Having twins can be an exciting and joyful experience for expecting parents. However, it also comes with unique challenges throughout pregnancy and delivery. One common question that often arises is whether twins always require a cesarean section (C-section) delivery or if a vaginal birth is possible.
Quick Answer
No, twins do not always have to be delivered by C-section. Many twin pregnancies are good candidates for a vaginal delivery. However, certain factors increase the likelihood that a C-section will be recommended or required for the safety of the babies and mother.
Vaginal Birth Versus C-Section for Twins
For many years, the standard practice was to deliver all twin pregnancies by C-section. However, research over the past few decades has shown that 60-75% of twin pregnancies may be good candidates for vaginal delivery.
Some key advantages of a vaginal delivery for twins include:
- Quicker recovery time for the mother after birth
- Lower risk of infection, blood clots, and other complications from surgery
- Lower risk of breathing problems for the newborns
- Opportunity for immediate skin-to-skin contact and breastfeeding after birth
However, there are also some potential risks that must be carefully considered when determining if a vaginal delivery is appropriate for a twin pregnancy, including:
- Increased chance of needing emergency C-section during labor if complications arise
- Higher risk of injuries to the babies during delivery, such as shoulder dystocia
- Potential for the second twin to turn into an abnormal position after delivery of twin 1
- Higher likelihood of needing forceps or vacuum assistance during delivery
For these reasons, many providers will only consider vaginal delivery in twin pregnancies that are low-risk and meet certain criteria.
Factors That Increase Chances of Needing a C-Section
There are several factors that make a C-section more likely to be recommended or required for the safe delivery of twins:
- Baby positioned breech, transverse, or oblique – If Baby A or B is not head down, a C-section is usually necessary.
- Monoamniotic (“mono mono”) twins – These twins share a single amniotic sac and umbilical cord entanglement is common, requiring a C-section.
- Twin-to-twin transfusion syndrome – This complication requires laser surgery during pregnancy and C-section delivery.
- Placenta previa – A low-lying placenta increases risk of bleeding and calls for a C-section.
- Weight discordance – If one twin is substantially larger, a vaginal delivery may pose extra risks.
- Gestational diabetes – Poorly controlled gestational diabetes increases the likelihood of needing a C-section.
- Premature delivery – Twins born before 35-36 weeks are often delivered by C-section.
- Previous uterine surgery – Scarring from a prior C-section or other uterine surgery may make vaginal birth unsafe.
- Pregnancy complications – Issues like preeclampsia or placenta abruption increase the chances of requiring a C-section.
Additionally, other factors like the size and position of the placenta(s), estimated weight of the babies, and overall health of the mother will be considered when developing a delivery plan.
Twin Delivery Method Based on Presentation
The presentation, or position, of the babies is one of the most important factors determining whether twin delivery by C-section is recommended. Here is an overview of typical delivery methods based on twin presentation:
| Presentation | Delivery Method |
|---|---|
| Twin A vertex (head down), Twin B vertex | Vaginal delivery likely if criteria met |
| Twin A vertex, Twin B breech | C-section recommended |
| Twin A breech, Twin B vertex | C-section recommended |
| Twin A transverse or oblique, Twin B vertex | C-section recommended |
As shown in the table, a vertex/vertex presentation where both twins are head down is usually the only scenario where vaginal birth may be attempted. Any other presentation combinations, like breech/vertex or transverse/vertex, will typically result in a C-section delivery to avoid risks associated with breech or transverse positioning.
Criteria for Attempting Vaginal Twin Birth
If both Baby A and Baby B remain head down in a vertex presentation near term, many providers will consider attempting vaginal delivery if all of the following criteria are met:
- Pregnancy is 37-38 weeks or beyond
- Twin A is in the vertex position
- Twin B is in the vertex position
- No signs of placental abruption or placenta previa
- No major complications such as preeclampsia or IUGR
- Estimated baby weights are appropriate for gestational age
- Ultrasound shows adequate amniotic fluid levels
- No congenital anomalies or birth defects requiring C-section
- Mother is in overall good health without uncontrolled medical conditions
- Supportive hospital staff and environment to manage a vaginal twin delivery
Meeting these criteria indicates the pregnancy and delivery are likely low-risk enough to attempt labor and vaginal delivery. However, C-section backup must be readily available in case complications arise during the birthing process.
Making the Delivery Decision for Twins
The decision between vaginal delivery and planned C-section is made collaboratively between the mother and her obstetric provider after carefully reviewing the risks and benefits of each method.
If the criteria are met for a trial of labor, many mothers wish to attempt vaginal delivery to experience the benefits such as faster recovery and earlier breastfeeding. However, the priority is always the safety of the mother and babies, so providers will have no hesitation recommending a C-section if any concerns arise before or during labor.
Mothers carrying twins should be prepared for either a vaginal or C-section delivery by being flexible with their birth plan and working closely with their healthcare team throughout pregnancy to promote the best possible outcome.
Preparing for Either Delivery Method
To be ready for twins to arrive either vaginally or by cesarean, here are some helpful preparations:
- Attend prenatal visits regularly to monitor twin growth and health
- Undergo screening ultrasound and tests to detect potential complications
- Discuss delivery plans, options, and preferences with your provider
- Take childbirth preparation classes tailored to a twin pregnancy
- Learn about recovering from both vaginal and C-section deliveries
- Assemble help and support for the postpartum period
- Pack two hospital bags with supplies for you and both babies
Educating yourself, following provider guidance, and being flexible will help you feel empowered and ready to welcome your twins safely, whether by vaginal birth or necessary C-section.
Vaginal Delivery of Twin 1 then C-Section for Twin 2
In some cases, mothers may deliver the first twin vaginally but then require a C-section for the second baby. Reasons this may occur include:
- Twin 2 flips into a breech or transverse position after twin 1 delivers
- Twin 2 experiences fetal distress during the pushing stage
- Twins are substantially discordant in size, making twin 2 too large to deliver safely
- Bleeding or other complications develop after twin 1 delivery
Delivering one twin vaginally and the other by C-section offers the benefits of quicker postpartum recovery than a C-section alone. But the chance of complications occurring after vaginal delivery of the first baby means the birth team must be ready to rapidly move to a cesarean to safely deliver twin 2 as needed.
Special Considerations for Vaginal Birth After C-Section (VBAC)
Some mothers pregnant with twins may have previously had one or more C-sections for a prior singleton pregnancy. In these cases, options for twin delivery include:
- Elective repeat C-section for the twins
- Attempting vaginal birth after cesarean (VBAC) for both twins
- Trial of labor to vaginally deliver twin 1, then C-section for twin 2
Successfully delivering twins via VBAC occurs in 60-80% of cases, which is slightly less than the success rates for VBAC in singleton deliveries. Factors like the type of prior uterine incision will help determine if VBAC may be safely attempted.
Mothers interested in VBAC should discuss risks like uterine rupture with their provider early in the twin pregnancy to allow for proper counseling and planning if a trial of labor is deemed appropriate.
Conclusion
While every twin pregnancy is unique, many mothers wishing to attempt a vaginal delivery are able to successfully and safely welcome both babies vaginally. However, a C-section will be necessary in cases where complications arise or risks factors are present that make vaginal delivery unsafe or inadvisable.
By working closely with their obstetric providers and birth teams, mothers expecting twins can evaluate their options, risks, and chances for successful vaginal birth or need for cesarean delivery in their specific situation. Remaining flexible and preparing for either scenario is the best approach to take when planning for the safe arrival of newborn twins.