Read an Excerpt
Expecting Twins, Triplets, and More
The Big Surprise and What to Do About It
"You Knew You Were Having Twins, Right?"
Wot in hell have I done to deserve all these kittens?
Don Marquis, Mehitabel and Her Kittens in Archy and Mehitabel
Thursday, November 9, 2000
Yesterday I found out I was pregnant with twins. My husband and I had gone for the routine ultrasound and had waited until I was eighteen weeks along so we could find out the sex of the baby.
I lay on the table and the tech put the goo on my belly. You know the stuffnot quite slime, not yet lotion. I'd always been convinced that some company decided that making conductive gel feel too much like a pleasant spa treatment would make it feel less like an actual diagnostic tool.
I already had the discomfort of a full bladder, and now this lady was pushing the probe right on top of it all. I felt like I was riding in a jeep over giant boulders wearing a too tight seat belt while trying not to pee on myself. But I was anxious to see the child we had made in England, and up until those first words out of the tech's mouth"You knew you were having twins, right?"I thought I could handle it.
Some strange picture popped up on the screen, and I quickly recognized it for what it wasthe abdomen and the head of a baby, side by side. I knew one baby couldn't make this picture. I was convinced thatsomeone must have put the tech up to this. I had many friends in this hospital. Which one did this?
Then she moved the picture, and I saw two hearts, side by side. Twins!
I went completely numb. Ben, my husband, now says he felt all the blood leave his body. Then, partly recovered, he noticed that I was pale and hyperventilating. "Honey, are you okay?" he asked as he squeezed my hand. "Honey, you're not breathing. You've got to breathe."
"I am breathing," I insisted. I focused on the screen as the picture developed, fully switching into my "doctor mode," as my family calls my coping mechanism. Two sacs, two placentas (good, no twin transfusionmaybe), closed spinal cords (no spina bifidamaybe), intact hearts. The larger picture soon emerged in my mind: Side by side in separate sacs with the membrane between them running from the top of my uterus to the bottom, and ... they're perfect. A boy and a girl, we think, with two arms and two legs each, normal bones and hearts, and just the right size for their age.
I began laughing for fear I'd cry.
Whether multiple pregnancy is fortune's touch or the result of an arduous journey through the infertility clinics of the world, it is inevitably somewhat of a shock to most of us. While many who read this book may have known sooner than others that they would be carrying multiples, their uncertainty will likely be no less acute. You will undoubtedly have many of the fears and insecurities I had when first embarking on this adventure.
I want you to know that you've joined a sisterhood (and an amazingly strong fraternity for you dads) that is largely invisible to the world of "one kid at a time" families. You will be embraced (and accosted) with more stories than the average expectant mom. You will receive the stares and comments of those uneducated souls who think you're just plain fat. You will hear horror stories of terrible outcomes and predictions of the end of your social life from those who had only one at a time. I have been told, "Honey, you really need to watch whatyou're eating. Baby doesn't need all that," and "Just wait until they're six months old. You won't be able to go anywhere." Be kind in your thoughts toward these people; they haven't the slightest clue what you're going through. Ignore the ignorant. They mean well when they're not trying too hard to be clever. My response has typically been to ask them in feigned earnestness how old their twins are. It usually stops the intrusion.
Embrace the parents who have been where you are. They know the truth. Parents of multiples have had the fears you've had, and they've survived. From parents of multiples I have heard only reassurances. Strangers, friends, or patients, they remind me so often what a blessing their twins or triplets are and how they have weathered hardships and come out stronger. Ours, and now yours, is a survivors' club, forever changed by what we have endured and strengthened by new priorities, renewed patience, and a learned behavior of expecting the unexpected.
So, what is a multiple pregnancy, how rare is it really, and how does a couple survive it with their sanity and relationship intact? First, you need to arm yourself with some facts. Then, you need to assemble the team of experts you can trust to guide you the rest of the way through. With luck, patience, and learned skills you can soon begin to deal with stress and with the unexpected conditions of an experience completely out of control.
