Baby, Baby, Baby! Preparing for the Arrival of Twins and Triplets
When Babies Make Four or More!
Getting the news that you're expecting multiples is one of the biggest surprises most people experience. It changes the landscape of planning for nearly every aspect of your life. Your obstetric care, childcare plans, home life, and working life will all be drastically different from your singleton-having counterparts. With so many decisions and double (or triple) the questions and concerns, it can be hard finding a place to start. However, with a little diligence and a sense of humor, you can embrace the amazing journey of becoming a parent to multiples.
Number of Babies
Quads or More
Before The Big Day: Obstetric Care
One of the biggest differences in your experience as a parent of multiples begins before your babies even arrive on the scene. For a multitude of reasons, twin and high order multiple (HOM) pregnancies are considered high risk. This makes sense—in the majority of pregnancies, there is only one occupant taking up residence in the womb. When you add more people, naturally you increase the risk factors for complications that can occur in all pregnancies.
For the majority of women carrying two or more babies, extra care is part of the package - and it begins early. You may be regularly followed by a doctor called a Maternal-Fetal Medicine (MFM) specialist—this is an obstetrician who has years of clinical experience in a range of high risk single and multiple pregnancies. While you can still opt to be seen by your regular OB/GYN and may deliver your babies with them (a practice called co-management) the majority of your care will be overseen by the specialist. During visits (which can be as often as weekly for the duration of the pregnancy) your MFM will check heart rates and activity for each baby, take measurements of their growth and environment, look for changes in your cervix and uterus, run (with your consent) a limited amount of tests for genetic issues, and manage any complications that arise from the extra weight and physical demands of carrying two or more babies.
With close management by a team of specialists, risks can be mitigated to a degree, which will allow you to carry your pregnancy as close to term as possible. Even a few extra days of gestation can make a huge difference in the health of your babies, which may reduce or eliminate their time in the Neonatal Intensive Care Unit (NICU). For twins, the average is about 35 weeks. For triplets, this number is approximately 32 weeks. Quadruplets and more typically have even shorter gestation, 29 weeks, due to the physical demands of their multiplied weight.
I am not a medical professional, so it is important to ask your doctor if you have any questions. This article is for informational purposes only.
Special Delivery: Delivering Twins or More
While every delivery is different, there are special circumstances when delivering more than one baby at the end of a multiple pregnancy. Your chance of having a cesarean section is much more likely with multiples, for a few reasons. First, babies in multiple gestations are often much smaller than their singleton, full-term counterparts. Twins average around 5.5 pounds each, while triplets typically average 4 pounds each, and quads often weigh in at a mere 3 pounds. In addition, your babies are likely to be premature, and depending on their gestation, may have some growing left to do outside the womb. For this reason, natural childbirth may be too much for your little ones to handle. For example, their size or individual position in the womb (called "presentation") may not lend itself to natural birth, one baby may experience distress as their siblings are being delivered, and other issues such as cord prolapse—a condition where the umbilical cord precedes the fetus out of the womb during birth - can make vaginal delivery risky in multiple pregnancies. For this reason, many twin and most high-order births are conducted by cesarian, where doctors can care for the babies in a controlled setting.
While the above sounds scary at first (considering the average single birth is about 7 pounds) successful delivery the babies doesn't have to be frightening. In a scheduled c-section situation, a team of obstetricians, neonatologists, and nursing staff will be assigned to the delivery in order to care for the needs of each baby. In this manner, they can be individually assessed from the moment of birth, and given any supportive measures needed to stabilize them and allow them to grow outside the womb.
Special Care: Life in the NICU
Although many twins spend little to no time in the NICU, it will help to familiarize yourself with the lingo and workings of the Neonatal Intensive Care Unit (NICU). If you are the new parent of premature multiples, it is very likely you will spend at least some time in the NICU while your new arrivals prepare for life in the outside world.
Firstly, the NICU can be a pretty intimidating place, but it doesn't have to be scary if you remember that every alarm and piece of equipment is functioning with a single purpose—to give your babies their best start in life with minimal complications. The best way to avoid the overwhelming aspects of the neonatal unit is to understand the equipment, what it does, and why.
The Isolette: Upon arrival in the NICU, many babies require help regulating their temperature. Temperature control is something that comes naturally to the majority of full-term babies; however, pre-term infants may have been born too soon for their nervous system to effectively regulate their body temperature. For this reason, your little one may spend a few days in an isolette or incubator chamber - a warmed plexiglass enclosure - in order to keep their body temperature steady until their body functions take over this task for them. During this time, nursing staff may ask that you limit your babies' time outside of the incubator to nursing or feeding. You will want to ask your staff about "kangaroo care," which is skin-to-skin time with a caregiver. This special bonding time provides much-needed nurturing for your babies, and may also help develop their internal temperature control.
