If an ultrasound shows that you’re expecting twins, and the one baby your thoughts have recently been revolving around suddenly becomes two, you may initially feel overwhelmed. Soon, you’ll probably have plenty of questions about pregnancy and childbirth: What’s special about a twin pregnancy? Is it twice as exhausting? What should you consider? And what about the delivery? In this article, we’ll answer these and many other questions.

How do twins form?

Identical twins

25 percent of twins are identical (monozygotic) twins, while 75 percent are dizygotic ( dizygote ). In identical twins, one egg is fertilized by a sperm cell and divides within three days after fertilization into two nuclei , which then migrate separately to the uterine wall. Once in the uterus, the embryos implant with identical genetic information , usually in separate amniotic sacs, and each develops its own Placenta . In that case, it is called a dichoriale twin pregnancy, which usually proceeds without complications. In rare cases, the fertilized egg splits only after implantation in the uterus. As a result, only one placenta develops, which is shared by the two embryos—this is then called a monochorial twin pregnancy. The embryos develop either in a shared amniotic sac ( monochorial-monoamniotic ) or in two separate sacs ( monochorial-diamniotic ). If twins share a placenta, this can lead to undernutrition and growth retardation in one child. Additionally, if they develop in a shared amniotic sac, there is a risk of Umbilical cord knotting . To detect these risks early and, if necessary, take action, monochorionic twin pregnancies are monitored very closely by medical professionals.

Fraternal twins

Fraternal twins develop when two eggs mature in one cycle and are fertilized by two different sperm . The embryos always have their own amniotic sac and a separate placenta. Since they develop from different eggs and sperm, the genetic makeup of fraternal twins differs, and they can also be of different sexes.

Even though multiples are always a little miracle, the probability of expecting multiple children at the same time increases after the age of 35. One reason may be that, with increasing age, the female body mobilizes all reserves, and multiple ovulations per cycle become more common. Also, with fertility treatments, which couples increasingly use with age, multiple eggs are often fertilized. In both cases, the probability of a pregnancy with fraternal twins increases. Some families have several sets of twins—then there is probably a familial predisposition. However, there is no way to naturally induce a twin pregnancy.

When can you find out if you are expecting twins?

If you are expecting multiples, you will probably find out quite early and have enough time to prepare for life with several babies. During the Ultrasound examinations in pregnancy, your doctor specifically checks whether it could be a multiple pregnancy. Twins developing in two separate amniotic sacs (regardless of whether they are identical or fraternal) can often be detected early on with ultrasound; in the case of identical twins in one amniotic sac, this is usually between the 8th and 12th week of pregnancy . From the 16th week of pregnancy onwards, it is no longer possible to determine whether your children share a gestational sac or have separate sacs. Therefore, the first ultrasound examination is especially important to determine whether the twins share the amniotic sac and/or placenta, so that any associated risks can be monitored closely.

How does the body change during pregnancy?

Medically, every twin pregnancy is automatically considered a High-risk pregnancy – but that does not mean it cannot still proceed without complications. In general, being pregnant with twins places more demands on your body than expecting just one child:

• Especially connective tissue, the pelvic floor, muscles, the skeleton, and skin are heavily challenged by the volume and weight of more than one baby.

• Your weight gain is slightly higher, averaging 15 to 20 kilograms.

• During a twin pregnancy, the body automatically produces more hormones. The increased release of the pregnancy hormone HCG can cause more pronounced typical symptoms, such as early nausea .

• The risk of high blood pressure, fluid retention, or bleeding is also slightly increased during a twin pregnancy.

What does medical care look like during a twin pregnancy?

To better monitor your well-being and your babies’ development—and to respond promptly to possible complications—the frequency of preventive examinations is higher during a twin pregnancy . Depending on whether you are expecting identical or fraternal twins, prenatal care, including four to six ultrasound examinations, will initially take place every two to three weeks and, toward the end of pregnancy, even weekly. Your doctor will focus especially on possible growth retardation or undernutrition, as well as on signs of premature Contractions . Since the risk of a Preterm birth is higher in a twin pregnancy, the length of the cervix is also monitored regularly, and the cervix is prophylactically reinforced if necessary.

There is also the risk of the so-called monochorionic twin pregnancy fetofetal transfusion syndrome (FFTS or Twin Syndrome). In this case, one twin figuratively takes blood from the shared supply at the expense of the other. As a result, it can lead not only to insufficient supply and growth delays in one child, but also to overfeeding and related complications in the other. Regular ultrasound examinations are therefore especially important during a twin pregnancy to detect potential differences in the babies’ growth early and treat them if possible.

Even though close medical monitoring is recommended, there are no fixed guidelines for how often prenatal care should take place during a twin pregnancy. Instead, the frequency of examinations depends on individual circumstances and the course of the pregnancy. It’s best to discuss with your doctor how often the check-ups make sense for you.

What should you pay attention to during pregnancy?

If you are pregnant with multiples, it is advisable to seek early assistance. Try to find a Midwife who will accompany you through pregnancy and support you with advice and practical help. Take good care of yourself by drinking plenty of fluids and by addressing complaints such as high blood pressure, nausea, Fluid retention , and protein in the urine early on. As in every pregnancy, you should now also pay special attention to a healthy and balanced diet to ensure your babies receive sufficient nutrients. During a multiple pregnancy, blood volume increases even more than in a singleton pregnancy. Therefore, it is often recommended that prophylactic iodine and iron preparations be taken. It’s best to discuss this with your gynecologist.

