Placental abruption for Twin B?

My OB is agitating that I have a scheduled C-Section for my twins, both of whom are vertex/vertex right now. She says that there is a high risk of placental abruption for the second twin, after the first twin is delivered, because if the uterus doesn't contract down fast enough, the placenta will rip away and Twin B might die or have serious medical problems.

I understand the concerns, but after looking at the numbers, I can't help wonder why she is pushing for a C-section. She even wanted me to plan a C-section at 37 weeks (I'm 32 weeks right now).

Does anyone have any thoughts about her vaginal/vaginal delivery and possible complications experienced?

 

my twins are 5 and in all the years I've been on this site I don't think I've ever seen anyone's baby B abrupt - I'd research the online statistics, and present to the OB...also do you see a peri? what is their take on the situation...there are quite a few women around here that have had safe vag deliveries...

 

I think that sounds crazy and that your OB might just be wanting to do what is convenient for her. I would not back down on what you want to do. As previous person said, I have never heard of that happening and I can't imagine the stats are that high especially in comparison to complications during a c-section---even those aren't that high. If you feel you really want a vaginal birth and your babies are in prime position, push hard for what you want!! They can't force you into a c-section.

 

IMO, this is an OB who is not experienced with twin births. Of course there is a statistical risk of some things. But as Amy said, I've also never seen a doc overly concerned with placental abruption. I would also ask your peri & look for a new doc, personally, who is comfortable with twin births.

 

I agree with the pp's. I wish your OB would have told you way sooner, to give you the option of finding another doc. It really sounds like your OB isn't confident. My boys were vertex/breech and we delivered vaginally without issue. And I'm with Amy, I haven't heard much about that on the site, from my brief research just looking on the net, the numbers are like 12 out of 1000 abruptions for twin pregnancies and those numbers are referring to abruptions that take place BEFORE delivery. I'd talk to your OB, insist on a vaginal delivery if conditions are favorable and just plain ask why, we need some stats.

 

By that reasoning every woman should just automatically have a c-birth, whether they're expecting twins or just one. Yes, placental abruption is always a possibility, but it is rare. I'm assuming your twins are di/di? Also, a placental abruption doesn't automatically mean that baby needs to be born via c-birth. There are a lot of factors that influence that including how far along in your labour you are & whether it's a partial or a complete abruption.

The first thing I would clarify with your OB is what is a "high" risk? I would want specific stats & even info on where she got those stats from. But to be honest, if I were in your position, I would be looking for a new caregiver (it's never too late). It seems to me that even if you refused the c-birth she would come up with some reason you needed one during the course of your labour. She sounds like someone who likes to have things in her control & feels nervous when faced with the variables of a twin vag birth.

 

ITA with the pp. I was offended when my OB told me "I won't do anything I'm not comfortable with," meaning trial of labor and vaginal birth under any but the most perfect scenario. I was irritated because I thought my preferences should matter more, since I was the one having the babies after all. But mulling over her comment, I understand and agree with her. You don't want an inexperienced, reluctant OB to be delivering your babes. I transferred at about 30 weeks along and had a great vaginal twin birth.

Ask around (L&D nurses, doulas, local MoM club) and find a OB who's comfortable and experienced with vaginal twin birth. You want to find a provider as experienced as possible, and supportive of the kind of birth you'd like to have. Of course things may change, but do what you can to set things up well for a good birth now.

32 weeks is not too far along to transfer!

Good luck,
:youcandoit:

 

I am in nursing school and I work on a very very busy Mom Baby unit. I have only seen a few placental abruptions and most (NOT ALL!!!!!!) were from moms who abuse drugs. I know it can happen in any case, in any situation at any time but I have never seen it with twin birth. My twins were vertex/transverse and I had both vaginally. As long as you deliver in the OR, even if God forbid the placenta did abrupt, they would have that baby out in no time.

 

Your OB is not wrong. This is why twin vaginal deliveries are done in an OR with the epidural placed.

Some docs feel comfortable doing twin vaginal deliveries; some don't. One thing is for sure--you don't want a doc who isn't comfortable doing a vaginal delivery. I suggest you discuss this issue with your doc--and don't rely on information from strangers on the internet as to the risks involved. If you want to transfer care, I'm sure your OB can help you find another OB.

