The process of labor prepares the mother's body for a vaginal delivery. After the first stage of labor completely opens the cervix to provide a gateway for the baby's exit from the womb, it's time for the second stage of labor: pushing the presenting baby through the pelvic bones and out the vaginal opening. This stage can last for five minutes or several hours. Usually, it lasts about an hour. On average, it takes three to five pushes to move the baby out.
After the fast and frequent contractions experienced during the transition part of the first stage, this second stage of labor provides some relative relief. However, while the contractions may subside somewhat in frequency, they won't lessen in intensity, and they will be accompanied by an overwhelming urge to push or bear down. Your doctor or midwife may guide you to coordinate your pushing efforts with your contractions, or you may be encouraged to bear down when it feels right. If your epidural is still effective, you should probably receive some coaching, as your sensation will be dulled.
The bad news: You have to experience this stage of labor separately with each baby. The good news: Twins are usually a bit smaller than singleton babies and most mothers of multiples don't have a difficult time pushing them out.
The force of your uterus's contractions will continue to force the baby through your pelvis toward the vaginal opening. If necessary, an episiotomy will be performed to prevent tearing of the perineum. The doctor will make a small cut to the tissue that stretches between your vagina and rectum. The clean cut heals faster than ripped tissue. Or perineal massage may help stretch the tissue to accommodate the oncoming baby.
Once the head crowns, or bulges through the perineum, the excitement really begins. Your doctor or midwife will slowly coach the first baby's head out of your vagina. You may be instructed to stop pushing for a moment while her nose and mouth are suctioned. After the head, the largest part of the baby's body, has exited, the arms, torso, and legs slip out without much exertion. The umbilical cord will be clamped and cut, and your first twin will be handed off to a waiting attendant.
It's done! The first baby has arrived! You can bask in the joy of this moment and relax for a few moments. You're not completely finished yet, though. There's more to come.
The Intermission: Between Babies
If you were having a singleton, your childbirth experience would end here. But you're having another baby! While twins may be born within a few minutes of each other, most twins arrive at intervals of twenty to thirty minutes. This intermission between babies is a crucial time, during which both babies' condition will be assessed.
There have been some cases where twins or other multiples experience an extended intermission between births. Usually this occurs when preterm labor cannot be halted and one multiple is delivered extremely prematurely. In a delayed interval birth, the labor is stopped after the birth of one fetus, and a cerclage is performed to close the cervix. This gives the remaining baby or babies more time to develop and optimizes their chances for survival.
With more room to move, the second baby may stretch out and change position—with luck, into a vertex presentation. His rearrangement will likely be monitored by ultrasound to determine the course of action. If the baby is in a breech or transverse position, your doctor may attempt to turn him. This process, called external cephalic version, can be uncomfortable, as the doctor pushes forcefully on your abdomen in an attempt to turn the baby head down.
This baby requires some careful monitoring during this time. If his bag of water remained intact during the delivery of his co-twin, it will need to be broken now. With his brother or sister out of the way, his situation poses some risk. The previous contractions and pushing activity may have caused the placenta to detach, reducing the amount of oxygen delivered to the remaining baby. And there is always a concern about cord compression or prolapse, if the umbilical cord enters the birth canal before the baby does.
Your contractions will also be watched carefully during this time. If your uterus slacks off, you may receive a dose of Pitocin to reactivate the contractions to deliver the second baby. If everything is in place, it's time to push out the second baby. With a path already paved by her co-twin, the good news is that the second twin usually requires fewer pushes and is often born relatively quickly.
Final Stage: Delivery of the Placenta(s)
After both babies are delivered, there's one final step. You have to deliver the placenta(s). This important organ has been the source of nutrition and nourishment for your babies for the last few months, but now that it is no longer needed, it is time for it to depart your womb.
Most hospitals do so as a matter of routine, but you'll want the placenta(s) sent to pathology for examination. An analysis may reveal your babies' zygosity. A monochorionic placenta will indicate that your twins are monozygotic, or identical.
Your contractions will continue, with a different purpose. Instead of dilating your cervix or forcing out a baby, these contractions serve to separate the placenta from the uterine wall. A final push will expel it through your vagina. Fused or single placentas will be delivered in one shot. If your babies had separate placentas, you may have to go through this process more than once.
When the doctor or midwife clamps each cord, request that they distinguish the cords—and the corresponding placentas—so that they can be identified for ownership. In the event that there is a problem with one of the babies, an examination of cord or placental abnormalities might help pinpoint a diagnosis.
With your hard work done, you can lie back and relax. If you were given an episiotomy or experienced any tearing, you'll be stitched up and cleaned up. Your epidural may be removed at this time if you don't require any follow-up care.