Routine internal foetal monitoring of twin1 from early onset of labour in normal presentation of non-identical twins

[curiositykilled]

I really don't want this and cannot find any literature about what risks monitoring twin1 from early labour might reduce. My obstetrician is unwilling to discuss the topic with me and will only say "well, twin pregnancies are at higher risk of complications so it is hospital policy but we can't make you do anything you don't want"

I think this is a very unhelpful attitude as I believe movement during labour and certain delivery positions will help twin2 to be in an optimum position for delivery and RFM makes both of these impossible. I was wanting to know what risk would be reduced by monitoring the first all the way through labour and no-one providing the care is willing to have this discussion with me - if there was a benefit I would not obect to it and I feel unconfident in pushing to not have it without the obstetrician's explanation of the risk. I cannot find any research on the subject - only on normal presenting singleton delivery which says only effect is increased section rate, and there are no NICE guidelines on the subject. Also, having expected a homebirth before I knew it was twins I am reluctant to have any over-medicalisation of the birth.

I'll link this into our chat thread and see if some of the girls have helpful advice.

FWIW, I didn't have RFM. I did have heart monitors for each DT, and one for me, strapped about me (externally) for labour which was a lot of kit, but they weren't necessarily in my way. Personally, if there is nothing to suggest a problem then I would be like you, I'd rather not.

I'm not saying that twins births are not risky or don't change minute by minute but I do find some consultants panic at the thought of a twin birth and only know the 'on paper' on what they are meant to be watching for. I'd be inclined to discuss it with the team of midwives and take their experience.

If he's not willing to discuss........that speaks volumes. Could it be he doesn't really have a strong argument for????

When are you due?

The midwives will not discuss it either - have been to several normal appointments and spoken to the consultant midwife (2 hour appointment) and been told to discuss with the consultant.

I think if you are planning any birth all you can really do is plan for everything being normal, decide how you might feel about certain unexpected but likely situations that may crop up during labour and be ready to be flexible and unflappable. They are not instilling me with much confidence after poorly handling my care in pregnancy with my last child and being like this now.

I'm due 3/11 with a boy and a girl. I am healthy, have excellent hip space, easy pushing stages and two previous normal deliveries so stand a much better chance than most of everything being fine but consultant laughed when I said this and said "It's HUGELY unlikely everything will be fine, we'll more than likely induce you" which makes me believe the next argument will be over routine policy of inducing twins at 38 weeks... sigh I think it is more than likely he doesn't know about the monitoring and just does it because it is policy but it is hard to know if there is a real reason when he won't discuss it at all.

I'm giving serious thought to travelling twice the distance to go to a more experienced hospital which might allow me the midwifery unit as I'm put off consultants for life!

Think also we live in a town where most people want medicalised birth and so it is unlikely the hospital or the midwives have much experience of vaginal deliveries with twins. Lots of people have elective sections in our area so doubt anyone has enough experience to discuss it properly which is why I'm hitting a brick wall. Plus, I refused induction at 36 weeks with last pg and worry I might have got a reputation...

have you tried Mary Cronk?

It is your decision as to how much monitoring you want (unless a clear medical need) and you do not need to be induced. One of my clients went to 40 weeks and 5 days before spontaneous labour with twins.

Whereabouts in the country are you? If you could afford an Independent Midwife then you can still have a home birth if you want to.

What you need is an honest discussion with a Consultant so that you can decide the pros and cons.

I'm reasonably sure that there must be some yahoo groups where you could find some information. Sorry I can't help more.

Hi there, just to play devil's advocate - I really wanted a natural birth and to be able to move around as much as poss but after my waters breaking and no spontaneous labour, I was induced at 38+3 with my lovely DTs and had twin one RFM. The process of getting the monitor to stick to her head was horrible - she had lots of hair and it took a few go's , and she was left with a nasty scab on her head afterwards BUT I had them vaginally and was able to move about/stand up/sit on a birthing ball. In some ways, it was easier than trying to keep two heart montiors in position on your belly, and however distressing for me, DT1 seemed none the worse for it. That's not to say that some of the other interventions didn't cause probs afterwards, but that's another story, the birth itself was great. But I made sure they justified every step to me to my satisfaction - I think you are doing the right thing pushing them as far as you can to make yourself feel reassured. Good luck!

