Prenatal care & delivery options with twins

Hi everyone,

this is my first post here. I am currently 10.5 weeks pregnant with di-di twins. I am also a twin myself (a di-di identical) so know a little bit about twins.

I had my first OB appointment last week where my doctor outlined her policies.

1. She only allows vaginal delivery if both babies are head down. I was hoping for an OB who also allowed the chance to try vaginal if Baby A was head down and Baby B was breech since I've seen that as an option while reading the forums. She, personally, has no breech experience so won't do it, which is fine, but I'm wondering if I might be better served by looking for an OB who is comfortable with Baby A vertex/Baby B breech? I only wonder this because I had a very easy first labour with my son and would prefer to avoid a c-section if possible (obviously, I have no idea what these babies will be and I am open to a C-section if necessary--I know having twins changes the labour and delivery game somewhat). I had just read so much about women with twins being allowed to try vaginal with Baby A vertex/Baby B breech that I was surprised it wasn't an option in the practice I go to (a large University-based OBGYN practice).

--Can anyone weigh in on this? Is my expectation or desire to find an OB who is ok with that configuration unusual or over the top? Anyone have experience with Baby A vertext/Baby B breech?

2. How much monitoring is normal? My OB said I would be going every 2 weeks starting at 24 weeks and then would have weekly ultrasounds starting at 30 weeks. They will also do ultrasound at every appointment? Does this seem like a normal course of action? I'm not opposed to it, but I'm going from my experience with a low-risk, barely monitored singleton pregnancy to a twin pregnancy so I'm not sure what is normal.

thanks! I've already had a bleeding scare due to an SCH and found the threads here on SCH and bleeding very reassuring while waiting and wondering what was going on.

Jan

 

Congrats!

As you'll hear in responses, every OB's approach is different. I was lucky that my OB with my twins was pro-vaginal birth. I was told from the start that the only way I would have a c-section is if Baby A was breech, she was willing to deliver Baby B in whatever position he was in! I ended up delivering vaginally, Baby A was head down and Baby B was transverse. Once his brother was out of the way and his water was broke, he pretty much fell head down and was born quickly and easily.

For monitoring, I remember my appointments at the OB were closer to that of a singleton pregnancy. I remember my OB telling me she would treat me that way until I had a problem, with a few differences. I did start going in every two weeks around 24 weeks. I had monthly ultrasounds until about 30 weeks, then every other week until 36, then once a week until 38, then twice a week until I delivered. The ultrasounds were mainly to check my boys' growth because they weren't sure if they were identical or not and wanted to be on the look-out for TTTS. I had NST's done at my OB's office regularly towards the end. I had a very easy, problem free pregnancy.

When I found out I was pregnant with this one, the first OB I went to automatically said that if I had another set of twins, I would "have to have another c-section." When I explained that I never had a section to start with, the doctor was visibly appalled! She asked me why I didn't have a c-section and I answered that there was no reason to do one. I switched OB's to one who was more encouraging of a natural birth, even after I found out that there is only one this time! I know the area where I live now, it's almost unheard of to have twins naturally. Were I lived when I had my twins, that wasn't the case.

 

If you are determined to attempt a vaginal birth if only A is head-down, I would find another OB. I have heard and read many stories where experienced OBs were able to turn Baby B or deliver them breech and it sounds amazing (if you have the chance to do it). Truth is, it's not as risky to deliver Baby B by his feet for example because your cervix has already been opened wide by Baby A.
My OB said I can definitely attempt vaginal if both are vertex. I asked about if only Baby A is vertex, could she turn Baby B? She said it is risky but did not go into detail (I read about it on my own so I knew what she meant). She did not say she absolutely would not do it. It really depends on the situation THAT day and we won't know until it happens. It is not unreasonable to want a vaginal birth--it was more common when c-sections were considered risky, but now that c-sections are safe and very successful, newer doctors are just not trained to deal with tricky situations (according to what my reproductive endocrinologist told me). Plus they have you on those fetal monitors and freak out if Baby B sounds like they are in distress (which may or may not be the case since the external monitors they have to use for Baby B are not as reliable...also, certain meds can make it seem like the baby is in distress)

I have been having monthly appts. They will change to bi-weekly at 25wks. The longest I've gone without an u/s was 6wks, so most have been monthly. At 18 wks I had my ultrasound with a high-risk OB (the level II u/s) and I continue to go to him for the rest of my u/s. He also checked my cervix by transvaginal u/s. I REALLY recommend this in the 2nd trimester. Sounds like you had a normal first pregnancy so your cervix will probably be fine. GL!

