Nearly all women expecting twins or more give birth in a consultant-led hospital unit. Your obstetrician and midwife are likely to advise you that this is the safest place for you to have your babies. However, much depends on your circumstances and how your pregnancy is going.
Your hospital will have worked out its own policy on twin births, taking into consideration national guidelines. These guidelines recommend a planned (elective) birth for twins or more.
A planned birth is one where:
your labour is induced or
you give birth by elective caesarean section
Hospital is the only place where you can have these types of birth.
A planned birth also means that your obstetrician will recommend a date for your labour to be started or for your babies to be born by c-section. She should discuss the timing of your babies' birth with you early in your third trimester.
Your obstetrician will take into account whether your twins share a placenta (monochorionic) or each one has their own placenta (dichorionic) when recommending a date for them to be born.
National guidelines recommend a planned birth for:
Dichorionic twins from 37 weeks.
Monochorionic twins from 36 weeks.
Triplets from 35 weeks. Mums expecting triplets will be offered a course of steroids to help their babies' lungs develop before they're born.
It's safest for babies who share a placenta to be born in hospital, where specialist medical care is at hand. And even if your twins have their own placentas, there are still potential risks that could make birth difficult.
In any birth of multiples, there's a greater likelihood of heavy bleeding for the mum after the birth. Newborns often need immediate help after birth too. Just under half of twin babies and nearly all triplets need to spend some time in special care.
All these reasons point to why you're most likely to have your babies in hospital. But, ultimately, the decision is yours. Talk to your midwife or obstetrician about your birth options, in the context of how your pregnancy is going. You could also make an appointment with the head of the labour ward or a supervisor of midwives at your hospital to discuss your preferences.
If you opt for a hospital birth, check out these ways to make your room comfortable for labour.
Do I have to have a planned birth with twins?
Despite hospital policies and national guidelines, it's up to you to decide where and when to give birth.
If your twin pregnancy has been without complications, and your babies don't share a placenta, it is possible to wait for your labour to start naturally. This could also open up the option of giving birth at a birth centre or at home. You'll need to plan this well in advance with your obstetrician and midwifery team.
National guidelines recommend planned birth for all twins because, in complicated pregnancies, it reduces the risk of one or both of the babies being stillborn.
However, for uncomplicated twin pregnancies, it's not clear whether planned birth by induction or caesarean is better for mums and babies than waiting for labour to start naturally.
If your babies are healthy and growing well, and you want to wait for labour to start naturally, your obstetrician should support you. It's an individual decision, and some parents consider a wide range of issues when weighing up what to do, including:
how well mum is coping with the pregnancy
how they feel about interventions during labour and birth
how likely it is that a caesarean will be needed
whether opting for a planned birth would affect the mum's chosen place of birth
If you decide against an induction or planned caesarean, you'll need weekly checks with your obstetrician to ensure that you and your babies are healthy.
What are my chances of having a vaginal birth with twins?
If both your twins are growing well and you've had no complications during your pregnancy, you may be able to have a vaginal birth. About four out of 10 twins are born vaginally.
Some hospitals insist on a mum giving birth by caesarean if she's carrying identical twins who share a placenta.
Ask your midwife or obstetrician what your hospital's policy on twin births is, and whether any of the maternity team has experience of vaginal twin births. Ask them to explore thoroughly the risks and benefits of vaginal birth with you, taking into account your circumstances.
The position of the twin that's likely to born first will have a big influence over the type of birth you have. If your first twin is in a head-down position, you may be able to have a vaginal birth.
It's likely that your second baby can then be born vaginally too. Once your first baby is born, there'll be more space in your womb (uterus). So if your second baby is in a breech position or lying across your cervix, your obstetrician can turn her into a head-down position.
Your obstetrician may move your baby by palpating your belly in a manoeuvre called external cephalic version (ECV). Alternatively, she may be able to insert her hand through your fully open cervix to reach your second baby.
Attempts to turn a second twin are usually successful. In less than five per cent of cases, the second twin needs to be born by caesarean.
What's a vaginal twin birth like?
Because you're giving birth to more than one baby, there'll be more health professionals in the room than there would be for a singleton birth.
