twin delivery ?/situation

[tricia]

I have a set of twins. I also was in the exact situation as you. Especially since I know a lady who had a section in between the babies. I did NOT want that. So instead of re writing my twins' birth story to share here is the link to where you can read it if you want to.

 

twins birth story

[Sara R]

I'm not a twin mom, but I was recently reading about what can go wrong with a twin birth. It's not only malposition; there's more to it than that. Twin A is generally fine, but a lot can happen between Twin A and B.

 

There's a risk of having a vaginal birth for A but needing a c-section for B, which seems to be the worst of both worlds. Here is an OB explaining:

 

 

 

The high risk of placental abruption is THE reason that twin birth is considered high risk.

 

 

 

Before birth the entire surface area of the placenta adheres to the wall of the uterus. Once the baby is born, the uterus contracts around the empty space. The placenta is incapable of contracting. The illustration demonstrates that as the uterus contracts the placenta is forced off the uterine wall. The space between the contracted uterine wall and the peeled off placenta fills with blood. The pressure of the blood in the enclosed space forces more placental surface off until the entire placenta comes away accompanied by a gush of blood, the blood that filled the space between the uterus and placenta.

 

 

 

In a twin birth, the first baby is born and the uterus contracts down around the empty space. The placenta is incapable of contracting, both the placenta of the baby that has born and the placenta of the baby still in the uterus, still depending on the placenta for all of its oxygen. That's the main reason why twins are considered high risk. The second baby may lose its supply of oxygen long before it can be born vaginally. That's why the second twin needs to be monitored very carefully, typically in an operating room with a team standing nearby to start an immediate C-section if the placenta begins to detach.

 

 

 

 

Now, continuing with Grand Rounds, let's assume that this case was vertex/breech, how would we plan this delivery? What are our risks? Let's list them. Yes, placental abruption, also, unrecognized twin-twin transfusion (so no delayed cord clamping), cord prolapse with second twin, malpresentation of second twin, distress in second twin, hemorrhage in mom. OK, that's a pretty good list, we might be missing a few...

 

 

 

So how do we approach this? Well, we want to be sure we are ready to do a C/S immediately if B seems to be in trouble, so we want mom to have an IV. If we can do the actual birth in the OR with a full team standing by, including anesthesia, that would be ideal. If mom is willing, an epidural catheter in place will allow us to give her anesthesia quickly without having to resort to general. If she wants an epidural for the labor, so much the better. We may have one or two sick babies, so we want a team for each, and we want a second OB standing by to assist.

 

 

 

OK, so mom is admitted in labor, draw labs just in case, blood typed and crossed just in case, heplock placed, epidural if and when mom agrees.

 

 

 

For second stage, transfer to OR, assemble whole team. Yes it's a circus-sized number of people standing by, but any reasonable parent is grateful, and you can ask people to stand behind a screen or in the adjoining OR. You can dim lights and try and keep the ambiance as much as possible. It's a tradeoff, but there you are. Keep your anesthesiology team with you and mom and dad. Keep second OB with you.

 

 

 

Deliver first baby following usual maneuvers, clamp cord. Let mom skin-to-skin if baby is vigorous. Have your OB colleague perform ultrasound continuously to monitor B's heart rate and position. If you can guide B's head down, that is ideal. If the breech presents, be ready to do a breech delivery, with all that entail (now do you see the virtue of knowing baby B's size as determined by ultrasound? Most of the time you will be able to have the head come down.

 

 

 

Epidural is ideal because your mom will be more comfortable with the necessary maneuvers, and you'll be able to convert to C/S if B is in trouble and not delivering promptly. And of course you have your full resus team right there to help you if B is depressed in any way.

 

 

 

 

Twin-to-twin transfusion is where the placental blood is shared by both twins instead of each twin getting its own supply. If, for any reason, the oxygenation level drops [as in abruption], both babies can be fatally compromised. Indeed, the birth of the first twin automatically compromises the second. Rare, but very dangerous.

 

[Matryoshka]

My OB told me a few months ago that if Baby A was head down I could deliver naturally and give Baby B a chance to flip if not already head down. Yesterday, however, my doctor said that unless both babies are head down I get a c/s. I couldn't say a word as she was telling me, I was so shocked. For the twin mamas or those who know twin mamas, could you advise me on this? I do not want a c/s unless it is absolutely medically necessary! I'm 27 weeks and suddenly find myself panicking even more than I already was about the upcoming delivery.

