Burning Question: Can I deliver my twins vaginally?

This is a quick guide for moms of twins if you are wondering whether you can opt for a vaginal birth or not. It is recommended to always talk to your healthcare provider about your options in order to choose the safest mode of delivery for your babies. Mothers expecting triplets or more are not encouraged to have vaginal births.

What type of twins can be delivered vaginally?

So the risk of vaginal birth for twins depends on a number of factors, the first being the type of twins:

  1. Monochorionic/Monoamniotic (Mo/Mo) twins. These are identical twins and are on the top of the list of high-risk pregnancies when it comes to twins. They share one placenta and one bag (they are in the same bag). Ideally, these twins should not deliver vaginally. The first baby is usually not the biggest concern, it is the second baby that is at risk when they share a placenta as the placenta can start detaching after Baby A is born, leaving Baby B at risk of no longer having oxygen supply. This can be a fatal situation for Baby B which is why these twins are preferred to be delivered via Caesarean.
  2. Monochorionic/Diamniotic (Mo/Di) twins. This means that they share one placenta but they are each in their own bag. These can be identical or fraternal twins because two placentas can also fuse and form one placenta – increasing the risk for complications during a vaginal birth as Baby B is once again at risk of the placenta detaching after Baby A is born. These twins are also preferred to be delivered via Caesarean.
  3. Dichorionic/Diamniotic (Di/Di) twins. These are almost always fraternal twins although there are cases with identical twins where an embryo has split before implantation and implanted into two separate places in the uterus. This is the lowest risk twin-pregnancy for a vaginal birth as the twins don’t share a placenta or a bag and after Baby A has been born, Baby B doesn’t have the risk of a shared placenta detaching. However, baby B will be monitored closely to ensure he/she is coping throughout.

What type of twin positions can be delivered vaginally?

About 50% of twins are delivered vaginally in the public sector in South Africa. The second factor to consider for a vaginal birth of twins is the position of the babies.

  1. If Baby A is head down and baby B is head down, it is safe to continue with a vaginal birth.
  2. If Baby A is head down but baby B is breech, it is riskier as any breech delivery comes with certain possible complications but you can still attempt a vaginal birth if your healthcare provider is comfortable with the risk such a delivery holds for you and the babies. Note: After baby A is born, baby B can assume a different position due to the extra space. If necessary and indicated, your healthcare provider can attempt to turn the baby into a position that can be delivered vaginally.

Here are some more resources on a vaginal birth with twins:

When would a vaginal birth not be possible?

The following scenarios will not be favourable or you might be advised against attempting a vaginal birth due to certain risks – mostly to the babies and not to the mother as much.

  1. Mo/Mo or Mo/Di twins
  2. Baby A breech (regardless of baby B’s position)
  3. Any malpresentation of one of the twins, for example a transverse lie
  4. A large weight discrepancy between Baby A and Baby B (Baby B should not be much bigger than Baby A)
  5. Health concerns of your babies, because labour will add a lot of stress on their bodies and your healthcare provider will advise if they think your babies will be able to cope with labour or not. Premature babies will usually rather be delivered via Caesarean section rather than vaginally due to the stress fo labour on their little bodies. Note: If you have gone into spontaneous labour, you might very well end up delivering preemies vaginally.

Is it possible to end up with both a vaginal birth and a caesarean section?

Yes. It is not common, but it happens sometimes that after Baby A is born vaginally,  Baby B is no longer coping with labour or ends up in a malpresentation that requires you to have a caesarean section.

Some healthcare providers prefer to take moms to theater to do a vaginal birth in case of a caesarean that is needed and then they can quickly convert to an operation as the mother is already in theatre.

Can I have a VBAC with twins?

There is a lot of research available on VBAC’s (Vaginal birth after a Caesarean section) but each twin pregnancy is a unique case. Normally VBAC’s are considered low risk for mothers with singletons but twin pregnancies bring their own set of complications. This is a discussion to have with your healthcare provider.

Technically, a VBAC is always possible and there are mothers attempting a vaginal births after more than one caesarean sections and they would advocate for that as well. From a medical perspective, the risk for complications during a VBAC increases significantly the more caesareans you had before, specifically in terms of hemorrhaging ( bleeding). In South Africa where the litigation around childbirth is extremely high, you will struggle to find a healthcare provider willing to take on such a risk with twins. It is in their and your best interest to advocate against a VBAC in certain instances but ultimately the choice is yours. However, they will be implicated and can lose their license to practice if you or one of your babies suffers from serious or fatal complications which is why the topic of a VBAC is very contentious and necessary to be discussed in detail with your healthcare provider.

VBAC with twins is  not recommended because there is a lot of strain on the uterus with a twin pregnancy and the scar from a previous caesarean is a weakened area in the uterus and the risk with a VBAC is tearing of the uterus that can lead to massive blood loss. This is not meant to scare anyone but too many mothers and babies have suffered because of a lack of adequate information. Make sure you are willing to trust your healthcare provider with your life,  because that is exactly what you are doing so you have to be 100% certain of the decisions you make.

Some additional reading on VBAC’s: