Twins
From William Smellie’s “A sett of anatomical tables, with explanations, and an abridgment, of the practice of midwifery”
Conceiving and carrying two babies at the same time is an immense blessing, not to mention totally normal for our species. Allopathic medicine and modern culture has made twin pregnancy and birth out to be extremely risky and fraught with complications, which doesn’t have to be the reality.
It’s my belief that we all choose our paths as souls before we come into these bodies in this lifetime, and if you conceive twins it is because you have everything it takes (in all realms: physically, mentally, emotionally, and spiritually) in order to carry, birth, and raise/nurture two babies at once. And you also need this experience, for whatever reasons, to grow as a soul family.
With all that in mind, there are some considerations to think about when carrying twins and planning your birth of them. And there are some things *I* will consider as a midwife when approached about attending a woman who is planning to give birth to twins at home.
Whatever your path is, my hope is to help provide some of the information needed in order to make the best decision for you and your family. If there are ways I can, I will support you, with whatever path you choose. :) Please reach out if you have any questions or concerns!
Considerations for a twin mama
Mother’s commitment to nutrition and general wellness during a twin pregnancy
The nutritional needs of a twinning mama are even greater than a singleton mama, as you would imagine. Some issues like aggravated signs and symptoms of pregnancy, worse nausea, more body aches and pains, and fluid retention can all be normal during a twin pregnancy. Most common pregnancy complaints, whether a singleton or twin pregnancy, can be resolved with nutrition and movement.
Women under midwifery care for twin pregnancies frequently see their babies go full term to 40 weeks or more. Please don’t expect to have your twins by or around 36 weeks or the last month+ of pregnancy will be very uncomfortable for you! With excellent nutrition and physical activity, your babies will be born healthy, vibrant, and full term.
By the end of your twin pregnancy, you should have 200% of the blood volume you normally have! This is required to sustain two babies and two placentas. Undernutrition is the reason why the medical establishment sees more cases of preeclampsia/eclampsia and preterm (35 weeks or earlier) birth for twins. This is not normal (though the medical world has normalized it!) and is not a necessity for twins.
For a twin pregnancy, you should try to consume 130 - 150 grams of high quality whole food protein and 3000 - 4000 high quality whole food calories each day. This is also dependent upon your activity and stress level, and whether you are nursing an older baby, etc. The more active or stressed you are, or if you’re nursing, you’ll have to try to squeeze in this higher range. This surely seems like a tall order to most women, and it really truly is challenging! Especially toward the end of pregnancy when there is less room in the digestive system.
We can brainstorm about the best ways to get all of the nutrition in, but keep in mind that to prevent preterm labor and many adverse health conditions sometimes associated with twin pregnancies, you must view your nutrition as your number one job.
On top of food intake, you will probably want to supplement with a really great quality prenatal multivitamin with easily assimilated forms of vitamins and minerals. Pay special attention to getting lots of vitamin C and iron, especially, during a twin pregnancy. Some women pregnant with twins take 2x the normal dose of prenatal vitamins because of the added need for micronutrients during a twin pregnancy.
Visualizing your ideal pregnancy, birth, and postpartum (over and over again!) and journaling about your emotional experience are also both powerful tools to encourage a healthy and grounded experience for yourself.
I will be utilizing all of these modalities as well, if we work together during your twin pregnancy, and visualizing your birth experience over and over, happening with ease and joy.
If you’d like help brainstorming about ways to incorporate these things into your daily routine, please reach out.
Type of twins (di/di, etc) and mother’s willingness to get an ultrasound
Dichorionic/diamniotic twins (di/di twins) are not identical and each baby has their own placenta, cord, and chorion and amniotic sac. They develop individually the whole time. (They are like two houses in the same neighborhood.) Monochorionic/diamniotic twins (mono/di) are identical twins that are each contained within their own individual amniotic sacs, but they share an outer layer (the chorion layer) surrounding both of their sacs together. There is a single/shared placenta. (They are like two apartments in the same apartment building.) Monochorionic/monoamniotic (mono/mono or mo/mo) twins share their amniotic sac and the outer layer (the chorion) as well, plus share a single placenta. (They are like two people sharing the same room.)
All non-identical twins (66-75% of all twins) are di/di. Identical twins (25-33% of all twins) can be di/di (35% chance), mono/di (65-75% chance), or mono/mono (4% chance).
Mono/mono twins carry more chances for divergence from the usual twin pregnancy and birth scenarios. Twins who share an amniotic sac have increased chances of their cords tangling up with each other, or their cords could be not totally separated from each other (this last part is very rare). The cord of one baby could be wrapped around the body and neck of the other, creating issues with descent during birth. Also extremely rare, but a possibility, is the chance that the twins’ bodies could interlock with each other and prevent descent or cause dystocia or fetal demise/death during birth.
An ultrasound may be suggested to try to determine whether your twins are mono/mono or otherwise. Because of the greater likelihood of complications, mono/mono twins are outside of my scope of practice for home birth.
