Twin homebirth

[Blueindigo79]

Hi, new here with pregnancy #2 18 weeks with twins. I had a great unmedicated birth with DD in a hospital and was looking forward to using a birthing center this pregnancy until we risked out bc of the twins. I have had 2 prenatals with an obgyn but am not happy with the hospital policies and am thinking about homebirth. We are in Austin and met with one homebirth midwife who was not supportive at all and rubbed us the wrong way. Any advice or suggestions? Is homebirth with twins unsafe?

[labortrials]

Do you know if they're fraternal or identical?  I think 'my' kind of twins could have been handled at home, but MWs here aren't allowed to assist with twins.  My twins are fraternal girls - separate sacs & placentas.  I think twin B did suffer a bit of IUGR, but I carried to term and both were healthy, no NICU, etc.

If a twin HBAC had been an option for me, I'd have done it.  However, both babies flipped breech in the 3rd tri.  NO ONE around here does vagi breech, so it was a repeat c/s for me.

Good luck to ya!  I love being a mom of twins!!

[AlexisT]

I prefer to say that homebirth of twins is poorly studied. Until it is studied (and it probably won't be due to low numbers), no one can say for sure if it's safe or unsafe. There are practitioners with experience in twins, and many of them have good records, but an individual is not proof. I would say that, as with any situation, you need your midwife to be comfortable with it. It's not a bad thing for someone to recognize their own limitations--if they don't feel they have the experience or knowledge to deal with a situation, they're probably not the best person to deal with it.

The ideal situation for home birth of twins is the same as in hospital: Separate sacs and placentas, vertex position (or at least vertex baby A). Monochorionic twins (shared placenta) need to be monitored for TTTS. Monoamniotic twins (shared sac) are extremely high risk with a high fatality rate and should not be birthed vaginally. Luckily, they are very rare. (I am going to assume, though, that since you were with an OB, these possibilities have been ruled out.)

Ask about a midwife's experience with twin deliveries, what she'll do about a breech baby B, and what happens in the case of an emergency with baby B. Also, what happens if you develop complications--the rate is higher even with separate sacs. As many as 25% of twin pregnancies may be complicated by preeclampsia, for example.

[labortrials]

I'd like to add that you'll find positive HB stories about all sorts of types of twins regardless of shared placentas, sacs, presentations.  Many of them are UC stories because of course due to lack of experience, mainly (IMO), CPs are often unwilling or unable to attend vaginal twin births.  That doesn't make it right.  That doesn't justify a 75% cesarean rate for twins (reported for my state by March of Dimes).

I guess I was lucky.  I didn't feel "high risk" at any point (except the 1st trimester due to my pregnancy loss history).  I didn't develop any problems.  I was still out mowing the yard at 36 weeks pregnant.  I started swimming my butt off once Baby A flipped breech.  I carried my twins to term (and yes, 40 weeks is still considered term for twins, even by specialists).  Baby A kicked her way out quite vigorously and yet my uterus didn't explode.  The cesarean in my case was prudent due to presentation.

I'm not trying to make light of concerns that can and do arise with twin gestation; I just want to share how joyful and uncomplicated twin pregnancies can be.  Twin birth can also be joyful and uncomplicated.  I wish that for you BI79!!

[AlexisT]

The historic fatality rate for monoamniotic twins is 50%. Success stories are very rare for those. Again, these are rare, but I feel it's important to distinguish between twin pregnancies with a good prospect of being uncomplicated and those that are high risk from the outset. A 75% CS rate is too high, I agree.

I deliberately wrote "ideal" because I wanted to distinguish between the best case scenario and acceptable, but less desirable, ones. A frank breech singleton may also be delivered vaginally, but that doesn't mean vertex wouldn't be even better.

[Gena 22]

Wow, yeah to everything AlexisT and labortrials said.  Almost like I don't need to respond, they've made so many EXCELLENT points!

A couple comments: when you're looking at studies of twins, one thing that bugs me a little is that all twins are lumped together.  Of course this is unsurprising, since it would be hard to find a good sample size, but it would be nice to know the different risks for all sorts of things differentiated by di-di, mono-di and mono.  The mono-mono situation has been discussed above, but there is some suggestion that mono-di carries unknown risks as well, beyond TTTS.  From my reading, it doesn't seem like there is an consensus, but if that is the configuration of your twins it bears some thought.  If twins with known higher risks are included in studies, then they are overstating the risks to di-di twins. 

I had my di-di twins at home, and I'd like to tell you it was amazing.  It was amazing and wonderful, but I'm a touch humble about it.  I had one MW attend, and she left early for a vacation and I ended up birthing with her back-up.  This was very fortuitous, because my initial MW did not have the experience to resolve a minor positioning issue, and if she had stayed I would have ended up transferring for a c/s I didn't need.  To some extent I agree with Ina Mae Gaskin (my paraphrasing) that twin birth is just one birth followed quickly by another.  That seems generally true.  But with two babes involved, you need an experienced MW more than ever.  If your first MW rubbed you the wrong way, ask around and see if you can find someone else.  Or go on a birthing vacation to the Farm!

Here's a link to my current favorite twin pregnancy and birthing study:

http://www.uptodate.com/contents/delivery-of-twin-gestations

Best wishes!

PS - Sorry, I see that article isn't available free anymore!  As I remember it said that absent other considerations, going the full 40 weeks with twins results in better outcomes (lower NICU, less respiratory distress, etc.) and that vaginal delivery is a good option in cases where Baby A is vertex.  There are a couple good tidbits in there, but not sure if it's worth paying for.