Surprised by the ill feeling from others towards elcs... For twins!

[legallyblond]

I'm 20 weeks with dcda twins (big surprise - already have a 2.5yo DD!) and, after a long discussion with my consultant, will almost certainly be having an elcs.

I am a lawyer and therefore think in "risk" terms so was keen to go through the details of all the risks with the consultant. Considering the risks to twin 2 after twin 1 is delivered, including the risks of emergency medical intervention at that stage, an elcs seems safer. The consultant said that she would prefer all twin deliveries to be by cs as its so much safer in her view. So.... With that in mind, it's looking like elcs!

But given what the obstetrician said re safety (to the babies!), I have been totally shocked by the reactions of some people I have told about my decision! Some seem to think its all a con by the medical profession and can't believe I've allowed myself to be "swayed". The main concern from these people seems to be maternal recovery. I am just that some might place maternal recovery over the babies' safety! Also, re breastfeeding, that has been given as a reason by some (ie it's harder after c section), but having bf DD until she was two, I know how versatile it can be in terms of positions!!!

I had a wonderful very natural birth with DD (mostly in water and no pain relief throughout). It was really amazing, but the recovery wasn't a bed of blinking roses! I had a significant episiotomy and, although no infection, I would say I was in pain for 7-8 weeks...

Are these RL reactions normal? Cs was not remotely discussed with DD do this is the first time I've encountered this strength of feeling about what seems to me to be a non issue!!!

Patterns of care are indeed very important, and it may well be that women here in the UK are making decisions in the knowledge of what is available to them locally. The lead investigator Dr Jon Barrett comments that the newer generation of obstetricians should be trained that the best way to deliver twins is vaginally.
What's interesting about the Twin Birth Study, is where the women were recruited. It is a multicentre randomised controlled trial. If you look at the PDF file below, with particular reference to the recruitment table on page 34, you will see that large numbers of participants were recruited from Argentina, Brazil and Canada. Relatively few have come from the UK.
What is not clear, is who is actually delivering these babies in these countries.

www.obs-gyn-atlantic.ca/Assets/presentations%202012/Armson,%20A%20-%20Cesarean%20For%20Twins.pdf

In the UK, midwives are often providing the lead, with medical staff being called in when difficulties arise, as they are prone to do with complex deliveries. Often the younger cohort of obstetric trainees are relatively inexperienced at delivering twins vaginally in this country.
Is the set-up different in Brazil Argentina and Canada? Are twins being delivered vaginally in these countries by experienced obstetricians on a one to one patient basis? I don't know the answer to that question, but the answer certainly DOES impact on how applicable the results of the study are to us here in the UK.
One could argue that the long term answer here in the UK is to train our obstetricians to be confident and competent to deliver twins vaginally, but where does that leave women in the here and now? Here in 2013 in the NHS, obstetric cover at night and the weekend can be seriously stretched. This will, in turn impact on how quickly a doctor can attend labour ward in an obstetric emergency. Experience levels and competence with instrumental delivery will also vary. It may be that an elective section during normal hours, to be undertaken by an experienced operator (i.e consultant) remains the safer choice at the moment here in the UK. Again, I don't know the answer for sure.
I've been a bit long winded, but the interim results of this trial need to be interpreted with caution here in the UK
As others have commented, one person's rational decision can appear to another as entirely reckless.

I had two traumatic births ending both times in 3rd degree tears before my elective cs with number three. It was the easiest recovery of the lot, with the added bonus that I wasn't doubly incontinent for 6 months after his birth like the first two. I am also a solicitor and completely understand weighing up the risk, I did this too, the risk to baby during a section is the lowest of all forms of childbirth (according to my obstetrician). Maternal risk is higher due to infection but it was a risk I was willing to take. Do midwives not have to manually internally turn the second twin sometimes? That can't be good for your bits and maybe you could point this out when you encounter the raised eyebrows when ELCS is mentioned. I got that reaction when I was asked about my impending birth so I would remark that the first two births left me with just one big hole down there and I would rather not shit myself for the forseeable future. Don't ever recall being asked follow up questions...

