Inducing Multiples ~38 weeks?

[LemonPie]

My SIL is due with twins in January. Apparently her OB is willing to "let" her deliver them vaginally as long as the first one is vertex. We were talking about that today over lunch. My OB nurse mother said, "He won't let you go past 38 weeks right?" I said, "Why???" and my brother (who is a 4th yr med student) said "They get too big!"

Huh?

This argument sounds about as ridiculous as the CPD garbage. Can anyone clue me in? Pass some valid research my way?

Jen

[crazy_eights]

Originally Posted by 2Bugs

My SIL is due with twins in January. Apparently her OB is willing to "let" her deliver them vaginally as long as the first one is vertex. We were talking about that today over lunch. My OB nurse mother said, "He won't let you go past 38 weeks right?" I said, "Why???" and my brother (who is a 4th yr med student) said "They get too big!"

Huh?

This argument sounds about as ridiculous as the CPD garbage. Can anyone clue me in? Pass some valid research my way?

Jen

I can't link you any research, but the issue is not that they get "too big" but a study (possibly more than one?) that showed that twins fare better if delivered by 38 weeks. They now tell moms that 38 weeks is "term" for a twin pregnancy and a really progressive OB might let her go another 2 weeks. I think it's bogus for a healthy mom with good nutrition, but that has become the standard of care.

[wifeandmom]

Most current medical research indicates the BEST overall outcomes with twins is when they are born between 37-38 weeks. Anything sooner or later than that 'magic' window has greater complication rates.

Finding an OB and/or peri that routinely advocates twin moms going past 38-39 weeks is virtually unheard of around here, and it's based upon this research.

It's not so much that they 'get too big', but one of the potential complications that increases as the babies get larger is cord compression. There's only so much room in there, and as time goes on, research shows that cord accidents resulting in stillbirth start to go up around 38-39 weeks or so. Things just get squished in there for lack of a better description.

After carrying my own twins to 38w3d, I can definitely see how that happens.

I personally wasn't comfortable going past 38w, but welcome to the world of military health care. Thus my delivery at 38w3d. A couple of the peris at the time would have pushed for 39w, but the main one I saw was a believer in 38w+ is enough.

Because it's so much more common to have twins born prior to 37 weeks, I think the issue of when to intervene is one that is often overlooked. Some docs not up on current research might actually say 'the longer the better', when in fact, that is NOT supported by research at all.

[wifeandmom]

Originally Posted by mom2seven

I think it's bogus for a healthy mom with good nutrition, but that has become the standard of care.

Are there newer studies out that show the previous ones to be incorrect, or do you feel the 38w 'term' concept is bogus for some other reason? I ask because it's not like they pulled it out of thin air or anything. It's actually one of the more evidence based practices going around in OB today, so it's curious to me that it's being criticized.

[crazy_eights]

I have not heard cord compression from peri's here, but the "placenta degenerates faster" in a multiple pregnancy. If there is sufficient fluid, the cord should not get compressed (which bring you back to "placental insufficiency"). I would have to look up studies and honestly haven't.

[veganf]

LOL. Back in my August 2006 DDC, SlingwearinMama vaginally birthed twins at 40 weeks who each weighed 8lbs 15.5oz. Tell that to them!!!

[SublimeBirthGirl]

I'd have to look at the studies pretty carefully. I'm no scientist, and what I'm finding is that a lot of studies are done by doctors with no scientific background. They're not any more valid than they would be if I did them.

[MsBlack]

Thank you, Sublime!

Sorry, can't give you a link, but this year I was in a discussion on another list about this very topic--the 'best' time for multiples to be born. According to the study oft-quoted by one mw (who herself had lost one twin at 40wks delivery), the study group was enormous--something like 20,000 pairs of twins were included. Mind you, this was not a single random control trial research project in which they managed to enlist 20,000 twin moms; data was drawn from numerous other prior twin studies. Hmm, I think that's called a retrospective study? Not a statistician...

