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Twins, triplets and more

Twins, triplets and more

Information for expectant parents

How twins are formed

Identical or monozygotic twins or triplets are the product of a single sperm and a single egg. In an early stage the embryo divides and each half will become a separate individual. If one of these halves splits again they will become identical or monozygotic triplets. As the embryos come from the same sperm and egg, the babies will be of the same sex and genetically identical.

Non-identical or dizygotic twins or triplets are the product of two or three different eggs fertilized by two or three different sperm. They go on to develop into two or three different individuals. They will be genetically different and may be of the same or different sex. In other words, siblings; born on the same day.

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Possible complications of multiple birth pregnancies:

  • Morning sickness or hyperemesis (excessive nausea and vomiting).
  • Increased reflux.
  • Increased risk of swollen legs and varicose veins.
  • Increased shortness of breath in last trimester.
  • Pre-eclampsia (high blood pressure with protein present in the urine).
  • Anaemia (low iron in your blood).
  • Twin to twin transfusion syndrome (affects 10 per cent of monozygotic twins).
  • Preterm birth and risks of prematurity.
  • Antepartum haemorrhage—increase chance of placenta praevia.
  • Higher rates of birth defects.
  • Increased risk of miscarriage or stillbirth.
  • Increased risk of cerebral palsy.

Signs of preterm labour

Approximately 50 per cent of twin pregnancies and virtually all triplet pregnancies will be born prematurely (before 37 weeks gestation). Signs of preterm labour include:

  • a show (mucous plug)
  • contractions
  • rupture of membranes.

Enhancing the psychological development of twins, triplets or more

  • Refer to your children by name; not as ‘the twins’ or ‘the triplets’
  • Help your children to develop their own friends and interests
  • Arrange for each child to have time away from their brothers and sisters
  • Make eye contact with each child when speaking to them
  • Reward each child for individual achievements
  • Compare them with their peer group—not with their co-multiples
  • Be careful not to stereotype each child i.e. as the ‘noisy one’ and the ‘quiet one’ as you will find other people adopt your stereotypes and may take this to the next step—as in ‘we won’t ask the noisy one over to play’
  • Enjoy your babies as the individuals they are.

Helping twins and triplets sleep at the same time.

By putting your babies to bed at the same time, it is more likely you will be able to keep them on the same or similar sleep patterns. Remember to follow safe sleeping guidelines at all times.

A soothing bedtime routine involving a warm bath, a bedtime story or familiar soothing music, a cuddle or massage, and quiet talk will prepare your babies for sleep. If you stick to a consistent routine your babies will learn the signs that it’s time for bed.

Wrapping your babies firmly, but not tightly, in a light wrap will help them feel secure and ready for sleep. Young babies may also sleep better with an article of clothing you have recently worn or a breast pad that still has mum’s scent.

Put your babies to sleep in the same cot. Babies are comforted by close physical contact. You may find that they will cuddle each other or suck each other’s hands. When you chose to put your babies into two separate cots is up to you, but be sure they can still see each other.

Accept that multiples will sleep through the night when they are ready. Sleep routines depend more on your baby’s weight, not their age. Identical twins tend to sleep through at about the same time. Fraternal twins sleep patterns will be more independent, especially if the babies are very different in size and temperament.

Discourage night time waking. Do this by keeping night time as quiet and calm as possible. Use only a dim night light and avoid playing noisy games. If you use a reliable disposable nappy overnight, only change babies if nappies are soiled not just wet. Feed babies if a feed is needed and settle straight back to bed. Putting on familiar quiet music may help. Older babies may like a toy or favourite rug to settle with at night.

During the day give your babies plenty of time to cuddle, suck, rock and play. Don’t be afraid you will spoil your babies by overdoing it in any of these areas. Fathers with their strong, gentle touch can often soothe screaming babies more easily than mothers.

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Breastfeeding twins

The benefits of breastfeeding twins are the same as for breastfeeding single babies.

  • Breast milk is more easily digested.
  • Convenient.
  • Economical.
  • Helps prevent infection; particularly important in preterm babies.
  • The release of oxytocin during breastfeeding assists with ‘bonding’. Especially important for mothers of multiples who may be separated after birth if the babies are transferred to the Neonatal Critical Care Unit.

Preparing for breastfeeding before your babies arrive

  • Be prepared by reading information about breastfeeding twins. The Australian Breastfeeding Association (ABA) and The Australian Multiple Birth Association (AMBA) both have information about twin feeding.
  • The AMBA can put you in touch with other mothers who are breastfeeding twins and they also sell and hire twin feeding pillows. A twin pillow is not essential, but will make life easier in the early months. Mater Mothers’ Breastfeeding Support Service also sells twin feeding pillows and they can be contacted on telephone 07 3163 8847. These pillows can also be purchased in baby equipment stores. You may find your pillow is no longer needed after the first few months, as babies feeding in the ‘football or twin’ hold on the pillow, become too long to continue with this feeding position. By this time the babies should have good head control, making feeding easier in general.
  • Purchase maternity bras that are easy to undo and do up with one hand.
  • You may find it easier to have a haircut that doesn’t fall into your eyes, or remember to tie hair back when feeding—you may not have a spare hand to brush hair off your face.

