Considerations for Twin Home Birth by Leah Hymas | indiebirthmidwiferyschool.org

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Considerations for Twin Home Birth by Leah Hymas

May 23, 2022

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We are mamas and birth workers who decided to do birth differently– and bring others along with us. We are kind, fun to work with, and great at (lovingly) calling people on their bullshit when necessary. With 11 children and 16 years of midwifery between us, we’ve learned a thing or two along the way, and Indie Birth is our space to share it all with you.

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Considerations for Twin Home Birth

Having a satisfying, empowering, confident, twin home birth is totally possible for families if that’s what they desire! I work with families when these criteria are met for home birth:

  • Both parents are prepared for and committed to a home birth
  • Both parents understand the increased work involved to grow a full term twin pregnancy and are committed to making sure mama gets the rest, nutrition and movement needed for a healthy pregnancy
  • An ultrasound has been obtained to determine the type of twins
  • An understanding that twins can sometimes change to a transverse lie position in labor. Babies that can’t be coaxed from transverse into a head down or breech position can not be born vaginally and will need a surgical birth
  • An understanding that one or both babies may present breech and both parents must understand the risks around breech birth as well as being informed of the risks of cesarean birth for breech babies
  • The parents and the birth team have discussed and agreed to when hospital care would be indicated 
  • Both parents and those present at the birth are comfortable with the expertise and guidance provided by their chosen home birth team
  • Twins are di/di twins (fraternal) or mono/di (identical babies that have their own amniotic sac but share a placenta)
  • Spontaneous labor begins between 36 +0 and 42 +0 weeks in pregnancy
  • Mama and both babies are healthy and thriving during pregnancy and labor
  • Planned birth location is within a 20 miles of the nearest hospital with obstetric services

Special considerations that are unique to twin pregnancies compared to singleton pregnancies include:

  • Greater likelihood of fetal anomalies
  • Greater likelihood of polyhydramnios (excess amniotic fluid) which increases the risk of one or both babies being in a position other than head down
  • Greater likelihood of fetal umbilical vessel(s) running through a portion of the amniotic sac (velamentous insertion). There is a risk that these fetal vessels could be damaged during pregnancy or birth which posses a great risk to the baby’s life
  • Greater likelihood of cord prolapse in non-head down positioned babies
  • Twin-to-twin transfusion syndrome (TTTS) is a rare twin specific condition where one baby (the donor twin) transfers blood to the other baby (the recipient twin) via the placenta. This syndrome occurs in identical twins (mono/di or mono/mono). Severe, untreated TTTS, this can cause serious detriment to both babies and rarely death

The second twin born may very rarely experience any of these complications:

  • Reduced blood flow from the placenta after the birth of the first twin necessitating hastening the birth of this second baby
  • Delayed descent into the pelvis after the birth of the first baby
  • Premature detachment of the placenta (which could block the cervix, preventing birth and jeopardizing the second baby’s life)

Nutrition, Rest and Movement

Excellent nutrition, ample rest and joyful movement are vitally important to all pregnancies but double important to when pregnant with twins. 

A minimum of 110 grams of protein (from plant and animal sources) and at least 3100 calories per day is needed for optimal health for mama and baby in the last trimester of pregnancy. Eating and drinking every 1.5-2 hrs during the day and snacking once during the night helps ensure that the mama can consume the amount of liquid and calories needed. 

https://docs.google.com/presentation/d/10sRGCIIVGVY3Goih2RJLU4NVfYXpKIKvLCFRClsDm_k/edit?usp=sharing

http://drbrewerpregnancydiet.com/id32.html

Rest! Lots of rest! Daily naps, going to bed early and listening to cues to not over do it ensure that the pregnant twin mama isn’t burning up all the calories she’s eating so her babies can grow optimally.

Move in a way that feels good. Low impact, gentle movement like walking, dancing, yoga, swimming and any other movement that feels good greatly adds to the wellbeing of healthy twin pregnancies and promotes optimal fetal positioning.

https://www.spinningbabies.com/pregnancy-birth/baby-position/twins/

Considerations for Breech Home Birth

About 4% of term babies will be in a breech position when labor begins. You, as the parents, are the best decision makers as to how and where your baby should be born. Most breech babies who are otherwise healthy will have a healthy, safe, vaginal birth when you are supported by a provider who understands physiologic breech birth and some will benefit from a cesarean birth. Some parents, after learning about breech will choose to assist their baby in turning head down either with bodywork, Webster chiropractic care, maternal positioning or a provider assisted external cephalic version (where the baby is physically guided abdominally to head down). You will know if these options are best for your baby or if your baby is breech because that’s the position they need to be in.

