Overview of Multiple Birth Delivery
Having more than one baby at a time, like twins or triplets, comes with more risks than having a single baby. In 2021, for every 1000 babies born, 21.3 were twins while 80 in 100,000 were triplets or more.
The best way to deliver twins is a topic that is often discussed among doctors. As of now, the guidelines from the American College of Obstetrics and Gynecology (ACOG) do not require a cesarean section or “C-section” (a surgery to deliver the baby through the mother’s abdomen) just because a woman is having twins. They do note, however, that there are certain situations that can make the birth of the second twin more difficult. These include changes in the babies’ position, risks related to the placenta or the umbilical cord, and changes in how much the cervix is open.
A large study that looked at how twins are born found no difference in risk to the babies whether they were born vaginally (through the birth canal) or by C-section. Even with this information, delivering twins can still be challenging for doctors. They have to monitor both babies during labor and may need to use special techniques to deliver the second twin.
But not all twin pregnancies are suitable for a vaginal birth. First of all, the mother must want to try for a vaginal birth. Additionally, the first twin to be delivered needs to be positioned head-down. If the twins’ weights are too different (over 20% difference), a vaginal birth may not be recommended. Any situation that would rule out a vaginal birth for a single baby would also apply to twins. These could include complications with the umbilical cord, previous abdominal surgeries, problems with the placenta, infections like herpes, or if the baby is not handling labor well. Ultimately, the way twins are delivered depends on the type of twins and the mother and babies’ health at the time of delivery.
Why do People Need Multiple Birth Delivery
The plans for giving birth to twins depend on the type of twins involved. There are three main types: monochorionic monoamniotic, monochorionic diamniotic, and dichorionic diamniotic. If you need more detail on how twins form or how to care for twin pregnancies, please check out our article, “Twin Births.”
Monochorionic Monoamniotic Twins
Monochorionic monoamniotic twins, also known as ‘mo-mo’ twins, are quite rare, making up about 8 out of every 100,000 pregnancies. These twins are in a single amniotic sac which increase the risk of complications, such that these pregnancies can have mortality rates as high as 30% to 40%. Their delivery plan is established based on the mother’s and babies’ health conditions, with frequent ultrasound checks scheduled to monitor growth and the level of amniotic fluid from the 16th week of pregnancy onwards. From 28 weeks, these checks are normally conducted every week until birth. Medical professionals usually recommend a delivery time frame between the 32nd and 34th week. As for the method of delivery, it’s often a topic of much conversation. Most prefer cesarean delivery to minimize risk, but some studies show that vaginal deliveries can also be safe for those suitable.
Monochorionic Diamniotic Twins
Monochorionic diamniotic twins (‘mo-di’ twins) account for 1 in 5 twin pregnancies. They have separate amniotic sacs but share a placenta, which can lead to complications – these occur in about 15% of ‘mo-di’ pregnancies. The plan for labor and delivery also relies on health checks, fetal growth, and the mother’s health. Regular ultrasounds are conducted starting at 16 weeks to check on amniotic fluid and the twins’ growth. For those in normal health, delivery can be planned between the 34th and 37th week. In cases where one twin is growing less than the other, the delivery might come sooner, between 32 and 34 weeks. Some may also receive doses of medicine to promote baby lung development if birth is planned before 34 weeks. They may be candidates for vaginal delivery if certain criteria are met. In fact, a study showed that the risks for babies are the same whether the delivery is vaginal or planned via cesarean section.
Dichorionic Diamniotic Twins
In the case of dichorionic diamniotic twins (‘di-di’ twins), the twins each have their own placenta and amniotic sac. Pregnant women carrying di-di twins will begin weekly antenatal testing from 36 weeks until labor. This may begin earlier if there are complications. For those of normal health, delivery is usually scheduled between 38 weeks. For di-di twins where one is not growing as much as the other, delivery may come sooner – between the 36th and 37th weeks. In some other conditions too, like abnormal uterine blood flow or pregnancy-induced high blood pressure (preeclampsia), delivery is advised between the 34th and 36th week. ACOG (American College of Obstetricians and Gynecologists) advises that a vaginal delivery may be possible for di-di twins if there are no significant complications.
Higher-Order Pregnancies
Pregnancies of three babies or more (triplets or higher) are rare. There isn’t a standard plan for ensuring well-being and timing delivery for these babies, as each case is unique. However, delivery for triplets or more is usually by cesarean section due to the increased risk of complications.
Who is needed to perform Multiple Birth Delivery?
