by Jane Evans
Throughout my career I have been involved in a number of
twin pregnancies and became interested in the complications and care
needed and given in such circumstances. My concerns and frustrations grew
as I watched that daunting, but thrilling, experience being taken over and
medicalised so that it became a nightmare of worry and something to be
'put up with' in the cause of being lucky enough to survive and have two
healthy babies. Were midwives supporting women enough to enable them to
follow their instincts and to have a positive birth which they could
treasure and savour, while still using the available technology to ensure
the best outcome?
Medicalised twin birth
One case stays
clearly in my mind as I feel that I was unable to support the woman
sufficiently. I went to book her for a home birth for her second
pregnancy. She had had a positive birth experience first time and wished
to have another. We soon realised that she was carrying twins; this was
confirmed by ultrasound scan. She and her partner were thrilled but also
disappointed to see their chance of having a planned home birth receding.
Her antenatal care was given at the hospital but she kept in contact with
her GP and me. She was very worried that she was being 'medicalised' and
strongly felt she could grow and give birth to twins quite happily. After
some lengthy negotiations, we made a plan. If I was on call when she went
into labour I could accompany her and care for her.
One very wet
night the call came and I was the community midwife on call. We duly
aquaplaned to the local maternity unit, which had a newly installed pool.
She wished to use water for pain relief for the early stages, but the
night sister would not countenance this. There was no twin monitor
available and as one twin was OA (occiput anterior) and the other OP
(occiput posterior) it was impossible to get a good trace from both twins
so panic set in. The second twin's heart was clearly audible with
hand-held sonicaid but there was no trace.
She laboured rapidly to
full dilatation and was soon pushing out the first twin. She was upright
but still tied to the first twin's monitor. The medical express invaded.
Flat on her back - PUSH - PUSH. Twin 1 came out and was whisked away to
the paediatrician. Meanwhile, someone shoved Twin II down (from the
stomach end). The waters were broken and the Ventouse applied. Twin II was
extracted and given straight to the paediatrician. These twins were at
38-39 weeks gestation and weighted about 7.5lb (3350g) each. The parents
were traumatised and had not had time to acknowledge the first twin before
the second twin was pulled from the mother. They were all fit and healthy
and soon escaped home where they breastfed happily but the scars are still
with the mother and I felt I had let her down and not supported her
wishes.
The Cavalry Invades Again..
The second such
incident occurred when I was working on labour ward. A woman carrying
twins came in, in labour at 33 weeks gestation. This was her third
pregnancy. A scan confirmed the babies were of reasonable weight and both
cephalic presentation.
After admission to labour ward everything
stopped for about six hours and no contractions were felt. Then suddenly
labour re-started and she rapidly progressed to full dilatation and gave
birth to the first twin while standing beside the bed. The position of the
second twin was checked. It was longitudinal and the head was coming into
the mother's pelvis.
Meanwhile the first twin was placed on the
bed and when separated taken to the resuscitaire and the paediatrician who
had only just arrived. Then the medical cavalry arrived - how could this
woman give birth standing up? She was physically lifted up and laid on her
back on the bed, whereupon she started to scream and the second twin's
head bobbed back out of the pelvis. Luckily she had more contractions, the
head came through and soon the second twin was born and given straight to
the paediatrician. Both babies were healthy and had good Apgar scores, and
after an initial stay in Special Care Baby Unit were discharged fully
breastfeeding.
The mother remembers the birth for the ease of the
first and the terror and back pain of the second. The midwife remembers
the birth for the positive birth of the first and the horror of the
mother's screams and the disappearing head of the second twin and the
relief when it re-engaged and was born safely.
Once again, I felt
I had not fully supported the woman when she was following her instincts.
Is it any wonder that second twins are in danger of malpresentation when
the influence of gravity is removed?