 

My ob will do vaginal delivery as long as Baby A is vertex and Baby B is not bigger than Baby A. She says if the 2nd one is bigger there can be problems getting him out. She's definitely a fan of only doing C sections if medically necessary (for baby or mom). I go in every 4 weeks right now, around 24 weeks it will become every two weeks. And they do u/s every time I walk through the door.


Sorry if this posts twice, I thought I responded but then it disappeared..

 

If you know of or have heard of other drs in the area that are good I would totally check their policies. The office that delivered my twins had the same policy as yours both head down or c section. I had an ultrasound at every visit - so that they could distinguish between the two heartbeats. I also was referred to a peri for close monitoring because I was having twins and I had some bleeding ( SCH) starting at 9 weeks. I liked the extra monitoring as it set my mind at ease. I was seen twice a month between the OB and the peri until 28 weeks when it was found that baby A had a low fluid level and was not growing. From then on I was seen twice a week and put on bed rest my girls.were delivered at 38 weeks. My girls are also di di.

With this last baby, I was disappointed that they didn't do an ultrasound each time LOL!!!

 

I would definitely check around. My twin pregnancy was pretty smooth and my OB treated it like my previous singleton pregnancies. I had only one extra U/S and that was to check positioning during labor. My boys were vertex/breech and the plan with my doc from the beginning was as long as baby A was head down and baby B was fine we would try a breech delivery. That is exactly what we did too. Baby A was delivered head first, just fine and baby B was born feet first just fine. Never missed a beat. It really helps to know, as best you can, what to expect on your big day!

 

I think the answer to your question depends on your own feelings & thoughts on birth and how strongly you feel about stacking the deck in your favor for a vaginal birth. If you're willing to do the leg work, you can even find caregivers willing & capable of delivery twins when baby A is in a breech position (this is, btw, a reasonable choice with a caregiver experienced with vaginal breech birth - yes, there are risks, but there are also risk for a c-birth. You'll need to decide which set of risks are preferable to you). Once you know that, you'll know whether or not it's worth your while to find another caregiver.

From my own personal experience I know that I will never again have a caregiver who's birth philosophy is vastly different from my own - I wasted so much time & energy just trying to be heard with my OB that half the time I just gave up on things even though I knew I was being reasonable about my options.

I think it's important to figure out what your own priorities are for your birth & then find a caregiver who's willing to support you in them. :good: GL!

 

Congrats on your twins!

As for delivery options it depends on your OB. Mine wouldnt do a vaginal birth unless both babies were head down. I did want a vaginal delivery but she delivered my fist son and I was comfortable with her and trusted her and didnt want to find another OB. It was a moot point for me anyway as mine were Baby A Breech and baby B Transverse. As for monitoring it also depends on the OB. I had mono/di boys and I had an ultrasound once a month until about 28 weeks when there was a definate size disrepency so I was moved to every 2 weeks. I also had PTL at 24 weeks so I went for NST's twice a week from 24 weeks until they were born at 37 weeks.

If you feel strongly about this, then you should see if you can find an OB that does do a vaginal delivery with a breech baby B.

Good luck!

 

Congratulations on your pregnancy!

If you are hoping for a vaginal birth you might think about seeing a midwife in addition to you OB or finding an OB practice who cooperates with midwives. Where I am, even midwives with lots of "twin experience" will not take on a twin pregnancy and birth on their own but are required to be present for every birth, including hospital births. The midwives are usually much more experienced in delivering breech babies vaginally. In my case with two vertex babies, my risk-averse "home" OB was recommending a c-section (he does for all multiples regardless of position), the hospital specialist OB was all for attempting a vaginal birth (as long as baby A stayed vertex, regardless of baby B's position) and the hospital midwives were awesome in supporting a vaginal birth.

I only had 4 ultrasounds during the pregnancy (not counting quick measurements of the cervix), one for dating early on, one by a specialist for determining that they did not share a placenta or have other risk factors, one each in the 2nd and 3rd trimester. As I wwrote above, my OB is extremely risk-averse but he felt ultrasounds were unnecessary stress for the babies - as long as everything was normal! I did have NSTs once or twice weekly beginning at 20 weeks (when PTL first occured) which were increased to daily in the last 3 weeks. Every OB has a different approach here and you need to trust that you and the babies are being taken care of in the best way!

 

Personally, I'd fine another doctor better trained for a vaginal delivery twins. Many docs are trained in breech extractions. As far as the monitoring, that sounds pretty normal.

