Ep 92: What to Know About Being Pregnant with Twins

I've had quite a few people ask me to cover today's topic, so I'm excited to be talking all about pregnancy & birth with twins in this episode!

Obviously having twins is different than having just one baby, but there are some key things you need to know about how your pregnancy, labor, delivery and postpartum period will be affected by having multiple babies. 

I will talk about how frequently twins happen, how we differentiate between the types of twin pregnancies, and how each type will affect your prenatal care. 

I will also tell you about the complications that can arise with each of the types of twin pregnancies, both during pregnancy and during labor & delivery. There are a few risks for the birthing person that are slightly different than with a singleton pregnancy, but overall the biggest differences in care will affect your babies. 

And lastly I'll cover why you should absolutely get in touch with a lactation consultant before your babies arrive and keep them on speed dial for any breastfeeding issues.

If you are a parent of twins, I'd love to hear your thoughts on the experience - send me a DM on Instagram!

In this Episode, You’ll Learn About:

  • How frequently twin pregnancies occur
  • The different types of twin pregnancies and why we look at the placenta and amniotic sac to distinguish them
  • How your provider will diagnose that you are having twins and monitor them throughout your pregnancy
  • Some of the different complications for the birthing person and the babies to watch for during a pregnancy with twins
  • Why you will definitely deliver your twins before your due date
  • What labor and delivery may be like with twins and when we recommend a Cesarean delivery
  • Why you should absolutely have a lactation consultant if you're having twins

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Ep 92: What to Know About Being Pregnant with Twins

Nicole: In today's episode, we are talking all about twins. Welcome to the All About Pregnancy & Birth podcast. I'm Dr. Nicole Calloway Rankins, a board certified OB GYN, who's been in practice for nearly 15 years. I've had the privilege of helping over 1000 babies into this world, and I'm here to help you be calm, confident, and empowered to have a beautiful pregnancy and birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com/disclaimer. Now let's get to it.

Nicole: Hello. Hello. Welcome to another episode of the podcast. This is episode number 92. Thank you. Thank you for being here with me today. So in this episode, you are going to learn all about twins, how frequently twins happen, the types of twin pregnancies. And it's going to be a bit different than what you're thinking, what prenatal care is like for twins, what labor and delivery is like for twins, some complications that can arise. And then the postpartum period specifically, I will talk about breastfeeding. This is an episode with a ton of informative information. I think you're really going to enjoy it. It's also pretty interesting as well. Now, before we get into the episode, let me do a listener shot out. This is from Malkah the queen that's M A L K A H. Love it. And the title of the review is a breath of fresh air. And the review says greetings, Dr. Rankins, just want to thank you for sharing your expertise in an unbiased way. As a woman of color, it is a breath of fresh air to listen to a bearer of the white coat without animosity. Your service is appreciated and your knowledge as well as delivery is respected. Thank you. Thank you. Thank you so much for that really lovely review. I genuinely love helping all women and birthing people regardless of race or ethnicity, but I recognize that birthing people of color have unique circumstances, challenges, and risk when giving birth. You know, I've talked about that on the podcast before. So I'm grateful that this space that I've carved out is helpful to you as a women of color. Now, it was mentioned in the review that I share my expertise in an unbiased way, and you know, where else I share my expertise in an unbiased way?

Nicole: The Birth Preparation Course. The Birth Preparation Course is my online childbirth education class that ensures you are calm, confident, and empowered to have a beautiful birth. This is what one of my students had to say about the course, highly recommend this course for first time parents, I appreciated the wide variety of topics covered and easy to understand terms with research based guidance. You too can feel that way about your childbirth education. Just check out the Birth Preparation Course at drnicolerankins.com /enroll. It is currently deeply discounted during these crazy COVID times. So check it out again that's drnicolerankins.com/enroll. I would love to have you inside the course. All right. So let's get into talking about twins. So twin births account for about 3% of live births in the U S and they also account for about 97% of multiple births in the U S.

Nicole: Dizygotic twins are the most common, and that is the fancy term for fraternal twins. And I'll explain kind of what that means a little bit more later, but dizygotic twins are the most common. Those are fraternal more so than monozygotic twins which are identical. Approximately 70% of twins are fraternal. Whereas 30% of twins are identical. Now, in terms of the types of twins, we commonly say fraternal or identical, but in medical terms, we actually look at it in a different way, and it has implications for pregnancy. So let me explain what I mean. We actually talk about twin pregnancies in terms of chorionicity and amnionicity and chorionicity essentially refers to the number of placentas and amnionicity refers to the number of amniotic sacs. So basically are there one or two placentas and one or two amniotic sacs?

