Birthing Twins and Triplets Naturally? Why Not!

Nowadays, we see more and more multiple births occuring, meaning when a prengnancy includes more than one baby. They occur more often now in great part because of all the fertility treatments available today. On top of that, because of all the technology available now, it is possible to know very early on if a pregnancy is multiple or not. Once the shock of the news had passed, a ton of questions and doubts arise, wether they are about what to expect during the pregnancy, for the birth, and all about the future organisation of the family to welcome two, three or more bundles of joy. The first thing that changes when a mutiple birth is announced, is that the pregnancy is now considered ''at risk'', and will be monitored more closely. Then, the fact of having to birth more than one baby changes things considerably when it comes to planning the birth. Nowadays, a great deal, not to say the majority of multiple pregnancies end in elective c-sections.

Three babies!

Is it really that dangerous to give birth naturally to twins and triplets? What are the real risks? In which conditions a vaginal birth is possible, and in which conditions is it better to opt for a c-section? I will try to answer these questions in the following text. Please note that this article will only mention twins and triplets, and not high order multiples (such as quadruplets, quintuplets, etc), which are a whole other ordeal. Please also note that althought the next two paragraphs talks in terms of ''risks'' of various approaches, I consider twin and triplet births simply a variation of normal, and not a medical anomaly. Meaning that even though these pregnancies should be closely monitored, MOST of multiple births, if well handled, and if the mother is well prepared (as for any other birth, really), can happen naturally.

What are these famous risks related to a multiple birth? First of all, the risk of postpartum harmorrhage is slightly higher. With a singleton birth, the uterus has to contract right after the birth to stop the bleeding and expluse the placenta. With a multiple birth, it is possible that the uterus may be less efficient and have more trouble contracting. Please note that this is not only for a vaginal birth, as cesarean sections also increase the risk of haemorrhage (even with a singleton). When there is more than one baby, the occurence of premature labor is also increased. If the babies are too small and that the premature birth in inevitable, the doctor may consider an emergency cesarean if the babies are believed too fragile for the strain of a vaginal birth (though premature babies are often very easy to deliver). Because of the presence of two or three babies, the labor may be longer (though anything can happen). The good part is that because the babies are often smaller than singletons, they are much easier to push out and come out quite quickly. After the birth of the first baby, there is a possibility that the second or third baby enters foetal distress, or takes a bad position, which could require an emergency cesarean. Sometimes, in the case of a natural birth, if the second or last baby is malpositionned, the doctor may have to reach into the uterus to put the baby in a good position or to pull it out. This can be very painful for the mother, but recovering from a cesarean is very painful too.

Photo by Anne Geddes

Here are the conditions that favor a natural birth:

- Babies at term (or close to term)

- The first baby to come out should be head down. Still, I must mention that breech births are more and more possible, and that natural birth has been attempted even with the first baby in a breech presentation. The problem lies with some medical protocols that won't allow breech birth (even with singletons). It is always better to find doctors who are at ease handling breech births even before the situation arises. Here is a beautiful story about a twin breech homebirth.

- The weight of the second (or/and third) baby(ies) should ideally be inferior, equal or very close to the first baby (this is very hard to estimate before birth, please keep in mind that ultrasound imagery is not as precise in weight estimations as we may think it to be).

- No foetal distress in any of the babies.

- The mother ideally shouldn't have had a cesarean section done in the previous 18-24 months

- Easy pregnancy

-Of course, all the other facts applying to a singleton birth apply here as well (no cord prolapse, or placenta praevia, etc.)

It is clear that attempting a natural multiple birth is slightly more complicated than with a singleton. But a cesarean birth is not without risk either. It robs the mother and her babies of the hormone cocktail of birth, so important in the boding process, and augments the occurence of breastfeeding issues. Babies born by cesarean section are more at risk of having breathing problems, and will not be able to enjoy the essential first skin-to-skin contact with the mother right after birth. Cesarean birth is much more traumatic for babies and for mothers, and it will often be a few hours before the mother can even see her babies. Let's not forget also that cesarean birth is a major abdominal surgery, and that the recuperation period is much longer than with a vaginal birth. Imagine having to recuperate from major abdominal surgery while having to care for two, or three new babies. For more information on cesarean sections and their various issues, I highly recommend the book The Cesarean, by Dr. Michel Odent.

Let's now put all the risks aside (really, I don't like talking in terms of ''risks'') and also consider all the benefits of natural childbirth. I shall not proceed into an exhaustive list of all these advantages, but here are a few. First of all, the hormones produced by the mother during natural labor help, among other things, to prepare the babies' lungs for breathing, which prevents breathing problems. This is even more beneficial when the babies are a few weeks early and need all the help they can get to be prepared to life outside the womb, even though they are not completely ready. The first contact with the mother is more gentle, and the mother can enjoy her peak of oxytocin and take the time to meet with each baby as they are born, and have some skin-to-skin contact with them right away. The general state of the babies is usually much better and they recover much more quickly from the birth when they are naturally born. As mentionned earlier, it is a fact that multiples are often smaller and come out more easily. Finally, the recuperating period is much easier for ther mother afer natural birth then after a cesarean section.

The advantages of natural childbirth are incalculable, and when no dangerous condition make a cesarean section the only option, it is recommended to opt, or at least attempt a natural birth.

Duting a twin or triplet birth, labor will be more closely monitored. Foetal heart(s) monitoring will be longer and more frequent, and if the birth is happening in a hospital, the pushing stage will probably have to take place in a surgery room in case an emergency cesarean becomes necessary. In Quebec, multiple births must take place in hospitals, because our midwives are not allowed to handle these pregnancies, as they are considered ''at risk''.

Lotus birth (the non-severance of the umbilical cord until it falls off naturally) is also possible with twins (though good luck with in having one in a hospital). I don't know if the experience has ever been attempted with triplets, but I suppose it is possible. Here is a beautiful example of lotus identical twins sharing the same placenta.

Reading all the information online about twin births, the informations on natural birth can get scary, with all their risks. But if you really think about it, the risks are only proportionnal to the number of babies. With a well trained doctor or/and midwife (if you are lucky enough to live in an area where midwives attend multiples), who is alert to the early signs of complications, it is entirely possible to give birth naturally to twins and even triplets. It only requires a little more preparation, more courage, and conviction that it is the best choice and that it is possible, and absolute confidence in your power to birth (that applies to any birth, actually). Hiring a doula can also make a difference and be very beneficial in the outcome of your birth.

Here is the link to an interesting study about natural triplet birth: Delivery of uncomplicated triplet pregnancies: is the vaginal route sfer? A case-control study. This study concluded that in cases when everything is normal, ''vaginal delivery of triplets may be safe''.

Photo by Anne Geddes

I hope this article will have helped to shed some light on twin and triplet pregnancies, and the possibility of completing them with natural birth. In my case, these explorations reassured me on the security of attempting natural childbirth when there is more than one baby. A good deal of twin births, and a good majority of triplet births end up being cesarean sections (often elective too). Sometimes, when it becomes the norm, we tend to forget that the natural alternative is still possible.

Here are interesting links and testimonies:

Natural triplet birth

Triplet home birth (photo)

Twin home birth

Twin home birth at 41+weeks

Natural twin hospital birth

Twin homebirth

Natural hospital twin birth

Twins born naturally in the hospital

Studies:

Delivery of uncomplicated triplet pregnancies: is the vaginal route sfer? A case-control study

Obstetrical management of triplets: a series of forty-five cases

Maternal and neonatal outcomes in 54 triplet pregnancies managed in an Australian tertiary centre

Fetomaternal outcome in triplet pregnancy