Having a satisfying, empowering, confident, breech home birth is totally possible for families, if that’s what they desire! I work with families when these criteria are met for home birth:

  • Both parents are prepared for and committed to a home birth.
  • Both parents and those present at the birth are comfortable with the expertise and guidance provided by their chosen home birth team.
  • Baby is in a Frank breech position (with bottom presenting and feet up by the head) for first time mothers. First time mothers are prepared to give birth on land and not in water.
  • Labor begins spontaneously between 37 +0 and 42 completed weeks in pregnancy.
  • An ultrasound has been obtained to rule out fetal anomalies, to determine that the baby’s head can flex, and that the baby is growing normally. 
  • Mama and baby tolerate labor well.
  • Mama hasn’t experienced pelvic trauma (broken pelvis) or doesn’t have a pelvic shape anomaly.
  • Parents understand physiological breech birth (and have watched upright breech birth videos) and understand the risks and benefits of vaginal breech birth as well as the risks and benefits of cesarean birth.
  • Planned birth location is within a 20 miles of the nearest hospital with obstetric services.

Up to 30% of the time the breech baby whose mother is in an upright position, will benefit from assistance to complete its birth after the birth of the bottom (rumping).  The common reasons why a baby may need assistance include: malpositioned legs obstructing rotation and/or descent of the baby’s body, arm(s) extended next to or behind the head obstructing the rotation of the baby’s body or descent of the body, an extended head caught at the inlet (rare), or a baby who needs help flexing its head at the perineum for it’s head to be fully born. Breech babies are more likely than head down babies to need assistance to begin breathing after birth. Most often, when a baby needs assistance, a few breaths given by mouth to mouth or with a bag mask is all that’s needed. Very rarely, full resuscitation is needed. Cord prolapse is more common with babies in a complete/incomplete (taylor sitting with the bottom and feet presenting at the cervix) than with head down babies. In a cord prolapse the umbilical cord presents first, ahead of the baby’s feet and bottom. Cord prolapse in a head down baby means it’s very possible for the cord to get pinched between the baby’s head and the bony pelvis pinching off blood supply to the baby. In a breech cord prolapse, the cord is much less likely to get pinched because there’s space between the baby and the cord protecting it from compression.

Resources for learning more about breech birth:

Complex Birth Reflections

Where does all of this leave you? 

It’s sobering and somewhat heavy to think about owning responsibility for having the skills needed in complex birth situations. At every birth something COULD come up that calls on us to step up and act quickly and decisively with know-how and experience. In twin or breech birth there is a much greater likelihood that our skills and judgment will be needed. These are most definitely births that benefit from two midwives (or maybe three for twins). Given how few women are choosing vaginal birth for twins and breech babies let alone home birth, hands-on experience with these types of births can be challenging to obtain. While there is no substitute for actually attending breech and twin births, skills training with drills and simulations using mannequins is super important for gaining skill. I’m excited to attend Dr Stu’s breech class this spring (I took his breech/twins 2 day workshop in October 2020 and really enjoyed it).

I need to experience more breech and twin births and to work with more midwives in these situations. I’m a collaborative learner and midwifery is learned by doing (not just reading about it).

What questions about complex birth do you need to continue exploring? 

I need to think out loud. I need a space to ask questions and hear other midwives’ experiences. Debriefing, brainstorming, case reviewing all of that is super important to my learning process. Developing relationships with other midwives so I can do that more is imperative to my growth and development as a midwife.

What do you feel more confident about? 

I learned so much from this class!!!! It really helped me put into context a whole bunch of pieces of information that I knew about breech and twins. The Indie Birth style of class design works really well for my brain. I love how the class structures are multisensory/engage different learning styles. Watching videos, then reading about a subject, then getting out my doll and pelvis, and then listening to a podcast on a subject feels like a beautiful immersion experience. My knowledge and confidence are growing (although I humbly admit, more experience attending births is where the real learning happens)!

