These archives contain extracts from discussions held on the UK Midwives and Consumers email list, a discussion group for people interested in midwifery in the UK. Open to midwives, students, mothers, and anyone interested in improving maternity services in UK. Posts in these archives express the views of the individual authors, and not those of the Association of Radical Midwives.
I have just been privileged to be present and assist a woman giving birth to twins actively in a hospital. It seems awful to relate that nearly all my previous experiences of twin birth as a midwife have been negative with ARM, continuous monitoring and quite frequently a traumatic (as I see it) and hurried (pushed on) delivery of the second twin.
My previous experiences have filled me with such horror that I find myself in the position of feeling that if I were to be pregnant with twins I would be scared stiff of how I would cope with the labour and all that it entailed. I didn't think it was possible to get a positive birth in a hospital — until this week.
I cared for a woman (I'll call her Mary) who came in while I was on night duty. 38+ weeks, twins, both cephalic, both felt a good size. Mary came in and was in early labour, (cervix 3cms dilated) and wanted to use the bath, did not want continuous monitoring, wanted to be free to adopt different positions with no unnecessary interventions.
I ran a warm bath for her and she stayed in there for an hour and got out when the contractions began to dictate frequent position changes and settled onto the bed with a beanbag in an all-fours position.
The doctor on call would have preferred a CTG trace (electronic monitoring of babies' heartbeats) but it was difficult to monitor both babies adequately with Mary in this position and in any case I had no concerns about the size or condition of them. I listened in intermittently and both babies seemed to be coping well with the labour. He would equally have liked an ARM (artificial rupture of membranes) and FSE (foetal scalp electrode) attached to Twin 1 but I told him this was out of the question and as far as I could see there was no need to interfere.
This non-intervention was very important to Mary and she had already swapped hospitals in her pregnancy to increase her chances of a normal delivery and it was important to me to only interfere if it was really necessary.
Two hours after admission and Mary was experiencing urges to push, membranes of the first twin ruptured spontaneously and 15 minutes later he was in the world and yelling healthily. With Mary's permission I performed a VE (vaginal examination) to assess presentation of the second twin. Head down still and just above the spines. Twenty minutes later he arrived to join his brother.
This birth has restored my faith in the maternity services although I think it also had something to do with the ethos of our unit. While the doctors were very "quivery" and nervous, the other midwives were not, and I received good support from them. In my last unit the situation would have been very different and both I and Mary would have been given a very hard time in trying to meet her wishes from both doctors and midwives.
In fact, even our doctors did not put huge pressure on Mary or me regarding intervention - I know they have very different experiences and mean well in their approach but in this case their intervention was not needed. I feel that I was able to apply our guidelines regarding care of a labouring mother with twins without being absolutely rigid, and without my colleagues waving them in the background and predicting dire outcomes if they were not followed.
Mary said afterwards that the birth had been very positive for her and that she had so worried about routine intervention. I am just glad she birthed her babies with us and not in a huge and medicalised obstetric unit (like my last unit, where she would have been just another in a long line of women to be processed).
I didn't think until this week that it was possible for the mother of twins to give birth so positively in a hospital. I am glad to be proved wrong. This posting is long-winded, I know, but I just feel so pleased with this outcome.
Jade
Midwife Jane was awaiting home birth twins. Well, she waited and waited with their mum. They have now been born, two boys - both over 3kgs at home in the space of 3 hours and are happily growing on their family's love and mother's breast milk. They were born at 11 days plus dates.
Medicalising of twin pregancies is one of the examples of the pathologising of childbirth in this country. Years ago, my clever old midwifery tutor was born at home with her also clever twin sister born 24 hours later. Her mother was attended by a midwife and a G.P.. All of them slept over the night after the first baby was born and then woke up ready for the next labour. This story has always inspired me. As I understand it, having twins used to be a normal home birth event in the UK.
Nutrition as with all pregnancies surely must contribute to these healthy twin outcomes, but ..I've heard stories from retired UK midwives where even smoking and poor diets haven't seemed to cause any problems.
