Two heart beats. Everyone has questions about twins. Fraternal, identical, same placenta, double ovulation, why twins seem more common? We are fascinated by how twins occur, how they grow in utero, how they are born. There is a big long list.

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In this ep we give some gold for twin mamas and for those simply curious about twins. We also have a special treat – the women from “too peas in a podcast’ have a little cameo and give us practical tips about their experience as mothers of twins.

If you want to head over to “too peas in a podcast” here is the link

This episode talks about:

• The different types of twins
• Why twins are often a high risk pregnancy
• A little bit of myth busting
• What is considered full term for twins
• Questions to ask your hospital
• Vaginal and Caesarean birth of twins

Photo credit @ansleyadventures

Brigid [00:00:36] Well, welcome, everyone. This is episode 21 to a much anticipated episode, isn’t it, Pat? Yes, I’m excited about this one. We’re talking about twins,. 

Brigid [00:00:44] Twin pregnancy. So but before we get onto that, Paddy, I just wanted to actually talk about some of the testimonies that we’ve been getting on our podcast and coming through either on the podcast or through dms or through e-mails. And we just love reading them. 

Patrick [00:00:58] So great to hear from people. Isn’t this fantastic? 

Brigid [00:01:01] So I’m going to read this one from Katie. Hi, guys. Just wanted to say that I love your podcast so much. This is my first pregnancy and I’ve been loving listening to the great advice on your podcast. It is my favorite and has been really helpful. 

Brigid [00:01:13] I love being anyone’s favorite. Fantastic. We don’t even know that person. Yeah, I know. This is good. This is from Leah. 

Brigid [00:01:21] I’ve been listening to your podcast in the States. It’s great. Thank you. 

Patrick [00:01:26] Maybe one more. Yeah, I’m okay. Keep going. Keep going. Keep going. Okay. This is from Claire. Hi, Dr. Pat and Bridget. Just wanted to say thank you both so much for your wonderful, informative podcast. Because of your podcast I recently had a prepare screening test. Luckily, I was low risk for everything, but it’s still such good peace of mind. 

Patrick [00:01:45] Isn’t that fantastic? That’s someone who’s listened to our what do we wish everyone knew before they got started? 

Brigid [00:01:51] Yeah, I know. I think that is episode 2, isn’t it. Yeah. Yeah. So keep them coming. And we just love reading them out. So thank you for all your feedback. So on with the show before knowing you paddy and delving deeper into this baby world that we’re in. The most I used to think about twins was wrangling toddler twins. 

Patrick [00:02:09] Yeah, well I think that would be one of the hardest bits. 

Brigid [00:02:11] Yeah. And I think maybe at each ultrasound, that very first ultrasound, I used to say, oh my gosh, if I hear two heartbeats, I think I might just cry the whole pregnancy. 

Patrick [00:02:20] Yeah, well I think that that happens sometime. Someone would come for an early ultrasound and will diagnose twins and it’s kind of good news and bad. 

Brigid [00:02:28] All right. So, Pat, it’s a bit confusing and it’s confusing for me. So maybe we could get some definitions first. So firstly, how do twins even happen? 

Patrick [00:02:37] Yeah, well, this is interesting because there’s this sort of two different ways that twins can come about. And I guess the most common way is for woman just ovulate twice in one month so that there’s two eggs produced and they’re fertilized and we wind up with two, you know, genetically different fetuses growing and most of those twin pregnancies. That’s the kind of the type we want. They’re the relatively straightforward to manage from a medical point of view, because in many ways they they work like two discrete pregnancies that just so happen to be occurring side by side in the in the one woman. And interactions between the two pregnancies are not very common. Major complications are not very common. And apart from coming a little bit early, those twin pregnancies tend to turn out fine. And have we got a name for that? Yeah. That’s called Dizygotic Twins. And most of them have a type of plumbing in the twins called DCD A, which means Di Choriotic Di Amniotic. And that means that each twin has its own inner and outer sack. So they behave very much like two singleton pregnancies that just happen to be happening at the same time. 

Brigid [00:03:55] So what happens to the woman? Is she then double the size when she’s growing the twins? 

Patrick [00:03:59] They’re not quite double the size, but pretty big. And one of the many reasons why they might come early is that the uterus can only get so big and eventually the waters will break and the woman will come into labor. 

Brigid [00:04:11] Yes. So it’s the pressure of the size of the uterus growing that perhaps would cause the waters to break here? 

Patrick [00:04:16] Yes, your uterus can only get so big. And eventually one of that, one of the one of the sacs will break, just like a balloon, a bit be like a balloon. So there are other complications that can happen even in that good type of DCDA twins, mostly related to complications of the babies like problems with growth and sometimes related to more maternal complications like a much higher risk of things like pregnancy, diabetes and high blood pressure and preeclampsia. And sometimes those things get in the way. And the babies come early because we make them come early. 

