Multiples!

One of the assignments that we had to complete for our postpartum doula certificate was about the differences between a singleton and multiples pregnancy. I found the information super interesting and would like to share it with you all. Enjoy!

You’re Having Multiples!

Congratulations on your multiples pregnancy! I know this may not be what you were expecting when you found out what you were ‘expecting’ but carrying, birthing, and raising multiples is a going to be fabulous experience. Now I can’t guarantee that you’ll enjoy every moment but let me tell you it’ll all be worth it. Below are some tips and tricks for soon-to-be mamas of twins, triplets, and quads. 

Your Pregnancy

You may have had a singleton pregnancy previously and have immediately noticed the difference between that and this pregnancy. This may be your first pregnancy and are feeling very overwhelmed. Either way, let’s try and calm whatever fears you may have (if you have any at all) and learn about what is going to be physically and emotionally different.

Emotions

Due to the fact that you have more placentas implanted into your uterus, there are more hormones running through out your body. You are also traveling within your own emotions. There are five stages to your as well as your partner’s emotional hike: Shock, Denial, Anxiety/Anger/ Depression, Bargaining, and Acceptance/ Adaption. You should attempt to identify what stage you and your partner are in to help you cope in ways that are healthy both emotionally and physically.

      • Shock: Between the positive pregnancy test and the knowledge of the multiple embryos there’s a good reason for shock to happen in the beginning of the pregnancy. Unexpected complications can also cause shock.
      • Denial: Blocking out reality, restrained reaction to the news, and ignoring alarming information may be signs of denial
      • Anxiety/ Anger/ Depression: Every pregnant woman experiences anxiety but mothers expecting multiples more so, it is a valid emotion. Anger can rise in the form of resentment because of the feeling of no longer being in control of your life due to special circumstances that many multiples pregnancies experience. This resentment often leads to guilt because mothers don’t feel responsible for the ‘high-risk’ status of their pregnancy. From self-blame depression can arise.
      • Bargaining: After being so overwhelmed with the previous emotions, you don’t want to loose the sense of control that you’ve recently gained. You want to start bargaining with your care provider to let you do things that you’ve always done (i.e. work overtime, go shopping, etc.)
      • Acceptance/ Adaption: You can now cope with a pregnancy crisis in ways that are healthy in both mind and body

Weight Gain and Nutrition- I am not a medical professional, these are recommendations that should be taken to your care provider

Quality and Quantity will affect your babies’ health; this is true in all pregnancies but especially for multiples. An excepting mother must make every bite count to give her babies’ the best chance of survival when they’re born. Think of it this way: Multiples are almost always born early, meaning you have less time to let them grow. The typical delivery dates are as follows:

Single: Average of 40 weeks gestation

Twins: Average of 35 weeks gestation

Triplets: Average of 32 weeks gestation

Quadruplets: Average of 29 weeks gestation

Moms-to-be should be eating 3 meals plus 2-3 snacks per day, stabilizing their blood sugar levels. This is the basic diet for a diabetic but the same principles apply: eat often (3-4 hrs), consume lean proteins, healthy fats, carb-rich foods, and eat a bedtime snack that includes dairy. This is especially important before the 28th week because that’s when you need to gain most of your weight to sustain the rest of the pregnancy. A mother of a singleton should gain 20 pounds by the 28th week and then 5-15 pounds for the rest of her pregnancy. Twins 38 pounds first then 2-18 pounds. Triplets 54 pounds first then 4-21 pounds. Quadruplets 65 pounds first then 5-15 pounds. The totals are as follows:

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Photo of Mother having Twins

 

Single: 25-35 pounds

Twins: 40-56 pounds

Triplets: 58-75 pounds

Quads: 70-80 pounds

All of these numbers depend upon the health of the mother pre-pregnancy- Underweight mothers need to gain more, overweight in a different capacity. The quality of the food consumed is also important- if healthy foods are consumed then the babies will grow better and you won’t keep the weight on after birth. Supplements should also be considered and recommended by your care provider.