Get ready for the two most common questions you will hear at home, at work, at the grocery store, at church, or at the mall: "Ooh, are they twins?" (in the first two years of life I think the answer should be "duh") soon to be followed by "Are they identical?" You may also hear my favorite query: "Are they natural twins [triplets, and so on], or did you go through fertility treatment?" For some reason the intrusion on one's privacy when one has multiples doesn't end with pregnancy, as it blessedly does for those with a singleton pregnancy.Whether you like it or not, you will be fodder for the public's perceived "right to know" for some time. Whether you answer them or not (especially about the fertility treatments), you should be familiar with the terms used when referring to your pregnancy and babies.
Ladies, if your husband is anything like mine, he will undoubtedly take this opportunity to pride himself on his skill at having impregnated you twice or more at one go. Ben was said to have returned to work after the first ultrasound bragging that he had been "shooting from both barrels" the night I conceived. I think it's compensation for their suppressed desire to turn tail and run in the opposite direction from the diagnosis.
By definition, a multiple pregnancy is one in which either more than one egg was fertilized or the fertilized egg split early in its development. The babies produced in a multiple pregnancy are defined in such a way as to clarify the source of multiplication and to help doctors identify potential problems as early as possible. Many of the following definitions are those pertaining to twins. Your doctor can help you with definitions for your pregnancy if you are having more than two babies.
Those babies produced from more than one egg are called fraternal twins, triplets, and so on. The medical term for them is dizygotic (two eggs) if they are twins. These babies by definition are as similar as any other siblings and will each have her own sac of amniotic fluid and her own placenta. Dizygotic twins will have their own potential complications but will be spared others (discussed in other sections and in the Rapid Reference Guides in chapters 14 and 15). By luck of the draw, these multiples can be any combination of boys and girls.
Babies who are the result of a single fertilized egg splitting are called monozygotic (one egg). They share an identical set of genetic material and are of the same sex. They have the potential to look exactly alike, although not all do because of the different ways in which our genetic material can express itself. These eggs split at different stages of development, during which time the parts essential to support life inside the uterus (placenta, fluid, protective sac [chorion], and umbilical cord) are forming. Because of this difference, these babies can live life inside their moms in a variety of conditions. If the egg splits within the first three days, each child will have his own amniotic sac and placenta and live a completely separate life in the womb. They are known as diamnionic/ dichorionic if they are twins, and frequently have the same promise and potential problems as fraternal (dizygotic) multiples. If the egg splits after certain components of fetal life have formed, the babies can share the placenta or sac or both (known as monoamniotic /monochorionic). Those eggs that wait too late to split (around days thirteen to fifteen) give rise to conjoined, or Siamese, twins. Very rarely do eggs splitting at this stage result in more than two babies.
Twins do tend to run in families. The likelihood of having twins resulting from one egg (monozygotic) can be inherited from our mothers, and the likelihood of having twins from two eggs (dizygotic) can be inherited from either parent. The odds of having twins is 1.7 times normal for those whose sisters have had twins, and 2.5 times normal for those who are the children of a twin mother.
In 2002, the last year for which statistics are available, there were more than 4 million live births to women of all ages. Just over 125,000 of these births, or 3.1 percent, were to moms of twins, and almost two in a thousand pregnancies resulted in the birth of triplets, quadruplets, or more babies. This represents a continued increase in the number of women having twins and a slight decrease in those having more than two babies per pregnancy. Overall, the chance of having twins has increased from one in eighty (according to a 1993 textbook I have) to one in thirty-two pregnancies!
The chance of having multiple births increases with older mothers, those who used assistive technologies (Clomid, in vitro fertilization, and so on; see the discussion below), and with mothers of African-American heritage, followed by non-Hispanic black women and Caucasian women. If you are a new member of this sisterhood, you remain unusual to the rest of the world, but you will probably see anotherparent of multiples at the mall about every other time you go shopping with yours.
The incidence or number of multiple pregnancies each year has risen dramatically since 1990, with the number of moms having twins increasing 30 to 80 percent, depending on race; the number having triplets increasing over 400 percent; quads, more than 1100 percent; and quints or more, over 500 percent. The greatest increase has been seen among older women (more than forty years old). From 2001 to 2002 the number of twin births to women over forty increased 10 percent.