Respiration Aids: There are several ways babies' breathing is assisted in the NICU, depending on the level of help the baby requires.
The very earliest pre-term babies may need to be assisted by a ventilator until their brain is sufficiently developed to control breathing independently. While this apparatus can be scary, it helps to remember that may premature babies require this level of help for a few days or weeks. It is not necessarily an indication of your baby's overall health, so much as a necessary aid while they continue to develop toward independence.
You may see the use of an oxygen "hood" in your babies' care. This device delivers a steady supply of increased saturation oxygen for your baby to breath. It is a semi-open, clear dome, and does not impede baby's movement or vision. It can seem far less intimidating than a ventilator, and for good reason—it indicates that your baby is regulating his or her own respiration without help from an invasive device, and this is a very positive thing in terms of development.
Least invasive is a nasal cannula—a small tube with two nasal ports to deliver oxygen to your baby's nose. You may find this option less scary, as it is familiar (often used in hospitals when patients require minimally invasive help with breathing).
Monitors: The background noise of the NICU is best described by constant rhythm of alerts and monitors. Babies spending time in the NICU may be hooked up to monitors in order to assess their condition. Three of the most common monitors are the heart-rate monitor and respiration count monitor (attached by sticky probes on the chest, the oxygen saturation monitor (usually taped to the base of the foot).
The first two monitors measure your babies' heart rate and breaths per minute. These will alert if either drops below an acceptable level. This can happen for several reasons - while sleeping or feeding, when premature babies may momentarily "forget" to breathe (sometimes referred to as "drifting"). A primary alert will sound for temporary drops. You may notice the intensity of the alert increases if the readings do not normalize right away. A floor nurse may come to check the baby, make sure the probes are securely attached or rouse the baby if there is a need. This is often referred to as a "spell" or "spelling." Nurses keep track of these spells to help determine when a baby is ready to go home. Ask your nursing staff about the requirements for release.
The oxygen saturation monitor keeps a record of the amount of oxygen entering the baby's bloodstream. High oxygenation is important because it indicates self-regulation of the autonomic functions such as breathing and circulation. In addition to reading oxygen saturation ("sat levels") nurses may take blood pressure from your babies' limbs in order to ensure equal oxygenation and blood flow.
Bilirubin Phototherapy Lights: One common complication of prematurity is an increase in the bilirubin in the urine or blood. Excess bilirubin is common in premature babies and may result in yellow, jaundiced appearance in the skin or eyes. Babies who have very high bilirubin that does not decrease naturally may be helped by blue phototherapy lighting for a few days. Reminiscent of a tanning bed, the lights are affixed to the top of an incubator for a certain amount of time each day. The baby must wear protective eye covers during treatment that look like foam goggles. Most babies respond to phototherapy within a day or two, and levels begin to decrease to acceptable levels shortly thereafter.
First off, it is important to understand that, just like any other milestone, babies develop at their own pace. For this reason, your babies may not come home at the same time. While one baby may be breathing normally and eating well, another may need some more time and help to become proficient in all the skills needed for "life on the outside." If this happens, don't fret. The best thing you can do for yourself and your babies is to develop a calm, healthy schedule that balances needs for yourself, your at-home baby or babies, and your baby still in hospital care. Establish a set time to go in for feedings, to break for lunch and breaks, and to go home and rest. You will be tempted to stay at the NICU until after your energy runs out. Fight this urge (and allow the nursing staff to encourage you in this).
Please remember, your own needs are not secondary to those of your babies for one simple reason—you need to be rested and fed in order to be the best parent you can be while your time is split between home and hospital. If you are breastfeeding and/or pumping, this is doubly the case. Without proper rest, nutrition, and hydration, you will not be able to sustain a milk supply for your babies. It also puts you at risk for engorgement and mastitis (from not pumping often enough). Adopt the following mantra: "Taking care of me means I am taking care of them."
Also, while many parents are torn by the idea of coming home with one child while another stays behind, there is a small opportunity in coming home with one baby. You can ease into life with a new (tiny) family member, with some of the pressure off. You can get over the fears and anxiety common to all first-time parents at home with one child, eased by the knowledge that your other baby or babies are in the capable hands of their nursing staff. You can integrate all the babies into the rhythm of home life as they come home, easing the transition for the whole family.