Anyone out there who can help me make a decision about my breech twin birth?

[ShesADreamer]

Hi,
Am 35 weeks with twins, twin1 is breech, twin2 vertex.

When it became apparent that twin1 had flipped to breech last week, I was told I needed to be booked in for a CS at 36 weeks. Queried this and we are now waiting till 39 weeks.

With 2 children at home I am very keen to avoid a CS. Both my previous pregs and births have been natural and trouble free. This preg has also been very healthy (both myself and the babies). They are fraternal twins with separate sacs and placentas.

I am happy to be prepped for a CS, monitored and have a mobile epidural so, if things go wrong, we can go to a necessary section straight away. I am very grateful for the advances in medicine which allow women and babies to have these options in childbirth but am wondering how necessary it is for me to be having a planned section.
Is it unreasonable of me to ask to be allowed to try and labour naturally with precautions in place should issues arise?
While both babies are predicted to be healthy weights, they will still be smaller than either of my singletons.

Many thanks in advance for anyone who can shed some light on this for me!

If your Consultant is happy to go with this plan then it sounds like you are taking sensible precautions. The issue that concerns staff in your situation is that the breech baby can be born up to the shoulders and then the head is trapped behind the second baby's head because the second one has descended into the available space. Obviously that's not a good situation to be in and I assume this has been explained to you. I would want assurances that very experienced staff are on duty when you are in labour with immediate access to a scan machine and theatre on standby. Hopefully that wouldn't be necessary but best to be informed and prepared. Good luck, let us know how you get on.

It's a hard decision and not one I'd like to have to make. In your favour is the fact you've had two vaginal births before. You should be able to birth breech twins vaginally.

The problem is though if one of the babies is born so that its body is out but it's head is stuck then a section is pretty much impossible at this point. I've seen two babies stuck like this and neither had a good outcome. You can't push a baby back up that has its body all the way out.

You wouldn't be able to get assurances that experienced staff will be on duty. You'll get who happens to be on shift when you're delivering. It may be that you have a shift where none of the midwives or the registrar have seen a breech birth before. Though hopefully the consultant would attend.

I think the majority of consultants would have. However there's a slim chance that a young/new consultant wouldn't have.

On the other hand you could be lucky and have a very experienced consultant or even a reg who has seen a lot of breech births.

Back from bath & bedtimes. Thank you for all your answers.
Traffic consultant not aware of my proposal yet. Was told by registrar I would now be booked in for CS at 36 weeks. Asked them to delay this, which they are happy to do as long as I present myself immediately I suspect labour. Am now pencilled in for CS at 39 weeks so am sculling about on hands and knees while trying to research my options!
Spoke to independent midwife Jane Evans today and she was hugely generous with her time and very helpful.
Interlocked twins was the stated reason for moving to CS but it seems to me that this is very rare and happens with premature babies who share a sac?

Viva both consultants are older and very experienced (although have not specifically asked them about breech births yet). One originally trained and practised in India where I presume he would have seen more BBs than in the west.

If baby's head got stuck like this would that mean episiotomy and Piper forceps?

Meeting with consultants, head of midwifery and consultant anaesthesiologist next week so really appreciate your help.

Will definitely keep you all updated.

It would be difficult by that stage to do an episiotomy. So either use forceps to try and deliver the head or try and use flexion from something like the Marcieau-Smellie veit maneuver to try and deliver the head.

Will one of the experienced consultants be there if you went into spontaneous labour in the night? Where I work we don't have consultants in the hospital at night.

One of the breech births I saw the reg was trying to deliver the baby and couldn't. She hadn't seen a breech birth before. Consultant wasn't on the labour ward as he was busy with a gynae emergency. If its a weekend or a night you can't bank on them been there.

Good point and another to add to my list of questions for next week.
I guess the risks of what I'm proposing are all dependent on how experienced the birth attendants are.

Very good to know I'm not being silly to ask though. Is there anything else I should ask about or can offer to do to minimise the risks?

