The Difference in TWIN pregnancy
Labor & Delivery
Most of what we do, what you need to know about twin pregnancy is the same as a regular pregnancy with only one baby in the belly. There are a number of exceptions to this rule. Here is a list of the most common, most expected differences in twin and multiple pregnancy.
Medically, twin pregnancies are classified in three categories, based on how many placentas (chorionic) and how many amniotic bags (amniotic). The most common, and potentially least complicated is two placentas and two sacs: DiChorionic- DiAmniotic. The least common, and often most complicated, is MONOchorioinic-MONOamniotic, where two babies share one placenta, and one bag. The middle ground is MONOchorioinic-DiAmniotic, babies who share the placenta, but have their own amniotic bag.
KNOWING the number of placentas and number of sacs is essential to planning prenatal care. The diagnosis is made in the first trimester, before 13 weeks.
In general, prenatal care for twins, during the first 20 weeks of pregnancy is the same as for any pregnancy. We use ultrasound and the period, to determine the due date. We get all the same lab tests for singleton and twin pregnancies. Women with twins have the choice to do extra Down Syndrome testing, just like in any pregnancy. Early pregnancy care includes a full physical exam, breast exam, pap smear, and routine testing for gonorrhea and chlamydia…[read more]
There are many more ultrasound necessary to make sure twin pregnancy is going right. Early ultrasound, done around 8-12 weeks after the last period, is used to determine one or two placentas, and one or two amniotic sacs. Ultrasound between 11 and 14 weeks may be done to evaluate for Down Syndrome. Ultrasound around 20 weeks is done to look for normal anatomy of each growing fetus. Then, ultrasounds are done every 4 weeks to monitor not only growth, but also symmetrical growth. There is a long list of disorders specific to twins, which are diagnosed based on too slow growth of one or both babies. Later in pregnancy, the ultrasounds may be done every 2 weeks, or weekly, depending on what is found…[read more]
Premature Labor and Bedrest
The due date in normal pregnancy is 40 weeks. Most twin pregnancies are delivered by 38-39 weeks, either with the onset of labor OR by induction of labor. If labor begins after 34 weeks, we will let twins deliver. If labor begins before 34 weeks, we use medicine intended to stop early labor AND to help babies get ready for early delivery. Often, there are warning signs of early labor, including frequent contractions, extra vaginal discharge, and early dilation and thinning of the cervix. Between 22 and 34 weeks, prenatal care for twins is designed to look for, find, and treat evidence of early labor. Sometimes we manage warning signs of early labor with modified/reduced maternal activity. The most extreme limitation of activity, used for specific reasons, is bedrest…[read more]
If everything goes well, visit frequency for twins increases only after the 20 week/anatomy scan. The first half of pregnancy is managed just like any other pregnancy. Ultrasound measurement of the babies happens every four weeks, and we schedule office visits, every four weeks, between the ultrasound visits, so women are seen AT LEAST every two weeks. If there are regular contractions, concerns or symptoms regarding cervical dilation and early labor, or problems with elevated blood pressure/hypertension, some women may come in for weekly visits. The most complicated conditions require hospital admission, for daily, even hourly evaluation.
Labor, delivery and cesarean section
Many twin pregnancies can have regular vaginal delivery of both twins. Labor is safe and appropriate, near the due date, if the first baby is head down, and the second baby is estimated, by ultrasound, to be similar or smaller size.
The possible combinations of delivery details for twins includes: vaginal delivery for both babies, head first/head first; vaginal delivery for both babies, head first/feet first (breech), vaginal delivery for the first baby and cesarean section for the second, and cesarean section for both babies. The most complicated delivery, and the delivery to avoid, if possible, is cesarean section for the second baby after vaginal delivery of the first.
Some twins are delivered by planned cesarean section. Breech, or head up position of the first baby is reason for cesarean section in (almost) all pregnancies, twins or not. Other reasons for cesarean delivery of twins include: prematurity, severe growth problems in one or both babies, and pregnancy complications in the mother or the babies.
If the first baby is head down, and vaginal delivery is considered safe and appropriate in a twin pregnancy, there are certain considerations and preparations for labor.
- Timing: Either the twins are delivered at the time of natural labor, or induction can be scheduled 1-2 weeks before the due date. Whether to allow a twin pregnancy to continue beyond 38 or 39 weeks is a controversial issue.
- Basics: At the time of hospital admission for twin labor, all mothers have blood drawn, get an intravenous line places, and we monitor both baby’s heart beats and contractions, continuously. The IV line and monitoring does not mean staying in bed, and many mothers will choose to walk around and/or get in the bath tub.
- Pain Management and Epidural: Many women will choose to treat labor pain with an epidural. In certain situations, women laboring twins are encouraged to get an epidural in labor, even early in labor. Having an epidural in place allows the medical team to treat labor pain, treat extra pain at the time of delivery, and may facilitate anesthesia for cesarean section. (Not all women with twins need cesarean, but the chance is increased.)…[read more]
- Pushing: At complete dilation, 10 centimeters, it is time to push. Women may begin to push in the labor room. Delivery may occur in an operating room. The operating room is much bigger, and brighter, and is filled with people and things to make the delivery safe for the mom and both babies.
Delivery of the First Baby
The first baby comes out head first. If medically necessary, we may use forceps, vacuum, or an episiotomy, the help get the baby out safely. After delivery, the cord is clamped and cut, and the newborn is taken to the warmer for evaluation. After the second baby comes out, both babies can be with the mother, at the bedside. The first placenta is Not delivered until the second baby is out.
Delivery of the Second Baby
After the first baby is delivered we must assess the position of the second baby, either by vaginal examination or with ultrasound. If the second baby is head down then the mother will push. We will break the amniotic sac and the second baby can delivery head first, just like the first. If the baby is not head down, there are some options: grasp the baby by the feet, and deliver the baby feet first (breech extraction) OR attempt to turn the baby to head down position, to deliver head first. The turning maneuvers may be a combination of the doctor’s hands on the mother’s belly and/or hand inside the uterus.
Cesarean Section for the Second Baby
If we are unable to get the baby out head first or feet first, turning or not, OR the baby gets into trouble a cesarean section for the second baby may be necessary. Trouble for the baby is detected by a slow heart rate, either by seeing the heart beat on ultrasound, or listening, just like in the rest of labor. Two common reasons for second baby trouble include early separation of the placenta and the umbilical cord falling out before delivery.
Delivery of the Placentas
Both placentas are delivered after the second baby is born.