Nicole: And this is important because that chorionicity and amnionicity, depending on the combination that exists, that can impact outcomes in twin pregnancies. And I'll talk about this throughout the episode. So dizygotic or fraternal twins, they occur when two eggs are released. So a woman has two eggs during the period of ovulation. And both of those eggs are fertilized, that will always result in what's called dichorionic diamniotic placentation. So chorionic is two placentas, diamniotic is two amniotic sacs, essentially. That's just two babies who are genetically different. They just happen to be sharing the same home. So two separate eggs are fertilized with two separate sperm. That's always to result in dichorionic diamniotic pregnancies. That's the lowest risk type of pregnancy. We often shorten that to di-di twins. Now, monozygotic or identical twins result from a single egg being fertilized, and then that fertilized egg splits.

Nicole: And it's the timing of that split that determines the placentation. So that determines the chorionicity and the amnionicity. So monozygotic twins may have two separate placentas, or they may have one, well, two separate placentas in two sacs, or they may have one placenta with one sac or one placenta with two sacks. And how that ends up depends on when they split. So if that single fertilized egg splits within the first three days after fertilization, then you're going to have two placentas, two amnions, so you're going to be dichorionic diamniotic. So in that case, you can't necessarily tell for, for a dichorionic diamniotic pregnancy, whether or not those twins are identical, unless they are different, uh, sex. If they're, you know, one's a boy and one's a girl, then obviously they're going to be fraternal. But if they're both boys or both girls, then you won't be able to tell that until they're born. That's if they split that single egg splits early in after fertilization.

Nicole: Now, if the twins, if that single egg and sperm or a single fertilized egg, rather if it splits between days four and eight after fertilization, then that results in one placenta and two amnions. So that will be monochorionic diamniotic okay. So mono di, monochorionic diamniotic. I'm gonna try not to get tongue tied saying that throughout the episode. All right. And then if they split later between the eighth to 12th day, then it's, monochorionic one placenta, monoamnionic, one amniotic sac and both babies are in the same amniotic sac. This is the highest risk type of twin pregnancy, a monochorionic monoamniotic pregnancy. And I'll talk about why those risks are higher a bit later. Now, conjoined twins result from when that fertilized egg splits even later, and it doesn't completely separate. Conjoined twins are very, very, very rare. They don't happen very frequently at all.

Nicole: I've never seen conjoined twins in my career. Most of us will not. And interestingly, conjoined twins, it makes sense. They're always joined at the same body part because they incompletely split. So they're always either joined at the head or the chest or the pelvis it's wherever they didn't completely split. There'll be joined at the same spot. Okay. So let's go on and talk about some factors that influence the risk or the chances of having twins. And I'm specifically talking about fraternal or dizygotic twins that can be influenced. Actually identical twins, that number is pretty consistent across the world. So that number doesn't change very much. There aren't factors that we know that influence how often identical twins happen, but there are factors that influence fraternal twins. Now the biggest one of course is use of fertility drugs. And that's whether you use IVF or whether you use medications that cause you to release more eggs like Clomid or Letrozole, as you can imagine, when you use those fertility enhancing, uh, treatments, whether it's releasing more eggs or IVF, where typically two embryos are put back into the uterus, that of course is going to increase twins. It's actually these fertility drugs that have accounted for most of the increase in twins that we've seen in the United States in the past several years. In fact, over about one third of all twins born in the U S are attributed to either in vitro fertilization or isolation induction with medications like injectables or Clomid or Letrozole. Another factor that can increase the rate of twins is maternal age. So part of the increase in multiple births has been attributed to women having children at a later age, the frequency of naturally conceived fraternal twins increases two to threefold between age 15 and age 35. And we also know that older women are more likely to undergo fertility treatments. So those two things together mean that twins are more likely to be seen in older moms. There's also a significant race and geographic variation in the incidents of naturally conceived dizygotic or fraternal twins. In one report, twins were present in 1.3 per 1000 births in Japan, eight per 1000 births in the United States and Europe and 50 per 1000 births in Nigeria.

Nicole: And we see a similar sort of distribution in the U S, spontaneous twins are more common in those who are black or African-American descent, as well as Hispanic mothers than in white mothers. Of course, we know that family history also plays a role in twins and that genetic component is typically expressed in women, although it can be inherited from either parent. So what I mean by that is that a woman is at an increased risk of having twins if she has a family history of twin, she herself is at an increased risk, but a biological father doesn't have an effect on his partner's risk for having twins. However, if he has daughters, then his daughters may be at an increase risk, or can have an increased chance. I should say, I shouldn't call having twins a risk. They have an increased chance of having twins.

