So you’re going to have your hands full! Multiples often mean double (or triple, or even quadruple) the fun. That first magical smile, laugh… all of the good stuff comes in droves. Of course, keeping pace with so many babies (several diapers, feedings and even tantrums) can be a challenge. From the time a multiple pregnancy is confirmed planning begins to ensure the birth and life with your new little bundles is as smooth as possible.

A multiple birth occurs when more than one fetus is carried to term in a single pregnancy. Different names for multiple births are used, depending on the number of children. Most common multiples are two and three, known as twins and triplets, respectively.

This section explores the miracle of multiples and helps you prepare for your new arrivals.

If you're expecting twins or multiple babies, you can contact the Australian Multiple Births Association www.amba.org.au for advice and support.

Delivery options for multiples

Vaginal birth

Almost half of all twins are born vaginally and the process is similar to that of a single baby. If you're planning a vaginal delivery, your healthcare professional is likely to recommend an epidural for pain relief. This is because, if there are problems, it's easier and quicker to assist the delivery when the mother already has good pain relief.

If the first twin is in a head down position (cephalic), it's usual to consider having a vaginal birth. However, there may be other medical reasons why this would not be possible, which are outlined below. If you have had a previous caesarean section, it is not usually recommended to have a vaginal birth with twins.

If you have a vaginal birth, you may need an assisted birth such as ventouse or forceps to help deliver the baby.

Once your first baby is born, your midwife or doctor will check the position of the second by feeling your abdomen and doing a vaginal examination. If the second baby is in a good position, the waters will be broken and this baby should be born soon after the first as the cervix is already fully dilated. If contractions stop after the first birth, hormones will be added to the drip to restart them.

Triplets or more babies are almost always delivered by elective caesarean section.

Caesarean section

A common belief is thinking you have to have a caesarean section with twins. It is true that, in Australia in 2009, two-thirds of all twins (67.1%) and the majority of higher order multiples were delivered by caesarean section (93.1%). You may choose to have an elective caesarean from the outset of your pregnancy, or your doctor may recommend a caesarean section later in the pregnancy as a result of potential complications.

The babies' position may determine whether they should be delivered by caesarean section. If the presenting baby is in a breech position (feet, knees or buttocks first), or if one twin is lying in a transverse position (with its body lying sideways), you will have to have a caesarean section.

Some conditions also mean you will need a caesarean section, for example if you have placenta praevia (a low-lying placenta) or if your twins share a placenta (monochorionic).

If you have previously had a very difficult delivery with a single baby, you may be advised to have a caesarean section with twins. Even if you plan a vaginal birth, you may end up having an emergency caesarean section. This could be because the babies become distressed, the cord prolapses (when the cord falls into the birth canal ahead of the baby), you have high blood pressure, the labour is progressing slowly or assisted delivery doesn't work.

In very rare cases, you may deliver one twin vaginally and then require a caesarean section to deliver the second twin if the baby becomes distressed. This occurs in less than 5% of twin births.

What’s different about a multiple birth recovery?

• It can take longer to recover generally from the labour and birth.
• If the babies were premature or are unwell, there can be a lot of stress and worry for parents.
• There can be more vaginal bleeding and for a longer time than with a singleton birth.
• Establishing breastfeeding can take longer. This is especially the case if the babies cannot breastfeed and the mother needs to express her breast milk.
• It can take longer to “get back into shape”. There is often more excess abdominal skin from stretching so much during the pregnancy.
• It is important to do post natal exercises in particular pelvic floor and abdominal strengthening to build muscle strength and integrity. But managing the time to do this can be a challenge.
• It can take a while for the emotional and psychological transition of becoming a mother of multiple babies to sink in. Many parents of multiples experience adjustment issues, particularly if they do not have good family support around them.
• Working out what suits you in terms of being a family. You will get lots of advice from well meaning friends and relatives but ultimately, you need to decide with your partner what is going to suit you and your little ones.
• If your babies were born premature and require ongoing intensive/neonatal care then you will need to establish a daily routine of spending time with them. This can be utterly exhausting especially for mothers who may also need to express their breast milk and still be recovering from the birth themselves. Having older children to manage can make this more difficult.
• It’s important to remember though, that despite all the challenges, the excitement and joy of having multiples makes up for the hard work.

Potential complications with multiples

“Twins and triplets are more likely to be born early, often before 38 weeks, so it's important to understand your birth options. Fewer than half of all twin pregnancies last beyond 37 weeks, and only 1.5% of triplet pregnancies go beyond this stage. The average length of the pregnancy for triplets is 34 weeks.”

While having multiples is truly wonderful, the risk of complications does increase during multiple births for both mothers and their babies. Until a multiple birth becomes a reality, many mothers assume they will have a normal vaginal delivery and may not have considered any form of obstetric intervention into their planning. However the chances of having either an instrumental birth (for example forceps or ventouse extraction) or a caesarean section are higher with multiples than with a singleton birth.

Be prepared for your babies to spend some time in special care. Just under half of all mothers of twins see at least one of their babies spend time in neonatal care, while over 90% of triplets require neonatal care. As twins are often born prematurely, it's a good idea to discuss birth options with your midwife or consultant early in your pregnancy. More health professionals will usually be present at the birth; for example, there may be a midwife, an obstetrician and two paediatricians - one for each baby. Many obstetricians have a standard practice management when it comes to multiple births. Some recommend caesarean section delivery only, and others may support trialling natural labour first. For this reason some parents to be “doctor shop” until they find an obstetrician or hospital which supports their preferences, while others are content to follow the recommendations of their healthcare professionals. It is important to remember, however, that there is no one size fits all approach to how multiples are born. Every woman and her pregnancy is unique, and depending on your individual circumstances and birth plan, recommendations will be made about delivery methods and locations.

What are the risks of a multiple birth?

• Premature delivery (birth before 37 weeks of gestation). Preterm babies often need specialist neonatal support (see below).
• Restricted foetal growth – this is generally due to the issue of limited physical space in the uterus not allowing for more than one baby to grow.
• Maternal blood pressure problems. As the mother’s pregnancy advances, a rise in blood pressure is common. This needs to be monitored in case it becomes too high.
• Placental abruption with/without haemorrhage.
• Placenta praevia. This is a condition where the placenta is lying either partially or fully across the cervix and potentially stopping the babies from descending through the cervix.
• Maternal anaemia. Depending on the level of iron in her blood and concentration of red blood cells, symptoms such as tiredness, loss of breath and a lowered oxygen transfer to the babies can result.
• Increased risk of complications including cerebral palsy, breathing problems due to immature lungs, difficulty maintaining body temperature and/or normal blood sugar levels, feeding difficulties and jaundice.
• General immaturity issues relating to their size.

It’s important to remember though, that despite all the challenges, the excitement and joy of having multiples makes up for the hard work.