When having twins, a doctor should be there for the birth because there might be a need to do a cesarean section, also known as a C-section, which is a surgical operation to deliver the babies. If the mother wishes, a midwife can also be there. This is a professional trained in childbirth.
There are other healthcare professionals who will be there to make sure everything goes smoothly, whether it’s a natural birth or a C-section. For example, nurses will take care of the mom, a specialized doctor called a neonatologist will check the twins, and separate care teams from the neonatal intensive care unit (NICU – where babies who need special care go) will look after each baby. There’ll also be technical staff to assist with the surgery and anesthesiologists – doctors who manage pain and make sure you’re comfortable during the operation.
If the hospital allows it and if the mother wants, someone like a family member or doula (a person trained to provide emotional and physical support during childbirth) can also be there to help during the birth.
Preparing for Multiple Birth Delivery
Before delivery, doctors need to know about a patient’s health background, including prior pregnancies, any other medical conditions, surgeries, and family and social contexts. Any plans for the birth, such as anesthesia choices, locations for delivery, and choices about who should be there in a supportive role, should be communicated to the clinical staff. Patients should also share any allergies and their effects. Medications that patients are taking should also be communicated to avoid potential complications.
Before commencing, the healthcare team will go over forms with the patient, discussing the potential risks of vaginal delivery, cesarean section, and blood transfusion (if necessary). Doctors will explain the assistance tools that might be used during vaginal delivery, such as forceps or vacuum, and when a cesarean section might be needed – with details of the associated risks. In case of an emergency, they will also discuss the potential for a blood transfusion.
On entry to the hospital, a needle is placed in the vein to give fluids and drugs as needed. Doctors take initial blood samples for routine lab tests, check for previously taken prenatal tests, and provide antibiotics if needed. They also perform an ultrasound to check the fetus’s position and the level of amniotic fluid.
A kit to deal with excessive bleeding after childbirth, known as postpartum hemorrhage, is prepared. It contains tablets and injections to enhance uterine contractions, reducing the chances of heavy bleeding. The kit may also include balloon devices to be used if necessary.
A “time-out” is taken before delivery, where doctors confirm both baby positions, their weights, and the plan of action for cord clamping. They’ll also check if the patient has any reasons not to take certain drugs that stimulate uterine contractions.
When it comes to delivering the twins vaginally, it takes place in an operating room. Once ready for the delivery stage, the woman is safely moved to the OR and placed in a comfortable position where she can push effectively while doctors can assist in case of any issues. Two separate neonatal intensive care units (NICU) teams are prepared with needed supplies to manage each newborn.
For a cesarean section, patients should avoid eating or drinking for at least 6 hours before surgery to avoid complications. Antibiotics are given before surgery to prevent infections. The dosage is matched with the patient’s weight. For patients who are allergic to penicillin or cephalosporins, other antibiotics can be substituted. Doctors will provide ongoing fluid supply via a needle in a vein and ensure adequate anesthesia for pain control during the surgery. The abdomen is cleaned, and sometimes vaginal preparation is done to reduce possible infection. The patient is then draped to maintain a sterile environment.
NICU team with resuscitation supplies needs to be ready in the OR with separate items for each newborn.
How is Multiple Birth Delivery performed
Vaginal delivery is a natural process for giving birth, which happens in two main stages. The first stage ends when the cervix (the narrow passage forming the lower end of the womb) is fully opened, at about 10 centimeters. The second stage is when the expectant mother can start pushing to deliver the baby.
While the mother pushes, the baby moves through seven key steps. First is engagement, where the baby’s head moves to the opening of the pelvis. Descent is the baby’s journey through the pelvis. Flexion means the baby’s head bends forward, to help it move through the pelvis more easily. Internal rotation means the baby’s head turns to fit through the widest part of the pelvis. At the opening of the vagina (the introitus), the baby’s head extends. Then, the baby’s head turns again to align correctly with its body (external rotation), before finally getting expelled from the mother’s body.
After delivery, the baby’s umbilical cord is clamped and cut, and the baby is passed to a neonatal intensive care unit (NICU) team for a thorough examination. If the mother is delivering twins (or multiple babies), the position of the second baby is then identified by an ultrasound scan, and the same process of delivery ensues. If the second twin is found to be in a less straightforward position (like breech or transverse where the baby’s head is not pointing downwards), the doctor may do special maneuvers to deliver the baby safely. Once all babies have been delivered, the next step is to deliver the placenta(s). Any lacerations or cuts are then identified and repaired.
