Nothing is routine in a multiples' pregnancy, and the surprises will likely keep coming through labor and delivery as well. Close communication with both your health care provider and a neonatalogist (a physician who specializes in newborn and preemie care) about the possible scenarios you and your children face at birth will leave you better equipped to make informed decisions.

Cesarean Versus Vaginal Delivery

About half of all twins are born via cesarean section, and the number goes up considerably for triplets or more. Because of the risk of umbilical cord entanglement, multiples that share an amniotic sac are usually delivered by C-section at or before week 34.

Whether other multiples are delivered vaginally or not will depend on how they are positioned in the womb. If the first baby is breech (feet or buttocks first), your provider will probably prefer a C-section. If at least the first baby is vertex (head down), a vaginal delivery may be performed. Women who feel strongly about having a vaginal delivery of their multiples should speak with their provider early on in the pregnancy about the issue.

A quick ultrasound in the labor and delivery room will reveal your babies' positions. In some cases when the first baby is born but the second is breech, external cephalic version may be attempted to turn a stubborn twin. (For more on version, see Chapter 16.) The fetal heart rate in the second twin will be monitored during the procedure.

Premature Birth

Babies who are born prematurely are at risk for respiratory distress syndrome (RDS) due to lung immaturity. According to the American Lung Association, an estimated 60 percent of preemies born before week 28 experience RDS. After week 28 but before week 34 of gestation, that figure drops to 30 percent.

Preemies who develop RDS are also at risk for a lung disease called bronchopulmonary dysplasia (BPD). BPD occurs in up to 30 percent of infants who survive RDS and is triggered by trauma to the immature lungs from infection, respiratory therapy, or the stress of oxygen itself. Symptoms include wheezing, rapid breathing, cough, and straining of abdominal and neck muscles.

Treatment for RDS takes several forms, depending on the severity of the condition. Animal-derived or synthetic surfactants may be administered shortly after birth to hasten lung maturation. An oxygen tube that fits under and into the nostrils can provide continuous positive airway pressure (CPAP) to force the alveoli (air sacs) of the lungs open. A newborn might also require intubation and breathing assistance with a mechanical respirator until lung function can develop further.

Postpartum Hemorrhage

Women who have delivered multiples are at an increased risk for postpartum hemorrhage (or excessive bleeding) after delivery. Some of the tocolyctic medications (for example, magnesium sulfate) can also increase the risk of bleeding by inhibiting uterine muscle function. Once the placenta is delivered, the uterus must continue to contract in order to tamp down and seal off placental blood vessels. In a womb that is overstretched from multiples, the myometrium — the smooth muscle layer responsible for contractions — may not function efficiently. Postpartum hemorrhage can be the result.

If postpartum hemorrhage does occur, the uterus will be double-checked for any remaining pieces of the placenta (another cause of postpartum bleeding) and massaged to control the bleeding. Oxytocin or prostaglandin may also be administered to stimulate contractions.

When Babies Are in NICU

You've waited and waited to hold your babies in your arms, and now they're in the neonatal intensive care unit (NICU), behind glass and bound up by wires and tubes. Be assured that even though they may be dependent on machines, your presence and parental touch is critical in speeding their recovery and eventual discharge.

“Kangaroo care,” skin-to-skin parental to preemie contact, has been shown to have a positive impact on parent-child bonding and to improve the motor and cognitive development of premature babies. But early on, some very premature babies may not yet be ready for the sensory overload of touching. Be assured that they will want and need it as time goes on, and NICU staff and neonatal physical therapists can instruct you on nurturing forms of touch with your babies.

Never forget that your presence is essential to making this scary, sterile world a loving, temporary home for your babies. Holding their tiny hands, getting involved with their care and feeding, and learning how to care for any unique medical needs are all critical tasks right now. The skilled nursing staff of the NICU can be a tremendous resource as you become comfortable with your babies' care. Tap their expertise while you have the opportunity.

Barring any other serious medical problems, your new family members will be discharged from the hospital once they've reached a predetermined weight goal (usually around 2000 grams, or 4.4 pounds) and are able to maintain their body temperature, feed, and breathe well on their own. If any of your children require special medical monitoring or attention after discharge, home visits from a nurse can help you become adjusted to their care routine. (Turn to Appendix A for more on preterm birth.)