Cord Prolapse Risk - How risky is it really w/ breech twins?

[proudmama4]

Preggo w/ twins here. Both are now breech. (2nd was vertex, and was hopping for Twin A to turn vertex, but instead twin B turned breech as well.)

My OB said he would like to see a scheduled c/s at 36 weeks and would really push for one at 37 weeks. My son had a pediatrician appt yesterday, and I talked to her. She said, as a pediatrician, she'd much rather see 37 week twins than 36...if everything is fine to keep them.

The reason the OB gave me for scheduling the c/s, instead of waiting until I go into labor, and then doing the c/s then is because of the risk of cord prolapse. He said for a singleton breech, it's not as risky, but for twins, because of 2 cords in there is more of a worry.

Anyone have any information on this? (Any links to "good" info.) He did say that if my water breaks, I need to get to hospital ASAP.

My OB is super natural friendly and supportive...IF TWIN A IS VERTEX. I can tell, when he saw Twin B had turned breech, he was disappointed for me. (or at least seemed to be.) He said "Well, that was the opposite of what I was hoping."

After talking w/ DH, we have decided to get checked at 36 wks. If I'm still not dilated or effaced (Thursday, I was "soft", but not effaced or dilated.), then we will wait for 37 wks. If I am dilated or effaced a lot, then consider the 36 wk c/s.

Thanks for any information you might have. I'm still praying for a natural birth. I really don't want the recover time of a c/s with twins and a 2.5 year old!

[aylaanne]

I personally wouldn't consider a scheduled c/s for twins until at least 38 weeks and preferably not until after 40 weeks. Twins need just as long to gestate as singletons do. I'll do some research on this if I get a chance this week. How many weeks are you now?

It's your body that he wants to cut open, and the burden of proof is on him. Ask your OB for the research that shows that cord prolapse is more likely with breech twins. The March of Dimes reports that 25% of preterm births are due to early induction/c-section (http://www.marchofdimes.com/professi...14332_1157.asp), so it's important that if you're going to take the babies out early, that it is really more dangerous for you and the babies to stay pregnant than it is to give birth.

[honeybee]

I'm not sure about the research on twin breeches and cord prolapse... but given this information is true, I still don't understand how waiting until you go into labor would be a much greater risk. Do you have a history of very fast births? Are you a great distance from the hospital? I don't believe you can have a chord prolapse until after your water breaks... so if you just wait for active contractions, and go in at that time, I don't see the problem. I guess there would be a risk of your water breaking at the start of labor... but even that wouldn't automatically mean there would be a prolapse right away.

If your water did break, perhaps there is some plan of action to help prevent chord prolapse. One plan of action would be to lay face down on the back seat of the car on the way to the hospital, with your torso flat and your butt high in the air, thus working against gravity. Midwives are trained in using these types of positioning to help get clients to a hospital in the event of an actual prolapse.. so it makes sense to me it would help prevent one. But I am not an expert by any means... these are just research avenues that I would pursue in your situation.

Every decision is a risk assessment. How does the chance of chord prolapse during labor before you can get to a hospital for a c/s compare to the risk of removing the babies too early? There probably isn't any way to get hard numbers on that, and in the end only you can decide which is the lesser risk.

Best wishes, and I hope your babies turn again soon! Have you tried seeing a chiropractor knowledgable in Webster? Is an external version possible with twins? Have you checked out spinningbabies.com? You're probably already pursuing all these methods, but I just thought I'd mention them just in case.

[proudmama4]

Yes, I saw a chiropractor certified in Webster for the last 2 months 1-2x/week. This week, I decided to stop that. I am continuing to do inversion and walking around on my hands an knees as much as possible. The problem, is I'm also needing to lie down a lot, because I get pretty tired, and my feet are starting to swell a little. I try to lie down on my left side as much as possible, since twin A is on my right. I figured lying on my left, would give my right side more room for him to turn.

[Gena 22]

There are two issues here: when to schedule a c/s if necessary, and what the risk of cords is.

My pediatrician was also the only medico that wished me a full 40 weeks with my twins. Pedis really know what a difference a week or two can make. Unless there's a medical reason for taking your twins early, resist. Here's a study to that effect:

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

And cord problems should not be too much of an issue if your twins are di-di.

Give your twins a few more weeks to get into a good position, and good luck!

[turnquia]

So you have one twin that is lower correct and one up high or are both right side by side?

If you have one way lower and blocking the exit so to speak the risk of prolapse is't as high. Cuz really its one baby and cord that can reach the exit at a time. Unless they are both like sitting on a hip... but if they are di/di then BOTH sacs of water have to break in order to have a cord prolapse Which I would think would be odd for both at same time to go.

My providers are not any more concerned about a prolapse cord with twin A breech, its more concern over what happens when twin A comes out and twin B has a lot of free space to drop and do whatever. That's when I was told was the highest risk of prolapse.