Ultrasound carries its own risk, and is not always able to determine if the babies are within their own sacs or each have their own placenta, depending on when it is performed. It can, however, determine if you have two babies for sure, or just one. Palpating and using non-technological means alone can be tricky to determine if there are for sure twins or not, depending on the gestation and other factors. If your babies are two different sexes, they will each be in their own sac for sure.
If you do have ultrasound, and you do have twins, here are some things to look for for your consideration:
Sex (if different, this indicates dizygotic twins and eliminates the possibility of TTS and monoamniotic twins)
Is there a membrane separating the sacs and how many layers are there to the membrane
Two layers means babies share a chorion (mono/di)
Four layers means babies have two chorions and two separate placentas (di/di)
No separation means monoamniotic twins (mono/mono)
Number and location of the placentas
If there is circulatory connection between placentas
Signs of fetal anomalies
Amniotic fluid volume in each sac and relative to each other
Placental attachment site and other placenta considerations during twin pregnancy
With low lying placentas with one “above” or closer to the fundus and one “below” or closer to the cervix, the edge may be over or very near the os (cervical opening).
Usually the placentas are fused and come out after the second baby. Extremely rarely, once the first baby is born, the sudden emptying from the baby and waters leaving the uterus MAY cause the first placenta to detach and need to be expelled before the second baby can be born. This is very rare.
Because there is a larger placental site in the uterus with twin pregnancy, plus the uterine muscles are extra stretched/distended, plus the extra blood volume in a twinning mom, plus added emotional shifts after a twin birth, there is occasionally more bleeding after a twin birth. To help avoid experiencing shock even if there is more bleeding, optimal nutrition during pregnancyis key. If we notice extra bleeding before/during/after the birth of the placenta(s), we may use herbs, homeopathics, and/or traditional Chinese medicinal remedies, as well as manual methods like uterine massage/compression to try to help bleeding lessen and stop.
Please also check the section below on baby growth and development for more info about TTS, a potential placental/blood vessel issue.
Position of babies during twin pregnancy
The baby on the mother’s left will usually be born first. Most common positions for twin babies are cephalic/cephalic (both head down - 45% chance), or cephalic/breech (one head down and one butt down - 37% chance). Two breech babies has a 10% chance and all other combinations/presentations have a 5% chance or less.
If one of your babies is breech, going over normal breech birth physiology with your partner as well as normal head down physiology is a smart idea. It’s important for you both to have a good mental image of how all variations of this birth experience could look like.
If one baby is transverse (sideways in the uterus), that doesn’t mean it will remain transverse once the first baby is born. BUT, if the second baby remains in the transverse position once the first baby is born, despite efforts to turn the baby to a vertical position (turning babies during labor carries a small risk of cord prolapse and uterine rupture), there may be some reason for this that we can not judge from the outside and the hospital may be the safest place for that baby to be born.
Alternatively, there is an option of a trained and skilled attendant to reach in and pull the baby out if medically necessary or in an emergency situation, but I do not have the experience of doing this and you may be more comfortable transporting to a hospital if there is time for it in this scenario.
Labor may be stalled or completely obstructed by positioning of the babies, particularly if they are mono-amniotic babies. Additional factors that may impact baby positioning and potentially obstruct labor are fetal size, maternal pelvis size, low amniotic fluid, and uterine muscles which are hyper-tight for some reason. If either of the babies’ descents are arrested because of positioning, and external attempts to reposition them in the uterus do not work, the hospital may be the safest place for these babies to be born.
In-utero growth and development of twin babies
Twin-to-twin transfusion syndrome (TTS) occurs when -- because of cord/placental vasculature -- one twin gets more blood/nutrients than the other twin. This causes a large disparity in size and growth. If this becomes an issue, an ultrasound can confirm or deny, and there is the option of laser surgery while in utero to correct the issue/close the blood vessels that are contributing to the TTS. (Both ultrasounds and laser surgery have their own sets of risks/benefits that should be considered.)
Once the first twin is born, there is also the possibility of “acute TTS.” Because the cord is still attached to the first twin and there is perhaps some small vessel(s) still connecting the two babies via their cords/placentas, the first born baby will get more blood pumped into its body during the labor of the second twin and have excess blood/blood cells, and the second twin still inside will get less and could be born anemic or with other issues (kidney/liver or central nervous system issues) because of this.
For this reason, some practitioners suggest clamping the first baby’s cord sooner after its birth instead of waiting until after the second twin is born before clamping the first baby’s cord. Alternatively, because of what we know of how babies regulate their own blood volume after birth and even after the placenta is born as well, others suggest leaving both cords intact until after both babies have been born and both cords stop pulsing at the umbilicus, to allow the twins to equilibrate their own blood volumes.
If both babies are about the same size and chronic (in-utero) TTS is not suspected, I see no reason to clamp the cords earlier than you would normally.
Dizygotic babies (non-identical twins) do not experience TTS.
