Though a birth plan can be helpful, please remember that labour and birth are unpredictable. You may need to be prepared to do things differently if complications arise.
Timing of birth
The average length of a pregnancy depends on how many babies you are expecting. Twins usually arrive around 37 weeks, triplets at 34 weeks, and quadruplets at 31 weeks, weighing in at an average 5.5lbs (2.49kg) for twins, 4lb (1.8kg) for triplets and 3lb (1.4kg) for quadruplets.
Make sure you have packed your hospital bag and finished antenatal classes well in advance of these dates, as twins or more are more likely to be born early.
In 60% of twin pregnancies spontaneous labour or a medical reason for delivery (like complications of pregnancy for mum or concerns about babies’ growth) will occur before 37 weeks. This will occur in 75% of triplet pregnancies before 35 weeks.
Where the pregnancy has been entirely uncomplicated, your doctors and midwives will recommend planning delivery from 36 weeks for babies sharing a placenta (monochorionic) and from 37 weeks for babies with their own placentas (dichorionic). For triplets this will usually be from 35 weeks. This is because there is evidence that the risk of complications like stillbirth start to increase after these time points in multiple pregnancy. If you choose not to schedule delivery, your team will recommend close monitoring of the babies’ health with weekly check ups and fortnightly growth scans, but unfortunately there are no tests that are proven to reliably estimate the risk of complications for the babies.
When making plans for delivery, you will be able to discuss the risks and benefits of Caesarean sections and vaginal birth with your care team. There are lots of factors to consider when making this choice such as your individual background, your health, your babies’ health during pregnancy and your wishes for future pregnancies. In most cases Caesarean is recommended for triplets and higher order multiples and for monochorionic twins.
The Twin Birth Trial showed no difference in outcomes for babies with their own placentas whether delivery was planned to be by Caesarean or by vaginal delivery. However, about 40% of women who had planned vaginal delivery ultimately delivered by Caesarean because of a need for urgent delivery arising either before or during labour.
A little over half of all twin babies in the UK arrive by caesarean section, and almost all triplets and quadruplets, so even if you plan a vaginal delivery it might be helpful to prepare a birth plan for a Caesarean too. There are lots of reasons why you and your doctor may decide a caesarean is best for your birth. Among these, it may be that first baby is lying in the breech position (feet, knees or buttocks down) or transverse position (across your uterus) making a vaginal birth difficult. Or you may have a condition such as placenta praevia, where the placenta covers the cervix. In these cases you will be booked in for a planned caesarean.
An emergency caesarean is performed when a problem occurs during labour and it is necessary to get the babies out quickly. Again, there are many reasons why this can happen, including the babies moving into a difficult position, concerns regarding their well-being, high blood pressure that doesn’t respond to treatment, slow progress, or where an assisted delivery (forceps or ventouse) does not work. Very occasionally, a first baby is born vaginally but the second becomes distressed or cannot be safely delivered vaginally and has to be delivered by caesarean section. This happens in less than 5 percent of twin births.
For a Caesarean birth plan, consider who you would want to be present with you (in most units they will limit this to one person), whether or not you want to have skin to skin contact with the babies in the operating theatre (if they are born healthy at term), if you want to have any music playing, who should announce the sex of your babies (if you don’t already know) and if you want photographs to be taken as the babies are delivered.
It’s a good idea to write a birth plan expressing your wishes on pain relief, who will be present at the birth, positions for delivery, and whether you want zygosity testing to see if the babies are identical (the placentas will be examined and cord blood sent for analysis, for which you may have to pay), as well as anything else that’s important to you. Bear in mind that the plan will need to be flexible, taking account of how your labour goes.
Multiples are nearly always recommended to have continuous monitoring during labour, even when they haven’t been induced. Your midwife will strap a belt with small pads and sensors onto your tummy to assess your babies’ heartbeats and the intensity and frequency of contractions. You should still be able to move into different positions as you labour. If external monitors can’t clearly pick up two separate heartbeats (sometimes this is difficult if they are very close), the first baby can be monitored internally using a fetal scalp electrode attached to the babies’ scalp.
