County Durham and Darlington

NHS Foundation Trust

Multiple Pregnancy

Content Page

Introduction3

Different kinds of twins 4, 5

Screening for abnormalities 6

Complications for your twins in pregnancy7

Timing and place of delivery8

Prematurity (preterm birth)8

Caesarean section or a planned vaginal birth – risks and benefits9, 10

Labour and birth10

Giving birth11

Parentcraft12

Breastfeeding12

Support12

Taking care of yourself13

Resources14

Introduction

If you are expecting two or more babies at the same time, you have got a ‘multiple pregnancy’. This happens to about 1 in 80 women but fertility treatments significantly increase the chance of you having twins, triplets or even larger multiples. You’re also more likely to have a multiple pregnancy if you are older, if you already have other children and if twins run in your family.

Any pregnancy brings with it a mixture of worries and positive emotions for women, partners and other family members. With multiple pregnancies, it is particularly important that you are well prepared for the changes that will take place during the pregnancy and after the babies’ birth.

This information leaflet has been produced by NorSTAMP, a group of NHS healthcare professionals based in the North of England whose interest is in promoting good clinical care for women pregnant with more than one baby.The aim of the leaflet is to provide you with information that will (1) help you to understand more about multiple pregnancy and (2) help you to make informed choices about the care you receive in your pregnancy. Further information is always available from your midwife and from your Consultant Obstetrician.

Different kinds of twins

  • In some cases women release two eggs at the same time and both get fertilized. It is possible for the babies to be both boys, both girlsor one of each. These non-identical or dizygotic twins are no more similar to each other than any other brothers or sisters.
  • You can also get a twin pregnancy if you produce a single egg that splits into two after fertilisation. These are genetically identicaland are called ‘monozygotic’ twins.
  • All dizygotic twins and one third of monozygotic twins have separate placentae (‘dichorionic’) and develop in separate sacs (‘diamniotic’).
  • Two thirds of monozygotic twins have a shared placenta (‘monochorionic’) but develop in separate sacs (‘diamniotic’).
  • 1% of monozygotic twins has a shared placenta (‘monochorionic’) and develop in the same sac (‘monoamniotic’).

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Screening for abnormalities

All pregnant women are offered a scan at about 12 weeks to screen for Trisomy 21 (Down’s syndrome) and another scan is also offered at around 20 weeks to look at the baby’s development. If you are pregnant with twins, the chance of these tests finding a possible problem is slightly higher than with other pregnancies.

Blood tests can also be used to screen for abnormalities in a baby’s development. Blood tests taken at the time of your 12 week scan can be combined with the scan results to give a more accurate result, even in multiple pregnancies. This combined test is now routinely offered in multiple pregnancies.

The NHS publishes a leaflet called ‘Screening for Down’s syndrome in Multiple Pregnancy’. Your midwife should be able to give you a copy of this leaflet.

Complicationsfor your twinsin pregnancy

The ability of the placenta to provide oxygen and food to your developing babies can be reducedif you have a twin pregnancy. For this reason, you will be offered extra ultrasound scans as the pregnancy progressesto monitor their growth. The fluid around each babywill also be measured together with the blood flow in each baby’s cord as an indicator of their health.

Monochorionic twins can get twin to twin transfusion syndrome (TTTS). It occurs if there is a direct link in the blood supply between thetwo babies, which happens in around 15% of monochorionic twins to some degree. TTTS can put the lives of both babies at risk.In this case you will be offered treatment which has to take place in hospitals with specialised expertise and this can involve reducing the fluid around one of the babies or even using a laser to separate the two circulations.

Monoamniotic twins are rare. They can get their cords tangled, causing thebabies to lose their oxygen supply. Because of this, monoamniotic twins sometimes need their well-being assessedseveral times a day as pregnancy progresses and they are usually delivered before full termby caesarean section.

Minor problems like morning sickness, heartburn, swollen ankles, varicose veins, backache and tiredness are more common in multiple pregnancies. These get better without any specific treatment after the pregnancy is over. When you are carrying twins you are susceptible to more significant medical conditionstoo. These tend to be problems that can arise in any pregnancy likehigh blood pressure, diabetes and liver problems of pregnancy– they are just more common with twins. For this reason, your midwives and doctors will want to see you frequently inthe antenatal clinic throughout the pregnancy.