 

I have never heard of this being a concern with twin vaginal births. Cat mommy where did you hear it? Not being argumentative - just genuinely curious.

We had a vaginal birth with the boys and my OB and peri never once mentioned it as an issue that might come up. They did mention the 1% chance of uterine rupture and we talked about the benefits of a VBAC vs c/s (and the benefits of a c/s over a VBAC if both twins weren't head down.) But placental abruption never ever came up. My VBAC with the boys was done without an epidural present and it was never ever suggested to have one. They did have an anesthesiologist present and said if something went wrong they would put me under completely because it would be too quick for anything else. All went great and I was so happy not to have had a c/s recovery like I had with the girls.

 

I had a very successful and easy vaginal birth with baby A vertex and baby B breech. My OB had said early on that she would very much prefer a vaginal delivery over a c-section because the risks associated with a c-section are greater. Not to mention how much longer and more difficult the recovery is, generally speaking. If you are hoping for a vaginal birth, I would look for a new doctor. Good luck!

ETA: I ended up having an epidural, but my OB gave me the choice; it was not required.

 

Sounds like your OB is just very cautious. Maybe she had that happen before and does not want to risk it again even if the risk is low. I do agree that if your OB is not comfortable delivering twins vaginally, I would not insist on it. Are there other drs in the same office that you could see and discuss it with them? If not then it may be hard to change drs at this point.

Good luck!!!

 

Kim: Here is an explanation. abruption info I know the OP isn't considering a homebirth, but this link still provides useful info on abruptions in a twin hospital birth. The author of this blog can be quite harsh, so I suggest you ignore her tone and focus on the info she provides (she is an OB).

 

I feel like the information in this blog is clearly skewed toward one Dr's way of thinking. This doesn't even read as an informative, clinical comparison.

 

I would get a second opinion. If another dr can give hard facts on why you should have a csect then okay that's the route that you need to go. I'd be almost worried she isn't telling you everything about the pregnancy that you should know if she's that worried. Id for sure ask her how many twins she's delivered. I had my girls via csect due to how fragile jessy was.

 

I too find this biased. The woman had been directed to have a csection due to the babies not being in ideal position. She did not seek a second opinion and made her own choice. In a hospital the moment that baby b had stressed they would have most likely done a csection

 

Oh Amy Tuteur. She's the obstetrical equivalent of home birthers & free birthers who think there is only the one way to give birth. There is absolutely NO guarantee that had that woman given birth in hospital both her boys would have made it. Is it possible that they both would have made it had she been in hospital? Without a doubt. Is it guaranteed? Nope.

And I don't think this post provides much useful information at all - it offers an anecdotal description of a tragic event but like the OP's OB doesn't go into the hard numbers - all she says is "high risk". What does that mean exactly? Because I'm quite certain that we would perceive the risks differently - and it's not Dr. Tuteur's (or any care provider's) right or responsibility to decide for me (or any woman) what level or types of risk are acceptable. That is the individual woman's right & responsibility.

Instead of fear mongering, I really wish these types of doctors would just lay out the facts, explain in a straight forward manner the risks & benefits of the options an individual woman is facing and then let the woman make the decision that is right for her.

 

Thanks for all the replies -- definitely food for thought. I'm in my early 40s and these twins are IVF. My OB is an MFM -- she's not even going to be there for the delivery as she doesn't do them. I'm at an academic medical center so I will be subject to the vagaries of staffing (whoever's on that night will deliver me). One of my big concerns is, once I'm laboring with an OB I don't even know, I feel I'll be railroaded into a plan I don't want even if my MFM and I come to a detente. The main reason I ended up at that hospital is because of my insurance. The other hospital/OB group I would choose is out of network.

That was most definitely a very scary story on that Skeptical OB blog. I think the example of the midwife missing the abruption probably won't apply because I know that, whatever route I end up with, I'll be in the hospital under OB care. 45 minutes is a super long time to wait in between Twin A and B. My understanding is that Twin B really needs to get out within minutes.

Even at 32 weeks now, I'm definitely considering changing OBs but want to meet with her again before I do. I was pretty upset when she just wanted me to schedule a C section for 37 weeks, and then she was arguing that 38 weeks is too long, when I have read that twins can stay in up to 40. I told her I would pay even for just a counseling appointment where we do nothing but talk, because she's never given me a hard reason to back up her assertions, except for generic claims of "it's dangerous".

