me when I’ve been a doula for twins, as well as when I wrote about twin births on pages 211-214 of my book.  Depending on the care provider or hospital, mothers of twins may be expected to:  use an epidural even if they prefer natural childbirth, because of a small increase in the chance of a stat cesarean; have an induction as a routine protocol, or because complications develop that are more likely with twin pregnancies; and/or move into an Operating Room during the pushing phase of a vaginal birth, as a precaution in case of emergency.  Kim has written an excellent guide that mothers and doulas can use to help them have a dialogue with care providers about birth options with twins.  To correspond with Kim for more information, email her at

This is a guide to help facilitate discussion between you and your medical care providers.  Women who are pregnant with twins or higher order multiples are often considered “high risk” and the medical management of their pregnancy, labor, and birth is often different than that of a woman pregnant with only one baby.  Most women, upon finding out they are pregnant with more than one baby, don’t realize how very important it is to ask questions of their care providers and to seek information particular to multiple birth, as it is different than having just one baby.  Not all women pregnant with more than one baby are truly high risk though, and it doesn’t mean you have to have a high-intervention birth.

For that reason, understanding what the usual policies and practice patterns are with regard to multiple pregnancy for both the place you’ve chosen to birth and the provider you’ve chosen to care for you and your babies can be a great help to you as you prepare for their birth!  The vast majority of twins and higher order multiples are born in hospitals, but some are born at home.  Half of all twins are born premature and by cesarean birth, and nearly all higher order multiples are both premature and born by cesarean.  Being knowledgeable and prepared can help you to have a healthier and happier pregnancy, birth, and postpartum experience.

Knowing what to expect by asking some of these questions allows you the opportunity to research and further discuss your choices with your doctor or midwife so that you can make the best choices for you and your babies along the way.  It is helpful to also become familiar with your rights and responsibilities as a patient and understand informed decision making.  Knowledge is power, but only if you use it.  Don’t be afraid to ask more detailed questions or ask for research supporting a particular practice if you want additional information.  If you don’t like the answers or don’t agree with them, find a care provider who shares your philosophy.  They are not all the same.  Nor are all pregnant women the same.

This list addresses common questions among women pregnant with multiples, but is by no means exhaustive.  Every birth, every woman, and every baby is unique!  There is no right or wrong answer, only what is best for you and your babies. 

Regarding pregnancy:

  1. How will my care be different than a woman expecting only one baby?
  2. What nutritional guidelines should I follow?  How many calories should I consume?  How much weight should I gain?  How much should I drink?  How much protein, iron, calcium, and fiber should I be getting?  Is a regular prenatal vitamin sufficient?
  3. Can I exercise?  Are there any limitations I should be aware of?  Now?  Later?
  4. How many ultrasounds will I need to have?  When and why?  What are the benefits/risks of having or choosing not to have ultrasounds in pregnancy with twins/more?
  5. How often will I need to come for prenatal appointments and how long do they last?
  6. Will I need to have a Perinatologist (a doctor who specializes in high risk pregnancy) for my care?  Why or why not?
  7. Will I have to be on bed rest at some point?  Can you define bed rest?  (In bed all the time and only up to use bathroom, no working, no going out of the house, etc.) Why?  When?  What are the benefits/risks of bed rest?  What are the benefits/risks of not going on bed rest?
  8. What will happen if I have pre-term labor?  What is done to stop it?  At how many weeks would you let my babies be born if I were to go into labor prematurely?
  9. Do I have any other risk factors for pre-term labor or other complications right now? 
Regarding labor/birth:

