Twin Birth Magic - A Signature Workshop by Deborah Rhodes

We’re still coming down from hosting Twin Birth Magic! It was a 2-day workshop, taught by Deborah Rhodes. Debs has 30+ years of midwifery experience - from the NHS and independent midwifery practice in the UK, to traditional birthkeeping in Spain. She has always had a deep interest in twins, stemming from her childhood when her mum was pregnant with her twin brothers. During her career she has been sought out as the midwife to support twin and breech homebirths. Along with providing support to birthing women around the world, Debs also shares her knowledge, wisdom and experience at her signature Birth Magic Workshops. Find Debs over on instagram @debsbirthmagic.

There were 8 of us present for this workshop - a mixture of independent midwives, an NHS midwife, a student midwife and a doula. On day 1 we first settled into our circle - introductions were relaxed, allowing everyone to speak without rushing. It was really interesting and inspiring to hear about the varied experiences in the room, including from the two midwives who have been on the NMC register for 40+ years. These elder midwives have seen SO many changes in midwifery and the culture of birth in their time and they’re still offering homebirth care and still attending workshops to learn.

Identical or Non-Identical: Understanding the Types of Twins

After getting to know one another, we dived straight into the different types of twins - did you know there are 7 categories in total?! We spoke about the differences between non-identical and identical twins (including the several rare variations of identical twins), how common each of the types are and the unique considerations that are associated with the different placentations. We also spoke about the importance of making the language around twins accessible - rather than heavily medicalised - so for this article we’ll try to do the same.

Here’s a little breakdown of the medical language around twins:

DCDA (or DiDi) Twins = Dichorionic Diamniotic - these twins have their own placenta and their own amniotic sac. They are usually non-identical, but about 30% are be identical.

MCDA (or MoDi) Twins = Monochorionic Diamniotic - these twins share a placenta but each has their own amniotic sac. These are identical twins.

MCMA (or MoMa) Twins = Monochorionic Monoamniotic - these twins share both a placenta and an amniotic sac. These are identical twins.

Overall about two thirds of twins are non-identical and have their own placenta and amniotic sacs. About one third of twins are identical - coming from one egg (ovum) splitting. Depending on when the egg splits after conception will affect whether they share a placenta and/or an amniotic sac. Non-identical twins are associated with fewer complications than identical twins that share a placenta and/or an amniotic sac.

Key Considerations When Supporting a Twin Pregnancy

We then split into groups to discuss the unique considerations that exist around supporting twins. This included looking at topics like: breastfeeding, pre-term birth, breech, position of the second twin, place of birth, mode of birth and twin specific complications. This sparked some great discussions and challenged what most of us have been exposed to with the medical model of childbirth. Most women experiencing a twin pregnancy will have consultant-led care in the NHS. That consultant may or may not be a twin specialist. Women should also caseload by a Twin Specialist Midwife - however as far as we’re aware, there’s no requirement for midwives in this role to have necessarily undertaken any further education or training around twin births. In terms of our own midwifery training, twin birth was touched upon but we cannot recall ever having the types of discussion we had at this workshop - highlighting for us how twin pregnancies have been removed from the midwifery scope of practice.

Nutrition For Twin Pregnancy: It Matters More Than You Think

On day 2 we looked at nutrition and how this has been neglected in mainstream maternity care - for all women really, but especially for those expecting multiples. Lily Nichols is a US based dietician whose work we return to time and time again. Her book Real Food for Pregnancy is well researched and debunks some of the myths around what you can and can’t eat in pregnancy. Lily also has a twin-specific nutrition guide that you can buy from her website - well worth it if you’re expecting twins or you’re supporting clients who are. There are also heaps of free articles on her website for you to peruse to support your nutrition in pregnancy. Being pregnant with twins is a huge load on the body so we need to be more aware of the chance of anaemia and its associated complications too.

