This chapter has been compiled from information gleaned from a PTSD sufferer who has had three multiple pregnancies and one singleton pregnancy.

Multiple pregnancies are considered "high risk" and are therefore monitored more closely. The usual pregnancy complaints, eg. pre-eclampsia, morning sickness, are more likely and often more extreme. The likelihood of premature labour also increases. In order to reduce the risk of PTSD and to lower the risk of premature birth, stress needs to be kept to a manageable level as far as is possible.

Here are examples of some of the more common risk factors that are present during multiple pregnancies and births (in addition to those mentioned on the "Risk Factors" page).

PREGNANCY

• Conflicting advice.
• Lack of information eg.
  • information regarding dietary needs.
  • premature labour signs.
  • what to expect in labour - worries are often fobbed off as "it's just because you're carrying twins/triplets."
• Multi-handling.
• Increased risk of losing the baby due to:
  • twin to twin transfusion syndrome (affects 15% of identicals).
  • cord entanglement (mono chorionic/ amnionic babies - sharing a sac).
  • very pre-term labour.
  • or one baby may die in-utero. This may mean the mother may need to continue with the pregnancy to give the other baby/ies a chance to survive (small % but it does happen).
• Increased risk of anaemia, pre-eclampsia and placenta praevia.

DELIVERY

• Managed labour.
• Induction.
• Lack of information.
• More staff present who are not known or introduced.
• Less control during labour than with a singleton.
• Increased risk of intervention.
• Invasive procedures without explanation or consent.
• Increased risk of post-partum haemorrhage.
• Subsequent baby/ies may move into unfavourable birth positions.
• Separation of mother and babies.

DO's

• If you are not happy with your LMC - change LMCs. Ring your local multiple birth club for names of midwives
/ obstetricians that others have found supportive.
• Ask as many questions as you have a need for answers.
• Write a realistic Birth Plan and involve your support people in your plans. Discuss the "what ifs" and develop contingency plans. Your support people may need to be your advocates during labour especially if continuity of care is lacking. You will all need to be clear and strong about what your needs are.
• Take a support person with you to appointments if you feel you are not being listened to.
• Visit the newborn intensive care/ special care unit "just in case." Approximately 50% of babies going through these units are multiples! Being familiar with the units will reduce the stress levels if your babies require specialist care.
• Have at least 2 support people with you in labour. If 1 or more babies needs to go to the newborn intensive care unit, one person goes with the babies and one stays with the mother. This also gives the support people the opportunity to "recharge their batteries" during labour.

DON'Ts

• When you are feeling worried don't be fobbed off with "It's just because you're carrying twins/triplets." -ask for more information. When told "It'll be different for you because you're carrying twins/triplets." Ask how it will be different.
• Don't go under the care of a "team" unless you have to. Continuity of care has been shown to bring the best results. If you have no choice, try to arrange to see the same midwife/ obstetrician by finding out when they are on duty and arranging your appointments accordingly. When you arrive, ask to be seen by the same midwife/ obstetrician. This may mean a longer wait but it's worth it for the continuity of care.

EXAMPLES OF QUESTIONS TO ASK:

• Are my babies identical or fraternal? (Identicals with a single placenta are at higher risk of complications)
• What knowledge and experience do you have of multiple pregnancies? How many multiple pregnancies do you handle?
• What can I expect during labour? How is it different to singleton delivery? How many people are likely to be present?
• What are the premature labour warnings?
• How do I reduce the risks of premature labour?
• How much weight should I aim to put on during this pregnancy?
• What is a recommended diet for a multiple pregnancy?
• What is the recommended time to stop work when carrying multiples?

Mothers of multiples also have an increased chance of PND (some say 30%) due to birth separation, intervention, and a host of other things. (How much of the diagnosed PND is actually PTSD?) Isolation and the lack of help available can only compound these factors.
 

Multiple Birth Clubs Multiple Birth Clubs exist countrywide. They are listed under "Multiple Births" in the White Pages along with the N.Z.M.B.A. contact address. Along with hire equipment, books, videos, newsletters, playgroups, etc, most clubs also have a New Mother contact and someone with knowledge of at least PND. It is helpful for all expectant mothers of multiples to meet up with others in the same situation. It provides the opportunity to compare notes, share experiences and have contact with others whose babies are of a similar age and development. This contact may also be helpful in reducing the chances of PND as you are more likely to pick up the phone and discuss whatever it is that is bothering you. This is also helpful for those wishing to breastfeed their babies, again because of the mutual support.

TABS is aware that there are now antenatal classes for multiples being held in Auckland. For further information they can be contacted on (09) 828 7538 or E-mail: squibs@watchdog.net.nz.
 

TABS hopes that the need for antenatal classes for multiples will be recognised as essential and begin to be met alongside the regular antenatal classes nationwide.

BIRTH PLANS FOR MULTIPLE BIRTHS

Labour and birth where multiples are concerned can be both overwhelming and daunting. Higher numbers of staff present and less say in what goes on, all risk previously traumatised women being re-triggered.

The birth plan therefore needs careful consideration. However, it must also be recognised, that on the day, due to the situation, it may mean that everything planned or hoped for may go "out the window."

• Ideally have one Lead Maternity Carer (LMC).
• Working with your partner, write your IDEAL birth plan. This will help your caregivers to gain a clearer understanding of your hopes and of your knowledge of the labour and birth of multiples.
• Next, sit down with your caregiver(s) and go over the birth plan. Questions to ask include:
  • What stages of the labour and birth do you (the caregiver) need to have total control of?
  • Are there other areas where you are willing to be more flexible?
  • Given my previous obstetric history, I'd like to avoid the following procedures/ situations, (give examples.)
  • If it becomes necessary to proceed with these, are there any alternatives we can consider?
  • If not, what suggestions can you offer to help me to cope with a situation that could easily re-trigger my PTSD, an option I am obviously trying to avoid.
• When both parties are happy, and a point of compromise has been reached, rewrite the plan as your REALISTIC birth plan.
• Ensure that all the necessary people have a copy including your support people (have at least two), your caregivers and have a spare copy in your bag to take to the hospital.
• If, when you arrive at the hospital, you find unfamiliar caregivers on duty, INSIST that they read through your birth plan. With familiar caregivers, remind them of it if you feel this is necessary.

The hope is that with realistic expectations of the birth, good communication and informed consent throughout, your labour and birth will be the happy occasion it should be.

A personal account:

I can't believe you are still conscious: A mother tells of her experience with Twin to Twin Transfusion Syndrome.