Nicole: So let me say that again, cause it feels sort of confusing. So a woman, if she has twins in her family, she's at an increased chance of having twins. A father, if he has twins in his family, his partner will not have an increased risk, but if or chance, but of his, if he has daughters, then his daughters will have an increased chance of having twins, I just think that's kind of cool. And then finally weight and height can influence the chances of having twins. So actually those with a body mass index greater than 30, which in medical terms is considered obese and then tall women, women who are greater than, um, five feet, five inches tall, they have a greater chance of having fraternal twins compared to shorter women or women who are underweight. Okay. So let's move on and talk about how we diagnose twins.

Nicole: Twins are almost always diagnosed on ultrasound these days. Most women get an early first trimester ultrasound in order to definitively establish how far along the pregnancy is. And we can see twins very early in pregnancy. So most of the time it's picked up on that early ultrasound. There are some things that may cause us to be a little more suspicious of twins. Like if you used IVF, then we're probably going to be looking for twins more so than if you did not. If your uterus is bigger than we expect, that may be a clue that there are twins. If you have a family history of fraternal twins in particular, because remember identical twins don't appear to be influenced by genetics. It's only a fraternal twins, or if you have severe nausea and vomiting in pregnancy. So hyperemesis gravidarum, those are things that may clue us in that you may be at a higher risk of having twins, or I keep saying risk, have a higher chance of having twins then, uh, we're going to look for it, but we're going to look for it anyway. And it doesn't mean that if you have severe nausea and vomiting, that it's likely that you have twins or anything like that, it's just, these are things that may clue us in. But most of the time it's just found on an early ultrasound. Also, in that ultrasound, we can see pretty early that chorionicity and amnionicity. That's the way that we can tell whether it's mono or dichorionic or mono or diamnionic. We can see that on an ultrasound after seven weeks, it gets a little bit harder to see it, the further along the pregnancy gets. So ideally you want to get it done within that first trimester, but ultrasound we can see it very well. If we see two separate placentas, then that is highly reliable, that it's dichorionic or two placentas.

Nicole: And then the other thing we look for is the presence or absence of something called an inter twin membrane, and then the characteristics of how it looks on the ultrasound, help us determine whether it's dichorionic diamniotic all of that good, great stuff. The other thing we do on that early ultrasound is label each twin. One twin will be twin a, the other twin will be twin b and we want that to stay consistent throughout the pregnancy so that we can accurately track each twins' growth and development. All right. So let's talk about what prenatal care looks like for twins. One of the biggest differences is probably weight gain. Since you're growing two babies, you're going to be eating more food or needing more caloric intake. If you are underweight, we actually don't have a lot of data in order to determine what the right amount of weight gain is for twin pregnancies.

Nicole: Um, so that is a little bit more of a estimate or best guests. That would be, uh, an instance where for sure if you're underweight and then you have a twin pregnancy where you should see a dietician, we should actually probably send all pregnant people to a dietician. But I think twins especially can be a situation where it's very helpful. Now, if your normal weight you would expect to gain between 37 to 54 pounds, if you're considered overweight. And this is based about based on BMI, and that's a BMI of 25 to 29, then your weight gain would be 31 to 50 pounds. And if you are considered obese prepregnancy, then you would want to gain between 25 and 42 pounds. If you have twins. So really you don't need to increase your caloric intake that much above someone who has a singleton pregnancy, and singleton just means one baby.

Nicole: So a normal weight woman needs to increase her dietary intake by approximately 300 calories a day, compared to what a woman is who's carrying a singleton pregnancy, or 600 calories a day above someone who is not pregnant. Okay. Now, roughly in terms of how much weight you should gain after 20 weeks, it should be roughly one and a half pounds per week for normal weight women. And just a little bit lower than that for overweight and obese women. Now, as far as physical activity and exercise, especially in early pregnancy, women with uncomplicated twin pregnancies can generally follow and do the same exercise and physical activity as women who have singleton pregnancies. And it's really an individual approach of course, but especially in the early part, most people can still have similar activity, but as pregnancy progresses, just the physical changes that happening. I mean, obviously you're just going to be a lot bigger.

Nicole: There's no way to get around. It is going to limit the type of exercise that you can do and the duration of the exercise, but you can certainly still remain physically active during your pregnancy if you have twins. All right. The other big thing that's different with prenatal care is ultrasound. So we typically do the same anatomical survey. The anatomy scan, the level two scan as it's sometimes referred to, that's performed between 18 to 22 weeks in all pregnancies, including twin pregnancies and that's to look at all of the structures and make sure everything looks okay, that's our best opportunity to see everything. Well, now it's important to have this in twins because the incidents of congenital anomalies is higher in twins. Um, specifically monozygotic twins or identical twins is actually three to five times higher than, than in fraternal twins. And, um, also higher than singleton pregnancies.