A study published in 2000 showed that 43 percent of multiple births were the result of "assistive reproductive technologies," such as in vitro fertilization in which multiple embryos are created by the union of sperm and egg in a laboratory and then placed inside the mother to increase the chance of a successful pregnancy. Forty percent of multiple births were due to the use of medications such as Clomid (clomiphene), designed to stimulate the ovaries to make eggs, or to intrauterine insemination, in which the sperm is placed directly inside the woman in a doctor's office. The use of these technologies is reflected in the higher incidence of twins in women over forty-five. The number of women in this age group who had babies in the years 1990 to 2002 increased from 39 to 991 per year, and the risk of each pregnancy resulting in twins increased from 1 in 43 to 1 in 5.5! The controversy that surrounds the use of these technologies can result in an emotional strain on couples already desperate to have a child, and it is not my primary focus in writing this book. Suffice it to say that there are simply a lot more of us having a lot more babies at once than our mothers had. In fact, 18 percent of triplets or more are conceived naturally!
Unfortunately, the risk of having problems in your pregnancy is higher than for your friends who are expecting one child, but for the most part they are manageable or even preventable with early prenatal care and frequent monitoring. These will be discussed in more detail later in the book, but I include the most common and most obvious here because I know my mind was racing with terrors long before Iwent in search of information. What is most likely to happen, and why do you need to be certain you have a concerned and skilled team of health care professionals behind you in your quest for a healthy outcome?
First, multiple pregnancy carries with it a higher risk of preterm labor and low birth weight babies. Twins have a greater than fifty-fifty chance of being "low birth weight" (born weighing less than 5 pounds 5 ounces) and a 10 percent chance of being "very low birth weight" (weighing less than 3 pounds 4 ounces). The risk for triplets is 94 and 38 percent, respectively. Nearly 100 percent of pregnancies with more than three babies result in prematurity and low birth weight. This makes sense when you consider that most of us were built with a uterus designed to carry only about 15 pounds' worth of baby plus other stuff (fluid, placenta, and so on).
Start considering now how you can arrange it if your doctor someday suddenly says that hospitalization, bed rest, reduced work hours, or reduced workload are necessary. Start the nursery now or find someone who can do it for you. Get ready for that hair-raising event known as "telling the boss," to be discussed later.
As a result of the increase in early delivery and low birth weight, you may find yourself in the Neonatal Intensive Care Unit (NICU) caring for your newborns. This can be a stressful experience for new parents, whether first-timers or those with other children at home. Early preparation can help you be more comfortable with the staff and doctors who will care for your precious ones, and allow for financial stability during what may become a prolonged period of adjustment.
Dealing With It All
November 9, 2000
So many worries. We figured we could do the "one kid, two jobs" thing, but we don't know anyone with twins where mom doesn't stay home. My brother's wife had wanted to be our nanny, but how couldshe agree to twins when she has a little one still at home? What will I do with preeclampsia, preterm labor, bed rest, labor, and delivery (an epidural is definitely an option now), NICU, amniocentesis, and four hundred more of these lovely ultrasounds? How can I still see patients and build a practice? How in the world am I supposed to breast-feed twins? How can I get them on a schedule so I have time to sleep?
All I can say is that God must have a wonderful sense of humor. He must have decided that Ben and I were having way too much fun and that I was just a bit cocky. Well now, I'm challenged.
We all have our own ways of dealing with stress, and each method can be either healthy or harmful. For those of you who would otherwise resort to smoking or drinking, let me be the first to tell you that neither is a good way to deal with pregnancy. In fact, many of us doctor types think it's downright bad for your babies' health. If you do smoke or drink alcohol, stop now. If you smoke, never start againit was a bad idea to begin with.
For those of you who would love nothing better than a five-mile run, I'm afraid your doctor may not allow it in a multiple pregnancy. To those who eat until they can eat no more to combat stress, I see where you're coming fromjust don't overdo it. Some of the complications of multiple birth to be discussed later require careful adherence to a healthy diet, and remember that any unnecessary weight you put on is weight you have to try to lose later. The "baby weight" excuse lasts only so long, even with a twin (or more) pregnancy.