A twin mother’s belief in herself and my belief in her and her babies
Mom and partner need to have 500% confidence in her abilities and also to trust in me if I will be attending their birth. Both parents need to have the desire and trust to birth at home. I need to have no fears and complete trust in the woman and her babies to be born healthily and with ease at home, and in her partner to support her fully and me fully as well. If I have any fears or lack of trust, I should not be at the birth.
Building trust in yourself and confidence during a twin pregnancy takes time and gets easier with more knowledge and information. The process of unlearning all of the fear that has been ingrained in our culture about twin vaginal or twin home birth is a delicate one, as well a honestly evaluating your thoughts and feelings about the risks that are (or aren’t) there.
If there is any way that I can help you along in your process, or provide additional information or support, please reach out to me.
Twin labor that starts spontaneously and progresses normally
There will be no induction of labor — “natural”/herbal induction or otherwise — for twin births. I don’t advocate for this for any reason for singleton births as well.
The birth should progress smoothly with no issues along the way. The first baby should be born uneventfully. If there are a lot of hiccups along the way or the labor starts feeling like it’s not easeful in spite of all of our efforts to encourage it to be so, there could be some unseen issues at play that may make birth at a hospital a safer option than at home.
There may be a resting phase between the birth of the two twins, anywhere from 15 minutes to as long as a record of 44 days (extremely rare)! Average is 1 hour to 1.5 hours. Time between babies is not an issue if there is no bleeding, if the baby inside sounds healthy and normal, and the mama is doing well.
Intrauterine infection is a risk the longer the cervix is open without a mucus seal (and baby A’s cord hanging out!), so proper and strict hygiene must take place between the two babies.
If there is delay in the birth of the second baby with signs of fetal distress in the baby still inside, call for transport may be prudent and perhaps if the baby is in a desirable position, trying to encourage the birth of the second baby if the situation warrants it (extreme emergencies) could be prudent as well.
If there is significant delay between the two births, and the baby inside seems very healthy and has a normal heart rate, its own intact sac, and its own placenta, and it is very high in the uterus and not engaging, and emotional processing doesn’t encourage labor to begin for the second twin, there are options of watchful waiting or deciding to transfer to seek medical opinion and care.
The second baby will often be born with lower apgar score initially, regardless of the time between the births, because there is less “healthy stress” or compression on the second baby, which squeezes out more fluids for the first than the second. This lower apgar in the second twin will usually normalize pretty quickly after the birth.
Taking fetal heart tones (FHT) more often than usual during twin birth
The mom should be ok with measuring the babies’ heart rate during labor more often than would be usual, especially for the second baby. There is also more likelihood of externally palpating more often than usual in labor to determine position and descent of both babies.
This is not in a fear-based way but just to gain more information and be able to assess the well being of the babies more often, as there is a slightly higher risk that issues will come up in a twin birth compared to a singleton birth.
Using the fetoscope for taking FHT in labor is an option but using a Doppler might be easier or quicker and more convenient.
More attendants at a twin birth
For the birth of twins, there will be 3 minimum skilled/trained attendants, one for mom and one for each baby.
Emotional and spiritual factors during a twin pregnancy and birth
There are similar emotions that come up for a twinning mom as a mom carrying one baby, of course, but there are also some new feelings that may come up that you are not used to if you’ve given birth to a single baby previously.
The shock of carrying two babies instead of one, being overwhelmed by the responsibility of parenting two babies, the impact on your relationship to your partner or older children, financial issues, breastfeeding worries, etc.. are all normal emotions to come up during a twin pregnancy and birth.
Expressing your feelings, journaling, connecting to your partner and a higher power, can all help keep energy flowing throughout pregnancy and the birth experience.
More support after the birth of twins
The early days and weeks of caring for twin babies (as well as the end of pregnancy, to be honest) are challenging. Calling in support for at the very least, the first 2 weeks after giving birth, is of vital importance to your mental/emotional/spiritual well-being, and honestly that of the babies as well.
Ideally, you will arrange support for the end of your pregnancy to keep up with cooking/housework and errands and keeping up with older children if applicable, and then for 2-6 weeks+ after your birth to help with the same.
Many twin parents say the first year flies by and is a huge challenge, but somehow it works, and they needed all the support they could get in that time. Like I said in the intro, I believe those of us who are blessed with twins are the ones who have the ability to care for them, so keeping that in mind while calling in all of the extra support necessary to be able to survive and even thrive while doing so is incredibly important.
Conclusion
If after reading this and sitting with it all, or at any time during the remainder of your pregnancy, you decide that giving birth at home is not a good option for you and your family, I will still continue to support you if you desire. We can do prenatal care together still, and I can support you during your hospital or birth center birth, and provide normal postpartum care as well.
Carrying twins can feel so massive, and choosing how and where to birth is a major decision with so many possible ramifications for any option. I hope this info is helpful for you if you’re carrying twins, and that you reach out with any questions, comments, or concerns you may have during this time.
