Being Induced With Twins

The short answer

Yes. RCOG's multiple pregnancy information describes the decision as whether to plan for a vaginal birth, usually after an induction of labour, or a caesarean birth. For most twin pregnancies, the planned birth date NICE recommends is an induction date rather than an operating list slot.

When induction is offered, by type

NICE NG137 sets the timings by chorionicity and amnionicity, and they are not interchangeable.

For an uncomplicated dichorionic diamniotic twin pregnancy, NG137 says to offer planned birth at 37 weeks, and to explain that planned birth from 37+0 weeks does not appear to be associated with an increased risk of serious neonatal adverse outcomes while continuing beyond 37+6 weeks increases the risk of fetal death.

For an uncomplicated monochorionic diamniotic twin pregnancy, it says to offer planned birth at 36 weeks after a course of antenatal corticosteroids has been considered, and to explain that planned birth from 36+0 weeks does not appear to increase the risk of serious neonatal adverse outcomes while continuing beyond 36+6 weeks increases the risk of fetal death.

The NHS lists the same timings: 37 weeks for twins with a placenta each, 36 weeks for identical twins sharing a placenta.

When induction is not the plan

NG137 offers a caesarean rather than induction for monochorionic monoamniotic twins at the time of planned birth, between 32+0 and 33+6 weeks, and for triplet pregnancies at the time of planned birth at 35 weeks. It also says to offer a caesarean if the first twin is not cephalic at the time of planned birth, and in established preterm labour between 26 and 32 weeks if the first twin is not cephalic.

The NHS adds that triplets or more are almost always delivered by planned caesarean, and that if you have had a caesarean section before it is not usually recommended that you have a vaginal birth with twins.

The four conditions for planning a vaginal birth

NG137 says planned vaginal birth and planned caesarean are both safe choices for an uncomplicated twin pregnancy if all of four things apply: the pregnancy remains uncomplicated and has progressed beyond 32 weeks, there are no obstetric contraindications to labour, the first baby is in a cephalic presentation, and there is no significant size discordance between the twins.

It also asks teams to be honest about how often the plan changes. NG137 says more than a third of women who plan a vaginal birth go on to have a caesarean section, that almost all women who plan a caesarean do have one, and that a small number who plan a vaginal birth will need an emergency caesarean to deliver the second twin after the first has been born vaginally.

How induction itself works

The methods are the ones used in any induction. The NHS describes hormones given as a vaginal tablet or gel or as tablets you swallow, usually offered first, with a hormone drip sometimes needed to speed labour up and waters sometimes broken artificially. If induction does not work, the NHS says your obstetrician and midwife will assess you and your baby, and you may be offered another method, a caesarean, or a period of waiting followed by reassessment.

With twins the setting is different from the start. Twins Trust says vaginal twin births usually happen in a hospital delivery room or an operating theatre, so that staff and equipment are close by. NG137 asks for intrapartum care from a multidisciplinary team with experience of twin and triplet pregnancies.

What is different on the day

NG137 asks for a portable ultrasound scan when established labour starts, to confirm which twin is which, the presentation of each, and where the fetal hearts are. It asks for continuous cardiotocography for women more than 26 weeks pregnant in established labour, using dual channel monitors so both babies can be tracked at once, with the maternal pulse displayed on the same trace. It says not to offer intermittent auscultation.

It also asks for intravenous access at the start of established labour so that fluids or blood can be given promptly, and for a maternal blood sample for a full blood count and group and save.

On pain relief, NG137 says to offer an epidural to women with a twin or triplet pregnancy who choose a vaginal birth, explaining that it is likely to improve the chance and optimal timing of assisted vaginal birth of all the babies and to enable a quicker emergency caesarean if needed. The NHS says the same, and Twins Trust notes an epidural can also make it easier if the second twin needs turning.

Between the babies

RCOG says the second baby is usually born within about 30 minutes to an hour of the first, and that the team will check the second baby's position by feeling your abdomen, doing an internal examination and using ultrasound. The NHS says that if your contractions stop after the first baby is born, hormones may be offered through a drip to restart them.

If you would rather not be induced

NG137 provides for this. For women who decline planned birth at the recommended timing, it says to offer weekly appointments with the specialist obstetrician, with an ultrasound scan, amniotic fluid assessment and umbilical artery Doppler for each baby at each appointment, in addition to fortnightly growth scans.

Declining is a recognised option with a defined monitoring plan attached, not a rejection of care.

After the babies are born

NG137 says not to offer physiological management of the third stage to women with a twin or triplet pregnancy, and to offer active management instead, explaining that it is associated with a lower risk of postpartum haemorrhage or blood transfusion. That conversation should happen by 28 weeks at the latest.