 

I don't have any experience with delivery...yet...since I'm 30 weeks, but my doctor has stated that as long as baby A is head down and in position, it doesn't matter what baby B is doing. Currently both babies are breech and have been that way the entire time. I have been seeing a high risk perinatologist my entire pregnancy, but only go in once a month for a check-up/ultrasound. I'm going in today at 30 weeks. I think after this she said I'd go back in in 3 weeks. She has actually been quite relaxed with how she has treated me, but I haven't had any issues since making it through my first trimester (I had a SCH as well). Good luck!

 

Thanks for the responses and information, everyone!

After leaving the appointment my gut instinct was to find a new doctor with more experience with twins and maybe with breech birth. It is a large practice with OBs and midwives and my current doctor told me there are OBs on staff who will deliver Baby B breech so it may just be a matter of switching to a different doctor in the same practice.

I would like to do everything to maximize my chances for a vaginal birth while still being conscientious of the risks associated with breech birth.

I did feel like the weekly ultrasounds were overkill as well and it seems it might be if everything is progressing smoothly.

So now the hunt is on to find a new doctor, which I never find easy. I think most practices are going to be similar, with some docs being ok with breech and others not, and then the issue of "who is on call" if I do go into labour on my own. I asked for recommendations on a local parenting board but didn't really get any good answers, even from the twin moms (all who resonded who had vaginal births had both babies head down and doctors who wouldn't do breech at all).

In the meantime, I'll just keep hoping both these babies are head down at birth. It's been a little hard for me to imagine a potential c-section given how easy my first birth was (along with an easy recovery). It's also made a little harder knowing my mom gave birth to my sister who was frank breech and I followed along head first. Her entire labour was 12 contractions, 45 minutes and then two babies. And my mom didn't even know she was having twins until just before my sister was born.

 

It was only after the birth of my twins that I heard of a promising local doctor who's supposed to be supportive of natural birth and specializes in multiples. (Which was OK, I had a great homebirth, but it would have been nice to consider a good OB ahead of time.)

I'd recommend joining your local twin / multiples club and asking around - who liked their doctors, who had positive experiences with vaginal deliveries, etc. Maybe you switch within your practice, but you want to know all your options.

Another thing that I realized in hindsight is how much experience counts with multiple births. Lots of providers will take twin moms on, but there's a huge range of experience. And with positioning issues and all those multiple-baby considerations, you want a doc who's seen it all. You can be confident of their abilities, and they will not sweat all the little things like weekly u/s and "trial of labor only if Baby A is vertex." At my first periontologist appointment (19.5 weeks), my doc told me to make an appointment for 4 weeks from then for a second u/s, and four weeks thereafter until birth. When I asked if that wasn't a long time between appointments, he told me I should be glad, he'd only call me back more often if there was something to be concerned about. That's the kind of attitude I wanted. This was a doc that deals with triplets and higher order multiples, and a healthy twin mom with no issues was a breeze for him.

Hope you find someone wonderful, and don't be afraid to ask lots of questions and feel them out.

Good luck!

 

I had a doc like this. It was tough to get in for routine appointments, but when my cervix shortened at 28 weeks I got in the next day. I really think most of my di/di pregnancy bored him- I was just fine physically for much of my pregnancy but understandably freaked b/c there were 2 in there. To him, 4 is a big deal- 2 was just another day at the office.

 

I would also add the caveat to ask why specifically they liked their doctor, as different women like different things about different doctors (for example, one woman may have loved her OB because he was perfectly willing to schedule her for an elective c-birth at 37 weeks while for another woman that would really bother her, KWIM?). GL with your search!

 

Oh yeah, that's an important point. When you chat with other moms in your local multiples club, be prepared for a wide range of experiences, and to be honest, a lot of horror stories. I've got a hot and cold relationship with MoM clubs. On one hand I think they are wonderful support systems, great resources and I especially love our twice a year consignment sales. On the other hand, it seems that lots of moms who have easy, trouble free pregnancies and twins don't bother with the clubs. In my local, there is definitely a high proportion of MoMs who had a whole world of health issues. But then again, there are three of us who've has twin homebirths. You just have to ask around, be gentle, and have a bit of a thick skin.

When the scary stuff gets you down, here are a few things to read:

A blog post about going full term with twins. Oldie but goodie, with hundreds of wonderful comments:

http://www.lookydaddy.com/weblog/2007/06/i_know_that_mos.html

A good site about, well, the name says it:

http://www.naturallyparentingtwins.com

Best wishes!

 

thanks for all the tips and information!

