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Originally Posted by rachel65655  I think that the practice of immediate cord clamping after Twin A is born has a lot to do with the need to resuscitate Twin B's and them having a lack of oxygen.
The clamping of the cord signals to your body that it is finished with the placenta and it will start to detach. With Twin B still in there, I am sure that they are then being deprived of oxygen.
We are going to be delaying cord clamping for at least a few minutes. But we also know that both babies have separate sacs and placentas. In the case of identical twins, this wouldn't be safe obviously if the are sharing a placenta, but...
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Originally Posted by Novella
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Originally Posted by rachel65655
In the case of identical twins, this wouldn't be safe obviously if the are sharing a placenta, but...
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I'm not sure that one can say this is "obvious".
Dr. George Malcolm Morley, a proponent of delayed cord clamping has written about how delayed cord clamping is beneficial even in single placenta pregnancies. (I looked quickly for the link and couldn't find it, but have only a few minutes right now). |
I don't know what Dr. Morley has to say on the subject and when I was pregnant (monochorionic twins) I never got good answers about delaying or not delaying with Twin A's cord, but I was going to comment on Rachel's post, as well. Just to question whether the initial comment could INDEED apply to identical twins who share a single placenta. After all, if clamping the first twin's cord signals the placenta that it is "done" and can begin the process of detaching, and that is the only placenta, then it would seem that would increase the likelihood of complicating things for Twin B.
My babies were born thirty minutes apart. They shared a placenta. Late in those thirty minutes between babies, things got a little iffy with Baby B. I don't know if it was that they lost his heart tones (they did for a bit, at least) or if his heart rate was too low. But it suddenly went to a "must come out now" place.
I know they were mixing his heart rate up with mine (I remember them saying, "That's the mother's!"), or else they did have his but it was low enough that they
thought what they heard was mine. The anesthesiologist who had just been sitting there got up, took my wrist, watched his watch and then reported my pulse rate. I remember hearing the number and I'm not sure if it matched what they had on the doppler (which meant they didn't have a fetal tone) or if the too-low rate doppler tone was the baby's after all (didn't match mine but was too low to be good.) At that point, I got down off my knees (I was upright to push for both babies) and we used the vacuum to get the baby out. Out he flopped. His color was pretty bad and he seemed dazed (this is how my husband remembers it; I just remember that he looked purple or gray or something and he was very still.) They cut/clamped and they were pretty rushed/intense with whatever they did (suctioning, I imagine), but my husband saw him move and he did begin to make some noise. I remember my husband was quick to assure me that the baby was "fine" after he saw him moving, which basically meant "alive."
I really don't know what happened with him, whether his dark coloring was basically within the range of normal, whether he was stunned from his sudden removal, what had happened with his heart tone, etc. I had ended up with the on-call OB and I never really thought to talk to nurses who were there. I was seriously low-energy from the postpartum hemorrhaging (and had already known that a blood test just before that weekend indicated my hg was much lower than I'd have liked, and that if I hemorrhaged I would likely need a transfusion, which I did), I was mostly focused on nursing them, and I just wasn't "on my game" in terms of asking questions about that second birth.
I have always wondered if cutting the first baby's cord immediately had a negative impact on baby B, in one way or another.
The closest thing I've read to anything on the subject (and this was about acute TTTS and whether or not to clamp the first twin in a mono/di vaginal birth) was a comment that clamping the first cord sort of "freezes" the transfusion as it is. The implication was that it would be negative to do so, but I'm not certain why, exactly. I guess retaining flexibility in a low-grade/undetected transfusion situation could be desirable, but it seems that if it is low-grade, then "freezing" it and removing any chance of increase/decrease wouldn't exactly introduce a transfusion problem (if there was no detectable problem before.) I can see that if a detectable transfusion was going in a bad direction, it could be bad to sort of cement it there, but I am not sure if there's a lot of flux in those acute situations, anyway, so that it would be "better" to keep both lines open.
It doesn't make a lot of sense to me. I've never been clear on it, at all. But aside from acute TTTS issues, it seems that if clamping could compromise placenta function, then that would/could negatively affect the remaining twin who needs that placenta.
For what it's worth, there was no diagnosis of acute TTTS in our situation. Their hemoglobin was tested and the first twin was at the low end of the range of normal (for iron) and the second twin was quite high, but still in the normal range. Neither could be diagnosed as truly anemic or polycythemic. So.....no talk of TTTS at the time. The second twin obviously "got everything" after his twin's cord was clamped, and I don't know if the placental flow shifts from dividing the goods to flooding them all in the remaining direction at that point. I guess that could have been a factor in the second twin's distress.
But no evidence to support a diagnosis of acute TTTS. However, at six months, twin A was severely anemic (although it was a totally non-clinical case. He seemed "rosy enough" to our doctor and he was active and strong, enough so that she was convinced that the very low numbers were a lab mistake. Not so.) And twin B had iron levels in the normal/expected range.
The explanation we got for that was that it wasn't a recent development-- that twin A's iron had been depleted for a long time, probably as a result off an undetected or fast-developing acute TTTS situation during labor/birth that left him starting out with little or no iron stores. He had been coping/compensating for a long time and did not present with any obvious symptoms.
So in that scenario (of acute TTTS), twin B would have been the recipient, and it's true that the first twin's cord was clamped right away. (Theoretically locking in twin B to whatever inequality or overload existed at the time.) I guess something about that could have resulted in B's eventual distress, instead of the placenta getting a confusing message and starting to shut down. I don't know.