It depends on the consultant.
The worry is that you might be monitoring the same twin twice, and the other one might be deteriorating and you would know nothing about it. The "old school" believe in this. You may get a consultant that if you get clearly different traces on your two EFMs is happy with that.
However a lot of units don't deliver all that many sets of twins nowadays vaginally... so I think they like to play it safe. Hope you get a great outcome for you and your twins.

I didn't like how my first labour was handled. Took me 2 years to accept it and I was damn sure I wasn't going into my DTs birth the same way. I travelled out of town to a hospital I felt happier with. I had to drive myself there weekly, with my DD1, for the checkups and I didn't think twice about the 'risks' (i.e going into labour en route or being kept in after a routine checkup) because I felt well and I knew I was well. I did this until I was 2 days short of 41 weeks.

I'm only saying this because ultimately, its your choice and I feel if you are not happy with your care then you should move until you are. I always feel the same result can be given to you, but handled in a much different way.

I think it was Mars who said "if momma ain't happy, then nobody is happy".

You won't take risks, your babies are too important, but I would expect to hear this sort of chat with the consultant a month before.......how can he predict how things will look by Autumn? Let alone your due date.

Just for the record: my DTs were both vaginal births, one was breech, overdue, I had my waters broken but it all progressed totally normally (late epidural as DT2 was breech and c-section highly likely if he came down across the neck of the womb). I had a great, great labour with only two midwives for the first birth and three by the time DT2 was ready. Everyone else stood patiently and respectfully outside the room drinking tea and passing biscuits (I could hear them ). It was lovely. It can happen.

Hi Curiosity - your case (and hospital) sound like mine. Dd1 born naturally with no probs/intervention. Hospital known to have a high section rate. DTs (boy/girl) born 8 weeks ago at 35+6. Throughout straightforward pregnancy saw 6 registrars all of whom said it was too early to make a plan but that most likely if both babies head down they would still want to monitor continually.

Anyway, had them the week before we were going to "plan" the delivery. 2 1/4 hours from start to finish, completely natural and with no intervention - thought I might fancy an epidural this time but all too quick and didn't get any gas and air even. Was strapped up to external monitor but I guess it was all a bit quick for anything else (especially as I was told that the monitor wasn't picking up contractions so I wasn't having them when I kept pointing out that I was!). Never seen anyone move so quick when they finally decided to have a look and could see the head of twin 1). Babies both absolutely fine - twin 2 took a while to pop out - think he liked the extra space.

Guess a lot depends on their position - I know they can still turn at the last minute but mine were both head down for quite a while. Good luck with the rest of your pregnancy (especially in this heat) and getting the delivery that you are comfortable with.

Thanx to everyone for the support. It sounds like you are mostly agreeing with what we had thought ourselves about moving hospitals.

I'm reluctant to have any kind of monitoring before twin 1 is born unless they can justify it. Research I have read argues a good case for external monitoring of twin 2 beginning from after twin 1 is born and until delivery, if everything is normal with twin 1 and if twin 2 is a normal breech presentation or normal head down presentation. I want to discuss it with the consultant now because if they cannot justify their policy we will try to change our care to the MLU at Liverpool Womens - the people there are making promising noises about allowing this, as the MLU is just down the corridor from the delivery suite so an obstetrician/operating theatre would be on hand in any emergency.

All the obstetrician or midwife would say is that they would want some kind of monitoring all the way through labour with a preference for an internal monitor for twin 1 and that this meant they would not allow me to move around in labour or deliver in any position other than lying on the bed. They might concede to external monitoring every hour for 20 min periods but I cannot see the point of this as it would likely be difficult to get a good reading so it would defeat the point of doing it at all.

mars - I have read Mary Cronk which seems sensible but would not want to plan a homebirth with twins because all obstetric facilities are quite far away and so if intervention was necessary for twin2 it is likely the baby would have serious complications or die on the journey. Sure it is often a safe option and independent midwives do valuable work but I have an aunt with cerebral palsy and would not feel comfortable with the extra risk because I am a bit (probably overly) scared because of what happened with her birth.