Yanbu.

Who have you told? I was completely secretive about the fact our DC would be induced (with cs a high possibility) two weeks early. Didn't tell those who knew that I had a firm date to go in either - stated v vague!

I had a section and quite honestly it was a breeze. Pain very manageable, scar quick to heal and bf'ing established. LO did lose quite a bit of weight and get jaundice partly because my milk was a little slow to come in. You should think about banking colostrum to help solve for that issue.

Anyway, I'd just stop telling people. Good luck and congratulations!

Thanks for all the comments all. Thanks Kllews for your very insightful comments - I appreciate the reading into the study!

I am going to have faith in the obstetrician's opinion here and sticking with elcs. But I am still amazed by the strength of feeling around the topic! not here, but in RL!

I had an ELCS due to PTSD from previous traumatic birth.

In the run up I felt I needed to justify it, but I also felt that my reasons were intensely private (not to mention I couldn't even think about the first birth without breaking into a sweat, let alone talk about it).

Now, 3 years later I seriously couldn't give a monkeys what anyone thinks/thought of my decision.

People are rude - it's none of their damn business. By the end of my pregnancy if someone I didn't know well asked why I was having an ELCS I would reply "why do you need to know?"

Just don't get into it with them. It's none of their damn business.

Congrats on your twins btw!

legallyblond - don't assume there isn't strong anti-ELCS feeling on MN, as there is (though that's obviously not the whole of MN)

I am also coloured by the fact that DH's best and oldest friend is a consultant obstetrician and, although he hasn't proffered an opinion yet on this birth, he has previously explained that rather than having 2-3 mins to get to a baby in need of oxygen, thd reality is that, of a baby is in true distress, you have less than a minute.

Also, although H would make this decision on a purely risk based basis, I am coloured by the knowledge of recovery from an all night very natural labour with an episiotomy. It was a wonderful thing, but sitting down an walking was painful for weeks (well over 6 weeks).

I would be interested to know whether a midwife would give me a different view (my mw af 16 weeks just said it was likely I'd have a c section).... But decision made!

Excuse typos! On phone!

I found my episiotomy worse than my c-section incision, if that helps at all.

People are so ridiculous and tbh I find midwives in a lot of cases equally as disparaging of C/S as many of the general public.

I have found that any Consultant Obstetrician I have seen has a very balanced approach to risk in terms of C/S and I trust their views far more than I would trust a midwife tbh - both because the Consultant is more experienced in dealing with Surgery usually and because their level of medical training is higher.

The push for natural birth by midwives no matter what the cost to mother or baby within our health system horrifies me. While many births are absolutely fine, there are others where surgical intervention is necessary and it is very important not to be blinkered to risk.

FWIW knowing a few twin mums I think you are doing the right thing. One went for a natural birth and had to be rushed into theatre for a section on number 2 as the baby was in serious distress. May as well have had her ELCS in the first place and minimised the risk of harm to twin 2.

I'm not having twins, had EMCS last time, and am currently being pushed towards VBAC.

My last pregnancy was in Canada - where I did have a completely different experience, and had great confidence in my care (both midwives during antenatal, and the doctors/maternity nurses once it all went a bit wrong).

In Canada all my choices, risks and options were always discussed (even as things got a bit risky - they made sure I understood what was happening). I had 1-to-1 care throughout the experience (albeit with different nurses as the shifts changed), in a large, single room with ensuite bath - and this was public healthcare, all the mothers had the same. If I told the story, it would sound like a fairly harrowing experience, but in actual fact I feel totally positive about it, and that's entirely down to the quality of care I received.