In terms of twin pregnancies, there has been one (fairly small, but very interesting nonetheless) study back in 2003 that looked into the effect of giving women expecting twins specific nutritional support which included increasing their recommended daily calorie intake, supplementing with vitamins, and dietary education. The results demonstrated a reduction in pre-term birth, pre-eclampsia, and preterm rupture of membranes. It also showed higher birthweights, longer gestations and lower levels of neonatal morbidity. The researchers also followed up the children until they were 3 years and found less hospitalisations and less likelihood of developmental delay. Unfortunately the study isn’t open access (free for everyone to read) but we did manage to obtain a copy of it and you can read the abstract here. The study is over 20 years old and based on a US population, but given the positive results it seems crazy that further studies haven’t been done on the effects of nutrition and twin pregnancy outcomes.

The Risk of Stillbirth for Twins: Understanding the Statistics

Another interesting topic of discussion that came up was around the mainstream management of twins. Current UK guidelines recommend birth of uncomplicated identical twins, who share a placenta but not an amniotic sac (MCDA), by 36+6 weeks and those that share both a placenta and an amniotic sac (MCMA) by 33+6 weeks. For uncomplicated non-identical twins (DCDA) birth is recommended by 37+6 weeks. This is because the chance of stillbirth increases for each of these types of twins after these gestations. However, as with lots of guideline recommendations when you take a deeper look at the research and the stats, the risk of stillbirth is overall still very small. The NICE guidelines simply say, ‘explain to women that…continuing the pregnancy beyond [insert appropriate gestation] increases the risk of fetal death’, without saying what the actual risk is. This isn’t very helpful to women and birthing people who are considering their options for the birth of their twins.

One piece of research from 2015 looked at a large cohort of multiple pregnancies from the US (454,626 twins were included!) and the chance of stillbirth when complicating factors such as high blood pressure (hypertension), gestational diabetes and growth-restricted babies (IUGR) were excluded from the analysis. So essentially women who were expecting twins but who had otherwise healthy pregnancies. 

Here’s what the study found:

Stillbirth rate:

37 weeks = 6.7:10'000. (0.06%)

38 weeks = 17.3:10'000 (0.17%)

39 weeks =14:10'000 (0.14%)

40 weeks = 46.6:10'000 (0.46%)

Any stillbirth or neonatal death is tragic and we don’t mean to take away from that, knowing that behind these statistics are real families who have suffered a great loss. But we also can’t ignore that the chance of having a stillbirth is used to pressure women into accepting an early birth (either by being induced or having a planned early caesarean birth). As you can see from the figures above the chance of actually having a stillbirth is overall very small, <1% where the pregnancy is otherwise uncomplicated. This study wasn’t able to differentiate between chorionicity (identical or non-identical twins) which would be really helpful information for any future research and might show even more favourable outcomes for non-identical twins, for example.

For comparision, the risks of stillbirth in an uncomplicated pregnancy with one baby are:

37 weeks = 3.11:10’000 (0.03%)

38 weeks = 3.62:10’000 (0.03%)

39 weeks = 4.53:10’000 (0.04%)

40 weeks = 6.2:10’000 (0.06%)

These statistics are from this piece of research from 2019.

The Problem with Risk in Pregnancy

The risks of induction or caesarean birth, in our experience, can be understated and often there’s not much thought given to long-term outcomes. For example, if babies are born before they’re naturally ready, say at 37 weeks - how is their long term health affected? How does it affect their breastfeeding journey? And if they encounter breastfeeding issues how does that affect their overall health and the wellbeing of their mother / birthing parent? And if a woman chooses an induction that leads to a caesarean - what’s the impact of that on her long term health and wellbeing? Too often obstetrics is focussed on the short term outcome of a live mother and a live baby - which is obviously what we all want, but we also want women and babies to be absolutely thriving without any long-term health consequences as a result of birth.

Given that the chance of experiencing a stillbirth is <1% in an uncomplicated twin pregnancy - do we need to rethink the guidance that recommends early induction of labour or caesarean section? Do the potential benefits of these interventions outweigh their risks?