I then gradually moved into
independent midwifery and my enthusiasm and passion was rekindled. Women
can give birth and we are privileged to support them. I went to
Independent Midwifery Association meetings and listened to the skills used
by midwives to strengthen and support women to positive outcomes whatever
the circumstances.
Sally and Steve
Sally and Steve were
expecting twins in early December 1994, and in August they asked me and my
colleague to care for them. This pregnancy had been started by IVF
treatment after some years of infertility treatment. Sally and Steve felt
they had been medicalised enough and, having once got pregnant, nature
should be allowed to take over. Sally was a healthy woman with no obvious
problems and the pregnancy progressed well; her main problem was
tiredness.
The babies were non-identical and grew well and equally.
Sally was booked into the local maternity unit, which had a SCBU, but she
wished to have the babies at home if they were both head down. She had
spoken to other women who had birthed twins at home. We all discussed what
could or would happen in certain circumstances and we stayed in contact
with the obstetrician and the supervisor of midwives - both of whom were
very supportive. We arranged for a third midwife to attend if the birth
was at home, and Sally and Steve continued reading all they could. My
colleague and I attended a workshop run by other independent midwives on
twin and breech births. There was much lively discussion and a slide show
broadened everyone's knowledge.
Since she had facilities to rest at
midday, Sally continued to work until 33 weeks. She wished to avoid
frequent scans and hospital appointments and the babies both remained
cephalic until 36 weeks when the second twin turned to breech
presentation. We saw the consultant and the positions and equal growth
were confirmed. Sally was prescribed Temazepam for when she was desperate
for sleep. Terry Wogan worked well but not until 7:00 am!
Sally
started labour spontaneously at 39 weeks and, after a false start in the
morning, labour became established in the evening. I arrived at 2300 hours
and all was well. Sally seemed to be progressing well. She wanted to be
transferred to hospital and when we got there I found her to be 7 cms
dilated. All continued to progress well and at 04 05 Sally had the urge to
push. She had been lying on her left side but became active and found it
most comfortable kneeling facing over Steve's knees while he was sitting.
The first twin was born at 04 42. He had good Apgar scores and was
passed to his parents. His cord was clamped and cut immediately. The
second twin was immediately palpated and was confirmed to be lying
longitudinally and breech at the brim of pelvis. As the breech engaged
into the pelvis the fetal heart rate heart was raised so Sally consented
to CTG, which settled and was fine. After 30 minutes the contractions
started again and the membranes broke. Neither cord nor cervix was felt on
examination and soon the breech was visible and advancing well. Sally
remained in an upright position. The second twin lined her foot up on the
perineum and stretched her leg, so a small second-degree tear was
sustained. At 05 45 she was born with good Apgar scores.
The
unbelieving paediatrician broke into the room, snatched the baby and
rushed to the resuscitaire, thus preventing Sally and Steve saying that
precious first 'hello'. My partner gave I M syntometrine five minutes
after the birth of the second twin as Sally had a brisk blood loss. The
joined placentas were delivered at 05 55. We had quiet unobtrusive support
from the obstetric registrar and, apart from the over-enthusiasm of the
paediatrician who could not believe that a breech baby would not need
resusci-tating, Sally and Steve were very happy with the birth. They were
all home five hours later in bed breastfeeding and all continued to go
well.
Lucy and John
The following April I was contacted
by another couple who were expecting twins. They had had a very good
experience with the birth of their first child in water in the same local
unit and had been planning a home water birth. Now they were expecting
twins, Lucy and John were feeling very frustrated and would not accept
that although the first twin might be born normally, the second would be a
'James Herriott job' with epidural and IV in situ and Lucy in the stranded
beetle position. Lucy was adamant that she would stay at home if that was
all the hospital could offer.
After heated debate the consultant
obstetrician agreed that Lucy could labour in water for a time if all
appeared normal. The scan had confirmed non-identical twins and both
babies had grown well and equally to 30 weeks gestation when Lucy and John
booked with our practice for midwifery care. If Lucy was supported in her
wish to use water and not to be interfered with unless necessary in
labour, they were happy to go to hospital. We gave Lucy contact numbers of
other parents of twins.
