Twins and Multiple Pregnancies

Twins & Multiple Pregnancies

Patient Information

Obstetrics & Gynaecology Department

• Author ID:           AV, FK, AC-I
• Leaflet ref:          Obs 033
• Version:              7
• Leaflet title:         Twins & Multiple Pregnancies
• Last review:         July 2024
• Expiry Date:        July 2026

Introduction

A woman is said to be carrying a multiple pregnancy if she is expecting two or more babies. This is something you might expect if you have undergone fertility treatment, but if you become pregnant naturally it can come as a big surprise, be it a delight or total shock.

How common are multiple pregnancies? 

Multiple pregnancies account for one in every 80 pregnancies conceived naturally.  With fertility treatment, the incidence of multiple pregnancies increases to one in every four pregnancies resulting from treatment. 

How will I find out if I am carrying a multiple pregnancy?

This is usually diagnosed when you attend for your dating scan between 10 and 14 weeks.  The scan will also help to determine the type of multiple pregnancy you are carrying, as this information is very important for the management of your pregnancy. 

What are the types of multiple pregnancies?

Twin pregnancies are the most common type of multiple pregnancies accounting for about 1% of all births.  Higher order multiple pregnancies, which include triplets or more, are rare. Triplets occur in one in every eight thousand.

• Identical (or monochorionic or MC) twins: These twins develop from one fertilised egg.  Identical twins can also occur within higher multiple pregnancies such as triplets 
• Usually identical twins each have their own sac of fluid (amniotic sac) and are termed diamniotic (DA). On rare occasions they are both in the same single sac and are termed monoamniotic (MA).  It will often be recorded in your notes as MCMA or MCDA
• Non-identical (or dichorionic or DC) twins: These come from two fertilised eggs and are the more common form of twins.  They are no more alike than any other siblings and can be of different sexes. Non-identical twins are more common in women over 35 and those having fertility treatment.  These twins are always in separate sacs of fluid and will be recorded in your notes as DCDA 
• Higher order pregnancies (triplet or more): these come from one, two or more fertilised eggs developing into three or more babies in your womb.  They can all be identical or a mixture of non-identical and identical babies 

What are the problems associated with multiple pregnancies?

• Minor problems such as morning sickness, heartburn, ankle swelling, varicose veins, backache and tiredness can be increased
• Anaemia (low iron)
• Pre-eclampsia (high blood pressure with protein in urine)
• Gestational diabetes (pregnancy related diabetes)
• Ante-partum and post-partum haemorrhage (bleeding during pregnancy and after delivery)
• Fetal growth restriction (one or more babies being small)
• Preterm labour (before 37 weeks) and delivery – 60 in 100 twin pregnancies deliver before 37 weeks, and 75 in 100 triplet pregnancies deliver before 35 weeks
• Problems with babies being born prematurely (e.g.  breathing difficulties)

Monochorionic twins have other complications particular to them (see leaflet on monochorionic twin pregnancy (Leaflet Ref. Obs 032).

How will my pregnancy be managed?

A multiple pregnancy can have more complications than a singleton (single baby) one. Therefore, your pregnancy will be monitored closely to ensure that any complications are detected and treated as early as possible. 

Most of your antenatal care will be in the hospital with your obstetrician, and in between these visits, your community midwife and GP will also be involved. 

As additional care is needed during labour and delivery with multiple pregnancies, you will be advised to have your babies delivered in the hospital, where there will be ready access to people (midwives, obstetricians, anaesthetists and paediatricians) and resources (including the special care baby unit and theatre), should they be needed. 

Antenatal care

At your antenatal visits, routine checks to determine your babies’ and your general wellbeing will be carried out.  These include taking your blood pressure, testing your urine for protein, blood tests to check for anaemia and scans to check your babies’ growth. 

Due to extra demand for iron and vitamins, which can lead to anaemia, you will be offered iron and folate tablets throughout your pregnancy.  It is important you take adequate rest and remember to do your pelvic floor exercises.

A detailed scan will be arranged between 18 and 20+6 weeks to check the physical structures of the babies. 

To check that your babies are growing well, you will be having a series of scans, which will be co-ordinated with your antenatal clinic visits.  These will be every 2 weeks from around 16 weeks if they are monochorionic (identical) twins, and every 4 weeks from 24 weeks if they are dichorionic (non-identical) twins. 

Labour and delivery 

Your doctor (obstetrician) will discuss with you the best method and appropriate time of delivering your babies.  If it is felt that you may be going into premature labour or we are planning to deliver your babies early (before 37 weeks), you may be offered steroid injections to help mature your babies’ lungs.  The injection helps to reduce the risk of breathing difficulties for your babies after birth.