  1. Will you automatically schedule an induction if I have not had my baby by a certain time? If so, why?  What are the benefits/risks of induction versus waiting?  What is that time and why do you recommend that?  What method of induction do you typically recommend?
  2. In what circumstances would you recommend a planned cesarean birth?  Why?  What are the benefits/risks of a cesarean compared to waiting for labor?
  3. If twin A is vertex (head down) and twin B is not, can I attempt a vaginal birth?  If not, why not?
  4. What should I do when I think I am in spontaneous labor?
  5. When I am in spontaneous labor at the hospital, how will the babies be monitored?  Will I be able to be out of bed, walk in the halls, change my position, and use the shower/tub?  What about if my labor is induced?  If not, why not?
  6. What routine procedures can I expect at the hospital?  (Things like an IV, restrictions on eating/drinking or mobility, etc.)
  7. Is telemetry (portable) monitoring available if I need to be continuously monitored?
  8. Do you recommend an epidural at some point?  If so, why?  What would be the benefits and the potential risks to me and my babies, for both getting and choosing not to get an epidural?
  9. What if I wanted to avoid pain medications in labor?  Will you support me in that decision?
  10. If I did opt to have an unmedicated birth and a cesarean became necessary, what type of anesthesia would be used and why?  What would the potential benefits and risks be to my babies and me?
  11. Where does the birth of the babies take place?  Will I have to push/deliver in the O.R. or can I stay in the labor room?  If we need to move, why?  What if I want to remain in the labor bed rather than push on the O.R. table?
  12. If I have to push in the O.R., can the lights be dimmed; can we bring our music, etc.?
  13. What positions can I use for pushing?  Do I have to use leg supports (stirrups) or can I try sitting, squatting, or all-fours if I desire, assuming there are no complications?  If not, why not?
  14. Who can I have for support in labor and for the delivery?  Is there a limit on how many people I can have with me?  Can the babies’ sibling(s) be present with their support person?  What about if I need to have a Cesarean birth?
  15. When the first baby is born, what will happen?  Will I get to hold my baby right away and nurse if I desire to encourage the delivery of the second?  If not why not?
  16. Can we take photos of the labor/birth/immediately after?
  17. How long is the interval between the delivery of the first baby and that of the second (or third)?  Is there a time limit after which you would intervene?  Why?  What would you do to facilitate the delivery of the second baby?
  18. If the second baby is breech, will you try to turn it or will you deliver it vaginally as a breech, or will I have to have a cesarean for the second baby?  Can you explain your reasoning?
  19. What are the risks and benefits of a vaginal breech delivery to my baby and me?
  20. What will happen when the second baby is born?  Will I get to hold it right away and nurse it if I desire?  If not, why not?
  21. If any of the babies need to go to the nursery or NICU, how soon can I go to see them?
  22. If I need a cesarean birth, what can I expect to happen in the O.R.?
  23. In the event of a cesarean birth, will my partner and I get to hold the babies (assuming they are healthy and stable) and not be separated, or will the babies have to go to the nursery?
  24. What is your philosophy on breastfeeding twins/higher order multiples? 
  25. How long will we be in the hospital after the birth?
  26. Are there any services we can get at home to help us?
  27. What can I expect physically the first few days and weeks after the birth?
  28. What can I expect emotionally the first few days and weeks after the birth?
  29. Can you recommend any resources for me?


  1. My OB fought me tooth and nail all through my twin pregnancy on doing anything natural. I went on bed rest early on due to a possible incompetent cervix and had a cerclage placed as well. She fought me on letting me do progesterone suppositories, but I finally convinced her - and I believe it made the difference between having the twins at < 28 weeks versus 35 weeks.

    Had I actually gone into labor, my OB would have made me get an epidural and push in the OR "just in case". I needed an emergency C-section (yes, it was necessary), so my plans for a natural birth all went to heck anyway.

    When I got pregnant after the twins, the OB wanted to automatically place a cerclage and schedule a repeat C-Section. That's when I switched to a midwife. No one is doing any kind of unnecessary surgery on me! Not only didn't I need the cerclage with my singleton, but I had a successful VBAC as well.

    You are your best advocate! Do not be afraid to tell your OB what you want and don't want. Try to get in to see a midwife who works with an OB so you can go as natural as safely possible.

  2. This is awesome!! I am pregnant with twins and found this list to be very thorough and extremely helpful in making decisions regarding my prenatal care and labor/delivery. Thank you!

  3. I say add to that list have a plan in case you are placed on bedrest know who you can call to make meals, visit, watch kids if needed, ect. because bedrest can be long and it is certainly hard. It is more successful if mom is comfortable and not stressed. I think it is just as important as having a postpartum plan in place for who you can and will call on for support and if you will use a postpartum doula. Laurie Birth and Postpartum Doula mother of twins

  4. I am pregnant with twins and found this list to be EXTREMELY helpful! Thank you!