A reader, Hannah, asks a very important question about normal twin birth:
Hi, I am 5.5 months pregnant with twins. My first pregnancy. I am fit and healthy and the twins are doing well. I have had to change gyne already, as only one on the small island where I live would agree that I did not automatically need a c-section with a twin pregnancy. The new consultant is much better, but insists that I have the 3rd stage active management as due to the twins over-stretching the uterus, he says I will absolutely need it as it will take too long to contract on it’s own. He also insists that I am induced at 38 weeks and that I have drip throughout labour. All these things I do not want, but as he is the most open-minded and the only one to permit a vaginal delivery, I can only hope that I have the ability to refuse these things on the day. If any one has any advice about what I can do, I’d be mst grateful. It is on my mind almost all the time, as I think I’ll be busy enough without having to argue my way out of these interventions when I’m in labour. There is no such thing as a ‘birth plan’ here.
Hannah, I admire you for having the courage to change providers in order to have the birth you decide is best for you and your babies. I think the best way to approach this situation is a common-sense approach. We know that no birth is risk-free, and complications can and do occur in even the most low-risk of pregnancies. Your pregnancy, carrying twins and planning vaginal birth, is slightly higher risk, but does that mean we need to pull out the “big guns” before any sign of problems occurs? This is a matter of looking at the risks of waiting versus intervening, and deciding which risks you are most comfortable accepting.
You say the physician wants to induce you at 38 weeks. This is pretty standard among many physicians, as there is a slightly increased risk of serious complications in twin pregnancies which continue past 38 weeks. You can reduce those risks if you are a non-smoker, healthy, careful about your diet (getting plenty protein, avoiding refined foods, lots of fresh veggies & fruit, etc.). Much of what health care providers recommend, such as induction at 38 weeks, is based in fear. Will the woman sue me if I don’t recommend this? What if there is a complication after 38 weeks? I’m sure everyone can understand how this could be motivation to intervene. As health care providers, we want to eliminate every possible complication and risk of birth. The problem is, we can’t. And our well-intentioned efforts often create more risk than allowing birth to unfold normally.
I have delivered vaginal twins where the mother has gone full-term (her preference) and have had beautiful births. It is not always necessary to induce a twin labor at 38 weeks. The induction and oxytocin infusion itself will place you at higher risk of hemorrhaging. Your physician is correct that twin pregnancies carry a higher risk of hemorrhage due to the size of the uterus, and how much it has to contract down to control bleeding. However, this is only an increased risk, not a for-sure thing. Since it is your first baby, you are less likely to have excessive bleeding. If you are not induced, you are less likely to have excessive bleeding. If your contractions were regular and strong throughout the active part of labor, and closer than 5 minutes apart, you are less likely to have excessive bleeding. If you are able to put a baby to breast right away, you are less likely to have excessive bleeding, and it will also stimulate contractions without needing oxytocin, to birth the next baby.
Some things about a vaginal twin birth are necessarily different. Once the first baby is born, the cord must be cut and clamped without waiting for pulsing to stop. This is because the babies can share circulation, and it would be dangerous to the second baby if the first baby continued to receive blood that should be going to the second. The first placenta will not be delivered immediately (unless it were to come out on its own) but the cord is clamped with one clamp to identify it as belonging to the first baby. Then the second baby is either turned into position by grasping the butt and head externally and manually turning it, or the feet can be gently brought down and the baby delivered breech. Neither of these maneuvers needs to be done if the baby is already head down. Once the second baby is born, the cord is clamped with two clamps, to identify it as belonging to the second baby. At this time the placentas can be delivered or you can wait for them to separate if they haven’t already. Many times, the placentas are fused and come right on the heels of the second baby. At this time, oxytocin could be given if bleeding was excessive.
It is preferred that the time between delivery of the two babies not be too long, because the longer it takes between babies, the more likely there will be complications. For this reason, some doctors will automatically start oxytocin at this time if it’s not been running before. This is not always necessary, however. In a recent twin birth I attended, both babies were head down. The first baby was delivered normally and handed to the mother. I then checked for the position of the second baby and found the head had moved into the pelvis, so I asked her if she felt like she could give me another push. The cervix, of course, was completely dilated at this time and everything was very relaxed since a baby had just come through, so the second baby came out quickly with only one push. Both babies were now in mother’s arms, and the placentas delivered right after, fused together. Mother had less than a cup of blood loss altogether. These were her first babies and both weighed over six pounds.
