Twins: Extra Considerations for a Natural Labor & Hospital Birth

Attempting a natural twin birth can be pretty daunting.  With twin c-section rates at 75% in 2008 (3), even if you know someone who has had twins, you likely don’t know someone who had a successful vaginal delivery for both babies.

However, despite professional opinions being mixed due an inadequate number of published studies on this topic, several studies have shown that when the presenting twin is in the vertex position (head down), vaginal delivery should be attempted.  In fact, Dr. Jon Barrett, the head of the maternal fetal medicine department at the Sunnybrook Research Institute in Toronto, and his colleagues found that a planned c-section is no safer than a vaginal delivery for term twins where the presenting twin is vertex.

If you are planning a vaginal twin birth, there are several additional considerations to contemplate regarding your labor, birth, and immediate postpartum period.  Based on my personal experience interviewing doctors and having a vaginal twin birth, I have compiled the following list of topics to think about and address in order to increase you chance of achieving your ideal birth.

·       “High Risk” designation:  Prepare to be categorized as “high risk” even if you don’t have any complications except for the fact that you are growing a second fetus.  Twin pregnancies usually have a higher chance of pregnancy-related complications like gestational diabetes and pre-eclampsia.  Additional prenatal testing such as the Glucose Tolerance Test may be encouraged, so you may want to research whether or not you feel this testing is necessary based on your individual risk factors.

·       “High risk”; all the drawbacks and none of the benefits:  It will be harder to find an out-of-hospital birth location for your twin birth, and at the same time, you may not be “high risk” enough to get an appointment with an OB that has specialized twin experience.  For example, I knew a doctor that was willing to deliver breech babies.  He was one of the only ones in my area, so I wanted to hire him as my primary obstetrician.  However, he was a specialist in Maternal Fetal Medicine (MFM).  I couldn’t switch my care over to him because I didn’t have a condition that qualified me as “high risk” besides being pregnant with twins.   I was not “high risk” even though I was “high risk”.  A conundrum.

·       Induction at 37 weeks:  Lots of docs will induce at 37 weeks if your babies didn’t get the memo that a twin pregnancy should not go longer than 37 weeks.  In general, both for singletons and twins, the chance for some complications like chorioamnionitis (infection of the membranes), still birth, placenta abruption, pre-eclampsia, and postpartum hemorrhage are lowest at 37 weeks, then go up from there.  These are relative risks we are talking.  The absolute risk is still very small (think an increase from 0.4 per 1000 at 41 weeks to 0.6 per 1000 at 42 weeks for stillbirth) (1).  However, a doc may use this to intimidate you into inducing at 37 weeks to minimize risk for these problems.  If faced with this situation, don’t forget to consider your individual situation and how well you fit the data set.  Also consider the risks of inducing labor before your body and babies are ready.  Factor in the chances of hyperstimulation of the uterus and increasing your chances for a c-section (1).

·       OB’s willingness to deliver a breech baby:  for the position of babies in a twin pregnancy late in pregnancy, you can expect 40-45% of babies to be vertex/vertex, 35-40% vertex/non-vertex, and 20% non-vertex presenting twin (2).  Therefore, a big question that you should discuss with your doc is if they are comfortable delivering a breech baby.  Even if they are both vertex during labor, after the first baby is born, baby #2 may flip around in the newly vacated space, 20% of babies do this (2).  Run through scenarios with your doc about possible situations and how he/she would handle each.  For example, both babes are vertex.  Twin A is born and then Twin B flips breech.  What kind of actions would the doc take?

·       Don’t let anyone tell you that babies stay put after a certain gestational age.  One of my 7+ lb twins flipped breech to vertex at 40 weeks.

·       Continuous Fetal Monitoring: In order to keep track of two babies, some doctors may encourage continuous electronic fetal monitoring (EFM) rather than intermittent.  Check to see how your doctor feels about intermittent monitoring of twins.

·       Second stage positions:  in order to best see what is going on and monitor babies by EFM, some docs may require that you stay in a bed during late first stage and second stage of labor.  Most OBs are not as comfortable with twin deliveries as they are with singletons.  Consider also if you are having an unmedicated birth, this may be the first for your doctor.  In order to feel comfortable, they may prefer a position that is easier for them rather than best for you.