ETA: My friend had twin VBAC a few weeks ago... baby A switched to Vertex WHILE in labor

And I absolutely wouldn't schedule twins at 36 weeks. I would wait until 38 weeks. Full Term. Unless there is some other medical reason to do a CS early is seems highly inappropriate to intentionally deliver preterm babies who could have potential problems.

[proudmama4]

One baby's butt is over the cervix (although they're moving around a lot still), there is some cord next to the butt. Overall the babies are side-by-side. They are very close to each other.

I get another appointment and ultrasound Thursday.

My doula, who is also a homebirth midwife, said that there is an increase risk w/ breech babies because the butt, or feet, or whatever doesn't plug up the hole, like a head does. But she said she can't find any research supporting scheduled delivery before 38 weeks.

[mambera]

Originally Posted by aylaanne

Twins need just as long to gestate as singletons do.

Interestingly, the uptodate link posted by Gena 22 indicates that this isn't true.


- A retrospective study comparing PNM among 89,000 infants born of multifetal pregnancies to PNM in six million singleton infants reported that PNM in twin gestations reached a nadir at 37 to 38 weeks of gestation and then increased, while the lowest PNM in singleton pregnancies was at 39 weeks [5].
- Data from the United States National Center for Health Statistics, including over 11 million singleton and almost 300,000 twin births, showed that the lowest PNM for singletons was at 39 to 41 weeks (approximately 1 fetal and 1 neonatal death per 1000 deliveries), but for twins lowest PNM was at 37 to 39 weeks (3 to 4 fetal and 2 neonatal deaths per 1000 deliveries) [7]. Moreover, as of 39 weeks gestation, the prospective risk of fetal death in an ongoing twin pregnancy exceeded the risk of neonatal death...

There are few studies evaluating the upper gestational age limit for allowing a twin pregnancy to remain undelivered. One such series included over 60,000 twin pairs delivered at 37 or more weeks of gestation [19]. The odds of neonatal death (unrelated to congenital anomalies) significantly increased at ≥40 weeks compared with 37 weeks of gestation (OR 4.24, 95% CI 2.65-7.00).


Interesting that the pedis are still pushing to go to 40 weeks. I wonder whether there are any studies looking at postnatal morbidity (which is presumably what the pedis are seeing) vs perinatal mortality, which is what the OBs are seeing.

[RedOakMomma]

Originally Posted by proudmama4

Preggo w/ twins here. Both are now breech. (2nd was vertex, and was hopping for Twin A to turn vertex, but instead twin B turned breech as well.)

I had twins 8 years ago, and went to 40 weeks. Babies were big--7 and 8 pounds, and even then in the last two weeks, baby B flipped twice. He went from breech to vertex back to breech. I could hardly believe he found the room to flip, and truly--it was like an alien movie watching my belly.

All of that is to say, I wouldn't go in early for a c-section unless the NSTs showed problems. There is still time for baby A to turn.

(We did a vertex/breech birth, btw, and our ob was great about it...Baby A took 3 hours to push out, then he helped deliver Baby B by breech extraction.)

Best of luck to you!

[aylaanne]

Originally Posted by mambera

Interestingly, the uptodate link posted by Gena 22 indicates that this isn't true.

...

Interesting that the pedis are still pushing to go to 40 weeks. I wonder whether there are any studies looking at postnatal morbidity (which is presumably what the pedis are seeing) vs perinatal mortality, which is what the OBs are seeing.

That is interesting. Thanks for pointing it out.

[turnquia]

Some current studies are saying full term for twins is 38 weeks and that going to 40 weeks is like 42 weeks with a singleton. That said.. its 38 weeks! Not 36. It seems very irresponsible to deliver prematurely. Because even at 36 weeks with twins, there could be issues of lung maturity etc.

Unless there is some medical reason with myself or babies I would NO WAY deliver before 37-38 weeks. We all know that with teeny babies a week or two can make a HUGE difference in how well they do and if they require NICU or nursery time.

As long as our babies are complete or frank breech or vertex I will be delivering vaginally, provided no other issues going on. And my doc has already agreed... that no scheduled section... it will be waiting for labor since things can change.

[Gena 22]

This is a tricky thing. I believe, as it seems pedi do too, that twins need just as long gestation times as singletons. Mortality and development are not the same thing. Yes, PNM may be higher sooner for twins, but that doesn't mean they are more developed. There are studies that show twins need all 40 weeks to get over preterm risks like low birth weight and respiratory issues.

The PNM issue is a tough one, and one every momma has to evaluate on her own. Those large studies which show an earlier PNM rate lump all twins together - mono-di, moms with preclampsia, etc. Those will change the results. We need this broken down, so each mother can make an informed choice based on her situation.

