Optimum gestation for ELCS for DCDA twins?

[BagofHolly]

My planned section is booked for 37 weeks, privately, based on my dates which are spot on cos we had IVF. my NHS hospital won't deliver before 38 weeks and have booked me in, but have based the date on their dating scan. They measured the babies at 4 days bigger than their dates really are, and have booked the section at what is REALLY 37+4. I'm very keen to avoid any complications and wondered who is right? Should I ask can I hang on and deliver later? I can't find any absolute guidance about when is the optimal time for delivery for DCDA twins.
(just to clarify, I'm booked in with the NHS too so that if I have an emergency I can still go in and quickly have my section as it's all agreed in my notes, even though I'm hoping not to go into labour at all and make it to the private unit in London.) So, can anyone tell me what's the best thing to do?

[e3chick]

I was looking into this when I was approaching the birth of mine (also DCDA). Mine were natural, but as I approached 40 weeks I was starting to hear murmurs of induction/monitoring. I didn't find anything convincing that made me want to hurry them out, there just didn't seem to be the research.

Personally I'd wait until 38 weeks to minimise chances of them being too early as 37 weeks is bang on the cusp of being term. But you didn't ask my personal opinion!

What do you want to do? Have they given good and convincing reasons why they are booking you in for 37 weeks? Are you/the babies in danger if you have any natural labour?

[BagofHolly]

Thanks for replying. I don't know why my private chap does them at 37 and I'm seeing him shortly so that's one of my questions, but I suspect it's because he'd rather do a planned section than a rushed one. I don't understand why the NHS consultant says 38 weeks and then ignores my dates, either, so I'll ask her when I see her next! I'm tempted at the moment to ask can I push it back a few days, but my nightmare is going into labour, and then having to dash into London and have a CS whilst already labouring and the further I push it back the more likely that is!
How far along did you get?

[e3chick]

Oh I see. Tricky one really. Are you far out - how long would it take? Have you laboured before?

I got to 39+6. How far are you now?

[Poppet45]

I thought 37 weeks was regarded as full term for twins. I think me and my sister were induced at 36 weeks due to pre eclampsia and we were 4lb 4 and 4lb 8 and were just fine even way back then. I wouldn't worry about labouring against the clock. Chances are you'll have a good 12 hours or so to have that section and the start of labour is very slow and easy to deal with, and if you're in active labour, you'll go right to the top of that day's list, past all the electives, bar the women in real dire emergencies.

[e3chick]

'How far are you now' - I meant how many weeks are you?

The thing about what is regarded as full term seems to vary according to the hospital. Which to me translates as 'they don't really know'.

[BagofHolly]

It'd take about 90 mins to get to hospital in London, longer with traffic. I've never laboured before (and don't want to!) and I'm 31 weeks today. Interesting that the protocols vary between hospitals. I had my son at 38+5 and there wasn't a whiff of labour and we have no family history of early delivery - quite the opposite. It's the unknowns which are scary!

[mears]

Elective CS are best done at 39 weeks when babies are most likely to have mature lungs. Your CS would be best done any time after 38 weeks as it is common for babies to need admitted to the neonatal unit with breathing problems when delibvered earlier. If there is a real need to deliver earlier then NICE guidance suggests that corticosteroids should be given to the mother prior to delivery. The longer babies are in, the better. Labour isn't a bad thing to happen as it also stimulates babies to make them ready for birth. If you haven't laboured before then 90 minutes is fine to get to hospital. Labour usually lasts a number of hours.

[mears]

Term is universally agreed as 37 weeks onwards. Babies who go through labour are usually fine. Babies who are delivered by elective CS can have TTN - transient tachypnoea of the newborn - due to the fluid not being 'squeezed' out their lungs during the natural birth process. Less likely the 'older' they are at delivery.

[BagofHolly]

Thanks Mears. The other complication, if that's the right word, is that I'm on heparin, which if I've had it too close to delivery, can mean I can't have an epidural or spinal block, and would have to deliver under GA, which is another reason for the planned CS. I don't want to deliver vaginally - I'm nearly 40 years old and a vbac with twins is more than I want to attempt, and as it happens at the moment, they're both transverse anyway.
My son had TTN despite being delivered at 38+5 and I beat myself up about it terribly, despite assurances that waititing 36 hours until he was 39 weeks probably wouldn't have made any difference. I'm hoping to avoid the same situation with the twins but as I say, am trying to get my head round balancing all the risks.

Ok, so I'm going to ask about putting it back a few days and see what he says. And then hope I don't go into labour spontaneously before then anyway! Eek!

[mears]

Why don't you ask about steroids?

Chances of labour before 38 weeks will be slim if babies are both transverse as there is nothing putting any pressure on the cervix.

My sister had her elective CS for twins at 38 weeks with no sign of labour. They were good weights but rubbish feeders because I think they came out too soon. Her first was breech and she was 46 so didn't want to labour.

The heparin issue also influences the decision too. You really need to discuss it fully with your consultant. Not sure why you have 2 - NHS and private? Does private not do emergency CS? Is it a matter of distance?