The medical team may include two midwives, an obstetrician and, as your babies' birth approaches, two paediatricians and possibly two neonatal unit nurses, one for each baby.
Your midwife will offer you pain relief such as gas and air and pethidine.
It's likely you'll also be offered an epidural or to have one set up, along with a needle in a vein in your arm (a drip). Having an epidural and a drip set up means you can have your pain relief topped up quickly if you need an assisted birth or a caesarean later on.
It's worth discussing your pain relief options with your midwife during pregnancy. You can then include your preferences in your birth plan.
Keep in mind that labour and birth are unpredictable, though. Your midwife or doctor may recommend a course of action at any time that isn't what you'd hoped for, but which will always be in the best interests of you and your babies.
During labour, expect to have your babies monitored with electronic fetal monitors (EFM). This is standard practice for multiple births.
Your midwife will strap a belt with sensors attached to wires around your belly. The sensors pick up your babies' heartbeats and the intensity and frequency of your contractions. You will need to have two belts to pick up each twin's heartbeat.
Once your waters have broken, your midwife may ask your permission to attach a wire to the top of your first twin's head. At this stage, your baby's head will be showing through your widening cervix. The wire is called a fetal scalp electrode, and it's a clearer way to measure your baby's heartbeat.
When you're ready to push, your obstetrician may ask to move you to the operating theatre, in case you need an assisted birth. Some hospitals have a policy of carrying out assisted births in a theatre setting. You'll also be in the right place in the unlikely event you need a c-section to give birth to one or both of your babies.
Once your first baby is born vaginally, your midwife or doctor will check the position of your second twin by:
feeling your tummy
asking your permission to do a vaginal examination
carrying out an ultrasound scan
If your second baby is in a good position to be born, your midwife or obstetrician will break the waters surrounding him. Your second baby is likely to be born very soon after your first, because your cervix is already fully open (dilated).
If your contractions stop after your first twin is born, your midwife will add hormones to the drip to restart them.
Once you've given birth to your babies, you'll deliver the placenta or placentas. This is the third stage of labour. Your midwife will recommend that you have a managed third stage, when delivery of the placenta or placentas is helped along with a hormone injection.
Your midwife will give you the injection in your thigh, soon after you've given birth to your second baby. The injection helps to protect you against heavy bleeding. There's an increased risk of bleeding when the placenta is larger, and because your womb has been stretched by two babies.
Why might I have to give birth by c-section with twins?
Your babies will have to be born by caesarean if the placenta or one of the placentas is covering the opening to your cervix (placenta praevia). Placenta praevia is case where a vaginal birth is not possible.
In addition, you may be advised to have a planned caesarean if:
You've had a caesarean before.
You've had a difficult or complicated birth before.
You've had a complication during your pregnancy, such as one or both of your twins are not growing as well as expected.
Your twins share a placenta and an amniotic sac (monochorionic monoamniotic). A caesarean is recommended because of the risk of your babies' umbilical cords becoming tangled during vaginal birth.
You may go into labour, but still need to have an unplanned caesarean if:
There is a complication with your labour, such as your twins moving into an awkward position.
One or both of your babies have become distressed during labour.
Your labour is slowing down.
You have high blood pressure or pre-eclampsia that doesn't respond to treatment.
The cord falls through your cervix ahead of your baby or babies (prolapse).
What can I do to avoid a caesarean?
Try to stay as fit and healthy as you can during pregnancy, as this will help you to cope with labour when the time comes. Try to stick to a gentle exercise programme throughout your pregnancy.
Be as active during labour as possible. Keeping mobile may improve your chances of avoiding a caesarean.
However, this may be a challenge in a twin birth, as fetal monitoring can restrict you physically. Some hospitals have mobile monitors that allow you to move around freely.
Having a birth partner to give you continuous support while you're in labour may reduce your chances of having an unplanned caesarean. You'll need good, solid support from the moment your labour starts. You could ask your partner, a friend, a relative, or a doula to take the role.
Have a look at this infographic, which summarises the risks and benefits of giving birth by caesarean section if you're expecting twins
source: http://www.babycentre.co.uk/a3585/giving-birth-to-twins
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