The pregnancy continued to progress well
and Lucy and I had long discussions about her hopes for the birth Lucy had
a good diet and used homeopathy for any health problems. At 34 weeks
gestation we discussed her vague wish to give birth to the first twin in
water. I tried to get as much information as possible about twin births
underwa-ter but I was unable to speak to anyone in his country who had
experience of this.
Lucy had treasured the time saying 'hello' to
her first child while his cord pulsated before separation and the third
stage. I spoke to other independent midwives who were experienced with
twins and they always clamped the first twin's cord immedi-ately and gave
syntometrine for the third stage after the second twin was born. Lucy
wished to avoid both these procedures. As there was no risk of placental
transfusion I said I was happy to support Lucy's ideas and await
events.
At 35 weeks Twin II turned to breech presentation so Lucy
got busy with positive 'cephalic' thoughts and the baby obligingly turned
back. Otherwise all appeared well I had just climbed a steep hill on a
family walk when my ever present phone rang. It was Lucy at 38 weeks
gestation having had diarrhoea overnight from some suspect chicken. She
had gone shopping and bent over to tie her shoelace and felt a pop - she
was now contract-ing. The family all ran down the bill again - shades of
Monty Python - and I was soon with Lucy. She was leaning over her bath and
seemed to be about 5-6 cms and I suggested we leave for hospital if we
were going. Lucy asked me to confirm dilatation before we left and she was
6 cms, contracting 1: 4. I arranged to meet my partner at the hospital,
then John began to pack.
We arrived at the hospital at 1620 and
they had run the pool and Lucy got in and felt instant relief. At 1740
hours she had an urge to push and at 1750 the vertex was visible. The
membranes were ruptured just as the head crowned and Lucy gently breathed
the first twin out. He was brought to the surface immediately and Lucy and
john said 'hello'.
We immediately checked the lie of the second
twin. It was longitudinal, the head had engaged and the heart rate was
satisfactory. At 18 05, just five minutes after the birth of her first
twin, Lucy had the first contraction for her second. She felt she could
not hold her first twin any longer. His cord was pulsating only weakly so
it was clamped and Cut and John held his son I immediately checked Lucy.
The second twin's head was on the perineum with membranes bulging. These
were ruptured and again Lucy breathed the baby out and she is as brought
to the surface immediately at 18 12 and given to Lucy.
Lucy and
John were thrilled to have a daughter and spent time saying 'hello' while
her cord pulsated. There was no blood loss in the pool and Lucy's pulse
remained normal until her second twin's cord had stopped pulsating. At
1825 it was clamped and cut. Lucy had some afterpains, got into a
squatting position and pushed out the placentas under water with a blood
loss of about 100 ml. No syntometrine was needed. Lucy got out of the pool
and breastfed her babies. Everyone was home and in bed by 2300
hours
Margaret and Graham
The following May I was
contacted by another couple expecting twins. They had had a 'high-tech'
birth with their first birth. Margaret was induced for post-maturity but
had managed a 'normal' birth. Their second and third children were born at
home at 42 weeks gestation, so Margaret had great confidence in her
ability to give birth. They were very concerned about how to avoid
interference and what their choices were. Margaret wanted to have the
babies at home, but Graham was against this.
They set about reading
what they could and we again gave them contact numbers. It was very
important to Margaret to as avoid interference and wished to have an
active birth which was quiet and private - not in a room full of people.
She did not want an epidural. Margaret's last birth was quit rapid so we
made sure her GP and obstetrician were aware that she may not get to
hospital in time.
The pregnancy progressed well. Margaret needed an
iron supplement quite early on as she was showing signs of anaemia and her
blood count was a little low. The early scans had shown two separate
placentas - one each side of the uterus. The babies grew well and equally
throughout the pregnancy. They were both cephalic to 33 weeks, then one
was breech and the other transverse.
