Epidural for Safety???

[RadTwins]

Has anyone been told by their OB that it's "safer" to have an epidural with twins?

I've heard two reasons for this so far:

#1 - If they have to turn the second twin, they'll be sticking their hand way up inside which is quite painful and an epidural will make it easier.

#2 - If they have to do an emergency c-section, especially for the second twin (in the case of a prolasped cord, etc.) there won't be time to put in an epidural if I don't already have one in, and in that case would have to give me general anesthesia. The OB said general anesthesia is harder on the baby and of course there's the aspiration probablem if I've eaten anything recently.

I really want a natural birth (no drugs), but am running into several roadblocks. Midwifes in Maryland won't deliver twins, and the OB's I've talked to all want to put me in the OR as soon as I'm ready to push, just in case. (I've read Ina May's books and she stresses the need for a good environment, which I don't envision an OR will be. Though one doc said at that point I really won't care.) Then of course, if the babies aren't in the right position, they'll just do a c-section outright.

The last doc said that in my situation, it's too risky for me to consider a completely natural birth. I'm 39, these are my first, and it took us three rounds of IVF to get here. He said this may be my one chance at having children and he thinks a natural birth is too much of a risk to take.

Any thoughts?

[Gena 22]

Yes, those are all common comments for OBs to make. Don't know exactly where you are, but I originally planned on birthing at Anne Arundel Medical Center. It's very lux and has a great NICU. But an 80% twin c/s rate.

Yes, the OBs have some arguments for an epidural. Buuuutttt, my big problem is that as a first time mom especially, it'll be important for you to move around and birth upright if desired. These are WAY more important than the OB reasons for an epidural, not to mention the way an epidural can slow and stall labor.

A couple links for you:

http://www.naturallyparentingtwins.com/drupal/node/139

My birth story. I was 31 at the time and my twins were spontaneous, but I don't think either of these things makes any difference:

A good study on twin gestation / delivery:

http://www.uptodate.com/home/content...=labordel/5122

PM for the name and contact info for my fantabulous midwife! You're out of her way, but she might agree to come.

Congrats on your twins! Stay positive and grow a thick skin. Twin pregnancy can be a roller coaster. You will hear all sorts of things, good and bad. But I remember it as a very joyful time.

[Intertwined]

that to Gena. I had my twins at home so I'm the wrong person to ask those specific questions to but I will say that I specifically chose home birth because of just those pressures.

Place of birth DID affect my labor and how I felt about them (I had my first two in hospital and my last four, including the twins, at home) so at least for me, your OB is incorrect. I knew that putting me in an OR gave them that much more chance to decide I need a c-section without just trying to resolve the issue first. I did not want to have an sort of version, internal or external. I was fine having a vaginal breech and in fact, my first baby came breech and it was fine.

There is ZERO chance I'd have been given the option of laboring, much less birthing, a vaginal footling breech baby in hospital. I'm very glad I gave birth at home but of course it's not the choice for everyone. There are for sure increased risks for a footling. I understood the risks, evaluated my particular situation, and chose to continue with my planned birth.

I think both personally and as a birth professional that laboring with an epidural in an OR will increase your fear factor by a lot. A VERY good doula and supportive care provider would be your best bet.

[mysticmomma]

lots of mw do twins in md.

[phathui5]

Have you started looking for a doula yet? There are listings at www.dona.org (to start). I would really recommend a doula to help you get the birth you're looking for.

Also, what midwives have you asked? (I'm from Baltimore).

[attached2mason]

Yes, I got this song and dance too. My OB seems genuinely concerned and, I suppose that makes sense if a person is coming from a perspective where you don't see any 'downsides' to an epidural. I, on the other hand, see far more risk attached to epidural than to what she is worried about. When pressed (after a few visits) she admitted that most cases allow enough time for a spinal block to be set before a csection. I indicated to her that in the event of a true emergency where a spinal could not be set I would happily accept the general. Seems crazy to take pain meds I don't want for the small chance that I will have to have a section that fast.

I do know that I am taking the risk of having a version/extraction without pain meds and I am okay with that. Can't imagine it will be fun , but it is worth it to me.

If you can't come to an understanding with your OB and you want to find a compromise you could consider having the epidural set and then not having it connected to meds until/unless necessary (version, section, whatever) - my OB is advocating for me to do this. That said, in the time it would take to get the epidural up and running for a section they could pretty easily have a spinal block set.