Brigid [00:04:49] All right. We’ll talk in more depth in a minute about the complications, because there’s a couple of other different types of twins, isn’t it? Is that also fraternal twins? 

Patrick [00:04:56] Yeah, that’s what that’s called. Fraternal twins share what we just discussed. And then there’s the other type of twins which come from one egg that splits apart. So one egg is produced. Sperm fertilizes the egg. Pregnancies start growing and then splits apart. And those pregnancies are much more complicated. And how complicated they are depends on how late the splitting apart happens. So if the splitting apart happens right at the very start, then they’re a bit like fraternal twins. They’re genetically identical. But in terms of the medical progress of that pregnancy, they’re DCDA and they have minimal. Nations split apart a little bit later and they and they have shared circulation and the shared circulation can lead to something called discordant growth, where one is much bigger than the other or one is hogging more than its fair share of the placental output at the expense of the other one. And a rarer a thing called twin to twin transfusion syndrome, where one twin is really hogging major part of the blood supply from the other one gets really big and fat, the other it gets too small and too skinny. 

Brigid [00:06:07] And as an as a I don’t know, is it as a sonographer? When do they how do you know what time that egg splits? 

Patrick [00:06:14] Well, you can look at the sacks on a first trimester ultrasound and there’s some ultrasound clues as to exactly what type of twins they are if they’re DCDA. They’ve both got their own inner and outer sacks. Then between each baby, there’s four membranes that in outer and then outer inner. Yeah. So that looks thicker on ultrasound and you can see that. Yeah. So usually in the first trimester ultrasound they can tell us exactly what type of twin pregnancy it is. And therefore as obstetrician we can put together a plan for that woman based on expected complexity. Yeah. Wow. Okay. So if we get it back to a moment to those ones that split apart. If the splitting apart happens a bit later again, then you get a rare type of twins where they’re in the same sac together. Wow. Like they’re floating around next to each other and there’s no membrane between them. And that’s a very complicated type of twins called mono amniotic twins. And the complexity of that one is that they can get tied up in each other’s cord. In fact, they always do. Yeah, right. So those twin that type of twins will be electively delivered very early because they’re better off being premature than tied up in each other’s cords, causing a stillbirth situation for one or both babies. And then the latest. They split apart if they split apart very late. That’s conjoined twins. 

Brigid [00:07:35] Yeah. Right? Yeah. I’m just like my brain’s just going pop up puppet. So fascinating, isn’t it? Yeah, it is fascinating. 

Patrick [00:07:42] And you know, when we when we think about twin pregnancies as obstetricians, it reminds us of just how much is going on in that first week of post conception life. 

Brigid [00:07:54] And I’m a bit confused. Say we things such as do they share a placenta or does that depend again on whether it’s fraternal or identical? 

Patrick [00:08:01] Yeah. So it depends on what I call the plumbing. Like how how they’re how they’re plumbed in. And, you know, the good part about D.C. D.A. twins is that there’s basically two placentas working independently. And whilst any sort of pregnancy complication could happen. It doesn’t happen hugely more commonly than it does for singleton pregnancies. Yeah, but in a shared placental situation, complications involving one baby being significantly bigger than the other are pretty common. I always say my patients with twins, I have to work harder to get the same outcomes for you and your babies as I would have to if you just had a singleton baby on board. So we’re trying to get the results for twins to be as good as the results for women having one baby at a time. And we’re not quite there. But even to get close, we have to work a lot harder. There’s more tests, there’s more reviews, there’s more surveillance and there’s more interfering. 

Brigid [00:09:01] Mm hmm. Yeah. Yeah. Because I don’t know. We see the end result. Well, I see the end result in happy little twins running around. But you know what’s gone on before that to get those twins to be toddlers that are happy and healthy. That’s that’s a lot of work for everybody. 

Patrick [00:09:15] It’s actually a fair bit. And a degree of prematurity is is very common. And so, you know, our friends at the two peas in a pod cast, which we’ll be talking a bit more about that later on, we’ve gotten we’ve got a little special treat for everybody later on this fantastic podcast of mothers of twins. So, you know, they make the point in the recording they did for us just about. 

Brigid [00:09:37] You just gave it away. Surprise! 

Patrick [00:09:40] So they make the point that you have to, it involves a degree of accepting that things may not go exactly according to your dream plan with a with a twin pregnancy and to be prepared for the very real possibility of those babies coming early. 

Brigid [00:09:59] Absolutely. So one thing that I thought might be useful for everybody is to find out how common twins are. So the latest stats from the Australian Bureau of Statistics said that there’s four thousand two hundred and ninety one sets of twins, which represents about one point four percent of all births. 

Patrick [00:10:15] And that’s to be expected. So we know that twins occur naturally at a rate of about one in 80. Yes. So one point four percent is going to be about one in 80. And it’s a little higher sometimes than what we would expect to see naturally. 