I have checked out the local MoMs club and was planning to join once I was safely out of the first trimester (I have two 11 week miscarriages in my history), but I think I will go ahead and join now since their first meeting of the fall is next week.

Gena 22: thanks for those links. They were very helpful. We were planning a homebirth this time if it was a singleton, but decided against it with twins but perhaps if everything continues to go well it might be an option (although finances may dictate the choice for us, unfortunately--my insurance covers 100% prenatal and hospital birth but explicitly does not cover homebirth and things are tight right now).

I am so busy right now but I need to get researching!

 

This was exactly how my OB was. However, four days before my scheduled induction baby B was measuring 1lb 6oz bigger so we turned my induction into a c-section. If you are wanting to try for a vaginal if baby A is vertex, I would find another OB especially if you aren't super attached to your current one!

 

Same for me - my OB was willing to deliver baby B breech as long as baby A was head down and the bigger twin, which is exactly what happened. My baby B was delivered feet first, and they had to reach in and yank her out... which was not nearly as traumatic as it sounds!

I think having an OB that is on board with your plan and willing to support you is very important. My OB knew that I wanted a vaginal delivery and was very pro-vaginal delivery, and so even when I begged her to do a c section after I had been in labor for 26 hours and was in extreme pain, she still pushed me to stick it out and do a vaginal delivery. I am very grateful now to her for that

 

I thought I would update this post since you all were very helpful!

I ended up switching to a new OB group and hospital this week that will allow me to try for a vaginal birth as long as Baby A is head down (regardless of Baby B's position). No one gave me any horror stories and they were very supportive of vaginal birth and prefer twin moms go into labour naturally rather than being automatically induced at 38 weeks (which was the policy at my old hospital). The OB group has a very good reputation, it deals with a very diverse patient group and has a high-risk practice built into its regular practice (which the OB I saw said I could be seen at even though I'm not high risk if it would make me feel more comfortable). The hospital has a level 3 NICU and the second-lowest c-section rate in the city (22%) despite having a diverse patient population (i.e., the hospital with the next lowest rate actually limits itself to low-risk births only whereas this one deals with a lot of high-risk births as well).

I have gotten recommendations from several people about this hospital and OB group (including recs from women who were high-risk or had multiples there) and they all had good things to say about their experiences. In fact, the more I talked to people about my old hospital, the more stories I heard that were not so good even for moms with just one baby. the old hospital had a c-section rate of 32% even though it didn't primarily deal in high-risk births. Also, the practice kept scheduling me with the OB I didn't like and I ended up being cancelled TWICE for her because she was in emergency surgery, which I felt was a bit telling of that doctor, in particular, but also of the practice.

I am happy I switched. It was stressful getting my insurance sorted out and all my records transferred but it went smoothly.

Obviously, I can't control what position these babies will be in and I know I still have a higher-than-normal chance for a c-section, but I feel like I've given myself the best chance of a vaginal birth if things work out favorably with the babies' positions.

 

oops this was an old post--sorry if i repeated myself but now that i'm at the end of my pregnancy, i can answer more fully:

I had two early ultrasounds with my fertility specialist and had my first regular OB appt at 10wks--they were not going to do an u/s since pregnancy was confirmed but I asked for one because I was concerned about vanishing twin syndrome. Then I opted to do the NTS, so that was an extra ultrasound at 12 wks. At 18 wks my OB sent me to a perinatologist for my anatomy scan (be prepared--this takes extra long with twins!!) and we also did a transvaginal ultrasound to check my cervical length. I HIGHLY recommend this because of the risk of preterm labor. So every 4 wks I had full scans of the babies and a scan of my cervix. In the meantime I was put on bedrest at 22wks as a preventative measure because my cervix had changed quickly. At 30 wks I had my last cervical ultrasound and at 34wks my last full scans of the babies. My OB will have her tech scan them if there is anything they need to check in the next few days.
So yeah it sounds like a lot but I am very thankful for all the precautions because I did end up having preterm labor at 31wks and I think it could've happened much earlier if I had not been on bedrest.
i think i started bi-weekly appts with my OB at 25 wks and then weekly appts around 31-32 wks.

glad you found an OB you're more comfortable with!!!

 

I'm glad to hear you have found a practice you're more comfortable with! Sending vertex vibes to baby A.

 

Thanks, Rachel!

Praises: The monitoring is still the same at the new practice. So I am having an ultrasound every 4 weeks and will the increased monitoring for a twin pregnancy. My main goal was to get a better chance at a vaginal birth because I was having c-section pushed on me from day 1 at my first practice. I like the extra monitoring!