One of the most common conditions that arise in pregnancy is anaemia, usually because of a lack of iron. This is partly because your developing babies use up a lot of iron. To help with this problem, you may be given an iron tablet to take each day throughout the pregnancy.

Timingand place of delivery

You are more likely to go into labour early if you have a multiple pregnancy. The naturalaverage timings of labour and birth weights are:

Average Timing of Labour Average BirthWeight

Single baby40 weeks3.5 kg

Twins 37 weeks2.5 kg

Triplets34 weeks1.8 kg

Quadruplets32 weeks1.4 kg

In order to ensure the best outcome, your doctor may advise you to give birth before your due date, either by having labour induced or by having a caesarean section. Most doctors advise delivery of dichorionic twins by about 38 weeks and monochorionic twins by 36 to 37 weeks. These are not exact figures because it is not yet known when the best time is for apparently healthy twins to be delivered if the pregnancy has been uncomplicated.

Place of birth - You will be advised to give birth in a Consultant led maternity unit if you are having twins so that you can get help from specially trained doctors if needed. This may be at your local unit or the larger regional unit depending on how your pregnancy progresses and what gestation (stage of pregnancy) you are when you give birth.

Prematurity (preterm birth)

A small number of women end up going into labour so early that the babies are born before they are fully developed. If this seems to be a possibility for you, you will be offered steroids. These are given as a series of two injections. They help your babies’ lungs to mature and reduce the problems your babies will have with breathing after their birth. Twins and other multiples are more likely than single babies to be admitted to special care baby unit because of problems like prematurity, but most often, they are well enough to stay on the postnatal ward with their mother.

Caesarean section or a planned vaginal birth – risks and benefits

If you’re having twins, youwill get the chance to discuss your plans for giving birth with your midwife and obstetrician during the pregnancy. Your decision to have a vaginal birth or a caesarean section will depend upon several factors:

  • If one baby nearest toyour cervixis presenting as a breech towards the end of the pregnancy, a caesarean section is usually recommended. The positionof your second twin should not have a major effecton your planned mode of delivery. This rule may not apply, however, if you go into labour very early as premature twins in spontaneous labour are usually delivered vaginally. If your labour is well established then a caesarean section may not be necessary and you should discuss this with the medical staff on the labour ward for best advice.
  • Triplets and quadruplets are usually delivered by caesarean sectionunless you are in very preterm labour or you give birth to the first baby very quickly.
  • Complications in labour are more common if one of your twins has significantly reduced growth, particularly if this is due to the placentanot being able to provide a good oxygen supply. If this is a major concern, your doctor may recommendacaesarean section.
  • A planned caesarean section is thought to be the safest way to deliver monoamniotic twins so that they don’t get their umbilical cords tangled up.

The benefit of a planned caesarean section is that it can help you to avoid an emergency caesarean section while you are in labour. The risks of a planned caesarean section include:

  • Bleeding during or after the operation, sometimes leading to blood transfusion or a second operation to stop the blood loss.
  • Infection, for example in the wound, the womb or the bladder.
  • Thrombosis (blood clots) in the veins of your legs, pelvis or lungs.
  • Damage to internal organs, especially the bladder.
  • Cut to one or both of your babies, which may need stitches and could leave a scar.

We aim for all parents to be given accurate information in order to make a well informed decision around the birth. Your own preference is an important factor, once you have been given enough time to consider all of the relevant information. The agreed plan will be written into your hand-held notes and your hospital notes by about 34 weeks.

Labour and birth

When you get to the delivery suite in labour, your midwife will askwhether the plans were for a vaginal birth or a caesarean section. If you have planned to have a vaginal birth, your progress in labour should be almost as quick as for women who are having a single baby. Yourcondition will be assessed continuously with regular progress checks. If yourcervix is dilating very slowly, your contractions may be increased with a drip.

Continuous monitoring of both babies’ heart beats with an electronicmonitoring system is recommended in labour. This is usually done by putting one belt around your tummy for each baby. This can give a clearer picture of your babies’ heart beatsto ensure thatwe are aware of any changes in their well-being.

