Trying to decide about Natural Birth or Elective CS

[StopTheRoundabout]

Hello. I'm due to have non identical twins in 6 weeks and I'm trying to decide which type of birth to opt for. Since 20 weeks Twin 1 is head down and twin 2 is breech but very active. I have terrible haemorrhoids and around my pelvis is very swollen and sore. My Consultant wants me to try to have a natural birth but I'm very apprehensive. I don't want twin 1 to be born naturally and then have a breech vaginal birth or emergency cs with Twin 2. Does anyone have any advice please?

It’s a difficult decision. I personally couldn’t stand the idea of surgery or recovering from an op while caring for two babies, but I can see why you are apprehensive about a vaginal delivery. It’s also impossible to know how the labour and birth would go as there are so many variables.

I have two sets of twins both born vaginally and in both cases my second born twins were born breech.

There was a global study done about 8 years ago on the outcomes for the second born twin based on delivery method. Participants were randomly allocated into elective c/s or vaginal birth. I don’t know what the findings were but you can probably look it up. It was undertaken by a university hospital in Ottawa I think.

My twins presented the same as yours, and I was induced, both born vaginally. Twin 1 came out head first (as expected). With Twin 2 they thought she had moved to head down and midwife held my belly, but turned out she hadn't. She was born breech. No issues with either baby, I had an episiotomy (can't remember at what point, might have been to help get out twin 1 actually) but quick recovery from that too.
I think although breech for first baby is not recommended, if one baby has just passed through the area (as it were) it's easier for the next one to come out breech.

When I was in your situation I asked what type of birth I would be looking at if I went for a vaginal birth. what they described to me was an induction, epidural in case of an emergency caesarean, and possible internal manipulation if twin 2 did not turn once twin one was out of the way (breech).

I was also being pushed towards a vaginal birth but there was nothing about what was described that was natural to me. They told me I would have to labour on my back because I would be constantly monitored and because of the epidural. I didn't have any other reason to need any of this apart from twins so I would suggest that you ask what the birth they are trying to plan for you would involve. I ended up having an emergency section due to complications of premature labour but had I gone any further along I would have been pushing for a caesarean. Not least because induction and epidural increases the risk of forceps and ventouse and that is the last thing I wanted. If I could have had a go at an active birth where i could move around with no epidural then I might have been more willing to try a vaginal birth. Although I was restricted in what I could do after the birth I physically recovered well so I wouldn't necessarily let that put you off, especially if you have help lined up because you will probably need that with twins regardless of how they come out.

How long can you wait to decide? If you went into labour naturally I’d personally try that, but if you’re looking at induction for a first pregnancy I’d probably go for a c section.
I’m 36 weeks with DCDA twins and both are head down and also it’s my second pregnancy with first born vaginally, so I’ve been keen on aiming for natural. However I’ve got a week til my booked induction with no signs of labour and I’m wavering a little. I have a sweep the day before and if they say things don’t look at all ready I might be tempted to try and delay induction or ask for a c section. But I’m lucky in that my hospital and consultant gives twin mums a choice if twin 1 is head down and doesn’t try and and push either option.

I don’t fancy the recovery from c section with a toddler around too; but equally the thought of starting life with our new babies not exhausted from a long labour or difficult sleepless nights in hospital while being induced does sound fairly appealing...

Oh - yes the epidural bothered me too. I didn’t have one with DD. But again my hospital said if both are head down I shouldn’t need one but just have to accept a slightly increased chance of a crash section if they couldn’t site a spinal. However with one breech they would strongly recommend it due to more likelihood of needing internal or external manipulation (either turning or holdinfnbaby in place)

I wouldn't have minded an epidural itself. It was more to do with the increased risk of forceps. All things considered, if i was facing a c sec vs forceps id rather the c sec. You kind of know what you're getting, whereas with forceps etc anything could happen. The only real benefit of a vaginal birth i could find in my research was being pushed down the birth canal helps baby's lungs. To me that didn't outweigh getting them out safe and sound without risk of serious tears to myself or lasting injury to one or both babies from the forceps . And like you, i was very concerned about a long labour followed by an emcs. If i went through it again i would choose an elcs and fight for it, but its hard to get information to make an informed choice because elcs was kind of the elephant in the room even though i had good reason for my choice. Even online there's a lot of judgement about choosing elcs.