I would not recommend waiting and trying to be strong enough to refuse things at the birth, unless you have no other option. Here is how I would approach this situation: “Dr. ____, I want you to know that I am very pleased to have found a physician that will help me to have a vaginal birth of my twins. I understand that this carries some increased risks over having just one baby. However, there are some things that are very important to me for this pregnancy, and I hope we can work together on them. I respect your opinion, but having considered the risks of waiting to go into labor normally, I am more comfortable with the increased risk of complications if I wait to go into labor normally then I am with the risks associated with an induction. Should my babies or I ever be in jeapordy, I would certainly be willing to be induced if necessary, but if all is well, I prefer to wait. I would also like to first try putting my first baby to breast right after birth, and monitoring my bleeding rather than automatically receiving oxytocin. If my contractions do not resume quickly and I need some oxytocin, I would be open to it at that time. After both babies are born, I would like to try nursing them instead of automatically receiving oxytocin. I am not against using medication, but would like to use it only if I am having a problem. I am willing to sign informed refusals stating that I am requesting to do something different than you recommend, so that you are not responsible for my choices.” If your doctor absolutely will not bend, and you cannot find another provider, then you may be left with battling out on delivery day. If that’s the case, I would recommend taking a doula or other support person besides your partner, who can help you stand firm for what your wishes are. You will have enough to keep you busy without having to argue with staff.
Readers, please share your experiences with natural twin births. Has anyone else experienced a twin birth without induction or active management of third stage? Hannah, I wish you the very best as you work to have a normal, healthy birth for your babies!
I have two questions regarding this:
“Once the first baby is born, the cord must be cut and clamped without waiting for pulsing to stop. This is because the babies can share circulation, and it would be dangerous to the second baby if the first baby continued to receive blood that should be going to the second.”
1) If two babies share circulation in utero, why does one baby coming out change this? Why would that one get more than its share of blood all of a sudden?
and
2) I understand premature clamping and cutting of the cord deprives the baby of a certain percentage of his blood volume. Doesn’t cutting the cord in a twin birth deprive the baby who came out even more of own blood than would be lost in a singleton if it is shared? Is this not dangerous?
Thanks!
These are very good questions. There are different types of twins and different types of placentas. A wonderful website for visualizing the variations is How Stuff Works.
Identical twins can share a placenta. If this is the case, due to the change from fetal circulation to newborn circulation once a baby is born, the unborn twin could bleed to death if the first twin’s cord is not cut. Yes, the baby whose cord is cut right away may miss getting some of the blood that a single baby could get by delaying cord cutting, but in this instance it is more dangerous not to cut the cord. It is often difficult to determine whether twins share a placenta or not, thus the practice of clamping and cutting just in case.
Hi, thank you very much for the excellent advice. I will write a letter similar to the one you suggest and get it to the consultant. I had wondered about whether the 1st baby’s cord could stop pulsing before it is cut, so thank you for clearing that up for me. Also, I didn’t know that as it is a first pregnancy I am at less risk of excessive bleeding. I have ben told and am not sure if this is at all true, that because my hair is auburn I am likely to bleed more/ have a more painful labour?!
I may add to the letter that I am open to natural means of inducing, but that I think the risks involved with drug-induced labour mean that it should be a last resort. The drug the dr mentioned for third stage was ergometrine not oxytocin (or is that the synthetic name for the smae thing?)
I also wondered whether you have views on the drip. As having one will restrict my movement and be distracting I believe, lack of mobility and extra stress increasing my likilhood of further interventions, I would like to refuse that in the letter also.
Many thanks again,
Hannah
It’s been an old wive’s tale for ages that redheads bleed more. Many studies have refuted this belief, and I have seen one study which suggests that redheads may, indeed, bleed more due to a particular gene they inherit. Bottom line, if you are healthy and well-nourished you are less likely to bleed. I’ve had women with all colors of hair (including purple!) who have bled excessively, and redheads who’ve not bled at all.
Ergotomine is not the same as oxytocin. It is not recommended in the US, because it’s thought to create more problems in third stage than oxytocin. I would recommend doing a Google scholar search on “ergotomine in active management of third stage” if you are interested in reading the research.
