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?
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 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 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.
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
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.
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
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AH updated 30 June 2000