Hospital/doctor twin birth policies and protocol

[annettemarie]

Forgive me if this is a stupid question. If I wanted to know what policies or protocols I might be facing giving birth to twins, would I want to ask my doctor, the hospital, or both? Might they differ? Does one override the other? Could I just call up the maternity ward and ask to speak to someone? And what would a good list of questions be?

I'm becoming increasingly anxious because a friend who is a labor nurse said that the hospital where she works, about 1/2 hour a way, doesn't allow a vaginal delivery to be attempted unless both babies are head down, and she's never seen that happen. I understand that the hospitals around here tend to be rather conservative-- we have a c-section rate of over 40%, there are no NICUs in the read, etc-- but I'm really feeling like the deck is stacked against me.

[Gena 22]

Sorry to be negative, but yup, the deck is stacked against you. Your L&D friend is your best source. Your doctor will tell you that yes, you can try for a vaginal birth, but when push comes to, well, push, there'll be every thing in the book riding against it.

Epidural required.
Pushing in the OR.
More monitoring required.

My hospital had an 80% twin c/s. Since I had an "unproven pelvis" I knew there was no way I could hope to be in the 20%. In a conversation about me, my SIL's OB said she'd be really happy to have a vaginal twin birth, because she had never seen one. Don't know how long she had practiced, but she wasn't a greenhorn.

Any sort of natural hospital twin birth is really, really tough. You'll have to KNOW that your doc is supportive. I'd have him sign a birth plan that you could wave in the faces of all the nurses who try to derail you.

There are lots of good twin hospital birth stories. It can be done. But you'll need a spectacular and unusual OB, a strong will, fast and cooperative babes, and plenty of luck.

As you might guess, I opted for parallel care right up to the end, and then, knowing everything was good, I stayed home with a fantastic midwife. As her 43rd twin homebirth. Who was more experienced, and who was I safer with? My HB midwife or my SIL's "willing" OB? No question.

If you're anywhere near south central PA I'd be happy to PM you her name.

And sorry to be so hard, I'm still mad about the choice I had (in my opinion, none) and the treatment of the OBs. Hopefully you'll have a better time.

Best wishes!

[annettemarie]

I'm actually up about an hour and a half from State College. A homebirth is out, for multiple reasons. My friend isn't at our hospital, she's at one the next town over.

[cileag]

Yep, I am a L and D nurse and we have just about the same policies---vertex/vertex or vertex/breech with a multip, but for a first time mom, they usually won't "allow" a mom to deliver vaginally. And because of the "risk" of a c/s, they urge you to have an epidural and labor in the LDR rooms, but yep, push and deliver in the OR with C/S people on hand. My favorite twin delivery was a precipitous one where the mom showed up at 10 cm and pushed her babies out in 10 minutes--she didn't even get an IV.

[annettemarie]

That's what I'm hoping for. Well, I'm definitely "proven," LOL! I've had 4 vaginal births, 2 completely natural. I am just wondering where to get the best scoop on what these policies are-- the doc or the hospital.

[Llyra]

I'm not in PA, I'm in NJ. But the way I managed to get straight answers on the hospitals' protocols was by two routes-- one was taking the hospital-sponsored childbirth preparation class and asking some very direct questions of the nurse doing the class, who is usually an L&D nurse. The second actually was by asking our chosen pediatricians. The OB has a vested interest in telling you what you want to hear, because they want to keep you as a patient so they get paid. The peds spend a lot of time on the ward and know exactly what's happening, but they have no vested interest in telling you anything but the unvarnished truth.

[hotmamacita]

I had some fears about the closest hospital once so I asked for a meeting with the Chief of Obstetrics & Gynecology. (I was pregnant with a singleton at the time and planning a homebirth. This was 18 months prior to my multiple pregnancy.) I was able to get the appointment. We spoke in his office about what standard procedure was if I were to transfer there. We talked about protocols, immediately after birth, for the baby and me. We spoke about his thoughts on homebirth and vaginal, unmedicated birth. He and I were at opposite ends of the spectrum but we had a very respectful and communicative meeting. I understood where he would not budge on protocol and he understood my heart and reasons to homebirth. In the event that I transferred, I wanted to be treated with respect. He heard that and agreed to...for the most part.

It was a very helpful meeting for me. I sent him a thank you note. I did not transfer, btw.

AM-- trust your instincts, mama! If you are in the headspace to do so, I might ask for a consult with the Chief to learn about their protocols and to discern his views and his level of respect for patients. I might also talk with your Doctor as well.

