Welcome to AMBA's perinatal mental health information page for families with multiples.

While it has been estimated that at least one in ten pregnant women in Australia suffers from depression and/or anxiety (1) there is consistent evidence that the emotional health of mothers of multiple infants is poorer and they are at higher risk of becoming depressed, anxious and clinically exhausted after childbirth than mothers of single infants. Research has shown that mothers of twins experience rates of clinical anxiety are three times higher than among mothers of singletons and rates of depression five times higher (2). Even higher rates of depression have been reported among mothers of triplets (3).

While parenting multiples is a joy, there are also many challenges such as:

• The time and intensity of caretaking multiple babies – and sometimes balancing this with older siblings
• Less and more fragmented sleep
• Relationship stress
• Financial strain – more babies mean more resources are needed and returning to work can be difficult
• Increased risk of perinatal medical complications
• The challenge of establishing breastfeeding

It is so important to seek help. Our suggestions are to:

• Join an AMBA club to meet your peers – there is no reason for you to feel that you are alone. AMBA clubs provide many opportunities for contact with other multiple birth families including an ‘Expectant Parents Meeting’ and online forums.
• Visit the Multiples pages on the COPE website to access their resources and search their e-COPE directory for local providers 
• Review our sleep advice and look into support from your local sleep and settling service (such as Tweedle in Victoria)
• Keep up communications with your partner
• Know you have feeding options - your midwife is there to support you. If you have left hospital and are at home, review our advice and seek out support from The Australian Breastfeeding Association or look to your peers for advice on bottle feeding; there are a surprising number of helpful tools and techniques.

1. Austin M-P, Highet N and the Expert Working Group (2017)  Mental Health Care in the Perinatal Period: Australian Clinical Practice Guideline. Melbourne: Centre of Perinatal Excellence. 
2. Hay, D. A., Gleeson, C., Davies, C., Lorden, B., Mitchell, D., & Paton, L. (1990). What information should the multiple birth family receive before, during and after the birth? Acta Geneticae Medicae et Gemellologiae, 39, 259–269.
3. Robin, M., Bydlowski, M., Cahen, F., & Josse, D. (1991). Maternal reactions to the birth of triplets. Acta Geneticae Medicae et Gemellologiae, 40, 41–51

Pre-school activities at home

Part of our role as parents is to help our little humans prepare for the daunting and exciting time of commencing school.

Many parents have made the decision to stay at home with their children until they’re school-aged, whereas others have returned to work and have close family or friends care for their children, or have them attend day care. We all have times when we’re strapped for ideas on activities we can do with our children at home. What can we do to keep the little ones entertained, as well as empowering them with new skills and abilities that will prepare them for school?

While it is easy to compare your multiples, they are little individuals as well, even identicals! Each will have strengths in different areas and as they grow, it is important that we teach them just that and it’s okay to be different. 

These are only a few things that can be done at home by any carer. It’s important to remember all children, including multiples, develop at different rates. And they can only focus on one area at a time. That is, if they are developing their gross motor skills they may not be as interested in sitting still to do fine motor activities. There are so many activities parents can do at home that are low cost. 

Here are some ideas.

Activity #1 Fine motor skills

Make a necklace or bracelet by threading uncooked penne pasta onto some string will help with their hand-eye coordination. Make some playdough. Manipulating playdough is a great way for children to strengthen their hand muscles, which will help them develop the control needed to learn to write.

Activity #2 Young children explore and learn by touch

Sensory play is important for development so provide them with a variety of tastes, textures and smells. Exploring like this makes them more receptive to new experiences as they get older. Different foods – warmed, cold, blended, hard, soft, sweet, salty [in moderation], bitter – can stimulate all five senses: sight, touch, smell, taste and hearing. Next time you put some milk in rice bubbles, let your children listen to the snap, crackle and pop! Other sensory activities can include scented playdough, messy tray play (shaving cream, slime, ice cubes, jelly), ripping up paper for papier mâché, scrunching cellophane for a collage, or using items found on a nature walk to create a picture.

Activity #3 Get children moving

As part of developing gross motor skills, try to get your children to learn to hop, skip (step hop, step hop) and jump. Make it fun. Put the peg basket at one end of the yard and while hanging out the washing, ask your children to grab a red / blue / green peg. Or change the locomotion, hop over to get a peg, walk  backwards, jump like a kangaroo. Use words like over, under, through, around, into and next to, which help with spatial concepts. Use balls or bean bags to throw, catch, roll between legs, hit a chalk target on a wall.

Activity #4 Count. All the time.

Count forwards and backwards. Don’t just stop at 10. Eleven to 20 and beyond are important too. See that fruit in the basket? Can you please get me three oranges? We need to share this packet of biscuits between you and your brother. Can you make two equal groups? Make a pattern or sequence and see if your children can copy it, or predict what comes next.

~End.

Settling multiples into a good sleeping pattern

Not everyone gets the joy of experiencing multiples. You may have had friends tell you that getting their baby to sleep was hard and challenging, but when you have two or more to settle and establish a good sleeping routine for, it can feel overwhelming and daunting. The important thing to remember is that no two babies are the same, so what might work for others might not work for you and your multiples. 

Establishing a routine early on is really beneficial to you and the babies. Multiples on different feeding and sleeping schedules are going to be extremely taxing on you, both mentally and physically. An established routine will not only make your day more predictable and help you understand what your babies need (e.g. whether they are hungry or tired), it will make having multiples a lot easier and you will be able to enjoy them more. The more sleep the babies get, the more rest for mummy. Remember: happy babies = happy family!