HTH.

[RadTwins]

Thanks for the replies. I guess I'm misinformed on the MW issue. I called both MW practices associated with Anne Arundel in Annapolis and they both said right away that they don't do twins. So I assumed none would. Not sure why I made that leap, but I did.

I have started to look into doulas, but need to work on that some more. I do think my situation might carry too much risk (for my comfort factor anyway) to do a homebirth, plus my husband would not be on board and I do want him to be comfortable with the whole thing. He's an engineer (into facts and statistics) and has been known to faint at the sight of blood (usually his own), so that's just not a route I've looked into. Which is why I wanted to try the midwife practices attached to the hospital. But no luck there.

I have an appointment this week with another OB in Annapolis who is supposed to be more low key, so maybe that will help. But I'm coming to the conclusion that maybe I just need to let this part of being a mom go and focus on what comes next, breastfeeding, babywearing, etc. I find it interesting that many men and OBs don't seem to care about the process of birth, just the outcome. "If you and the babies are healthy, why does it matter HOW you gave birth?" Just a different way of looking at it I guess.

I'm still going to work toward a natural birth in the hospital, but am preparing myself to accept a c-section if that happens. Since I'm not willing to go the home birth route, I think that's the best I can do--that and get a doula.

[Intertwined]

Get an experienced doula who's seen some natural twin births-in the hospital setting would be awesome! They are going to know who the OB to talk to is going to be as well as the best hospital to get your desired birth from. And remember that you are your own best advocate. It's OK to just say "No thanks, where's the refusal to consent form you'd like me to sign?"

And if you change your mind about the home birth, send me a PM. I'll be happy to talk to you both about how it went as well as how my husband went from 10000% against birth at home to a loud and sometimes obnoxious advocate for home birth.

[4Marmalade]

Originally Posted by RadTwins

But I'm coming to the conclusion that maybe I just need to let this part of being a mom go and focus on what comes next, breastfeeding, babywearing, etc.

I just wanted to comment on this. I think that this is an OK thing to do. It is the decision that I came to as well. I am so in awe of many moms here who have made those hard decisions and feel comfortable with their choice. I had originally hoped for a homebirth with a midwife with my third pregnancy until we found out there were two. Unfortunately, midwives here can't deliver twins so I was off to an OB and a hospital delivery. They gave the same reasons you got for the epidural. I questioned it for a bit but in the end did not feel like it was the make it or break it decision that it is for many. I can't say that I liked the epidural as if inhibited my pushing ds out and it didn't really alter the pain but it wasn't really an issue for me. In the end, I needed general anesthesia as the epidural was not strong enough for the emergency c-section necessary to deliver dd (who remained in a transverse position as I started to hemmorage).

I chose to embrace my very pro-bf OB and pediatrician and concentrate on taking care of my babies the best I could with all the AP skills I had learned over the last 7 years. Looking back I have no regrets. I still wonder with the "what if's" but there is nothing negative associated with it.

Good luck making your decisions. Research, research, research....

[Gena 22]

Originally Posted by 4Marmalade

Good luck making your decisions. Research, research, research....

Oh the memories are flooding back! I too contacted the Annapolis MWs and was really bummed about being turned down. Two years later I can be cooler about it, but for a while I was really angry that having twins meant having so few options. It's not evidence based, it's liability based. Yes, there can be problems for twin moms. But don't make problems where they don't exist (preterm inductions, routine interventions, etc.)

Having BTDT in very nearly the same region as you (I used to live in Annapolis and was a patient of Chesapeake Women's Care), here's my advice. Please take it for what it's worth - $0.02 on a good day!

I can totally understand the choice to birth in a hospital. Not the choice I made, but I understand. But in some ways it's a harder path. Now, how to go about it. If you're an intrepid soul, research, research and research some more. So your husband doesn't support a homebirth? OK, you're respecting his preference. But your preference is for a natural birth, and that is hard to come by for twin moms in our area. I would INSIST on going to the BEST twin OB in the area. IMO, Dr. Jean Tsabo in Arlington. Yes, it's a long drive for you, but you're a first time mom and likely to have some time before active labor. I've asked around a lot and not found an OB in Annapolis who is open to natural twin birth. Many, if not most of them, have NEVER SEEN ONE! They may not have even seen a vaginal twin birth. I could be wrong, there could be someone better and closer for you. But ask, ask, ask and be sure of their experience and creds. I was the 43rd twin mom for my homebirth MW. She had seen it all. Hopefully you can find a doc with somewhere near that much experience. From what I've heard, Dr. Tsabo is it. She respects natural birth and is a multiples specialist. YogaFeet birthed with her and is a fan.