Nicole: Now some clinicians will also screen for a short cervix. So the length of the cervix, we know that twins are at an increased risk of preterm birth. I'll talk about that as one of the complications in a bit. And one of the things that we know that can predict preterm delivery in singleton pregnancies is a short cervical length. However, it's not really as well demonstrated in twin pregnancies, whether or not screening for cervical length is useful. And in general, it's not known whether looking for cervical length is useful and in women who are asymptomatic. So you may have varying opinions in management, um, options or approaches more. Some providers will screen for cervical length and some providers won't. It really just depends. There's not necessarily a consistent approach across the board in terms of measuring the length of the cervix during pregnancy. Now there is more consistency in doing regular ultrasounds throughout the second and third trimesters.

Nicole: And that's for a couple of reasons. One is we need to look at the placenta. There's increased risk of abnormal placenta findings in twin pregnancies, including placenta previa, which is when the placenta is over the cervix. And we think that's the case because there's just more volume of placenta. There's just more placenta there. So it's a higher risk of it covering the cervix. Placenta previa is a potentially dangerous pregnancy complication. So something that we definitely need to know about because it means an automatic C-section for baby safety, other things that can happen or have a higher risk of happen are vasa previa, which is when the vessels through the cord- it's kind of hard to explain without a picture, but the vessels go through the cord and the placenta and an abnormal way that puts the baby at risk for having poor outcomes or velamentous cord insertion, which is where the cord inserts on to the placenta.

Nicole: And that, um, depending on where it is, like if it's on the side that can increase the risk of bleeding. So the short story is that there are issues with the placenta that can be dangerous in pregnancy that have a higher chance of happening in twins. So we really need to be careful and look for those. The bigger reason that we do repeat ultrasounds or serial ultrasounds, every three to four weeks in twin pregnancies is to evaluate fetal growth. So evaluate how the babies are growing both individually and how they are growing in comparison to each other. That's something called growth discordance. And the reason that we measure those is that because poor growth or if there's a significant difference in the growth that can impact outcomes for the baby. So we want to know about that early, so we can try and intervene and improve situations.

Nicole: And by intervene really, it means just like closer monitoring, steroid medication, maybe inpatient observation in order to improve outcomes, sometimes even delivery early. So most people with twins, I would say all really are going to have regular ultrasounds to look for the baby's growth. This is even more important because normally we do like fundal height, where we measure the, the height of your uterus in order to tell, or give us a clue as to how a baby's growing. But that is completely unreliable in twins. We don't have any standard numbers for that for twins. Now, some providers will also do something called antepartum fetal testing for twin pregnancy. Some providers do that routinely, but this is something that also varies among different practices, varies among different pregnancies. So this is not standard. And what that is, is non-stress tests where you'll put on the monitor and measure the babies heart rates to see how they look on the monitor, there's some specific things that we look for. Also biophysical profile, which is some ultrasound things that we look for: are the babies breathing, moving, um, tone, the amount of fluid around them. Um, sometimes we look at Doppler velocimetry. I can never say this word, velocimetry. So look at the blood flow through certain vessels in the baby, particularly in the baby's head. Um, those are different things we can look at to assess how babies are doing inside of moms. Again, some centers will routinely do that for twins. Some people won't, it may depend on if you have some other complications. So it's just really individualize. All right? Speaking of complications, let's talk about some of the complicating things that can happen with twins. One of the things that can happen is something called a vanishing twin. In a vanishing twin is when a twin pregnancy early in the pregnancy course reduces from a twin pregnancy to a singleton pregnancy.

Nicole: That's called the vanishing twin. It's actually not uncommon. It happens in up to 36% of in vitro fertilization twin pregnancies. It's not very clear how often it happens in naturally conceived twin pregnancies, just because we don't typically image them as early as we do IVF pregnancies. And we really don't have a good understanding of what causes a vanishing twin to happen. Rarely you may see a vanishing twin, like evidence of it at birth, but usually it's something that's seen on ultrasound now, as far as other complications beyond if there's a vanishing twin. So if both twins go on to continue to grow beyond 20 weeks, then twin pregnancies are associated with a higher rate of pretty much all potential complications of pregnancy. And I don't say that to scare you. It's just kind of the reality of it. And I'll talk about what those complications are.

