Multiple births

Although a wonderful concept, the reality is that multiple births do carry an increased risk of complications for both mothers and their babies. So as a rule, from the time that a multiple pregnancy is confirmed, planning starts for making the births as safe and ideal as possible. Weighing up the health and safety issues with what the mother and her partner want from their babies? birth can be a delicate balancing act. But no matter what is desired, the safety of the mother and her babies always needs to be the paramount goal.

Until a multiple birth becomes a reality, many mothers assume they will have a normal vaginal delivery and haven’t factored any form of obstetric intervention into their planning. But the chances of having either an instrumental birth e.g. forceps or ventouse extraction or a caesarian section are much higher with twins and/or triplets than with a singleton birth.

Many obstetricians have a standard practice management when it comes to multiple births and for safety’s sake as well as the very real risk of litigation, they only recommend caesarian section delivery when there is more than one baby involved. Some women and their partners “doctor shop” until they find an obstetrician or hospital which supports them to have a trial of labour. Others are content to follow their doctor/hospitals recommendations – we are all different and to a point, have choices regarding what suits our own beliefs.

Multiple pregnancies are always closely monitored and it is important that women have access to good quality obstetric care. Planning needs to occur early in the pregnancy for where and how the babies will be born. For women who live in rural or regional areas, relocation is often necessary. This is ideally to a capital city or major town where a maternity hospital and neonatal care unit are located. Though despite all the planning in the world, many babies and their mothers have needed to be retrieved and transferred by road or air ambulance to a tertiary maternity hospital. This is especially the case when there has been insufficient time to move before labour started or the babies have been very premature.

It is important to remember that there is no one size fits all approach to how multiples are born. Every woman and her pregnancy is unique, and depending on her individual circumstances, recommendations will be made by her obstetric team about how and where she should have her babies.

Far from being a passive recipient of information or being told what she do, pregnant women and their partners need to be actively involved in any decision making about how their babies are born.

What do I need to do?

Being organised early in the pregnancy and leaving little to chance will help you and your family. Have your hospital bag packed very early on, make lists, start cooking and freezing meals and enlist the help of family and friends to help you after the babies are born. Use your pregnancy as a time to reflect on all the small jobs which, if done now, will save you lots of work in the future.

Invest in every labour saving device you can including a dishwasher, dryer as well as household help if you can afford it. Stockpile necessities and each time you do the grocery shopping add a couple of essential baby items so you’re not going to be broke just before the babies are born. Include some treats for yourself as well.

Avoid embarking on a lengthy house renovation just before you are due. Although this may seem, in theory at least to be a fabulous idea, there’s always the potential and reality, for both budget and finishing times to extend. You really don’t need the stress.

What are the specific risks of a multiple birth?

• Premature delivery, i.e. birth before 37 weeks of gestation. Preterm babies often need specialist neonatal support (see below).
• Restricted foetal growth – this is generally due to the issue of limited physical space in the uterus not allowing for more than one baby to grow.
• Maternal blood pressure problems. As the mother’s pregnancy advances, a rise in blood pressure is common. This needs to be monitored in case it becomes too high.
• Placental abruption with/without haemorrhage.
• Placenta praevia. This is a condition where the placenta is lying either partially or fully across the cervix and potentially stopping the babies from descending through the cervix.
• Maternal anaemia. Depending on the level of iron in her blood and concentration of red blood cells, symptoms such as tiredness, loss of breath and a lowered oxygen transfer to the babies can result.
• To the babies – there is an increased risk of complications including cerebral palsy, breathing problems due to immature lungs, difficulty maintaining body temperature and/or normal blood sugar levels, feeding difficulties and jaundice.
• General immaturity issues relating to their size.

How is a multiple birth managed differently?