If the OP is like me, and goes full term with ABSOLUTELY NO complications for mother and baby, when is the optimal gestation time? Do all twins need to be induced? I honestly don't know the answer to this. And I wouldn't want a twin mom to take on an unecessary risk. I choose to avoid a known problem (preterm birth) to risk an unknown one (possibly higher PNM). It was an informed choice, but made from cobbling together studies here and there. There isn't a good study. As I read it, the link I posted comes to the same conclusion - that otherwise uncomplicated twin pregnancies should go to 40 weeks.

[proudmama4]

I am anxious to talk to the doctor more tomorrow. Mondays are the start of my weeks, and I've had appointments on Thursdays...So I think I will talk to him about going for 37.5 weeks.

DH IS the father...and he is saying, "You picked this doctor because he's the most natural friendly one you could find...so maybe we should listen to him." DH is a little torn, because he HATES the idea of them going to the NICU, but he also wants to listen to the doctor. I think if I can get some reassurance from the doctor that even if my water does break, that we have time to get to the hospital before anything crazy happens. So, if we have a plan in place, that will make DH more comfortable. This ISN'T all about me...I DO want my husband to have a voice as well. (And I know that there are some women who respectfully disagree with that, and that is OK.)

Needless to say...I'm living on my hands and knees today! I have an u/s tomorrow! lol. I so pray for Twin A to flip, so we don't have to "deal" with this!

Thank you ladies for the great links (especially the uptodate one) and your thoughts.

[turnquia]

Originally Posted by proudmama4

I am anxious to talk to the doctor more tomorrow. Mondays are the start of my weeks, and I've had appointments on Thursdays...So I think I will talk to him about going for 37.5 weeks.

DH IS the father...and he is saying, "You picked this doctor because he's the most natural friendly one you could find...so maybe we should listen to him." DH is a little torn, because he HATES the idea of them going to the NICU, but he also wants to listen to the doctor. I think if I can get some reassurance from the doctor that even if my water does break, that we have time to get to the hospital before anything crazy happens. So, if we have a plan in place, that will make DH more comfortable. This ISN'T all about me...I DO want my husband to have a voice as well. (And I know that there are some women who respectfully disagree with that, and that is OK.)

Needless to say...I'm living on my hands and knees today! I have an u/s tomorrow! lol. I so pray for Twin A to flip, so we don't have to "deal" with this!

Thank you ladies for the great links (especially the uptodate one) and your thoughts.

Well I think this is where a 2nd opinion from another practice comes in handy. I say from a different practice because your doc can influence those in their practice. Also, just ask docs when they prefer to section twins... include the section is ONLY for a breech and not any other reasoning.

I also think the 2nd opinion from a perinatal is nice because they see truely HIGH risk women. High risk... so they will have more insight on PNM vs Prematurity. The perinatal may tend up being more laid back... since really there is't a valid reason to do a csec SO early.

I agree with Gena with the whole risk vs prematurity. For me I'm ok with delivery at 38 weeks if I"m sure of dates, etc. I think i've heard twins tend to do well with lung development. I think that's why so many can be born early with minimal if any issues. Think about it most twins come by 38 weeks on their own. And IF i was to do a CS that early I would ONLY do one IF I had an amnio done for fetal lung maturity.

We personally are doing steroid shots early and two sets due to other issues just in case... so lol i'm thinking at 38 weeks our lungs will be fine

[proudmama4]

Well, it's weird. Yesterday...they were still breech. So I asked the doctor when he was thinking of a c/s. He said 37 weeks. He didn't even mention 36. I was happy about that. I asked him what the real risk of cord prolapse was, and he said it was very small. He didn't seem concerned about it in the least this week?????? My cervix was still doing nothing. Yay! So if next week it's still doing nothing, I'm hoping I might be able to push him 1 more week to go 38 weeks.

I also had an u/s. It estimated the boy a full pound smaller than the girl. The boy is twin A. So I hope the size of the head (if he does flip) isn't a reason for no vaginal deliver. (I've heard if 2nd twin is a lot bigger, they will still want a c/s.) They've been within 10 % the whole time, though, so it's weird. I gotta think it's just wrong estimating. The u/s tech also said twin A had less fluid in his sac than twin B. I guess the girl is getting greedy! I have di-di twins. So I hope the size discrepency isn't placenta aging or anything for the boy, and reason to deliver early. I'm thinking it gives us a really good reason to wait longer, especially with "wimpy white male syndrome." Waiting to get a response about this from my doula/midwife.

I started doing the breech tilt from spinningbabies.com instead of inversion yesterday. I was able to do it for 20 minutes at lunch, but could only do it for 15 minutes last night. Too much rushing to my head. I find Spinningbabies.com to be a little confusing as far as what to do. After I'm done breech tilt, should I crawl around? stand up and walk around? Anyone know?

[SalmonBayDoula]

If you are going to have a planned cesarean, for whatever reason, why not ask for an amnio to determine lung maturation. and certainly, if the babies' lungs aren't showing as mature, waiting some more time? Good luck in finding the path that feels right to you!

Sharon