24wks w/Twin - How to effectively argue with OB

[PartTimeCrunchy]

I just transferred to an OB at 21wks from my midwife when I got the Twin news. OB is "friendly" to natural, unmedicated childbirth - as is the hospital. There are midwives that deliver there, that work under her, so she is the best OB I could find. She still likes to scare me every time I go in. *sigh*

She wants me in every 4wks for an ultrasound, my midwife predicted this and suggested negotiating for every 6wks. So I had a Level II ultrasound 1wk before I met the OB, then she said it was incomplete and wanted a second. I agreed. So 2wks later I had another Level II and an appointment with her right after. The Dr at the second Level II said that it looked like Baby B *may* have club feet, but it's most likely just his position currently. This is our second scare after finding cysts on Baby A's brain that are normal and gone now. So now I'm rolling my eyes at the ultrasound people.

So when I made it to my OB's office 30min later she said that she wanted another ultrasound in 4wks. I said "maybe we can go 6wks since everything is good". Her response was "Oh, did they not tell you???" I said "oh the possible, but not likely club feet?" I think she expected me to freak out about it. I mean, really. It isn't a for sure thing, and even if it is, we can't do anything about it until AFTER they are born. So no, I'm not going to spend the rest of my pregnancy freaked out. I refuse. So when I told her this, and asked about the 6wks she then said it was really about TTTS. So she changed her reasoning for wanting the ultrasound. *grrr* After informing her that I knew that normally happened to mono-mono twins, she said that my baby's placentas *could* fuse and *could* end up with TTTS. I've heard the chances of this are so small (anyone know exactly how small?).

I get that there are a million risks out there, but if they are really that freaked out, couldn't they just have us on bedrest in the hospital for all 40wks???

I feel like everytime I see her, she is doing her best to scare me into a c-section at 37wks - so SHE feels better.

Anyone dealt with this? She has agreed to Hep lock instead of IV, knows I plan to move around, has refused food during labor (will sneak in protein bars), agreed to delayed cutting of placenta, agreed to internal version to move Baby B down IF his heartrate drops, and as long as he is good - has agreed to up to 2hrs between babies. So I know that compared to other OBs, she is great, but I want more. Is it worth fighting it out now, and what is a good way to argue and not get kicked out of her service? Is it better just to refuse stuff at the end and sign a waver for things like intermittent monitoring? I haven't asked about this one, but I'm pretty sure I know the answer! ;)

Thanks for reading my long post, and help is greatly appreciated. I'm just not used to having to fight for MY birth. My singleton - midwife and I were on the same page!

[phathui5]

I wouldn't tell her that you are going to do things that you know you won't agree to, but it might not be worth having a huge discussion over each item. 

With the ultrasounds, I would decide for myself how often I want them done and then go with it. If they're getting worried about things that can't be addressed until after the birth and they can't explain the benefit to looking now, refusing additional ultrasounds is perfectly reasonable.

For the birth, do you have a doula? Even though you didn't mention it, I wanted to make the suggestion. I've been a doula for two twin births and it can really help to have someone to advocate for you in the hospital.

[PartTimeCrunchy]

I have a doula, who is fabulous. Thinking about bringing on a second.

Thanks for all the advice!!! Wish my doula had 2 twin births under her belt like you!!!
 

[SympatheticDad]

