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We continually strive to improve the quality of information
given to patients. If you have any comments or suggestions
regarding this information booklet, please contact the Head of
Midwifery, Women & Children’s Directorate, Buckinghamshire
Healthcare NHS Trust, Stoke Mandeville Hospital, Mandeville
Road, Aylesbury, Buckinghamshire. HP21 8AL
Approvals
Maternity Guidelines Group: Sep 2012, V3 Feb 2014/May 2014/Oct 2014
Divisional Board: Oct 2012, V3 Mar 2014
MSLC: V2 Sep 2012, V3 July 2014
Equality Impact Assessment: V2 Dec 2012
Patient Experience Group: V2 Feb 2013, V3 Dec 2014
Women & Children’s Directorate
How can I help reduce Healthcare Associated
Infections?
Infection control is important to the wellbeing of our patients,
and for that reason we have infection control procedures in
place. Keeping your hands clean is an effective way of
preventing the spread of infections. We ask that you, and
anyone visiting you, use the hand sanitiser available at the
main entrance of the hospital and at the entrance to every
clinical area before coming into and after leaving the clinical
area or hospital. In some situations hands may need to be
washed at the sink using soap and water rather than using
the hand sanitiser. Staff will let you know if this is the case.
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Twins and Multiple
Pregnancy
Monochorionic Twins (MC)
Patient Information Leaflet
If you require a translation of this leaflet please contact
your Midwife
Author:
G Suri / A Reddy / H Beddall
Issue date:
January 2015
Review date: January 2018
Leaflet code: WZZ1785
Version: 3
Safe & compassionate care,
every time
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How common are multiple pregnancies?
Multiple pregnancies account for 1 in every 80 pregnancies
conceived naturally. With fertility treatment the incidence of
multiple pregnancies increases and can be as high as 1 in
every 4 pregnancies.
How will I find out if I am carrying a multiple pregnancy?
This is usually diagnosed when you attend for your dating scan at
10-14 weeks, or earlier if you have experienced any early
pregnancy problems such as bleeding and pain.
The ultrasound scan will: help determine the type of multiple
pregnancy it is, help us plan the best care for you, usually identify
if the babies are identical or non-identical by their location as
Twin 1 and Twin 2 to allow us to monitor each of them individually.
Types of Multiple Pregnancies
Monochorionic or MC twins: These twins develop from one
fertilized egg and are therefore identical and share a placenta.
Usually MC twins will have their own sac of fluid (amniotic sac)
and are termed diamniotic (DA). You may see in your notes the
letters MCDA this means that you have identical twins with two
separate sacs of fluid. Rarely though they will share a single sac
and are then termed monoamniotic (MA), they will then be
described in your notes as MCMA twins.
Dichorionic or DC twins: Usually these come from two fertilised
eggs and are the more common form of twins (see separate
Dichorionic leaflet). Occasionally if a single egg divides early the
twins are DC but identical.
Type 1
Identical DC twins
2 membranes each
Inner sac or Amnion
Outer sac or Chorion
MC twins, single outer
membrane, one inner
membrane each
Type 2
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ward with you. There are Midwives, Nursery Nurses and
Breastfeeding Support Workers on this ward to help you establish
breastfeeding if desired and care routines.
If your babies need to go to the Neonatal Unit for any reason (usually
prematurity), the Midwives will care for you on the ward and ensure
you spend as much time as possible with your babies in the Neonatal
Unit.
Postnatal depression is more common with mothers with multiple
births so it is very important that you and your partner tell your
Midwife, GP or Health Visitor if you are feeling low.
Further Information
If you have any further questions or need further advice on any
issues covered in this leaflet, please ask your midwife or Obstetrician
at your clinic appointment. You can also contact us directly on any of
these numbers:
Stoke Mandeville:
Antenatal Clinic Sister: 01296 316128
Screening Co-ordinators: 01296 316269
Labour Ward: 01296 316103
Wycombe:
Antenatal Clinic Sister: 01494 425575
Screening Co-ordinators: 01494 425575
TAMBA – Twins and Multiple Births Association
2 The Willows, Gardner Road, Guildford, Surrey GU1 4PG.
Tel (twinline) 01483 304442 (10am-1pm & 7pm -10pm daily)
Telephone (office) 01483 302 483
Web: www.tamba.org.uk
Multiple Births Foundation
Hammersmith House, Level 4, Queen Charlotte’s & Chelsea
Hospital, Du Cane Road, London W12 0HS
Tel 0208 383 3519
Web: www.multiplebirths.org.uk
The UK Twin to Twin Transfusion Syndrome Association
Web: www.twin2twin.org.uk
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labour or we are planning to deliver your babies early, you will
be offered steroid injections (two injections over 24 hours) to
help mature your babies’ lungs and reduce the risk of breathing
difficulties after birth.
If you have any concerns that you may be going into premature
labour, such as noticing more frequent tightenings/contractions
or your waters breaking, please phone the labour ward on
01296 316103. The line is staffed 24 hours a day by an
experienced midwife.
Where will my babies be born?
Your babies will need to be born in hospital where there is
access to staff (Midwives, Obstetricians, Anaesthetists and
Paediatricians) and facilities (including theatre and the Neonatal
Intensive Care Unit).