A friend of mine had to have her singleton in a hospital. She talked with her doctor and the staff there about privacy, low lighting, personal items in the room, letting her walk around during labour, etc. She really built a working friendship, during her pregnancy, with the doctors and staff and her hospital birth was calm and beautiful!

I am sooooooooo excited for you AM! You are on a wonderful journey.

[Gena 22]

Originally Posted by Llyra

I managed to get straight answers on the hospitals' protocols was by two routes-- one was taking the hospital-sponsored childbirth preparation class and asking some very direct questions of the nurse doing the class, who is usually an L&D nurse. The second actually was by asking our chosen pediatricians. The OB has a vested interest in telling you what you want to hear, because they want to keep you as a patient so they get paid. The peds spend a lot of time on the ward and know exactly what's happening, but they have no vested interest in telling you anything but the unvarnished truth.

Great answer. I got a lot of honest answers from my hospital sponsored childbirth class too, and the pediatrician is also a great idea. My pedi was the only doc that wished me a full 40 weeks gestating. I love him, but didn't think to talk to him about birthing policies. I'd guess it would be really hard to get answers from your OB. It was impossible from mine.

4 births already! You're a pro! Hope you can come to a good understanding with your birth team, and that yours is a precipitous but smooth birth.

Best wishes.

[turnquia]

Annette. I would ask both the doc and the hospital. Ultimately your doc does have final say, because lol fibbing can be done. Like my doc will do a breech for a singleton lol but tell mom in advance to tell nurses no checks period. And will say he had no idea baby was breech. He told me recently...

" I completed my residency in the 80... back when everything came out of a vagina"

But I would check policy on both. My hospital doesn't have any requirements on OR or epi required... but its encouraged. That said just 3 weeks ago my OB caught a set of twins Vertex/Breech without and epi in the L&D room. OR was prepped and waiting on hand just in case.

This is partly why we will be doing a homebirth once we hit 36 weeks. Because I really do not want to fight the nurses or residents. Its me and my OB who make the decisions. He is even on board with the homebirth if that's what I feel is best. No negative comments even given

He also said if they are both breech and I'm not comfortable with the homebirth to show up pushing. They won't have a choice on how to deliver them

[RedOakMomma]

I had a hospital birth (unmedicated/natural) with my first babies...identical twins...and it went great!

I think the best person to ask is your OB, but it's also helpful to see if your hospital has any tours or classes geared toward twins. We had a whole twin labor and birth class (which was mostly but was illuminating in terms of hospital policies).

My twins were vertex/breech. I knew from the beginning that my OB would deliver breech babies. It's one of the reasons we chose him. We did a lot, early on, to get with an OB who had a non-interventionist mindset and who felt comfortable in high-risk twin births (our boys had heart conditions). He's an older guy, too, and had no qualms about delivering the second baby breech.

A big help was having this OB on my/our side. He was very known and respected at the hospital (loved, really), and he approved our birth plan, so if anything came up that the labor nurses questioned I had them call him. For example, I wanted to be able to eat and drink normally, and I also wanted the chance to drink, rather than get an IV, if my fluids were in question. Both choices were reinforced by my OB, and the nurses didn't argue. When it came time to push, I actually pushed with ds1 for over three hours. Normally that's "against" hospital policy, but my OB and I had agreed that extended pushing would be okay as long as I was making progress over time and the babies weren't stressed.

The only thing I didn't like about having our twins in the hospital was that I had to give birth in the operating room (think bright and shiny metal, though they did bring in a more comfortable laboring bed for me). I also needed to have an anesthesiologist on-hand, though I'm not sure if that was because of the twins or because of the heart conditions. In the end, the operating room birth was not a big deal...in those three hours of pushing (I think only two were in the OR), I was so in the zone that I hardly opened my eyes, much less took in the atmosphere.

I should say, too, that everyone was respectful. The anesthesiologist introduced himself in the delivery room, said something like "I know you said you don't want any pain meds in your birth plans, but I'm going to stand by during the pushing stage in case I'm needed." He was warm and encouraging, and I never noticed his presence again. Even the NICU teams standing by stayed toward the back of the room, and kept mostly quiet. It didn't feel like a room crowded with people.

