Twin Prep

PREPARING FOR NATURAL CHILDBIRTH WITH TWINS

By Tracy Goutbeck

Previously published in Birth Issues Summer 2012

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When I discovered I was expecting twins I grieved the loss of another home birth with a midwife. It was at a time after registration but before funding of midwifery. My midwife was being paid out of pocket, but my delivery was out of scope of practice for her. I was able to maintain shared care with an obstetrician. Looking back, this was probably the best of all worlds. I had the same number of prenatal visits between the two care providers, but had to have a hospital birth.

The first barrier that a mother of multiples runs into is that she is more likely to deliver early. As a nurse, I never liked going with the moms into the Neonatal Intensive Care unit (NICU) to visit moms their babies. Preterm (before 34 weeks) or even near term (34 to 37 weeks) babies have more issues and parents have more stressors with an NICU stay. As a woman pregnant with twins, I resolved to get to term. I read books like Elizabeth Noble’s Having Twins and Dr. Luke’s When you are Expecting Twins, Triplets or Quads. Both these excellent books recommended adequate rest and diet. They especially recommend high protein intake and weight gain. So I bought high protein foods I had never tried before, included protein powder in shakes and tried to eat more than usual to gain weight. I sometimes had to eat when I did not feel like it to meet their recommended 60 grams of protein a day. I also made smaller meals and snacks more frequently; so I was eating 6 times a day.

Now that I am studying to be a midwife, I would also recommend a source of Omega 3 fatty acids in your diet to get to help avoid preterm labour. Eat fish 3 times a week or take fish oil capsules (Olsen, 2004, Genuis, 2008). I also had a lot of people praying for me to get to term. I spent a lot of time visualizing the babies growing, being head down and my cervix being tightly closed like the neck of a pop bottle. I had less than 5 hours labour for my first baby, so I was visualizing and asking God for a 3 hour labour. I asked for a definitive sign of start of labour so I would know when to go to hospital.

I had heard that term gestation for twins was less than that for singletons (single babies). Since I was doing all that work to get to term, I did not want to be told I should be induced. I wanted spontaneous labour, for a lot of reasons. I dug into medical research and tried to verify the idea that twins might be ready to be born earlier for some reason (supposedly twins mature faster and are considered full term at 38 weeks instead of 40 weeks). I found no evidence of this and resolved to wait for spontaneous labour; when the babies chose to say they were ready to be born.

TracyGoutbeck03The next thing I feared was that one of the babies would be breech. The girls were born at a time when local obstetricians had bought into the Hannah trial results that recommended all breech babies be born by caesarean section. Today this pendulum has swung back again, and in some cases, doctors are willing to deliver breech presentations vaginally (Lawson, 2012). I once again dug around Medline and found that when labour is not interfered with, when women have freedom of movement, and when a woman has the support of a qualified caregiver—breech delivery is quite safe (Alarab et al., 2004). Since I did not intend to be induced, augmented or anaesthetized, and I had easily had my first baby at home, I was a good candidate for breech vaginal birth. Doctors have developed specific criteria as to who is considered a good candidate for a vaginal twin birth. Most are okay with vaginal delivery for two babies if you have already given birth, if you did not have a cesarean, if you are healthy, if your babies are head down, if the first twin is head down and the second breech and if you are determined and informed. Other combinations of presentations (breech and transverse, both breech, etc.) are less accepted as they carry more risk (Bjelic-Radisic et al., 2007) and you may need to strongly advocate if you are determined to have a vaginal birth.

I worked in a hospital in labour and delivery and felt best delivering at the place I worked. So I was very prepared to navigate the levels of hospital policy, nurse and doctor preferences and procedures. I also armed myself with research about things that hospital staff do. Some things done in hospital have little evidence and some things are just done because we have always done it that way. In this way, I felt ready to advocate for myself and I wrote a reasonable birth plan that everyone could agree to.