Have you looked at the Mary Cronk stuff about breech births? She is very enthusiastic in her support of breech and states if a breech birth is progressing well then it should continue to do so. It's something I'm sure the drs and midwives will be aware of but you need to be too. That if you do go for a vaginal breech if labour isn't progressing then that's a sign to go for a section. She's worth googling.

The Hannah Breech trial is the piece of research that stopped breech vaginal births in their tracks. However it's since been recognised that the research is flawed. Unfortunately since then skills have been lost.

If they can't guarantee experienced staff I wouldn't go for it. Though you could make your decision on the night if it came to it, see how experienced the staff are when you get there. Though that relies on the registrar on duty been honest. But if the consultant is there/prepared to come in then that would be good.

all I can add is that DS4 was footling breech and there was no discussion of a possible VB - I didn't want to even talk about it and the consultant sighed with relief. we agreed on ELSC in about 2 seconds.
but that's me and the "footling" part freaked me out.

had VBAC with DS5 (head down) then same with DD, if that helps.

good luck either way.

Hi - more of a lurker than a poster but wanted to reply to this with my experiences. I had twins in June. Twin 1 was head down and twin 2 breech. If twin 1 was breech my consultant would not have entertained a vaginal delivery. I too was adamant that I wanted to avoid a section if at all possible because i also have a 2 year old and i wanted to be in and out of hospital as quickly as possible. However, if twin 1 was breech I would have not hesitated in having the section.
I had a text book twin delivery - they broke my waters as was 3cm (had been on expectant monitoring for a week as refused induction at 38 weeks) and they were both here within 2 hours. It was nothing like my singleton delivery though. Very medicalised, room full of people and i was strapped to millions of wires, monitors etc. i think honestly in that circumstance it would be very hard to deliver twin 1 breech because you would effectively be tethered whilst they try to keep monitoring twin 2 (i read extensively on this subject and all the guidance seems to be hands off the breech and freedom to move). I don't want to put a downer on this but twin deliveries are harder and more brutal than singleton deliveries (i was quite naive about how different) and if twin 1 did not turn i would be minded to opt for a section. It is hard to keep a reliable trace on twin 2 whilst delivering twin 1 and for that reason you often end up on your back covered in wires.
Good luck with your chat with the consultant. Have you got a copy of your trust's twin birth protocol? I found that helpful in understanding their risk framework (and fitting it to my own!).

Good luck with your decision. It sounds like a truly tough one. I cannot say what I would do personally, but I would certainly research my options thoroughly, and not just the 'theory' part, but the actual reality of the ability and confidence of the staff.

I opted for something as common as a physiological 3rd stage in a MLU with my first and the midwife got all jumpy after 15 minutes and started tugged hard on the cord causing me to bleed heavily. I expect when you present you'll get the most experienced people available, but that doesn't mean they have the skills you need.

I really do hope you find a way to manage the VB it though if it is possible.

On Starlights last point about being surrounded by the most experienced people when you present i did not find this to be true. When i delivered there were three other twin deliveries going on at the same time (of which two were inductions). I believe that this is why they prefer to induce twins rather than just letting you present in labour so they can try to staff it appropriately. I had a student midwife as my main carer, a few other random midwives who kind of just appeared and a registrar and a minimal paediatric team because everything happened so fast. The consultant appeared for two minutes to do an ICV on twin 2 and that was it. Definitely worth asking about staffing and ratios etc when you see the consultant and how they would balance it all in terms of other emergencies.

Hi
Sounds like a difficult decision to make (but fwiw sounds like you're thinking about it carefully and considerately!). My experience is that I had an elcs with DTs after a straightforward vaginal delivery of DD1. DT1 was breech throughout the pregnancy and I agreed to the section without raising any of the questions you've raised here.
My recovery was much better than I was expecting. They were born in the morning, I was walking around by the afternoon and we were discharged within 48 hours (twins were born at 38wks and both fine). I was out and about within 4/5 days of the section. I didn't drive until 6 wks after (though as much as anything because I couldn't face the logistics of getting DTs plus 18-mth old DD1 in the car!), but I was pushing the double buggy up hills with one in a sling within a couple of weeks.
I suppose the point I'm trying to make is that I don't think you're at all unreasonable to be proposing an alternative, but if you do end up with an elcs the recovery might not be as bad as you think.
(The other thing that happened to me is that when the twins were born DT1 had turned over and was head down and in position! I had my last scan 8 days before the section and I hadn't felt him turn over. So it's just possible things could change anyway.)
Good luck with it all. Hope the conversation with your consultant is helpful.

