Management of multiple pregnancy

Specific management for multiple pregnancy will be determined by your doctor or midwife based on:

• Your pregnancy, overall health, and medical history

• The number of fetuses

• Your tolerance for specific medications, procedures, or therapies

• Expectations for the course of the pregnancy

• Your opinion or preference

Management of multiple pregnancy may include the following:

• Increased nutrition
  Mothers carrying two or more fetuses need more calories, protein, and other nutrients, including iron. Higher weight gain is also recommended for multiple pregnancy. The Institute of Medicine recommends that women carrying twins who have a normal body mass index should gain between 37 and 54 pounds. Those who are overweight should gain 31-50 pounds; and obese women should gain 25-42 pounds. 

• More frequent prenatal visits
  Multiple pregnancy increases the risk for complications. More frequent visits may help detect complications early enough for effective treatment or management. The mother's nutritional status and weight should also be monitored more closely.

• Referrals
  Referral to a maternal-fetal medicine specialist, called a perinatologist, for special testing or ultrasound evaluations, and to coordinate care of complications, may be necessary.

• Increased rest
  Some women may also need bedrest — either at home or in the hospital depending on pregnancy complications or the number of fetuses. Higher-order multiple pregnancies often require bedrest starting in the middle of the second trimester. Preventive bed rest has not been shown to prevent preterm birth in multiple pregnancy. 

• Maternal and fetal testing
  Testing may be needed to monitor the health of the fetuses, especially if there are pregnancy complications.

• Tocolytic medications
  Tocolytic medications may be given, if preterm labor occurs, to help slow or stop contractions of the uterus. These may be given orally, in an injection, or intravenously. Tocolytic medications often used include magnesium sulfate.

• Corticosteroid medications
  Corticosteroid medications may be given to help mature the lungs of the fetuses. Lung immaturity is a major problem of premature babies.

• Cervical cerclage
  Cerclage (a procedure used to suture shut the cervical opening) is used for women with an incompetent cervix. This is a condition in which the cervix is physically weak and unable to stay closed during pregnancy. Some women with higher-order multiples may require cerclage in early pregnancy.

How are multiple pregnancies delivered?

Delivery of multiples depends on many factors including the fetal positions, gestational age, and health of mother and fetuses. Generally, in twins, if both fetuses are in the vertex (head-down) position and there are no other complications, a vaginal delivery is possible. If the first fetus is vertex, but the second is not, the first fetus may be delivered vaginally, then the second is either turned to the vertex position or delivered breech (buttocks are presented first). These procedures can increase the risk for problems such as prolapsed cord (when the cord slips down through the cervical opening). Emergency cesarean birth of the second fetus may be needed. Usually, if the first fetus is not vertex, both babies are delivered by cesarean. Most triplets and other higher-order multiples are born by cesarean.

Vaginal delivery may take place in an operating room because of the greater risks for complications during birth and the potential need for cesarean delivery. Cesarean delivery is usually needed for fetuses that are in abnormal positions, for certain medical conditions of the mother, and for fetal distress.

At The Children's Hospital of Philadelphia, healthy mothers carrying babies with serious and life-threatening birth defects have the option of delivering at the Garbose Family Special Delivery Unit (SDU). Babies prenatally diagnosed with birth defects often require specialized care before, during and after delivery. Having this comprehensive care in one location is critically important to the well-being of babies born with complex congenital conditions.