• Mothers need to be in or have close access to a major tertiary level maternity hospital. This also needs to have a neonatal/intensive care nursery on site.
• The mother is often advised very early in her pregnancy that a caesarian section delivery may become necessary. If she has had a previous caesarian section or a complicated vaginal delivery then the chances are higher of her needing a repeat caesarian.
• Many maternity hospitals have a policy of not allowing partners into the operating theatre if the mother needs a general anaesthetic. However, if she is having an epidural anaesthetic there is generally no problem with a partner being present. If you are unsure, check with your individual hospital and become familiar with their policy.
• The babies may need monitoring by way of electrodes during labour, so their heart rates can be continuously checked for signs of stress.
• The mother may have an intravenous drip inserted to keep her well hydrated, in case of complications or needing a caesarian section.
• Most obstetricians recommend an epidural block during the second stage of labour. This is necessary in case the second baby needs to be turned to a head down position.
• Mothers need to be open minded about their labour and delivery. Although they may have a birth plan and goals for a normal vaginal delivery, sometimes this is just not possible without compromising her own health or that of her babies.
• A mother may require an oxytocin infusion to ensure her uterus is contracting strongly. After the babies have been born, an injection of syntometrine will also help her uterus to contract down so bleeding is minimised.
• More staff will need to be present in the labour room or operating theatre to manage the mother and each individual baby. Teams are often assigned to concentrate on one baby each. This is to minimise confusion and optimise the level of care each baby is receiving. It also helps to clarify which baby is which and what treatments have been initiated.
• Very close monitoring and observations will be done to ensure the babies are not becoming stressed by the labour and delivery.

If one’s already out won’t the other one/s come too?

With twin and triplet vaginal delivery, the general concern is based around the birth of the second twin or subsequent baby. Even when the first baby is cephalic (head down) there is no way to predict how the second (and following) babies will manage being born vaginally.

There is often a delay of 15 minutes or more between the vaginal births of each baby. Alternately, they may be born very quickly. Although this can make it easier for the mother it is not ideal for the baby as they can sustain trauma from being delivered too forcibly. The general guide is that if the second or subsequent baby has not been born within 30 minutes of the first one, a caesarian is performed.

Which way is out?

Subsequent babies also have a tendency to change their position in the uterus and so instead of being (ideally) head down and ready to be born, they move into a transverse (sideways) or breech position (bottom or foot/feet first). All of a sudden there is more room for them to move and this, combined with their smallness, often leads to a change in the way they are lying in the uterus. This is a problem because there is a potential for them to become stuck and unable to descend normally out of the vagina. In this case a caesarian section delivery of the subsequent baby needs to occur. For this reason, most planned, elective caesarian section deliveries are booked from around from 38 weeks of gestation onwards. If the mother goes into labour before then and there was no plan for her to trial a vaginal delivery, an emergency caesarian section delivery is done.

In cases when a mother is very keen to have a vaginal delivery with her twins/triplets, she needs to be monitored closely. Induction is commonly arranged at between 37-38 weeks as it can become extremely uncomfortable for any woman to carry twins or multiples past this time. Another issue is that complications, if they were to occur, are more common past this point of gestation.

A team of midwives, obstetrician and neonatal paediatricians need to be present in the labour ward in case they are needed. Mothers who are trialling a vaginal delivery with a multiple birth are often advised to have an epidural anaesthetic in case a caesarian section delivery becomes necessary. In many hospitals, a trial of labour is done in the operating theatre so that if a caesarian section is needed, there is no delay in transferring her.

What’s different about a multiple birth recovery?

• It can take longer to recover generally from the labour and birth.
• If the babies were premature or are unwell, there can be alot of stress and worry for parents.
• There can be more vaginal bleeding and for a longer time than with a singleton birth.
• Establishing breastfeeding can take longer. This is especially the case if the babies cannot breastfeed and the mother needs to express her breast milk.
• It can take longer to “get back into shape”. There is often more excess abdominal skin from stretching so much during the pregnancy.
• It very important to do post natal exercises in particular pelvic floor and abdominal strengthening to build muscle strength and integrity. But managing the time to do this can be a challenge.
• It can take a while for the emotional and psychological transition of becoming a mother of multiple babies to sink in. Many parents of multiples experience adjustment issues, particularly if they do not have good family support around them.
• Working out what suits you in terms of being a family. You will get lots of advice from well meaning friends and relatives but ultimately, you need to decide with your partner what is going to suit you and your little babies.
• If your babies were born premature and require ongoing intensive/neonatal care then you will need to establish a daily routine of spending time with them. This can be utterly exhausting especially for mothers who may also need to express their breast milk and still be recovering from the birth themselves. Having older children to manage can make this more difficult.

It’s important to remember though, that despite all the challenges, the excitement and joy of having a multiple birth makes up for the hard work.

For more support

• Australian Multiple Birth Association
• Multiples NZ

NB Most multiple birth associations have their own state specific organisations and groups. Check the contact details for the one which is right for you.