Physical Changes

Besides the obvious circumference changes there are other physical changes that can happen during any pregnancy. Examples are as follows:

  • You may have more hair, with glowing skin
  • Chloasma- aka a pregnancy mask where there’s darkness around the eyes and nose
  • Linea Nigra- A brown line on the stomach
  • Red, itchy palms/ soles of feet
  • Spider veins on legs
  • Stretch marks- these mostly depend on genetics

Potential Issues

I’m not including this section to scare you. I’m including it so that you can know what the signs and symptoms of common issues are during a multiples pregnancy and attempt to prevent them. Your goal is to have the healthiest, longest gestation possible and you should know when you need to seek medical attention or not.

        • Morning Sickness: AKA: Potential All Day Sickness. Ways to Help: Try eating something salty& sweet (ex. pretzels and lemonade, chips and coke), Eat frequently to prevent low blood sugar, eat lots of protein, try dairy, sucking on a popsicle to prevent dry heaves, have a 2 am snack with dairy, ginger anything, dress for comfort to prevent the gag reflex, acupressure sea-bands
        • Bleeding: Within the first ten days your baby had implanted into your uterus, Afterwards it could be a sign of miscarriage or vanishing twin syndrome
              1. Incompetent Cervix: Your cervix opens too early and can cause miscarriage. Signs: Bleeding, Vaginal Discharge, Heavy Feeling in Pelvis
              2. Placental Problems: Most common after 20 weeks.
                  1. Abruptio placenta: placenta partially detaches. Signs: Moderate/ severe bleeding, Ab pain
                  2. Placenta privia: Placenta is covering the cervix. Bleeding bright blood occurs while cervix is opening

***Contact your care provider immediately, they will most likely put you on bedrest ***

        • Iron Deficiency Anemia: Signs: fatigue, lightheaded, poor coloring, shortness of breath. Ways to help: Increase iron rich foods (i.e. red meats, liver, liver pate, supplements)
        • Gestational Diabetes: Signs: Unquenchable thirst,increased frequency/ volume of urination, constant fatigue, recurrent vaginal yeast infections, it runs in the family. Ways to help: Your care provider may add a diabetic physician and dietitian to your care, follow a diabetic diet, you may need to take medication of have injections.

***You have higher changes of developing Type 2 Diabetes later in life, make sure your
      care provider checks at your annual exam ***

        • Growth Problems: AKA Intrauterine Growth Restriction. An ultrasound will determine if this is an issue or not. Nutrition and Diet are very important here. Your care provider may have you deliver early to give the smallest child the best chance.
        • Twin-to-Twin Transfusion Syndrome (TTTS): This only happens with identical twins that are sharing a placenta. Blood moves from the donor to the recipient twin. Signs: your abdominal enlarges too rapidly over a 2 week period. Ways to help: You may need bedrest, Amniocentesis (removal of some of the amniotic fluid), fetal later surgery (separates placenta into two). At birth the donor twin may need a blood transfusion while the recipient may need medication to reduce their amount of blood.
        • Preeclampsia: Most likely to occur during the second trimester. Women whom already have high blood pressure are more likely to get it. There’s a 5% chance for singleton pregnancies and a 20% chance for multiples. Signs: High blood pressure, protein in the urine, sudden weight gain, swelling in the hands/ face. Ways to help: Increase intake of Omega-3, Calcium, Vitamin C & E, Bedrest, and essentially birth.
        • Preterm Labor: Most common for a multiples pregnancy. Signs: Contractions occurring 6 or more/hour, Rhythmic/ persistent pelvic pressure, menstrual like cramps with or without diarrhea, Sudden or persistent low backache, vaginal discharge that had changed color/consistency/volume, you have a funny feeling.

*** Drink a big glass of water and empty your bladder: dehydration and a full bladder can trigger contractions ***

Helpful tricks

Below are some some tips for other discomforts during pregnancy.

          • Get some uterus support with a prenatal cradle
          • Backache remedy: glass of mild with a teaspoon of honey
          • Carbs can cause swelling, try to cut back closer to bedtime
          • Cutout onions, high fat foods, and chocolate for heartburn
          • Drink your water before 8pm and it will lesson the chances of having to get up at night to pee, will also reduce swelling
          • Working moms pregnant with multiples will most likely need to take maternity leave by the 28th week, this is for their health- don’t argue with your care provider about it
          • Maternity leave: Find out all of your rights before you talk with your employer and tell them in a very professional manner. Also you should be getting the same amount of time as your male counterparts if they had a medical issue (i.e. a broken leg)

Your Birth

Yay! You’ve made it to the big day and get to meet your little ones. This section is about the different possibilities that may or may not happen during you labor and delivery. This is not all inclusive, so make sure you have an in-depth conversation with your care provider about what to expect all the way down to the tinny details. No one wants to go into such a big event without knowing something important if they don’t have to.

