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AIMS Journal, 2017, Vol 29 No 4
Mars Lord, mother of twins and doula to many twin parents, writes about some key issues which parents of multiples may wish to consider
Based on my own experience as a mum of twins, and as a doula specialising in supporting mothers of twins and multiples, I offer a perspective firmly rooted in the notion that women expecting twins and multiples should not be dissuaded from considering themselves to have options, just like any other pregnant woman.
Contrary to popular belief, you will not necessarily be excessively sick when you are pregnant with twins, so this is why it often comes as a shock to arrive at the dating scan and find out that there is more than one baby. Of course, some parents already know that the chances of twins are high, due to IVF, twins in the family, etc.
One thing that we don’t tend to count on, on discovering our double blessing, is the wave of negativity that fills the air. It can hit us from all sides: health care providers, family, friends, strangers in the street. Everyone knows someone, who knows someone who had twins and their life is hell. Why don’t the positive ones find us first, the ones who revel in their multiples? I’m not talking about people who have no realistic view about what having twins means, but the people who love it and see it as it is... wonderful, exciting, challenging, life changing, fun! Still, forewarned is forearmed and can allow you to more prepared to make decisions that are right for you.
A barrage of questions
Twin mums can face a barrage of questions from day one. Questions and comments fly from all corners, even before we’ve met with our health care providers.
Small wonder that by the time we are sitting talking to a doctor and/or midwife, fear may have crept in. It’s strange how much fear is put upon mothers of multiples, as though more than one baby is the scariest pregnancy prospect of all. The language that is used with multiple mums includes the word “risk”. Risk is not a word that brings comfort in this situation and I prefer to use the word “consideration”.
Assumptions and Decisions
There is often an automatic assumption that because you are pregnant with twins you will need to have a caesarean birth. More and more women are questioning the need to cut into their healthy bodies when twins can be born vaginally, and fortunately the medical world seems to be at last realising that surgery is not necessary for the birth of most twins. However, there may be additional decisions or more information needed when you are expecting twins.
When will my babies be born?
Like all mothers, mothers of twins are likely to wonder when the babies will be born. Just over half of women carrying twins will have gone into labour by 37 weeks, and three quarter of those carrying triplets by 35 weeks, as early labour occurs more often with multiple births. The signs and symptoms of preterm labour are just like those of labour at full term - regular contractions of the womb, building up in strength and frequency, the appearance of the mucous plug (‘show’) or waters breaking.
Contractions that do not become regular are a common occurrence in pregnancy. These may be particularly noticeable and common with twins and triplets; but in most cases they are not a sign of preterm labour. However, it can be very difficult to determine if labour is imminent or not and if you experience these symptoms you will be advised to inform your health care provider immediately and it is likely that you will be advised to go to hospital. Although it is difficult to stop true premature labour, it can sometimes be delayed, giving time to prepare the babies for an early birth. This is where conversations about steroids and other medication to help the babies’ lungs and other possible interventions and drugs come in, unless you’ve already had this conversation due to a history of premature birth.
Will my babies grow normally?
Most twins and triplets grow normally in the womb, although they do tend to be a little smaller than singleton babies. In all pregnancies, however, there is a chance that babies will not grow as they should, so good nutrition, along with a balance of exercise and rest, is important in giving your babies the best start possible.
You will be offered scans to determine whether your twins or multiples share placentas, and amniotic sacs, and your health care providers should explain how these things affect the growth of your babies and their births.
Although, it is important that growth restriction does not go unrecognised and that specific issues with some types of twin are monitored, you have a right to make decisions about whether, or not, to accept any tests including ultrasound scans that are offered to you.
Early delivery may be recommended if one or more of your babies is not growing well, and your health care providers should explain all your options, so you can decide what is right for you and your babies, and whether you want to accept any interventions they are offering.
Other Pregnancy Issues
There are more considerations to bear in mind when looking at and talking through options. Issues such as pre-eclampsia, gestational diabetes, anaemia occur more frequently in multiple pregnancy, but most mothers of multiples will still not experience them. However, if these considerations present themselves in pregnancy it is worth pausing and having an informed conversation with your health care provider. Seek as much further information as you need in order to make an informed decision about how, if at all, this changes your plans for your pregnancy and the birth of your babies.
Will my babies be head down?
The positions of your babies as you get close to term may determine what you decide is the best for your babies. If your babies are head down babies, or the presenting twin, the one that is in the position to born first, is head down, then health care providers are likely to be happy to support a vaginal birth. If the second baby is breech, then your health care providers are likely to talk about turning that baby or managing a breech vaginal birth. It is important to remember that you still have options and you have the right to be told what they all are, and to make an informed decision about what is right for you.
The second or subsequent babies are likely to reposition themselves after the birth of the previous twin, triplet, etc. Breech and transverse lying babies are often presumed to need caesarean births, but while transverse babies can only be born vaginally if they turn (or are turned) before they are born, breech babies, with the right support, will usually be born vaginally.
Do I have to have my babies in hospital?
Consider where you might want to birth your babies. You still have options but, depending on your local maternity services, you may have to ‘fight’ to birth your babies at home or in a birth centre. This may not be something that you desire, and as with all things, it’s about informed consent and where you feel safe birthing your children. Most health care providers appear to try to insist on continuous monitoring of multiples in labour. But guidelines and policies are not rules; you have a right to be told the research that these policies are based on, if any, and to accept or decline care as you choose. The physiology of birth does not change for the birth of multiples, so you may want to ask why they think there is an issue for your babies.