I agree with you, I would not want to be tethered to a drip. I would ask for what we call a saline lock in the US, which is an IV catheter inserted and taped down, and then capped off so you are not connected to any IV fluids. As long as you are able to drink enough fluids to hydrate yourself, and everything is stable with your labor, you should not need an IV drip, but if there are problems, particularly with bleeding, you have a open line immediately available. This is my personal preference; many midwives don’t even put in a saline lock.
Thanks again for the info.
So if the twins have seperate placentas (as mine do) what happens with cord-cutting then?
Thanks,
Hannah
If it is known for certain that the placentas are separate, then it is not a problem to delay cord clamping and cutting. Getting your obstetrician to agree to this might be another story!
Indeed ! Thanks
Twin mom here. I had identical preterm twins vaginally with epidural in the OR room. Policy was to place an epidural in case I needed a c/s. I needed pain relief since I was scared out of my mind too, they were 9 weeks early. From other twin moms I know, it’s probably about 50% c/s rate. Most doctors will require that baby A is head down and then it’s mixed as to position for B, some will do a breech extraction or some will try to turn the baby to vertex position. We didn’t discuss cord clamping since my twins shared a placenta. It’s thought that twin placentas (either one or two) tend to start degrading prior to 38 weeks hence the induction deadline they gave you.
Thank you for this article. I too am expecting twins on my first preggo (April). I am not interested in a hospital birth and will be signing on with a midwife tomorrow to guide me through a home birth. No birthing center in our LARGE METRO AREA will accept twins.
I, too, share your view of pregnancy & birth, and have accepted that I may end up with a c/s, but I plan to do all that I can to avoid it. Again, thanks for this!
Hi all, me too pregnant with twin and its my 20th week going on. My first pregnancy. I too fear from birthing pain and wana relieve myself with this terror by avoiding vaginal delievery.. I would prefer a C/Section but could anyone tell me what are the side effects with cesarean or any drawbacks(acute care) involved with it??
waitng for reply plz….
I had twins at home at 40 weeks 2 days gestation. It was my first pregnancy.My labor was 6 hours long, starting with a rupture of twin a’s membranes,and ending in the birth of twin B in the caul, 32 minutes after twin A. I did bleed heavily, but did not need a transfusion.I would do it again. I had already chosen homebirth, but when i found out i was carrying twins, i interviewd local OB practices. I was informed that i would have to be induced at 38 weeks, have to be tethered to internal and external moniters,and that i should expect a csection. So i stuck to my origional homebirth plan, Good luck
Twin mom here. I had identical peerrtm twins vaginally with epidural in the OR room. Policy was to place an epidural in case I needed a c/s. I needed pain relief since I was scared out of my mind too, they were 9 weeks early. From other twin moms I know, it’s probably about 50% c/s rate. Most doctors will require that baby A is head down and then it’s mixed as to position for B, some will do a breech extraction or some will try to turn the baby to vertex position. We didn’t discuss cord clamping since my twins shared a placenta. It’s thought that twin placentas (either one or two) tend to start degrading prior to 38 weeks hence the induction deadline they gave you.
my first pregnancy i had mono/di twins (my girls shared a placenta, but had their own amniotic sacs) & i had a drug free vaginal birth with both of them. a couple of other things about my girls – they were both head down, my baby B was about 1.5 lbs heavier than my baby A & they came 6 weeks early.
almost predictably, my OB, quite early on, started recommending an elective c-birth (she gave me a long list of things that *might* go wrong in labour but there were no imminent medical indications for c-birth). i remember one appointment in particular where i finally told her that i was not going to have a c-birth unless something changed & i didn’t want to talk about it anymore. she immediately shifted gears & started insisting that i have an epidural.
at my last appointment (the day before the girls’ birth), i agreed to the epi. i was just so tired of arguing about everything! that evening i was having mild contractions about every 5 minutes or so. i didn’t really think i was in labour, but my doctor had wanted me to go into the hospital if i was having contractions closer than 10 minutes apart, so in we went. i stayed in triage all night at 4cm with those obnoxious monitors on my belly. i was so uncomfortable.
the next morning they discussed possibly sending me home, but then decided to have me stay as i was still have regular contractions. the triage nurse asked if i wanted to have a shower which i did desperately (anything to get off of those monitors!). as soon as i got back from my shower, baby A’s water broke. they hooked me back up to the monitors but after that my contractions became very intense & i just could not stand the monitors anymore, so i told the nurse i had to go to the bathroom so i could get off of them. when i came back from the bathroom, i “forgot” to tell the nurse, so she wouldn’t put me back on. the contractions were coming hard & strong at that point & i remember thinking “boy, i’m glad i agreed to get an epidural”.