Nicole: The only two things that twin pregnancies are not at risk for are big babies or macrosomia, and then also post term pregnancy. So going like 41 42 weeks, that almost never, never happens in twin pregnancies. Now the most serious risk in preterm pregnant, I'm sorry, in twin pregnancies is preterm delivery. That's probably the biggest risk factor, um, for, for carrying twins. And it really depends on that chorionicity and amnionicity, like I talked about. So for dichorionic diamniotic twins, the risk of preterm birth at less than 32 weeks is about 7%, 7.4%. Okay. Now, when you look at monochorionic diamniotic twins, the risk of preterm birth doubles, and that is 14%. And then when you look at monochorionic monoamnionic twins, then that risk of preterm birth less than 32 weeks goes up to 26%. So the risk of preterm birth really depends on the type of that chorionicity and amnionicity.

Nicole: Like I talked about the least, or the lowest risk is in the dichorionic diamniotic pregnancy, highest risk is monochorionic monoamniotic pregnancy. There's also a higher rate of growth restriction in twin pregnancies. And that can be manifested in various ways. Or I should say three ways. One is that one twin can be small. Okay. That's considered selective fetal growth restriction or both twins can be small. Or one twin can be very much so smaller than the other, although neither is smaller than expected. Okay. So if you look at, for example, like at 28 weeks, this third, let me try to like explain different examples of what this would look like. So at 28 weeks you can have one twin who looks like it is 25 weeks. Okay. Then that one twin would be small for gestational age, that's selective growth restriction, or you can have both twins that are small for gestational age.

Nicole: So if at 28 weeks both twins look like they're 25 weeks, then that they're both growth restricted, or you can have one twin that's significantly smaller than the other. So say if at 28 weeks you have one that looks like, it's say falls within what would be considered normal. So like looks around 29 or 30 weeks, but then the other twin is 28 weeks or 27 weeks. So there's just a big difference or gap in between them. And all of them can have issues or complications usually for the smaller baby at birth and the risk, again, for that small for gestational age or that growth restriction varies by the type of pregnancy. Um, in this case, it's a little bit different. It's about the same, roughly for a dichorionic diamniotic pregnancy and a monochorionic monoamniotic pregnancy. It's a bit higher for monochorionic diamniotic pregnancy.

Nicole: Now, some other things that can be an issue, um, in twin pregnancies, I've talked about this earlier. There are higher rates of congenital anomalies in twin pregnancies, and then once twins are born, there's also higher infant mortality in twin pregnancies. So infant mortality is death within the first year of life for a single pregnant singleton pregnancy. That number on average is 11 per 1000 live births. For twins that number is 66 per 1000 live births. And a lot of that difference is attributed to the fact that twins are often premature. Um, they op like preterm labor happens at higher rates twins.

Nicole: There are some more specific things that can happen with monochorionic twins. Okay. So twins that have one placenta, and that is the case because when there's one placenta, then the twins are sharing circulation and that can potentially lead to some complications. The biggest ones are twin twin transfusion syndrome, where essentially, um, it's like there's unbalanced blood flow between the twins. And usually it results in low fluid oligohydramnios, or no fluid around one twin and then polyhydramnios or extra fluid in around the other twin. And I'm not going to go into the details of the complications of that, but just know that that's one of the possibilities from a monochorionic. So one placenta for two babies sharing that circulation. Another possibility is something called twin anemia polycythemia sequence. And that is when one twin is anemic. The other twin is something called polycythemic where they have more red blood cells then, um, is considered normal and also growth restriction where one twin doesn't grow as well. There's also a higher risk of that in a monochorionic pregnancy. Now, when you add on top of a monochorionic pregnancy, a monoamniotic pregnancy as well. So monochorionic monoamnionic that's when there's one placenta and both babies are in one sec that has the additional complication of cord entanglement, where the babies umbilical cords can get entangled with one another, and that dramatically increases the risk of a fetal death. So we really have to be careful with those monoamniotic monochorionic pregnancies that actually impacts the timing of delivery. And I'm going to talk about that in a minute.

Nicole: Okay. As far as risk go for moms, women carrying twins are at a higher risk for some adverse outcomes. And I'm going to talk about those in a second, but that doesn't vary, depend on the chorionicity and amnionicity. So it doesn't matter if it's dichorionic or diamniotic that part doesn't matter in terms of the risk for moms, where that does matter for the risk for babies. And some of the things that moms carrying twins are at higher risk for are gestational hypertension and preeclampsia. They're also at a higher risk of acute fatty liver of pregnancy, which is a really rare thing that happens anyway. And they're also at a higher risk of things like pups, which is a skin condition. Um, intrahepatic cholestasis pregnancy, which is a liver condition, anemia, I talked about the higher risk of hyperemesis gravidarum, also at a higher risk of placenta abrupt abruption.