Patrick [00:10:30] And that’s because there’s two factors at work these days that increase the twinning rate. One is IVF pregnancies. Quite a lot of babies these days are born from IVF and IVF pregnancies are more likely to be twins. In the early days of IVF, they used to put two embryos back in there just to hope for the best. Wasn’t it to make it work more often? Yeah. And that was a reasonable idea. But it did result in an awful lot of twin pregnancies. So Australia eventually started leading the way in single embryo transfers. So just putting one in it at a time. And even if you do that, a single embryo transferred at IVF is slightly more likely to split apart than a naturally conceived embryo. So even with all the care and attention, there’s still high twinning rate from IVF. And then the other factor that makes similar kind of twins other than family history is the mother’s age. So as the age of the average pregnant woman goes up in Australia, the twin rates going up as well. 

Brigid [00:11:24] This might be a question you can answer, but so for people where they do have twins in their family and they say that it skips a generation, is this just an old myth or is that true? 

Patrick [00:11:34] It doesn’t reliably skip a generation. It might appear to, but it doesn’t work like that. There is a genetic predisposition to twins that can run through a woman’s family. 

Brigid [00:11:44] Can it be any sort of twin or is it more that you’d have fraternal or identical twins? I think it’s any sort. Yeah, right. Yeah. Okay. You’ve just got splitting eggs or double ovulation. 

Patrick [00:11:53] Yeah, I think it’s a tendency towards double ovulation. Yeah. 

Brigid [00:11:56] Okay. So I know in a couple of our podcasts we’ve actually talked about particularly the Ovulation Ninja One EP 2 and you talk about the ovulation induction and you say like we just really want to get the dose right to get a single baby. Yeah, because twin pregnancies are not ideal. And when you said that back in episode 2, I thought, well, that’s a bit harsh. But really, you had complications on your mind, didn’t you? 

Patrick [00:12:20] Well, yeah, that’s kind of my job to try and get things, especially with women undergoing ovulation. So let’s just clarify. These are couples who are having trouble conceiving. And the problem turns out to be the fact that the woman isn’t making an egg each month. If she’s capable of making that egg, then usually that couple don’t need anything as dramatic as full on IVF. Usually what we do is treat the woman with some fertility drugs to help her ovaries pick an egg each month and pop it out and restore monthly of ovulation. Then she’ll usually get pregnant. So the trick to that, of course, is to make sure that we can give the right amount of the fertility drug so that we don’t overdo it and give them twins or triplets. And what we’ve got in mind, sometimes couples who are struggling with their fertility think they’re twins or triples and we’ve go from nothing to everything will be fine. But these pregnancies are a bit complicated. Twins is not quite as good as having your babies, one at the time and triplets, it can be a real problem. So to be honest. There are plenty of happy outcomes from triplets. But these pregnancies aren’t going to term, babies are coming early and it’s not as desirable as having the babies one at a time. If you get naturally conceived triplets. Well, there you go. We’ll just we’ll just manage that and we’ll manage that and do our best. But have you only delivered triplets? Yes, I have you once at the Royal Women’s. So you know that these it’s complicated, but you naturally conceive. Well, we takes our chances. But if we’re going to give a woman, you know, a medical treatment that raises her risk of multiple pregnancy, then we need to be careful about doing that. So we use it we use supervised ovulation induction where you take the fertility drugs at the start of the month and then we ultrasound the ovaries before ovulation. And you can see how many follicles, how many egg sacks are coming up on the ovary. And if it looks like this two or certainly if it looks like there’s three, then you cancel the rest of that month and you abstain. Yeah. Condoms on no sex or whatever for the rest of that month. So those eggs can pop out but not be fertilized. And then you see the woman in the next month and give her less. Yes. The medication idea being babies one at a time. Yes. 

Brigid [00:14:32] So talking about complications, you’ve mentioned it a few times now. I think we should cover it. And that is that twins can come prematurely. Yes. So what’s considered full term for a twin pregnancy? 

Patrick [00:14:43] Well, I think full term is still considered full term. But realistically, if we get out to about 36 or 37 in a twin pregnancy, the situation, if we’re lucky enough to get that far or through good management, we’ve got that far, we might say, well, if we’re going to proceed from here, we’ve got the risks of complications developing and no particular benefit. So let’s get on with it. 

Brigid [00:15:09] Yes. And since you’ve already spilled the peas, nice. The two peas in the podcast, girls, Mandy and Kate, they do talk about get to know what the special care nursery is and what the NICU is. Yes. And so for those listening who want to find out, we’ve we’ve actually covered a lot of that in Episode 7 when your baby comes too early. So I really recommend you go back and have a listen to that as well. 

Patrick [00:15:33] Yeah, I think that’s a good one for anyone whose baby might be coming too early anyway. For example, there’s some sort of complication. The team is starting to talk about that your baby needs to come early. So as part of the process of getting your mind around that, you go visit the nursery. So you know what, your baby’s going to go for a while and what’s going to be like to be there. And for twins, certainly if there’s some growth complications or something like that and there’s every chance we might need to get on with it. Well, within the timeframe where the baby would need to go the nursery, then a visit to the nursery to see what that’s like is part of the deal. 