And don’t forget that every baby is different, so with multiples you need to find that happy medium that works for you as well as for both (or all) babies. As a mother, father, or primary carer you need to guide your babies into a routine. The routine doesn’t always need to be regimented, but it does need to be consistent. Your babies will be unsettled at times, but they will sleep at some point, which means so can you. It is all trial and error and everyone makes mistakes, so don’t beat yourself up. You will find a way that works for you, maybe just not on the first try.

Here are some tips and ideas designed to save your sleep and happiness.

Tip #1 Sleep signals

A successful sleep routine starts with established sleep signals. All babies and toddlers respond well to routine. The sleep signal should be an ongoing sign that you repeat each and every time you put your multiples to sleep. It helps your babies to recognise when it’s time for sleep. Some examples of sleep signals are: a dark room; singing a song; wrapping babies in a grow bag; placing a comforter near the babies in bed; a white noise CD; a teddy bear; etc. Remember that you want to choose a signal which you can use anywhere and which does not limit you to your house. Use the signal every single time you put your multiples to sleep (day and night time sleeps).

Tip #2 Swaddling

We are firm believers in swaddling. It is well reported that babies respond very well to swaddling and we suggest to swaddle babies from day one. During pregnancy, babies are used to the confined space in the womb, so swaddling and making sure they are tight and protected is comforting and calming to them. The swaddle is designed to be firm but not too tight; it is also used to stop their reflex actions from waking them up. In addition, it helps with regulating their temperature. Swaddling can also be a sleep signal, which you can use anywhere and anytime.

Tip #3 Self-settling

Try to put your babies down whilst they are awake. Self-settling is very important – even more so in the world of multiples. It is unrealistic to think that you will be able to rock two, three or even four babies every time you want to put them to sleep. Some of our members have told us that they feel guilty putting their babies to bed awake. Take a step back and look at how you go to bed yourself: we all put ourselves to bed awake and then fall asleep. Leaving the room is perfectly fine and is another way to signal sleep to your babies.

Co-bedding multiples

Co-bedding means placing siblings from a multiple birth on the same sleep space (cot or incubator).

Below are the Red Nose recommendations for sleeping twins safely. For higher order multiple births (triplets, quadruplets, quintuplets), please refer to your health professional for advice on providing a safe sleep environment for each baby.

Dads’ roles have changed dramatically in recent decades. Not only are more fathers present at the birth of their children than in previous generations, many men are trying to be more active and engaged fathers in a variety of ways. Many families have navigated this change at a pragmatic level without a lot of discussion and role reflection.

Where to find information

# Men's health kit 3: Practitioners’ Guide to Men and their roles as Fathers. Western Sydney University 2014

Look! Is it a bird? Is it a plane?

No, it's a parent of twins with free hands! Really.

Carrying twins together in a sling soothes bubs and gives parents free hands for errands, housework and older kids, but it's vital you know how to tandem-carry before you try it. Mum of twins plus one, CARISSA MASON, reported in a previous issue of the AMBA Magazine.

Volunteer “baby-wearing” consultant Bell Griffiths loved carrying her three singletons in slings so, when she fell pregnant with twins, she knew she would give tandem wearing a go. Bell, who is a member of the Albury-Wodonga Multiple Birth Association, said baby-wearing was so convenient.  "Tandem-wearing means I am able to meet both babies' need to be close while being able to tend to my other kids", she said. "I always tandem-wear for grocery shopping, and school drop-off is easier with carriers too." When her identical boys Ethan and Chase (now 18 months) were smaller, Bell was even able to breastfeed them both while wearing them - now that's multi-tasking! Husband Jamie (pictured with Ethan and Chase - Photo taken by MILK photography Australia) also tandem-wears the boys. "He's so proud of it!" Bell says.

Bell started tandem-wearing her twins using a stretch wrap and a ring sling as soon as she was home from hospital. "I have five kids (Taylah, 10, Rory, 9, Oliver, 4) and housework to do!", she said. Bell changed to a woven wrap once the bubs were nine weeks old so she could carry one on her back. She says it's important to use a woven wrap once babies reach about 4kg each as a stretchy wrap will start to sag and be unsafe. And it's never safe to use a stretchy wrap for back carriers. Now she uses full buckles because they're quicker and toddlers are wriggly.

Bell would wear her babies for two to three hours at a time when they were newborns, but now she wears them for shorter periods, up to two hours. "Now they want to get down and explore", she says. Bell says wearing two babies often draws attention. "Oh the looks! People stop me to chat every few minutes – mostly positive things like "they look like koalas", "great idea" or "I wish I knew about that". A few people say things about them being too big/heavy or bad for my back, but the weight is distributed evenly on your hips when you use a decent ergonomically correct carrier."

Bell, along with two other ladies, runs the local sling group. "We meet once a month and help people work out the best way to wear their little ones. We have carriers to try out and troubleshoot for people who are having issues with their carriers. It's volunteer work, but I love seeing babies get cuddles and mums getting their freedom back", she says.