at that point, my husband called our doula to have her come join us at the hospital. he said he watched as the nurse came around the corner, took one look at me while i was having a contraction & her jaw hit the floor. there was an intense flurry of activity (i had no idea i was fully & already starting to grunt/push at the peak of my contractions), as they ran me down the hall to an L&D room. my doula came in as i was settling in to pushing. i remember the resident asking when i was going to get my epidural & the OB on call telling her i wasn’t, i was pushing. that made me so happy.
about an hour and a half after baby A’s water broke, she was born. they immediately broke baby B’s water & she was born (with the assistance of a kiwi vacuum) 8 minutes later. i have no memory of it, but my doula assures me i was given a shot of oxytocin as baby B was being born to help manage the birth of the placenta. both girls were beautiful and, for the most part, completely healthy – they spent 2 weeks in the NICU feeding & growing & have kept me on my toes ever since.
i’ve learned a lot about birth since then (i now work as a birth doula myself & am training as a postpartum doula) & realize i would have done a lot of things differently if i knew then what i know now. the biggest one would have been finding a care provider who’s birth philosophy at least remotely coincided with mine. i think many of the other things that were frustrating to me during my pregnancy & birth could have been avoided with that one change. it’s so important to have a care provider you trust & connect with. that’s top of my list for any future pregnancies, although, hopefully from now on, it’ll be one at a time!
Well, now I’m curious for myself. I have already had a set of twin girls, they were di/di, it was my second birth. I had my first daughter 11 months earlier. I was young and stressed at the time and didn’t know I had options so I had an epidural in case of emergency but was able to deliver vaginally, Baby A was head down, baby B was born breach. They were 4 weeks early. almost 7 years later and after 5 miscarriages I am carrying twin boys. I am currently 18 weeks. Things are much different for me this time, Im in lots of pain (pelvic/pubic bones)and I am always having braxton hicks, sometimes even while just sitting. I guess I won’t be doing much till I have these little guys. Oh and they are also di/di. I have been really interested in accompilshing new things I have discovered. I would really like a natural birth (I am pretty confident of my body being able to do its job) delayed cord cutting, I will settle for Vitamin K shot but no vax, no bottles or water or sugar water to be given. I am just already intimidated about even discussing this with my doctor. He is the only one in his practice. And I am concerned out of convenience I will be forced to have a c section or not get any of my wishes for delivery. My husband and I really wanted an at home birth, but we just don’t have the finances to support it, and I am on baby aspirin and lovenox because of all my miscarriages (3 of my 5 happened at my second trimester). So I know I am at risk for bleeding already. And then reading that bleeding already is an issue for twin births, now Im wondering how a second multiple birth will end up? Anyways, so with di/di twins would I still be able to do the delayed cord cutting?
Hello!
I am 38 weeks and 4 days with di/di, boy/girl, twins. Baby A (boy) is bigger, discordance is consistently 21 to 38 percent, and he is vertex and presenting. Baby B (girl) is breech and seems to be stuck in a c position with her back to my abdominal wall. Space is starting to become limited for them. The initial post for this thread is similar to what I am facing. A practice of 3 very modern perinatologists that have been warning me of what I can expect to go wrong throughout my pregnancy. Bloodwork, including clotting panels, numerous scans, and nst’s later and I am a nothing but a healthy 25 year old single mom who is feels like I am the only one who has confidence in my body and my babies. It is going to be a huge battle no doubt when I go into the hospital and refuse any intervention unless there is genuine indication that the babies or myself are in distress and medical urgency is necessary. I am currently battling over induction with my OB and have already been told I am risking the lives of my babies by carrying past 39 weeks. LOTs more intimidation where that has come from. Again so far this has been a very healthy pregnancy and continues to be, but the pressure from my OB and her colleagues is starting to wear on me. I hope I can come back to this thread with news of successful twin vaginal birth story even if I have to battle for it. More than anything the health of the babies comes first, but I know intervention is not always necessary.
I would like to ask what instruction to give to a mother who has just delivered first twin.2 management of membranes post delivery of first twin.3 cord magement after first twin.which position to assume .when should she start pushing .AS A MIDWIFE
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