 

 

Haven't read the rest of the posts, but I've been through this myself. My OB was fine doing a Breech Extraction of Twin B if she didn't turn. Basically, that means he reaches his arm up there and yanks her out by the legs (reminded me of James Herriot's description of delivering troublesome lamb twins). Since I'd already be dilated enough for a head to pass after Twin A (who was head-down), he was fine with that (Twins were similar in size - I know that's not always the case). So, I was required to get an epidural and be in the OR rather than a regular L&D room just in case events didn't go as planned and emergency C-section was needed, but I was not forced to get a C-section.

 

Twin B never turned before delivery, but when Twin A was out, she promptly did a somersault and popped out headfirst. Didn't even need to be yanked.

 

I was lucky that my Dr. was experienced and had delivered breech babies before. Younger Drs these days seem too panicky to even attempt it.

[AuntieM]

I had the same situation. My concern was that I didn't want things to go both ways, that is, the first one be a v@ginal delivery, the second requiring a section. One way or the other would be okay by me, but not both.

 

My kids were really big for twins - the head down baby on the bottom was 6#1oz, the breech baby on top was 7#8oz.

 

I understand that *you* don't want a section, but, I gently suggest that the safety of the babies is a first priority and if the situation requires a section, you shouldn't fight your doctor on it. What I *would* be sure to demand is that he avoid making a vertical incision in your uterus. That was the biggest factor in my subsequent pregnancies.

 

(Just my two cents, given without reading all the other replies since I am on the run today.)

[ktgrok]

I had the same situation. My concern was that I didn't want things to go both ways, that is, the first one be a v@ginal delivery, the second requiring a section. One way or the other would be okay by me, but not both.

 

My kids were really big for twins - the head down baby on the bottom was 6#1oz, the breech baby on top was 7#8oz.

 

I understand that *you* don't want a section, but, I gently suggest that the safety of the babies is a first priority and if the situation requires a section, you shouldn't fight your doctor on it. What I *would* be sure to demand is that he avoid making a vertical incision in your uterus. That was the biggest factor in my subsequent pregnancies.

 

(Just my two cents, given without reading all the other replies since I am on the run today.)

 

I think suggesting the OP, or ANY mom, would put her own preferences above the babies safety is a bit rude. Of COURSE she will have a section if one is required. The point of the OP was to find out if one WAS required. As many have said, it isn't in this case, unless there are other circumstances. And I gently remind you that c-sections that are not needed are less safe than a vaginal delivery, both because of the common respiratory problems from them, and from risk of being cut by the scalpel. It happens a lot. I know a baby with a huge scar on her face from it.

[ktgrok]

Also, why does everyone think it is so awful to have one twin vaginally and one by surgery? Isn't that better than both surgically? I mean, that way both twins get to come on their own time. Both twins get the beneficial stimulation of labor. One twin gets the benefit of being squeezed through the birth canal, thereby lessening the chances of respiratory distress for that twin. And mom gets the benfit of the hormone surge that goes along with birth, helping her handle the pain and helping her bond with the baby. I mean, yeah, you will have two areas that need to heal. But the chances of tearing with a twin, who is usually smaller than average, seem low anyway. So no wound to heal. I've had a c section and a vaginal birth, and I can't imagine that having a vaginal birth before the c-section would have made it harder to recover from. I felt run over from a truck as it is. By the time I was off the pain meds I'm sure the healing from the vaginal birth would have been done anyway.

[AuntieM]

I think suggesting the OP, or ANY mom, would put her own preferences above the babies safety is a bit rude. Of COURSE she will have a section if one is required. The point of the OP was to find out if one WAS required. As many have said, it isn't in this case, unless there are other circumstances. And I gently remind you that c-sections that are not needed are less safe than a vaginal delivery, both because of the common respiratory problems from them, and from risk of being cut by the scalpel. It happens a lot. I know a baby with a huge scar on her face from it.

 

OP, please forgive any hint of rudeness. It was certainly not my intent to accuse you of putting your own desires over the safety of the babes. I meant to simply encourage you to widen your mindset to include the possibility without it resulting in great disappointment for you. Either way, you will soon meet your two new precious ones face-to-face.

