Checking my stats I discovered that ‘Risk factors for a home birth with twins’ was a search someone had started which had caused them to visit my blog. It’s interesting how these things must function as individually ‘risk factors’, ‘home birth’ and ‘twins’ would definitely all feature in my musings but I feel sure that I haven’t ever put them all together, and definitely never in a format suggesting that I would encourage a home birth for twins.
- There are midwives who will disagree with me on this one, they are brave, I am tremulous. I look at the risk factors during and following the labour and plump firmly for the ’birth units attached to an obstetric unit are lovely’ attitude.
- There are midwives who will disagree with me on this one too, they would rather the obstetric unit.
- There are midwives who will disagree with them on that one, they would rather an elective caesarean section.
So, there are 4 viewpoints on how the birth of twins should be managed. How would each group have reached their opinion? Most often the answer is experience, a bad experience of one method and a good outcome with another. To be honest, there are very few, currently practising, NHS midwives who will have experienced a planned homebirth of twins therefore we haven’t got any experience, be it positive or negative, on which to base our judgement. What we have to do is consider the twin births we have witnessed in hospital, read any evidence about outcomes at twin home births and weigh up the risk factors (I’m not even going to include Trust guidelines, policies and protocols here as they would completely bar a homebirth of twins).
Let’s consider the risk factors during labour. Immediately there is a difference between identical, one egg, twins and fraternal, two egg, twins. This arises because the identical twins will share a placenta and sac, whilst the fraternal each have their own home and placenta. I could scribe for ever if I muse about each so I’ll mention it when pertinent. So, Mum has gone into labour, twins will often come early, has the pregnancy reached 37 weeks? Before that there is a risk of one, or both babies, having breathing difficulties. I think that everyone would agree here that the birth should be in an obstetric unit purely for the paediatric support. Then, how are babies lying? Are they behaving themselves? Ideally both babies will be coming head first, if they are then risk regarding the birth immediately decreases, this is when I muse about a birth centre environment, as long as it stands along-side an obstetric unit.
First one, head down (cephalic) with the second breech? Gosh. How big are these babies? Is the first one larger than the second? Even though the research on vaginal breech births being a no no has been rubbished obstetricians, and midwives are still hugely wary, at this juncture many professionals would advise an elective caesarian section. I say many, not all. If one of my women was pushing for a vaginal birth with T1 cephalic and T2 breech I would have a long discussion about the problems which may be encountered due to breech presentations but, if they were fraternal, ultimately I would support her with her desire for a vaginal birth in an obstetric unit. Identical twins, more problematic, it’s that one placenta worrying me, is it going to start separating before the 2nd baby is born? The breech may deliver with no difficulty, so hopefully there are only a few minutes between babies, it may take it’s time though, or decide to stick a leg down and then require more manoeuvres to help it out or the cord may snake down, I’m weighing it up, placenta might separate = lack of oxygen, baby might take longer to be born, certainly there is higher risk for a poor outcome with the second twin, my feeling, obstetric unit and possibly an epidural. Many, many people and some midwives would disagree with me, I’ll put a couple of links here, Emma Barker’s twin birth and Homebirth org which have a more relaxed stance than me. Both babies breech, obstetric unit and, in my world, whether fraternal or identical, elective caesarian section.
Why all this worry? After all it’s just giving birth to two babies rather than one. Unfortunately it really isn’t that simple, and the second baby really does fare less well than the first baby. Several reasons, mainly due to the extra space available once number one has been born. Even if the second baby was coming in a good position, be that cephalic or breech prior to its sibling leaving the womb, that can change as soon as room has been created for it to move around. Routine at twin births is stabilising the second twin as soon as number 1 is born. An assistant will, externally, attempt to ensure that wriggly twin 2 doesn’t perform celebratory gymnastics. There is also the risk that the cord will present before baby, someone will check this and, if it there and baby is in a good position plus already striving to come out s/he will be assisted in their endeavours but, if baby is still high, or the part the examiner is feeling is a leg , shoulder or arm then the safest way forward is a caesarean. If T2 is behaving then generally, after a short rest, contractions will continue. This isn’t always the case though and, due to the uterus contracting down following the 1st baby, there is a risk that the placenta will start to separate, causing number 2 to suffer with a lack of oxygen so some units will routinely put up a syntocinon IV to ensure that contractions can be stimulated if necessary. It’s also handy to have the syntocinon hanging around for the third stage, that time when the placenta, or placentae are coming away. There is much talk in this entry about the uterus, and it’s size and during the third stage is when it can cause the mother more problems. With one baby there is a much smaller area where the placenta was attached, with two it is really quite large, and in essence this is an open wound which can bleed quite impressively if the uterus doesn’t contract down really quickly, and then stay contracted down. Following a twin pregnancy all the associated tissues and muscles have been hugely stretched so the chance of an atonic, non-contracted uterus, is more probable, therefore the strong possibility of a postpartum haemorrhage is something to be kept in mind. This is where the syntocinon IV comes in handy as it may well be required to help a reluctant uterus to contract.