Handling the Shock
A multiple pregnancy is a voyage into the unknown, and that can be frightening. In fact, for those who, like me, are compulsive control freaks, it can be downright maddening. Allow yourself to be a little scared for now if you need to be. Things will get better later, and a tincture of time is a balm for many worries. If you have a need for control, recognize first that you need to work on controlling your stress.Stress hormones increase the risk of many of the problems you may already fear, including high blood pressure, preterm labor, and other complications. Letting fear and stress get the better of you will only make the situation worse.
Try journaling your thoughts. I kept a journal by my bedside, and after years of failed attempts to keep one faithfully, I found that the wakeful hours of the night and early morning that come with the incessant kicking, heartburn, and general sensation of a bowling ball in my belly made for ideal times to write. My husband, bless his soul, was fast asleep, and there is still nothing good on television late at night, even with thousands of channels. When rereading those thoughts and fears while writing this book, almost two years after my babies' birth, I realized how much of the pain, comfort, fear, pure joy, and sheer expectation I had forgotten. At the time it had been helpful for keeping track of what my doctors had told us and for noting questions to be asked at follow-up visits. Now it is a connection to that time for my husband, my children, and me, free from the distortions of distant memory. The anecdotes in each chapter of this book are synopses of those early raw thoughts.
Don't be concerned about your writing skills if you journal. Even the most disjointed or poorly spelled or vaguely worded thoughts will remind you years later of the exact feelings you had. Write down your fears to objectify and control them. Write your hopes to share with your children later. Write down your prayers and watch how they change over time. Write about the changes your body goes through. Write about your joys. Write about your discomforts. Write about other people's reactions to your pregnancy and whether they amused, frustrated, or frightened you. Write down your "to do" lists and when you finished them. Note how long it took to accomplish them in your new reality.
Invite your babies' father to write in the journal. One of the most poignant and memorable passages in mine is a four-page summary my husband wrote of a hospital stay for an illness I had, two days of which I don't remember. I had a high fever and abdominal pain, andwent into preterm labor. My doctors later decided it was just a viral illness made worse by my pregnant condition, but during the time it was happening, they were worried enough about an internal infection to consider an amniocentesis, in which a needle is placed inside the uterus and fluid removed to test for problems. In the journal Ben described with tearfulness his love for me and our twins, as yet unborn, and the fear he felt when facing the outcome of my illness. It stands now as a testament to the love we hope our children will take with them into the world and as a message to them of how to love one's spouse.
If you are more comfortable with scrapbooking, start now. You will have more ultrasound pictures, more pieces of paper to save, and more factoids to record than you ever imagined. Buy a good-quality scrapbook and record the day you found out you were pregnant, the day you found out how many babies you were to have, each month of pregnancy, how you came to name each child, and what the weather was like when you went into the hospital to deliver them. Take photographs of yourself at each stage of pregnancyyour burgeoning belly, your swollen feet, your glossy hair. Save their hospital bands, their newborn footprints, their bassinet name cards. Even consider saving the hospital bill; you'll probably want to use it as leverage when they want those new cars on their sixteenth birthdays. Consider keeping a scrapbook for the pregnancy and first year of life for each child, remembering that each is his or her own person. By the time you deliver, you will have begun your memory albums and spent a few hours in pleasurable activities related to the pregnancy that might otherwise have found you consumed with your worries. Remember that this is your pregnancy, and it is a time in your life well worth vivid remembrance.
Exercise has long been known to be a healthy adaptation to stress. In most people, moderate exercise lowers blood pressure, raises good cholesterol, increases energy levels, and decreases the risk of heart attack. Exercise decreases stress and has been shown to help in problem-solving efforts. It prevents obesity and prepares you for the habit ofspending time on yourself each day when the children are born. Strenuous exercise has even more benefitsin a nonpregnant woman. I'll discuss your goals for returning to fitness a little later. Meanwhile, if your constantly shifting puppy sack of a belly hasn't reminded you, you are pregnant with multiples and need different guidance.
For those of you who are accustomed to regular exercise, ask your doctor what you can safely do. While moderate exercise in most pregnant women can increase birth weight and decrease delivery time as well as some complications of pregnancy, women pregnant with multiple babies are at risk for hypertension and preterm labor. Exercises that can safely be done in most pregnancies will be discussed in chapters 3 and 4.
