What kind of careprovider should I have?
There are many choices available to pregnant women these days from family practitioner, midwife, obstetrician, or perinatologist (maternal-fetal medicine specialist). Because carrying multiples has more risk (possible complications) than a singleton pregnancy, it's important to find a careprovider who is VERY experienced in handling multiples pregnancies. The office staff also needs to be well-versed in handling multiples because you will need to interact with them as well. This is not the time to be a guinea pig or settle for just any careprovider. Do your homework, check credentials, and find the best you can.
If you're carrying twins, it doesn't mean you have to give up all of your dreams for a non-interventive pregnancy and birth. However, you will need to have more frequent appointments, ultrasounds, and non-stress tests to make sure the babies are growing properly. If you're interested in seeing a midwife, make sure they have experience with twin pregnancies and that they have a qualified obstetrician or perinatologist for backup.
Because triplets or more are usually delivered by cesarean, an obstetrician and/or perinatologist is needed for these pregnancies. A perinatalogist is also called a Maternal-Fetal Medicine (MFM) Specialist. This type of physician is an obstetrician with advanced training in high risk pregnancy care. MFM Specialists complement the care of general obstetricians by providing prenatal care for high-risk women.
With our survey respondents, the twin parents mostly used an obstetrician only, but 23% of them saw both an obstetrician and a perinatologist. Six percent saw a perinatologist only. One percent of our parents used a midwife and a perinatologist. Six percent saw a midwife only or a midwife with an obstetrician backup. Four percent saw a family practitioner with an OB backup or a family practitioner only.
Whether a midwife can deliver twins depends on her arrangement with her back-up MD and her practice protocols. I delivered four sets last year and actually think my women get the best of all worlds. Prenatally, I give them normal midwifery care, with emphasis on great diet, unless they develop medical problems (none has). We do more ultrasounds than normal to make sure the twins are staying the same size and healthy, there is at least one visit with the OB, and we do NST's from 34 weeks to make sure the twins can do their little baby tricks.
I don't deliver twins outside the hospital, because of the increased possibility of complications, especially with the second twin and with possible post-partum hemorrhage. And I have my wonderful OB in the room for delivery (usually reading a book!). For me, this approach maximizes the health of mom and babies and the normalcy of the whole process while taking appropriate precautions "just in case."
I would recommend interviewing an OB or two who thinks of twins as "high risk" in order to get yourself well-educated about what they have actually seen. Assess your level of risk tolerance and your partner's and ask yourself what you would want to do under various scenarios. I'm sure you'll figure out the best thing to do.
Cynthia Flynn, CNM, Ph.D.
Am I considered high risk and what are the risks of a multiple pregnancy?
Mutliples pregnancies are usually considered "high risk." This means the odds that either you or one of your babies might have pregnancy related problems is increased compared to a woman carrying only one baby. This doesn't mean you will have problems, however. Many women have successful, uncomplicated multiples pregnancies. But, pregnancy involves some risk for every woman, and with each additional baby, the risks increase.
Increased Risks Of Multiple Pregnancy
|Severe Nausea and Vomiting
Early in your multiple pregnancy you may experience all the discomforts a woman with a singleton pregnancy feels. Nausea, vomiting, fatigue and breast tenderness are more likely to be severe in a multiple pregnancy. Sometimes a condition called "hyperemesis gravidarium" can occur. This is a condition where nausea and vomiting become so severe that dehydration can occur.
If you are experiencing a lot of vomiting or are unable to consume liquids, you should call your provider. You may need intravenous fluid replacement and medication to reduce the vomiting. If you notice a decrease in the frequency of when you urinate, or if you notice that your urine is dark in color, you should call your provider. These can be signs of dehydration.
One of the biggest risks of carrying twins or more is that you will deliver your babies early. Twin pregnancies have about a 30 percent chance of a premature delivery. The risk increases for triplets and if you are expecting quadruplets or more you can be fairly certain you will deliver early.
Early delivery can occur for a number of different reasons. Preterm labor is common in multiple pregnancy and is a leading cause of preterm delivery. Preterm labor occurs when uterine contractions become too frequent or intense enough to cause cervical shortening (effacement ) or opening (dilation) prior to week 37 of your pregnancy.