Inductions, epidurals, c/s for twins are now almost the norm I believe. Only the women who challenge this and are well-supported by midwives get to avoid being messed with, like someone Jane has as a client.
KerriAnne
This has prompted me to write about the birth of my second twin, Amelia. My girls presented as vertex (presenting twin) and transverse from about 28 weeks and didn't budge. I'd rejected the care of the secondary care clinic, a multidisciplinary team managing all level 3 pregnancies, and stayed under the care of my midwife Sandra.
Come labour at 40 weeks they were still in the vertex/transverse position. I had previously decided that if they were not both head down by term I wouldn't have a homebirth, but would go into the hospital to give birth. So in we trotted and met Sandra who directed us to the new flash labour/delivery rooms with lazy boy chair and big deep tub ( big whoop). Rose was born first (7lb 2oz) fairly easily and caught by Sandra.
Amelia continued to float high and transverse so in came the obstetrician( who we had managed to avoid thus far) to do what I had been dreading more than a C/section, an internal version. He couldn't reach her despite using his other hand to perform external version at the same time. With the next few contractions she moved to the oblique, the Ob had left in a panic to call the anesthetist as Sandra had put a light epidural in prior to the version ( the anesthetist had set it up and left the anesthetic for Sandra to top up when needed) and he wanted to put a full one in so I could go to theater.
When he came back in and saw she was at the oblique and FHR (by hand held Doppler) was good, he decided we could have a while longer to get her right around. Before he left he wrote in my notes in big letters "Patient wants a normal as possible birth" - when did I become a patient??? I digress.
Between contractions (which were very far apart because of the epidural) I kept my hand on Amelia's rump keeping up pressure so she wouldn't slip back. Nearly an hour after Rose was born Amelia made her grand entrance face up and weighing a pretty decent 8lb 7oz.
I am so pleased I kept my midwife as my lead maternity carer as I am sure I would have ended up with a C/section (or worse, vaginal birth and C/section) had I gone under the care of the 'team'. I am eternally grateful to her for her commitment to my babies and myself. It was no picnic for her either - she was under pressure to relinquish my care, and if anything had gone wrong she most likely would have lost her access agreement with the hospital..
Regarding 'Can a Twin Birth be a Positive Experience?' by Jane Evans:
I found what she said about gravity very interesting, for me my twins were stacked and Milly had been transverse since 28 weeks, so birth position didn't account for much there, but once Rose was born getting upright (as much as you can just after giving birth and breastfeeding that baby to assist the birth of the next) assisted in her tipping down. Also pushing was very different with trying to birth the first twin, all my pushing efforts went onto Milly who was on top, and rose got this weakened second hand push to help her out, needless to say it took much longer than I was used to, to birth her.
Andrea
Andrea's twin birth story for Rose and Amelia is online.
I am 38 weeks pregnant with twins (39 weeks tomorrow). They are both head down and they are in separate sacs, separate placentas. I was wondering if I could ask you all some advice on a couple of topics:
1. how long you think I should hold out before I allow myself to be induced? Looks like I may be able to hold out til Monday as my hospital seem cooperative. My blood pressure was 128/80 today and urine clear. Last scan (a month ago) showed growth and placentas fine.
2. I am being strongly advised to have an epidural in case I need a c-section for the 2nd twin. I would like to avoid this if possible. Does that mean that if I do require a c-section for the 2nd twin, I will need a general anasthetic and will be unconscious for the birth?
3. I would like to have a physiological 3rd stage - do any of you have any opinions on this for twins? I am being strongly advised against it but would like to try it and wondering how long to wait ie how much blood loss should I allow before I have the injection?
Many thanks for any help you can offer.
Susie, mother
> 1. how long you think I should hold out before I allow myself to be > induced?
I would think you could hold out just as long as you could with a singleton pregnancy, assuming there were no problems! What is the rush? Usually the problem with multiple gestation is that the babies want to arrive early! You're doing great.
> 2. I am being strongly advised to have an epidural in case I need a > c-section for the 2nd twin.
(sigh) Probably. This type of thinking is wrong on so many levels. I think that an epidural could actually contribute to problems that might lead right to that c-section!
