A: Congratulations on your pregnancy! Many women with twins are able to have uncomplicated vaginal deliveries, so don't give up hope. Deciding the best route of delivery with twins depends on a number of factors.

There are some situations that necessitate a cesarean section. A small proportion of twins share one amniotic sac rather than the more common situation, in which each twin has its own sac. Usually this is determined by an ultrasound exam. These pregnancies are higher risk because the fetal umbilical cords can entangle, which can be very dangerous. In this case, a cesarean is always performed, often before 36 weeks to avoid risks during the last weeks of pregnancy.

Another reason for a cesarean section relates to the positioning of each twin. If both twins are developing well, and both are vertex (which means each head is oriented in the direction of the birth canal) a vaginal delivery can be attempted. Some doctors will allow for a trial of vaginal labor if the first twin is vertex and the second twin is transverse (oriented sideways) or breech (oriented with buttocks first). However, if the first twin is not positioned headfirst, a cesarean section is the safest route of delivery.

Having two babies at once does increase risks during labor and delivery, and additional precautions are taken. Both twins will need fetal heart rate monitoring; one will have external fetal heart rate monitoring and the other may have an internal scalp electrode for monitoring. If either twin shows signs of distress during labor, a cesarean section will be advised. An anesthesiologist and a neonatologist are often expected to stand by in case of emergency. With twins, you need to be flexible and ready to adapt to unexpected surprises. It's also possible to deliver your first twin vaginally and then need to deliver the second one by cesarean section! This could be necessary if fetal distress occurs after the first twin delivers, or if the second twin is unable to maneuver through the birth canal.

I suggest you take a childbirth preparation class early in your pregnancy, as many twins go into labor earlier than single pregnancies. Choose a class that discusses cesarean section in detail so you will be familiar with your hospital's protocol. Many physicians encourage the use of an epidural during labor. Find out what suggestions your doctor has for you ahead of the big event.