[mears]

You need to have 12 hours after last dose of heparin to have spinal

[BagofHolly]

I'll ask about steroids for sure. I have two consultants because I'm having all my antenatal stuff done locally at Addenbrookes, and also if there's an emergency I can go straight in and they've got my file etc. The only reason I'm also under a private chap is that the postnatal care in the private hospital is much better than the NHS and I think I'll need all the support I can get. My private cons is more than happy to work alongside the NHS but I get the impression has a bit more flexibility about some of the decisions he makes.
As for the Heparin issue, my haematologist and consultant both said 12 hours but ideally longer, but the anaesthetist was much more cautious and decided at the last minute to do a spinal block rather than epidural, and made it clear that if it didn't take, she'd do it under GA. She infinitely prefers to use epidurals but didn't feel it was worth the risk in my case.
The private hospital does do emergencies - my cons was totally chilled about it - he just said to call the labour ward on the way in and that he'd meet me there, day or night. If it were a BIG emergency (don't know what - massive blood loss etc etc I'd 999 it into my local hospital obviously, rather than get my husband to drive me all the way down to London.)

[BagofHolly]

Sorry, brackets in wrong place!

HOw far in advance of delivery do steroids have to be given in order for them to be effective?
That's a shame your sister's babies weren't good feeders - I think there's such an element of luck as well as skill with breastfeeding. My son fed like a champ but mainly from one side in the first few weeks, and got the hang of the other side once we got going. I BF exclusively for 7 months before weaning and then carried on BF until he was 13 months old, and only stopped for more IVF. I was very lucky too - I had a good supply from the start which obviously helps and I'm hoping to BF these too - in my experience CS needn't be a barrier, but I realise that a lot of things which could have gone right for us, did.

[mears]

You will have the advantage with breastfeeding that you have fed successfully before. My sisters twins were her first (and only, sadly) pregnancy. Where I work we always do CS under spinal if labour isn't planned. We only use epidurals for labour and top them up for CS. Sometimes they don't top up well and they need removed and spinal used instead. Some placed use combined spinal/epidural but we don't. Steroids are meant to be given at least 24 hours before delivery as a minimum preferably at least a week or more before though. It is 2 injections 24 hours apart. Hope all goes well for you.

[mears]

www.rcog.org.uk/files/rcog-corp/GTG%207.pdf

Page 5 of the link I have posted refers to steroids for elective CS

[mears]

antenatal steroids

[BagofHolly]

Thanks for those links Mears, that's very kind! I saw my private chap today and talked about putting back the CS a bit. He said that in his opinion there wasn't any point because I'm so big in all likelihood I won't get to 37weeks anyway. He said 37 weeks is term and that I was just unlucky with DS having ttn and there was no reason that these two should have the same problems. I forgot to ask about steroids which I'm really cross with myself about. I'm seeing him again in 3 weeks so I'll ask about having steroids then. So many unknowns!

[mears]

Yes 37 weeks is term but he is a bit bold saying babies won't have TTN. That has nothing to do with weights. Print off the RCOG paper and take it with you epecially if planning early CS before 39 weeks (even more so if less that 38 weeks).

[BagofHolly]

Thanks so much. I'm now officially rattled. The original plan was to see me once before the delivery and all my other monitoring be done via NHS. Now though he wants to see me again in 3 weeks so I can ask then or email. On the one hand the rcog info seems compelling, but then on the other, on page 7 it says there's an absence of evidence about the safety of steroids after 36 weeks. I was also reading a paper about the benefits/risks of twin ELCS and how the vest time is between 37-39 weeks and after that, morbidity and mortality increases, unlike in singleton births where it's fair to say the longer the better.
My cons didn't say they wouldn't have TTN, just that there was no reason that they would have it and it was v bad luck last time as my son was born at 38+5 and was also a good weight.
Don't know really what to do - I don't want to be one of those awful patients who thinks they know best, but then I also don't want to miss an opportunity to reduce my risks purely on the basis of my being too shy to ask. (I'm rambling now, sorry.)
If I go into labour early, as is widely predicted, it's all a moot point anyway isn't it? Thanks for listening to me bang on, I'm getting myself in a tizz about it!

[mears]

Remeber though, if you go into labour the babies are getting stimulated and don't need steroids. Keep them there as long as poss. as a compromise 38 weeks is good. 37 weeks is borderline. Didn't mean to rattle you but in my experience, 37 weeks is too soon.

[BagofHolly]

No I know you didn't Mears, I'm just overthinking everything and really appreciate your point of view. Are you a midwife?

[mears]

Yes I am. Hope all goes well for you whatever you decide.

[MasalaDosaMum]

I had my twins at 37 weeks+1 and they were absolutely fine. They came straight up on to the post natal ward with me, and needed no intervention whatsoever. My consultant did intially advise me to wait until 39 weeks, however, I was so uncomfortable/fed up by 36 weeks that he agreed to book me in for an induction at 37 weeks.

A number of friends with twins were also induced/had ELCs at 37 weeks, and I don't recall that any of their babies had any problems.

Good luck with whatever you choose.