There's a whole community of sling groups all over Australia. Mum of three Lisa Chaplin helped establish Darwin Babywearer's Inc and also advocates for tandem baby-wearing. "I first wore my girls (fraternal twins Kallie Jade and Mahlia Rose, 3,) when they were five days old on the day we got home from hospital. It settled them so easily and made my life so much better to have them close to me. And it was the easiest option for me as a single mum as I only have two hands!" Lisa says wearing both her girls enabled her to be hands-free and allowed the twins to interact together more easily than in a pram.

Lisa, who is a member of the Northern Territory Multiple Birth Club and also has a 13-year-old daughter, Tehlita Ruby, says she has tried out quite a few wraps. "I used a Moby Wrap (commonly referred to as a stretchy wrap) to start with and, very quickly, after many YouTube visits, moved onto a long woven wrap."  Lisa has used Didymos woven wraps, a Maya tie wrap and Boba and Manduca soft-structured carriers, but, as a self-confessed "larger mum", her favourite is the Mei Tai with a ring waist. "It has extra long straps to enable it to go over me and to then put one of the girls on my back and one in the straps at the front."

Lisa says she tandem-wore her twins everywhere, including the zoo, expos and on holidays. "I have only just stopped wearing them as now they are strong-minded, independent three-year olds who want to walk everywhere", she says. Lisa encourages parents to consider tandem-wearing, do some research, find a local baby-wearing club and ask for advice.

Three deaths have occurred in Australia since 2010 as a result of suffocation in a baby sling. Dr Kirsten Vallmuur, from Queensland University of Technology's Centre for Accident Research and Road Safety – Queensland, says the biggest risk was babies placed in a C-like position, which restricted their ability to breathe. Babies don't have the strength to move out of unsafe positions. Babies have also been injured by slipping out of slings and falling, or while being positioned in or removed from a carrier. "Although there are risks with using baby slings, if used safely and correctly, there are benefits such as ease of breastfeeding, forming attachments to the infant and also providing a practical, comfortable and convenient way of carrying the baby", Kirsten says. She is working with the Queensland Office of Fair Trading on a nationwide education campaign to better inform parents about safe baby-wearing.

Specialist Paediatric Physiotherapist Melissa Locke, from Movement Solutions Physiotherapy in Brisbane, says it is vital parents protect their babies' airflow and ensure they are at a comfortable temperature while in a sling or baby carrier. "All babies in slings must have sufficient air flow and adequate support of their airway and oesophagus (food pipe)", Melissa says.

She insists parents of premature babies consult a health practitioner before using a sling. She explains: "In my experience, kangaroo cuddles, or skin-to-skin contact, are hugely beneficial for premature babies. Slings can help facilitate this skin-to-skin contact, however babies who are premature or have a low birth weight may be frailer than and not as strong as full-term infants. As well their motor skills can take longer to acquire."

"I would recommend carrying young babies who have not as yet developed head control together at the front, so that you can see them and can make sure they are in a good position. As babies develop better head control, you could carry both on either side, then graduate to wearing one on the front and one on the back as they gain good head control and wake more often." Melissa says she recommends parents always followed the TICKS guidelines - Tight, In view, Close enough to kiss, Keep chin off chest, Supported back.

She says it is also important for parents, especially new mums, to take care of their spine, joints and muscles. "During pregnancy the female body undergoes significant change in body posture – the normal curves of the spine are exaggerated, making your lower back curve more inwards and your upper back round more. On top of this, hormonal changes allow ligaments to become more lax. These changes can cause postural distortion and muscle imbalances." Melissa says it is important for mums who have delivered via caesarean to ensure their core is stable before baby-wearing and ensure it doesn't put too much strain on their lower back. She recommends consulting a women’s health physiotherapist.

"I don’t recommend new mums ‘wear’ their babies for prolonged periods of time. If possible, dads can help out with additional baby-wearing duties as they don’t have major body changes to contend with", she says. "All parents must make sure they balance the load so that it is symmetrical on their bodies, and that wearing the babies doesn’t affect the way they stand, bend or lift as this could put them at risk of back injuries or musculoskeletal conditions.

"(When choosing a baby carrier) I would look for breathable fabric, an adjustable model to make sure your baby doesn’t slide down too low and good-quality head support. Parents will also appreciate soft shoulder straps and models that are easy to get on and off, especially when they are on their own", Melissa says.

AMBA and members are proudly supported by Celeste from AngelRock Baby, supplier of the versatile TwinGo Carrier. Celeste has completed the Trageschule advanced training course and is working on a Multiples Babywearing Workshop.  If you are a member of an AMBA club you get 5% off your purchase from Celeste, quote your AMBA member number or show her your card.  A 5% donation from purchases will be given by AngelRock Baby to support AMBA. 

TIP from Celeste: Tandem carrying is best when built on the skill of solo carrying, so once you can carry one baby confidently then you can try tandem carriers.  I think this also removes the feeling that mums need to be superwoman, they can start slowly rather than jumping in the deep end. This is actually one of the reasons I love ringslings and TwinGo - both allow you to start with one at a time.

