Welcome to

Twins Trust Antenatal Course

with
Sheikha Thomas RM
©2019
 Congratulations
The best thing about having twins and triplets
The fun they bring
They always have each to your life and the
other there -starting The best thing is being gratitude for being
It’s so special, I love cuddling
nursery, starting school, able to watch a so lucky
them at the same
holiday clubs...it’s so beautiful friendship
time...they always wriggle
comforting knowing they develop...they
close to each other even
have each other to get wouldn’t be without
when we’ve put them apart.
them through the each other
Melts my heart every time
milestones

Watching that wee bond

between them grow and
Double the cuddles
Cuddles, kisses, friendship and grow is so special...don’t
and seeing their wee
watching 2 help each other out try to mess with their
personalities shine
to solve problems and twin!
through
challenges
 Topics Covered
• Guide to multiple pregnancy and antenatal care

Online session part 1

• Packing your bag for hospital
• When to phone the hospital
• Labour and Birth
o Signs of early labour
o Induction of labour
o labour 1st, 2nd 3rd stage
o Assisted delivery
o Elective/Emergency caesarean section
• Pain relief
• Recovery following twin pregnancy

Online session Part 2

• Postnatal ward
• Premature babies, - NICU and SCBU
• At home with your babies,
• Breastfeeding and formula feeding.
• sleeping, bathing, getting out
• Questions
 NICE & RCOG Guidelines
• www.nice.org.uk National Institute for Clinical Excellence
• Evidenced based guidelines
• National guidelines of care, local hospital guidelines should be
based on NICE guidelines.
• Excellent resource for parents and parents to be
• www.rcog.org.uk Royal College of Obstetricians and Gynaecologists
• Publish guidelines that set standards for excellent clinical care
• Develop education and training for health professionals
Types of Twins; Monochorionic and Dichorionic
 How common are multiples?

• 12,000 twin births in UK each year

• 200 triplet births each year
• Handful of quads
• In 2011 Nice guidelines stated multiple
births accounted for 3% of births
 Antenatal Care – Consultant led
• First Appointment and booking scan 11-14 weeks
• Consultant clinic
Monochorionic min 9 appointments with scans: 16,18,20,22,24,28,32,34
Dichorionic min 8 appointments:16, 20,24,28,32, 34, 36 (without scans at
16,34)
• Scan frequency varies by hospital:
– First scan usually identifies chorionicity
– 18-22w first anomaly scan (checks development, growth and placenta position)
– NICE guidelines (scans):
• Dichorionic 4 weekly from 20w
• Monochorionic fortnightly from 16w
– 34w twin 1 position determines delivery methods available
• More medically managed, even more so with monochorionic/triplet
 Antenatal appointment
• Scans – growth of babies
• Blood flow through cord

• Midwife appointment
 Blood Pressure, Urinalysis, swelling, headaches
 Maternal wellbeing
 Assess fetal movements
 Shouldn’t measure bump, individual preference for listening to
babies’ heartbeats.
 Iron levels checked at 20-24weeks and 28weeks
 Anti D given at 28 weeks if rhesus negative

• Consultant- review scans, make plans for care, follow ups and
delivery
 What may happen during your pregnancy
• Nausea (high HGC hormone)
• Vomiting (not just morning)
• Hyperemesis gravidarum
• Piles/Haemorrhoids
• Varicose veins
• Heart burn and indigestion
• Pain (low back, pelvic girdle)
• Anxiety
• Swollen feet
• Anaemia (FBC Booking, 20-24w and 28w)
• Hypertension
• Pre-eclampsia
• Growth restriction
• Obstetric Cholestasis
• TTTS
 Aspirin advice (NICE guideline 129):
Advise women with twin and triplet pregnancies that they should take 75mg of aspirin
daily from 12w until the birth of the babies if they have 1 or more of the following risk
factors for hypertension:

– First pregnancy
– Age 40 years or older
– Pregnancy interval of more than 10 years
– BMI of 35kg/m2 or more at first visit
– Family history of pre-eclampsia
 Timing and mode of birth (uncomplicated)
• 60% twin pregnancies spontaneous birth <37 weeks
• 75% triplet pregnancies spontaneous birth <35 weeks
• Monochorionic elective birth from 36 weeks, steroids will be given
prior to delivery
• Monochorionic monoamniotic elective c/s prior to 34 weeks
• Dichorionic twin pregnancies elective birth at 37 weeks
• Twin 1 cephalic (head down) suitable for vaginal birth
• Triplet pregnancies elective c/s from 35weeks, sterioids given prior to
delivery.
 Covid 19 –How it affects your birth
• 1 Birth partner when in labour only, no partner or visitors at
antenatal appointments, scans, antenatal ward, postnatal
ward
• Partner cannot attend birth if covid-19 symptoms
• Staff will be wearing mask and gloves when caring for you and
your babies.
• Please attend your scheduled appointments
• Visit RCOG.org.uk for current advice for pregnant women and
maternity units
• Guidelines changing daily so please check with your own
hospital for current advice
• You might not see our face but please know we will still be
smiling and caring for you
 •
What to take to hospital
Ear plugs if on ward to be induced
• Comfortable clothes, consider skin to skin access If you are travelling home by car your
• Music babies will need a properly fitted car
• Snacks and drinks (partners) seat……….don’t bring car seats to the
• Toiletries hospital until the babies are being
• Phone numbers discharged
• Camera
• BIRTH PLAN

After the birth:

• Clothes/nightwear
• Underwear
• Maternity bra
• Sanitary towels
• Breast pads

For the babies:

• Sleep suits (Babygro) Feeding pillow
• Vests
• Mitts
• cardigan
• Hat, and blanket for home
• Nappies and cotton wool
 When to call triage
• 24/7 service
• Any signs of preterm labour (<37 weeks)
• Rupture of membranes (waters break)
• Reduction in baby(ies) movements
• Headaches, visual disturbances, flashy lights
• Bleeding
• Cramping
• Any concerns
• YOU ARE NEVER WASTING OUR TIME, HAPPY TO SEE YOU
 Signs of early labour
• Show (mucus plug)

• Rupture of membranes (waters breaking)

• Uterine Activity (contractions)

 Start as irregular period like cramps becoming stronger
and more often
 Backache
 A quick guide to labour

• Hormone oxytocin stimulates

contractions
•Smooth muscle around womb
shorten (contract)
•Cervix softens, shortens, and
begins to open from closed to
10cm dilated
•Baby descends into pelvis
•Urge to push once fully dilated
 Induction of labour
• Cervical priming – cooks balloon, vaginal
pessary, gel
• Artificial rupture of membranes (waters
broken)
• Syntocinon infusion (The drip!)

• Continuous monitoring of babies’

heartbeats during established labour
even if not induced
 Stages of labour
1st stage- latent phase - up to 4cm dilated
irregular weak contractions
established - 4cm to fully dilated (10cm)
regular, moderate/strong contractions
2nd stage from fully dilated until birth of second twin.
may be given time for descent of twin 1 before active
pushing.
 Stages of labour continued
• Following birth of twin 1, doctor will carry out scan to
determine how twin 2 is lying.
• possible external turning and stabilising lie of twin 2.
• Allow for descent of twin 2
• Artificial rupture of membranes (if applicable) possible
need for syntocinon drip to stimulate contractions
• Usually no more than 30mins between births of twin 1
and twin 2
• Episiotomy – small cut made to hasten birth
• Forceps, ventouse or kiwi – to quicken delivery in event
of fetal distress or maternal exhaustion
 3 stage
rd

Twin 1 born, cord clamped and cut after

60secs (unless monochorionic).
Twin 2 born,
Injection to minimise blood loss
Twin 2 cord clamped and cut following
60secs
• Delivery of the placenta(s)
• Birth partner can cut cords if wishes
 Who’s in the room!
• Birth partners –Usually 2 allowed (1 during covid19)
• Midwife 1 to 1 care in labour

• Birth- senior doctor, at least 2 midwives, junior doctor.