When you arrive in the hospital in labour with twins, you will be treated as though you are about to have surgery. This means the staff will want to start an intravenous, collect blood, ask you not to eat or drink and monitor your babies continuously. Your doctor may have recommended an early epidural. I encourage you to explore what each of these interventions is for and decide how much you want done. I chose to have an IV but to have it capped off to increase freedom of movement and prevent fluid overload. I agreed to the blood draw but chose to drink fluids.

There is evidence that epidurals interfere with the progress of labour (Anim-Somuah, Smyth, & Jones, 2011; Eriksen, Nohr, & Kjærgaard, 2011) and I declined to have one. Some women may choose to have the epidural catheter put in place and not be given any medication till later. This can work, but sometimes the epidural isn’t effective as the catheter migrates out of position.

TracyGoutbeck04Monitoring your babies is part and parcel of giving birth. Heart rates can be monitored continuously or intermittently every 15 to 30 minutes. A probe will be held on top of your abdomen to listen to your babies’ heart rates to make sure it is strong. I chose to have intermittent fetal monitoring of the babies and I would have agreed to a scalp electrode (direct monitoring) of the first twin if there were concerns about tracing them both accurately (in some circumstances).

Twins are often delivered in the operating room because it is bigger and the staff feels better about being there. If you need a cesarean, you are already there. It also has more room for caring for two babies, especially if they need help to breathe at birth. Sometimes hospital staff will want to limit the number of support people you have with you in the operating room, so labour in a normal room for as long as possible. You only go into the operating room when you get close to pushing. You need to wear a hat and support people wear scrubs and shoe covers to keep the room clean. There may be additional spectators in the room as twin vaginal delivery is still an infrequent occurrence. Students usually stay out of the way, but you can request only essential staff be there. After delivery, you will be moved back into a normal room.

Giving birth to one child is an emotional experience and has the potential of heightening most people’s adrenaline levels. So imagine having two babies. On top of that the operating room can also be a place where lay people feel more nervous. There is also the unspoken high-risk twin label, which invites the possibility of an emergency. All of this may create an environment that alters normally calm caregivers. I am familiar with this environment, but most patients are not. Make sure you prepare yourself and discuss with your doctor how to create an environment where all can be comfortable.

A quick thought about the time between the babies. You may have a small portable ultrasound machine brought during the birth to verify your twin’s presentation. Although previous ultrasounds may have showed that your babies were both head down, this can change during the labour—or even after the birth of the 1st twin. If your baby presents in a breech position, you can expect your doctor to want you to push continuously until your baby is born. If your baby appears with a foot first (footling), you can expect either a cesarean section or your doctor reaching inside you and manoeuvring your baby out. Because doctors need to act very quickly, there isn’t much room to converse about the pros and the cons while it is happening. It is important for you to think about it in advance and know what your preferences are if any such situation arises.

After the first baby is born, try to stay vertical or in leaning forward positions. It takes some time for the uterus to contract down and get any pressure on the next baby to give you an urge to push. Encouraging the next baby to be in a head down, flexed and anterior position is worthwhile. If I had planned for this, I might have saved myself hours of easy contractions and a posterior second twin. I didn’t have an ultrasound between the girls. I don’t know why they didn’t do this for me; but I started labour with two head down babies and that is the way they stayed. I am of two minds about knowing the second baby’s position. If I knew she was breech it might have made me more anxious. Or I might have been more prepared for manoeuvres that a doctor might have had to do. There is some evidence that a longer time between babies can be associated with lower APGAR scores for the second twin. Staying vertical will encourage that second babe to come along in less time.

Newborn procedures will vary depending on the size and gestational age of the babies. If they are full term and a good size, they can stay with you in your room. Many hospitals are striving to minimize separation. If your babies are near term (34 to 37 weeks) or small (under 4 pounds), they may go to the nursery, have their blood drawn, have IV antibiotics and monitoring or just heel pricks for blood glucose levels. Of course, if they have any breathing difficulties they will be sent directly to the NICU after birth. Near term babies need to have a car seat test to ensure they will continue to breathe and keep their heart rate within normal limits when riding in a car seat.

