Women's Healthcare Topics

Delivering Twins

Reviewed by James Brann, M.D.

Expect Delivering Earlier than Your Due Date

Expecting two babies can be stressful—and expensive! In addition to differences in how much you need to eat and how many strollers you need to buy, you should also know what to expect for labor and delivery.

Many twin pregnancies are delivered earlier than pregnancies with only one baby. This is because twin pregnancies distend the uterus more than singleton pregnancies. The uterine distension causes the uterus to contract earlier.

How Early are Twins born on Average?

More than 50% of twins are born preterm. If you are carrying twins your risk of preterm birth in the United States is 59 percent before the 37th week of pregnancy and 11 percent before the 32nd week of pregnancy. More than half of the preterm twins weigh less than 5.5 pounds and 10 percent weigh only 3.3 pounds or less. [1] If you are carrying two boys you are at the highest risk of having a preterm birth. [2]

If you are not having contractions or other signs of preterm labor, your physician routinely will not perform any tests to identify your risk for early birth. If you are having signs of early labor your physician will then perform two tests, a fetal fibronectin test and cervical length test. The fetal fibronectin test will predict if you are at an increased risk for early birth. [3] A short cervical length will also indicate you are at risk for early delivery.

If you go into labor before the twins are 36 weeks along, your doctor will probably check to see how developed your baby’s lungs are. If they are not quite ready, you may be given a steroid shot. Your doctor will then try to delay the birth for 48 hours, until the steroids have had time to help your baby’s lungs develop.

If you and the twins do not have any health problems, you may be able to carry the twins up to 40 weeks (full-term). No matter how long your pregnancy lasts, when you go into labor, your babies will be monitored closely to make sure you have the safest delivery possible.

Delivering Twins, Learn What Every Mother Should Know.

What Type of Twin Pregnancy Do You Have?

Depending on the “type” of twin pregnancy you have, your delivery options may differ. Many doctors will try to find out whether your twins are in their own sac or not. If the twins are in the same sac, your doctor may encourage you to consider elective delivery at 36 or 37 weeks. If they are in different sacs, you may be able to carry the twins the full 40 weeks.

Twins in the same sac (monochorionic) often have higher risks than twins in different sacs. Because the risk of problems increases as the pregnancy continues, you may need to be induced. A doctor may give you drugs to start contractions at 36 or 37 weeks. If you want a C-section instead of a vaginal delivery, your doctor will probably schedule it around this time.

Position of the Twins

The position of your twins will be a big part of what you can expect for the delivery of your twins. Depending on how they are positioned inside your uterus, you may not be able to choose how you want to give birth. Sometimes, the position of the babies makes a C-section delivery the only option. Your twins may be in any of the following arrangements when you go into labor or are induced:

  • Vertex/Vertex: Both babies are head-down. This is the best position, especially if you want to have a vaginal birth.

  • Vertex/Breech: The first baby is head-down; the second is bum- or feet-first. This is the second best possibility if you want to have a vaginal birth. Many times, the first baby is born normally and the second is moved or turned inside of you to be born vaginally as well.

  • Breech/Vertex or Breech/Breech: The first baby is bum- or feet-first; the second is either head-down or in the same position as the first baby. This combination can make vaginal delivery risky. Your doctor will probably recommend a C-section if this is how your babies are lying.

  • Transverse/Any position: The first baby is sideways (horizontally across your uterus). No matter what position the second baby is in, your doctor will probably recommend a C-section delivery.

In general, if the first baby is head-down, there is a good possibility that he or she can be born vaginally. The second baby may or may not be able to be delivered vaginally. If the first baby is not head-down, it is safer in most cases to have a C-section delivery, regardless of the position of the second baby.

How will I deliver my twins? Vaginal Delivery

If the babies are both head-down, most doctors will recommend a vaginal delivery for twins. Unless there is a health risk for you or the babies, vaginal delivery has fewer complications than C-sections do. Vaginal childbirth for twins is even possible for women who have had a C-section in the past. Your healthcare provider will check you and the babies before and during labor to make sure a vaginal delivery is a safe option.

During labor, the doctors will monitor the heartbeat of both twins. If they notice warning signs of a problem, they may try to speed up delivery. Doctors may help labor along by giving drugs to increase your frequency of contractions. This often happens when the labor is going too slowly.

Many doctors try to deliver the second twin less than half an hour after the first twin is born. If the second twin’s heartbeat appears normal, though, no particular time limit is needed. Up to 25% of second twins are born via C-section after the first twin was delivered vaginally. This can be due to problems the second baby is having or a risky position of the second twin.

How will I deliver my twins? C-Section Delivery

More than 60% of twin births are C-section deliveries. Sometimes the C-sections are “elective,” or chosen and planned ahead of time. Other times, they are emergencies: no one planned the surgery in advance, or something happened during vaginal labor that made a C-section necessary and urgent. Overall, C-sections are common and safe for the delivery of twins, but they are not needed in every case.

Elective C-Section with Twin Pregnancy

Depending on your health and the health (and type) of your twins, your doctor may recommend a planned C-section before natural labor starts. This may be done if the twins are in the same sac and labor hasn’t begun by 37 weeks. Sometimes, vaginal delivery can be risky, and an elective C-section is planned to avoid danger for the twins or the mother. The mother can also choose, in many cases, to have a C-section at her request once the twins have reached a minimum of 36 weeks.