• Anaesthetist will be nearby but not neccesarily in room
• Neonatal team x 2 ready at resusitaires
 Pain relief
• Aromatherapy Tens Machine

• TENS

• Entonox (gas and air)

• Pethidine, Diamorphine, Morphine

• Epidural
 Entonox
• 50% oxygen and 50% nitrous oxide gas.
• Not complete pain relief but will help take edge off and make contractions
more manageable.
• Easy to use and woman can control it.
• You breathe in the gas and air through a mask or mouthpiece, which you hold
yourself. The gas takes about 15-20 seconds to work, so you breathe it in just
as a contraction begins. It works best if you take slow, deep breaths.
• Does not pass to baby, quickly eliminated when not in use
• Side effects -Nausea, light headedness, spaced out – if this happens, you can
stop using it
 Opiates –morphine, pethidine, diamorphine
• Injection into thigh or buttock to relieve pain. It can also help
you to relax, an anti sickness injection given alongside.
• It takes about 20 minutes to work. The effects last between
two and four hours, so wouldn't be recommended if you're
getting close to the pushing (second) stage of labour.
• Side effects – nausea, vomitting, confusion
• Does pass to baby, can make baby sleepy and can affect
breathing at birth. May also affect feeding.
 Epidural
• A needle is used (with local anaesthetic) to insert a fine plastic tube between the bones in
your back. The anaesthetic infusion gives continuous pain relief. However, you can press a
button to give an extra dose if needed.
• It is important that you sit still while the epidural is being inserted and let the anaesthetist
know if you are having a contraction. It usually takes 20 minutes to set up and 20 minutes
to work.
• Most women can have an epidural, however if you have had a previous operation on your
back or problems with blood clotting it may not suitable for you. Please discuss this with
your anaesthetist.
• Side effects - Can cause a drop in blood pressure – IV access, fluids
• Unable to walk about, will need a urinary catheter passed (4hrly)
• Can walk approx 2-4hours after birth
Benefits
• Provides the most complete method of pain relief.
• Does not make you drowsy, but as they offer good pain relief
women are often able to sleep after having one.
• Minimal amounts of the drugs used pass to your unborn baby.
• Epidurals can be ‘topped up’ for procedures in the operating
theatre, for example caesarean section with no extra injections.
Side effects and risks
• Doesn’t increase chance of caesarean but does increase chance
of instrumental delivery.
 Caesarean Section
• In theatre, can have birth partner present
• Usually can play music, elective section very relaxed
• Usually under spinal unless medically
contraindicated.
• Spinal – injection into lower back given by
anaesthetist
• Catheter sited, lower abdomen shaved
• Lots of noises and machines, bright lights
• Senior doctor, junior doctor, anaesthetist, midwife x
2, scrub nurse, 2 theatre assistants, neonatal team.
• 1 to 1.5hrs until ready for recovery area –skin to skin,
feed
 Recovery from a caesarean section
• Approx 6 hours until able to walk following spinal
• Urinary catheter removed following 12-24 hours
• Generally hospital stay 2 to 3 days (could be longer if babies need
extra care, issues with feeding or small weights)
• Will be difficult to lift babies in and out of crib in hospital that first
day – staff are there to help you & assist with baby cares.
• 6 weeks recovery time, don’t lift anything heavier than your babies,
no driving, hoovering, turning or twisting until you feel able.
 Recovery following multiple pregnancy
• Separation of abdominal muscles (diastasis recti) –higher instances with
mulitple pregnancy as muscles have been stretched more.
- Signs include “doming,” loss of core strength, lower back pain,
- Simple core strenthening exercises can resolve issue – can get a physio referral
• Pelvic floor – even if not vaginal delivery there has been greater strain on
pelvic floor.
- Heavy feeling in vagina or urinary incontinenece
- Can speak with health visitor or GP if concerns, especially if no improvement 6
weeks post birth and they can make appropriate referrals. Usually can be
treated with pelvic floor exercises
• www.nhs.uk/conditions/pregnancy-and-baby/your-body-after-childbirth/
 You and your babies -Skin to skin
• Regulates heart rate and breathing
• Maintains baby’s body temperature
• Exposes babies to natural flora on skin helps
develop immune system
• Bonding
• Increases oxytocin levels (milk releasing hormone)
and prolactin levels (milk producing hormone)
• Stimulates rooting
• Not just for breastfeeding
• Dads, grannies, aunties can do it
 The postnatal ward
• Midwives, nursery nurses, support workers there to care for you and support you with caring
for your babies.
• You may find you need to stay in for a few extra days to feel confident with 2 babies, it’s ok to
ask for help.
• Breast feeding support –bring your feeding pillow to help tandem feeding
• Formula feeding- hospital will supply formula and bottles
• Most units no visiting with current Covid 19, this also includes birth partner.
• Mum and babies will not be separated (unless babies are in NNU but mum can visit anytime).
Bedside crib for babies.
• Also some units are allowing dads to visit NNU –please check locally.
• Babies will have newborn examination, weight and length at birth. Prior to discharge home will
have full paediatric examination and hearing test.
• If babies are <37weeks gestation, <2.5kg or <2nd centile will need to stay 72hours for weight
check.
 NICU and SCBU
• Neonatal Intensive Care Unit
• Special Care Baby Unit
• Can be a scary environment
with lots of alarms
• Important not to compare
your babies to others
• May be ready to come home
at different times
 The preterm infant
• Immature system
• Needs extra help from birth until physically
mature (around due date).
• Help with breathing, oxygen or ventilation to
help lungs
• Maintaining temperature
• Maintaining blood sugars
• Feeding (latch technique generally inefficient
until approx 35weeks. Will require NG tube
• Tire easily
• More likely to become jaundiced -phototherapy
 The Neonatal Unit
• Bright lights
• Lots of monitors, beeps and alarms
• Lots of staff
• Hand hygiene imperative
• Nurses carrying out regular observations,
strict feeding schedule ml/kilo/day
• Regular blood tests –jaundice, blood sugars,
infection screens
• Ask questions, parents can be present
anytime (except handover)
 When you’re home
• Feeding
• Sleeping
• Bathing
• Getting out and about