 

Also, why does everyone think it is so awful to have one twin vaginally and one by surgery? Isn't that better than both surgically? I mean, that way both twins get to come on their own time. Both twins get the beneficial stimulation of labor. One twin gets the benefit of being squeezed through the birth canal, thereby lessening the chances of respiratory distress for that twin. And mom gets the benfit of the hormone surge that goes along with birth, helping her handle the pain and helping her bond with the baby. I mean, yeah, you will have two areas that need to heal. But the chances of tearing with a twin, who is usually smaller than average, seem low anyway. So no wound to heal. I've had a c section and a vaginal birth, and I can't imagine that having a vaginal birth before the c-section would have made it harder to recover from. I felt run over from a truck as it is. By the time I was off the pain meds I'm sure the healing from the vaginal birth would have been done anyway.

 

My recovery from my twin-delivery section was MUCH faster and MUCH easier than my recovery from a long, complicated labor and v@ginal delivery with a fourth degree episiotomy. If I had to endure damage to two major areas of my body while having and attempting to nurse two newborn babies, I would have had to hire help!

 

ETA - My big twin was larger than his non-twin brother, just for the record.

 

But of course, that's just me. Maybe I'm just a wimp.

[simka2]

I wonder if she had the twins yet?! ;)

[AuntieM]

I wonder if she had the twins yet?! ;)

 

Simka, you are funny! This is an old thread, but not that old. Looks like she's not due until November. Was that the joke, or did I miss something?

[chepyl]

My friend had twins naturally (well, I think she had an epidural). She did not want a c-section and her OB told her she would need a c-section if both babies were not head down. She went in to be induced (at 40 weeks) with both babies head down. Baby A was born and baby B flipped. Before they had time to check on the baby's position, out popped a foot. Baby B was delivered breech.

 

Baby A was 7.5 lbs and Baby A was 8.5 lbs.

 

From reading other posts, and her experience; I would say that baby A head down and baby B breech at time of labor, is more ideal. The force of one baby being delivered plus all that new space would seem to cause baby B to move and flip in most situations.

[simka2]

Simka, you are funny! This is an old thread, but not that old. Looks like she's not due until November. Was that the joke, or did I miss something?

 

My bad! I thought I read that she was 34 weeks. I was just a little off;)

[Danestress]

Having BTDT. I'm not saying that I would make decisions that would negatively impact the twins based on the fear of this happening, but I will say that it was awful. I was seriously compromised in my ability to take care of my babies. It was okay, because I had my mother and my husband both there, and they both were taking care of both the babies and I pretty much full time.

[celticmom]

I think suggesting the OP, or ANY mom, would put her own preferences above the babies safety is a bit rude. Of COURSE she will have a section if one is required. The point of the OP was to find out if one WAS required. As many have said, it isn't in this case, unless there are other circumstances. And I gently remind you that c-sections that are not needed are less safe than a vaginal delivery, both because of the common respiratory problems from them, and from risk of being cut by the scalpel. It happens a lot. I know a baby with a huge scar on her face from it.

:iagree:

[MeganW]

I had triplets, so a little different situation, but I ended up with both a vaginal & C-section at the same delivery. I would not wish that recovery on my worst enemy. I was in the hospital for 8 days after the babies were born, and was seriously freaking when they sent me home b/c I was not yet walking more than a few steps.

 

If there is any question of needing both, just do the section!

[kalanamak]

I started calling around already...2 out of 2 OBs say "no", only 1 left to go. :glare: I don't believe this!!!

 

Is it because of how many babies you've had? Uterine rupture might be worrying them.

 

Unfortunately, "informed consent" doesn't hold up in court very well. Tearful person claims they didn't understand what they were signing. How can one prove s/he did understand?

 

:grouphug:

[BakersDozen]

I understand that *you* don't want a section, but, I gently suggest that the safety of the babies is a first priority and if the situation requires a section, you shouldn't fight your doctor on it. What I *would* be sure to demand is that he avoid making a vertical incision in your uterus. That was the biggest factor in my subsequent pregnancies.