If Arlington is too far for you, personally, I'd make a harder choice. Please don't flame me for this! Honestly, I'd pick a great surgeon in Annapolis and schedule a c/s. I gave this some thought at the time. For me, I didn't want the stress of fighting hospital and Dr.'s preferences. I didn't want to "try" for an induction I knew would be unsuccessful. It was too much stress for me. I'd pick my battles and find a Dr. that would agree to a c/s at not a moment before 40 weeks, or as soon as labor started. The timing would be my sticking point. Try not to get talked into the 38 week deadline, the evidence is shaky. See the link I posted earlier.

Finally, if you're a tougher mom than I am, get the best local doc you can and a great doula. Do your best for a natural hospital birth. It does happen, and may be worth fighting for.

These are hard choices, and I hope you don't get as hung up on them as I did. Think of all your options as good. You're picking what's right for your family. Birthing and pregnancy care are very important, but nothing's worth getting a pregnant momma stressed. Be calm, think it over.

But you're right, this is just one thing on your path to motherhood. You've got a long career in front of you!

[twinmama2010]

I had a very open minded OB who did not require an epidural, but our local hospitals wanted us to be in the OR. So- we traveled an hour away to be able to l and d in a suite. But- as far as having the epidural for safety- there is almost always time if it becomes necessary, even if cord prolapse becomes an issue or if there is a possibility that you may need internal versions. I have to tell you- I gave birth to twin a without any medication, and then twin b was frank breech and would not turn. My OB attemped 4 internal versions (reaching into my uterus to try and grab her feet and pull her out or turn her around to get her head down). And- it was painful, but after just pushing out a baby, it wasn't that bad. I was also on that ridiculously amazing natural birth high. The internal versions effected my healing- I was pretty swollen, but even if you need that you would have time to choose an epidural. We tried for 4 hours before my OB insisted on an epidural and the only reason he did was because it was going to be the last shot before a c-sec and after all of that time and attempts I was starting to hurt pretty bad.

I think the best you can do is find an OB that is relaxed and open minded and realize within yourself that you can't make decisions about how your birthing experience will go until you are in the moment, just have a very supportive team in place and a strong education and things will go as they need to.You have to have faith in yourself and know that you will be able to make the decisions when you are there. No matter what- you will definitely be amazing since you are already thinking about these things and like others have said- it has no impact on the type of mama you will be. I definitely compromised, but you heal and become a great mom no matter what. Good luck to you!

[klocke]

I know for me it is not merely a recommendation but a requirement by both my OB and the hospital that I'll be delivering at (assuming I even get the chance to go vaginal). I was seeing a home birth midwife until 20 weeks when I found out I am having twins. She did not feel comfortable continuing my care with twins. So I called around and only found one m/w in my area that would even attempt a home birth with twins and she wanted way more than we could afford for the birth. So I had to switch to an OB. After calling literally 20 Ob practices I finally found one that would consider a vaginal delivery. That is who I am with now. But the only way he'll allow it is if I get an epidural. The hospital is the same. Basically the hospital said if I don't like it I can deliver somewhere else. Since that isn't an option I am going to give in to the epidural. It may be a mute point anyway because Baby A refuses to turn head down and the hospital will only allow me try vaginal if Baby A is not breech. Personally in my situation of either an automatic c-section or having to have a epidural to have a vaginal birth I am going to choose the epi. any day.

[Kat's Mommy]

I thought I'd chime in because these are the two reasons my OB wanted me to have an epidural. Quite frankly, I was willing (and wanted) the epidural if it meant the safety of birthing the twins. My reason for wanting it was because I had a stillbirth in January 2009, and I was on eggshells for this entire pregnancy, and I did not/could not have "what if's" if something went wrong.

My twin A was head down. My twin B was breech. And, with u/s, it looked like twin B was bigger (she wasn't - they were the same size, 6lbs, 1oz).

