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Giving birth to multiples

Will I have to deliver by c-section if I'm carrying more than one baby?

Not necessarily. Whether you're able to try for a vaginal birth depends a lot on how the babies "present" — that is, how they're positioned in the uterus.

Most practitioners recommend trying for a vaginal birth as long as:

  • Both babies are head down (which they are in about 40 percent of twin pregnancies).
  • Neither you nor your babies have problems that would make a c-section necessary.
  • You're at least 33 weeks pregnant when you go into labor.
  • Your babies each weigh close to 3.5 pounds or more and have been growing at approximately the same rate.

On the other hand, you can count on having a scheduled c-section if your first twin (meaning the one that's lower in your uterus, who will be born first) isn't head down, if your twins share one amniotic sac, or if you're carrying more than two babies.

There's less agreement on what to do if the first twin is head down but the other one isn't. Some experts argue that attempting a vaginal delivery is a reasonable choice, while others feel that a planned c-section is the best way to go.

Finally, you should be aware that even if you successfully give birth vaginally to the first twin, you may still end up needing a c-section for the second. This happens about 10 percent of the time, and it's even more common when only the first twin is head down. In fact, in one study, nearly 1 in 4 women with one twin positioned head down and one not ended up having a c-section for the second twin.

Assuming I can try for a vaginal birth, how will labor and delivery be different?

You have a higher chance of complications during labor and birth than a woman delivering a single baby, so you should plan to deliver in a hospital.

Potential complications include a higher risk of a prolapsed cord when your water breaks, a placental abruption (particularly after the delivery of the first twin), and postpartum hemorrhage for both vaginal and c-section deliveries. For this reason, certain precautions are necessary.

First, you'll need to choose an obstetrician skilled in delivering twins. The doctor should be affiliated with a hospital that has adequate medical staff immediately available throughout your labor. The hospital should have a nursery equipped to care for premature babies, since many twins are born a little bit early.

When you arrive at the hospital, an ultrasound will be done to confirm the position of your babies. You'll also receive an IV, as well as continuous  electronic fetal monitoring of each baby for the duration of your labor.

If you want pain medication for labor, an epidural is the best choice. An epidural can later be used to provide additional pain relief in case the doctor has to reach inside your uterus to manipulate the second twin after delivery of the first or you need an immediate c-section for any reason.

When it comes time to deliver, you'll give birth in a delivery room that doubles as an operating room instead of a regular birthing room. Your team of medical personnel may include one or two obstetricians, a midwife (if you're using one), an anesthesiologist (in case you need to deliver by c-section), at least two nurses (with additional help on stand-by), and two pediatricians (one for each baby) — plus your partner or birthing coach, of course.

After you give birth to the first baby, you practitioner will assess the position and size of your second baby abdominally and vaginally, and possibly by ultrasound as well.

What happens next will depend on the position of the second baby. If the baby's head is near your cervix and low enough in the birth canal, your practitioner will rupture the amniotic sac and continue to monitor the baby's heart rate.

The contractions usually start again shortly after the birth of the first twin (if they don't, you may be given Pitocin), and you'll push the second twin out much as you did the first, though it's likely to take a lot less work on your part.

The second baby may arrive within minutes of his sibling — or as much as half an hour or more later. If the baby's heart rate doesn't remain normal or other complications develop during this time, he'll be delivered promptly by c-section.

If the second twin's head isn't down but his buttocks descend into your pelvis, this is called a breech. Your practitioner may deliver this baby vaginally as well or do a c-section.

When neither the baby's head nor his buttocks are in place near your cervix (which can happen even if he was head down before the first twin delivered), the doctor may perform an "internal podalic version." This involves reaching inside the uterus, grabbing the baby's feet, and extracting him feet first. In some cases, a c-section will be necessary to deliver the second twin.

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