Get more information

• BCIA: Baby Carrier Industry Alliance: The BCIA has created a safety campaign 'Visible & Kissable' aimed to communicate the simplest and most easily remembered advice.  Members of BCIA, including educators, retailers and manufacturers access this safety information and abide by guidelines to promote healthy and happy babywearing.
• Safety advice about slings and baby carriers is at www.productsafety.gov.au > baby products > baby carriers
• Instructions on how to wrap babies in various slings is at www.slingbabies.co.nz
• For Australian advice and support, Bell Griffiths runs a Facebook group called twin/tandy babywearing. Lisa helped establish the Darwin Babywearer's Group, which is also on Facebook. Both mums recommend Facebook's national Babywearing Buy Sell Swap Group.
• Find your local sling group: http://www.slingmeetsaustralia.com/find-your-local-group/

Always follow the TICKS rules for safe baby-wearing - UK Sling Consortium

Tight: Slings and carriers should be tight enough to hug your baby close to you as this will be most comfortable for you both. Any slack/loose fabric will allow your baby to slump down in the carrier, which can hinder their breathing and pull on your back.

In view at all times: You should always be able to see your baby’s face by simply glancing down. The fabric of a sling or carrier should not close around them so you have to open it to check on them. 

TIP from Celeste: The adult should be able to monitor by turning to look over the shoulder.  If the adult is not flexible enough they may need to wait until their child is bigger to back carry.

Close enough to kiss: Your baby’s head should be as close to your chin as is comfortable. By tipping your head forward you should be able to kiss your baby on the head or forehead.

TIP from Celeste: in a back carry baby needs to be high enough that you feel their breath on the back of your neck if they are young.  One of the things I loved about back carrying my youngest son from 8-9 months old was hearing his voice in my ear - he also slept with his cheek on the back of my neck, and it was lovely to have him so close.

Keep chin off the chest: A baby should never be curled so their chin is forced onto their chest as this can restrict their breathing. Ensure there is always a space of at least a finger width under your baby’s chin.

Supported back: When carried upright a baby should be held comfortably close to the wearer so their back is supported in its natural position and their tummy and chest are against you. If a sling is too loose they can slump, which can partially close their airways. (This can be tested by placing a hand on your baby’s back and pressing gently – they should not uncurl or move closer to you.) A baby cradled in a pouch or ring sling should be positioned carefully with their bottom in the deepest part so the sling does not fold them in, half-pressing their chin to their chest.

TIP from Celeste: Take a little mirror with you to check on your child.  Use a cup with a straw, you can hold it and they can drink while still up.  If your bub is old enough to grab at things be careful, for example in a supermarket, you may get donked on the head by items taken off close shelves!

What is Twin-to-Twin Transfusion Syndrome?

Twin-to-Twin Transfusion Syndrome (TTTS) affects approximately 15% of identical twins that share a placenta. The condition occurs when blood from one twin (commonly called “the donor”) is transfused into the other twin (commonly called “the recipient”) via blood vessels in the shared placenta. It can also occur in triplet or quadruplet pregnancies in which foetuses share a placenta - the placenta image on this page is from an identical triplet pregnancy where all three boys shared the placenta: read more.

Although it only affects a small number of pregnancies (approximately 2% of twin pregnancies), it is a potentially serious condition and can have life-threatening effects on either one or both of the twins.

In the normal situation, blood vessels on the surface of a shared placenta of identical monochorionic twins connect to one another. There is a balanced amount of blood that flows in both directions. If there is a disturbance of this balance with more blood flowing from one baby (the donor) to the other (the recipient), TTTS occurs.

As the donor loses blood, the amount of urine produced by that twin decreases. This results in a drying up of the amniotic fluid around this baby. This lack of amniotic fluid is known as ‘oligohydramnios’ and sometimes the donor twin is referred to as the ‘stuck twin’. The recipient twin, on the other hand, gets too much blood and results in the recipient twin producing copious amounts of urine and rapid accumulation of fluid. This extra fluid results in a condition called ‘polyhydramnios’.

The extra blood the recipient twin receives can result in enlargement of the heart, and the heart can start to fail. The recipient twin’s body cavities may accumulate fluid and this can result in a condition called ‘hydrops’. If the recipient twin develops hydrops, its life is seriously threatened. The growth in the donor twin becomes restricted and in severe cases, this twin is in danger of dying.

TTTS will normally develop between about 16 and 28 weeks’ gestation. The mother’s abdomen may increase in size rapidly due to the extra amniotic fluid around the recipient twin. This may result in rupture of her membranes and/or premature labour.

Occasionally, one of the twins may be lost before delivery. If this happens, the vascular connections in the placenta may cause a serious risk to the surviving twin. The drop in blood pressure at the time of the death of a twin may cause an acute transfusion between the twins. However in about half of these cases, this transfusion may be small and not cause any damage to the surviving twin. In a further quarter of cases, the surviving twin may lose so much blood that it also dies. In the remaining quarter, the surviving twin sustains major damage to the brain and other organs due to the acute loss of blood. This may result in major disabilities such as cerebral palsy.

Symptoms of TTTS In the mother:

• Sudden weight gain
• Fundus appears large for dates (often will appear like a term pregnancy)
• Abdominal pain and tightness
• Premature onset of contractions

In the babies (determined by ultrasound assessment):

• Evidence of a monochorionic (shared) placenta
• Same sex twins
• Thin, hard to find, separating membrane
• One twin may be much larger than the other
• Different size bladders in each twin
• Polyhydramnios around one twin (more than 8cm pocket) and minimal amount of amniotic fluid around the other twin (less than 2cm pocket).

TTTS is diagnosed after an ultrasound is performed. Ideally, once identical twins are diagnosed, ultrasound scans should be performed at regular intervals so that if TTTS develops, treatment can begin as soon as possible.