With ds2, who was breech, we had chosen to have him by breech extraction (where the OB reaches up into your uterus, finds his feet, and gently guides/pulls the baby out). This was 8 years ago, and I honestly can't remember why we chose this, but I think it had to do with getting him out more quickly...ds2 had the more noticeable heart tumor. The breech extraction was uncomfortable, and ds2 got stuck briefly, but this is where it really paid to have an experienced OB...he knew what to do, and ds2 ws born healthy.

Both boys were looked over in bassinets by the NICU staff right after birth (though I was able to sit up, touch, and see both of them before they were taken to the bassinette). In a short amount of time, they were given back to me, and I got to roll out of the OR with two babies in my arms.

At our hospital, rooming-in is encouraged...even with twins. We did have to deal with a little bit of "really? you're not going to supplement?" from one of the nurses and one of the pediatric doctors, but it was fine. I think if I had been a more experienced mom those things wouldn't have phased me. I roomed-in the entire time, breastfed and slept on demand, and it all worked out well by the time we went home.

...and if you do deliver both without meds, get ready to be a labor/delivery floor rockstar. The whole two days we were there (three if you include labor), the nurses would whisper/peek in/introduce themselves with "wow! Unmedicated full-term twin birth! That's amazing!" I felt a little like a freak, but in a good way.

Does that help? If you have any questions, let me know... the hospital birth of our twins was really one of the most beautiful, most empowering, most hopeful experiences of my life. I wish all the same for you!

[RedOakMomma]

If it helps (hope this isn't over-kill ), this was our birth plan:

Birth Plan for -----(my name)------ (Twins)

Mother-to-be: me
Father-to-be and Support Person: dh
Practitioner: Dr. James ----
Due Date: Between Feb. 2 and Feb. 10

We have prepared this Birth Plan to help you understand our philosophy and the kind of care we hope to have for the birth of our children. We wish for as natural a birth as possible, avoiding all unnecessary procedures and medications. However, if medications or procedures become necessary, we ask that you discuss them with us in advance so we can participate in the decision-making. Thank you!

First Stage (Labor):

•Dim Lights and Quiet
•Would prefer to have a minimum of people in the room (no students/observers)
•NO IV, but Heparin Lock is OK. (If for any reason an IV must be connected, I do not want any medications administered through the IV without permission from my husband or me.)
•Maintain mobility (walking, rocking, up to the bathroom, etc.)
•Eat and drink to comfort (fruit juices, tea, toast, etc.)
•Please do not offer me pain medications. I will ask for them if I want them.
•NO augmentation with pitocin.

Induction:
•I would prefer to use natural methods to start labor.
•I would like for my labor to proceed at its own pace, and would therefore like to avoid measures such as rupture of membranes, stripping of membranes, and/or pitocin unless a specific medical need arises.

Augmentation:
•If necessary, I would prefer walking, nipple stimulation, and rocking to speed labor.


Second Stage (Birth):
•Would prefer to have no students or observers in the room.
•Prolonged length of labor (longer than 3 hours) allowed if progress is being made and babies are not stressed
•Spontaneous bearing down rather than directed pushing
•NO Episiotomy:
•I would prefer to tear than have an episiotomy, but please use compresses, massage, perineal support, and positioning.
•In the case of severe fetal distress, an episiotomy may be necessary. I would like to be informed of the episiotomy before it is performed.

In the case of a Cesarean Birth:
•I would prefer an epidural rather than general anesthetic
•Partner present and able to take photographs
•Free one of my hands to touch the baby
•Partner to cut the cord
•Breast feeding in recovery room

Baby Care:
•Baby to be set immediately on Mother's chest/abdomen after birth (observed/checked in parents' arms)
•Would prefer to have Father discover and announce the baby's sex.
•Father cuts the cord
•Delay the eye medication for 1 hour
•Delay all routine examinations of babies for 1 hour post-birth to allow for bonding
•Breast Feeding Only, no pacifiers or glucose water
•Mother or Father with babies at ALL times
•No Hepatitis B vaccine; no vaccines without permission from Mother and Father.

Sick Baby:
•Breast feeding as soon as possible. Mother's expressed milk to be used until then.
•Handling of the baby (Kangaroo care, holding, care of, etc.)

[_ktg_]

A very good friend of mine is who is an OB/GYN (just finished her residency too!) delivers twins vaginally. She's done 2 sets already and 4 more lined up. I've heard baby b can flip once baby a has been delivered because hey there like more room!

OTOH - another friend just had her twins delivered via c/s, but I'm going to chalk it up to her living in L.A. vs a positioning problem.

I'm crossing my fingers for you to have a wonderful birthing experience!