 

Thank you for your suggestion (and no offense taken on my part, I assure you). The thing I was fighting was my doctor's immediate assessment of a c/s without any consideration of other options. Since posting originally I have found half a dozen OBs who readily assure me that a natural delivery is indeed possible if Baby A alone is head down.

 

Now, however, I've met with a doctor who says she will deliver Baby A frank breech (baby's current position). Given the # of deliveries I've had she is comfortable doing so; I, however, am not. I am all too aware at this point of the risks involved in a twin delivery and adding to that risk with a frank breech presentation for Baby A just isn't worth it, IMO.

 

Babies are moving but the wrong way (clockwise vs. counterclockwise) so unless they decide to reverse direction I'm looking at a c/s. I think I'm accepting that and am more OK with it although I do have moments of extreme panic. ;)

 

I also am looking at 1.5 hour drive once I go into labor so that has me a bit worried...just a teeny, tiny bit. OK, it keeps me awake at night!! Maybe I'll have a slower labor this time...

[Melissa in Australia]

The high risk of placental abruption is THE reason that twin birth is considered high risk.

 

 

In a twin birth, the first baby is born and the uterus contracts down around the empty space. The placenta is incapable of contracting, both the placenta of the baby that has born and the placenta of the baby still in the uterus, still depending on the placenta for all of its oxygen. That's the main reason why twins are considered high risk. The second baby may lose its supply of oxygen long before it can be born vaginally. That's why the second twin needs to be monitored very carefully, typically in an operating room with a team standing nearby to start an immediate C-section if the placenta begins to detach.

This happened to my twin brothers. first one born then the placentas both detached, second twin's heart stopped and the doc yanked him out and was able to revive him.

This was a long time ago, pre ultrasounds . The Doc didn't know mum was having twins until after the first one was born and she still had a large tummy.

[Osmosis Mom]

Thank you for your suggestion (and no offense taken on my part, I assure you). The thing I was fighting was my doctor's immediate assessment of a c/s without any consideration of other options. Since posting originally I have found half a dozen OBs who readily assure me that a natural delivery is indeed possible if Baby A alone is head down.

 

Now, however, I've met with a doctor who says she will deliver Baby A frank breech (baby's current position). Given the # of deliveries I've had she is comfortable doing so; I, however, am not. I am all too aware at this point of the risks involved in a twin delivery and adding to that risk with a frank breech presentation for Baby A just isn't worth it, IMO.

 

Babies are moving but the wrong way (clockwise vs. counterclockwise) so unless they decide to reverse direction I'm looking at a c/s. I think I'm accepting that and am more OK with it although I do have moments of extreme panic. ;)

 

I also am looking at 1.5 hour drive once I go into labor so that has me a bit worried...just a teeny, tiny bit. OK, it keeps me awake at night!! Maybe I'll have a slower labor this time...

 

I think you are making the wisest decision. I was also in a remote area with 1 1/2 hours drive if I wanted to deliver vaginally vs. right down the street for the c-section. I was actually in labor when I went in for the section so they were out in one hour from when I got there. All me labors have been pretty much the same so don't expect this one to be different (having a history of us getting babies!).

 

Take care.

[Ria]

If it helps any, I had a c-section with my twins and it went just fine. My babies were uncooperative - they were both breech. LOL.

[creativish]

Thank you for your suggestion (and no offense taken on my part, I assure you). The thing I was fighting was my doctor's immediate assessment of a c/s without any consideration of other options. Since posting originally I have found half a dozen OBs who readily assure me that a natural delivery is indeed possible if Baby A alone is head down.

 

Now, however, I've met with a doctor who says she will deliver Baby A frank breech (baby's current position). Given the # of deliveries I've had she is comfortable doing so; I, however, am not. I am all too aware at this point of the risks involved in a twin delivery and adding to that risk with a frank breech presentation for Baby A just isn't worth it, IMO.

 

Babies are moving but the wrong way (clockwise vs. counterclockwise) so unless they decide to reverse direction I'm looking at a c/s. I think I'm accepting that and am more OK with it although I do have moments of extreme panic. ;)

 

I also am looking at 1.5 hour drive once I go into labor so that has me a bit worried...just a teeny, tiny bit. OK, it keeps me awake at night!! Maybe I'll have a slower labor this time...

