If you’re expecting twins, you may be wondering if there are certain considerations you need to be aware of that are different than those carrying singleton pregnancies. To help you address this, here are some common questions I hear from pregnant women expecting twins.

1. What are my delivery choices with twins? Is it possible to deliver without surgery?
In my experience, about 50 percent of twins are vertex/vertex (both head down) in the uterus. The next most common presentation is vertex/breech, with one baby head down and the other baby bottom down. The second baby can be delivered breech or turned by external cephalic version (ECV). Either option is reasonable. Twins can also both be breech, and I have delivered breech twins vaginally.  Of these three possible presentations, the breech/vertex position is considered a poor choice for a vaginal birth because of the chance of locking chins. The pregnant women I’ve treated have not exhibited this presentation, but the American College of Obstetricians and Gynecologists (ACOG) recommends a C-section in such cases. So in most cases, yes — it is possible to deliver twins without a C-section, and even without an episiotomy.

2. How common is it to have one twin delivered vaginally and one by C-section?
I’ve often said that birthing the first twin vaginally and the second twin by C-section is the worst of both worlds. I have never done this procedure. Management of the second twin requires patience, discernment, judgment, and luck. Of these, patience is the most important. A new mom who has a combination vaginal/C-section delivery will be more tired and sore, and will need much support at home to avoid depression. Recovery time will also be longer, from 4 to 6 weeks. To avoid the vaginal/C-section combination delivery, new moms need to know their options and discuss them with their doctor. If your babies are not vertex/vertex (both head down), what is your obstetrician’s comfort level with managing the delivery?

PRO TIP: Dads can play a big part in post-partum support. In my experience, dads attending prenatal visits and classes are more able and willing to help out after delivery. The father of the quads I delivered took an active part in caring for his babies. He told me he figured out that he changed 7000 diapers per month! Now that’s dedication and commitment.

3. What unique aspects of being pregnant with twins should I be aware of in each trimester?
First trimester: Nausea, lack of interest in food, and risk of miscarriage are all higher during the first trimester.
Second trimester: Risk of preterm cervical dilation and hypertension increase in trimester two.
Third trimester: When pregnant with twins, preterm delivery is common in trimester three. With twins, 38 weeks is considered term.

4. Does giving birth to multiples lead to higher postpartum baby blues, depression, or psychosis?
A multiple pregnancy can have everything a single pregnancy can have, and have more of it. So yes, more baby blues, more depression, and for some, more post-partum psychosis are possible. Dads are most important. They are most available to help. Stay in touch with your care provider and ensure you have a strong support system of friends and family in place for the first few months after you give birth—especially those first few weeks.

5. Can you share tips for nursing twins?
First off, know that nursing twins can absolutely be done. Most often, nursing is simultaneous and each baby gets one breast. Nursing is wonderfully adaptive. The babies can be held like a football under each arm, with the head on the breast and the body and legs to the mother’s sides and back. Most importantly, don’t worry! About the only thing that wrecks nursing is worrying and thinking you can’t. If you think it can’t happen, it won’t. Until your milk production catches up, you may need to top off the twins’ feedings with formula. Please do not worry when providing your twins with a little formula. You are not bad or inferior. Your babies must eat and gain weight.

6. Giving birth to one baby carries some risks for mother and child. Are those risks the same when giving birth to twins?
Giving birth to twins offers more risks for everything. But in my experience, it’s not twice as much risk.

PRO TIP: Don’t smoke!!!

7. Can I maintain my pre-pregnancy exercise regimen when pregnant with twins? What modifications should I make, if any?
Maintaining your pre-pregnancy exercise program depends upon what your  pre-pregnancy program was. I would avoid running five miles daily—or even one mile daily. Yoga would be better.

8. Do I need to eat more when pregnant with twins than I would with a singular pregnancy?
Although we kow the optimum weight gain for singleton pregnancies, less is known about multiples. My experience with twins indicates you should eat about 50 percent more than with single pregnancies, but not twice as much. Certainly you need the maternal volume increase, which will be about four pounds a month. There will be more amniotic fluid, more blood volume, more placenta, and more baby.

9. What should I do in terms of self-care when pregnant with twins?
Set your mind at ease by learning more about what it means to carry, birth, and raise twins. The more knowledgeable you feel, the more you will be able to advocate for yourself with your care providers, and navigate all the unique realities that having twins will present to you.

All pregnancies require an increased level of care and attention from expectant mothers. Carrying twins simply means a slightly higher level of due diligence on your part to protect your health and your babies’ health during pregnancy, delivery, and especially during their first few months of life.

Stay in touch with your care provider through each step of your journey, and don’t hesitate to ask these and other questions to help you incorporate the information into your unique pregnancy and birthing experience.

FUN FACT: With deliveries on one side of midnight and one on the other, I have had twins deliver on separate days, separate months, and even separate years (New Year’s Eve / New Year’s Day)!