Since the probability of a premature birth is increased with multiples, you should take care of organizational and logistical aspects —including preparation for birth and Postpartum —as early as possible. That way, you can take things more easily toward the end of pregnancy and rest as much as possible, which in turn reduces the risk of preterm birth.

You may be wondering whether participating in a Childbirth Preparation Course during pregnancy is also useful in the case of twins. The answer is yes. There are special prenatal classes for expectant parents of multiples —both online and in person. Here, you’ll learn about the special aspects of the birth process and receive lots of information for the time after birth, including topics such as breastfeeding and feeding. And even if you only attend a "regular" childbirth preparation course and it is already certain that your babies will be born via Cesarean section , you can still benefit from elements such as gymnastics, pelvic floor exercises, or relaxation techniques. Your midwife can help you find the right exercises for you.

What is special about a twin birth?

Many expectant parents of twins wonder whether their babies can be born naturally. If this is your first birth, a vaginal delivery is generally possible as long as the leading baby is in a head-down or longitudinal position. Both babies should also have reached a certain weight, and their weights should not differ significantly. Usually, this means a hospital birth —preferably in a facility with maximum pediatric care.

Once the first twin is born, it may happen that your second baby turns again thanks to the newly gained space in the uterus . Your midwife and doctor are prepared for this situation and will try to adjust the second baby’s position so that, like their sibling, they can be born naturally. If there is no other option and the second twin turns into a position that makes a vaginal birth impossible, or if sudden supply issues for the second baby are observed, it may be necessary to deliver your second baby by cesarean section. However, this is only necessary in rare cases.

Although a natural birth of twins is possible, the proportion of Cesarean sections in twin pregnancies is still higher than in single pregnancies. A cesarean section may be necessary, for example, if your babies are in an unfavorable position, if they are particularly large or small, or if there are other risks for you or the babies during a natural birth. When deciding whether your twins will be born naturally or whether a cesarean section is the safer choice, your doctor and midwife will support you. It’s best to schedule a consultation between the 30th and 34th week of pregnancy for Birth Planning at the maternity hospital.

As already mentioned, most twins are born a little earlier , on average in the 37th week of pregnancy, when they are also considered mature. The reason is that the uterus, carrying two babies, is under greater tension, which can lead to premature labor. Under certain circumstances, the birth may also be deliberately initiated earlier , or a cesarean section may be scheduled before the due date. monochorial twins who share a placenta usually have their planned delivery between the 34th and 37th week of pregnancy, as the risk of under-supply for one twin increases in the last weeks. If the babies also share a common amniotic sac ( monochorial-monoamniotic ), they are usually born between the 32nd and 34th week via cesarean section, as the risk of umbilical cord knotting would otherwise be too high. Even before birth, midwives, obstetricians, prenatal diagnosticians, and pediatricians work closely together to make the pregnancy and the start of your babies’ lives as safe as possible.

Triplets and quadruplets are born in most cases by cesarean section in a hospital equipped with maximum pediatric care and a neonatal intensive care unit. The reason is that three or more babies usually do not meet the requirements for a natural birth, and therefore it would be too risky: if the 34th week of pregnancy has not yet been reached, if at least one baby weighs less than 2,000 grams, if one baby is more than 500 grams heavier than one of their siblings, or if the first baby is not in a head-down position, a cesarean section is always performed as a precaution.

What practical things should be kept in mind?

Maternity protection

If you are expecting twins, in Germany Maternity protection begins, as in a singleton pregnancy, six weeks before the estimated due date, but after the birth it extends to 12 weeks —four weeks longer than after the birth of a single child. If your babies are born earlier than the estimated due date, the missed maternity leave is added at the end so that you do not lose any time. After a twin birth, you also have the right to extended follow-up care . For the most accurate information, contact your health insurance provider directly.

Parental leave

Parental leave is calculated per child—for twins, you and/or your partner in Germany are therefore entitled to up to a total of six years of parental leave. These 36 months can be divided into up to three sections, but the rule also applies to twins that at least twelve months of parental leave per child must be taken within the first three years of life.

Parent and child benefits

Since the Parental allowance serves as compensation for your loss of earnings, it is also paid out only once for twins or multiples. However, you will receive a so-called Multiple Births Surcharge . For twins, you receive €300 on the basic parental allowance or €150 on parental allowance plus. For triplets, the allowance doubles, and for quadruplets, it triples.

Child benefit , however, is paid per child , so the payment doubles for twins. Some federal states and municipalities also offer support to parents of twins through additional financial assistance . Detailed information about the organizational aspects of multiple pregnancies can be obtained, for example, from pregnancy counseling centers or other contact points that your midwife can recommend to you.

There is no manual for life with multiples—nevertheless, we hope this article has answered some of your questions about twin pregnancies and helped you approach this exciting phase of life with confidence. Daily life with twins is certainly a challenge, but a beautiful one you can look forward to. We wish you all the best for this special pregnancy and the time afterward!