When will my babies be delivered?

Your obstetrician will decide with you the best time, depending on the type of multiple pregnancy and how your pregnancy is progressing. 

• Triplets and other higher multiple pregnancies are usually considered for delivery by Caesarean section at 32-34 weeks 
• Monochorionic (identical) twins are usually considered for delivery between 36 and 37 weeks (and 32-34 weeks if monoamniotic)
• Dichorionic (non-identical) twins are usually considered for delivery between 37-38 weeks

Timing delivery at these stages of pregnancy does not appear to be associated with an increased risk of problems for the babies but continuing beyond these points does increase the risk.

You may go into labour naturally on your own or may be offered induction of labour at the appropriate time.  If your waters break or you think you may be in labour, contact the delivery suite as soon as possible.

How will my babies be delivered?

It may be possible to have vaginal delivery; however twins are more likely to require medical intervention (vacuum, forceps or Caesarean Section).  If you are expecting triplets, or more a Caesarean Section will usually be advised.

If the first baby (twin 1) is coming headfirst, it is usual to recommend trying for a vaginal delivery.  However, if twin 1 is breech (bottom first) at the time of delivery, then a Caesarean operation may be recommended as the safest option.  Caesarean section may also be advised if there are other concerns about the babies, such as a significant size difference.

There is a small chance that a Caesarean section may be required for the delivery of your second baby (twin 2), even if your first baby (twin 1) is born vaginally.  This may be due to twin 2 being in a position not suitable for vaginal delivery, or due to an abnormality in the heart tracing which would require urgent delivery. 

Heart trace monitoring is advised for all multiple pregnancies to help midwives and medical staff manage your labour and delivery safely.  Around two-thirds of women who plan for a vaginal delivery will achieve that, but a Caesarean section delivery may become advisable.

Where will my babies be delivered?

•         It is recommended that you plan to have your babies at a unit that has appropriate monitoring equipment and medical staff on hand, should there be a need for a Caesarean Section. This includes Wigan Maternity Unit for twins over 28 complete weeks gestation, 800gm (1pound and 12.2 ounces) estimated weight and in absence of complex birth defects (eg. complex heart problems, genetic or nervous system problems).
•         Occasionally, during pregnancy, you may need to be transferred to a tertiary baby care unit, i.e. one that has special facilities for more advanced care and treatment for babies, if it is deemed safe to do so. This transfer will be arranged, if delivery is likely to occur at <28 weeks of pregnancy, estimated foetal weight <800gm (1pound and 12.2 ounces), or any foetal complications for which a high level Neonatal Intensive Care input may be required for the babies at birth.

What about pain relief in labour?

There are different types of pain relief available, and these will be discussed with you. 

Epidurals are often recommended for pain relief in labour and also in preparation for the birth of the second baby, who may need to be helped into a better position for delivery.

Post-natal care 

Mothers of twins or triplets have extra needs after birth.  The midwives will make an individualised plan with you to ensure your needs are met.  Having one baby is tiring and having more than one, even more so.  If you have a husband/partner, they are an obvious source of help.  You may still need more; relatives, friends and neighbours are all possibilities. Ask around and do not turn down any realistic offers of help.

Post-natal depression is more common with mothers with multiple births, so it is very important that you and your partner tell your midwife, GP or health visitor if you are feeling low.

Can I breastfeed my babies?

Although some mothers decide to bottle feed their twins, it is possible to breastfeed twins if you want to.  Many mothers manage this very successfully.  The midwives will give you advice and support.  They may be able to arrange for you to meet another mother who has breastfed twins.

Further information

If you have any questions or need further advice on any issues covered in this leaflet, please ask your midwife or obstetrician at your clinic appointment.  You can also contact us through switch board (01942 244000) or directly on any of these numbers: 

Maternity ward:        01942 778506

Delivery suite:          01942 778505

You may also find further information and other support services available to you from the addresses given below:

TAMBA - Twins and Multiple Births Association

2 The Willows, Gardner Road, Guildford, Surry GU1 4PG Tel (twinline): 01483 304442

(10am - 1pm & 7pm - 10pm everyday)

Telephone (office): 01483 302 483

Web: https://www.tamba.org.uk/

Multiple Births Foundation

Hammersmith House, Level 4, Queen Charlotte's & Chelsea Hospital, Du Cane Road, London W12 0HS

Telephone: 020 8383 3519

Web: http://www.multiplebirths.org.uk/