From the moment I went into the hospital, I said I wanted the epidural. I gave them the story my OB gave me - I needed to deliver in the OR in case I needed an emergency C section, twin B was bigger and breech, etc.

The nurses delayed and delayed, until it was too late for an epidural.

In the end, I delivered twin A without drugs. They tried to turn twin B around, but it did not work. 11 minutes later (and I think they gave me some sort of mask with ?) the OB had to stick his hand up me and pull out twin B because the heart rate dropped to 60bpm. Thank goodness he did, there was a full,tight knot in the umbilical cord.

I had delivered so fast, that I also experienced post partum hemorraging and required a blood transfusion.

[tngirl11]

Originally Posted by Intertwined

Get an experienced doula who's seen some natural twin births-in the hospital setting would be awesome! They are going to know who the OB to talk to is going to be as well as the best hospital to get your desired birth from. And remember that you are your own best advocate. It's OK to just say "No thanks, where's the refusal to consent form you'd like me to sign?"

And if you change your mind about the home birth, send me a PM. I'll be happy to talk to you both about how it went as well as how my husband went from 10000% against birth at home to a loud and sometimes obnoxious advocate for home birth.

Absolutely find an experienced doula! I know my doula saved me from both a c-section and an epidural when I delivered my twins. When I arrived at the hospital, baby B was transverse, so they wanted to do a c-section. My doula was so good at calmly explaining to them that I wanted to avoid one unless it was absolutely necessary. Then they wanted to give me an epidural because they said it would be soooo painful when they turned baby B that I just wouldn't be able to handle it . But I said, "No thanks," and I honestly didn't feel any additional pain from the turning. I did have to deliver in the OR "just in case", flat on my back, which was definitely not ideal, but it still went well. So it's definitely possible, and a great doula makes it a lot more probable I think!

[RadTwins]

Thanks for all of this great advice and the links. I've now added some new sites to my favorites list to spend some time reading through.

It's great to hear what others have been up against and how each of you handled it. Definitely going to spend some time on the doula search this week.

Big hugs to all of you for chiming in!

[MawrtyrB]

I had switched to a midwife before I found out I was PG with twins. We made the decision to stay with her and use the natural friendly hospital if there were no complications going in. My understanding is that you are pretty much required to deliver in the OR with twins anywhere you go. I was insistant on a natural birth. We did a pitocin induction but otherwise did a natural pain-drug free delivery. I never made it to the OR because Twin A just shot out of me less than a minute after being examined and declared 8 cm.
Go with a doctor or midwife that you can trust.

[AmyC]

I went through some of the same processing when I was pregnant. I was in a situation in which I didn't meet with our OB until I was fairly far along, maybe around 18 or 19 weeks pregnant? Gearing up for that meeting, I did a lot of thinking & researching on the epidural issue, assuming that the "just in case" epidural would be recommended.

In the end, it was kind of anticlimactic, because I learned that the hospital where we had our babies doesn't even offer/give epidural anesthesia, and so they don't use epidurals for c-sections (planned or not.)

Still, when I acknowledged that there was a possibility of ending up with general anesthesia in a true emergency, the OB really minimized that possibility (to my surprise.) She basically said it was very unlikely that they wouldn't have time for a quick spinal placement, and that if I ended up with a c-section that's what I'd be having. (That particular OB was okay with a version but not a breech extraction, so perhaps she was thinking of a c-section for position, etc., rather than a crash emergency section.)

There have been threads on this subject before & after my babies were born (my twins are 20 months now) and I can think of "just in case" epidural as one search term that might work to pull up some of those.

For me, the big factor was the whole idea of having the epidural "in case," and whether that was a legitimate reason. (Reason enough to justify an initially undesired epi, I mean.)

I got some info on time from placement to surgery for epidurals and spinals, and spinals are faster. (General anesthesia being the shortest time.) If you have a previously-placed epidural, you still would have to wait for the increased dosage in order for it to be adequate for surgery. There are times when an epidural is in place but it won't prevent the use of general anesthesia in a true emergency, when there wasn't time to wait. (One response in this thread gave an example of needing general anesthesia in spite of having had an epidural.) If there's time to wait for the increased meds to take effect, isn't there time for a quick spinal prep?