Be sure you continue to seek the joy in the everyday living of life as you anticipate the needs of the future. Continue to work if it gives you comfort or fulfillment, as long as your physician allows it. Maintain your social life for as long as you can tolerate it and as long as your health holds out. Make it a priority to pause every day for one hour for yourself and your spouse. If you have other children, put them to bed or to do their homework or to play while you reconnect with a warm bath or quiet time. Let the world know that you are special during this time and that you need extra care.
If you are having difficulty squelching the stress and finding the quiet and joyful moments of your pregnancy, consider the possibility of seeking counseling. The two faces of pregnancy are that everyone else expects you to be continuously giddy and glowing while you may be feeling just the opposite. Signs of abnormal feelings are persistent uncontrollable anxiety or feelings of sadness, especially when accompanied by poor sleep, an inability to find the joy in once-pleasurable activities, and disruption in close relationships because of the feelings. True clinical depression or anxiety attacks can put your pregnancy at risk. If this persists for long, let your doctor know and ask for a referral to a counselor or seek one in your community.
Renew your acquaintances with dear friends and loved ones nearyou. Be unafraid to reach out around you and let it be known that you will need help. You will need help when your babies are born. If you belong to a family of faith, reach out to the ministers of your congregation, the women's groups, and the benevolence ministries. This is one time in your life when you will need to learn to ask unashamedly for help. Even those of us who are by nature self-sufficient need assistance during the transition from expectant couple to accomplished parents. Assembling your volunteer workforce will serve you well on the day you tire of the week you spent without a shower, the month you've had with no sleep, or the cold that knocks you down and prevents you from giving your babies the full attention they need. Whether you need a nap, a warm meal, another diaper run to the store, a date for yourself and your husband, or a round-the-clock shift for the feeding, diapering, and care of quadruplets, you will serve yourself well by being prepared now.
Many of us fear asking for others to take from their own lives to assist us in ours. Don't. Friends and loved ones are often waiting to hear what you need and are ready to jump on the bandwagon. Asking in advance allows time for them to work out their own schedules and lets them avoid the assumption that you must be doing just fine without them.
Take advantage of the friendships and support that can be obtained by connecting with other parents of multiples. Many Mothers of Multiples (MOM) or similar groups exist across the country and have been established to share thoughts, concerns, common experiences, and even hand-me-downs. The Resources section in the back of the book contains names of groups to contact in your area and Web sites with chat rooms to surf and perhaps to join.
As you work to combat the extra measure of worry that can accompany this unfamiliar kind of pregnancy, you also need to focus on assembling your medical team and preparing for the logistic and financial aspects of your new life. By doing so as early as possible, you can prevent or delay many of the problems you are concerned about.
"I got more children than I can rightly take care of, but I ain't got more than I can love." Ossie Guffy
Famous Parents of Multiples
Madeleine Albright Muhammad Ali Meredith Baxter Corbin Bernsen Debby Boone President and Mrs. George W. Bush Beverly D'Angelo (with Al Pacino) Robert De Niro Milos Forman Michael J. Fox (with Tracy Pollan) Mel Gibson Peri Gilpin Marcia Gay Harden Ron Howard Joseph Kennedy Emeril Lagasse Joan Lunden Martie Maguire (of the Dixie Chicks) Cathy Moriarty Soledad O'Brien Jane Pauley (with Gary Trudeau) Holly Robinson Peete Lou Diamond Phillips Patricia Richardson Julia Roberts Kenny Rogers Ray Romano Jane Seymour (with James Keach)Cybill Shepherd Donald Sutherland (Kiefer and his sister) James Taylor Niki Taylor Cheryl Tiegs Denzel Washington Mary Alice Williams
EXPECTING TWINS, TRIPLETS, AND MORE. Copyright © 2005 by Rachel Franklin, M.D. All rights reserved. Printed in the United States of America. No part of this book may be used or reproduced in any manner whatsoever without written permission except in the case of brief quotations embodied in critical articles or reviews. For information, address St. Martin's Press, 175 Fifth Avenue, New York, N.Y. 10010.