{slide= What treatments options are currently available in Australia?}

Amnioreduction

This involves draining some of the amniotic fluid from the recipient baby’s sac, hopefully reducing the risk of premature birth caused by the overstretching of the mother’s uterus. An amniocentesis needle is inserted into the recipient baby’s sac and the extra amniotic fluid is removed until a normal amount of fluid remains. This procedure may need to be repeated regularly (eg: every few days, weekly or fortnightly) and usually 1-3 litres of fluid is removed. There is a small risk of rupture of the membranes and premature delivery with this procedure. However it is seen to be one of the most effective ways of allowing the pregnancy to continue. Amnioreduction is the most widely used treatment for TTTS. However it does not treat the cause of TTTS, that is, the transfusion of blood between the babies via the placenta. About 60% of babies survive under this treatment, but 20- 25% of survivors can be affected by neurological complications including cerebral palsy.

Septostomy

This treatment involves inserting a needle into the uterus and piercing the separating membrane so the fluid can transfer from the recipient twin’s sac to the donor twin’s sac. The aim of this procedure is to equalise the amounts of fluid between the twins.

Umbilical cord occlusion

This treatment is only offered by some hospitals, when one twin is extremely compromised with a very real possibility of dying. If one twin dies, the drop in blood pressure causes an acute transfusion to occur between the twins. By tying off the cord of the compromised twin, this acute transfusion is unable to occur. However, the compromised twin is immediately lost.

Foetal laser surgery

This procedure is new to Australia with a limited number of tertiary referral hospitals currently performing it. A foetoscope is passed into the uterus and the connecting blood vessels in the placenta are sealed using laser. This results in the process of TTTS being halted. Although the overall survival rates by using foetal laser surgery are similar to that of amnioreduction, the risk of cerebral handicap is significantly less (10%). Laser surgery seems to be especially suitable for severe cases of TTTS (abnormal Doppler blood flow assessment, hydrops (excessive fluid accumulating in the baby) or early presentation of TTTS, whereas the survival with amnioreduction is much worse in these groups. Check with your obstetrician or hospital as to the availability of this surgery.

These options are not all available at every hospital.

This information has been provided by AMBA's Patron Assoc Prof Mark Umstad MB BS, MD, FRCOG, FRANZCOG Consultant Obstetrician, Multiple Pregnancy Clinic, Royal Women’s Hospital, Melbourne.

{slide= What support is there for families at risk of or experiencing TTTS?}

AMBA clubs around Australia can provide support to families during their pregnancy - www.amba.org.au/clubfinder

AMBA's Forum has a TTTS board and useful information - www.amba.org.au/forum 

AMBA's TTTS support contact can be emailled on ttts@amba.org.au. 

AMBA's Patron, Assoc Prof Mark Umstad, is happy to talk to anyone in need of a second opinion. Email chairperson@amba.org.au so we can put you in contact.

Tamba (UK) have some great information and downloadable resources on their website - https://www.tamba.org.uk/ttts-resources

TTTS Australia & New Zealand - This is a Facebook group for families who have been through Twin to Twin Transfusion Syndrome (TTTS) or are currently going through TTTS in Australia or New Zealand.

TTTS Grief Support - a US based group of parents who provide care packages at no cost to families around the world.

{slide=Contacts for managing TTTS}

This list has been provided by AMBA's Patron Assoc Prof Mark Umstad. Only major capital cities have the facilities and expertise to deal with TTTS complications. 

1. NSW: RPA Sydney

RPA Sydney is keen to see women with complicated twin / higher order multiple pregnancies. They offer a range of services to these women including:

• Serial ultrasound management through a dedicated ‘multiple birth’ ultrasound clinic (including serial Doppler for TAPS  (twin anaemia-polycythaemia sequence)/ sIUGR (intrauterine growth restriction).
• NT / cFTS (combined first trimester screening) assessment and NIPT (non-invasive prenatal testing) for aneuploidy screening
• CVS (chorionic villus sampling)/ amniocentesis
• Selective reduction (early pregnancy)
• Endoscopic laser photocoagulation of placental anastamoses in twin-twin transfusion syndrome
• Selective reduction (late pregnancy / cord occlusion)
• Management of MCDA (monochorionic diamniotic) twins / TRAP (twin reversed arterial perfusion)

The contact details for the service are:

RPA Woman and Babies / Fetal Medicine
Royal Prince Alfred Hospital
Missenden Road
Camperdown NSW 2050
Tel: 02 9515 8887 (to Fetal Medicine secretary)
Tel: 02 9515 6111 (hospital switchboard) then page the MFM or COGU Fellow
Email: jon.hyett@sswahs.nsw.gov.au

2. WA: KEMH, Perth

King Edward Memorial Hospital in Perth, Western Australia manages the majority of complicated multiple pregnancies in the state of Western Australia and all cases of TTTS. They have a successful laser program for TTTS (plus interventions for other twin complications). They have an active interest in complicated multiple pregnancies and will see any woman with a problem.

Service is based in the KEMH Maternal Fetal Medicine Service. Mrs Teresa Warner is our lead midwife and is the best person for first contact. She can be emailed: Teresa.Warner@health.wa.gov.au. She will be able to supply the information on our website etc.

3. Queensland: Mater Hospital, Brisbane

Brisbane Mater Centre for Maternal Fetal Medicine can be contacted through mhmfm@mater.org.au.