Getting started

  • As with single babies, ideally breastfeed within the first hour after birth.
  • If babies are well enough to go back to the ward with you, be sure to ask for help from your midwife with each feed, until you are feeling confident with latching the babies either separately or simultaneously.
  • If your babies are with you on the postnatal floors and you are experiencing a lot of difficulty with breastfeeding, talk to your midwife about getting a referral to the Breastfeeding Support Service.
  • The postnatal floors and the Neonatal Critical Care Unit (NNCU) have twin feeding pillows available to assist with positioning your babies.
  • If your babies are premature or unwell an
  • The first milk that you express is called colostrum. This is particularly high in antibodies and can help protect your babies from infection.
  • Please read information on expressing which will discuss how and when to express. This information is available in the NNCU.
  • Once you are using the pump to express, it is preferable that you use a double pump to express. This means having two attachments for the pump, one on each breast at the same time. Double pumping can save time on expressing as well as stimulate a larger milk supply as it simulates twin feeding.
  • If you are unable to double pump, super switching is recommended. This means expressing one side for five minutes and changing sides, back and forth every five minutes. Continue expressing for about 15 minutes with a double pump, or 30 minutes of super switching.
  • Express at least eight times in 24 hours. Expressing log books are available in the nursery. Writing down when and how much you are expressing may be helpful in the early days or weeks. Bring this booklet with you if you have an appointment with the Lactation Consultant especially if you are concerned about your milk supply.
  • Once babies in the NNCU are stable enough to have a cuddle with you, try Kangaroo Mother Care (KMC). This means holding the babies, one at a time or together, in skin to skin contact on your chest. KMC has significant benefits for babies and their parents. Babies are better able to stabilise their heart and breathing rates; they gain weight more quickly; they help their mothers release a hormone called oxytocin which can assist with bonding and help your supply of breast milk. KMC cuddles aren’t just for mothers. Fathers can also enjoy this experience and provide all these benefits for their babies.
  • When babies are able to start attempting breastfeeds, try to feed one baby at a time in the ‘twin or football’ hold. Once each baby is feeding well in this position you may like to ask your nurse to help you position both babies to feed at the same time. Twin feeding is a skill that you can learn. While it may be tricky to start with, it can save you a lot of time. However, whether you feed your babies one at a time or together is up to you. Twin feeding is not mandatory.

Should I breastfeed separately or simultaneously?

Some mothers always feed separately and some always feed simultaneously. Others will do a combination of the two. Some mothers chose to feed separately until the babies have good head control, and then they feed simultaneously.

Some mothers may feed simultaneously during the day and then feed separately overnight. In this way they can lie down to feed at night and hopefully get some rest. Also one baby may start to sleep for longer overnight and waking them may be undesirable. Other mothers chose to feed simultaneously at night to maximise sleeping time.

 

Advantages of feeding babies separately Disadvantages of feeding babies separately
  • it is easy to hold one baby at a time
  • feeding times my be twice as long
  • the baby who is not being fed may complain loudly, making feeding stressful
  • the second breast may leak profusely.
Advantages of feeding babies simultaneously Disadvantages of feeding babies simultaneously
  • both babies are calmed and satisfied at once
  • can be relaxing once technique is mastered and a comfortable position is found
  • usually quicker as each baby feeds on one side.
  • you may get hot in summer with two babies and surrounding pillows so have a cool washer handy for yourself
  • may require a second person to help position your babies
  • may be difficult to get a free hand to have a drink
  • may need to wake the second baby to feed–then the sleepy baby may not feed as well (although babies usually adapt quickly)
  • babies may have different feeding needs depending on size and temperament
  • it can be difficult to feed discreetly in public. You may choose to feed your babies separately when out and about.

 

Which breast?

It is up to you to decide if you wish to use one breast for a particular baby or alternate feed to feed or day by day.

  • Are the babies of equal strength with their sucking ability? If not it would be desirable to alternate breasts to maintain a good milk supply in both breasts.
  • Some literature advocates alternating sides so each baby receives equal visual stimulation. If each baby has their own breast this concern can be overcome by carrying or burping the babies in varying positions.
  • Some mothers may have breasts that have very different milk producing capacities, meaning one baby would consistently be getting less.
  • One baby may have a strong preference for a particular side.
  • If the babies have their own breast, this breast will develop a milk supply based on that baby’s demands/needs. Each breast operates independently.