If you are having multiples as your first babies, go to a La Leche League meeting and learn about breastfeeding from other mothers. Go to a twin and triplet club in your area and watch multiples breast feed. I found nursing twins easier than learning it for the first time with a singleton. It is so worth it. Any breast milk you can give your children is better than none; there are lots of permutations and combinations of how to feed multiples. I would also suggest that if you need to supplement, consider obtaining donor milk from a breast milk bank (the only one in Alberta is the Calgary Mother’s Milk Bank1) or a good friend. Also find an experienced mother, like at the La Leche League, who you can call on for hints as your babies grow and their appetites change.

Last word of advice; take the help that is offered to you. Nothing has taught me humility and appreciation for my community like having two babies at once. I started having in home help a few days a week from 34 weeks gestation. I could not bend down to use a dust pan and broom. I would sweep up kid’s toys into a corner and wait for someone to come over and put them in the basket where they belonged! I used this help to rest 3 times a day. Public Health also has a program to offer in home help. There is no evidence that bed rest prolongs pregnancy, but getting adequate rest and blood flow to the babies sure helps. After they were born, I focused on nothing more than feeding the babies and taking care of myself for several weeks. Many thanks go to the family and friends who supported me during this intense time of family growth. I plan to give back to my community in the future the way I have received.

The rest of the story:

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My girls were dichorionic, diamniotic fraternal twins who came in a hurry at 38 weeks and 2 or 3 days. My first twin was born at home as I had 15 minutes of labour. My second twin came posterior at the hospital 3 hours and 2 minutes later the next day! They were 6 lb 8 oz each and exactly the same weight in grams. My delivery was thrilling and better than I could have hoped for. I even got the doctor I wanted on shift that night. I just did not expect to have one baby at the beginning of the labour and the other at the end of the three hours that I had prayed for. So my lesson was: when you ask the powers that be for something, be specific!

Tracy Goutbeck has been a registered nurse in obstetrics since 1999 and has finally completed her Masters in Midwifery. She balances 4 children, a love of baking, and learning with catching babies as a student and occasionally working to pay for her education. She hopes that midwifery registration procedures will be straightened out by the time she applies.

Notes:
  1. The Calgary Mother’s Milk Bank is a community based not-for-profit organization in Alberta that provides screened and pasteurized donor human milk to babies in need when mother’s own milk is not available. For more info go to, www.calgarymothersmilkbank.ca or call 403-475-6455.
 References:
– Alarab, M., Regan, C., O’Connell, M. P., Keane, D. P., O’Herlihy, C., and Foley, M. E. (2004). “Singleton Vaginal Breech Delivery at Term: Still a Safe Option”. Obstetrics & Gynecology, 103 (3), 407–412.
– Anim-Somuah, M., Smyth, R. M., & Jones, L. (2011). “Epidural versus non-epidural or no analgesia in labour”. Cochrane Database Of Systematic Reviews (Online), 12, CD000331.
– Bjelic-Radisic, V., Pristauz, G., Haas, J., Giuliani, A., Tamussino, K., Bader, A., Lang, U., et al. (2007). “Neonatal outcome of second twins depending on presentation and mode of delivery”. Twin Research And Human Genetics: The Official Journal Of The International Society For Twin Studies, 10 (3), 521–527.
– Eriksen, L. M., Nohr, E. A., & Kjærgaard, H. (2011). “Mode of Delivery after Epidural Analgesia in a Cohort of Low-Risk Nulliparas”. Birth: Issues in Perinatal Care, 38 (4), 317–326.
– Genuis, S. (2008). “A fishy recommendation: Omega 3 fatty acid intake in pregnancy”. British Journal of Obstetrics and Gynecology . vol. 115, 1-4.
– Lawson, G. (2012). “The Term Breech Trial Ten years on: Primum Non Nocere?” Birth – Issues in Prental Care. 39 (1), 3-9.
– Olsen, S. (2004). “Is supplemenation with marine omega -3 fatty acids during pregnancy a useful tool in the prevention of preterm birth?” Clinical Obstetrics and Gynecology. 47 (4), 768-774.