Nicole: Now there does not seem to be a higher risk of gestational diabetes with twin pregnancies. Now, I don't want to scare you like all of these risks and things that can happen. Most twin pregnancies do not have significant problems, but we do have to be on the lookout. We do have to be careful. We do have to do the closer monitoring to make sure that we can avoid any risk before they happen or treat things when they occur. All right. So what does labor and delivery look like for twin pregnancies? The biggest difference is the timing of delivery. In general twin pregnancies, we never recommend that they go all the way to 40 weeks. So you can count on if you have twins, even an uncomplicated twin pregnancies, we routinely recommend induction. And I'm going to talk about the timing based on the amnionicity and chorionicity, and just a moment, but we routinely recommend induction before 40 weeks. So you can always count on not going to your due date with twins. So for dichorionic diamniotic twins that are uncomplicated, babies are growing fine, then ACOG, that's the American college of obstetricians and gynecologists and the society for Tom for maternal fetal medicine. That's the society for harvest pregnancy doctors recommends delivery between 38 weeks zero days and 38 weeks and six days for uncomplicated twins. And we're balancing that risk of delivery versus the increased risk of higher rates of stillbirth that we know about. So that's why we recommend it early for monochorionic diamniotic twins. So that's one placenta, but two sacs. Then we suggest delivery anywhere between 34 and 37 weeks six days, there's a little bit more of a wider spread of, of, um, what's considered acceptable options and that's based on a ACOG and SMFM what they recommend. So that's going to be a bit more individualized. And again, we're balancing the individual needs of the pregnancy, as well as the risk of stillbirth and like being able to take care of the baby better on the outside. Now, monochorionic monoamniotic twins, one placenta one sack. We routinely deliver those pregnancies or those twins between 32 and 34 weeks, because there is a high risk of stillbirth related to cord entanglement the further along the pregnancies get. Okay. So that's the highest risk that monochorionic monoamniotic pregnancy. You're definitely going to be delivered early. This may change depending on some other issues that could potentially pop up. Like if there's growth restrictions specifically in one twin, if there's twin twin transfusion syndrome, that may cause things to be different. So of course it's going to be individualized, but roughly depending on whether you're dichorionic, diamniotic, monochorionic mono or diamniotic, you can expect to be delivered anywhere from 32 weeks at the earliest to 38 weeks at the latest.

Nicole: Now, twins are always delivered in a facility that has the capability, obviously to manage twins and also has the anesthesia staff available, the pediatric staff available, to care for two babies at once. And depending on how far along mom is in the pregnancy, or if there are other issues present, then you may need to be delivered at a higher level facility, um, a higher level of care than your local hospital offers. Now, as far as the route of delivery and by route, I mean, vaginal versus cesarean, that really depends on the presentation of the babies. And by that, I mean like what part is presenting first, is the head down, or is the head that not down? So let me get the easier part out of the way. I shouldn't say easier, but the more straightforward recommendations regarding cesarean delivery. So we definitely recommend cesarean birth for monoamniotic twins.

Nicole: So twins that are in one sac. And I should say that that's not very common. Monoamniotic twins are not very common at all, but cesarean delivery is recommended, um, for those type of twins, just because of the risk involved with those, both babies being in the same sac. Okay. So for diamniotic twins where the first twin is not head down, then we also recommend cesarean birth. Okay. So at the first twin is breach or of the first twin is, um, transverse meaning going across. Then we recommend the cesarean birth in that circumstance. And again, that happens in about 20% of the time that the first twin is not head down.

Nicole: In very rare circumstances, you may find an older provider who was experienced in breech birth and may feel comfortable doing breech delivery of a first twin, but that is not very common at all. Okay. So let's talk about the other circumstance. So the other 80% of the time when the first twin is head down and then roughly it's like, it can be 50, 50, actually a little bit more where the first one is head down and the second twin is head down or it could be the first twin, is head down. And the second twin is, is not. So the second twin is breached, but most of the time, or a little bit more, I should say, they're both going to be head down. Now, there will be some providers who even if both heads are down, will recommend, or offer cesarean birth, even recommend I say. But actually it's perfectly reasonable and appropriate that if both heads are down, then a vaginal delivery is safe. I have seen in a lot of instances where providers, you know, recommend cesarean deliveries for all twin pregnancies. I think a lot of that has to do with the fact that the labor tends to be, um, not the labor tends to be longer, but especially if both heads are down, there can be a long period of time between when the first baby's born and the second baby is born, it doesn't happen necessarily right away. And by a long period of time, I mean, it could be an hour or two more of pushing and that's not necessarily conducive or, um, I mean, I'm gonna just be honest. It doesn't work as well with like an office schedule or being in the hospital.