• Be aware risk of passive smoking

• Friends and family support
• Routines or wing it –up to you
• One up both up system
• Kitten hold
 Breast feeding –Yes you can breastfeed twins
• Supply and Demand, the more you feed or express the more you will produce.
• If babies being tube fed in NNU you will need to express 8 to 10 times in 24hours (does not have to be evenly spaced),
including a session between 2am and 5am as prolactin levels highest.
• If babies preterm and even if you choose to formula feed at home, any breastmilk you can express for them is very
beneficial.
• Try and do as much skin to skin in the early days to help establish feeding –encourages babies to look for food and latch
and also helps you to produce milk.
• 1st few days colostrum, yellow or clear, sticky consistency (production starts in pregnancy)
• Milk changes to watery and white approx days 3/4. Breasts will feel full and tender.
• Suckling at breast stimulates ‘let down’ milk release, can feel like stinging, pins and needles.
Getting enough
• Feed at least 8 times in 24 hours if babies <37weeks. Aim for 3hourly feeds starting from
beginning of one feed to begining of next feed.
• From day 4, 4-6 wet nappies in 24 hours with mustard coloured loose stools
• Generally content and takes self off the breast
• Storage
– 5 days fridge
– 6 months freezer
 Feeding cues
(breast or bottle)

Look for feeding cues.

•Eyes opening and looking around
•Licking lips
•get restless
•suck their fist or fingers
•make murmuring/lip smacking sounds
•turn their head and open their mouth
(rooting)
•Crying is the final cue, try get to them before
 Positioning and Attachment – Key to successful feeding
Positioning
• Head and body in straight line
• Nose to nipple
• Baby’s body in close- ‘tummy to mummy’
• Comfortable and sustainable for mummy

Signs of Good Attachment

• Rounded cheeks –good mouthful of breast,
not sucking on end of nipple
• Bottom lip curled out
• Chin in close to breast
• More areola seen above top lip than below
bottom lip
Positioning and attachment
Useful resources

www.kellymom.com
www.unicef.org
Twins trust webinars
Breastfeeding twins and triplets
facebook group.
Harmony Duo
Peanut and Piglet