·       Time between the births:  How much time are they comfortable with going by between the deliveries of the babies?  Will they let your body do what it’s going to do as long as Twin B’s heart tones are good?  Will they administer Pitocin immediately following the birth of Twin A to be sure that Twin B is born in a “timely” manner?  Timing between births can vary quite a bit in a natural twin birth.  Don’t forget about putting Twin A to your breast immediately following birth to stimulate contractions for Twin B.

·       Run through scenarios in general with your OB:  Playing the “what if” game allows you to explore situations that you may have overlooked in your original questioning.  In order to be respectful of their time and to maintain a good relationship with your doctor, you don’t have to cover every single situation in depth.  However, keep in mind that you are hiring this doctor to provide a service for you.  They are your safety net in case of an unexpected situation.  You have the right to research your options and investigate whether your provider will be a good fit.

·       Ask which procedures and interventions are linked together.  For example, at my 40 week induction for my twins, I consented to Pitocin administered slowly over a long period of time.  I didn’t realize that it was hospital policy that if a patient is given Pitocin, they must also have continuous fetal monitoring.  I didn’t want continuous monitoring, but once I said “yes” to Pitocin, I inadvertently said “yes” to monitoring,

·       Epidural for Breech Extraction:  Be prepared to be encouraged to have an epidural because of the possible need for extra procedures in the event that Twin B is breech or transverse after the birth of Twin A.  One or more of the following procedures may be applied in this situation:

o   External cephalic version:  when a doctor tries to turn the baby to vertex by manually pushing on the outside of the mother’s abdomen.

o   Internal Podalic Version and Breech Extraction:  in short, the doctor reaches into the uterus, grabs the baby’s foot or feet, and pulls them out of the uterus through the vagina

Both of these procedures can be quite painful.  Therefore, some OB’s recommend an epidural just in case one or both of these procedures need to be performed.  This is where your run-through scenarios come in handy. What specific actions would your doctor take if Twin B does not immediately turn vertex after Twin A’s birth?  Going back to the timing for the births, 20% of second twins change position after the delivery of the first twin (2).

·       Be prepared to be encouraged to have an epidural in case of c-section.  If you don’t have an epidural in place and an emergency c-section is required, general anesthesia may be used.  Again, run through this scenario with your doc to see if an epidural could be placed if a c-section was required or if a general would be used.  A general means you will be completely out during and immediately after the actual birth.

·       Delivery in the OR:  Many doctors and hospital staff encourage twin moms to move to the OR for the delivery of their babies.  Laboring in the labor room is accepted, but at crowning, mothers are encouraged to move to the OR.  For mom, this means physically moving out of the room and down the hall.  In general the OR tends not to be as comfortable as labor and delivery rooms.  Lighting is harsh, temperature cooler, and labor bed less flexible.  Docs may feel more comfortable here in case an emergency c-section needs to be performed for one or both twins.  OB staff during my labor suggested that moving to the OR would actually give me more time to push.  They would let me push a bit longer if they knew that they could do a c-section immediately rather than add a cushion for moving me to the OR during the actual emergency.  This risk will need to be evaluated on an individual basis.

·       Cord clamping and cutting:  Is delayed cord clamping for Twin A possible (or Twin B for that matter)?  This topic goes hand in hand with “time between the births” bullet point.

·       Twin nursing support:  Is there twin nursing support person at your hospital?  Mainly, is there a person who can help you tandem nurse immediately after delivery?  Likely your hospital can provide lactation support, but usually this support is offered in the hours and days following birth.  Someone who is experienced with tandem nursing should be present immediately following your twin birth to help you get both twins latched right away.  If you are lucky, your nurse may have some experience.  However, you could arrange your own support by hiring an experienced doula.

Remember, do you homework before your birth so that no matter the method your babes arrive earthside, you can feel confident that you did your best.  The adventure is just beginning!

 

 

1.       Dekker, Rebecca.  “Evidence on Inducing Labor for Going Past Your Due Date”.  http://evidencebasedbirth.com/evidence-on-inducing-labor-for-going-past-your-due-date/

2.       Christopher, Diane et al.  “An Evidence-Based Approach to Determining Route of Delivery for Twin Gestations”.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3252881/

3.  Pearson, Catherine.  “Twin Birth Study Finds No Benefits to Planned C-Section”.  The Huffington Post.  10/2/2013