Four in the morning. One wakes up, and while you latch him the other wakes too. You settle both, one on each side, and for the next twenty-five minutes you cannot move: you cannot scratch your nose, you cannot drink, you cannot change position for a shoulder that has already started to burn. Then it ends, and an hour and a half later it starts again.
Almost nobody talks about this part. People talk about milk, latch, and how fast they grow. Not about your body holding a static, asymmetrical load for hours a day, a few weeks after a birth that was often a caesarean.
The short answer: the right position for breastfeeding twins is the one in which you are not holding anything up. It is not a question of the name (rugby, crossed, reclined), but of how many of your heavy parts are resting on something that is not you. The second thing to know is that the evidence here is almost non-existent: nearly everything you will read, including what we write, is extrapolated from studies on mothers with a single baby.
The most honest thing: the evidence hardly exists
This is not false modesty: it is a measured fact.
The 2017 Cochrane review searched for randomised studies on breastfeeding education and support for women with twins or higher-order multiples. It found 10 trials with 5,787 participants recruited, but the usable data on mothers of twins came from only two studies and concerned 42 women, and none of the interventions had been designed for those with more than one baby. The authors could not carry out any statistical analysis, nor apply the GRADE system.
A 2024 narrative review, starting from 256 studies, lists the obstacles (low milk supply, fatigue, anxiety, little support, prematurity, neonatal intensive care) and the useful strategies: education, expressing milk, stable routines, correct technique, varied positions, comfort aids, family help. It then concludes that few studies provide solid evidence.
So anyone who tells you with certainty what "the right position for twins" is, is repeating clinical practice. That is not useless, but it is not data.
There is one reassuring number, though. In an Icelandic study of 63 mothers of twins, the start of breastfeeding was almost universal, and at one month the figures were almost identical between late preterm twins and term twins (88% and 85%): the gap opened at four months, 44% against 75%. Where twin breastfeeding is lost is not at the start: it is the month when the help runs out. This is the same theme that emerges from a British qualitative study of 94 parents of twins, followed by 18 interviews, summed up by one of the interviewees: "with twins you really need a village".
The sum nobody does for you: time
This part is arithmetic, not research. Take it for what it is: if one feed lasts twenty minutes and the babies feed eight times a day,
- one at a time makes 2 × 8 × 20 minutes = over five hours a day seated while breastfeeding;
- together makes 8 × 20 minutes ≈ two hours and forty minutes.
Feeding together therefore does not double the total time: it halves it compared with feeding singly. This is why so many mothers do it, and it is excellent.
But the sum has a second line: within each feed the weight you hold doubles, and the chance to adjust disappears. You cannot move one baby without moving the other, nor slip out an arm, nor get up to drink. The load is not high: it is static and long, the kind that neck and shoulders tolerate worst, because there is never a moment when they switch off.
And there is a third line. In a study using actigraphy and diaries with 75 families with newborn twins, the average 24-hour sleep duration in the first three months was between 6.7 and 7.5 hours: the total is not catastrophic. What is: periods of consolidated sleep averaged three hours or less. An earlier small pilot of 8 parents, too few to make a rule of it, pointed in the same direction. A tissue that never rests in one stretch tolerates less load the next day: this is why the same feed that did not bother you at two weeks leaves your shoulders on fire at six.
The three positions for feeding them together
A preamble. The position with the most evidence behind it is the reclined one, but that evidence comes from mothers with a single baby: a meta-analysis of 12 studies and 1,936 mother-newborn pairs found less nipple pain (RR 0.24; 95% CI 0.14–0.40) and less tissue damage (RR 0.47; 0.29–0.75) compared with traditional positions, but no difference in the comfort felt by the mother (SMD 0.09; 95% CI -0.63 to 0.81; p=0.798), and it also included non-randomised studies. Better for the nipples does not mean more comfortable for you, and with two babies that distinction becomes central. The full picture for a single feed is in breastfeeding positions: which to choose and why.
