Our hospital's policy is 20 mins based on their twin guidelines. I am working with the hospital to produce a general care plan which works outside the guidelines. They have been very, very good. I would recommend speaking to the consultant midwife, getting a copy of the hospital's twin guidelines and seeing if you can produce a plan which you are all comfortable with that works outside it.
We transferred our care to a bigger hospital with a specialist twin clinic and a consultant midwife for normalcy - it is worth checking if your hospital has one of these if you are wanting to discuss the necessity of the various planned interventions.
My hospital's guidelines recommend routine monitoring from early labour (twin1 on internal scalp electrode), epidural anaesthetic and intervention to reduce the time between delivery of twin1 and twin2 and intervention (aided delivery, turning baby, section) for breech/transverse presenting twin2 if baby won't turn.
When I have been planning my birth these are the things I have considered and found out:
The routine monitoring is based on multiple gestation being 'higher risk'. There is no research on the effect of routine monitoring during twin labour (hospital's own twin guidelines even confirm this). It could be advantageous or disadvantageous, they don't know. They want the internal monitor for twin1 so they can be sure of getting a good trace for both twins.
Routine monitoring in normal singleton labour has been shown only to increase the chance of emergency section so they have stopped doing it as standard in normal singleton delivery. Obstetrically if twin1 is presenting normally (head down, no maternal problems, spontaneous labour) then twin1's labour should be treated as a normal singleton.
There is a need to monitor twin2 carefully after twin1 has been born because of the risk of placental abruption, moving into a bad position, having to go through the strong contractions of birth twice.
The main reasons for wanting mothers to have epidural anaesthetic is to make it easier to give interventions such as aided delivery of twin2 and section.
Epidural anaesthetic has been linked to increased chance of emergency section, tearing, prolonged labour, increased chances of operative vaginal delivery. I believe that a refusal of epidural, an active labour and the ability to give birth in various positions will enable optimum positioning of twin2 for birth and enable me to have an increased chance of a natural, vaginal delivery with twin1 and especially with twin2.
The main reasons for intervening to reduce the time between deliveries of twins is that prolonged delivery time between twins seems to be associated with problems with the second twin which might affect it's postnatal outcomes and seems to be unrelated to the mother's physiology.
This means they worry about prolonged intervals because they seem to be more often indicative of a problem rather than problem causing in themselves. For this reason I would rather attempt a natural delivery of twin2 before any intervention is given as I would rather it was only given if necessary.
There are different impacts of different types of malpositioning. Persisting transverse lie of one or both twins are good reasons to section, as is footling breech because there is a bigger risk of trapping the cord during vaginal delivery and starving the baby of oxygen.
If twin1 persistently presents in any type of breech or transverse then section is appropriate. If twin2 is persistently footling or transverse after twin 1 is born then the doctor can reach in to turn the baby and pull it out or an emergency section can be done.
It can be appropriate to attempt vaginal delivery of twin2 if it is persistently presenting frank or complete breech as the cervix will have already stretched for twin1 and there is less risk of trapping the cord. This should be supervised by a doctor and with midwives experience in breech delivery.
My hospital has an MLU down the corridor from the CLU. My pregnancy has been straightforward, no problems gynaecologically or in conceiving, my twins are fraternal, on separate sides, both consistently head down since 26 weeks, this is my third pregnancy. I have long labours but easy deliveries, with my first I had an MLU labour but transferred to hospital for oxytocin drip to speed up labour (after 50 hours) but a normal delivery with no intervention and pethidine and TENS pain relief.
With my second I had an uncomplicated homebirth (12 hour labour) with TENS pain relief. I have a hypothyroid which is under control. Basically, I have a near perfect obstetric history. This has enabled the hospital to be very comfortable with my wish for natural delivery without interventions or obstetricians. What things you should prepare for and concede to having should depend on your own personal history and circumstances and so it is necessary to discuss what you would like, ask what the hospital would be comfortable with and why.
The best thing is to find a hospital that you feel is supportive and sensible in their outlook to you as an individual, to think about what you would like, what is sensible and to listen to what the people who will be delivering you are comfortable with and why. Sometimes, if you can explain why you feel a certain way people will become more comfortable with your suggestions, having someone be your advocate can be very helpful.
I am having consultant led care with a midwife led unit delivery. They are going to monitor externally on admission in order to assess me and the babies then revert to intermittent monitoring. They will allow me to be active and to deliver in any position even at the expense of the monitoring if I feel it necessary. I am not having an epidural or any intervention to speed delivery of twin2 (unless necessary). I want monitoring of twin2 after twin1 is born. I will agree to fasting and a line if they feel it necessary. If I choose to deliver twin1 lying down I want a midwife to stabilise twin2. If I need a doctor and one is unavailable I agree to transfer to CLU. They will allow breech delivery of twin2 because the midwives in the MLU are comfortable but want a doctor to supervise it. I am also refusing to let them monitor my feeding on the postnatal ward as I have already breastfed two babies for 10 months and feel if I need advice I would rather ask for it.
Ahh, long post... I feel strongly about being able to get a natural delivery with only sensible interventions as and when they are necessary. I hope the post is of use, I am 32+5 so will let everybody know what things I was allowed and how my birth went in relation to the plan for those behind me.