The other factor is the oft-repeated "If I have to be reaching up in there" line.....everybody seems to say it (when they're recommending epidurals, at least. My doctor never mentioned this issue, though she planned to attempt a version if necessary.)

That is a true factor to consider, and one thing that can help is to consider all the responses of people who have experienced an internal version or a breech extraction. What was it like? Did they notice it? Was it tolerable? How would they contextualize it?

You can read a variety of responses to that one, and quickly see that experiences vary widely.

I ended up with the on-call OB and he was planning a breech extraction for the second twin (he didn't agree with attempting a version), and I got into position for this to happen. I don't recall anything, at this point. He reached in, I guess (that's what he said later), but I didn't feel anything. The baby was on his way to turning, was in a good position (I sort of wonder if he just turned himself and the OB didn't have to do anything, but the OB told me he saw it was happening and "reached up and turned him," so....), and whatever happened, happened. [ETA: It's not like I've blocked out everything at this point or something, and "don't recall anything." I just really don't remember anything particularly noticeable, physically. I was in position, then he sort of yelled, "We have a cephalic presentation!" and said I could labor in any position I wanted because the second baby was now head-down.]

I got back upright (twin A was born with me upright on the operating table in the O.R., holding onto a nurse's shoulder's on one side of the table and my husband's shoulders on the other side) so that I could labor & push with the second baby since he now was vertex.

I've heard some people say it wasn't fun but it wasn't overwhelmingly painful, etc. A lot of people can provide feedback on having someone "reaching around up there" and what that was like, and I think that's reasonable to consider when weighing the value of a "just in case" epidural.



To me, presenting a woman with "pre-placed epidural anesthesia or general anesthesia" as the two options for a possible c-section is disingenuous. Are those really the only two options---you are facing general anesthesia (as your only likely option) if you don't labor with an epidural in place? And you WON'T risk general anesthesia at all if you have that epidural in place???

Are the epidural meds going to be that strong so as to facilitate painless abdominal surgery all through labor? (Yeah, that's going to be effective pushing....) If not, then why is there not time for spinal anesthesia before a c-section? And if the need for c-section is urgent enough that there's no time for a quick spinal prep, then there's not time for the epidural meds to cover it, either, and in a true crash situation you will be looking at general anesthesia even if you have an epidural in place.

You could check with anesthesiology about what they use for c-sections, the timing involved, and go from there.

[Intertwined]

I love you Amy.

[Free Thinker]

I had an epidural, and a manual version for twin B (he was breech, turned sideways and stuck and arm out, OB stuck it back in and turned him). I'm glad I had the epidural. If twinB had come breech, my OB was okay w/ that, but when he turned, I was SOOOOO glad I did the epidural. I really do not think I could have done it otherwise, I probably would have had a c-sec for twin B. As it was, it wasn't painful, but it certainly wasn't comfortable, I try to block it out, it was pretty weird experience, not somthing I like to think about. I also delivered in the regular L&D room, but the OR was just across the hall and was left open for me (and my SIL was wheeled in to deliver her baby via c-sec as soon as I was delivered). I think I had a great OB and as far as my experience goes, I think what happened was about the best considering the circumstances. My OB really worked to give me the kind of labor I wanted (no c-sec unless absolutely necessary),and while I do wish it had gone better (no version, either breech birth or two vertex twins would have been great), I think in the end it was the best as could be expected. I was a 5 or so when tey started the epidural, I was a 9 right after it was done, I dont think I had it in much more than an hour, I was admitted to the hospital about 4, twin A was born before 7, twin B about 30 minutes later 7:07, so it didn;t slow my labor at all. This was my third pregnancy, though.

Oh, and I have had a baby w/o epidural before, too. I will agree that it was a better experience and it is what I would recommend in a normal situation. Twins, and especially twins in differnt positions is not a normal regular birth.

Good Luck!

[Kat's Mommy]

and one thing that can help is to consider all the responses of people who have experienced an internal version or a breech extraction. What was it like? Did they notice it? Was it tolerable? How would they contextualize it?

I never thought to explain what it was like. Good point!

Well, I didn't really notice the OB going "up there". Didn't feel a thing. I didn't even know he pulled her out. I think that's because I felt the pain of twin A coming out, so really...would I feel extra pain for twin B?

Hubby took a video, and I still watch it every day