Anyway, this mw and some of the others in the discussion (both hosp and home birth mws) seemed to feel that the results of this study were basically to be considered 'gold': twins do better if delivered anywhere from 37-to-39wks, perhaps best of all being 38wks. My question--never answered--was 'were these all medically managed mothers intending to birth in hospitals?' and my second question was 'has anyone gathered data on planned homebirths and twins/multiples'. That was never answered either. But the answer to the first is of course Yes, and to the second, No.

but the whole point is, as a hbmw (and mom), I cannot take as gospel any data on women and babies that arises from within the medical model. There is too much weight of the attitude and actions of modern mediciine that freights these mommas' care, and the conversations that occur about their pregnancies and births, from day one of knowing that multiples are coming.

So...I suppose it can be truthfully enough said that within the medical model/hospital birth, at least one major study seems to show that twins under medical care are safest when delivered btwn 37-39wks. If you are planning a hospital birth, then it may be that your babies will be safest if induced by that time--if only because then, you will not have to contend with the growing fear and interference of your OB.

And, I have to say that all of the dozens of twin homebirth (and a few triplets, too) stories I have read and heard from mws in my acquaintance, I've seen no evidence that wks gestation at birth is a defining factor for safety. Many hbmws believe (not all) that it is more dangerous to mess with induction than to patiently wait if mom is taking great care of herself and babies.

Now, I am always glad to see more data--so if anyone can provide any, please do! But this is the way I understand things at the moment.

[Sileree]

I agree with MsBlack.

Personally I think those babies' "golden window" would be when they signal the mother's body that they are ready to come out. Just because they are 38 weeks doesn't mean they are ready to breathe... Twins are not an emergency or pathological, they are simply a variation of normal. Its hubris in my mind to say we know better than the body.

[wifeandmom]

Originally Posted by Sileree

Its hubris in my mind to say we know better than the body.

Always?

There are so many exceptions to your statement that come to my mind that I wonder how anyone could truly believe that about birth or any other bodily function. Modern medicine 'knows better' than our body quite often.

Look at how many people wear corrective lens for example. Imagine a very blurry world for a very large percentage of our population, but we have modern medical advances to thank for clear sight.

So, yes, sometimes *we* certainly DO know 'better than the body'.

[Sileree]

Wifeandmom -

Maybe I need to clarify?

I meant interfering routinely even when there is no problem.

Your example of using corrective lenses isn't applicable to this situation. Interference when a problem arises is not arrogance.

Assuming we must jump in routinely to control a physiological process when there is no problem is.

We are talking about inducing a labor at 38 weeks no matter what, even if the babies are being monitored and are ok.

Induction of labor has inherent risks, and should only be used, in my opinion, when the risk of the babies staying in is greater than using pitocin or whatever drugs to get them out. Just being pregnant with twins is not a good enough reason to routinely induce labor.

[wifeandmom]

Originally Posted by Sileree

Wifeandmom -

Maybe I need to clarify?

I meant interfering routinely even when there is no problem.

Your example of using corrective lenses isn't applicable to this situation. Interference when a problem arises is not arrogance.

Assuming we must jump in routinely to control a physiological process when there is no problem is.

We are talking about inducing a labor at 38 weeks no matter what, even if the babies are being monitored and are ok.

Induction of labor has inherent risks, and should only be used, in my opinion, when the risk of the babies staying in is greater than using pitocin or whatever drugs to get them out. Just being pregnant with twins is not a good enough reason to routinely induce labor.

So is there *ever* a point where induction strictly because of gestation length would be appropriate or do you think *all* women should simply be monitored (how exactly?) until they finally do go into labor on their own?

Current standards say that an NST, AFI, and BPP are 'good' for about 2-3 days as far as telling us whether or not baby is still thriving in the womb. Would you advocate all of this testing every 2-3 days indefinitely, despite clear research evidence that shows babies born between certain gestation lengths do better, even those that had to be induced in that time frame.