Rugby hold. The two babies tucked under your arms, bodies along your sides, feet towards the back of the chair. It is the most used, and the reason is good: it keeps the bodies away from the belly, which after a caesarean is the whole point. What it asks of you: your hands support the head and neck, so the forearms stay in the air with no support, and the load goes onto the deltoids and trapezius for the whole feed. It is the one that gets worst without support, and improves most with one.
Crossed, in an X. One baby in the classic cradle, the other crossed over the top: they sit more gathered and more visible. What it asks of you: it is the most asymmetrical of the three. One arm is underneath, the other on top; one shoulder rises, the trunk rotates towards the lower baby, the head tilts to check the latch. If you already have one side of the neck complaining, this is usually the one that wakes it up. If you use it, alternate which baby is on top: not for him, for you.
Lying on one side, or double reclined. These are two different things: lying on one side you feed one baby only, whereas reclined backwards the two babies lie on your chest, face down, supported by your body and not by your arms. What it asks of you: almost nothing, and that is the point. It is the best choice for night feeds and for days when your neck has already gone. The cost is the time to set it up, and vigilance: if you risk falling asleep, the surface must be a safe one for sleep, not a sofa.
A useful finding after a caesarean: in a randomised trial of 152 women, reclined and lying on one side gave the same breastfeeding outcomes, but the mothers were more satisfied with lying on one side. Try both in the first few days rather than choosing on paper.
The twin pillow: why it really changes things
The twin pillow is not a bigger breastfeeding pillow: it is a shelf.
Without it, your arms are the load-bearing structure: they hold two babies in continuous contraction for twenty-five minutes. With it, the weight rests on the pillow and on your thighs, and your hands are free for the only thing they really need to do: position the heads. It is not "more comfortable": it is going from continuous load to intermittent load, the difference between holding a shopping bag for half an hour and setting it down on a table.
On one condition: the pillow must reach the height of the breast, not the belly. If it is too low it forces you to bend forward, and then you have made things worse: the weight of your head off-axis for twenty-five minutes is exactly the load we are trying to remove. A low pillow can be raised with a folded towel underneath; if you do not have a twin pillow, two ordinary cushions stacked do the same job.
Honesty again: no one has measured the load on the mother's shoulders and back with and without a twin pillow. The only randomised trial we could find on a breastfeeding pillow involved 92 first-time mothers, measured a pillow that supports the baby's back, and its outcomes were latch and nipple pain. There is no trace of the mother's back: the mechanical reasoning is sound, but it remains reasoning.
Recovery starts further back
With a twin pregnancy you do not start from where another mother would. Three pieces.
The abdominal wall. In a cross-sectional study of 1,000 women assessed by ultrasound at 3, 5, 10, 20 and 30 years after birth, having had twins was an independent risk factor for rectus diastasis at 3 years after birth (p=0.001), but not at the other time points; using the criterion of a gap between the rectus muscles above 2 cm, diastasis was present in 36% of women at 3 years, and with the stricter criterion of 3 cm in 13%. It is not destiny: it is a starting point further back.
The pelvic floor. A 2026 review of maternal health after multiple pregnancies, which account for 2 to 3% of births in high-resource countries, is explicit: a twin pregnancy places greater mechanical stress on the pelvic floor, with higher rates of stress urinary incontinence that persist beyond the immediate postpartum period, although long-term outcomes remain poorly characterised. In a French prospective cohort of first-time mothers of twins (1,155 analysed at 3 months, 800 at 12 months), those who had given birth vaginally reported more symptoms at 3 months than those who had a caesarean: median PFDI-20 of 25/300 against 17/300 (p<0.0001), vaginal bulge 9% against 4% (p=0.0015). The conclusion, however, is encouraging: those symptoms largely resolved within 12 months. And one factor can be acted on earlier: in a retrospective study of 184 first-time mothers of twins, the 20 whose weight gain exceeded the recommended limits reported stress incontinence in 50% of cases, against 20.1% of the others (adjusted OR 4.42). Twenty women is few: it is a clue, not a law.