Margaret had seen the
obstetrician and felt worried about a caesarean section - she would prefer
to have a general anaesthetic. Margaret was reassured that there was
plenty of time for the babies to change position before labour started.
The babies remained one breech and one transverse until 36 weeks when
Margaret again saw the obstetrician who told her that the twins were now
unlikely to change position and booked a provisional date for caesarean
section at 38 weeks.
Margaret felt very demoralised and began to
that it would be best to comply. She felt a mild resentment towards the
twins because of the effect her confinement would base on the other
children. Graham had a very important conference on the date the twins
were due and so maybe it would easier all round. She was in emotional
turmoil. My partner and I worked very hard to support and encourage her
and to reassure her that there was still time for all to settle down and
for her to have the birth she wished for.
Margaret chose to have
regular scans to check position and at 36 weeks the first twin turned from
breech to cephalic. The second was still transverse but when Margaret had
some tightenings it soon settled into a breech longitudinal lie. The
contractions stopped and the pregnancy went on but Margaret had regained
her confidence in her body and was back on course for an active labour. We
visited twice weekly for a while to help Margaret's
confidence.
Margaret kept extremely active - giving shoulder lifts
for her three-year old, with buggy full of shopping, walking everywhere.
She had slight oedema in her ankles. At 38 weeks the first twin was
cephalic and engaged and the second was transverse. Margaret felt it was
trying to turn as the head was lower in the mornings. At 39 weeks both
babies were cephalic and the first was two-fifths palpable, but Margaret
felt they sometimes swapped which was engaged. Her confidence was fully
restored.
At term plus two - the night Graham was away - labour
started. It was very gradual with mild contractions for some hours.
Margaret decided she had better follow Graham's wishes and go to hospital,
as she had not gone into strong labour quickly. We called Graham back to
meet us at the hospital and left before the rush hour traffic. Labour
established about 08 00 and Margaret continued to walk round the labour
ward. At 11 00 she had some pressure m her bottom. A large bag of
membranes was visible at the vulva and dilatation was checked. At 11.35 no
cervix was felt and a head was felt behind the membranes, which were left
intact. We could see the liquor was clear. Margaret walked around and
jiggled her hips for a few contractions and then rushed back to hang on
the end of the bed and gave birth to her daughter very gently while
standing. This was a surprise as the first twin was definitely said to be
a boy!
Margaret's daughter's cord was quite short and stopped
pulsating after seven minutes and was clamped and cut Graham cuddled his
daughter. The second twin was in longitudinal lie At 12 25, twelve minutes
after the birth of her first twin, Margaret had the first contraction for
her second. The fetal heart rate of dipped at 12.40 after a continuous
pain and we called the paediatrician and obstetric registrar as we
suspected placental abruption. I checked for dilatation and presentation.
I could not feel the cervix but the head was still high and the membranes
intact.
Margaret was encouraged to push and the head advanced
through the pelvis. The heart rate was continually monitored with a
hand-held sonicaid by my partner and we were still concerned. There was a
small PV blood loss, then the membranes were at the perineum with the head
visible behind. An ARM was performed with clear liquor and Margaret gently
gave birth to her second twin at 12 47 still standing at the end of the
bed. The cord was not pulsating and he made no effort to breathe, so the
cord was clamped and cut immediately and her son was taken to the
resuscitaire where he was given one external cardiac pulse and some
suction and oxygen by bag and face mask. He soon pinked
up.
Meanwhile, Margaret had rested on a beanbag and at 1256 she
pushed out her second twin's placenta closely followed by that of her
daughter. Her estimated blood loss was 200 mls and her perineum was
intact. She immediately got up to see her son on the resuscitaire and then
went to breastfeed her daughter who had been shouting for food for some
time.