The fact of the matter is, the moment you have been determined to have a twin pregnancy - especially a monozygotic pregnancy - your pregnancy is no longer "low risk".  Telling you that is not trying to "scare you" but is a cold and accurate description of the facts.  As the mother in a twin pregnancy, you have a fourfold risk of preeclampsia (source).  Intra-uterine growth restriction affects 5 - 10% of all pregnancies (source), but is twice as common in twin pregnancies as in singletons (source) and cannot be predicted just by evaluating risk factors (source).  Babies under IUGR have significantly increased morbidity and mortality rates (not providing a source for this, but finding one is trivial).  This is why your OB wants you to have ultrasounds at a 4-week interval; no one ultrasound will actually be determinative, but at each ultrasound, they will measure the craniums, torsos, and crown-to-rump dimensions of your babies and note the data.  From that data, your OB can make a graph.  At some point, if they see the cranial growth in particular flatten out, that is a clear sign of IUGR and I would expect them to recommend that the babies be delivered at that point.  The difficulty in having an ultrasound every 6 weeks rather than 4 is that over a given period, you and the doctor will have fewer data points on which to base your decision.  In other words, the multiple ultrasounds are in fact part of the standard of care (source).  Frankly, every 4 weeks is pretty generous.  My full-blown TTTS twins were having sonograms twice a week once they got past 24 weeks so we could determine the optimal time to deliver them.  They're 8 years old now, and the sound waves don't seem to have harmed them at all; but, it's no exaggeration to say that they are only alive now because of the very active role taken by our MFM specialist.

You are free to decline whatever medical care you want.  But I urge you to figure out a way to work with an OB.  If the problem is that you don't have a good relationship with this OB, then find another one (or a maternal-fetal medicine specialist) that you can have a good relationship with.  If the problem is that you can't have a good relationship with any OB, then I urge you to engage in some self-reflection and recognize that, statistically, you are beyond the bounds of what any doula or non-CNM midwife is prepared to deal with.  It's entirely possible that your pregnancy will go swimmingly and you'll have no problems whatsoever; no one, including an OB, can predict the future.  What your OB is trying to do is to manage the risk of your pregnancy in advance of any crisis to try to maximize your babies' chance of survival.  Twins force a lot of compromises on parents.  I would suggest that recognizing that the risk profile of your pregnancy might mean that the smart decision is to compromise on your birth experience in order to maximize the chance of a positive outcome for your babies is the first one you are facing.

Good luck.

[maos211]

TTTS does not just happen on mono mono twins. My identical twins were completely five and at 19 weeks had a acute TTTS and I had to have emergency surgery in my utero. One of my daughters died after birth. If you have identical twins go to your ultrasounds. TTTS is nasty and comes unannounced. Feel free to private message me if you want more info.

[~Adorkable~]

i believe she made it clear that she had Di/Di twins. and folks can help her look it us, but frankly i have never heard of the fear of fused placentas having TTTS, many folks dont even know they are fused till birth (mine were super fused and not discovered despite many ultrasounds, they didn't look closely at that because it was not that big of a deal.  so i think everyone needs to calm down on the talk that is starting to sound like fear mongering. she is being sean by a OB and has good questions, lets just address those ok.

[~Adorkable~]

Part time crunchy, welcome to Mothering.Com! please dont let folks scare you away, there are many helpful ladies here for you learn from. (and dads too!)

in general i found there was very good ways to negotiate with your medical team, the first of which is to think of it as a negotiation rather than an argument. I'm sure you just used that word, but we mean the same thing.  i make  point to know my choices and know which i preferred and which ones i as lest comfortable with. i also took some time to understand what my priorites were and what i would give on in order to get those things.

i then regularly asked for them to prove what they wanted to do what based on good science and not lawyers fears or convenience.  they are YOUR team and YOUR babies, it is on them to show you why you should do something, not your job to prove why not.  know your science, your reasons and your limits and then be as flexible within those as you can. some things can seem like really huge deal at first and after a while seem like a detail that wont really matter, be open to changing your mind on something that you thought was a sticking point if you learn more info.

for me i was fine with ultrasounds, it was a small thing that made he medical team feel way better and helped them relax about other things. they can feel how you are , can see into your body and it freaks them out, so if we let them take a look they feel like they have more control and loosen the reigns a bit, i would consider not making that your sticking point if you feel like you can.

[SympatheticDad]

Originally Posted by PartTimeCrunchy 

 After informing her that I knew that normally happened to mono-mono twins, she said that my baby's placentas *could* fuse and *could* end up with TTTS.

Just noticed this.  TTTS also affects monochorionic, diamniotic ("mono-di") twins as well as "mono-mono" twins.  Not relevant to the original poster, I hope, but I wanted to make sure someone said that for the sake of future mothers looking for information.