The caesarean. In the United States, across 1,079,102 twin births between 2006 and 2013, the caesarean rate was 74.8% in 2013. It is an American figure, but it gives the order of magnitude: with twins the caesarean is the norm, and recovery begins with an abdominal wound (what you can do and when).
A guilt that you do not need to carry: in the three-month follow-up of the Twin Birth Study, 2,570 women out of 2,804 invited across 25 countries, there was no clinically important difference between planned caesarean and planned vaginal birth on any maternal outcome: breastfeeding 84.4% against 86.4% (p=0.13), probable depression 14.0% against 14.8% (p=0.57), problematic urinary incontinence 5.5% against 6.4% (p=0.31), fatigue 20.3 against 20.8 (p=0.14). How you became a mother does not decide how you will be at three months. The nine months before are covered in twin pregnancy: back, pelvis and movement.
Exercise when there are two babies
The problem is not motivation: it is that a forty-minute window does not exist. What works, fortunately, does not require one.
Trunk strengthening reduces pain. A systematic review with meta-analysis of 37 studies and 3,769 participants found that exercise alone, especially strengthening of the trunk muscles, reduced the severity of lumbopelvic pain by 2.21 points on a 0-10 scale (4 RCTs, n=210; 95% CI -3.33 to -1.08) and the associated disability (6 RCTs, n=296; SMD -1.17), with moderate certainty.
Curl-ups do not widen the diastasis. This is the most widespread fear, and it has been tested: in a randomised trial of 70 women between 6 and 12 months after birth with a diagnosed diastasis, including women after a multiple pregnancy, twelve weeks of head lifts and curl-ups five days a week neither worsened nor improved the gap between the rectus muscles (mean difference 1 mm at rest; 95% CI -1 to 4), but they increased the thickness (+0.7 mm) and strength (+9 Nm) of the rectus abdominis.
The pelvic floor has a better window than others. The 2020 Cochrane review of 46 trials and 10,832 women in 21 countries shows that training started during pregnancy in women who are still continent reduces incontinence in late pregnancy (RR 0.38; 6 trials, 624 women) and slightly at 3 to 6 months after birth (RR 0.71; 5 trials, 673 women), whereas a generalised approach started after birth probably does not reduce it. If there are symptoms now, what is needed is targeted, guided work, not a standard programme.
How you lift matters as much as what you lift. In a biomechanical study of 11 mothers lifting their own 15-week-old baby, the most demanding movement was picking the baby up from the floor, the car seat added about 4 kg, and the changing table, the least tiring task, made the trunk tilt and rotate asymmetrically. With two babies those movements double: lifting the changing table is worth more than one extra exercise.
In practice: five minutes, three times a day, attached to a movement you already make. The 2025 Canadian guidelines on the first year after birth conclude, with moderate certainty, that following them probably leads to large improvements in psychological well-being and in pelvic, musculoskeletal and cardiometabolic health, and to less fatigue, without adverse events. Less fatigue: it is counterintuitive, and that is the point.
Red flags: when to stop managing on your own
Musculoskeletal pain has a signature: it changes with position and with movement. When it does not behave this way, or it crosses these thresholds, the first call is not to the physiotherapist.
- Fever above 38 °C with an area of the breast that is red, hard and hot: possible mastitis. A doctor within 24 hours, and in the meantime do not stop breastfeeding from that side without advice.
- Tingling or loss of strength in one hand that does not pass within a few minutes of changing position, or that makes you drop things: medical assessment.
- Pain that never changes with position, present even at night at rest, for more than two weeks: it is not mechanical, it needs looking at.
- Caesarean scar that after the first week becomes red, hot, swollen or discharges: a doctor straight away.
- One calf that is swollen, warm and painful, or sudden shortness of breath: A&E, not tomorrow.
- Urine leakage or a sensation of vaginal heaviness that continues beyond six weeks after birth: an assessment of the pelvic floor, not waiting.