Labor?

Whether you’re a first time mama or an old champ you always are questioning if you’re in labor or not. Below are the common signs that something might be happening:

          • Lightening: This is where you can feel one of your babies’ heads deep in your pelvis
          • Bloody show: Your mucus plug (Blood colored jelly-like substance) has dislodged from your cervix
          • Rupture of Membranes: Water breaking. We’ve all seen one form of this through the media (that awkward gush in the middle of a public space), but it can also be a slight trickle where you may just think that you’re peeing yourself
          • Contractions: You could feel contractions in your back, abs, or legs, during true labor your contractions get longer,stronger, and more frequent.
          • Funny Feeling: You may not feel any of the previous signs happening, but you feel off for a significant period of time

What to expect when you get to the hospital

When you’re expecting multiples, the probability of having an out of hospital birth is slim. There are some states that allow midwives with an overseeing OB attend twin births, but they normally still have to be in the hospital. In these cases they may have even more restrictions on the mother, having her give birth in the Operating Room (OR). All of this depends on state law and insurance policies.

When you think that you’re in labor, you should call your care provider and they will most likely direct you to the hospital’s labor and delivery department. When you arrive,they will first send you the triage area to determine if you’re actually in labor and can be admitted or sent back home. There you will change into a hospital gown, take your vital signs, conduct a pelvic exam, monitor contractions and your babies’ heart rates.

Interventions

Intervening with birth started in the victorian era (1837 – 1901) when corsets were popular and rickets was common. These two events physically changed a woman’s body to where they truly couldn’t birth a baby on their own, their physiology wasn’t compatible with the process. Nowadays we don’t normally constrict our torsos to such an extreme and obtain enough vitamin-D to prevent the deformation of our pelvis but the interventions are still prevalent. Today, most of the time the interventions are unnecessary but are still practiced due to lack of education, insurance policies, and a care provider’s need to help/ do something even when everything is going well. Now, with this being said in certain situations interventions are needed. As long as you’re informed of the pros/ cons and feel a part of the decision making process everything should go well. Below is a list of the common interventions:Lamaze_CesaraenInfographic

          • Induction: When a care provider helps start the labor process. Common practices are: Breaking your water, Give prostaglandins/ pitocin, separating of the membranes
          • Continuous Fetal Monitoring
          • Epidural: This blocks the feeling in the lower half of your body
          • Restricted Movement: Where the mother isn’t allowed to move in any way that feels natural to her while laboring
          • Episiotomy: This is a surgical cut to the muscle between the vagina and anus
          • Forceps/ Vacuum Extraction: Where the care provider uses tools to physically remove the baby from the birth canal
          • Directed Pushing: Where the mama-to-be is told to hold her breath and push for 10 counts through a contraction
          • Cesarean Birth: Where the Doctor surgically removes the babies from your uterus.

Vaginal versus Cesarean

For a singleton pregnancy many moms wonder if they will have a vaginal or a cesarean birth. For multiples the pregnancy is deemed ‘high risk’ and has a high probability of a cesarean birth, all quads and most triplets while twins are on the boarder line. It all depends on your care provider and the positions of your little ones. Sometimes the first is born vaginally and the second is born via cesarean because they flipped when they had more room to move. Sometimes a vaginal birth depends on if the mother has had a previous cesarean. Where her scar is, what her care provider thinks, and the culture of where she’s giving birth can also be determining factors in whether or not she can try for a VBAC (Vaginal Birth After Cesarean, Vee-Back).

Many mothers of multiples will schedule their c-section birth with their doctors before they have any signs of labor. There are a few reasons for this and they could include: poor positioning, a decrease of the mother’s or a baby’s health, or a real failure to progress where one baby has been born but the other(s) won’t engage. There are a few risks associated with having a c-section, as there is with any other major surgery, including: problems with anesthesia, bleeding/ blood clots/ infection, or weakening of the womb for next pregnancy. With the case of multiples and the sterilized conditions of American hospitals the benefits have a great probability of outweighing the risks. Talk with your care provider about any concerns you may have.