Brigid [00:16:05] And if you’ve had your babies at sort of 36, 37 weeks, are they more likely to go into a NICU or a special care nursery? 

Patrick [00:16:14] Well, if we get to 36 or 37, then then very much the special care nursery case. That’s a lower level of care. Mostly things like jaundice, feeding difficulties and minor levels of respiratory support. 

Brigid [00:16:27] And in most hospitals have a special care nurse, right? Yeah. 

Patrick [00:16:30] Yeah. Most most hospitals that have babies being born there would have some sort of special care nursery. And the level of that special care nursery varies. And big hospitals can keep babies that are earlier and sicker and smaller hospitals tend to transfer based on their level of expertise they’ve got there. And NICUs are for very sick or very premature babies with much higher levels of support. 

Brigid [00:16:54] Well, let’s talk about Melbourne because we know Melbourne. 

Patrick [00:16:56] So which hospitals would have a NICU if any of our babies in Ballarat need transfer, either born or about to be born? Then we go to the big hospitals like Monash, the Mercy Hospital for women in the Royal Women’s who have the highest level of care for those very premature or very sick babies. 

Brigid [00:17:15] To be worthwhile for someone that is pregnant with twins, to just check out their hospitals and make sure you know what level of care they have Premmie babies. 

Patrick [00:17:24] Yes. So you can ask at your hospital in an ordinary antenatal visit what the cutoffs are for your hospital. So they might say we can keep any baby that’s born over 33 weeks. Yeah, that’s nice to know that figure, because you can take that figure away in your mind and think, okay, if I get to 33 weeks, I can still have my baby at my hospital in my community. 

Patrick [00:17:45] Yes. Without needing to move. Move. 

Brigid [00:17:47] Yeah. Go back and listen to Episode 7. There’s there’s lots of gold in there. But are there any other main problems in twin pregnancy that you’re concerned with? 

Patrick [00:17:58] Yeah, I like to divide these up into the complications that could happen to anyone. Yeah. That are more common with twin pregnancies. And unfortunately, that’s kind of the whole list. Yeah. So anything I say to my students, if anyone ever asks you what are the complications of twin pregnancies, it’s a trick question. It’s just anything. So the mum’s bigger, she’s got more placental hormonal boys. She’s got a bigger placental mass. 

Patrick [00:18:23] And any complication is basically more common. And it’s not the end of the world, we can manage these things. But if you look at something like gestational diabetes, more likely to get it, it’s more likely to be difficult to control and you won’t likely to need insulin. Well, so be it. We can manage all of that. Or something like high blood pressure. You’re more likely to get it. You’re more likely to need medication to manage it, and you’re more likely to develop the complicated form of high blood pressure known as preeclampsia. So that’s alright. We can manage those things as well. Sometimes with a twin pregnancy that we’re starting to get concerned about, we might even give mum a dose of antenatal steroids, the injections to mature the baby’s lungs so that if the baby does have to be born at 34 weeks on obstetric grounds, then comes out more more like having the lungs of a 36 weeker. And that that makes those babies go better in the nursery.

Brigid [00:19:13] How long do they have to have steroids for before it actually impacts on the baby, makes the baby’s lungs stronger? 

Patrick [00:19:19] I work straightaway. So you have you have two doses a day apart, one on a Wednesday, one or Thursday. And even if you had to deliver those babies on a Friday, you’d still get some benefit. Yeah, right. And in the days following that, more benefits. 

Brigid [00:19:30] Yeah. All right. So. And what about growth problems? 

Patrick [00:19:33] Yeah. So they’re very common. And so when we’re seeing a woman with twins in the antenatal Clinic, we’re much more likely to do a serial growth scans. You know, when you get to the obstetrician, if you’re pregnant and we measured tummy with the tape measure, it doesn’t really work for twins. Yeah. What he did double it. Yeah. Yeah. That’s right. So the normal ranges are less clear and it’s less predictable. We got two babies in there. You might have one sitting on top of each other one week, next to each other the next week. And it doesn’t really, it’s not really useful for twins. So that’s why we use ultrasound all the time. And in a perfect world, we get the same scanner, the same actual person doing the scan from time to time. That’s been shown to help with accuracy. And what will often do in the third trimester with twins is you see that woman every week and every second visit will do a growth scan, make sure the babies are good and on the off visits, a scan to make sure that there’s plenty of water around each baby and that the blood is flowing normally down the cord and in through the baby. 

Brigid [00:20:30] And I know I mean, we’ve got a fancy whiz bang ultrasound unit in our rooms and you do ultrasounds. Is that something that you would do or you send off to a sonographer? 