Feeding positions

Twin, rugby or football hold, using a twin feeding pillow. Ideally place your hands at the back of your baby’s neck and shoulders, and not behind their heads, as in the next picture.

Breastfeeding triplets or quads

Once a mother has made the decision to breastfeed triplets or quads she is going to need information and positive support and encouragement from those around her. As with twins, it is important that mothers of triplets or quads read information about breastfeeding higher order multiples; expressing and storing milk; breastfeeding preterm infants and breast pump hire. Most of the questions or concerns of the parents will be about things such as milk production, feeding patterns and planning of breastfeeding times. Expressing extra milk to maintain supply or have milk available to feed by bottle is essential for most mothers.

Mothers will need someone who is going to provide support and assistance at home. Fathers or partners of multiples must get involved. They need to be included in any education the mother receives, before and after the babies arrive.

Ways to breastfeed triplets and quads

Some mothers may feed separately until the babies have good head control and attach more easily—then feed simultaneously. The twin pillow can make it easier to position two babies at the breast. The third (and fourth baby) can then be fed when the first two are finished or alternatively could be fed a bottle of breast milk or formula by a second person. Next feed the mother may rotate which babies had the breast or the bottle.

Feeding Baby A Baby B Baby C
1 Breast Breast Bottle
2 Bottle Breast Breast
3 Breast Bottle Breast

Advantages

  • two, three or four babies satisfied and calmed at once
  • will provide the mother with longer breaks between feeds and hopefully more rest.

Disadvantages

  • may get quite hot in summer with two babies and surrounding pillows—having a cool wet washer handy may help
  • may require second person to help get into position initially and to bottle feed the third and/or fourth baby
  • may be difficult to get a free hand for a drink
  • may need to wake other babies to feed; then sleepy baby/babies may not feed as well, although most babies adapt quickly
  • babies may have very different feeding needs depending on weights and temperament
  • it can be very difficult to feed discreetly in public.

Some mothers may choose to feed simultaneously by day then feed separately overnight. In this way the mother can lie down to feed each baby and hopefully get some rest. Also one baby may start to sleep longer overnight so waking them may be undesirable. Other mothers who feed separately through the day may opt to feed simultaneously overnight to maximise sleeping time. It is a good idea to learn to feed in a side lying position, this way any time you are feeding only one baby you can lie down and rest!

Which breast?

Mothers breastfeeding more than two babies will need to rotate the babies between breasts to ensure that each baby receives adequate breast milk over the day. While still allowing each baby to have untimed access to the breast they each need to have a chance to start or finish the feed. A formalised rotation plan can be followed.

Feeding Baby A Baby B Baby C
1 Left breast Right breast Both breasts
2 Both breasts Left breast Right breast
3 Right breast Both breasts Left breast

Breastfeeding higher order multiples will require a lot of time, patience and a strong desire to succeed. Parents can be taught to set goals for their breastfeeding, and once achieved to set new goals. For some parents the goal will be to provide breast milk while the babies are in hospital. Other parents may wish to breastfeed or provide breast milk for much longer. As with any baby, some breast milk is a lot better than none!

Buying for your babies

Cots

Buy cots that comply with Australian Standards. Initially you do not need two cots, as both babies can sleep in the same cot.  If your babies are co-sleeping it is important to follow the safe sleeping guidelines. These can be found at www.sidsandkids.com.au

Car restraints

  • Queensland legislation requires that all children up to seven years of age are to be secured in an approved child restraint that is installed according to the manufacturers’ instructions.
    • Birth to six months (less than 8 kilograms) rearward facing baby capsule or infant restraint
    • Six months to one year (8–12 kilograms) rearward or forward facing infant restraint
    • Six months to four years (8–18 kilograms) forward facing restraint with built in harness
    • Four to seven years (14– 26 kilograms) booster seat with H-harness or a booster seat with a secured adult seatbelt
  • Look for a label or sticker that states the child restraint complies with the Australian Standard.
  • If you have a second-hand restraint, you need to be assured of its history and that it has not been in an accident. If you do not have this information, the manufacture’s fitting instructions, or the restraint is more than 10 years old you should not use it.
  • If you are unsure about the fitting of a child restraint, you can contact the Child Restraint Fitting and Checking Service on 07 3854 1829.
  • Restraints and strollers should have a five point harness system.
  • Never leave your baby unattended in a car.
  • For further information on child restraint laws may be located at http://www.tmr.qld.gov.au/Safety/Driver-guide/Child-restraints.aspx or telephone 13 23 80
  • If you have a small car, check that both restraints will fit next to each other.

