Double Trouble

Delivering Twins


Every week we seem to deliver at least one set of twins at my hospital. A couple of weeks ago we had three. Two sets were delivered vaginally—scheduled inductions; one was delivered by scheduled cesarean section. Those twins are a lot of trouble. Throughout pregnancy there's twice as much to worry about. Are they growing properly? Is their growth relatively symmetrical? Is one twin huge and the other tiny? How's the placenta (or placentas) holding up? How about contractions? Carrying two babies annoys the heck out of the uterus. She gets all cranky about it, sending out flurries of preterm contractions that get everybody all worked up. Then of course, we worry about how Mama's putting up with things. She gets twice the aches and pains; her circulatory system has to work harder and she's just plain miserable carrying twice as many babies as every other mother.

We were totally excited about the vaginal twin deliveries. They're tricky and sometimes dangerous. A scheduled cesarean section is a whole lot easier and most practitioners prefer them to "vaginal twins." It's that second twin who causes all the trouble. Once the first twin is out, anything can happen. All of a sudden there's a whole lot more room in the uterus and baby number two might wiggle around, do gymnastics and cause all kinds of problems. Just to clarify terms, Twin A is the one that comes out first. We always deliver twins in the operating room with an anesthetist standing by. If Twin B gets into trouble, we go for Plan B—cesarean section —pronto.

Here's the hoped for scenario: Mom comes into the hospital at 38 weeks gestation for her twin induction. We're all wildly impressed that she's lasted this long and give her tons of praise for toughing it out. We know how uncomfortable single pregnancies are and stand in awe that anyone can stand up with two passengers on board. We get her labor going using all our standard induction techniques plus one: we ultrasound to make sure the babies are in a good position for a vaginal birth. That means Twin A is head down (vertex presentation) and Twin B is mighty close to head down. Labor progresses and as we get near the pushing stage, we move to the operating room. We have it all set up for twins with two sets of baby nurses, pediatricians, respiratory specialists (whoever it is we've pre-determined we'll need for delivery. The makeup of delivery teams varies depending on the twins individual needs and hospital standards), two bassinettes or radiant warmers, two sets of emergency equipment. Mom pushes Twin A out and while that little cutie is being stabilized, swaddled and handed to dad, her doctor's attention is totally focused on Twin B. The ultrasound might be used again to determine where that baby's head is going to land. Remember, all of a sudden there's a whole lot more room in there and Twin B might just go exploring. Hopefully, Twin B heads towards the light (the spotlights in the operating room) and plants his head at the cervix, just like he's supposed to. From there, it's only a matter time (sometimes hours) until he winds up with a vaginal delivery too.

But what if Twin B misbehaves? What if, instead of his head slipping through the cervix, his umbilical cord comes out first? Bad, bad news. If his head pushes down on the cord, he might compress his own blood flow and have, shall we say, a very, very tragic outcome. If that happens, we're on it. We're already in the operating room, all prepared for an emergency cesarean section. We'll get that kid out fast as lightening. In another scenario, what if Twin B gets confused and plants his butt on the cervix? A lot of the time, this results in a cesarean too. Breech deliveries are tricky because little arms can get in the way or even worse, we might get the shoulders delivered but then discover that the head is too big or is poorly aligned and can't get out. Then we run the risk of, shall we say, a very bad outcome. Lots of times, though, doctors can turn Twin B around and get him delivered vaginally. It requires patience, skill and nerves of steel.

So, last week's vaginal twins were celebrated. Both moms had previously delivered babies vaginally so we knew they could do it. Both sets of twins were positioned in the best possible ways for safe delivery, so we knew we could do it. And, we had, shall we say, very, very good outcomes.

And the cesarean twins? Well, mom was a first timer (she had an "unproven pelvis" meaning we didn't know for sure that she could get a baby through it). Twin A's head was somewhere near her hip and twin B was wrapped around her sister in some kind of wrestling hold. The chances of a vaginal delivery depended entirely on both babies turning to a good position and twin B letting go of Twin A. Not gonna happen. We could tell immediately after we'd delivered these girls, there was very little chance that twin B was going to put up with any kind of separation from her sister. After delivery, Twin B screamed like a banshee until we wrapped her up in a blanket with Twin A. As soon as they were skin-to-skin again, she wrapped herself around her in that same wrestling hold, snuggled in and went right to sleep. Sometimes a girl just needs her sister. We celebrated those twins too, grateful to have the safe option of delivering them by cesarean.

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