The Position of the Second Twin: It Matters Less Than You Think

We spoke about the position of the second twin - and how it doesn’t really matter until the first twin is born. The second twin will get itself into its position once the first twin is out of the way - this might be head down or bum down (breech). The importance of being confident in breech birth cannot be understated when supporting twin birth - there’s about a 40% chance the second twin will be breech!

Breech extraction is a midwifery and obstetric skill, not frequently required but that can be life-saving - whereby the second twin is essentially pulled out where there are concerns about its wellbeing. It’s a significantly quicker way of getting a baby out and poses less risks to the woman. We spoke about how this skill has been lost by midwives and obstetricians and questioned if this could change outcomes in scenarios where the first twin is born vaginally and the second twin is then a caesarean birth. There’s an amazing example online of midwife Kristine Lauria doing a breech extraction at a triplet homebirth in the US, when it was found that the third baby had a low heart rate. These are skills that we hope to never have to use, but need to know about because it could just be the difference between life and death - particularly at a homebirth.

Medical Management of Twin Pregnancy and Birth: Where’s the Evidence?

The medical model has quite a strict criteria for managing vaginal twin birth in hospital settings - it’s a protocol that includes things like: induction of labour, recommending continuous fetal heart rate monitoring, recommending an epidural in case theatre is needed for the second twin, breaking the waters of the second twin, using the hormone drip (syntocinon) to bring on contractions after the birth of the first twin to speed up the birth of the second twin, manually stabilising the second twin (this usually looks like an obstetrician placing their hands on the woman’s abdomen and ‘holding’ the second twin in position). Some hospitals advise that the birth even happens in theatre, again - just in case a caesarean birth is needed. It’s worth knowing that none of this is evidence-based, rather it’s considered ‘best practice’ - but it doesn’t always make sense. For example, we know that CTG monitoring leads to more interventions. We know that epidurals increase the chance of needing an assisted birth. So in trying to prevent complications, the medical model often has a blind spot when considering how these interventions might actually lead to more interventions and or complications. This is true for all women, not just those expecting twins, and written with the understanding that for SOME women and SOME babies intervention is needed.

We spoke about how the medicalisation of childbirth - and especially multiple births - means that women are presented with risks over and over again, losing trust in their bodies ability to grow, birth and feed twin babies. How clinical the care can be, with things like hands-on abdominal palpation (an essential midwifery skill) not being used because scans are offered regularly. How women are told they’re not allowed to plan to birth at home or on a midwife-led unit because it’s too risky - instead of thinking how we can safely support women to plan the birth they want. Modern maternity care puts so much focus on the wellbeing of the baby, with very little attention truly given to that of the woman or birthing person and this is even more apparent for those expecting twins.

Reclaiming Midwifery Skills and Supporting Women’s Choices

The 2 days were full of inspiring stories, wisdom and knowledge. Whilst Debs has a focus on homebirth, the workshop wasn’t purely about supporting twin home birth. Hopefully you can see from this that it was about how we can support women and birthing people expecting twins better - from nutrition in pregnancy, to advocating for them when necessary, making sense of the statistics around stillbirth and the importance of getting to term. It was about how we can support these women when they birth their twins - whether that’s at home or in an operating theatre - remembering that birth is a huge life translation, not a medical event. It was about reclaiming midwifery skills and our voice when it comes to supporting twin pregnancies. Midwives have been silenced for centuries and we continue to be so and this not only negatively impacts us as a profession but impacts the care that women and babies receive and even their outcomes. There’s so much more to say on twins, but hopefully this gives you a taste of what the workshop was like!

We rounded off these two glorious days with reflections on what we had learnt and how we felt after being in the space together. Everyone left feeling more hopeful, more knowledgeable and more ready to support twin pregnancies and birth. We are grateful that people like Debs exist, boldly challenging the status quo, supporting birthing women and passing on her skills and knowledge for the better of all midwives, doulas, birthkeepers and ultimately women.

Juno Midwives Support Twin Pregnancy and Birth

If you’re expecting twins and are looking for more personalised care and support for your pregnancy, why not book a free intro chat? We support those planning homebirth or hospital birth - respecting your rights and choices every step of the way.