Problem is mostly just that the consultants are refusing to have an honest discussion and will only tell me it is policy and I have a right to refuse. I think for this reason we should just write them off and try somewhere else.

Curiosity ki;;ed have you asked for a second opinion ie another consultant.
The multiple birth foundation are useful
tbh tts in labour is higher risk for id mcda not non id so I feel you have got a point.

Hi, I think you should change hospitals if the consultant is not giving you the support you need.

Both my consultant and midwife were fully supportive of my wishes for a natural birth and had no concerns. It sounds like your consultant is inexperienced in twin birth? They said they could use hand-held monitors to listen in on the HBs, cos I wanted to be able to move around. I didn't want internal monitoring. I did have the belts monitoring me in the end because I wanted to stay on the bed. I had non-id twins too and had a vaginal birth with forceps for the first but nothing for DT2.

Ask the consultant for the hospital's twins protocol but don;t be scared to ask for something different if you don't agree with it all.

Emma Mahoney's book Double Trouble: Twins and how to survive them has a good section about natural birth and gave me the confidence to go after the birth I wanted.

My email address is n i n a k i l l e n @ g o o gl e m ail.com - message me and I will send you my birth plan if you want!

My consultant and the hospital are very inexperienced in all kinds of 'high risk' vaginal deliverys as their policy is to section immediately for any complication. My sis is getting me the hospital's twin policy but I'm pretty sure they say to routinely monitor and to book in for induction at 38 weeks. I don't believe the hospital will help to facilitate things they don't agree with. My experience in the past with them proved the lengths they would go to to try and trick me into what they thought was best. The trouble is that I can't really cause too much trouble with them as my sis has just qualified as a doctor and starts her job in obstetrics in december - they know I am her sister and she also has a currently good relationship with my consultant that I wouldn't want to compromise. I have a lot of medical support and varying opinions from my family. I think we are just going to change. I don't believe our hospital would even know how to facilitate a natural delivery with twins and I'm not sure I want to put myself in the position of having to debate issues with them during labour.

No you'll be in no position to do that in labour! Switch hospitals, good luck!

Little update:

We have transferred care. We had a very good meeting with the Consultant Midwife for Normality (!) last week. What a different experience! He had printed the guidelines for twins to give to me to read and spoken to the consultant and all the midwives that work in MLU in preparation for our visit. The outcome was basically that the main issues I am concerned about, I feel, will all be much better considered there.

He asked sensible questions about what I'd want or insist on in difficult circumstances and told me what he and the MLU/Obstetricians would be comfortable with and we worked out a good plan together. So, I am going to have Consultant led care with an MLU assessment then delivery with provision made for a transfer to CLU in certain situations.

We have agreed that if I am asking them to work outside the guidelines I will take responsibility for the outcome of the delivery and that we will not ask any individual to work outside their comfort zone.

So, we will go in at the very beginning of labour, be assessed in MLU have 30 mins of intial external monitoring so the midwives can be confident of having got a good trace on both babies. If everything is normal and they are confident of having got good readings for each baby then I can stay in MLU and have intermittent monitoring. If at any point the midwives are not confident about the intermittent monitoring I will go back to the external electronic monitor until they have a good trace then if they are confident again we can revert to the intermittent monitoring. If the midwives feel better about the electronic monitoring because there is not a big difference between the traces e.t.c. then we will stay on the monitor but I will be able to move around as much as I like and will be able to deliver in whatever position I feel comfortable.

They agree that monitoring the second twin after the first is born is the main issue and also agree that moving around in labour and different delivery positions with the first can help to optimally position the second and lessen the need for stabilisation. They have said they will offer me induction at 38 weeks but will allow me to go to 40+ weeks if I choose. If I am induced I will labour in CLU from the start.

