Supporting Labor Doula Clients Expecting Twins

I began my Labor Doula career when my sister-in-law found out she was expecting twins. She was getting frustrated with her doctors sharing various opinions about how she should birth these babies. Some doctors said the safest option was to schedule a Cesarean at 36 weeks. Other doctors in the same practice said she could try to birth both babies vaginally if Baby A was head down. If she decided to birth the babies vaginally, her doctors would only allow this if she had an epidural and delivered in the operating room. My sister-in-law was really hoping to avoid those medications based on past experiences. She grew increasingly frustrated with the uncertainty of labor—and her medical team.

Many of my clients have also experienced these same pressures from their providers when they are pregnant with twins. Our job as labor doulas is not to convince our clients to birth a certain way or tell them what is “best”. Our role is to help our clients learn about their options and then help them communicate with their care team so they are making the best decision for themselves and their babies.

Premature Birth

About 3.26% of births in the US are twin births. (CDC 2018) Being pregnant with twins/multiples automatically increases the risk for premature birth. In addition, high blood pressure, diabetes, smoking or drug use during pregnancy, poor diet during pregnancy, pre-eclampsia (high blood pressure combined with protein in the urine, restricts blood flow to the placenta), previous delivery of a premature pregnancy, and complications in pregnancy increase the risk for premature birth as well1.

If your client gives birth to premature (preterm) babies, the babies will likely face complications related to breathing, eating, and development. The babies may spend significant time in the NICU including time in an incubator or on a ventilator for breathing support. Things you can do to support your clients include:

  • Provide resources for pumping breastmilk and encourage your client to talk to the hospital lactation consultant(s) regularly. Videos from Stanford’s Newborn Nursery video series can also provide practical tips for Maximizing Milk Production and what to do if the mother is separated from their babies.
  • Help them communicate with NICU team to decide if Kangaroo care is possible and/or other bonding activities including talking to babies, participate in feedings, or just being present to talk to their babies.
  • Check in with your client regularly, ask how they are doing, and provide referrals for their support if needed. Having babies in the NICU can be very challenging. Many communities have NICU support groups or Facebook groups dedicated to supporting NICU families.

Vaginal Birth of Both Babies

Is this a safe option for your client? Possibly! If Baby A (the baby closest to the cervix) is head down in the vertex position after 32 weeks gestation, the risks of complications are about the same as singleton babies.2  

Trials have shown that, when the first twin has a cephalic presentation, and the appropriate equipment and personnel are available, at least from 32 weeks of gestation onward, an attempt at vaginal delivery should be the default plan, regardless of the presentation of the second twin.—Dwight J Rouse, MD

If you are supporting a client planning to birth both babies vaginally, it is similar to supporting a singleton labor and birth, with a few exceptions:

  • Your client may be “required” to get an epidural so the medical team can be prepared for an emergency. Encourage your client to ask questions about their options if they are not wanting an epidural.
  • Your client will likely labor in their hospital room but be transported to the OR for pushing/birth so the health team can be prepared for emergencies. Prepare your client for the bright, sterile environment that is contrast to many labor rooms.
  • After birthing Baby A, there will likely be some “down time” before Baby B is born. Encourage your client to take slow, relaxing breaths. Encourage your client to ask to see or hold their baby if possible.
  • There will be lots of examination via the doctor’s hands and ultrasound machines after Baby A is delivered. This is so they can determine the position of Baby B. There may be some manual moving of Baby B to a heads-down position, or a breech delivery of Baby B depending on the doctor’s skill/comfort level.
  • Provide lots of encouragement when it comes time to push for Baby B! Help your client find their “second wind”!

Planned Cesarean Birth of Both Babies

About 75% of twins are born in the United States are via Cesarean birth. A look at two Twins studies show that planned cesarean delivery was associated with higher neonatal morbidity and mortality, but only among twins born at less than 37 weeks’ gestation in the overall cohort, and at less than 35 weeks in the low-risk cohort. Cesarean delivery before labor is strongly associated with respiratory distress in term and late preterm neonates.2

If your client is having a planned Cesarean for their babies, encourage them to ask about a Gentle or Family Centered Cesarean experience. If you are allowed to attend this birth, you would support your client just you would any single baby Cesarean birth.

Combination Vaginal Birth and Cesarean Birth

It is rare that your client would vaginally birth their first baby and have their second via Cesarean. This only happens about 4% of the time.3 If this happens to your client, be sure to provide lots of encouragement especially immediately after the birth. Their mind and body have been through so much! You will likely be asked to leave during the Cesarean due to the urgency of the birth and you could ask to join your client again in the recovery room.

Postpartum Support

Here are a few more tips for supporting your clients after their babies’ births:

  • Encourage your clients to get lactation support if they are planning on breast/chest feeding. It is also highly encouraged to have your clients visit with a lactation consultant during their pregnancy if they are planning on breast/chest feeding their twins.
  • Check in with your client regularly and provide information about Postpartum Mood and Anxiety Disorders. Your client will be at a higher risk for PMADs because of the twins.
  • Many twins parents share that they are overwhelmed with help in the first weeks after birth. People are excited to bring meals, visit the babies, and help as needed. However, after those first weeks, new twins’ parents say that their support often disappears. The “novelty” of twins wears off and they are left feeling alone and exhausted. You can help by setting up a meal train that covers the first few months plus include days where people may help with laundry or caring for babies while parents get a chance to sleep. Referrals to Postpartum Doulas are a great option for many families (with and without family support).


1 Multiple births and premature babies. nidirect. Published April 21, 2020. Accessed February 24, 2021.

2 MacReady N. Twin Births: Vaginal Delivery Safer Than Caesarean. Medscape. Published July 26, 2020. Accessed February 24, 2021.

3 Alexander JM, Leveno KJ, Rouse D, et al. Cesarean delivery for the second twinObstet Gynecol. 2008;112(4):748-752. doi:10.1097/AOG.0b013e318187ccb2

About the Author

Katie Nyberg has served hundreds of mothers, partners, and families through her role as a birth doula, postpartum doula, and childbirth educator since 2010. She believes that our society is not supporting new mothers enough and has made it her mission to help provide the missing care for women during their childbearing years. Katie has been a part of CAPPA since 2015. She is excited to combine her passions for teaching and for supporting new mothers through her role as Postpartum Doula Trainer. Katie is a frequent speaker for mothers, families, and health care providers in Iowa. She has been featured in a doula magazine, Parents Magazine, and on her local television station.

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