Twin births may go well, but they can be more difficult and risky than a single birth. This video will show how to assist in the birth of twins and what additional problems to anticipate.

Suspect twins if the fundal height is large; often measuring more than 40 centimeters. The baby’s head may be small relative to the fundal height. The woman may have noticed movement all over her belly and you may hear 2 distinct heart beats.

Many of the complications with twins cannot be predicted before labor begins. If there is time, try to transfer the woman to a higher-level facility for the birth.

Twins are more likely to be born early, and to be small and weak. Twins are more likely to be in a difficult or, even, impossible birth position — for example, breech or side lying. The cord, especially of the second twin, is more likely to drop out early; or prolapse. The placenta of the second twin may start coming off the wall of the uterus after the first twin is born. This can cause dangerous bleeding. If the second twin is not born soon after the first, the uterus may get an infection. The second twin may die in the uterus if the delay is too long. The woman is more likely to bleed heavily after the birth — often with 2 placentas instead of one.

To assist in the birth of twins, monitor the labor the same as for a single baby. Make sure when you check the heart rate that you listen to both of the babies. Have an IV in place in case oxytocin is needed.

Deliver the first baby as you would any single baby. Dry the baby and place him skin to skin on the mother. Cover him with a warm dry blanket, then after a few minutes, clamp and cut the cord. But don’t deliver the placenta until after the second baby is born.

Now turn your attention to the second baby. Check the heart rate. Then do a vaginal exam. If the baby’s head is down and well-engaged in the pelvis, the membranes can be ruptured now if they are intact. Check for cord prolapse. The second baby should be born in 15 to 20 minutes. Deliver her as you would any other baby; then dry her and place her skin to-skin with the mother. After a few minutes cut the second baby’s cord and deliver the placentas.

Here are 4 possible complications you may experience during the birth of twins:

First — the second baby may be breech. Estimate his size. If you feel he’s no larger than the first baby, the cervix is still open, and you are trained in breech deliveries, monitor the labor and manage the delivery.

Next — The second baby may be sideways. If the baby cannot be moved to either a head down or a breech position, keep the woman lying on her side so that the second baby’s cord or arm does not fall into the vagina. The baby will need to be born by a cesarean operation.

Third — contractions may have slowed or stopped after the birth of the first twin. Let the baby breastfeed to encourage labor to start again. If the baby will not breastfeed, show the mother how to massage her nipples. If the second baby has descended, try breaking the waters. If the head or breech is still high, start an oxytocin infusion; increasing carefully to have adequate contractions. Seek advanced care if these methods do not start labor.

And last — the woman may bleed after the birth of the first twin and before the second twin is born. She may have early separation of the placenta. This is very dangerous. You need to get the second baby out as fast as you can: stimulate the nipples, break the bag of waters, try an upright position, and ask the woman to push very hard.

Remember, many of the complications with twins cannot be predicted before labor starts. Clamp and cut the cord after the first twin delivers. The second baby should be born soon after the first, within 15-20 minutes.