What should you expect in the operating room (OR) if you’re having a cesarean, whether it is planned or an emergency. For a planned c-section you’ll be admitted either the morning of or day before. Even if you’re planning a vaginal birth outside of the hospital, you should contact the closest hospital that you would be going to to ‘check in’. Basically you’d fill out all of the paperwork before you go into labor so that you don’t have to deal with it in an emergency situation. Upon arrival you’d change into a hospital gown, have your vitals taken, and get an IV for fluids and/or medication. When the staff is ready, you’ll be wheeled into the OR, have a catheter and epidural block inserted, and have your abdomen washed in antiseptic. A curtain or drape is put up to block your view (you can ask to have it lowered when your babies are being born) and the surgery will begin. There may be quite a few people in the room with you and your partner, having multiples tends to be a big deal and many teams of care providers like to stand by. The whole process takes approximately an hour with your little ones born within the first 15 minutes. While you’re getting stitched together, your babies will be taken care of and moved to the NICU (Neonatal Intensive Care Unit) for further observation. Due to the fact that multiples are born before 40 weeks gestation, they will most likely visit the NICU whether it be for a few hours to months. Please talk with your care provider about what you can expect and the  amount of time that they may stay in the hospital depending on what week they are born in  (20-40 weeks).

Helpful Tricks

        • You must have a great relationship with your care provider, and show consider a care team that includes your Doctor, pediatrician, dietitian, a doula, and the nurses you may come in contact with at that hospital.
        • If you’re having a vaginal birth move as it comes natural to cope with labor pains and if you decide to use medication talk with your care provider about the risks versus benefits
        • With a Cesarean, try to participate as much as you can. Ask for pictures, a description of what the doctor is doing while he’s conduction surgery, have the drape lowered for the births, see if your partner can watch the births, etc.

Your Postpartum

Oh my goodness!!! You have babies!! What an exiting/ scary time for you and your love ones. Congratulations! Now that you have worked really had at gestation, lets get going on your recovery.

While in the hospital

For a natural birth, after you’re done delivering your placentas you’ll be wheeled into your recovery room. This is where you’ll be for the next 24-48 hours making sure there aren’t any complications and that breastfeeding is starting out well. You should just spend this time bonding with your babies whether they can come and visit you or you have to go and visit them. Keep in mind that you do need to recover after any birth, you’ve been working very hard by gestating and now need time to replenish your energy to be able to care for those new babies. Also since you have to spend a specific amount of time in the hospital anyways you should take advantage of the automatic help you can receive. Get a full nights rest, take a shower, eat a lot, do everything you would do if you had just run a marathon (Because You Have!).

For a cesarean birth, 2-4 days is the normal length of time that you’ll spend in the hospital. It all depends on the policies plus how well the surgery went. The scar will hurt for the first few days but it shouldn’t influence your movements too much. You can take pain medications if you feel you need them, just ask your care provider. You’ll be encouraged to get up within 12 hours, go to the bathroom, take a shower,etc. This will make sure that everything is running smoothly and help you heal faster. The only restriction that they normally place is that you shouldn’t be picking up anything heavier than your baby or doing heavy housework. If you where stapled shut they will be removed 3-5 days postpartum and will just have to watch for any signs of infection. Everything else involved in your hospital stay is pretty much the same as a woman who’s delivered vaginally whether for a singleton or multiples.

NICU

Most of the time when multiples are born they spend some time in the NICU (Neonatal Intensive Care Unit). The reason for this is because they are usually born before a singleton’s full-term: 38-42 weeks. There just isn’t enough room in the uterus for them to grow that long. Even with very healthy twins they will most likely be monitored while you all are in the hospital and then discharge when you are. The earlier babies are born, the longer their NICU stay will be. There are a few different ways that this may be different than singletons.

Neonatal_Jacoplane

The differences are below:

        • You may have to leave them in the hospital. This isn’t different from that of a singleton NICU stay but, you are worrying about more than one baby and are extra stressed
        • You may bring one baby home at a time. This means that you will have to make a visiting schedule for both parents, allowing time to bond with all babies.
        • Premature babies are developmentally different than full-term babies. Premies will develop like they are still in the womb, meaning that at 6 months old they may not be reaching the same milestones as a full-term singleton. You should judge milestones by what your babies  gestational age would have been.