They have agreed to help a vaginal delivery of the second twin if it is presenting frank or complete breech and I will consent to section (if necessary) if it is presenting footling breech or will not move from transverse. They are training the midwives on breech delivery and a number have already stated they would be comfortable in this situation. The Obstetrician would wish to lead a vaginal breech birth so if the CLU is too busy for a registrar to come down to MLU I will be happy to transfer there for the second delivery.

They have agreed to allow me to deliver the second twin without intervention providing they are happy with the trace from the monitoring.

I do not want an epidural but will be happy to have a line in and fast during labour should the anaesthetist/obstetrician prefer.

After the twins are born, if everything is fine, I will be transferred to the high risk postnatal ward but will take responsibility for their feeding myself and do not wish to have their feeding monitored. If everything is fine and I feel I would rather be at home they agree to release me soon after the delivery.

I feel much more relaxed just being able to have open communication!

Hi curiosity your consultant midwife sounds fab what hospital does he work at I would love to direct expectant multiple parents to hip
galaxy twin antenatal teacher

Galaxy - He's at Liverpool Women's Hospital. He's lovely and seems very sensible in his suggestions - I just love that they have a post for a Consultant Midwife for Normality in the first place!

hey curiosity what a wonderful way to go into your labour - everyone is open and honest about what they expect and what they are happy with. Best of luck.
I had vaginal delivery of both twins - twin 2 was breech when i went in5to labour but my wonderful, experienced midwife helped her flip round and I pushed her out. I was so happy

jenny - I know I feel really lucky to have found them, and my doula whose idea it was in the first place!

curiosity I have been following your story now and am very pleased you have found peace about your plans, it must be such a relief.

Can I ask where you get your research from? I find it very difficult to get any meaningful information from the net as there are so many variables involved with twins and all the research I find seems to be for id twins.

Maybe I haven't looked hard enough - I haven't mentally started planning properly for the birth as I am primarily dealing with childcare issues first and will turn my mind to labour issues when I have passed 20 weeks or so. If I try to think of everything that I need to deal with at the same time I become totally overwhelmed!

Hi curiousity 3 votes for doulas and liverpool womens I hope you get the birth you deserve
e3 chick do you live near liverpool??
galaxy

e3 chick - I've looked generally at things that were available on the internet and have always read the BMJ often as it is always lying around at my parent's house. I check the NICE guidelines too. The NICE guidelines are not much help though as there's not much about twins.

Common sense and a bit of investigation into the source can normally uncover the reliability of anything you find on the internet. I work from the perspective that anything is worth a read because and if you think something sounds sensible or interesting then you set about finding out whether it is particularly reliable - this is often a decision rather than particularly clear cut.

Fortunately for me I can bounce ideas off my mum and sister and get them to look various official things up for me (they are both doctors). I have a doula who is good and has her own ideas too.

What things are you wondering about? If you ask your hospital for their guidelines on twins they should be able to print them out for you. That's a good place to start and in fact you might not need anything else. I think it should not be as complicated as I have made it sound, I had a very poor relationship with the hospital we transferred from which proved impossible to overcome.

Galaxy I am in London.

Curiosity, I suppose I wonder about different combinations of positions and planning accordingly, like you I don't want to be having any avoidable surprises on the day, so would like to have investigated as many of the options as possible. A woman once said that at my local hospital there is a time limit for the second twin's delivery so they break the waters of no. 2 in order to have it delivered in 10 minutes...that is something I would want to check out. Also information about monitoring and internal versions.

You are right about getting the hospital guidelines as that would be a starting point for discussions, if needed. I'll ask the consultant about that whenever I next see him.

just a quick one, to say stick to your guns. I had a fight to get what I wanted but it was so worth it.
Having a birth plan signed by the head of midwifery and the consultant was worth its weight in gold.
Dts are 5 weeks now. I had intermittent monitoring, no breaking of waters, and moved around freely.
I had a 3 hour labour and all went to the plan. My birth is on the birth announcements thread.
Really hope you get the birth you want.