The first stage of labour consists of uterine contractions that push the babies head down into the pelvis and open the cervix. Once it is 10cm dilated, you are ready for the second stage: pushing them out. Some hospitals will automatically transfer you to an operating theatre at this point. The benefit of being in the operating theatre is there is a bigger space to accommodate the larger team present at a twin or more birth and there is quick access to surgery if it is needed during the delivery. The drawback is moving during labour and being in a relatively more clinical and noisy environment than most delivery rooms. The number of people in the room or theatre will vary, but usually includes an obstetrician, anaesthetist, two midwives, one paediatrician for each baby, as well as students and junior staff. If you feel strongly that you don’t want lots of people present, ask for all non-essential staff to wait outside the room until they are needed. The essential staff will include the obstetrician, midwives and paediatricians and they may require assistance from the others for some of their tasks.
It can take anything up to two hours to deliver the first baby. Sometimes mothers are encouraged to give birth on their backs. It’s worth discussing your options on different birth positions and hospital policy beforehand. With support from your midwives, it is possible to deliver twins safely in different positions, including standing, squatting and on all fours.
If the second stage is going slowly or the babies seem to be developing distress, you may be advised to have an assisted delivery using forceps or ventouse (a vacuum device that attaches to the baby’s head). Both procedures often involve an episiotomy (small cut to the vaginal wall) which is done under local anaesthetic if you haven’t already had an epidural.
After the first baby is born, the doctor will check the position of the second. It may be necessary to manually move the baby into a head down position. This can be done externally, but it may be necessary to pull the baby out by its feet or to turn the baby internally, which requires pain relief if you haven’t already had it.
It may only be a few minutes before the second baby is born, and it is usually less than 20 minutes. Second babies usually deliver more quickly and easily than first babies.
You should have an opportunity to cuddle your babies before the third and final stage of birth, when you deliver the placenta. Waiting to deliver the placenta naturally can take up to an hour and is not recommended with twins because the larger placentas carry a greater risk of bleeding. Your midwife will probably recommend you have an injection of a drug (Syntocinon or Syntometrine) to contract the uterus and help the placenta deliver quickly, usually within ten minutes. This means you don’t need to push and you will lose less blood.
Pain relief in labour
You will be offered the same sorts of pain relief as a woman labouring with a singleton, including pethidine and gas and air. However, women carrying multiples are often advised to have an epidural due to the greater likelihood of having an assisted delivery or a caesarean, or complications such as the need to turn the second baby before delivery.
It is a good idea to use antenatal appointments to talk through your options so you have time to think about what is going to suit you and your babies.
Twins or more often arrive early, sometimes very early. In a Twins Trust survey, fewer than half of twin pregnancies went over 37 weeks, and only 1.5 percent of triplet pregnancies.
Reassuringly, studies show that premature twins or more mature more quickly than single babies born at the same time, so multiples are often better equipped for an early start. Some need only a short stay in neonatal care.
If it seems likely your babies will be born prematurely, you may have to stay in hospital so their condition can be monitored because premature labour can be fast and unpredictable. Your care team will discuss with you whether a Caesarean would be recommended if active labour starts. This decision will depend on the size, position, number and health of the babies. A Caesarean may reduce some risks, but Caesareans at early gestations carry extra risks for mum and the benefits for the babies are not clear in every situation. Medication can delay labour, while steroid injections help speed the development of their lungs. The babies will be taken to the Special Care Baby Unit (SCBU) in case they need help with feeding or breathing once they are born. Many hospitals will arrange for you to meet the neonatal team or visit the unit if you are admitted because there is a risk of preterm delivery.
In a survey, our parents highly rated the care their babies received in the neonatal unit. The help they received in the neonatal unit to support their babies, made them felt better prepared for the challenges of caring for their babies’ at home.
It is a good idea to visit the neonatal unit during an antenatal tour of the hospital so that if your babies do need to spend time there it comes as less of a shock. You can also download our Parent’s Guide to Neonatal Care.