So far in this country (also about 20 weeks) I just don't have the same level of confidence. My consultant (wants me to VBAC) doesn't appear to have read my notes, and is pushing inappropriate medication on me - and thrusting a leaflet at me to explain why (one that gives me no numbers so I can't make an educated decision), and telling me what I'd be 'allowed' to do, and what they'd do to me without any recourse to what I might prefer.

The VBAC midwife totally disregards all my risk factors, and tells me that my previous birth experience can't be counted as it was induced so my experience would be different here. (She did at least talk to me like I was an intelligent human though)

The community midwives seem to be entirely out of the loop, and have made comments that if they were me, they'd be going for an ELCS.

I would take the results of that study to be inapplicable to the UK - judging by my experience so far, in what I would otherwise class as a pretty good hospital following my experiences with my son on the Children's Ward.

Mutley - midwives and obstetricians do have different perspectives on birth. Midwives care for ALL women - high risk and low risk. Caring for women having c/s, high levels of monitoring and assisted deliveries, is part of their day to day work load. Obstetricians in the UK however are primarily surgeons and they only become involved once a birth becomes complicated. This means they have no input into the births of most mothers - healthy or unhealthy, as most high risk women still have unassisted vaginal births in the UK.

Midwives DON'T disregard risk to the mother or baby when it comes to this issue. But they are concerned, as are most doctors, that a lot of avoidable surgery is being done on healthy women at present in UK maternity units. They should be able to acknowledge this concern without being labelled 'anti-caesarean', or 'uncaring'. All the midwives I know are profoundly grateful for the existence of safe operative birth - how could they not be when they see surgeons saving the lives of mothers and babies in their work place every day?

I think I put that badly, I don't mean that she disregards the risk exactly, more that she minimises it to an even greater extent than I do, whereas the consultant exaggerates it (I feel).

I also am aware that she will be unlikely to be able to completely honestly tell me that I'm not going to get the level of support I might need to have the birth experience that could be possible - that in my case the birth experience is likely to be fairly medicalised no matter what I go for, and that all risks aside, my experience might be better as a CS patient.

I absolutely don't feel that any of the midwives I've spoken to have been uncaring - harried, busy, possibly with targets to aim for and little time to get to know me and my history - yes. Uncaring, absolutely not, and if I thought that I would receive the level of care that they would like to give I'd be much more confident about going for VBAC (or in OP's case, perhaps I'd feel better about the idea of having twins vaginally). As it is, I'm just not confident I would, and that it would all go to pot and I'd end up fighting against unwanted intervention at a vulnerable time and eventually getting an EMCS.

"I also am aware that she will be unlikely to be able to completely honestly tell me that I'm not going to get the level of support I might need to have the birth experience that could be possible"

I feel this is the problem with the midwife in charge of VBAC at my local hospital - she doesn't acknowledge that the reality of care for women on the labour ward is often a long way short of the sort of care women trying for a VBAC need in order to have an optimal chance of a normal birth.

" - that in my case the birth experience is likely to be fairly medicalised no matter what I go for"

You have to consent to continuous monitoring/a supine labour/regular VE's/a hospital birth. I know a good number of women having VBAC's who have not consented to these things who have been supported and accommodated by the hospital. At our local hospital VBAC mothers who request a home birth are always offered the use of the birth centre in preference, but ONLY after they've made noises about having a homebirth. Otherwise they're told that the birth centre is not available for women having VBAC's.

Just to clarify, in my case, with twins, the midwife all but washed her hands of me and handed me over to consultant care. I am not seeing the midwife again in this pregnancy! I do find that odd as was v midwife led last time.

But, the ill feeling I have experienced has been from other mothers, as opposed to midwives. I guess I still can't get over the quizzical looks and the notion from others that I have been conned when I explain that I have been told it is categorically more risky for the babies to have a natural birth. Whether that's true or not seems to be a finely argued pint amongst knowledgable medical professionals, but I guess I am still in shock that some think that that is not a good reason to have a c section.... I just can't get my head round it!!!! Hence venting a bit here.