If twin 2 was head down i would have been happier about trying a vaginal birth but you can only react to the circumstances you've got and make the best decision for you and your babies, not the best decision for the medical staff.

If you have support at home in the form of a partner then I wouldn’t necessarily not gave a cs because of recovery. Most cs are on their feet within hours of birth, walking, showering, getting dressed. etc . You can still (and are existing ted to) lift your baby, dress it, change nappies etc. You will need help in the first 6-12 hours but you’d be on a maternity ward so will have mw or if your cs is early enough, your partner until 9pm or whatever their partners visiting time end is. I have had 3 cs and find that it’s mainly women who haven’t had them that talk most about the recovery as if you are bed bound and unable to move for days on end. You carry on as normal, a bit gingerly but no more so (if less) than a vaginal birth with tears/cuts. You are very well stitched up, they close layers underneath, it’s not the skin layer of stitches holding you together. Good luck with whatever you decide!

*expected to

I insisted on a scheduled section as I was suffering badly from tokophobia - they fought me really hard but I found studies showing that for DCDA twins, c sections have marginally better outcomes statistically than vaginal deliveries so it wasn't a safety issue. In the end I needed an emergency section and my twins were in nicu (17 days and 2 months) so I didn't have to try and look after babies with post op, but I can't imagine it's a whole lot easier with an episotomy or severe tear. FWIW the recovery was far easier than I anticipated.

Moghle - I recovered from cs3 with a 2yo and 4yo in tow. I honestly hardly felt it. I was moving around fine, it wasn’t painful, I just had to not lift anything heavy or attempt any housework but other then that I felt absolutely fine and I was fine I appreciate it’s not the same for everyone but I really didn’t feel it was any harder than a vaginal birth to deal with. In fact I was grateful that everything down below felt perfectly normal instead of “a bit different” as some of my friends have said after a vagunal birth. Everyone different though.

I was given morphine, codeine, paracetamol and ibuprofen after my EMCS and found that it was fine pain wise. I was up and moving within a few hours.

I'm already on morphine so I have a really high tolerance to it and can really struggle after surgery as they usually don't give me enough but they were brilliant after my section. I only had to ask any time I needed more and I was given it. I was home in less than 48 hours. Had the section at 8pm Friday night, the worst of the pain was in the hours afterwards but it comes on gradually as the spinal wears off unlike when you wake up from a general anaesthetic and its all at once, so they can give pain relief as you need it. The worst part was very early morning when they sent me to the ward and I had to use my arms to roll myself so they could check and clean me, that was painful. Next morning I walked to the loo, DH pushed me to nicu in a wheelchair for most of that day. Following day I was walking gingerly but okay, went home, managed the stairs etc fine. I've had loads of keyhole abdominal surgeries and I didn't find this any worse, in fact less painful than some of them.

My hospital allowed the woman to chose so I chose elcs. If I had to chose again now it’s all happened I would make the same choice. If that’s what you want try and convince the doctors.

Don’t worry about the recovery. I got post natal pre clampsia (not related to having a section) about 10 mins after the birth and was critical for 12 hours. I was still home after 3 days (perfectly capable of looking after twins and walking up and down stairs) and walked to the park 7 days after the section. It’s really not that bad as long as you take the ibuprofen and paracetamol.

Thank you for all the advice and experiences. I am leaning more towards an elcs. I'm not against having an epidural, I had one last time and it really helped me through the birth. I had a third degree tear and episiotomy last time and don't want to go through that again. It was a very long and slow recovery and it still feels tender as my pregnancy is progressing. The antenatal team (Consultant and Mw) are making me doubt my decision but in my heart of hearts I feel an elcs is the best option for me and our twins. I have the support at home to help out.

