Scheduled C-section with twins... help get the right start!

[*Devon*]

I am a postpartum doula and I have a client going in next week for a scheduled C-section with twins. This is my first client where she has both NO breastfeeding experience and I'm not working with another doula who is also an IBCLC, so I'm nervous about starting her off on the right foot! She definitely wants to bf but I don't think her family will be very supportive, so it's just me and her and I so want it to go well.

What tips can I offer her to make part of her birth plan? I know the first hour after birth is so important but I don't have a lot of faith in hospitals accommodating that, especially after a C. I imagine she should put them on ASAP, right?

What are some concerns to look out for? What will the hospital try to pull?  Any tips or suggestions would be appreciated! Thanks so much.

[CheriK]

This sounds like my experience.  I had an unscheduled Cesarean, but no labor beforehand.  Are they taking the babies early?  There is still a trend among OBs to call twins "term" at 37 weeks, and schedule (often) unnecessary Cesareans early.  Near-term babies have trouble breastfeeding, twins or singletons, so if they will be early she should be prepared for this.  No labor means no hormone stimulation for mom and babies, so sleepy babies are likely.  Mom's milk might come in late as well.  Good to be prepared, make sure she tracks how often each baby is nursing, teach her what active nursing looks and feels like.  No one helped me with this; my babies were 4 days old and more than 10% under birthweight before I learned that although they were spending a lot of time at the breast, they weren't actually moving milk.  Teaching her about breast compression to ensure babies are getting plenty of colostrum is a good idea, too.

I'd strongly recommend the book "Mothering Multiples" by Karen Gromada.  Lots of good info and ideas for moms of twins, including lots about preemie and near-term babies, dealing with separation, ways to increase supply.  Is there a local twins support group?  NOMOTC (Natl. Organization of Mothers of Twins Clubs) is a good place to look for a local group.  Be warned though that groups vary widely in their style of parenting & she may or may not find support for breastfeeding.  But it's so very helpful to have IRL support from someone who knows what she's trying to manage!

Is the hospital at all breastfeeding friendly?  Many hospitals now realize how important early skin-to-skin and breastfeeding is, and will keep baby on mom's chest after delivery while the doc is closing the surgical incision.  This is more challenging with two babies, but not impossible if she has help.  She can be insistent about having support in the OR and keeping the babies skin-to-skin as long as they are breathing well.  I was told "one" support person, but when I made it an issue, I ended up having my DH, my doula, and my CNM friend all there.  We joked about the "cast of thousands" - OB surgeon, backup surgeon (happened to be my family practice doc who wanted to be there for us), anesthesiologist, nurse to help each doc, nurse for each baby, respiratory therapist for each baby. . . crazy.  No one offered me the option of keeping the babies with me, and I didn't know enough to insist, so they were taken to the nursery despite having no issues after birth.  It took an hour for the nursing staff to return them to me after I was in recovery.  No reason at all why they needed to be separated from me.  They also did all the postpartum "stuff" to them (including unnnecessary eye ointment - for Cesarean babies!!), baths, etc, so she might want to put what "routine" procedures she will allow in her birth plan. Since it's a scheduled Cesarean, no reason not to schedule it when an IBCLC will be available to consult within 24 hours of birth, also good to have in her birth plan.  Again, she might have to make noise for this to happen (assuming that the hospital HAS an IBCLC on staff. . .).

If the babies have respiratory challenges, they will likely be taken to the nursery for some period of time.  If separation seems likely, making sure she starts pumping or hand-expressing colostrum ASAP.  She might have to be insistent about this and it might be hard while she's recovering from surgery.

Good luck to her.  She's lucky to have your support.  She already has taken that major step by hiring a doula, so it's clear she has some ideas about what will help.

[*Devon*]

WOW! Thank you so much, Cheri, that is EXACTLY what I'm looking for!! I so appreciate you taking the time to share your insights and experience! I love MDC :)

[Llyra]

I had a scheduled section with my twins, too, at just under 37 weeks. Our primary challenges were:
1. incredulity from the nursing staff, who couldn't understand a twin mama wanting to EBF, and were constantly nagging and pleading to be allowed to give bottles

2. a long separation after birth for one twin, because of breathing issues

3. small, less-mature babies, who were sleepy and jaundiced and had trouble staying awake to move milk properly

What helped me through was having plenty of information ahead of time about how to manage problems, and a powerful commitment to refusing bottles. So I brought a SNS with me, and a pile of clean, sterile medicine droppers in individual packages. Yeah, the hospitals have those, but there's nothing like whipping one out of your bag to make the staff realize you know what you're talking about and won't be bullied. And an appointment to have an OUTSIDE IBCLC visit me on the second day was a big plus, again because the hospital ones are sometimes in cahoots with the nursing staff. An outside opinion was a big help-- she was willing to stand up to the staff for me.