You may wish to have an epidural in labour and this can be useful if any complications arise, for example, if the labour is proceeding very slowly or ifthere is concern over your babies’ heart beats on the monitor. The epidural can then be used to give you pain relief while your babies are delivered by the doctor. Some people believe that this increases the safety of your labour, particularly for the second twin. It is not essential for you to have an epidural,however, and the alternatives should be discussed with you.

Giving birth

At the end ofyour labour the aim is for both of your twins to be born vaginally, without any unnecessary intervention. Sometimes it is necessary to deliver the first baby by forceps or ventouse (suction delivery) so that thedoctor can gain access to your second twin.After delivery of your first twin, his or her cord will be clamped and cut in the usual way but the placenta stays inside the womb until the second baby has been born.

Your midwives and doctors will then confirm whether your second baby is coming down head-first or bottom-first by feeling your tummy, doing an internal examination or by using an ultrasound(scan) machine. As your second babycomes down the birth canal, the second bag of waters is often broken to increase your contractions. A normal birth should follow within about 30 minutes. If your second twin is being born as a breech, a doctor should be at hand to give you assistance. It is unusual for the first twin to be born vaginally and for the second to be born by caesarean section, but it can happen if the doctor feels that the second baby needs urgent delivery and that an attempt at vaginal birth would be unsafe.

The room may seem crowded when your twins are being born.There will be at least one midwife there, but two are often present. A doctor experienced in delivering twins will be available either in the delivery room or close at hand. Doctors and nurses specialising in the care of newborn babies may also be present. Finally, an anaesthetist is sometimes there to make sure that your pain is controlled. The staff can all help you and answer any questions you or your companions have at that time.

Parentcraft

The University Hospital of North Durham (UHND)multiple pregnancy team offer local parentcraft classes for women booked for delivery at UHND. The parentcraft classes provide multiple pregnancy specific antenatal information, advice and support, as well as discussion of delivery and postnatal wellbeing, including breastfeeding.

Breastfeeding

Breast milk is best for newborn babies and your body will automatically adjust to produce enough milk for your babies if you decide to breastfeed. Your midwives will give you the advice and support that you need. Feeding workshops are held at UHND and arranged by the multiple pregnancy team for women booked for delivery at UHND. This will give you more information and explore your thoughts and feelings around feeding your babies. Ifyou decide breastfeedingis not your preference or if you encounter any difficulties we are trained to guide and support you in this.

Support

Finding you are pregnant with more than one baby can be very exciting but also a challenge to some families. During pregnancy most of the attention is often focussed on the pregnant woman and often partners needs do not appear to be a priority. Having more than one baby is a very busy time for any household and it is made much easier if you are able to support one another.
Taking care of yourself

  • Plan ahead! Having more than one baby is very tiring. If you have apartner, they are an obvious source of help and support. Help from your family, friends or neighbours are all possibilities. Accept help offered and do not see it as a weakness or that it might look like you are not coping.
  • Make clear to family and friends what your preferences are concerning how you want things to happen once the babies have arrived (e.g.) don’t call them ‘the twins’, buying them things looking the same, picking them up when they are sleeping.
  • The cost of having more than one baby at a time can add up. Be careful not to buy equipment that you could borrow or buy second hand.
  • Babies can often come early so consider this before making plans, especially considering how long you will continue work.
  • Ask for help when you’re in the hospital so that you can build up your confidence. Get support for your choice of feeding for your babies.
  • Know your limitations and take short cuts with housework or chores to make life a bit easier in the early days.
  • Having a routine is useful when you have more than one baby to care for. Try to stick to your routine and make sure everybody knows about it.
  • It is fine to split the babies up between grand parents or helpers, it gives them a chance to learn to know the baby as an individual and each baby gets lots of attention that way.
  • Look out for activities and support groups in your local areas.

Resources:

The Twins & Multiple Birth Association (TAMBA) can be contacted at:

2 The Willows

Gardner Road

Guildford

Surrey

GU1 4PG

Tel: 08707 703 305

Twin line listening service: 0800 138 0509

Email:

The Multiple Births Foundation can be contacted at:

Hammersmith House Level 4

Queen Charlotte’s and ChelseaHospital

Du Cane Road

London

W12 0HS

Tel: 0208 383 3519

Email:

The Royal College of Obstetricians and Gynaecologists publish guidelines relating to monochorionic twin pregnancy in December 2008 as follows:

Produced by Regional Maternity Survey Office Date: June 2010

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