Patrick [00:20:39] Yeah, it depends on the situation. I don’t commonly do growth scans for twins. It’s a bit of a specialized field. I’ve got a really great ultrasound guy who is excellent at that. But, you know, the off weeks when when we’re scanning just fluid levels and cord flow, I certainly can do those myself. You know, in a public hospital situation, they’ll often be a scanner who comes to clinic, ideally so that the same person can help keep an eye on high risk pregnancies, including twins. 

Brigid [00:21:06] And so in a public hospital setting, someone with twins, are they just in the high risk pregnancy group or is there a specific sort of twins group? 

Patrick [00:21:14] Yeah. Good question. In a unit like ours here in Ballarat. We have a high risk clinic and people with pregnancy complications or people we’re particularly worried about and they would be seen by a senior doctor pretty much each visit as well as midwives and other people. But a senior obstetrics doctor being involved each time and we would put out our twins pretty much in that group. At a big tertiary referral hospital like the Royal Women’s. They have a specific multiple pregnancy clinic and they’re often being sent women who’ve got complicated problems. Like, for example, there’s a problem with the growth of the twins, but it’s too early to treat that by delivery. Yes. So if there’s a problem with the growth of the twins at 35 weeks, there’s a simple answer, get them out. But 25 weeks? What do you do? So, a twin clinic at a tertiary referral hospital is a way of concentrating expertise in one place. 

Brigid [00:22:10] Yeah, well, and you know, that does bring up some other complications like the possibility of stillbirth. 

Patrick [00:22:16] Yeah, well, this is what we’re trying to avoid by watching twin pregnancies very closely. There’s certainly a higher risk of stillbirth, unfortunately, with twin pregnancies. We get women to monitor the fetal movements in the third trimester and we’ve talked elsewhere about how important that is. But when you’ve got two babies, it’s very difficult to tell if they’re both moving. Yeah. Yeah. So, again, that’s why there’s more surveillance. And obviously the whole point of the increased amount and intensity of antenatal care is to pick up any problem before it results in stillbirth. 

Brigid [00:22:53] When did you say they start having weekly monitoring? 

Patrick [00:22:55] Was there? Yeah, as early as the start of the third trimester. 

Brigid [00:22:58] Yeah, yeah. Yeah. I think that would be kind of like such an anxious time for women carrying twins. I’m sure that there’s twin pregnancies where the woman is is going along really well and is having a fabulous pregnancy and doesn’t have those kind of worries. But, you know, if you’re alerted early, you know, say at twenty five weeks or something, there’s an issue and you’re just praying, hoping to get your babies to a point where, you know, they’re bigger and stronger to be delivered. 

Patrick [00:23:22] Yeah, that’s right. And look, a lot of twin pregnancy, especially DCDA. ones, go really great. And those, you know, we’re more than happy than us when we see those women go, fantastic, you’re going brilliantly. See you next time, clinic. Yeah. And, you know, this is a normal part of nature, but facts speak for themselves that the outcomes aren’t as good. So that’s what we’re trying to get them as good. 

Brigid [00:23:41] You know, I recently just went to a friend’s farm and she’s got so many sheep and they actually breed ewes for twins, you know. So there’s a whole paddock of sheep that have twins. And they just I was watching one have it and it was just like plop plop twins. Yep. Yep. 

Patrick [00:23:59] So that brings us to deliver it weirdly. 

Patrick [00:24:03] Not not as straightforward. So, you know, sometimes if I’m looking after a woman with twins, they’ll say, ah, so I should have the babies by caesarean section. And the answer is maybe. There are certainly some reasons why you might wanna have those babies by caesarean section and there might be some obstetric or medical reasons. So it’s easy to flip it on its head and say who is suitable for vaginal birth. Mm hmm. Okay. And when I’m going through this with people, the number one thing is you have to want it. 

Patrick [00:24:33] The woman has to want it. And these days in Australia, if you want to have your twins by caesarean section because you feel that’s the safest for you or what you actually want, then these days in that situation, we would say, fine and set that up. But of course, there are some people who want to have the twins vaginally if it’s safe to do so. So what makes it safe to do so? Well, the babies have to have reached a certain age, you know, gestational age where it’s safe to have a vaginal birth. 

Brigid [00:25:00] Where the babies will cope with a vaginal birth. 

Patrick [00:25:02] Exactly. First, you know, vaginal birth processes gives babies a good squeeze on the way out. And they have to be sort of big enough and strong enough to expect to cope well with that. Then the next thing is they need to be of a good size for their gestational age again, so they’ll cope with vaginal birth and they need to be about the same size as each other. We don’t want to have one slip out through a eight centimeter dilated cervix because it’s small. And then. Wait three hours for the big one. Yeah. Yeah. The distance between the two babies being born is important. 