If one or more of your babies appears to be small or have a growth rate that is declining, (intrauterine growth retardation or IUGR), early delivery could be indicated. Multiple pregnancies carry a higher risk of IUGR than singleton pregnancies.
Click here for more information about TTTS from the TTTS Foundation
Twin to twin transfusion syndrome is a disease of the placenta. There are connections between the blood vessels of the babies. This can cause an overload of blood in one baby, the recipient, while the donor baby does not get a sufficient blood supply. When the condition is severe, it can result in one large baby with excess amniotic fluid (polyhydramnios) and one small baby with too little amniotic fluid (oligohydramnios). The smaller baby is referred to as a "stuck" twin.
Twins that develop from one egg (identical) can share some blood vessels. This can lead to a pregnancy complication called twin-to-twin transfusion syndrome (TTTS). Your babies' risk of developing this syndrome is determined in part by when the egg divides.
Eggs that divide within a few days of ovulation are known as diamniotic-dichorionic (Di-Di). The amnion and chorion are the two layers of the sac of fluid that surrounds and protects babies in your uterus. Di-Di means that each baby has its own amnion and its own chorion. These twins do not develop twin-to-twin transfusion.
Eggs that split at about three to eight days after ovulation create twins that are diamnionic (each has its own amnion) and monochorionic ( they share a single chorion). These identical twins share some placental vessels and have the highest risk of TTTS.
for frequently asked
questions about TTTS.
||If one of your babies isn't growing as fast as the other(s), your doctor may become concerned about the smaller baby's health. This discordant growth can occur for several reasons. One baby may have a placenta that implants in an area with a less abundant blood supply.
|Pregnancy Induced Hypertension
||PIH usually occurs in the second half of pregnancy. It is characterized by increased blood pressure and protein in the urine. Hands and feet may become swollen. Women expecting twins or more develop pregnancy induced hypertension (PIH) more frequently. The risk increases with the more babies you are carrying.
How can I cope with the discomforts of a multiple pregnancy (ie: sleeping positions, heartburn, morning sickness, etc)?
Our survey respondents have great tips for you . . .
I made my husband sleep in the guest room at about 20 weeks so I could have the whole bed to spread out in. ~Jenni, mother of twins
My husband made me a mattress out of foam. He cut out a hole in the center for my belly. When I got too big to lie on my stomach, I rested my hips in the hole, which was comfortable. ~Debbie, mother of twins
I used lots of pillows and had one of those egg crate mattresses to lie on because the mattress was uncomfortable after awhile. ~Sheryl, mother of triplet girls
I laid on my side with a pillow underneath my stomach and a blanket between my legs and when I would have to roll over, it was awful! I had to have my husband turn me over most of the time. ~Becky, mother of identical twin girls
My only discomfort was sleeping so I slept in a recliner. ~Kelly, mother of twins
I could only sleep on my left side with two pillows under my head, a pillow between my knees, and one to my back. ~Tammy, mother of twins
I had two body pillows to prop me up so I slept sitting up in order to breathe at night. ~Ronette, mother of twins
As far as sleeping or sitting, I have only one word - PILLOWS! The heartburn was taken care of with watching how much I ate, what I ate, when I ate it, and TUMS until the last few weeks before delivery at which point nothing seemed to work. ~Tracy, mother of twins
I slept sitting up towards the end of the pregnancy; this helped the heartburn. I focused on the boys and the miracle that was happening within my body. ~Melanie, mother of twins
I tried to eat early in the day and in little tiny portions to help the heartburn. I really hated that part of the pregnancy! ~Lutey, mother of twins
I didn't have morning sickness but preparing food bothered me, and I was hungry but didn't want to eat. My husband prepared and cooked everything and made me eat. ~Libby, mother of identical twin girls
Until the very end, I wasn't nearly as uncomfortable with my twins as I was with my breech pregnancy. During all my pregnancies I used a wristband and ginger to control morning sickness, I slept in a papasan chair when I got really big, and I ate frequent small meals to reduce the incidence of heartburn. ~Hunter, mother of twin boys
Morning sickness was bad all day in the beginning. I just ate and drank what I knew would stay down until I felt good again. The heartburn was horrible. My doctor recommended plain vanilla ice cream, and it worked for a while. Then I just relied on good ol' Tums . . . can't eat one to this day! ~Liz, mother of boy/girl twins
I think you just do. You can't make it go away. Just take each day at a time and try to read as much as you can because you will find that it can be most helpful. ~Cassandra, mother of identical twins
I coped very well. I resigned myself to the fact that I would be very uncomfortable and somehow that made it easier to deal with. I guess I just stopped trying to make things better and more comfortable and that made me relax. ~wish, mother of twins
I had a strange taste in my mouth the entire pregnancy. I sucked on a lot of hard candy to relieve this problem. ~Jennifer, mother of twins
I kept in mind that it wouldn't last forever. ~Starr, mother of twins
Will I have to go on bedrest? If so, when?