Most MC twins are born by caesarean section. The reasons for
this are related to twin to twin transfusion as mentioned earlier in
this leaflet. The delivery will normally be between 36 and 37
weeks. However, sometimes complications may mean that your
babies need to be delivered earlier. In the operating theatre
there will be at least one Midwife (but usually two) a Senior
Obstetrician, their junior colleague, an Anaesthetist, a Theatre
Technician, a Theatre Nurse and a Paediatrician at the very
minimum. All these members of staff have very specific roles
in your care, so their presence is necessary.
Pain relief in labour
Different types of pain relief will be available and these will be
discussed with you. Epidurals are recommended for pain relief in
labour, especially given the increased chance of the team needing
to offer various procedures to either monitor the wellbeing of,
or help with the delivery of your babies. Spinal anaesthesia is
usually recommended for planned caesarean section.
Postnatal care
Mothers of twins or triplets have extra needs after birth. If the
babies are well and old enough to suck for themselves (more
than 35 weeks usually), they will be transferred to Rothschild
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Type 3
MC twins, no membrane
between (rare)
DC = Dichorionic
MC = Monochorionic
Higher order pregnancies (triplets or more): These come from
one, two or more fertilised eggs developing into three or more babies
in your womb. They can all be identical or a mixture of non-identical
and identical babies.
Problems which could be associated with monochorionic twins
Any multiple pregnancy can be associated with an increased risk of
most of the general complications of pregnancy.
These include:
• Morning sickness, heartburn, ankle swelling, varicose veins,
backache and tiredness.
• Anaemia (low iron). Pre-eclampsia (a condition which causes
high blood pressure with protein in the urine).
• Gestational diabetes (diabetes developing in pregnancy).
• Bleeding during pregnancy and after birth.
• Fetal growth restriction (one or more babies being small).
• Premature labour (ie before 37 weeks) delivery.
• Problems caused by babies being born prematurely (eg breathing
difficulties).
• Monochorionic (identical) twins have additional risks. These
twins share a connection between their circulation through a
shared part of the placenta. This can cause problems if the
blood is shared unequally. One twin (the recipient twin) may
get too much blood and become bigger, whilst the other (the
donor twin) gets less blood and is smaller. As a result of
having too much blood the larger twin gets rid of excess fluid
by passing more urine, which increases its amount of fluid in
the sac. The smaller twin who is not getting enough blood
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will tend to reduce the amount of urine it passes, and
therefore has less amniotic fluid. If this imbalance continues
the smaller twin can become anaemic (low red blood cell
count). This process is called twin-to-twin transfusion
syndrome (TTTS) and affects 1 in 6 MC pregnancies (so it is
quite rare) but needs close monitoring as it can become
severe and can lead to problems for both twins. Depending
upon how rapidly it develops and at what stage of
pregnancy, there are various treatments that can be offered
including delivery of the twins. To try to detect these
changes you will therefore be offered more frequent
appointments and ultrasound scans than usual to check the
growth of the babies and the amount of fluid around them.
Antenatal care
As MC multiple pregnancy can have more complications than
DC multiple pregnancy or a singleton (one baby) pregnancy we
recommend referral to a Consultant Obstetrician/fetal medicine
team to lead your pregnancy and hospital care from 16 weeks.
placenta need scans more often as they are the only type of
twins who may develop twin to twin transfusion syndrome.
Mothers with MC twins should have scans every two weeks
from 16 weeks onwards, until 28 weeks and then 2-3 weekly
until the birth.
Screening
Scan measurements and a blood test to calculate the risk of
each baby having Down’s syndrome can still be done as in
singleton pregnancies. This can be discussed in more detail
with your medical team.
When will my babies be born?
Your Obstetrician will discuss with you the best time to deliver
your babies depending on the type of multiple pregnancy and
how your pregnancy is progressing.
Triplets and other higher multiple pregnancies are usually
considered for delivery by caesarean section at 32-34
weeks.
At your Antenatal visits routine checks to determine your babies’
and your general wellbeing will be carried out. These include
taking your blood pressure, testing your urine for protein,
glucose (sugar) and signs of infection, blood tests to check for
anaemia and scans to check your babies’ growth.
Monochorionic (identical) twins are usually considered for
delivery around 36 weeks (and 32-34 weeks if
monoamniotic MA).
Having a multiple pregnancy can put you at more risk of a
condition known as pre-eclampsia and of blood clots. Your
individual risk will be assessed early in pregnancy and you may
be offered Aspirin tablets, or injections of a drug called Fragmin
through your pregnancy to reduce these risks.
We will advise early delivery if there is concern about your
health, or that of your babies. In these circumstances you may
be advised to have a caesarean delivery but this does depend
on your past history of childbirth if you have older children, as
well as the reasons for recommending early delivery.
Due to the extra demand for iron and vitamins that the
pregnancy can place on your body, you are at increased risk of
developing anaemia. For this reason you will be offered iron
and folate tablets throughout your pregnancy. We will check
your red blood cell count at around 20 weeks and 28 weeks.
Scans
Mothers carrying a multiple pregnancy need more than the usual
two scans booked for women carrying one baby. This is
increasingly important in MC twins as babies who share a
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How will my MC twins be born?
Your Obstetrician will discuss with you the best method and
appropriate time of delivering your babies. It may be possible
to have a vaginal birth, however MC twins are more likely to
require caesarean section, which will be discussed with you.
If you are expecting triplets or more, a caesarean section will be
advised.
Is premature labour likely?
Women with multiple pregnancies are most at risk of going into
labour early. If it is felt that you may be going into premature
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