 

Thank you so much for starting this thread! So much helpful info here!!

 

I just found out this week we're expecting twins (#6 & 7, eek!) in Feb and that our brand new hospital down the road from our house doesn't do twin deliveries unless it's an emergency (and for that it's a guaranteed c-section:sad:), they want me to deliver 1.5 hours away too.

 

I'm bummed and nervous. Driving 1.5 hours in the middle of winter in labor is not sitting well with me. :scared: And then not knowing if I'll be able to deliver vaginally or not... wow just a lot more to think about than I ever expected.

It's definitely keeping me up at night too, I'm thinking this is going to be my longest pregnancy ever (even if it's shortest in duration).:(

[Ria]

Thank you so much for starting this thread! So much helpful info here!!

 

I just found out this week we're expecting twins (#6 & 7, eek!) in Feb and that our brand new hospital down the road from our house doesn't do twin deliveries unless it's an emergency (and for that it's a guaranteed c-section:sad:), they want me to deliver 1.5 hours away too.

 

I'm bummed and nervous. Driving 1.5 hours in the middle of winter in labor is not sitting well with me. :scared: And then not knowing if I'll be able to deliver vaginally or not... wow just a lot more to think about than I ever expected.

It's definitely keeping me up at night too, I'm thinking this is going to be my longest pregnancy ever (even if it's shortest in duration).:(

 

Hey, congratulations! What fun! I'm sure everything will work out just fine. Do your research on where to have those babies, and find a doc who will work with you.

 

It would not be unusual for a doc to induce you in a situation you described once the babies' lungs are mature and you are far enough along. I had a similar situation with one of my singletons...we had moved 90 minutes away from my doc when I was 8 months pregnant. That winter we had several ice storms. I went for a visit at 39 weeks, baby was big and healthy, and another ice storm was predicted. I opted for induction (vaginal gel) that day so I wouldn't end up on the road in labor in the ice. All went very well.

[creativish]

Hey, congratulations! What fun! I'm sure everything will work out just fine. Do your research on where to have those babies, and find a doc who will work with you.

 

It would not be unusual for a doc to induce you in a situation you described once the babies' lungs are mature and you are far enough along. I had a similar situation with one of my singletons...we had moved 90 minutes away from my doc when I was 8 months pregnant. That winter we had several ice storms. I went for a visit at 39 weeks, baby was big and healthy, and another ice storm was predicted. I opted for induction (vaginal gel) that day so I wouldn't end up on the road in labor in the ice. All went very well.

 

:001_smile: Aw thanks!

More good advice!

Glad the induction worked out for you! I'll have to keep that in mind, as I could see that definitely being a possibility in our situation too.

[HS Mom in NC]

A friend of mine had her twins (8+ lbs. each , 39 weeks along) at home with her midwife. The first came out head down. The other flipped head down less than hour after the first was born. no problems at all.

 

Another firend of mine was told her OB would not deliver vaginally unless borth babies were head down. At 38 weeks one baby was still head up so she changed to a new OB that was willing to deliver vaginally she did.

 

All women who care deeply about avoiding c-sections should only seek out OBs with experience delivering frank breeches vaginally.

 

If you read "Obstetrical Myth vs. Research Reality" (written by medical clinicians for medical staff based on actual research, not routine training and standard of practice) you will see that an elective c-section carries the identical risks to mom and baby as a frank breech delivery with an OB trained to handle breeches. Since so few new OBs are trained in handling breeches anymore, they are themselves the risk-not the breech delivery itself.

 

Be very careful about who you choose to attend your delivery.

[The Girls' Mom]

I delivered my twins vaginally at 34 weeks with no major complications. Thankfully my OB was unable to come in (a leetle too much wine at the time I went into labor :lol:) and the hospital was VERY premie/twin shy so they sent me to another hospital. The attending Dr. there was awesome, knew what she was doing, and wasn't the least bit afraid of twins. I did deliver in the OR just in case, but all was fine. They were both head down at the time, which was a plus, but they said as long as A was head down, they would do vaginal delivery. Especially since they were not my first babies.

 

Their birth was MUCH easier to recover from than my first (induced, forceps delivery)

 

So, my advice is to try your best to find a doc that is comfortable with twin delivery, and a hospital that is too.