If this were a singleton pregnancy like last time, I wouldn't give it a second thought as, assuming I had no other complications, there would be no particular risk involved in a natural birth. Indeed, episiotomy aside, I know my body can do it. But this is different. And the people in RL are not stupid.... It's really weird!!!

Legally, just repeat in a slow, loud voice: I am having twins. I have been advised that a c-section is the safest option, which is why I'm having one.

Should put an end to any speculation.

That said, there is disagreement among doctors as to whether it's safe to attempt a vaginal birth with some twin presentations. I think doctors have a duty of care to make sure you're aware that there are differences of opinion on some issues between consultants - when it comes to breech delivery and twin birth in prarticular, even if they do guide you as to what they personally believe is the best option for you. Otherwise, if you're just being presented with one option in a situation where other doctors could reasonably present you with two, the doctor is not fulfilling their responsibility to enable you to make a fully informed choice of treatment.

"as for me DD's safety, rather than my birth experience.." to be fair, the mother's birth experience and her baby's safety are inextricably linked.

OP, I hear your irritation and agree, no one else's business. Your babies, your body, your choice.

Plus, what minifingers said.

I am also a lawyer, expecting twins and have older dc. Around here, its assumed that twins means elcs, and there would be suprise if I even suggested that I was planning a natural labour. So not an issue here about these type of views arising thankfully.

My birth options have not yet been discussed with me. I am 26 weeks. I find this a little concerning as want to have all the facts, plan ahead etc. I raised it briefly with my consultant in the early days, however he sensibly said 'its too early to make any kind of call, let's see how your pregnancy advances'.

I saw my midwife last week. Her (rather brash) view was that 'a c section aint a walk in the park, it isn't an easy option' and when I raised the risk to twin 2, she suggested that they could manually turn her if things got tricky. I did not like this response, and I understand from reading posts here that the manual turn is very risky for a baby?

My view is the same as yours, OP. Get the babies out safe, and preferably keep me safe too. I have done the natural labours (luck rather than anything else), done the over 12 mth breastfeeds x 2 (ditto), got the 'NCT medals' blah blah. I don't give a flying about other people's opinions and the demented view that nature is better despite known risks. My uncle lost oxygen when he was born which has meant that he has been profoundly disabled for his whole life.

My preference is therefore for an elcs. It does seem the least risky option to me (esp for twin 2) having read the research and people's experiences. The registrar I saw today said that this is generally done at 38 weeks, but I thought it was 37? Is the extra week so they hope that the babies come out naturally in the meantime thus avoiding the c section? Or am I just being paranoid?!

Ps. Pm me, OP, if you fancy exchanging experiences/thoughts

Oh yes beaches, totally 100% agree. I will pm when I am back on proper Internet/ computer... On my iPhone in hotel room after work function... Bleurgh.

I too feel I've "got the t shirt"... No pain relief in labour and bf DD until 2... Which is why I am consistently amazed by this debate as I had never experienced before!

Re getting the elcs, I've only seen the consultant once (I am 21 weeks) and she was very keen to confirm that if my preference is for elcs (which is also their preference) I would be 100% supported. I believe NICE guideline for DCDA twins is from 37 weeks (I'd have to check - I found the guidelines on google). I know someone who had a planned cs for 38 weeks but began labour at 36 weeks. They took her straight in for a cs as that was the option that she/her consultant had chosen. So I doubt you would have to have a vag birth unless you had jumped to fully dilated and/or baby 1 was too far down the passage...

Like I said, I'll pm!!

Ignore them, the safety of your babies comes 1st and foremost from any scewed opinions people may have.

hi there, i had my twins naturally at 38 weeks, both delivered by forceps, and had to have corrective surgery after... i wish id had a c section... but no one alive would have convinced me of that when i was preggers :) , birth in general is unpredictable, do what your most comfortable with... x