Normal Twin Pregnancy and Birth

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!

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