The best person to contact in the first instance would be the Midwifery Consultant, Barb Soong, who can direct any queries appropriately. Barb coordinates our fetal therapy service.

Alternatively Barb can be contacted directly by phone on +61 7 3163 1894 during office hours Monday to Friday.

4. Victoria: Victorian Fetal Therapy Service

All of the hospitals in Melbourne who collaborate to provide fetal therapy can be contacted via the contact page at http://vfts.com.au/html/contact.htm.

5. NSW: Fetal Therapy Service at RHW Sydney

The NSW Fetal Therapy Centre at RHW are always keen to review complex cases of monochorionic twin/multiple pregnancies.

The contact details for the Department are those below:

Clinical Fetal Medicine Enquiries:
T: (+61) 2 9382 6098
F: (+61) 2 9382 6706
http://www.seslhd.health.nsw.gov.au/rhw/Maternal_Fetal_Medicine/

Their lead midwives, Sandy and Kate, usually take faxed referrals and then we contact the clients directly. However, in many cases the clients themselves contact us directly, in which case they just require a GP referral. Their clinic is entirely within the public system.

{slide=What is being done to help fight TTTS?}

AMBA is working closely with Tamba (UK) to support families and fight TTTS.  Read more about the fight and how you can help on Tamba's website.

{/slides}

Breastfeeding

 Key points

• Take advantage of the midwives and nurses on hand while you are still in hospital, for early advice on latching and feeding.
• Whether you choose to tandem feed - feeding two babies at the same time - or feed separately is entirely up to you.
• A supportive partner or close family member is critical to successfully breastfeed multiples, particularly in the early days when you and the babies are all learning together.
• While breastfeeding is often understood as direct latching and feeding by your babies, you may wish (or need) to express breast milk for your babies to drink via a bottle. Information on ‘exclusive expressing’ is below. Our information on Bottle Feeding may also be useful regarding equipment, hygiene and positioning.

Learning to breastfeed multiples

Tandem feeding, with one baby on each breast simultaneously, will save you time - but it is a learned practice. Initially, many breastfeeding parents prefer to feed separately and give each child individual attention. Some parents move to tandem feeding after they and their babies are comfortable breastfeeding, while others continue to feed separately right up until the babies are weaned. 

It is useful to know from the outset that tandem feeding at home by yourself can be challenging as it requires a lot of pillows and other supports to position both babies correctly. If you are out and about, tandem feeding is generally not practical. Many parents prefer to tandem breastfeed only if their partner or other support person is at home to help. If you are thinking about tandem feeding, it is a good idea to try the positioning at least once while you are in hospital so that a midwife or nurse is on hand to help you and answer any questions.

Alternating the babies between sides will help you maintain a balanced supply. One option is to alternate sides with each feed, although this can be difficult to track. Another, simpler option is to alternate sides each day.

When feeding triplets or more, a bottle feed of expressed milk can be included in the rotation as a substitute breast.

Equipment and set-up

The following will be extremely helpful when breastfeeding multiples:

• A twin feeding pillow and other pillows to prop the babies up. Feeding pillows are often available to loan or purchase second-hand through your local multiple birth club.
• For those families feeding twins separately, and for higher order multiples: a bouncer or rocker for the baby/ies when it is not their turn to feed.
• A notebook for keeping track of feeds, especially in the early, newborn days
• Lots of snacks and water on hand (something you can eat with one hand/without cutlery)
• Your phone (and charger) on hand before you start each feed
• As much rest as possible
• A determined attitude
• A supportive partner, close family member etc.

Feeding on demand

Multiples can be successfully fed separately on demand. Many parents plan to feed their babies on the same schedule but find that this is not always possible or practical. The time-saving benefits of tandem feeding, or even feeding separately one after the other, will not be realised if your babies have different feeding habits and frequencies.

Feeding on demand does mean the babies may wake at different times (including during the night) and it may feel like you are nearly always feeding a baby or babies. Feeding on demand can feel especially daunting with newborn multiples, who may each need to feed 8-12 times a day. Rest assured that however you choose to feed your multiples, it will become easier over time as you all learn the art of breastfeeding and as your babies grow.

Seeking help

Breastfeeding might not come easily to you or your babies. They might have different birth weights and different challenges with breastfeeding. It is okay to change to bottle feeds if you feel that this is the best option for your personal circumstances. If you choose to keep breastfeeding, remember to take one day at a time, celebrate even the smallest improvements, and seek help when you need it. There are many supports available to help you work through any difficulties.

Lactation consultants can help with all your breastfeeding queries. They are available in all hospital units (including the Neonatal Intensive Care Unit and Special Care Nursery) and privately. The Australian Breastfeeding Association has a wide range of resources online and additional support (including breast pump hire) available to paid members. AMBA, and your local multiple birth club, can also assist with breastfeeding queries, pump hire, and putting you in contact with those who have travelled a similar path.

Exclusive expressing

Exclusive expressing carries its own challenges; learning to pump is an art form similar to, but distinct from, breastfeeding. Be kind to yourself, celebrate the small wins and stay positive as you are learning. 

Juggling multiples and expressing can be tricky. A hands-free pumping bra, a good routine and an orderly cleaning/sterilising set-up can address some of the challenges. Once a good routine is established, some families find expressing is a satisfying option when direct latching is not possible.