Going Home with all those babies

You’re probably thinking “what in the world am I going to do with all these babies?” First step: Recruit Help! Every new mom deserves the extra help, whether they have one or many, for at least the first few weeks of readjustment. In actuality you’ll probably need help longer than a few weeks just so that you have time to care for yourself every once and a while. To also help out with this, get on a decent sleeping/feeding schedule. Many believe that they need to feed-on-demand but this really isn’t applicable when you have many babies. Trying to get everyone on relatively the same schedule will let you get some well deserved rest and time to yourselves.

Tips and Tricks

        • You don’t need doubles/triples/quadruples of everything. Get multiples of car seats, cribs, stroller seats, Infant seats, and high chairs. Everything else may be nice, but budget wise you can survive with one.
        • Save steps: have multiple changing stations, and places to place babies within every room
        • Avoid interruptions and eliminate unnecessary tasks: if you’re nursing don’t take phone calls just concentrate on what you’re doing, getting back to them later. You don’t need to have the house “put together”, healing-wise it’s not healthy to push yourself too hard.
        • Get out of the house: Isolation promotes postpartum depression and anxiety. It may take you longer but the socialization will make it worth it.
        • You should super baby-proof. At some point in time you’ll have to leave one of your babies on the floor while you’re interacting with another. This is when the floor baby gets into trouble and you don’t want it to be bad trouble versus cute trouble.
        • Bonding:
            • It may take time. Between possibly having a c-section, and a NICU stay it’s going to take some time to get to know 2-4 new people.
            • You may not have time to focus on individuals. With multiples you’re just trying to meet their basic needs and don’t have time between babies to play with them. This is where scheduling  and extra help comes into play, getting everyone taken care of in an hour versus three will allow play-time.
            • Favoritism and Developmental delay. You may think that you’re not going to play favorites but it’ll probably happen either because one is the gender you were hoping for or they have a temperament that goes well with yours, etc. Developmental delay may affect your bonding because you’re expecting them to be doing one thing at their age but they’re not. This goes back to judging by gestational age versus birth age.
        • Older Siblings: With a singleton parents have more time to spend with all the older children, this isn’t necessarily true with multiples. Again getting on a regular schedule will allow you to spend your time with everyone (including your partner). Older siblings may also experience jealousy and resentment, make sure you recognize their feelings and validate them.

Postpartum Depression

All new moms have a chance to experience baby blues and/or postpartum depression. The baby blues start around 2-3 days after birth where the new mama is quick to cry for things that wouldn’t have bothered her before. It will normally disperse within a few weeks as long as the new mother learns to take care of herself as well as her babies.

Postpartum Depression on the other hand doesn’t normally go away as quickly nor on it’s own. Another issue is identifying it, because a lot of it’s symptoms can be seen as ‘normal’ new parenthood. The symptoms are as follows:

          • Uncontrollable Weeping
          • Hopelessness
          • Feeling inadequate
          • Loss of interest in activities that used to be enjoyable
          • Inability to concentrate
          • Memory problems
          • Food cravings or loss of appetite
          • Sleep Troubles

You’re probably like ‘these sound pretty normal from what I know of new mothers and fathers’. Technically you’re right, new parents may feel some of these things at some point in the first few months. The problem is that new moms with PPD have multiple symptoms all the time. They may also experience anger or extreme anxiety about all of the unknowns.

If you think that you may be experiencing postpartum depression you need to seek help from your care provider. There are many potential treatments that can make you feel like yourself again. Treating it will also let you bond with your babies better.

Your new partner relationship

I just want to acknowledge the change in your personal relationship. Before it was just the two of you (or you and your other children), now you have a responsibility for many children and all of your time seems to be dedicated to their care. You must find time for yourselves to be in-love again. Whether you take a night off twice a month or just create a routine where you spend time with one another for a specific time everyday, your relationship depends on it. If a relationship is going to end, there is a high probability that’ll happen after having multiples. I’m not saying that once you have multiple babies you’re instantly going to divorce, what I’m saying is that when you don’t pay attention to your own needs and the needs of your partner the relationship becomes strained. There is enough love to go around, you just need to recognized it.

If you have any questions, feel free to contact me and congratulations on your multiples pregnancy!

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