Patrick [00:25:35] And then lastly, the presenting twin, the one that’s coming out first really needs to be head to head first. You couldn’t do a breach first. No. That would be yeah. Probably more unacceptably risky. Yeah. So if you meet all those criteria, then it’s reasonable, very reasonable to have the babies vaginally. And a lot of people want that. And it can be done very safely. But it’s not a very, very straightforward process, however. Yeah. So again, what we’re trying to do is get the outcomes for birth to be as good for twins as they are for singletons. So that involves a fair bit of interfering in the in the vaginal birth process, especially if it’s a woman’s first baby. 

Brigid [00:26:19] What are we talking now? 

Patrick [00:26:20] Well, that’s the thing that involves a fair bit of counseling, because historically before a lot of the modern obstetric advances, the problem was for the second twin. With the first baby’s if it was head first tended to dilate up nicely progress normally, just like you having one baby. The woman starts pushing, pushes the first baby out and that baby’s fine. Historically, the problems were chiefly with the second twin, where that twin was not in a good position to come out. 

Brigid [00:26:51] Like sideways, because all of a sudden it’s got all this room. 

Patrick [00:26:53] It must just go really well. I can do that. Yeah. 

Patrick [00:26:56] With all the extra room created by the flatmate moving out, they can get into a difficult to deliver position like like sideways or back down. And that’s hard. And so what we try to do is set up a situation whereby we can have a first baby come out in the usual way, and then if the second baby doesn’t come out straight away, we can do some things to help that baby come out. And so basically, the way this is done is that if you’re laboring with the intent of having vaginal birth of twins, we’d like everyone to have an epidural, not just for pain relief or anything else, but just so we can interfere if we need to. And there’s different methods. But I think the ideal way to manage this is to very carefully watch the progress and monitor the two twins, each with their own fetal heart rate. Yeah, well, and then one dilates up, pushes the first baby out. Fantastic pediatrician has to look at that baby and everyting is good. And then we have a look and see what’s going on with that second twin. And if the second twin is trying to come down head first and the head is just up there, at the dilated cervix, then we might just be able to reach in, break the waters of the second twin. Yeah. Turn up the drip a little bit to get the contractions back on the boil because they’ll often go off the boil after the first baby comes out. And that baby comes out head first and everybody’s happy. Yeah. But if when we reach in and we find that that second baby’s in a very difficult or dangerous position, then the best thing to do is to reach in, grab that baby by the feet and pull the feet down. And have that baby as a breech. And that’s called a breech extraction. 

Brigid [00:28:34] Back to the sheep analogy here. 

Patrick [00:28:35] Well, that’s what the epidural is for. Okay. Because you don’t you can only do that with a block. So these are part of the vaginal birth of the twins. And I always think that this is something someone should know before before undertaking such a thing. 

Brigid [00:28:48] I could imagine. I mean that if you didn’t know that beforehand, I would be totally shocked. 

Patrick [00:28:53] Oh, absolutely. Yes. So this is the counseling process to make sure that people know what they’re getting in for. Yes. The good news is that, you know, if we do it that way, we do it carefully. Then then the results are great. And if someone wants to have their babies vaginally. Fantastic. 

Patrick [00:29:08] But they’ll be looking at intervention on that sort of level. Yes. And they have to they have to stack up that way, wiegh up that versus cesarean section. It’s less likely to be a walk in the park. Vaginal birth versus caesarean section. Yes. 

Brigid [00:29:23] And are there complications in a caesarean birth for twins? 

Patrick [00:29:28] Look, there’s there’s always possible complications from any operation, caesarean sections is an operation. But the fact that it’s twins is neither here nor there. It’s really it’s really the risks related to having a caesar. 

Brigid [00:29:40] Yeah. Which we covered in, I think that episode 18 and 19. So modern technique. It’s low. Yes. Yes. 

Patrick [00:29:48] So I always think that when you compare Caesar versus a complex vaginal birth, if someone wants a caesar I don’t blame them for that. Yes. But if people saying I’ve had a vaginal birth before or I haven’t, but I’m really keen on having these babies vaginally. That’s also perfectly reasonable, in my opinion, with an appropriate plan for safety. 

Brigid [00:30:09] Yes. Yes. So we’re looking at the size of the baby to begin with, you know, making sure that they’re going to cope with the process of contractions. And then we’re looking at, you know, the positioning of of the second twin. 

Patrick [00:30:21] You watch closely and have a plan for the safe delivery of the second twin. 

Brigid [00:30:25] Can I just ask how do they monitor each baby in utero independently? 

Patrick [00:30:30] Yeah, it’s tricky. The midwife is very good at this. You need to have, you know, those some. You know, with a CTG, you will have one strap around the time to measure contractions. And another strap to measure fetal heartbeat and then with twins you have a third one that measures the heartbeat of the other baby. Yeah, right. And then on and it prints it out on the piece of paper. And twin one will be the first line and then for twin to the machine will automatically at 20 beats per minute to twin two so that the lines are separated on the piece of paper. Otherwise the lines are going to be on top of each other and it wouldn’t be how to interpret them. So if it looks like one twin is going too fast, I always trick the medical students with this. So why arent I you about that? That second twin having a heart rate that’s too too fast. But the answer is the machines just added 20 for convenience. 