Nicole: So you will definitely see some providers who say, hey, for all twins, I just do cesarean births because quite frankly, it's, it can be faster. However, if both heads are down, you can certainly push for or ask for error certainly it's well, within your rights to say, hey, I want to try for a vaginal delivery. If that's something that you want to do now, if both heads are not down. So if the first baby is head down and the second baby is breech, then many providers will recommend a cesarean birth in that instance. But not because it can't be done as a vaginal birth it's that a lot of providers do not have experience or expertise in delivering a second baby breech. So in certain circumstances than a vaginal birth, if the first baby is head down or cephallic, and the second baby is not cephallic or is breach, if that first baby is bigger than we know that, that baby, when that baby's born vaginally, and that baby fits, then at the second baby is the same size or smaller than that second baby should fit.

Nicole: And if that second baby is breach, then you can do something. Well not you. The provider can do something called a breach extraction where essentially the baby is pulled out, um, breach. So the baby is pulled out feet first. And doing a breach extraction requires someone who has some level of expertise. And one study showed that about 40% of obstetricians did not feel comfortable doing that and felt comfortable doing cesarean delivery if the second twin is not head down. Okay. So it really depends on the comfort level and training of your provider as to whether or not they will do a vaginal delivery if the second twin is not head down. So that's really an individual thing. You really want your provider to do what they feel they are most capable of doing and within their training and what they believe that they can do safely.

Nicole: And that may be a cesarean birth if the second twin is not head down. So again, that really just depends. Some providers will also turn the second baby inside from breach to head down. That's something called a internal, um, version. Essentially not a lot providers will do that as well, but some will do that as well, where they'll turn the second baby to head down in order to have a vaginal delivery for the second. So again, the options are, if both heads down, you can certainly try for a vaginal birth. You should be supported in that. If the first baby is head down and the second one is breached, it really depends on the comfort level of the provider in terms of vaginal delivery. If the first baby is not head down, then really all providers or the vast, vast, vast majority of providers are going to do cesarean birth because that's what's safest.

Nicole: All right. Now, as far as management of labor, labor is pretty much the same in terms of monitoring the medications we use, the things we use. So labor is pretty much the same. The difference is that for the birth, we almost always do twin deliveries in the operating room for a couple reasons. One is that there's just more space and you like need to warmers and you need extra stuff. So we typically almost always do those births in the operating room. And then the second reason is that anywhere from up to 10% of the time, there can be an unplanned cesarean for the second twin. And that can happen if there's a cord prolapse. So after the first baby is delivered, and then the core, there's a cord prolapse of the second twin, that's an emergency that requires cesarean birth, or if the baby's heart rate drops of the second twin, then we may need to do cesarean birth emergently, or if there's a placenta abruption, because the uterus is now smaller.

Nicole: And then all of a sudden the placenta can't stay attached as well. What, you know, what's left that can necessitate emergency cesarean delivery. So we typically do twin births in the operating room to be able to transition to, to a C-section quickly if need be. Now, as far as how long birth happens, like you can push for the standard amount of time, um, with the first baby. And then if the second baby is head down, then you may push for several more hours. I think the longest I've seen in between delivery of one twin and a second twin is probably four hours. If both babies are head down, actually in that instance, those twins were born on, on separate days. One was born, you know, before midnight on one day and one was born after midnight on the other day. But if the first baby is head down and the second baby is breached, we typically do a breech extraction.

Nicole: So pull the baby out. So those babies will be born close together. So if both babies are head down, it may be a bit of time in between the births. If the first one's head down, the second one is breech, then they're typically born close together. Okay, whew we are in the home stretch. The last thing I want to talk about is just what happens in the postpartum period and specifically breastfeeding mothers of multiples can encounter some unique breastfeeding barriers and challenges, which can result in lower breastfeeding rates compared with mothers of singleton births. So for example, um, infants of multiple births are more likely to be premature, so they may have more trouble breastfeeding. Um, mom can be concerned about adequate milk production, and then also it just takes a lot of time. It's intense to breastfeed two babies at once with that being said, though, although breastfeeding can be stressful and it can be time consuming for moms with twins.