- Mood: in the Twin Birth Study, 14% of women had probable depression at three months. If for two weeks in a row you feel constantly low or have thoughts that frighten you, talk to your doctor. It is not a question of strength.
Where we can help
Ri-Hub is online physiotherapy by video call. We do not work on the twins: we work on you. Neck, shoulders, back, wrists, the abdominal wall after a caesarean, the pelvic floor, and the setup of the place where you spend five hours a day.
Here the video call is not a stopgap but the right place: it matters to see you while you breastfeed in your own home, on your own sofa and with your own cushion, not in a clinic with a cushion that is not yours. You start with a free twenty-minute introductory consultation: you show us a feed live and we tell you what to change. Subsequent sessions cost 29,90 €. The full pathway after birth is on Ri-Hub Mamma.
And if right now all you can manage is raising the cushion with a folded towel, that is perfectly fine: it is the change with the best ratio of effort to result in the whole article.
Sources
- Breastfeeding education and support for women with twins or higher order multiples: Cochrane Database of Systematic Reviews, 2017
- A Narrative Review of Strategies to Optimize Breastfeeding Among Mothers of Twins: Cureus, 2024
- A qualitative investigation of experiences of breastfeeding twins and multiples: Midwifery, 2024
- Breastfeeding initiation, duration, and experiences of mothers of late preterm twins: a mixed-methods study: International Breastfeeding Journal, 2022
- The effectiveness of the laid-back position on lactation-related nipple problems and comfort: a meta-analysis: BMC Pregnancy and Childbirth, 2021
- Comparison of Breastfeeding Outcomes Between Using the Laid-Back and Side-Lying Breastfeeding Positions in Mothers Delivering by Cesarean Section: A Randomized Controlled Trial: Breastfeeding Medicine, 2017
- Effect of the Ing Oun pillow for supporting baby's back in a side-lying position to promote breastfeeding: A proof-of-concept randomized controlled trial in Thailand: European Journal of Midwifery, 2026
- Sleep pattern gender differences and fragmentation in postpartum parents of twins: Sleep Science, 2021
- Sleep patterns and fatigue in parents of twins: Journal of Obstetric, Gynecologic & Neonatal Nursing, 2008
- Multifetal gestation and long-term maternal health: American Journal of Obstetrics & Gynecology MFM, 2026
- Impact of mode of delivery of twins on the pelvic floor 3 and 12 months post-partum: part II: International Urogynecology Journal, 2019
- Effect of gestational weight gain on postpartum pelvic floor function in twin primiparas: a single-center retrospective study in China: BMC Pregnancy and Childbirth, 2023
- Maternal outcomes at 3 months after planned caesarean section versus planned vaginal birth for twin pregnancies in the Twin Birth Study: a randomised controlled trial: BJOG, 2015
- Trends in the delivery route of twin pregnancies in the United States, 2006-2013: European Journal of Obstetrics & Gynecology and Reproductive Biology, 2016
- Prevalence and risk factors of diastasis recti abdominis in the long-term postpartum: a cross-sectional study: Scientific Reports, 2024
- Curl-up exercises improve abdominal muscle strength without worsening inter-recti distance in women with diastasis recti abdominis postpartum: a randomised controlled trial: Journal of Physiotherapy, 2023
- Impact of exercise on musculoskeletal pain and disability in the postpartum period: a systematic review and meta-analysis: British Journal of Sports Medicine, 2025
- Pelvic floor muscle training for preventing and treating urinary and faecal incontinence in antenatal and postnatal women: Cochrane Database of Systematic Reviews, 2020
- 2025 Canadian guideline for physical activity, sedentary behaviour and sleep throughout the first year post partum: British Journal of Sports Medicine, 2025
- Characterizing kinematics, kinetics, and muscle activity of postpartum mothers lifting their own infants during three everyday tasks: Journal of Biomechanics, 2025
Last source check: September 2026.