Prams and strollers

Choose a pram or stroller that complies with Australian Standards. Whatever type of twin pram you choose is your personal choice; however, you should consider the following when shopping around:

  • the split seats should lock securely into position
  • the seats should be adjustable so that one baby, who is awake, can be sitting up if the other baby is lying down 
  • it should easy to steer and manouvreable with solid and durable wheels
  • the brakes should have an effective locking mechanism
  • It should be easy to fold and not overly heavy.
  • check the dimensions of the boot of your car before deciding on a particular pram to ensure you will be able to transport it
  • check the covers are removable and washable.

Baby sling or pouch

These can be very soothing if one of your babies is unsettled. If using a baby sling, choose one that provides good, even shoulder support and has waist straps for extra support. If the weight of the sling is supported onto your hips this will help you to maintain a good posture. Keep baby’s weight close to your body. 

Change tables, baby baths and high chairs

A change table is convenient but not essential, as use a baby bath. Babies can be bathed in a normal tub, or a laundry tub, which is an ideal height to protect your back. High chairs can be purchased at a later date when your babies are sitting up and have commenced on solid foods.

Nappies

If using cloth nappies and assuming that you change a baby six to eight times in a 24 hour period, and wash every two to three days, you would expect to need at least three dozen nappies per baby.  It is not uncommon to average 90 to 110 nappies per week with twins and 130 to 150 per week for triplets, in the first few weeks

As disposable nappies are more absorbent than cloth nappies, a baby may only require changing five to six times in a 24 hour period, so you would require approximately 70 disposable nappies per week, with twins.  This can be quite expensive and you may choose to use cloth nappies during the day and disposable nappies at night.  What you decide to do will largely depend on your budget and your preference.

Clothing

You will appreciate practical baby clothes made with easy care fabrics such as stretch terry cloth. Extra clothing is needed so you do not have to wash daily.  The basic items you would require for twins would include:

  • 8 to 10 terry cloth one-piece stretch suits with snaps at the crotch
  • 8 to 10 cotton singlets
  • 4 to 6 matinee jackets or cardigans, preferably machine washable. These items depend on the time of year and the climate where you live.
  • 4 to 6 pairs of bootees or socks, again if climate warrants
  • 6 to 8  nighties ( or additional one-piece stretch suits, for sleeping
  • 4 to 6 blankets, bunny rugs or muslin wraps.

This is just a basic list, especially for clothing.  You will find that family and friends are usually very generous with gifts and hand me downs, and you will have more outfits than your babies can wear.

Household help

Very few parents are prepared for the realities of raising multiples. Some will have greater practical difficulties, especially if there are financial problems. Others may have plenty of assistance and living space but are challenged emotionally by the simultaneous demands of their children.

Arrange household assistance now for when you return home from hospital.  This basic need of all new mothers is more pronounced with twins, triplets or more especially after the increased risk of a caesarean birth.  If possible night help is needed, as well as during the day.

Many couples no longer live  near their families and have to rely on friends, neighbours or hired help to clean, cook and baby-sit. Sometimes your expectations of grandparents and other relatives are not met, and it is hard for them to ‘rise to the occasion’ which mostly requires the services of a full time worker. They rally around in the beginning, but after a month or so their visits may taper off because they figure you have everything well under control; but this is usually when your babies are more active, and you need it even more.

By preparing your support system well ahead, you will avoid feelings of low self-esteem when the reality of caring for two or more hits home, couples who image they will cope alone then feel guilty when they cannot and are reluctant to request help at that point.

Always remember, if people offer to help, accept their offers.

General tips from parents of multiples

The following tips are general advice for new parents by parents of multiples. Remember, what works for one family may or may not work for yours.

Bathing

  • ‘Top and tail’ morning and evening—bath babies every two to three days.
  • Have both parents bath the babies at eh same time. Relaxation baths are not relaxing with a baby crying in the background.
  • Try having a shower or bath with the babies when there are two adults present—one to shower or bath with one baby; the other to undress and redress.

Out and about

  • When traveling through crowds, a single stroller and one baby in a pouch may be easier to manage—or even both babies in pouches.
  • Trains may be easier to travel on than buses. Check first that there is a ramp or lift at the stations that you need to use.
  • When out and about by yourself with the babies, try to avoid picking up one baby who may want to get out of the pram—the other baby/babies will want cuddles too.
  • Carry some tongs in the cars you can easily pick up things the babies may drop.

Feeding

  • Experiment with different feeding positions and places around the house. You may even find it comfortable to sit on the floor.
  • If your babies are bottle feeding never prop their bottles.
  • When babies start solids, use one spoon and bowl. No matter how clean you try to be, multiples will always share illnesses.

Resources

Australian Breastfeeding Association

Phone: 07 3844 6488
www.breastfeeding.asn.au

Australian Multiple Birth Association

www.amba.org.au

Mater acknowledges consumer consultation in the development of this patient information.
Last modified 21/4/2016.
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