Expecting parents of twins or higher-order multiplets may be worried about the mode and place of delivery  of their children. Of course, you might rely on the recommendations of your health care providers .

Nevertheless,  we would like to share with you some general aspects about the delivery  of your children, which you may consider for any decision making.

Choice of perinatal center

Before delivery, it is important to choose a center where specialists have sufficient experience with multiple births and that those are available  around the clock. Therefore it is advised to pro-actively seek information about the health care providers assisting  you during counselling and the birth process.

General quality criteria for the perinatal centers should be evaluated:

1. Number of twin births/year; including deliveries of higher order multiplets.
2. Number of vaginal deliveries of twins or higher order multiplets in relation to the total number of deliveries. Make sure that specialized obstetricians can be present around the clock.
3. Since problems may even unexpectedly arise in the newborns requiring intensified care in any center where twins or higher order multiplets are delivered at least 2 pediatricians-neonatologists should be available.

Choice of mode of delivery 

Vaginal route

During counselling, the application of a peridural anesthesia should be discussed , which not only reduces  labor pain, but is also essential for  internal maneuvers that might be necessary for the delivery  of the 2^nd twin.

MEMBRANES

If there is no membrane between the two multiples (monoamniotic twins), an elective  caesarean  should be scheduled between 32 and 34 gestational weeks to avoid further risks of umbilical cord entanglement.

In both,  monochorionic  diamniotic and dichorionic multiple pregnancies a vaginal delivery can be planned provided the first twin is in vertex position. Nevertheless, special complications of monochorionic twins such as transfusion syndromes, malformations or severe  growth discordances should be excluded.

PRESENTATION OF MULTIPLETS

If the first twin is in vertex presentation (head down), there is no contraindication to vaginal birth regardless of the presentation of the 2^nd twin, in the hands of an experienced obstetrician. During childbirth, unexpected situations may occur that require a caesarean delivery.

If the first twin is in a transverse position at the beginning of the labor, the birth must always be carried out by caesarean section. Should the fetus be in breech position, the counseling of your experienced obstetrician is very essential. It is important to mention that a caesarean section is not always mandatory.

VAGINAL BIRTH AFTER CAESAREAN

Even if a mother already had a caesarean  in a previous pregnancy, vaginal delivery is not contra-indicated in a present multiple gestation

Caesarean delivery

To date, no study has proved that a  caesarean delivery is associated with a better outcome as compared to a vaginal delivery in twin pregnancies. On the contrary, the maternal risks such as injuries and infections and even the rates of neonatal morbidity are increased with caesarean delivery.

However, secondary caesareans  may always be necessary during a vaginal birth. Even  a caesarean in multiplets requires expertise of the responsible obstetrician.

Postnatal period

Regardless of the mode of birth  mothers of multiplets have  increased risks for postpartum hemorrhage The placental bed with open vessels is larger and the uterus contracts less due to overdistension Thus, it is recommended to plan the delivery in a perinatal center where hemorrhage can be treated rapidly during all stages of blood loss.

Neonatal care

It is also recommended that the maternity hospital has a neonatal care unit with neonatologists on site who are available around the clock. In case of preterm birth  before  34 gestational weeks, a neonatal intensive care unit should also be available.

More information that is detailed can be found on our information leaflet.