In terms of equipment, you will require all the bottle feeding equipment listed here plus a breast pump. There are many on the market, and your body may respond differently (in terms of supply) to different brands. In general, a double electric hospital grade pump is an expensive option but offers the most efficient and effective way to pump. You may be able to hire one through your local multiple births club on a short- or long-term basis.

Anything you store your expressed breastmilk in should be food-grade and BPA free. Expressed milk can be stored for up to 8 hours at room temperature (26°C or lower, and noting once a feed has commenced any remaining milk should be discarded after an hour), 72 hours at the back of the fridge, three months in the freezer section of a fridge (i.e. with a separate door) or twelve months in a deep freezer. 

The Australian Breastfeeding Association offers a range of resources on expressing and storing breastmilk for your babies.

Bottle feeding

Key points

• Some women choose not to breastfeed; for others, breastfeeding may not be possible. Whatever your circumstances, it is okay to bottle feed your babies. Only you can decide what is right for you and your family.
• Bottle feeding multiples involves a lot of equipment, cleaning and preparation. However, it can truly be a ‘team effort’ with both parents, and extended family members, able to actively participate in feeding the babies. 
• This page provides information on formula feeding via bottles. Information on expressing breastmilk for your babies to drink via bottles is available under Breastfeeding.

Equipment

You will need many bottles to feed multiples, but it is not worthwhile stocking up on a particular brand of bottle (and teats) until you know which one is right for your babies. There may need to be some trial and error - contact your maternal and child health nurse if you are having trouble finding the right bottles. And remember, each of your babies may end up preferring a different brand and shape of bottle and teat. When selecting teats, trial bigger or smaller holes until you find the right flow; there is no scientific evidence that babies need different teat sizes or shapes as they grow, or that one teat shape is better than another.

For cleaning, a bottle brush and a teat cleaning brush will make your job easier. You won’t necessarily need specialised equipment to sterilise your bottles and teats; this can be done by boiling them in a pot of water on the stove. However, other options include using a microwave steriliser, electric steam or UV steriliser, or soaking your equipment in a sterilising solution.

Formula

Choosing the right formula for your babies can be confusing as there are so many brands on the market. There are many different varieties catering for various food intolerances or allergies (which should be discussed with a doctor and/or dietitian) and some with thickener which can assist babies with reflux. Some formulas have lower levels of iron which can be suitable for full-term babies, but not for premature babies. Always consult your GP, paediatrician, or maternal and child health nurse to confirm the right formula for your babies’ needs.

Preparing bottles and positioning the babies 

Formula should be prepared according to the instructions on the tin, using pre-boiled water that has been allowed to cool. Bottles of pre-prepared formula can be stored in the fridge for up to 24 hours. A labelling system can be helpful to record when each bottle was prepared; if you are unsure of the elapsed time it is safest to discard the contents.

To warm bottles, you can purchase a bottle warmer, or place the bottle in a jug of very hot or just-boiled water. Check the temperature of the formula regularly to avoid overheating. Never warm bottles in the microwave or on the stove. Shake the bottle and test the temperature before giving it to your baby; the formula should be the same temperature as the inside of your wrist.

When it is time to feed your babies, a special feeding pillow can help to prop them up safely. Rockers or bouncers can be helpful too, once your babies are a little older. Feeding higher order multiples simultaneously can be achieved by propping two babies against your tummy, lying in your lap; this can allow you to hold two bottles in one hand and feed a third baby propped in a feeding pillow or bouncer beside you.

There are also some things to avoid:

• Never leave a feeding baby unattended
• Do not lay the babies flat on their backs
• Avoid bottle propping (using pillows or other items, instead of your hands, to hold the bottles).

Hygiene

Clean hands and a hygienic work station are essential for every feed that is prepared. All equipment must be cleaned and sterilised between feeds.

Do not reheat half empty bottles of formula, and discard any formula that has not been consumed within an hour of the feed beginning.

Wherever you live in the world, many of the issues relating to raising multiples are the same. As multiples progress beyond the toddler years and enter school, they experience a whole new range of issues and parents are faced with new challenges. How do we ensure we are catering to the educational needs of our multiples? How do we navigate our multiples through the education system?

Class placement is one of the biggest dilemmas faced by parents of multiples. Will our school allow us a voice in the placement of our children – will the multiples be kept together, or will they be separated? How do we encourage their unique bond while treating each child as an individual?

Publications

AMBA offers publications and resources for school-aged multiples. Read more here.

Resources

Downloads

From International Multiple Birth Awareness Week 2012

IMBAW Press Release 

Support Letter from Pat Preedy

Letter from Nancy Segal

Letter to Parents

Letter to Educators

Welcome to AMBA's Additional Needs information page for families with multiples.

If you find yourself visiting this site, chances are you are currently experiencing your own personal roller-coaster ride, or know someone who is. Families with multiples are in an unusual position of often having one child leading the way and highlighting how different their sibling can be. Whilst it can be normal to develop at different paces, this can be quite confronting for some families when one child is significantly delayed.

Perhaps as time goes by, you have begun to notice some differences between your children. It is not uncommon for some conditions not to be evident at birth. If more than one of your children has additional needs, then you will have an extra workload which is not experienced by many in the community.

Aims

The aims of AMBA's additional needs service are:

• To connect families in similar circumstances
• To offer support during challenging times
• To help families process the information given to them which may be contributing to confusion
• To provide empathic, friendly support

There is also the Facebook group Multiple Birth Families Special Needs Support which offers supportive community for Australian parents of multiples (twins/triplets or more) who have one or more children with additional needs on Facebook.  This group is proudly supported by AMBA, the Australian Multiple Birth Association.  