You could be me exactly a year ago. I'd like to post more but putting my twins to bed!

Mine were both breech at 35 weeks. I changed OB's as I hated mine and I was lucky enough to find an amazingly experienced one who was willing to deliver breech twins. We went thro the risks vs benefits and looked at the research that is out there.

In my situ and only if my OB or certain other experienced consultants were on duty when I presented in labour then we would go ahead. If that wasn't the case we would re-evaluate.

Then...both of the buggers took turns flipping every bloody day! I was even booked in for an EVC at one point, not to turn them but to get one of the boys foot out odd the way of the other ones head as neither were engaging.

Anyway long long story short I went into labour at 37.6days, my OB was on call, twin1 was head down and once I delivered him the OB reached in and grabbed twin2's head and I pushed him out 6 mins later. I didn't have an epidural so it was very uncomfortable but only momentarily.

Anything can happen, but stick to your guns. I can send you my birth plan if you want? It took intro account all possible scenarios and was followed religiously by the team who worked with me.

Spoke to the head of midwifery on the phone and she was really positive about the possibility of a normal delivery even with twin 1 being breech. Apparently lots of breech experienced staff available and they may be happy to monitor T2 intermittently.
Am going in to see her Friday so will have a clearer pic by then.
Thank you all so much for posting - esp those of you sharing your own experiences.

Viva Also have Mary Cronk's No. but called Jane first as Mary is retired and it felt a bit cheeky to call up out of the blue.

amazing Footling would worry me too!

chimper really informative. You've made me properly stop and think about the things we've already agreed - birth in theatre while prepped for surgery, monitoring, room full of docs, release forms for interventions etc. I know our hospital is 'celebrating' record numbers of births so very pertinent about staffing ratios. Another good question for my list, thanks.

Before T1 flipped to breech, had already agreed to give birth in theatre but with a mobile epidural so could move around. Maybe this coupled with the intermittent monitoring would allow me enough movement to be kneeling or on all fours?

Starlight panicky midwife sounds horrendous. Tugging after 15 mins ffs? Why? Hope you didn't suffer too much during those first days with baby.

Walrus thank you, that does really help. Am very much trying to get my head around CS recovery as I know it's pretty likely it will go that way. Am a bit of an old gimmer though so I doubt I'll knit together so well!

red That sounds amazing! Why did the OB go in after twin2 though? Was it to stop them turning breech or transverse with all the extra room? Would love to see your BP. So good of you. Have PMed my email.

Scan tomorrow lunchtime. My floors have never been cleaner and there's been an awful lot of roiling about in there today so you never know...

Will let you know if there's been any movement. Keep everything crossed for me.

Yey for sensible mw.

I've sent you a message and email. I forgot to say, I had the epidural placed, but no drugs administered which meant the whole medical team calmed down as they knew they could get me drugged up quickly if need be, but it meant I could labour free of drugs up until that point (which never happened).

She reached in for twin2 as he'd been buggering around and had gone transverse and breech a lot during my pregnancy and I think she was just worried he'd do the same then. Everything had gone so well, I don't think she wanted to risk him. Having said that, he was blue and a little bit quiet when he came out as he got shot out so quickly...who knows what could have been. I'm just amazed by how great the birth was considering some of the pressures everyone was under.

No experience of what you are asking but just wanted to add that my first 2 normal deliveries were fairly trouble free, babies popped out no problem but dc3 ended up getting stuck. Was very scary and not what I expected for a 3rd birth with a similar sized baby.

Hooray! T1 has flipped and now has his head pretty firmly wedged in my pelvis. Still a chance he could wriggle round again but looking increasingly unlikely.
Am still going to meet with the boss midwife and consultants in case he flips but am thrilled.
Thank you all so much for all your advice - red thanks for your lovely email. Have skimmed your plan and will read properly when the children are in bed - twins without pain relief! Sounds like a real rollercoaster!