Emergency C-Section with Twin Pregnancy

When a C-section is not planned ahead of time, it is called an emergency C-section. This can happen when the twins show slow heartbeats or other problems occur. Emergency C-sections also happen when the first twin is born vaginally but the second twin is not doing well. Sometimes, when a woman is pregnant with twins, labor naturally begins very early or another problem happens that makes an emergency C-section necessary. In general, C-sections are safer when they are planned ahead of time.

Pregnancy Health Section

Twin pregnancy symptoms -Twin pregnancy symptoms are similar to singleton pregnancy symptoms, but are usually more extreme. Even though you may think you are having twins, due to the exacerbation of your symptoms, it is impossible to know for sure. An ultrasound showing two babies or hearing two heart beats is the only way for sure to know. The following are hints or observations that you may be pregnant with twins:

  • Nausea seems to start earlier and be more severe with twins.

  • Breast tenderness can become very uncomfortable.

  • Blood pregnancy test (Beta-hCG level) will be higher for twins.

  • Trips to the bathroom are more frequent with twins.

  • Extreme fatigue is a common twin symptom.

  • Your belly will be much larger, for the same week of pregnancy of a singleton pregnancy.

  • You will eventually notice a lot more fetal movement then with a previous singleton pregnancy.

  • Your weight gain will be faster and greater.

  • A very suspicious and scary twin symptom is a high or positive AFP (Alpha fetoprotein tests for downs syndrome).

What are identical twins? Identical twins are called Monozygotic Twins. They result from the division of one egg after fertilization. This division forms 2 separate babies. The incidence of identical twins is 4-5 times per every 1000 pregnancies. They have all of the same genes, are of the same sex and look very much alike. The twins are often mirror images of each other. If one is right handed the other usually is left handed. Of interest is the fact that their fingerprints are different.

What do they call non-identical twins? Non-identical twins are called fraternal twins (dizygotic twins). They are formed from two different eggs and two different sperms. They do not have the same genes and may only resemble each other. Despite that they have the same birthday, they are different as a singleton sibling. Fraternal twins are more common after stopping long term use of an oral birth control pill. Even though non-identical twins can be any sex, 75-percent of the time they are the same sex.

What is the best way to diagnosis twins? The routine prenatal ultrasound, in the first or early second trimester of pregnancy, is the best way to diagnosis a twin pregnancy. The ultrasound exam will also determine an accurate gestational age of the twins and if they are identical or not.

How to tell if twins are identical or fraternal? The best and most reliable way to tell if you are having identical twins is with an ultrasound examination. Identical twins share a single placenta and the same amniotic sac. Whereas fraternal twins have separate placentas and are inside their own sac of water.

Which type of twin is more common? The most common type of twin is fraternal, (dizygotic or non-identical twins). The percent of fraternal twins depends on race, but the incidence of identical twins remains stable at 3 to 5-percent worldwide. On average the incidence of twin births is 3-percent.

Are twins at a greater risk of delivering early? All twin pregnancies are high risk and at an increased risk of delivering early. Most twin pregnancies delivery early before the 37th week of pregnancy (59-percent) and 11-percent deliver before the 32nd week. Of note boy-boy twin pairs are at the highest risk of delivery early. [4-6]

How much weight can I gain with twins? Healthcare providers recommend a total weight gain of 25 to 54 pounds for you if you are pregnant with twins. If you are obese, you should gain closer to 25 pounds. If you are considered overweight you should gain toward the middle of recommended weight gain and if you are a normal weight you can gain up to 54 pounds.

Do twin babies weigh less than single babies? One of many complications associated with twin pregnancy is the slow growth or weight gain of the babies. All twin pregnancy babies grow at a slower rate than singleton babies. The growth rate in the first two trimesters for twins is similar to singletons, but in the third trimester the babies start to slow down. Ultrasound examinations are performed every four to six weeks to watch for the slowing of growth. If it is found that the babies are growing slowly, your physician will start monitoring your pregnancy closely.

Are Prenatal Visits different for twins? Yes, prenatal visits are very different for a pregnancy with twins. The increased risk for complications requires increase visits and monitoring than a singleton pregnancy. Preterm birth and the twin slow weight gain (growth restriction) are the two most common complications seen. In the latter half of your pregnancy your physician will require frequent prenatal visits and fetal monitoring visits to avoid morbidity from these common complications.

What increases your chance of having twins? There are several main factors that will increase your chances of having twins. The most obvious is the use of fertility drugs. In the United States one third of all twin pregnancies are a result of fertility drugs.

Your age influences the increase chance of having a twin pregnancy. As you get older your ovaries require more follicle stimulating hormone (FSH) to release an egg. This increase in FSH stimulation will cause the ovary to release multiple eggs at one time. Thus, increasing your chances of a twin pregnancy.

Race and geographic area influences your chance of having twins. The chance of having twins in the United States and Europe is 8/1000 births, whereas the twin birth rate in Nigeria is 50/1000. Twins are more frequently seen in African American women then Asian or Caucasian women.

The more times you have given birth, the greater the chance of having twins with a subsequent pregnancy. This is especially true if you have a family history of twins. A family history of twins increases your chances of twins. This is because there is a genetic component expressed in women that can be inherited from her parents.

Your weight will influence weather you are at an increase chance of having twins. Obese and tall women will increase your chances for a twin pregnancy over underweight and short women

. Diet and folic acid can influence your chances of having twins. Folic acid supplementation has been show to increase your chances of twinning [7].

The Birth of Twins

Remember that it’s OK to ask your doctor all of your questions about having twins. He or she can help explain what you can expect based on your twins’ type, growth, and position. Finally, don’t be afraid about giving birth to twins! Even if you end up with a surprise delivery or an unexpected C-section, your twins have a good chance of being safe and healthy.


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