For more information, please contact the Additional Needs Support Officer.

Key points

• Over 70 per cent of multiples babies will spend at least some time in the Neonatal Intensive Care Unit (NICU) or Special Care Nursery (SCN) before going home.
• Having premature or sick babies can be frightening and overwhelming; this is not the start to parenthood for which you had hoped or planned. Having more than one baby in the NICU or SCN can add distress to an already stressful situation.
• Having premature or sick multiples may increase a sense of isolation, if you do not know other parents who have had a similar experience. AMBA can put you in touch with other parents who have faced the challenges of the NICU and SCN.
• Breastfeeding premature multiples is possible. Seek as much help as possible from the hospital’s lactation consultant.

Preterm labour

The causes of preterm labour are not completely understood, but carrying two or more babies at a time can be a contributing factor. There is no way to prevent preterm labour, though in some cases early diagnosis and prompt treatment can help to slow or pause the process.

Some warning signs for preterm labour may, in fact, be a normal part of your pregnancy and no cause for alarm. However, it is always safest to consult your doctor or midwife without delay if you have any of the following warning signs:

• Uterine contractions
• Menstrual-like cramps
• Increasing dull, lower backache
• Pelvic pressure
• Abdominal cramping with or without diarrhoea
• Increase or change in vaginal discharge
• Leakage of fluid from the vagina

If you have any of the following danger signs, go to hospital immediately:

• Water leaking or gushing from the vagina
• Blood coming from the vagina
• Contractions that come every ten minutes or less for one hour.

Do not hesitate to contact your doctor, midwife or hospital antenatal unit if you are concerned about possible preterm labour. You are the most important advocate for your babies, and you know your body and your pregnancy best.

Premature babies

Premature babies are those born before 37 weeks’ gestation. Generally (though not always), the earlier babies are born, the more support they will need in hospital before they can come home. Depending when your babies are born, they may spend time in the Neonatal Intensive Care Unit (NICU) or Special Care Nursery (SCN). Many premature babies will be ready to go home around the time of their due date, but some will need to stay in hospital longer than this.

The NICU and SCN

The NICU and SCN can be confronting and frightening places. However, your babies will be receiving exceptional, around-the-clock care from specialised doctors and nurses. Parents are recognised as critical members of the care team - you are your babies’ strongest advocate, and although you are not with them all the time, you know them best of all.

If your babies are born very prematurely or are very sick at birth, you may not be able to hold them straight away. However, all NICUs and SCNs promote skin-to-skin contact between babies and parents - ‘kangaroo care’ - as early and as frequently as possible. Even if you can’t cuddle your babies, you can assist with their daily care, gently touch them, and sing or read to them. Your babies know your voice and are soothed by your presence.

Complications and progress

Premature babies can have a range of medical complications. Generally, the number and type of complications will depend on the gestation of your babies at birth, how much they weigh and how well they are. Some babies are born quite healthy - just too early - while others will have a long road to recovery in the NICU and SCN. Your doctors and nurses will discuss with you the likely medical issues your babies will encounter, taking into account their gestation, weight and general health.

Breasteeding premature babies

Breastfeeding premature multiples is possible. If you are planning on breastfeeding, you will need to express until the babies can learn to breastfeed. Depending when your babies are born, this may involve many weeks or months of expressing before your babies have the energy and strength to breastfeed exclusively. Your midwives and the hospital’s lactation consultant will be able to answer any questions about expressing. A double electric, hospital-grade breast pump is very important. Your local multiple births club will be able to assist you with pump hire and may also have a breastfeeding representative who can direct you to other local resources.

‘Kangaroo’ cuddles (skin to skin) with your babies will help to stimulate milk production. Expressing at their bedside, or watching videos and photos of your babies when you are expressing at home, can also assist.

Emotional impact

Preterm labour often brings a unique form of grief: you have welcomed your beautiful babies but are very worried for their health, and you may feel robbed of many early parenting rites of passage in the first days, weeks and months of their lives. Depending on your babies’ gestation and any complicating medical factors, you may have had some difficult and frightening conversations with doctors and nurses. And in most cases, you will be discharged from hospital before your babies, an extremely difficult scenario and not one you had ever imagined or anticipated.

Your hospital should offer a debrief on your preterm labour. This can help you to understand why things did not go to plan and assist you in gaining answers to questions. If you are not offered a debrief, contact your midwife to arrange one. In the NICU, ask to speak to a social worker if you are not automatically referred by the nurses. The social worker will be able to connect you to a variety of different supports within the hospital and the broader community.

In the NICU, establishing a plan for being involved with your babies’ care and developing a routine can ease feelings of helplessness, and can assist you to bond with your babies during such a challenging time.

The NICU and SCN journey is often called a ‘rollercoaster’, as progress for preterm and sick babies is often not linear. The emotional impact of this rollercoaster is often intensified for multiple birth parents. It can be heartbreaking to see your babies progress at different rates and daunting to face the prospect of taking your babies home at different times (noting hospitals will try to avoid this scenario where possible). It can also feel isolating if the other parents you meet in the NICU or SCN are not multiples parents. Contacting AMBA, your local multiple births club and the charities that offer on-site support to parents, can help you connect with those multiples parents who have experienced an extended hospital stay with two or more babies.