One other thing I didn't see mentioned was pain relief. Many mamas will refuse pain relief, or try and get along with minimal meds, in the belief that the meds aren't okay for baby. This is a mistake, I believe. Being in miserable pain isn't good for learning to breastfeed-- it makes positioning difficult, it leads to a stressed and tense mama, and it can cause the mama to limit the length of feedings. Encourage her to accept whatever pain relief she needs, to be comfortable, and encourage her to ask to switch meds if the med isn't working, or if it's causing her too much drowsiness.

[JFTB1177]

I didn't have twins, but after really wanting another VBAC for my 3rd pregnancy I ended up with an "last-minute" section before labor ever started after finding out my water had been broken for days and I was GBS+. So it was basically like a scheduled section since I didn't labor.

I learned from my first section (my first baby, which was a section after an awful failed induction) what I did and did not want! With my first section I was completely doped up and out of it (which I believe led to bonding and BFing issues- mainly my milk not coming in and giving up), I was really nauseous during the procedure, and I was separated from my baby for what seemed like forever. It was devastating.

This time I made is CRYSTAL CLEAR that I wanted to BF and wanted my baby latched on ASAP! I also told them to not give me any sedatives in my IV, and to give me anti-nausea medication (which helped a LOT!). Also, I stayed on top of my pain meds which I believe helped a ton- by the 2nd day I was taking 800mg Motrin and that was enough for me to feel comfortable. I had my son latched on as soon as they wheeled me into recovery and my milk came in 2-3 days later, and we have an amazing BFing relationship! Again, I know it's harder with twins, but I just wanted to share what I did differently that helped me!

GL to your client!!! :)

[*Devon*]

Thanks! I am loving all these responses and will definitely file them away!! Unfortunately I think commitment is going to be an issue. I am being as encouraging and positive as possible, but I kind of feel like she's already resigned herself to it not working :( I am holding onto hope though!!

It's actually funny, because she stresses so much about money... I would think she'd rather push for the thing that's FREE... 

I did tell her to try to stay positive and committed because while you can always give up after a while, you can't decide to start in two weeks, and I think that affected her. 

I'm learning so much new stuff! Yay!

[CheriK]

Hmm, if she stresses so much about money, maybe take her shopping for formula, pacifiers, sterilizers, bottles, nipples. . . and remind her that formula-fed babies are at significantly higher risk for common infections such as colds, ear infections, pneumonia, diarrheal illnesses. . .and all of those cost money in doctor's visits, medications, missed time from work.  What's the current estimate of the cost of formula for a year?  I remember it being something like $1200, and that's probably a few years outdated, only for the actual cost of formula, and only for ONE baby.  And that assumes baby can tolerate a formula off-the-shelf and doesn't need a prescription hypoallergenic formula.  Even if she ends up needing to rent a hospital-grade pump, hire a IBCLC out of pocket, and can only ever make enough milk for one baby, she's going to save well over a grand. 

It was HARD at first, and one big frustration I had was that no one told me how hard it could be.  Maybe folks didn't want to be discouraging, but I was't prepared for how intense and insane those first couple of months were.  It was devastating for me to have to supplement with formula.  I felt like I was failing my babies.  I wasn't expecting it to be so hard emotionally.  BUT. . . after working through our issues, pumping for weeks, struggling with an SNS, hiring an IBCLC, finger feeding and bottle feeding and supplementing, not sleeping (really, truly NOT sleeping. . . that's something else I wasn't prepared for), successfully breastfeeding my twins is one of, if not THE, thing I am most proud of about my parenting, and honestly, probably my proudest accomplishment in my whole life.  It definitely impacts the way I parent even today.

I would say that the one thing that would have made the biggest impact for us at the get-go would have been to have experienced help right away.  I really thought something was wrong with my babies behavior at the breast within 24 hours of birth; the nursing staff basically dismissed my concerns.  We were given lots of misinformation in the hospital from the nursing staff and, unfortunately, from our doctor at the time.  And my babies were born in what, at the time, was considered to be a progressive hospital in a community with an extremely high breastfeeding rate.  If I had simply followed their advice, and hadn't been somewhat prepared, strongly motivated, and educated enough to realize "this doesn't sound right, " we would have not be successful.  If we'd had help and accurate information immediately, I think we could have avoided the worst of the supply issues and shortened the time we spent struggling.  So definitely being there for her, helping her get experienced help right away, and being a voice of support are so important & definitely you appear prepared to do that.