What I'm saying is that YES, there are risks to induction. BUT those risks seem to be LESS than the risks of staying pg after a certain gestation length (this applies to singletons as well as multiples, though the actual length is different).

How do you explain the fact that multiple research studies have shown that twins, INCLUDING those who were born after induction of labor, born between 37-39 weeks did BETTER than those who were born AFTER 39 weeks?

Obviously each individual mother needs to assess the risk factors and decide for herself. However, the research is most definitely there to support routine intervention somewhere between 38-39 weeks if labor has not begun on its own by then.

Does that mean that all twins left to gestate past 39 weeks are going to have problems? NO. Not at all. Not even most. A very few will have problems, but there will be significantly (statistically speaking) MORE with problems after 39 weeks.

Again, sometimes that is a risk a mother is willing to take for whatever her reasons may be. That's great as long as she understands the implications of her decision.

[wifeandmom]

Originally Posted by Sileree

Wifeandmom -


Induction of labor has inherent risks, and should only be used, in my opinion, when the risk of the babies staying in is greater than using pitocin or whatever drugs to get them out.

I went back and re-read your post, and this strikes me as odd.

The research available already shows that twins born between 37-39 weeks do best. Period. The end. No matter how they got here, be it spontaneous labor, induced labor, labor followed by c-section, or c-section with no labor at all. That gestation length has been found to be associated with the least complications overall.

It doesn't seem like a huge leap to see why one would conclude, given this research, that induction would be less risky to the babies than staying in the womb past a certain point.

If staying pg past 39 weeks awaiting spontaneous labor was BETTER for the babies, it would have shown up in the outcomes of at least some of the studies available to date. But it hasn't. The opposite has been shown to be true. Waiting for labor past 39 weeks with twins is associated with increased risk to babies overall complication rate.

[crazy_eights]

You know what? I'm actually going and reading the abstracts of some of the twin studies and it is just not so simple as wifeandmom is presenting it. First of all, some of the randomized control studies showed similar outcomes in both groups (induction at 38 wks. vs. "expectant management"). And some of the other studies mention significant risk factors (smoking, for example) or things that would be indications for induction (more than 15% discordance in growth) - and they are "thrown into the pot" so to speak with all other twin births. It's interesting, but definitely not so simple.

[alegna]

Twins or singleton- I would never induce without medical reason. Period.

Dates are not a medical reason.

-Angela

[crazy_eights]

Here ya' go. From just this August: Study finds no benefit in delivering twins by 38 weeks. And the study appeared in ACOG's "green journal".

This study suggests that the optimal date of delivery for twins should be <40 weeks of gestation, and we did not identify compelling evidence (such as, decreased risk of morbidity) for being delivered at <38 weeks of gestation," the investigators conclude.

[LemonPie]

Can you post the full text? I don't have a way to log in

Jen

[crazy_eights]

Originally Posted by wifeandmom

The research available already shows that twins born between 37-39 weeks do best. Period. The end. No matter how they got here, be it spontaneous labor, induced labor, labor followed by c-section, or c-section with no labor at all. That gestation length has been found to be associated with the least complications overall.

I'm really curious if you have actually taken a look at any of the studies or are basing your conclusions on what someone else told you (not to mention that there are now more recent studies contradicting this info).

[crazy_eights]

Originally Posted by 2Bugs

Can you post the full text? I don't have a way to log in

Jen

I'll PM it to you (I think it's a UA violation to post more than 100 words?). But Medscape (what I linked to) is free to join.

Or try this from bugmenot.com

Username bug_me_not
Password 12345

[HerthElde]

Originally Posted by wifeandmom

The research available already shows that twins born between 37-39 weeks do best. Period. The end. No matter how they got here, be it spontaneous labor, induced labor, labor followed by c-section, or c-section with no labor at all. That gestation length has been found to be associated with the least complications overall.

On an overall statistical basis, that may (or may not) be true. But at the level of the individual, it means nothing.