Multiple Pregnancy
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When you are pregnant with more than one baby, this is described as having a multiple pregnancy. This occurs in 1 in every 80 pregnancies and as often as 1 in every 4 pregnancies for those who have had fertility treatment.
Multiple pregnancies can come with an increased risk of complications for you and your babies that means you need to be monitored more closely during your pregnancy. While you are pregnant you should be offered a series of antenatal appointments to check on your health and the health of your babies. The number of check-ups and scans you are offered will depend on your individual situation, including your type of multiple pregnancy.
Who will provide your care?
Once your multiple pregnancy is confirmed by ultrasound scan, you will be referred to the multiple pregnancy specialist midwife and consultant obstetrician who are experienced in caring for people with multiple pregnancies. Your care will be shared between the hospital (Obstetric doctor and multiple pregnancy specialist midwife) and your community midwife.
Understanding Chorionicity
As soon as it is confirmed you are carrying twins or triplets it is important to find out the ‘Chorionicity’ of your pregnancy, which means whether your babies share a placenta (the afterbirth). This will then determine your individual antenatal care pathway.
Finding this out early is important because babies who share a placenta have a
higher risk of complications.
If your babies share a placenta, they are identical or MONOCHORIONIC
Most babies who do not share a placenta are nonidentical or DICHORIONIC
Dichorionic Diamniotic (DCDA)
Each baby has its own placenta and its own amniotic sac. This happens if two eggs are fertilised at the same time or if one egg splits into two soon after fertilisation. Two thirds of DCDA twins are non-identical.
Monochorionic Diamniotic (MCDA)
The babies share a placenta but they each have their own amniotic sac. This happens if a single fertilised egg splits a little later. These babies are always identical.
Monochorionic Monoamniotic (MCMA)
Rarely, the fertilised egg splits later still. In this case, the babies will share a placenta and are within the same amniotic sac. These babies are always identical. These types of twins carry additional risks.
Triplets
Triplets can be:
- Trichorionic: each baby has a separate placenta and chorion
- Dichorionic: two of the three babies share a placenta and chorion, and the third baby is separate
- Monochorionic: all three babies share the same placenta and chorion
Care pathway;
Twins with separate placentas (dichorionic) –
You will be offered;
- A dating scan and combined screening test between 11+2 and 14+2 weeks of pregnancy.
- A dating scan and quadruple screening test between 14+2 and 20+0 weeks.
Your screening options will be discussed with you in detail by the Multiple pregnancy specialist midwife.
- An anomaly scan between 18 weeks and 20 weeks 6 days. This is the second part of your screening and will look at the anatomy of the babies, the babies’ growth, and placental positions.
- Hospital appointments plus growth scans every four weeks from 20 weeks – you will also be offered extra appointments without a scan at 16 and 34 weeks.
Twins who share a placenta (monochorionic) –
You will be offered;
A dating scan and combined screening test between 11+2 and 14+2 weeks of pregnancy.
A dating scan and quadruple screening test between 14+2 and 20+0 weeks.
Your screening options will be discussed with you in detail by the Multiple pregnancy specialist midwife.
An anomaly scan between 18 weeks and 20 weeks 6 days. This is the second part of your screening and will look at the anatomy of the babies, the babies’ growth, and placental positions.
Hospital appointments plus growth scans every two weeks from 16 weeks with a fetal medicine consultant.
Triplets – You will be offered;
A dating scan ideally between 11+2 and 14+2 weeks of pregnancy.
Your screening options with triplets are more complex and will be discussed with you in detail by the Multiple pregnancy specialist midwife.
An anomaly scan between 18 weeks and 20 weeks 6 days. This is the second part of your screening and will look at the anatomy of the babies, the babies’ growth, and placental positions.
Hospital appointments plus growth scans every two weeks from 16 weeks with a fetal medicine consultant.
Pregnancies with a shared placenta and amniotic sac (MCMA)
Women with a twin or triplet pregnancy involving a shared placenta and amniotic sac will be offered individualised care from a consultant in a tertiary level fetal medicine centre, usually John Radcliffe Hospital in Oxford.