Cesarean delivery is another method of childbirth where the baby is delivered through an incision in the mother’s abdomen. The process for delivering twins or multiple babies through cesarean section is the same as for a single baby. After the skin incision is made, the doctor works through the layers of the abdomen to reach the womb. Then, an evaluation is made to find the best and safest way to make an incision in the womb. Once the incision is made, each baby is delivered one by one. After delivery, each baby’s umbilical cord is clamped and cut, with measures taken to ensure it’s easy to identify which cord belongs to which baby. Once all babies have been delivered, attention turns to delivering the placenta(s).
Possible Complications of Multiple Birth Delivery
Having more than one baby at a time can lead to health issues that might affect the mother, including gestational diabetes, high blood pressure, and anemia. These complications can occur with pregnancies of single babies too, and they are managed in the same way.
There aren’t any strict rules about how much time should pass between the delivery of one twin and the next. However, research suggests it usually takes about half an hour. If it takes longer than that, there’s a higher chance that a c-section will be needed. This can happen if the umbilical cord slips out, the baby’s heart rate or other signs are not stable, or if the baby’s head is not positioned correctly.
After the first twin is born, the mother’s uterus might start to contract quickly. If the second twin is not positioned head-down or is lying at a right angle, it may be hard to adjust their position due to this fast contraction of the uterus. In such cases, a single dose of nitroglycerin or terbutaline can be given to relax the uterus, making it easier to adjust the baby’s position to aid delivery. If adjustments are still not possible, a c-section should be planned.
If the second twin is head down but hasn’t moved into the birth canal yet, the doctor should give it some time to move down. During this time, an ultrasound can rule out any issues, like the umbilical cord being in the wrong place, that might mean a c-section is needed. There’s no set time limit between the births of each twin, so deciding when to switch to a c-section depends on the doctor’s judgment.
Occasionally, the doctor might have to use special tools to help deliver the second twin. This is called an operative vaginal delivery and might be needed if labor is taking a long time, if the baby might be in danger, or for the mother’s benefit. The doctor will make sure certain conditions are met such as the cervix is fully dilated, the water has broken, the bladder is empty, the baby’s head is in the right place and the mother has enough pain relief.
Several types of forceps, special tongs to help deliver a baby, can be used:
– Piper forceps help deliver a baby that’s buttocks first.
– Simpson forceps are handy when the baby’s head is in the birth canal and can help when the baby’s head shape has changed from the pressure of labour.
– Wrigley forceps are a shorter version of the Simpson forceps and can be used in both c-section and vaginal deliveries when the baby’s head is near the vaginal opening.
– Luikart forceps are used to turn a baby whose head is tilted to one side.
– Kielland forceps are used to rotate the baby from a back-facing to a front-facing position.
These forceps should only be used by a trained and experienced doctor.
While delivering the second twin, if it’s presenting bottom-first, there is a risk that the baby’s head might get stuck, which is a medical emergency. The risk is higher when the baby is born early or the mother’s cervix is not fully dilated. If this happens, different techniques can be performed to assist in delivering the baby’s head or medications like terbutaline or nitroglycerin can be given to relax the uterus further. If all techniques fail or if there are signs of the baby being in distress, the doctor might need to cut small incisions in the cervix to help deliver the baby. This procedure is done with great care to avoid harm to the mother’s anatomy.
What Else Should I Know About Multiple Birth Delivery?
Having more than one baby at one time (multifetal gestations) is becoming more common as fertility treatments increase. This situation comes with increased risks for both the mother and babies. The most significant risk to the babies is being born too early (prematurity).
For mothers, giving birth can carry severe risks such as bleeding heavily after childbirth (postpartum hemorrhage), high blood pressure during pregnancy that can cause serious complications (preeclampsia), and in rare cases, death. Some mothers may be able to deliver vaginally, but this can still have risks such as needing tools to assist the baby’s delivery (operative vaginal delivery), the baby’s head getting stuck (fetal head entrapment), or the need for a cesarean section, which is surgery to take the baby out through the mother’s abdomen.
Understanding the potential risks and benefits of vaginal delivery compared to a cesarean section can help mothers-to-be make the most informed choices about their birth plan. Doctors can provide the best care by clearly understanding the latest medical evidence and properly explaining it to the patients. Before the birth, the health team should discuss the delivery plan to ensure safety, covering topics such as what makes for a safe vaginal delivery, any risks correlated with delivering twins, potential risks that may arise with vaginal delivery or cesarean section.