Most careproviders these days do not routinely prescribe bedrest for a twin pregnancy (but almost always for a triplet or more pregnancy) unless a problem arises warranting bedrest. However, multiples moms are well advised to rest much more than singleton moms. Staying off your feet much of the day, resting with your feet up, and sleeping more will benefit your babies (and YOU) tremendously. Listen to your body, and when it's telling you it's tired, REST!
I was on modified bedrest at 30 weeks. That meant that I stopped working and "took it easy," but I never had to actually stay in bed. ~Ronna, mother of twins
I wasn't on bedrest, but I did rest a lot anyway. I was nearly 40 with three youngsters. Luckily, my husband and I both work from home so it was usually easy enough for me to lie down if I felt I needed it. ~Hunter, mother of twin sons
I stopped working at 24 weeks and had self-imposed partial bedrest. ~Coleen, mother of twins
I was on partial bedrest at 25 weeks and then hospital bedrest from 29 weeks until 32 weeks. ~Jenni, mother of twins
I was on and off bedrest from 20 weeks until I delivered at 32 weeks. ~Brandi, mother of twins
I started having a lot of contractions and went on medication for them at 20 weeks and was hospitalized for several days in my 24th week. After that, my doctor had me do "partial bedrest" . . . I could sit up and walk around the house, but was not allowed to leave home except for doctor appointments. ~Marina, mother of twins
My doctor put me on bedrest at 20 weeks even though I wasn't having any complications at that time. It wasn't strict bedrest at first but I had to stop working, stay home and off my feet as much as possible. He routinely does this for triplet pregnancies. ~Claudia, mother of triplets
When will I have to go on maternity leave?
This question is best answered with the help of your careprovider. Factors are how well your pregnancy is going, how you feel (energy-wise, etc), and what kind of job you have (are you standing a lot, have to do physical labor or have a stressful job). You may feel like taking a leave before delivery just to rest and store up energy for labor, delivery and the work of caring for newborn multiples.
I went into labour while I was still working. That was my biggest mistake. I thought that I wouldn't go into labor for weeks and when I did, I had had no time to myself or to rest beforehand. Try and get as much rest as you can and do the things that you love doing because you may not be able to do them for a while. Even things like shopping, going to the movies, dinner, and sleep . . . all these things I think I really took for granted. It's not that you can't do them with multiples; it's just more difficult. ~Cassandra, mother of identical twins
I was able to work from home from 32 weeks and then started maternity leave when the twins were born. ~Lynn, mother of twins
At 26 weeks, I cut back to part time and stopped completely at 33 weeks. ~Lisa, mother of twins
I went on leave at 20 weeks when I started having contractions and problems with preterm labor. ~Teresa, mother of triplets
I didn't take a leave. I'm an accountant and run my own small business from my home. I hired an assistant but was still ultimately responsible for the work getting done properly. All my clients knew I was having a baby and were willing to wait on non-essential tasks. ~Hunter, mother of twin boys
Fifteen percent of our survey respondents took leave before 20 weeks, and 20% left between 20 and 26 weeks. An additional 29% went on maternity leave between 28 and 31 weeks, with 24% leaving between 32 and 36 weeks. However, 12% worked up to delivery (and this includes those who delivered prematurely).
It's a good idea to discuss your multiples pregnancy with your boss so that s/he knows what to expect from you. This can be difficult! Remember that as a pregnant employee, you do have rights. Read up on the Pregnancy Discrimination Act and the Family Medical Leave Act.
Visit our Working Parents Cubby for more information
How much weight should I gain?