What about birth plans and preferences?
These are very valuable to prepare and have. They allow you to consider and think through all the options available to you, and to research the ones that perhaps aren’t offered, but might be right for you. Think about why you might want a vaginal birth and/or why you might want a caesarean birth. It you are offered the opportunity of seeing a ‘twin specialist’ you might want to ask what they are able to offer you that another consultant or midwife could not. You might want to know what the rate of caesarean, managed vaginal and physiological births is in order to decide whether they are the best person to support your birth preferences? Does it simply mean that all those expecting twins are under the care of this particular doctor or midwife, or does this person have a good record of supporting mums through choice and, hopefully, vaginal birth?
Despite the fact that many multiples are born early, many mother of twins find are offered induction. The AIMS book Inducing Labour: Making Informed Decisions could be a helpful resource. Talk about the reasons why your health care providers want to induce your labour. Ask what the ‘considerations’ are of both being induced and of not being induced. Is there clear evidence of benefits, or is it down to hospital practice? Ask what the actual statistics are when talking about the considerations of stillbirth and birth complications in multiple births. Hearing that something might double can cause us to immediately jump to imagine a high chance of something happening, rather than knowing that the percentage may still be very low, because doubling a very small number still gives a very small number. (eg. if there is a 1% chance of something happening, doubling it means there is now a 2% chance). As with all things, it is about what the considerations mean to you and whether, or not, you are happy with the advice that you are being given. Informed consent is important, but you can only make an informed decision if you know the facts and information on both sides of the coin.
After my babies are born
Immediately post birth can be very busy within a twin birthing room. The ‘golden hour’ is just as important for twin mums as singletons - the uninterrupted skin to skin and settling of the babies on the mother’s chest so that bonding may begin immediately. The smallest baby regardless of their size is often immediately or frequently checked for blood sugar, as though just being a twin makes this necessary. There is an assumption that twin babies should be identical in every sense, yet, how many people do you know who birthed singleton siblings who were the same size!
There is sometimes a rush to get both babies feeding, rather than allowing mum and babies to be still together. This is a time to clear the room, if all is well with mother and babies, and allow quiet to return, especially if there has been a lot of noise around the birth.
When considering feeding twin babies, it is important to get good help and support in place from the beginning. There are many people who do not believe that it is possible to exclusively breastfeed twins although, in fact, many, many twin mums do just this. For some the breastfeeding journey is complicated by the very health care professionals that one might look to for help, whether you are feeding one or more babies. Do ask if your hospital has an IBCLC (Internationally Board Certified Lactation Consultant) that can come by to help with breastfeeding. A simple tip that I share is this, do some early feeds where you feed your babies one at a time. This should enable you to learn the latch of each baby and identify issues quickly, rather than being confused as to which is which and who is who then progress to tandem feeding. The feeds will become more frequent and feeding them together is wonderful if it works for you. It may take time to find the right place and position to tandem feed and you may also need the support of your partner or someone else initially to get the babies in the right positions. You will also benefit from someone to bring you food and water and ensure that you are comfortable. If you are choosing combination or to bottle feed your babies, do read up on the guidelines for safely making up the milk. Our family and friends may not know these. Ask your midwife and/or health visitor about them.
There are different reasons why you may not get the birth and/or postnatal experience that you desire. One of your babies may need to go to SCBU (Special Baby Care Unit). These will be the babies who need a little support at the beginning, maybe oxygen, perhaps they need an eye kept on them for a few hours. It’s worth finding out whether your hospital has a SCBU or whether this care will be provided on the ward? Some babies may need to go to NICU (Neonatal Intensive Care Unit). These will be the babies who are seriously ill and need more care. It might only be one twin that goes into it. It might be two. It is worth asking if your local hospital’s NICU have double cots for babies? Both of these units will have their own rules about who can visit and when – although parents should have access at all times to their own babies. Your health care provider should be able to give you information about them.
Most women find it helps to have thought pre-birth about a ‘plan’ for post birth. What support will/can you put in place for your early days and weeks at home. Will you have family or friends help, or look to put in place some paid support? When deciding, think about what you might like. For most women it is about having support to enable them to focus on looking after the babies themselves, but for others it is about having someone to look after the babies. Think about the type of household you have and the type of people that you are. This should help inform your decision. You may wish to ‘wear your babies’ in order to be able to do other things whilst carrying one of more babies. There are resources out there to help you learn how to wear your babies simultaneously. It’s good to find out about these things early so that you have them to hand in those first days and weeks at home when you may be too busy with feeding, changing and sleeping to search them out.
The following may be helpful:
And Enjoy
Where possible, surround yourself with people who are confident about twin birth, or life with twins. Do some research early as to how you might like to birth your babies and where. Find out what your maternity services say. Read the AIMS book, Am I Allowed? and know your options. Be prepared to have a conversation with the senior consultant about your care. This includes your antenatal care. Find out if all your appointments need to be at the hospital. Think of ways to look after and nurture yourself as your body grows your babies.
This is an exciting time. Yes, you may be apprehensive as to how you will manage it all, but the support is out there. Congratulations. Welcome to the club!
Award winning doula and birth activist Mars Lord is a mother of five children, including one set of twins. She has had the privilege of working with hundreds of women, with a particular interest in multiple mums. Her work with pregnant women and their families has led her to speak at conferences and to lead workshops, namely Loving The Multiple Mamas and Cultural Competency.
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