Ultimately the choice of where a woman gives birth to her baby, however many, is her decision. That choice should be informed though. There are risks with a twin birth, and they are higher than for just one baby. The highest risk, prematurity has been passed with a planned home birth but there is still risk at term, particularly for the second baby. Professionals can advise, and on the whole we err on the side of caution so, if you are expecting twins and want to really know your options and the risks, read, read, and then read some more but make sure that what you are reading comes from safe sources.
Great article about twins – e.Notes.com
American discussion about twin births with international references
Postscript – (declaring an event which may make me biased)
My daughter had twins, by an elective caesarean section at 36 weeks. This was her 2nd pregnancy. The first ended with an induction of labour at 41 weeks and 4 days, failure to progress, cervix never more than 4 cms dilated after 15 hours on syntocinon, progressed to caesarean section and the birth of a 9lbs 12ozs baby girl.
The twin pregnancy was identical twins and was uneventful. Daughter was happy with the plan to deliver the babies at 36 weeks, I concurred as T1 was cephalic, T2 was breech, the history of the previous section and a close family history of twin-to-twin transfusion resulting in both babies dying. The babies weighed 6lbs each but T2 suffered breathing problems and spent the first 2 days of his life in NICU, he is fine now. In retrospect I would have encouraged waiting until 37 weeks, but hindsight is a wonderful thing.
An interesting read. I guess people think its just the same as giving birth to one baby but doing it twice but its not quite that straightforward is it. Lots of extra risk factors because there are two of them. Given all the drips and monitors you’d have to be on, this would really limit your ability to have an active birth. Personally I think I’d go for the planned c-section. Also is it possible to deliver 1 vaginally and then end up with a c-section for 2nd? Double ouch!
Freddie – Unfortunately vaginal birth with T1 then emergency section for T2, often due to T2 turning sideways, malpresentation. Evn worse when T1 was ventouse or forceps with an episiotomy and then followed by a section. Discomfort in all areas.
That was interesting and must admit I didn’t know much about the complexities of giving birth to twins other than a vague awareness that extra care was needed.
I also attended a presentation (by a specialist women’s care physio) today about pelvic girdle pain in preganancy which was very enjoyable and informative – and made me think of you (in your professional capacity of course!)
Blue Spice – Pelvic girdle pain, the epidemic of our time. Even 10 years ago we only saw, or heard about a few cases but now it feels like every 4th woman has it. Did the physio have any comment about the prevalence or causative factors?
She said that until recently it was thought to just be the “norm” and it’d settle after the birth, but that in fact this is not necessarily true. Prevalence was quite high I think (from memory – certainly it was higher than I expected) Interestingly she said that often in women who suffered with the first pregnancy, could be fine for the second but get it worse than before in a third pregnancy.
Causes include the pre-existence of an abnormailty in anatomy, function, posture etc which is aggravated by the pregnancy bringing it to notice. Also a possibility that the hormone “relaxin” does have an effect on the joints involved.
Often patients learn a lot from being shown how the joints and muscles in the pelvis work in symmetry and using giant sized tubi-grip increases patient’s awareness of the joints and movement. Although it’s stating the obvious, I’d never thought about it – using maternity supports is only of benefit AFTER the pelvis has been stabilised into a correct position/posture. It’s not good just fitting one on top of a pelvis which is out of alignment. Patients also advised NOT to push shopping trollies, do the hoovering, pick up toddlers (esp. on one hip) etc.
All of this is jsut from what I remember but if it would be of any interest to you, I can get you the proper notes and figures.
X
Really interesting, thank you. The thing about it not being the same as having a single baby twice in one sitting is really informative.
I’ve just started my midwifery journey, so I’m still ages away from decisions like these. Right now, if it’s anything more complicated than needing your pulse felt or your wee checked I’m probably not the best candidate!
With my NCT teacher hat on, I’d say that my experience suggests that the more “they” say that complicated = obstetric unit, lack of options, no discussion then the more women are likely to push for arguably higher risk things like twin homebirths.
Mrs M – Wow, student midwife, congratulations and good luck.
I find that if I can talk and explain everything to ‘high risk’ women first, get in before the consultant, then women are far more willing to compromise and consider options which are less hair-raising and potentially risky. If the G.P or consultant gets in there first, with an often very authoritarian approach. then I’m banging my head against a brick wall and really hoping that I’m not on-call when they labour.
Just a quick correction from a twin mom. A single amniotic sac or single chorionic sac is a definative indicator of identical twins. However, identicals can have completely separate pregnancies (chorion and amniotic sacs and placenta). It all depends on how early the fertilized egg splits.
And a single amniotic sac is a very high risk identical twin pregnancy, but it’s not so high risk if there are two separate amniotic sacs but one chorionic sac. A membrane separating the pregnancy eliminates any umbilicle tangling.
Also, fused placentas can happen with fraternal twins which emulate a single placenta. This happened with my fraternals (b/g) so there’s no question that they were fraternal.