Doulas Supporting Families With: Twins and Multiples

Around one in every 250 pregnancies are twin pregnancies, so it’s quite possible that you’ll be asked to support a family who are pregnant with two babies – or more!

As a doula supporting families pregnant with twins and multiples, what are some helpful things to know about? Sarah Hawkins, twin mum and doula, shares her top ten useful things for doulas to know about twins and more!

1. There are different types of twin pregnancy. Some multiples are called ‘monozygotic’, which means that they were one zygote that has split into two (or more). These twins and multiples are what we have come to refer to as identical. They are the same sex, and not only look identical but also share identical DNA.
   
   Other multiples are known as ‘dizygotic’. This means that each baby comes from a different egg/sperm pair. These are what we have come to call fraternal twins. They look as alike or as different as any siblings and can be of different sexes.
   
   There can be other differences, too! Sometimes, in a monozygotic (identical) twin pregnancy, the twins only have one placenta between them. This one placenta has two (with twins) or more (with other multiples) umbilical cords. These pregnancies are called Monochorionic. Monochorionic multiples usually have their own amniotic sac but in rare cases they have only one. If each baby has their own amniotic sac, they are known as diamniotic. If they share one, it’s monoamniotic. You will often see these pregnancies written as MCDA or MODI.
   
   It is important that families know what type of twins they have, because monochorionic twins face risks that dichorionic twins almost never do, so when navigating the medical system any healthcare provider must be aware and provide support with this in mind. A lot of the statistics around twin and multiple pregnancy and birth are risks associated with babies who share a placenta.

2. Parents will be given lots of information about medical conditions that twins may be at risk of. Encouraging parents to understand how their twins have developed can help them to feel more in control of their pregnancy, and to better understand the chances of certain outcomes. For instance, where babies share a placenta, conditions such as TTTS and TAPS¹ are significant enough that monitoring is likely to be strongly advised, but when they do not, these conditions are less common, although still important to know about. For instance, in MCDA twins, the rate of TTTS is 15% and TAPS is 5%². Doulas can help parents to understand that they need to ensure that information that they are given by their midwife or doctor, or what they may read elsewhere, is actually relevant to their types of twins.
   
   
3. Doulas can help parents-to-be to prepare their birth preferences. It might be helpful to consider some of the many pathways that can happen with twin and multiple births, and have “in the event of” back up birth plans. As with singletons, if your client is planning a vaginal birth, they may also wish to have a caesarean birth plan. If they’re planning a home birth, they may also want to have a hospital birth plan in case of a transfer.
4. Women and birthing people have control over the choices in their births, whether they are birthing one, two or more babies. However, their birth choices can easily be derailed when birthing twins and multiples. If something needs to be carried out urgently, your client still has autonomy to make their own decisions. For me, it is crucial that twin and multiple parents don’t become passive participants and that their autonomy is not undermined.
5. It is common for twins and multiples to be born early. When I work with pregnant women and people expecting multiples I suggest that they request to visit the neonatal intensive care unit (NICU). It’s helpful to find out if their babies can share an incubator or cot for example. I also suggest writing a NICU plan which includes the clients’ wants for their babies. Something I requested on my plan was that a sign be placed on or near the incubator asking each medic/health professional to introduce themselves to me and to include me in discussions about my babies’ care, using language I could understand. I also requested that they did not speak to me about SIDS or warn me against co-sleeping. I had done my own research about it. Your clients need the fact that they are the parents to be reinforced, as having babies in the NICU can leave people feeling helpless. They are still many options available to them, such as using reusable nappies or having a lotus birth within NICU for example.  They can choose the formula if they want to bottle feed, or if babies need top ups, and they can breastfeed if they want! Your clients may want to discuss Kangaroo care and the benefits of this. Listen to this invaluable podcast on skin to skin and Kangaroo Care from The Midwives’ Cauldron³. Remember to remind your clients that their babies are their babies.
6. If the babies are born very prematurely, and need immediate intensive care, the golden hour may not be possible. However, when the babies are well enough to be held, as much skin to skin contact as possible is valuable for them, and for your clients (again, listen to The Midwives’ Cauldron podcast!) Doulas can talk to their twin baby clients about having a fourth trimester when their babies are home. This isn’t to say that they can’t hold them and bond during their time in NICU (if they have NICU time), but from my personal experience the silence and calm of holding my babies at home is something I remember being very sacred, a time of emotional healing, skin to skin, feeding on demand etc. We took to bed when we got our babies home and we had no visitors and didn’t do much else for about two weeks. It was bliss.
   
   You don’t need to know the medical information about twins! That’s not the doula’s role. However, doulas can help parents to understand that research on twin and multiple pregnancies is limited. While this is improving, research into twin births is ethically challenging. There are various twin registers that are compiling data now, which is promising. Doulas can support their clients to do their own research, if they wish. Some ideas of topics to look at might include optimum cord clamping in monochorionic twins, and the hypothesised risks, and the evidence for and against induction of twins and multiples. The evidence around spontaneous twin and multiples birth at term is limited, as so many twins arrive early because of premature spontaneous labour or induction.
7. Breastfeeding  is something that your client may need to feel supported to do especially if babies are born prematurely. You may wish to signpost to local trained breastfeeding counsellors or lactation consultants. Parents may wish to buy expensive twins breastfeeding pillows, but they really aren’t necessary! This is the same for much of the twin paraphernalia!
8. Babywearing. YouTube has lots of videos about how to wrap and wear twins. If you are offering support postnatally, it might be helpful to have some ideas and signposts for good twin carrying videos. You might want to find out if there’s a Sling Library near you which has experience of supporting twins or multiples.

9. Be aware that MBRRACE Perinatal Confidential Enquiry – Stillbirths and neonatal deaths in twin pregnancies report found that 1 in 2 baby deaths, the care was poor. If care had been better it may have prevented the baby from dying.⁴ As doulas, our role in supporting families to advocate for themselves is therefore invaluable, especially if they need encouragement to speak up if they are worried about aspects of their care.

10. Lastly and most importantly, encourage your clients to ask for help if they need it! Raising multiples can sometimes feel very overwhelming. Yes, we are blessed, but we are also very, very tired!!

References:

1. TAPS: https://www.tapssupport.com/what-is-taps-in-twins/
2. TAPS frequency: https://twinstrust.org/let-us-help/pregnancy-and-birth/finding-out/complications/taps.html and TTTS frequency: https://twinstrust.org/let-us-help/pregnancy-and-birth/finding-out/complications/ttts.html
3. The importance of skin to skin contact – The Midwives’ Cauldron: https://podcasts.apple.com/au/podcast/the-things-they-dont-tell-you-about-skin-to-skin-contact/id1523178579?i=1000553524222
4. MBRRACE Perinatal Confidential Enquiry: https://www.npeu.ox.ac.uk/mbrrace-uk

Twin and multiples signposts for doulas:

ICOMBO – International Council of Multiple Birth Organisations: https://icombo.org/

Twins Trust – supporting families through twin and other multiple births: https://twinstrust.org/

The Multiple Births Foundation – educating health professionals about twins and higher multiples: https://www.multiplebirths.org.uk/

Twins Trust and St George’s collaboration – helping to provide medical support to women during their multiples pregnancy: https://www.stgeorges.nhs.uk/service/twin-trust-centre-of-research-and-clinical-excellence/

Sarah Hawkins is a mum of 4 including identical twins. Sarah is a Doula and birth activist who makes it her life’s work to raise awareness for twins and those pregnant and birthing twins and multiples. Sarah sees the important role doulas and other birth workers can play in a struggling maternity system.