I had my DTs by CS - DT2 breech. They were my 1st - I was terribly nervous about a vaginal birth and also about the risks to DT2.

But my cousin recently (3 months ago) had her DTs (also her 1st) vaginally, and DT2 was footling breech! Birth went really well, excellent recovery for mum etc.

I think it depends, as so many others have said, on how confident you are, how able to cope with a possibly fast-changing situation, and the competence of those around you.

Best of luck whatever you go for

WHOO HOO!!!! It's an enormous relief isn't it? Having said that, I think my OB was secretly annoyed as she wanted to write up having delivered a double breech birth. But this makes things much simpler.

Again, let me know if you've got any questions and come join us on the Multiples board once they're here.

Have had a bit of a lurk on the multiples board but am trying to block out the sleep deprivation waiting up ahead so not looking till we're there! Will definitely need the moral support by then though.

Scilly would definitely have plumped for the certainty of a CS if it was my first too. Good to hear your cousin had a good birth. How was your recovery?

Bluemonkey sounds terrifying. How was everything resolved in the end? Did you have to have a crash CS or was baby stuck too far down? Hope it wasn't too bad a recovery.
Almost worst when you've had previous positive experiences as you're totally unprepared for it.
Thanks for the timely reminder that we don't have any control of how things may go.

Not sure if you're still checking this thread but I had my twins at 33 weeks - both vaginally and both breech.
Not really a decision we had made but they were coming - went into spontaneous labour. Was scanned on arrival found DT1 was breech and DT2 was transverse.
No theatres available and I was already 4 cm.
The most senior consultant was called in from home- there were about 20 people in the room - I had just gas and air and they arrived after a 3 hour labour.
Was on all fours for most of it but in lithiotomy position to deliver and was given an episiotomy.
Twin 2 delivered 9 minutes after twin 1.
Good luck with your birth

Hi Chiger,
that must have felt incredibly fast! Your head must have been spinning.
I'm going to bombard you with questions so feel free to ignore if they're too intrusive.

Do you have any other children? If so, did breech birth feel really different (harder) than vertex?
Did T2 turn breech naturally after T1 was delivered or have to be turned by version?

Hope you and babies had a good recovery and were home quickly.
Bet a fair few of those 20 attendants had never seen a breech delivery before!

Hosp has agreed that all things being equal, they will support me to try and deliver vaginally even if T1 flips back to breech. All thanks to rather fab head of midwifery.

Unfortunately, obstetrician has said they will need me in theatre, wired up to monitors (including one internal which may involve breaking my waters), prepped for surgery (epidural sited) and in the lithiotomy position. Am arming myself with further research for more negotiations so hearing that you managed to stay on all fours for most of the time is heartening.

Am not at all woo and will be very grateful for interventions if they are needed but haven't been comfortable lying down on my back for months now and can't visualise how it will work for giving birth!

Thanks for sharing your experiences with me. It's really helping and I especially appreciate how precious spare time must be with twins!

Will update and let you all know how things pan out.

Fab news that twin 1 has turned. Yippee! Fingers crossed that they stay that way!
I am surprised your consultant wants you in theatre if twin 1 stays head down. This wasn't ever mentioned to me. They wanted an epidural in "just in case" and cannulas in pretty early doors (again just in case). I managed to stay standing up swaying around until they put the epidural in (just before twin 1 started crowning so all in all a pointless and horrible experience). Good thing was though that I could feel everything to deliver both babies - made the ICV a bit ouch though. Had twin 1 on my back and twin 2 in lithotomy position (she came out right foot first after refusing to be turned!). I too was really uncomfy on my back - made me all lightheaded. The breech delivery was the weirdest feeling in the world - she was pulled out by her feet and the sensation of delivering her head without anything following it is not something I could ever describe. She was totally perfect when she came out though - not squished at all.
Good luck - you are arming yourself with so much knowledge that you'll be able to understand why things are happening/ question appropriately. Please keep us posted.