Nicole: It can be done. If moms and babies have adequate support, moms do produce enough milk for twins. In this case, a lactation consultant is a must like you must talk to someone who is experienced in breastfeeding, in helping moms with twins breastfeed, because it is, it is a lot. It's a lot, it's a lot of time. It's, it's pretty intense now as terms of how you breastfeed, um, that really, again, is important to talk to a lactation consultant about it, but really the two options are, do you breastfeed them simultaneously or do you do them separately? I think most moms try to breastfeed them simultaneously because it saves time and you're not constantly having a baby to your breast. There are some positions that can help facilitate simultaneous feeding, like double football or double cradle. And again, a lactation consultant can explain those to you in more detail, but I definitely, definitely definitely recommend it is a must that you not only meet with a lactation consultant, maybe even during your pregnancy, but certainly while you're in the hospital and you need to have one on like speed dial, who you can contact at any time for help, because it is going to be, it can potentially be, I should say a lot.

Nicole: And then it's also just important in general, for families of twins to have support, because it can be a lot to have two babies at once. And if you have more babies at home or children at home, it can be a lot of stress. There is certainly a financial burden associated with it or increased financial costs. When you have two babies at once and you can't like space out those expenses and things like that. So for those reasons, parents of multiples are at a higher risk of depression, a higher risk of anxiety. They sometimes often need additional caregivers just to help with everything. So it may be worthwhile to get hooked up with organizations of parents, of multiples to help you find some coping strategies, because it is a lot and it is different than having, um, one baby, you know, having two and having two that are the same age, it can be a lot.

Nicole: It can definitely be a lot. It can be it's manageable, but it can be a lot. Oh, okay. So that is it. For this episode on twins. Just to recap, twins happen in about 3% of pregnancies. The vast majority of those are dizygotic or fraternal twins. We classify pregnancy by chorionicity and amnionicity. So whether they're dichorionic, monochorionic, diamniotic or monoamnionic, and those differences impact pregnancy. The biggest difference in prenatal care with twins is an increase in ultrasounds in the second and third trimester, in order to monitor the growth of the babies. We know that twins are at an increased risk for most pregnancy complications, especially preterm birth and growth abnormalities, growth restriction in particular, but most twins do just fine. If you have twins, you're definitely going to be delivered before your due date to reduce the risk of stillbirth. How much before your due date depends on the pregnancy.

Nicole: If it's a dichorionic diamniotic pregnancy, the lowest risk, that's going to be about 38 weeks. If it's a monochorionic monoamniotic pregnancy, the highest risk, that's going to be between 32 and 34 weeks. For twins that are both head down, vaginal delivery is certainly reasonable. So you can certainly feel confident in asking and advocating for that. If that's what you want. If the first baby is head down and the second baby is not head down, it really depends on the skill of the provider and the size of the second baby as to whether or not vaginal birth is safe. And then if the second baby is not head down or for monoamniotic twins, then we recommend cesarean birth. Whew. Okay. That's it. That is a lot, but I think it's a tons of great information for those of you have twins. I'm so curious to hear, send me some pictures or send me DM me on Instagram.

Nicole: If you are a mom who's having twins or tag me when you're listening to this episode, I would love to hear who my twin moms are out there. All right. So that is it for this episode of the podcast. Be sure to, oh, I forgot to say I'm @drnicolerankins on Instagram @drnicolerankins. So do tag me in a post or tag me in an Instagram story if you are having twins. All right. Be sure to subscribe to the podcast in Apple Podcast, Spotify, Spotify, wherever you're listening to me right now. And I would really love it. If you leave that review in Apple Podcast in particular. So many of you all have left such lovely reviews, and I so appreciate you taking the time to do so. It is a five-star rated podcast, which I so appreciate, but leave your honest review in Apple Podcasts.

Nicole: It helps other women to find the show helps the show to grow. Also, I've just mentioned Instagram, come follow me on Instagram. If you don't already, I'm @drnicolerankins there. Um, I provide lots of information about pregnancy and birth, helpful tips, inspirational quotes. I do live Instagram, live Q and A sessions on Instagram. So do come check me out on Instagram. That's @drnicolerankins. Now next week on the podcast, we have a really lovely birth story episode. So do come on back next week. And until then, I wish you a beautiful pregnancy and birth. Thanks so much for listening to this episode of the All About Pregnancy & Birth podcast. Head to my website, drnicolerankins.com to get even more great information, including free downloadable resources on how to manage pain and labor and warning signs to look out for after birth. You'll also find information on my free online class, on How To Make A Birth Plan That Works as well as everything you need to know about my signature online childbirth education class, The Birth Preparation Course. Again, that's drnicolerankins.com and I will see you next week.

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