Care during your pregnancy
Common problems that occur in most pregnancies can be more troublesome in multiple pregnancies, such as morning sickness, tiredness, swollen ankles, varicose veins. Your midwife and GP can offer you support with these common problems. They can also refer you to other professionals if required, such as a physiotherapist who can offer you support with issues such as back pain and/or pelvic girdle pain.
Pre-eclampsia
Pre-eclampsia is a disorder that happens in pregnancy and can cause complications for you and your babies. When you are pregnant with more than one baby you are at higher risk of developing pre-eclampsia.
The risk is also higher if any of the following apply:
- this is your first pregnancy
- you are aged 40 or older
- your last pregnancy was more than 10 years ago
- you are overweight (your BMI is over 35)
- you have a family history of pre-eclampsia.
Your doctor may advise you to take 150 mg of aspirin once a day from 12 weeks of pregnancy until 36 weeks of pregnancy. This list is not exhaustive, and your doctor may suggest aspirin for other reasons.
At each antenatal appointment, your blood pressure and urine should be checked for any signs of pre-eclampsia.
VTE – Venous thromboembolism
Physiological changes during pregnancy – and up to 6 weeks postnatally – increase the risk of developing a blood clot in your leg or lung. Your VTE risk will be calculated throughout your pregnancy, and you will be offered blood thinning injections if required. This can be as early as 12 weeks.
Anaemia
Anaemia is often caused by a lack of iron and is more common in multiple pregnancies than in singleton pregnancies. You will be offered extra blood tests for anaemia compared with singleton pregnancies. This will begin between 20 and 24 weeks and you will be offered an iron supplement if needed.
Preterm Labour
Being born earlier than expected (preterm birth) happens in 50-60% of twin pregnancies, your specialist team will discuss the signs/symptoms of preterm birth with you. They will also review your medical history for any predisposing factors that increase your risk of preterm birth.
To reduce the risk of preterm labour you will be offered a cervical length (vaginal) scan alongside your anomaly scan. This is to measure the length of your cervix to ensure that it is not prematurely shortening.
You will need to contact Maternity Triage if you think labour is starting, your waters break, or you wish to discuss any symptoms you are concerned about.
When will I have my babies?
The average length of a pregnancy depends on how many babies you are expecting, on the babies’ growth and your health.
In uncomplicated multiple pregnancies, national recommendations suggest that your obstetrician should offer elective birth (either induction of labour or a planned caesarean birth):
- From 32 – 34 weeks if you have MCMA twins
- From 36 – 36+6 weeks if you have MCDA twins
- From 37 – 37+6 weeks if you have DCDA twins
- From 35 weeks if you have triplets (depending on how many placentas the triplets have)
It may be advisable to offer you induction or perform a caesarean before these timing guidelines if your babies’ or your health would be at risk by continuing with the pregnancy. The planned timing of your birth will depend on your individual circumstances, but you will be able to discuss your birth plan and preferences with your midwife and obstetrician.
How can I birth my babies?
Your decision to have a vaginal birth or a caesarean will depend on several factors, including the position of the babies and the placentas, how the babies are growing, and your medical history.
It is possible to have a vaginal birth; however, with a multiple pregnancy there is a higher chance of requiring some intervention (such as forceps, ventouse or caesarean birth).
Your own preference is important, you should be given enough time to consider all the relevant information before deciding what suits you best.
There is currently no evidence to suggest that a planned caesarean birth is any safer for you or your babies compared to a planned vaginal birth as long your babies are headfirst, you have not had a caesarean previously and there are no other complications.
If the first baby is breech (i.e. bottom first) at the time of birth, then a caesarean may be recommended.
There is a very small chance (less than 1 in 20) that the second baby may be delivered by a caesarean even if the first baby was birthed vaginally. This may be because it is difficult to birth your baby in the position it is in, or because the electronic tracing of your baby’s heart is abnormal.
If you have a vaginal birth:
- We will recommend that you have a drip inserted in your arm, in case you need any extra fluids or medications such as a hormone drip (to help increase your contractions and prevent blood loss after the babies have been born)
- It is also recommended that your babies’ heart rates are continuously monitored using electronic fetal monitoring, during your labour and birth. This helps midwives and medical staff manage your labour and birth safely.