Women expecting two or more babies should have a higher weight gain. If you are expecting twins, a net weight gain at term of about 40 - 50 pounds is recommended. If you started your pregnancy underweight, a little more weight gain is desirable. Women starting pregnancy at a heavier weight should gain a little less. Studies have shown that adequate second and third trimester weight gain is very important with twin pregnancies. Weekly weight increases of about 1.5 pounds per week are desirable at this time and weight loss should be avoided.
If you are expecting triplets or more, your weight gain should be even higher. There isn't enough information about these higher multiple pregnancies to give specific weight targets. Most weight gain goals for pregnant women are calculated based on a full term pregnancy (37 weeks gestation or more) and you are likely to deliver your babies before this if you are expecting three or more. Aim for a weight gain of 1.75 - 2.0 pounds or more per week in your second and third trimester.
A prenatal vitamin is usually recommended with the increased nutrient needs of a multiple pregnancy. Be sure and take only one prenatal pill as multiple pregnancy does not double the need for supplementation and some vitamins or minerals can be harmful if taken in excessive amounts.
The average weight gain for our survey respondents was 41.2 pounds
Tips To Improve Weight Gain
- Eat often
Growing babies mean less room for your stomach to expand. Eating more often can compensate for smaller meals.
- Drink in some calories
Water takes up the same amount of room in your stomach as fruit juice or milk. Fruit smoothies and milkshakes are great sources of calories.
- Choose high fiber foods
Preventing constipation can help your appetite. Fruits, vegetables, whole grains, beans and bran cereals are good high fiber choices.
- Choose nutrient dense snacks
Peanut butter, nuts, cheese, dried fruit, granola and yogurt are a few.
How many weeks will I carry?
The average length of a twin pregnancy from the first day of the last menstrual period to delivery is 36 weeks. The average for triplets is 32-33 weeks and for quadruplets, it's 29-30 weeks. With the advances in medical technology, triplet and higher order multiples are being carried longer all the time.
For our survey respondents, the average twin pregnancy was 36 weeks, our triplet average was 32 1/2 weeks, and our quad average was 29 weeks. Our parents definitely fit the norm!
Keep in mind that these are averages. We had as many twins parents deliver after 36 weeks as delivered before 36 weeks. However, only 8% delivered before 34 weeks, and only 6 1/2% delivered after 38 weeks. 61% delivered between 36 and 38 weeks - a very healthy gestation for twins!
Can I have a vaginal delivery or will I have to have a c-section?
Fifty percent of twins and nearly all higher order multiples are delivered by cesarean section. With our survey respondents, 45% had vaginal births, 54% had c-sections, and 1% had both (delivered one baby vaginally and the other via c-section).
Besides your obstetrical history (i.e: prior c-section, etc), the position of the babies in an important factor in how you will deliver. If the twin closest to your cervix is head down (vertex), most doctors will recommend a vaginal delivery. If the baby closest to your cervix is breech or transverse or if you're carrying more than two babies, you'll probably have a c-section.
By 34 weeks, the positions that your babies are in are likely to stay that way as they are so confined, they can't move around much.
Which positions are your babies in? With a multiple pregnancy, you can have a myriad of configurations: less than 50% of twins are both born headfirst. One twin is vertex (head down) and one is breech (lower part of the body comes first) about 40% of the time. One (or more) can also be transverse (baby lies across Mom's pelvis). The McCaughey septuplets were in a pyramid configuration. As the babies get bigger, it's harder for them to move much to get into the proper birthing position. Your care provider will probably want to do an ultrasound(s) to determine presentation so that delivery plans can be made.
Be sure to discuss your options with your careprovider.
Read Twins Delivery for details on a twins vaginal birth.
How much will my babies weigh at birth?
The average birth weight in the U.S. for twins is around 5 1/2 lbs, 3 3/4 lbs for triplets, and 2 3/4 lbs for quadruplets. The breakdown for our survey respondents was:
36+ weeks - 5 lbs, 15.2 oz
32-35 weeks - 5 lbs, 1 oz
30-32 weeks - 3 lbs, 14.3 oz
Triplets: 3 lbs, 11.2 oz
Quads: 2 lbs, 8 oz
Our Multiples' FAQ:
Section I - Suspecting and Diagnosing Multiples
Section II - Preparing for Multiples
Section III - Pregnancy & Childbirth
Section IV - NICU
Section V - Going Home/Postpartum
Section VI - As They Grow
Section VII - Resources
Section VIII - Miscellaneous/Special Tips & Inspiration