How much intervention do you need?
Beth's sister is pregnant with twins and wants a vaginal birth. Beth says, "It seems like an uphill battle" because she has to labor in an operating room and have an epidural right from the start of labor. Beth wants to know if delivering twins is riskier than delivering a single baby, if twins are more fragile and if all this OR the epidural business is really necessary.
Kudos to your sister, Beth. I'm always glad to hear when a woman takes control of her own birth experience or at least as much control as she can, given the circumstances. The circumstances make all the difference. If mom is healthy, babies are near term, big enough (but not too big), positioned well and there are no other complications, then a vaginal birth is probably quite safe. If mom has health problems, the babies are premature, too small or large, in breech or transverse positions or there are other problems, then a vaginal birth might not be a safe risk and c-section might be the better choice.
Let's break the questions down:
Is a vaginal birth for twins riskier than a vaginal birth for a single baby? Not necessarily. It depends on the position of the babies. If both twins are in a vertex position (head down), then the risks are about the same as for single babies. There's a small amount of increased risk for prolapsed cord (where the umbilical cord slips through the cervix in front of the baby, potentially cutting off circulation), after delivery of Twin A (the one closest to the cervix), but it doesn't happen very often. When it does, it's c-section time.
If Twin A is vertex, but Twin B is not; a vaginal birth might still be a safe option. After Twin A is born, the doctor will either turn Twin B to a vertex position, deliver her breech or, if necessary, deliver her by C-section (that vaginal-plus-c-section scenario only happens in about 4% of twin births).
If Twin A is breech, however, there's very little chance she'll get her vaginal delivery. Some doctors and midwives will deliver single breech babies vaginally, but not twins. There are too many variables and things that might go wrong (they also might not and probably won't go wrong) and most won't take the chance.
Is a vaginal birth for twins riskier than a c-section? Not usually. In fact, studies in Ireland and France (both have better infant mortality statistics than the US) indicates vaginal birth can be safe and successful and a planned c-section is not necessary if babies are older than 34 weeks, in good positions and there are no other complications. A vaginal birth is usually less risky than a c-section (as long as everybody's healthy).
Why deliver in the OR? If Mom's in the OR and something goes wrong, they won't waste time getting her from her labor room to the operating room. They can start an emergency c-section immediately.
Why an epidural? So Mom can be quickly anesthetized for an emergency c-section.
Will spending her whole labor in the operating room make her birth safer? Not necessarily and it's not the standard of care in many hospitals. If something goes wrong during any labor, twins or not, the trip to the OR is usually very quick. Laboring in a birthing suite or labor room is way more comfortable than the OR for both parents. Mom can move to the OR when she's close to delivery (at push time) and have all the extra medical support and just-in-case c-section supplies she needs then.
And the epidural? We do crash c-sections all the time on women who don't have epidurals. We put in a spinal or if it's a really huge emergency and there's no time for that, we do general anesthesia. Since there's an increased risk that a c-section will be necessary (in case the umbilical cord gets in trouble or Twin B can't be delivered vaginally), it's very convenient if the epidural is already in place and ready for a c-section dose of anesthesia. If Beth's sister is committed to having an un-medicated, natural birth, one option might be to have the epidural tube placed, but no anesthesia injected into it during labor.
Is it an uphill climb? Maybe not, Beth. If your sister has found a doctor willing to give vaginal birth a try, she's pretty lucky. Far too many doctors flat out refuse to do vaginal deliveries for twins because they don't want to take any chances or they haven't been properly trained. A lot of doctors only learn in medical school how to deliver twins by c-section. So, give your sister's doc a high-five for being willing. If your sister's doctor is inflexible on her birthing options, the best plan is to talk it out until doc and sis better understand each other's perspective or, find another health care provider. Many midwives (who generally have a more relaxed attitude about vaginal births) are trained and skilled at delivering twins vaginally.
Of course, all bets are off if mom or babies have any significant health problems. The goal here is to deliver two safe babies to one safe mom. While a vaginal birth is safe in many twin pregnancies, it isn't the best option for all. Sure, France and Ireland do a little better than the US statistically, but we do pretty well too. Sometimes that's because we don't take very many risks, even if we are mighty quick to head to the operating room.
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