I knew a good bit about breech birth coming into the class but seeing Shawn Walker’s videos on using corrective maneuvers at a birth really helped me better visualize the timing of using maternal movement and provider maneuvers to restore the proper breech mechanisms and expedite the birth. Honestly, I’m feeling less confident about attending twins than before the class! There’s a lot going on with twin birth!

I learned a lot about how and why a midwife would help the 2nd twin be born faster and why the second twin is more likely to experience hypoxia and need resuscitation.

Who in your community (local or non-local) can you go to when you run into these things if you need more support? 

I have two midwives within a few hours that I can reach out to for more support. One of these midwives has attended about 500 births and the other midwife has attended about 1500 births.

What needs to change in your community to better support people having complex births?

Well our hospital has extremely limiting “policies” in place that are designed to limit choice for women surrounding twin and breech birth. There are several older OBs in town that have training in breech delivery (not upright birth) that won’t support breech birth because the hospital doesn’t want them too and they think C/S is safer aka easier for them. I’ve been told that hospital policies are unlikely to change for fear of litigation. If fear of lawsuits is the driving factor behind why breech birth was “outlawed” then why in the hell aren’t women suing for unnecessary c-sections? 

On the home birth front we need more midwives to support all kinds of births not just the complex ones and having a more friendly transfer environment would add to the safety of home birthing women. Because of the hostile situation, in the last two years we’ve had one midwife move away and four stop practicing which means we now have TWO home birth midwives in the entire state of North Dakota.

On an internal level; how are you doing? 

Oh it all feels very BIG and it should. Being a midwife is a big deal. Most of the time, the reason people hire you is so that you CAN handle complex situations. If every birth was all sparkles and rainbows and babies that just fall out then there would be no need for midwifery skills. Doulas can totally handle the normal, textbook births and for that matter no one would really “need” a doula either. I’m not saying that birth is only safe in retrospect. I do trust birth, I trust women and I lovingly step into the surrender that creates an optimal birthing environment. It’s just that I very much do believe that sometimes there is a practical need for midwifery skills to resolve an issue that otherwise might be detrimental to baby or mama. 

Is complex birth overwhelming or can you see how it might also be a variation of normal? 

Sure complex birth is a variation on normal, long labors aren’t inherently pathological, neither is breech or twins but these situations do need excellent observation skills and really knowing what is normal in these situations and what’s not normal and knowing when to get outside help.

What do you see in your own beliefs and consciousness that could use a shift around these topics? 

There is a bit of women blaming in my local midwifery community. Well, if she would have only (insert, eaten better during pregnancy, or taken the supplement I’d suggested or whatever then she wouldn’t have had X complication). I know I’ve thought these kinds of things too. This is midwifery copying the medical model thinking; that we have crystal ball or should spoon feed women the answers to the “problem”. I’m still working all this out in my head. How do I give solid suggestions that I know are really valuable and also fully support her in making autonomous choices and taking full responsibility for those choices? I think all of that matters even more when a women is having a more complex pregnancy or birth experience.  I am vaguely aware that the medical industrial complex thinks that it gets to set the “standard of care” for pregnancy and birth. Vaginal breech birth, vaginal twin birth (especially if one twin is breech or mama is a VBAC) or long labors are NOT the standard of care in my community. Since traditional midwives employ far different support (not solutions) for those situations and if a transfer is indicated it’s highly likely that the birthing women will be punished for making outside the box decisions for her and her baby. I guess this is where I need a shift currently. It’s really challenging for me to watch clients be punished. I know that those experiences have been hugely important for me in my process as a developing midwife. I think right now I need to create some space to reflect internally and do some debriefing with another midwife. I’m feeling the need to be heard. That it sucked. That it’s wrong to treat women this way. That by being me I am part of the solution. That there is power and great change that happens when we first prioritize our own experience.

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We are mamas and birth workers who decided to do birth differently– and bring others along with us. We are kind, fun to work with, and great at (lovingly) calling people on their bullshit when necessary. With 12 children and 18 years of midwifery between us, we’ve learned a thing or two along the way, and Indie Birth Midwifery School is our space to share it all with you.

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