Section all the way.
I was showering 2 hours after.
Walking around slowly but fine same day.
Totally fine in a week.

If that's what you want op then make sure your wishes are clear. You might need to be pushy. The way i saw it, for me elcs would have been the surest route to babies being born with all of us safe and sound. In hindsight it certainly would have been. There's nothing wrong with wanting that, however it looks for you. That's sensible.

Yes, you may have to insist. Also, look up the tamba research that shows dcda twins have the best outcomes when born at 37 weeks - it was published in 2016 (when I was about 33 weeks!). That may help to take with you.

After a week I honestly forgot I'd had surgery. The worst part by far was the spinal but mine did not go well and you've already been through that so it should be fine. Section was Friday, home Sunday afternoon, and Tuesday night I made my husband walk to a cafe bar up the road for something to eat after we got back from the nicu as we had no food in - took me about five times as long but it was fine!

Ladies thank you so much for the information in this thread. I'm a ways off having to make this decision for my DCDA boys, but it's prepared me well for conversations with my consultant. Thanks 💋

OP - I know some pp didn't have the best spinal but all 3 of mine were absolutely fine and perfect. I know not everyone's experience of CS is all well and dandy but having had 3 (at different hospitals) it was a relatively easy process. If you have previously had tears etc from VB then if it was me that would strongly influence my decision to minimise risk of any further damage, both if you still have trouble from it and also if you fully recovered from it because a VB would put the same area under pressure again, surely.

For one of my CS I did have to have an "interview" where a VB was discussed but I think that was the policy at the time. It was fairly lengthy but I had a good set of physical reasons so there was no problem and it was agreed without issue. The interview was with some kind of admissions sister at the hospital but a CS had been noted as preferable by my consultant already due to medical history. I think it was to identify those who would like a VB but feel it's too scary/too painful etc and offer them support in that, rather than to block a CS for good and genuine reason IYSWIM.

I don't want to dismiss anyone who's struggled with a CS (I completely sympathise and I know there are posters out there who have) but speaking entirely from personal experience, the pain was akin to a tender bruise and I hardly noticed it. As a comparison, toothache was worse (stabbing intense continuous pain). CS was a low-level tender pain. On a scale of 1-10 my pain from the CS was probably 1.5 for all 3 CS's. That's just me though. Everyone is different. I was back on my feet within hours going about business as usual except more carefully. Just trying to explain that it isn't (or isn't always) the case that you are in agony, knocked off your feet, can't move or do anything normal etc. The dressing for the CS gets taken off the very next day so it can air heal. I was surprised at that, thought I'd be all bandaged and packed up for weeks! Nurse comes to take stitches out after 5 or so days. Didn't hurt. Surface incision was healed over already.

HTH and good luck with whatever you decide

Oh and if you (or other posters) do go for an ELCS I have a few helpful tips, not many but a few good ones .

Oooh tips please!!

Take those tena lady “nappy” pants. They cover your scar and I wore them for days after!

Press a pillow to the site of the wound if you need to move around, for as long as you need to. Take all the painkillers on time, don't wait for it to start hurting. You might feel like your innards are going to spill out but they won't. You need to move around because of blood clots, they're not just being mean in forcing you out of bed. But if you're really not up to going to fetch your own breakfast then don't!

Completely agree with Sparkly - recovery from an ELCS is nothing like as bad as people make out. I've had two.

Thank you for all the helpful tips and replies. I'm going to stick to my guns and have an elcs. I would like to hear any other tips for preparing for the cs and my recovery afterwards. I felt the staff were scaremongering at my last appointment and I began to doubt my decision. I have read up on the RCOG and NICE guidelines and I am aware of the risks. No one made me aware of the permanent damage I could and did suffer from a VB last time. I have started gathering stuff for my hospital bags this week and it's starting to feel very real. I got the large high waist pants and breast pads. How many maternity pads do I need and when is the best time to get measured for nursing bras?