[MegBoz]

Originally Posted by annettemarie

If I wanted to know what policies or protocols I might be facing giving birth to twins, would I want to ask my doctor, the hospital, or both? Might they differ? Does one override the other?

I'm pretty sure a doc can override hospital policy. As Gena 22 wrote, you may want to have the doc sign-off on a birth plan to wave in the faces of the nurses. (Good practice for any hospy birth, actually.)

I think a L&D nurse is a great source for what typical hospital policy is. When I was going to a practice of OBs who would delivery at Johns Hopkins (a place I switched out of - AVOID for NCB!) The nurse at the office had been an L&D nurse for like 20 years & recently switched to office work, so I talked to her.

Maybe LCs might be another good source for "unvarnished truth" (good term!)? I asked them for their recs on pedis & they gave me some input. i just called the "warm line" for the hospital.

Originally Posted by turnquia

" I completed my residency in the 80... back when everything came out of a vagina"

Awesome! Good for him!!!

Best of luck to you!!

[annettemarie]

Thanks so much for posting the birth plan, RedOakMomma. That's on my 42-questions-and-growing list of things I wanted to research, LOL!

I feel a little better today. My youngest had his well child check today, and I was talking with our family doc, who used to deliver babies but doesn't anymore. She said that they will do vaginal births here for twins, they've even done breech birth. She said she knows for a fact the docs in my practice and my favorite midwife have done vaginal births. She doesn't think they both need to be head down. She thinks the biggest "rule" might be that I would have to have a ped there in the delivery room, and that she can't do it because she isn't certified in neonatal resuscitation, but that the peds on call are all really good and committed to doing whatever is possible to keep mamas and babies together. She also said that our hospital now has a Level I nursery and can keep babies after 34 weeks, which I actually did not know. It's not on the website.

She also said that most twins around here are delivered by c-section, but that's usually by the mother's choice, and she seemed to think they would find it refreshing to have a mom who wanted to delivery twins vaginally. Who knows, it could be educational for a resident, LOL!

I do have an in with one of the LCs, so I might call her as well, and I'm going to talk to the docs and midwives once I start seeing them. I'll be 12 weeks on Monday and so far I've only had the intake/health history interview with the nurse. Part of my anxiety is just not knowing, and hearing all the horror stories.

[AlexisT]

OBs can override many hospital policies, but not all. If they go too far over the line, or do it too often, their privileges can be revoked. If your style of practice makes enemies of your colleagues, or causes you to be viewed as a liability (because not practicing according to a commonly accepted standard is very damaging in a malpractice case), you may find yourself without a hospital to deliver in.

[butterflies]

I think you'll need to ask the doctors but also chat with the nurses and hospital staff. I got tons of useful info from the ultrasound techs too. I've found that in my area, it really depends on the relationship of the individual doctors, their practice and the hospital. In many cases I'd hear that one particular doctor was comfortable and experienced with vaginal breech twins but his colleagues in the same group were not so much. It would have been a roll of the dice, depending on who was on call when I showed up at the hospital.

I eventually went with a perinatology group that's hospital-affiliated. The head of the practice told me that all 4 of their doctors are very experienced with breech deliveries. They are completely comfortable with A vertex and B breech. (I've now unofficially heard that they sometimes allow breech/breech to deliver vaginally if the mom has previously given birth.) So far I'm impressed with their responsiveness and general approach.

[turnquia]

I was going to say docs can override SOME hospital policies. However a doc MUST write that in your admitting orders.

So if hospital policy says twins must have continuous fetal monitoring. In your admit orders he or she MUST write intermittent fetal monitoring , continuous fetal monitoring ONLY in the presance of unreassuring signs. Or something like that.

I'm a nurse at a hospital, I do not work on L&D but in a cardiac unit. its the same way. If a doc does't specify they want vital signs done every so many hours they are automatically done routine, which is every 8 hours, unless one of us nurses deems that patient needs them done more often.

It works the same way in L&D usually. When you go in a standard set of orders are used and doc doesn't really have to do anything except tell the nurse sign my name here. However any exceptions or special things must be written out. So if you go in with a signed birth plan and the nurse tries to say its require you can tell her she needs to call your doc back and discuss it with him to change the orders. Nurses aren't as evil as some thing we just have to do what we are told as long as its within reason. (LOL that being said I thought MY L&D nurses were evil haha)

But just ask everyone annette and get in touch with your local mom's of multiples group they will have some insight too.