> 3. I would like to have a physiological 3rd stage - ..wondering how long to wait ie how much > blood loss should I allow before I have the injection?
There's really no way that you'll be able to gauge your own blood loss. You'll have to trust their assessment of that. But there is no reason why they can't wait until after the placenta is delivered (by you!) to determine whether or not you need oxytocics.
Diane - midwife in US
(...who gave birth to lovely twin girls 4 weeks early, naturally, in
hospital, no IV, first one vertex, second one in pike position had to
be manually turned to footling breech to be delivered, physiologic
3rd stage. God bless that doctor and my midwife for being willing to
listen to what I wanted and help me get it. We went home with our
babes the next day.)
I have 15 month old twins and work as a midwife. Hopefully you will be fine to go to full term. After this point I'm sure sure hospital will monitor you closely.
If you need and emergency section, there should be enough time to get an epidural in, if not then yes you will be given a GA. Any signs of anything going wrong will probably be piked up during the course of your labour.
You can bleed more with twins which is why you are recommended to have an injection. It's not a case of holding out for a certain amount of blood loss. If your uterus has not contracted down after the birth and you are bleeding heavily, You will be given drugs to stop it, usually in the form of a drip. the injection must be given as the second twin is being born if you are going to have it.
midwife
I had dichorionic (different sac/separate placenta) twins in 2004 at my local NHS hospital. I am a midwife myself so I accept that that makes a difference. I declined 19/40 anomaly scan as I was having both babies no matter what. I had a scan at 36 to check for location of placenta and I watched them grow. I took Mary Cronk's advice and ate a high protein diet. I had the same midwife palpate the babies regularly to check their growth. I needed a renal scan in pregnancy and the growth was checked then and was fine. My advice on scanning is not to plan but decide as you go along.
BY the time I got to 36/40 and the placenatal localisation scan, the first baby was deep in the pelvis so couldn't be measured well and the second twin had her head pressed into her sister's tummy so that couldn't be measured either! I'm so glad about that as the first weighed 2.3kg (5lb 2oz) and the second 3.1kg (7lb). If this difference had been known by the obstetricians I am sure that I would have been pressured to have an induction.
I laboured spontaneously at 39/40 with my chosen midwife. I had a home assessment before going to the hospital. I entered the birthing pool at 5cm dilated with two midwives present and the third midwife was called. She was on call for me specifically as she was a supervisor of midwives and had experience of non-medical twin births.
Twin 1 born in the pool. Beautiful experience. Twin 2 born 43 minutes later, kneeling on a beanbag, in her membranes. Once again I used Mary's twin guidelines for birth. No more V.E's, no continous monitoring, no rupturing of membranes, no drips, etc. The whole medical team were aware and on standby but it was just me, my husband, my son age 10 and my 3 midwives in the room and to be honest I didn't even know they were there. I did have a horrible third stage and bled a lot but I can reconcile that because my birth was so beautiful and my twins were mine, birthed by me, with me in control. I can't express what that feeling means.
My advice about birth is to approach the head of midiwfery in your area and tell them what you want and how can they go about facillitating that. There will be midiwves willing to help you and who would go on call for you (There will also be those that won't so best to know in advance!) because they want you to have your needs met. I know that I would be on call for someone like you in a shot.
J - midwife
Would really appreciate somebody clarifying something for me. I understand that with twins there are two 2nd stages, and that the cervix 'undilates' slightly after twin one is born. Would it be possible to have two horrible transitions, and if 2nd stage in primips often lasts a couple of hours, could each 2nd stage last that long? How long does the second 2nd stage normally last? In this area there is a policy of synto after twin one, which would encourage contractions to return quickly, but would it shorten the second stage?
Sam - antenatal teacher
Speaking from personal and not professional experience (giving birth to twins just over a week ago), 2nd stage for the 2nd twin followed directly on from the 1st twin's 2nd stage (does that make sense?) with no 2nd transitional stage.
From chats with other twin mums this tends to be the case, regardless of whether or not drugs are used to speed up the delivery of the 2nd twin. (In my case no drugs were used at any point during labour, and although there was 50 minutes between the birth of each twin, there was no large delay from the 1st birth to the onset of contractions for the 2nd).