Brigid [00:31:14] I’m thinking, oh, I don’t know the answer to that. I would have failed

Patrick [00:31:18] You don’t have to but they do!

Brigid [00:31:21] I’m gonna throw it in there. But is there ever triplet vaginal births? 

Patrick [00:31:25] Over the history of the world? Many. Yes. In modern obstetrics? No. Yes. But the risks are not not worth it. Yes. If you stack up the relatively moderate, controllable risks of a caesarean section vs. the enormous complexity of her vaginal birth of the triplets. Then it would come out in favor of a Caesar every time. Yep. And in my view, with twins, it’s about equal. Mm hmm. Yeah. 

Brigid [00:31:50] All right. So we’ve had the babies and, you know, they may have come early. It’s reasonable to expect some women have to stay in order. You know, the babies are staying in. The woman has to stay in for a little bit. But it’s also reasonable to think that maybe she’s going. The mother’s going home before the twins or one of the twins. 

Patrick [00:32:09] Yeah, that can be it. That can be a thing which is kind of sad, sad day. Yeah. But a lot of hospitals have got a facility for the mum to move off the ward after three or four days into some sort of accommodation or you know, as with a lot of our patients here in Ballarat, they live nearby anyway. Yeah. And can spend all day, every day in the nursery with the babies. But go home to sleep. Yeah. And how long the babies need to stay in the nursery. It all depends what’s what’s gone on. How early did they come. Have they developed any new complications. Yeah. Yeah. But it’s not rare for stays of many weeks or month or more. And you know the very earliest babies, maybe three months. So the sort of things that that might need to go in the nose in the nursery would be those lights that treat jaundice, respiratory support and feeding issues. Mm hmm. Yeah. 

Brigid [00:33:00] So that as well as just the fact that there’s two babies, these these twin moms are going to have to have a lot of support aren’t they. Absolutely. So what do you think the best sort of support for these mums are? 

Patrick [00:33:12] Yeah, it’s such a good question. I think we need to be doing as much as we can, and I think we need to probably anticipate problems. And even if people seem to be going fine, we probably need to be setting stuff up so that when the next thing happens and the next thing happens, then we’ll support it. So I think the typical things that a hospital might have, like a perinatal mental health support, if you have one baby at full term, you might only want to use that support if you’re really running into troubles. And I think if you’ve got premature twins, you should be referred to that service regardless. 

Brigid [00:33:43] Regardless. Yes. Just even touch base a base line. 

Patrick [00:33:48] So even the most mentally healthy person in the world would find premature twins in the nursery when you’ve gone home to be a really difficult situation. So there’s that. And then there are the twin groups. Yeah. And they’re fantastic. So this is these are groups that usually have a boss or a moderator, but the rest of the group is other people with twins. Yes. And awesomely, people who’ve had twins who are grown up.

Brigid [00:34:13] And still so attached. Also, you know that they can really help. 

Patrick [00:34:17] Yeah. They come back to the group when they tell people stuff from the benefit of their experience. And these these are fantastic. 

Brigid [00:34:24] And that does lead us to our very special guests. I’m gonna say we’ve been sent a recording by Mandy and Kate, and they’re the women behind two peas in a pod cast. Now, we started listening to this just on a recommendation of one of our friends, Kate and Kate gave it to us. And she’s you know, she’s our age is well and truly her kids are in their teens. She doesn’t have twins. She doesn’t have twins, but they’re hilarious. She said, you have to listen to Mandy and Kate. And so we started listening and went a this this is really gold for our listeners as well. So they’ve rocketed up the charts, too. 

Patrick [00:35:00] Yeah, they’re fantastic. So. So it’s lots of terrific stuff about parenting in general, but specifically twins, about kids with special needs. And it’s delivered with a lot of comedy and a lot of humanity. 

Brigid [00:35:14] Yes. Yeah. They’re real gigglers, it’s good. So we’re going to leave you with Mandy and Kate talking about the things that they wish they had known. Take a listen. And don’t forget, if you haven’t subscribe to our podcast, please do so. 

Patrick [00:35:29] Refer a friend. We love it when people say, oh, you know, we heard your podcast because a friend told us to listen. We just love it. So until next week, keep well, all the best. 

[00:35:41] Hi there. Kate here. Hi, it’s Mandy and we’re ‘too peas in a podcast’. We sure are, but today we’re on a different podcast. So thank you, Dr. Pat and Brigid, for inviting us. Yes. Lovely. Yeah. So we’re going to talk about some of the things that we wish we had known when we were pregnant with our twins. 

[00:35:57] Yes. And Mandy and I both have twins. If you’ve heard our podcast, you’ll know all that, if you haven’t, great. You can scoot over and have a listen. 

