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Birth Plans for Twins, Triplets or More.

Smiling parents in hospital with their newborn twins.

The average length of a pregnancy depends on how many babies you are expecting. Twins usually arrive around 37 weeks, triplets at 34 weeks, and quadruplets at 31 weeks, weighing in at an average 5.5lbs (2.49kg) for twins, 4lb (1.8kg) for triplets and 3lb (1.4kg) for quadruplets. 

Make sure you have packed your hospital bag and finished antenatal classes well in advance of these dates, as multiples are more likely to come early than most.

Though a birth plan can be helpful, please remember that labour and birth are unpredictable. You will need to be flexible and be prepared to do things differently if complications arise. 

Caesarean section 

A little over half of all twin babies in the UK arrive by caesarean section, and almost all triplets and quadruplets. 

There are lots of reasons why you and your doctor may decide a caesarean is best. Among these, it may be that the babies are lying in the breech position (feet, knees or buttocks down) or transverse position (across your uterus) making a vaginal birth difficult. Or you may have a condition such as placenta praevia, where the placenta covers the cervix. In these cases you will be booked in for a planned caesarean.

 An emergency caesarean is done when a problem occurs during labour and it is necessary to get the babies out. Again, there are many reasons why this can happen, including the babies moving into a difficult position, concerns regarding fetal well-being, high blood pressure that doesn’t respond to treatment, slow progress, or where an assisted delivery (forceps or ventouse) does not work.

Very occasionally, a first baby is born vaginally but the second becomes distressed and has to be delivered by caesarean section. This happens in less than 5 percent of twin births.

Vaginal birth 

60% of twin pregnancies result in spontaneous birth before 37 weeks. 75% of triplet pregnancies before 35 weeks.

Women with uncomplicated monochorionic (share one placenta) twin pregnancies are offered an elective birth from 36 weeks, continuing uncomplicated twin pregnancies beyond 38 weeks increases the risk of fetal death. Women who decline elective birth must be monitored very closely with weekly scans, weekly biophysical profiles and fortnightly growth scans.

It’s a good idea to write a birth plan expressing your wishes on pain relief, who will be present at the birth, positions for delivery, and whether you want zygosity testing to see if the babies are identical (the placentas will be examined and cord blood sent for analysis, for which you may have to pay), as well as anything else that’s important to you. Bear in mind that the plan will need to be flexible, taking account of how your labour goes.

Multiples are nearly always monitored during vaginal birth, even when they haven’t been induced. Your midwife will strap a thick belt with small pads and sensors onto your abdomen to assess your babies’ heartbeats and the intensity and frequency of contractions. You should still be able to move into different positions as you labour. If external monitors can’t pick up the heartbeats, the first baby will be monitored internally using a fetal scalp electrode attached to the babies’ scalp.

Mother on hospital bed reaches out to her twins sleeping in the baby bed next to her

The first stage of labour consists of uterine contractions that open the cervix. Once it is 10cm dilated, you are ready for the second stage: pushing them out. Some hospitals will automatically transfer you to an operating theatre at this point, or your doctor or midwife may think it a good idea. The number of people in the room will vary, but usually includes an obstetrician, anaesthetist, two midwives, one paediatrician for each baby, as well as students and junior staff. If you feel strongly that you don’t want lots of people present, ask for all non-essential staff to wait outside the room until they are needed.

It can take anything up to two hours to deliver the first baby. Sometimes mothers are encouraged to give birth on their backs. It’s worth discussing your options on different birth positions and hospital policy beforehand. With support from your midwives, it is possible to deliver twins safely in different positions, including standing, squatting and on all fours.

If the second stage is going on a bit or there is a risk of the babies becoming distressed, you may be advised to have an assisted delivery using forceps or ventouse (a vacuum device that attaches to the baby’s head). Both procedures involve an episiotomy (small cut to the vaginal wall) which is done under local anaesthetic if you haven’t already had an epidural.

After the first baby is born, the doctor will check the position of the second. It may be necessary to manually move the baby into a head down position. This can be done externally, but it may be necessary to pull the baby out by its feet or to turn the baby internally, which requires pain relief if you haven’t already had it.

It may only be a few minutes before the second baby is born, and it is usually less than 20 minutes. Second babies usually deliver more quickly and easily than first babies.

You should have an opportunity to cuddle your babies before the third and final stage of birth, when you expel the placenta. Waiting to deliver the placenta naturally can take up to an hour, and is not recommended with twins because the larger placentas carry a greater risk of bleeding. Your midwife will probably recommend you have an injection of a drug (Syntocinon or Syntometrine) to contract the uterus and help the placenta deliver quickly, usually within ten minutes. This means you don’t need to push and you will lose less blood.

Below Specialist Midwife for Multiples, Sandra Bosman, speaks about going into labour and when you can expect to be scanned. Log in or register for FREE with Tamba today to unlock the whole playlist and listen to her answer all your FAQs about birth, including explaining the signs of labour and further information around neo-natal care.


Pain relief in labour

You will be offered the same sorts of pain relief as a woman labouring with a singleton, including pethidine and gas and air. However, women carrying multiples are often advised to have an epidural due to the greater likelihood of their having an assisted delivery or a caesarean, or complications such as the need to turn the second baby before delivery.

It is a good idea to use antenatal appointments to talk through your options so you have time to think about what is going to suit you and your babies.

Premature labour

Twin babies asleep in Special Care Baby Unit.Multiples often arrive early, sometimes very early. In a Tamba survey, fewer than half of twin pregnancies went over 37 weeks, and only 1.5 percent of triplet pregnancies.

Reassuringly, studies show that premature multiples mature more quickly than single babies born at the same time, so multiples are often better equipped for an early start. Some need only a short stay in neonatal care.

If it seems likely your babies will be born prematurely, you may have to stay in hospital so their condition can be monitored. Medication can delay labour, while steroid injections help speed the development of their lungs. Premature labours can be very fast, and you may need an emergency caesarean. The babies will be taken to the Special Care Baby Unit (SCBU) in case they need help with feeding or breathing.

In a survey, our parents highly rated the care their babies received in the neonatal unit. Because of the help they also received there to support their babies, many felt better prepared for the challenges of caring for them at home.

It is a good idea to visit the neonatal unit during an antenatal tour of the hospital so that if your babies do need to spend time there it comes as less of a shock. You can also download our Parent’s Guide to Neonatal Care.

To read more on your choices and what happens in a multiple birth, register for free to download our Healthy Multiple Pregnancy Guide.

Follow the links to find out more about finding out you are expecting multiples, antenatal carelooking after yourselfcommon symptoms in multiple pregnancies, complications , preparing for your babies’ arrival, and work and finance.


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 Neonatal guide


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