Her son had a short stay in SCBU for observa-tion but he was
soon discharged to his mother's care and breastfed well. Margaret and the
twins stayed m hospital overnight for her son's sake but everyone came
home the next morning. Her son was re-admitted to hospital on the third
day for 24 hours phototherapy but he smiled before his sister although she
moved before he did. Margaret continues to rush round after her family and
business while breastfeeding the twins.
Keeping Twin Birth
Normal
I have felt enormously privileged to be involved in the
support of these women and their conviction that their bodies can work and
grow and give birth to healthy babies. Through their beliefs I and my
partners have learnt of new positive ways to help at multiple births and
throughout the pregnancies. We saw how easily even these strong women can
be undermined by outdated obstetrics. We as midwives must surely fight the
trend of lying on your back with an epidural (Ogbonna and Daw, 1986) - no
wonder malpresentation of the second twin is deemed to be common - could
lack of gravity be the cause?
Why is caesarean seen as an easy
option when one twin is not cephalic? Time and time again research has
shown that so long as the predicted birth weight is above 1500g the
outcomes are the same (Rabmovici, Barkai, Reichman et al 1987, Morales,
O'Brien, Knuppel et al, 1989, Gxke, Nageitte, Garite, Towers and
Dorcester. 1989. A dam, Allen and Baskett, 1991, Tchebo and Tomai,
1992).
Why are women undermined in their belief that nature will
usually sort things out and that, given time and space physically and
emotionally, most babies will get into a good position (Divon MY, Mann MJ,
Pollack RN et al 1993)?
We should not underestimate the emotional
link between mother and babies and the effect positive thoughts can have.
There is research currently being undertaken on psychic links between
mother and child. Research has shown that only cephalic/ cephalic twins
show any stability in the third trimester. It also shows that the outcomes
for a non-cephalic presentation for the second twin are no worse than
those for version or caesarean section of above 1500g birth weight (Greig,
Veille, Morgan
et al, 1992, Fishman, Grubb and Kovacs~ 1993. Chauhan,
Roberts, McLaren et al, 1995).
Why is there still the rush and
panic to extract the second twin? Does it not occur to us that nature
intends, in many cases, a pause, a chance to ac-knowledge the birth of one
baby before the arrival of the next? Research again shows there is no need
for this rush and hustle in uncomplicated births (Feng, Swindle and
Huddleston, 1995, Bartmcki, Metenbuig and Saling, 1992).
With
positive support and good health and diet women can produce healthy twins
without compli-cations (Gaskin, 1992). Sally and Steve's babies weighed
2860g (6 lb 4 ozs) and 3050g (6 lb 10 ozs), Lucy and John's babies weighed
2760g (6 lb 1 oz) and 2600g (5 lb 12 ozs) and Margaret and Graham's babies
weighed 3629g (8 lbs) and 3510g (7 lb 11 ozs). They all breastfed
successfully and coped well with their double troubles after positive
labours - using their own analgesia - and positive births - leading to a
positive parenting experience.
We discussed the question of early
clamping of the first twin's cord and its effects of the third stage. In
situations where the woman can clearly be shown to be carrying
non-identical twins, or clearly has separate placentas, could the best way
of preventing excess blood loss and complications in the third stage be to
allow the cord of the first twin to cease pulsating before clamping and
separation, and also to allow the second twin's cord to cease pulsating
before interference, and thus allow a physiological third stage? In these
circumstances there is no need for syntocinon or syntometrine when the
labour and birth has been physi-ological.
As midwives we should be
supporting women in their choices by keeping ourselves up-to-date with
research and skill sharing, thus helping them to attain a positive birth
even when carrying twins (Edmunds, 1996, El Halta, 1996, Smith, 1996, El
Halta, 1996).
PS After Lucy's birth underwater I heard that there
had been one previous underwater twin birth in this
country
Original text: http://www.radmid.demon.co.uk/twins.htm