- There are lots of different options available for pain relief during your labour, including gas and air, medications such as pethidine, and an epidural. These options can all be discussed with you in more detail before and during your labour.
- After the birth of your first baby, a midwife or an obstetrician may hold your abdomen firmly to help keep the second baby in a good position (head or bottom down, rather than lying across your uterus)
- Once you have birthed your babies, we would recommend active rather than natural birth of your placenta(s). This means giving an injection of oxytocin into your muscle shortly after birth to help contract the uterus and expel the placenta. This helps reduce the risk of blood loss.
- There is an increased risk that a caesarean may be needed in labour, and this may be prompted by several scenarios, such as your babies moving into difficult positions, concerns about the monitoring of your babies, slow progress in labour, or if assisted birth (forceps or ventouse) does not work.
If you have a caesarean birth (this will be discussed with you in advance of your planned operation):
- Standard preparation for a caesarean birth involves avoiding food and drink for several hours. Unless you require a general anaesthetic (which is rare), your birth partner will be able to come with you into the operating theatre. You will need to sign a consent form and will have the opportunity to ask any questions you may have before the operation. A drip will be inserted into your arm or hand so that you can have some fluid and medications during the procedure.
- In most situations, you will be given a spinal anaesthetic which means that you will be awake for the procedure, you will feel touch and pressure, but you will not feel pain. A catheter tube will be inserted into your bladder once the anaesthetic is working, and this will usually stay in until the anaesthetic has worn off after the birth.
- A drape will be set up to form a screen so that neither you nor your birth partner can see the operation – although this can be lowered if you wish as your babies are being born.
- If there are no concerns about the babies’ wellbeing, we will ensure there is delayed cord clamping (which is beneficial for your babies), and you will have the opportunity for skin-to-skin contact with your babies.
Regardless of how you birth your babies, it is likely that there will be more staff present for the birth than if you were only having one baby. There may be senior midwives and obstetricians present along with an anaesthetist and neonatal doctors and nurses to help look after the babies.
What happens after I have birthed my babies?
Looking after multiple newborns can be a busy time for you and your household. It is quite natural to have concerns about how you are going to manage looking after more than one baby.
Feel free to talk to our staff about any questions or concerns that you have. Your specialist multiple pregnancy midwife is often a great source of information and reassurance. Your partner, family and friends are also useful sources of support.
Further information on your multiple pregnancy can be found on the websites given at the end of this booklet.
After you have birthed your babies, you will be supported to care for your babies on the postnatal ward by midwives, support workers and nursery nurses. They will support you with infant feeding and routine care for your babies.
You may like to consider expressing colostrum towards the end of your pregnancy, your midwife will discuss the benefits of this with you and provide you with a collection kit.
Some babies need to have specialist care from a neonatal unit, this is more likely if they have been born early. Should this be the case, we will support you and make sure that you spend as much time as possible with your babies on the unit.
Key points
- Multiple pregnancy occurs in about one in 80 pregnancies
- While most service users with multiple pregnancies will have a healthy pregnancy and healthy babies, complications are more common
- Extra antenatal checks and ultrasound scans to monitor your babies will be offered
- You are more likely to have your babies early if you have a multiple pregnancy
- You will be advised to give birth in a consultant-led maternity unit
- Your midwives and local support groups can provide you with advice and support after your babies are born
Throughout your pregnancy, feel free to talk to us about any worries or concerns you have. We are here to help!
Further information
Further information can be found by visiting the following websites.
Multiple pregnancy
Multiple pregnancy: Antenatal care for twin and triplet pregnancies
Screening
Relevant contact details.
Multiple pregnancy specialist midwife
Telephone – 01908 997579 – Non urgent enquiries
Mon-Fri 8:00 – 16:00
Accident & Emergency – Pregnancies under 18 weeks
Maternity Triage – pregnancies over 18 weeks 01908 996483 – Urgent and non-urgent queries 24 hours a day 7 days a week.