During my pregnancy I was led to believe synto after the first birth would shorten the 2nd 2nd stage, but in my mind this is not a good thing as nature has designed us to get a bit of a rest between each birth.
M, mother
In reply to your specific ? concerning the 2nd stage like practically everything else in midwifery unless there is a compelling reason to intervene the onset of the second expulsive stage to birth twin 2 is better awaited with vigilent patience, as the parents admire and cuddle twin 1.
Mary Cronk, midwife
I can only give you my own experience and that was somewhat atypical...
How long does the second 2nd stage normally last?
Mine was about 10 minutes - 3 contractions, although talking with friends with twins it does seem to be very variable, both the period of time in the 2nd 2nd stage waiting for contractions to restart and also once they have restarted how long it takes to birth the second twin.
>..there is a policy of synto after twin one, which would >encourage contractions to return quickly,
I would avoid it unless there is a strong medical need (eg contractions haven't restarted but twin 2 is in distress) as it is good to have a breather to let your body and your mind recover for some moments. Also it's great to have cuddle time with baby no 1 and maybe even start to breastfeed if you can, as that may naturally encourage contractions to restart as well as being great for your baby.
>but would it shorten the second stage?
Although it may shorten the time you have spend with your first baby waiting for the contractions to restart, I don't think it would necessarily shorten the actual expulsive phase as there is still the same amount of work to do!
I honestly didn't find that this was as bad as the first as you are already very stretched and there was not a 2nd transition or long pushing stage....but I guess it would be possible for this to happen to some people. A lot may depend on position, if the second baby is badly positioned then I think it can be very hard...
Fay, mother
just offering my own experience, home water births of twins in your area! (can you tell i'm still on a high about my babies' births?) After the birth of my first twin baby - Cephalic presentation, my second who was breech was born with a 10 min break of contractions then about 40 mins of a contractions with baby being born with just a few pushes. I'm still happy that i listened to my body and not the consultants. (although i'm sure they would be fab for those babes that actually need the help).
Lucy, mother
Does the genetic tendency to have twins run on the female line, or is there some male involvement?
The husband and his family history would have no bearing on whether his wife released more than one egg and thus conceived fraternal twins. However I did read in Elizabeth Nobel's book (I think) 'Having Twins' that there can be a genetic tendency for some sperm to predispose an egg, once fertilized, to divide. It could be an enzyme that certain sperm carry, who knows, but some fertility specialists are doing research into it after discovering a high number of monozygotic twins developing after early embryo transfer during IVF. So he may have an ever so slight influence, but on the whole no, the husbands family history has nothing to do with the wife's ability to conceive twins.
And just to confuse you even more, there is thought to be a third type of twinning, a blend of mono and dichorionic twinning, although it's very hard to prove. It's thought that the ovum goes through a third meiosis creating an original and daughter germ cell which are then fertilized by two different sperm. There is one animal, I think it's the hippopotumus or Rhino that always twins in this way. But like I said it's hard to prove in a human, but does explain why some fraternal twins are more alike than others.
I'll just plug our new web site www.nzmba.org, the web site of the New Zealand Multiple birth association. Linked to the site in browser form is 20 years of Multiple birth statistics kept in the form of a data register on thousands of multiple births in New Zealand. This data is only accessible to those doing research and you need a code to access it. Because it's now browser-based, researchers, including midwives, can access it from anywhere in the world. All you have to do is have your research passed by a university ethics committee and the NZMBA. One researcher has already found the diabetes gene and its link to low birthweight babies, from using our register.
Andrea, Mum of 9
Rose and Amelia: Twin Birth Story
'Can a Twin Birth be a Positive Experience?' by Jane Evans
Emma Mahony wrote in The Times about planning a home birth for her twins, and afterwards..
Twins - Twice, by Beverley Beech (AIMS). Natural birth versus caesarean section.
TAMBA (Twins and Multiple Births Association)
www.tamba.org.uk/
Multiple Births Foundation for parents and professionals
http://www.multiplebirths.org.uk/www/ms_home.html
AH updated 28 January 2010