Twin Z
 Formula feeding
•Equipment; bottles and teats, steriliser (Electric, Microwave, Cold Water).
•Always make up a feed when you need it not in advance. Water needs to be at least 70c to kill bacteria. A full
flask of boiled water overnight will be suitable
•Make sure your bottles and teats are sterilised.
•Always follow instructions on formula packaging
•Hold your baby fairly upright for bottle feeds or lying supported on their side. Support their head so they can
breathe and swallow comfortably. Brush the teat against your baby's lips and, when your they open their
mouth wide, let them draw in the teat.
•Always give your baby plenty of time to feed.
•keep the teat full of milk, otherwise your baby will take in air.
•Your baby may need short breaks during the feed and may need to burp sometimes. When your baby does
not want any more feed, hold them upright and gently rub or pat their back to bring up any wind. This may
only be a small amount.
•Feed on demand, don’t force them to finish a bottle
•Never leave a baby alone to feed with a propped-up bottle as they may choke on the milk.
 Your babies, your choice
Many options with feeding multiples

• Exclusively breastfeed (or expressed milk bottles too)

• Formula feed
• Combi feed (breastfeeding and formula feeding)
• Mixed bottle feeding (expressed milk some feeds, formula next feeds)
• Remember –difficult to establish supply at first so if wishing to give babies breastmilk only then don’t
rush to give formula or if for whatever reason babies requiring formula supplementation then express
express express to up your supply.
• Do not be disheartened if babies need formula in the first few days and you wish to exclusively
breastfeed, with determination and expressing/feeding your supply will increase.
• AND MOST IMPORTANTLY IT’S YOUR CHOICE HOW YOU FEED YOUR BABIES DON’T FEEL PRESSURE
FROM OTHERS.
 Sleeping
www.lullabytrust.org

• Not safe to share a moses basket or baby box

• Always put baby on back to sleep, no loose blankets. Tuck blankets under
arms. Sleeping bags are ideal but can only be used over a certain weight.
• No cot bumpers. An empty cot is a safe cot
• Flat firm waterproof mattress
• No sleepy heads, memory foam nests
• Can share a cot bed or bedside crib until rolling.
• Make sure not close enough to obstruct each other’s breathing.
• 1st 6 months should sleep in same room as you, this includes naps
 Sleeping arrangements

•1 cot or 2 cots
•2 seperate moses baskets
•Bed sharing – check unicef guidelines and
lullaby trust –not suitable for preterm
infants, formula fed infants, low birth weight
babies.
•Think about space available for cribs/cots
and cost of replacing when outgrown
•Safe space to sleep upstairs and in living
area
 Bathing
• One or both parents doing baths?
• Other siblings around at bath time?
• Bathing twins together or separately?
• Baby bath, sink or bath support in bath
• Have towels, clean clothes, nappies
ready first
• No soap, just plain water
• Warm room, no draughts
• Water 37 degrees
 Getting Out
• It will get easier, don’t put too much pressure on
yourself
• Prams –tandem or side by side
• Siblings, buggy board
• Car seats as part of travel system
• Think about your day to day life, try to make things
easier for yourself. E.g If you are nipping in and out of
car a lot it will be easier if you have car seats that clip in
and out and onto pram.
• No snowsuits or bulky coats in car seat
• 2 hours max in car seat
 Advice from Multiple parents
• Feed babies at same time, they are now on same schedule and wake up at the same
time.
• Name anklets for identical twins
• Remember you have 2 babies, trying to perform like you have a singleton isn’t always
possible especially in the early days. Don’t be hard on yourself if you don’t manage.
• Trust your instincts, you know best. Take other people’s advice with a pinch of salt.
• Slings –baby box sling
• Twin feeding pillow, baby bjorn bouncer chairs
• Always have changing bag ready and stocked
• Prepare the night before if going out for the day
• Get along to twins’ group
 Classes and Groups
• Practical parenting for parenthood Twins Trust –for details
book via HelenPeck@twinstrust.org
• Forth Valley Twins group
• Falkirk Twins Group
• East Kilbride Twins Groups
• Edinburgh and Lothians Twins Group
• Grampian Twins Club
• Check out local sling groups