[00:36:03]  I have fraternal girls

and I have identical boys and we had them premature and all that sort of stuff. So take it away, Kate, with our number one tip. 

[00:36:16] So our number one tip or thing that we wished we’d known is that your babies might be born preterm or. Yeah, pretty preterm. Yes. So very few twins that I know got to 38 weeks. 36 weeks, I think. Yeah. I mean, Dr. Pat will know more what is considered term for twins. But even at 36 weeks, you probably will go to special care nursery for a little bit. And so you maybe just need to try and get your head around the fact that you may not take your babies home. 

[00:36:43] Yeah. And you might you might even bring one home before the other one. Yeah. Then I remember someone telling me that and I was like, what? But I think it’s really something to kind of really pay attention to. 

[00:36:53] So that doesn’t surprise you if it does happen, because it’s still a really traumatic, grieving, painful time. But if you’ve got a few of those thoughts in your mind, maybe it’s a little bit easier. Maybe than the shock. Yeah. And then maybe briefly read up about what a NICU  is and what a special care nursery is and the difference. Yeah. And in the hospital you’re going to. And whether they have those. Yes, that’s right. And what happens if your baby’s born early, you know all of that. Like what? Where will you go at your hospital. Is there. Yeah. And ask your doctor that or nurse. Yeah. So those things. I think it was super important actually. Yeah, definitely. 

[00:37:28] Especially coming when we’ve been out the other side. Yeah. That’s right. So number two, the birth might be taken out of your hands. So in terms of thinking about what sort of birth you would want. I mean, I’m not saying it will be, but it may be. So I suppose, you know,  usually it’s a high risk pregnancy. Yes. So I suppose just trying to have an open mind about getting those babies out. However, however, you can get the best way for them. 

[00:37:57] So just say, yeah, Mandy had a vaginal birth. Yep. I had a zipper, either way that’s right. Yeah. That we our babies were born. Yes. Yes. Yeah. It’s it is scary at the time. But a few years down the track you are so glad you’ve got your baby. Yeah, definitely. Yeah. So the third thing that I wished I someone told me from the beginning of pregnancy up until I don’t know when they were two, accept every offer of help. Everything. Everything. And when someone goes, can I help you just have this little mental list or put it on your phone. Actually, yes. Could you pick up my dry cleaning? Could you pick up my child from my other child from kinder? Could you maybe drop around some soup? I know that your mum makes your, you know, biscuits we love. Those people do want to help and so accept it. Yes. Yeah. And that I’m happy if someone says this is the help I need, I like, oh, good. Right now I know that I can help them. Yeah. Yeah. Yeah. Two babies is a lot is really something. It really is. And you really got your hands full. You really do. Yeah. And I felt outnumbered. Yeah. 

[00:39:06] I remember when I had people coming and helping them when they left crying thinking I’m on my own now. You have to do all of this with these two people. Eventually you do. You will be fine. We’ll be fine. So that’s kind of good to know as well. Yeah. Yeah. You just cry a lot, but that’s okay. You know you will. So, yes, fine. And the other thing oh, the fourth thing I want to say is don’t worry about any sleep routines, particularly for those you know who you are, A type people up until the first six weeks. It does not matter how your baby goes to sleep babies, how they get to sleep, how they get back to sleep, just survive it. That’s the only job you have to do is to – survive those first six weeks. And then after that, if you’re up for some routine, that’s the  time to slowly start a bit of self settling if you want to. So I just want you to wipe any worry about sleeping and setting up bad routines for the first six weeks. Yes, if they’re on Nana let them sleep. It means you can go to the toilet. I put one on my mum, one of my mother in law and I went to bed. Did not care. No, it doesn’t matter. So Mandy knows, she is a sleep consultant. She so just knows. And so find me afterwards if you need help. Yes. Mandy hope she knows she settled a lot of Twins. I have settled a lot of twins. So it means nothing in those first couple of weeks. But she got mine to sleep, so. Yeah. So just just try and just concentrate on your feeding, establishing if breastfeeding or, you know, getting used to formula, you know,  your doing so much expressing in those six weeks, you also may have a sore fanny, I don’t know how much we can say on this. 

[00:40:43] I know we’re doing a whole podcast!  You might have a caesarean scar and you will be exhausted. So I had a hemorrhage after. All sorts of issues. So just don’t worry about that in the first six weeks. Sleep when you can. Yeah, that’s right. And day turns into night turns into day. It doesn’t  matter. Yeah. So anyway you can do it. We did it. Yep. You can do it. And we’re here for you to listen to any time you need. Yep. 

[00:41:10] We’ve got a pregnancy and first year a special care/NICU episodes. Yep. We do. If you need them. 

[00:41:16] I’m sure that you’re hearing lots on this podcast as well. Yeah. Anyway come and find us. Yeah. Thank you. Thank you for having us all. Thank you. We appreciate it. Bye bye.