Although I would say that one of my greatest fears is that Twin B becomes disabled because of a choice I made. I would seriously never be able to forgive myself... which puts me back to square one in considering the C section.

 

there are plenty of people that have hours between twins (and several that have had twins on separate days...I've never heard of the 45 minute thing...

 

@anyone who had vag/vag: How many minutes between your first twin coming out and your second?

 

6 minutes. I have heard of hours between (even 10 days but that is a whole different story)

 

My boys were vaginal, vertex/breech, 20 mins between them, no fetal distress of Baby B who was delivered feet first.

 

My girls were 8 minutes apart.

GL with your decision! I hope your conversation with your OB goes well & you're able to get some concrete answers from her to help you in moving forward.

 

I had a vaginal birth in a hospital, it was done in the OR 'just in case' but I had no issues what so ever. In fact my singleton delivery previous had way more complications-it just goes to show that anything can happen or nothing at all.
My twins were delivered 8 minutes apart.

 

Dr. Amy is a zealot, and not a good source of information.

To the OP, there are a lot of different opinions out there. Unfortunately there are plenty of loud, scary stories, but no guarantees and in my opinion, not enough science. There are some useful studies, but I wish more would be broken down by configuration - di-di, mono-di, positioning, etc. The risks one twin mom face are not the same ones another mom needs to weigh. But that kind of info would require bigger sample sizes, which is a real problem with twin birth studies. So, all you can do is be analytical, look over the research, and make the best choice possible for your family in your circumstances.

A favorite article of mine is no longer available free:

http://www.uptodate.com/contents/delivery-of-twin-gestations

It discusses timing and method of delivery of twin moms, where the pregnancy is not complicated by counter-indications. It supports spontaneous vaginal birth as a safe choice, between 38 and 40 weeks gestation. I think it's worth the money for the peace of mind and discussion with your OB.

FWIW - there was an hour between the births of my twins; that long because I needed to rest. Baby B's water was unbroken and she floated happily, well monitored, until I was ready to push her out. I think the average is 17 minutes between for vaginal births, and I have heard of longer than my hour.

 

Whoa. Even just the title of that article is condescending and awful. Like she's gloating about it. I could find many, many stories of people who have had terrible hospital experiences and have lost children due to OB practices and hospital regulations but what good will that do? When it comes down to it we all make the decisions we think are right for our children based on our own very personal medical history and what we feel comfortable with. I'm glad you're looking out for yourself OP, and not just blindly following medical advice that you don't agree with. It doesn't matter whether you do choose c/s or vaginal - at least you have looked at the options and found what's right for YOU.

FWIW I had a c/s with the girls and it wasn't a terrible experience. I also had the VBAC with the boys and hands down what I will choose again for this pregnancy. But I trust my Dr and know if she recommends a c/s it's because it's truly medically necessary and not just because she happens to be pro c/s (she's definitely not.) I hope you can find peace with whatever decision you make. And you're right - a twin hospital birth where you're monitored constantly is not even close to the same as a homebirth with a midwife (and I'm pro homebirth but there are situations where I personally feel more comfortable being monitored - multiples being one of them.)

Griffin was 15 minutes after Kian. We wanted to get him out with the next cx because he had been breech until labor and she was afraid he might flip into the breech position again. It took that long for my body to start up the cx again after Kian was born.

 

My girls were 16 min apart. They would have been closer except that Baby A was born on the floor in the bathroom in the delivery room. After that fiasco I had to get up, walk to my bed, be wheeled to the OR to push out Baby B (3 pushes).

My doctor had set a 30 min time limit before he would start to "intervene" but I have heard of several people having 2 healthy babies an hour or more apart.

 

I had a vaginal birth with my twins. They were both vertex born within 10 mins of one another. They were also mono-di, which some consider higher risk. Between babies, the OB kept his hand on baby B's head so he would not move out of position while we waited for my contractions to resume. Yes, that means he had hisrm up there- all the way. He gave me some pitocin to help that process. I was lucky to have an OB that is very pro vaginal birth and he was quite experienced. Experience is key. If your OB hasn't had any oruch experience delivering twins vaginally, you may want either another OB or have the c section. It is your body and your choice! Good Luck with everything and remember how they get here isn't that important in the grand scheme of things.

K