Is vaginal birth risky for 2nd twin? - Mothering Forums

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Old 11-30-2009, 03:27 AM - Thread Starter
 
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I'm not a mom of multiples, so I hope it's ok to ask this here... I have a friend who works at a group home for developmentally disabled adults. Because of her experiences there, she has some pretty strong opinions about birth. She thinks it's selfish and horribly dangerous to have a homebirth, for example. I don't engage her when she makes statements like these, since I know I'm not going to change her mind. Recently she said something about how she wished she didn't have to have a c/s for her youngest because it really sucked, but if she were to ever have twins she would definitely have one. According to her, there are "lots" of 2nd twins at the facility where she works. The first one is born fine, but the 2nd one... I'm not really sure, is somehow deprived of oxygen? I've never heard of this before and just wondered if there was anything to it?

Thanks!
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Old 11-30-2009, 11:00 PM
 
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I'm pretty sure there actually is a correlation between Twin B (second-born) and poorer outcomes in general - lower Apgars and more possibility of respiratory distress syndrome (RDS). But I'm pretty sure it's statistically significant but not the huge difference your friend is making it out to be. It's very easy for someone who is not deeply educated in the details to take a little bit of data (reading an article about a study showing poorer outcomes for twin B) and then a little bit of personal experience (2-3 twin Bs with several developmental issues) and draw a conclusion like that. FWIW, it was never mentioned to me as a risk factor during my pregnancy and my OB never tried to discourage vaginal birth on this (or any other) basis.

My Twin B actually did have more severe RDS than her sister, but both of them were born very premature and I had to have a c-section for the second baby, which I think is the more likely cause of her respiratory situation.

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Old 11-30-2009, 11:36 PM
 
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I'm also sure the second born does probably have a greater tendency toward those issues but I think it really depends on a lot of factors. My OB said he would only be concerned if twin A was not vertex but since both were it wasn't an issue for me & I never really thought much about it.

My twin B did need breathing help with CPAP for about 12 hours so maybe a long time ago when that intervention wasnt available that would have caused a problem for him.
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Old 12-01-2009, 01:27 PM
 
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Originally Posted by OGirlieMama View Post
It's very easy for someone who is not deeply educated in the details to take a little bit of data (reading an article about a study showing poorer outcomes for twin B) and then a little bit of personal experience (2-3 twin Bs with several developmental issues) and draw a conclusion like that.


I think it's probably true that the second baby has a higher risk of issues (although I wonder if that's innate or the rush to get him/her out that's the problem) and I can see how your friend might jump to the conclusion that a c-section is safer. In reality, it's a case by case basis. For sure, sometimes there is a better outcome with surgery. In some cases, it's safe to deliver both babies vaginally (and we probably all know the significant benefits of vaginal birth for both mother and babies).

I gave birth to my twins at home. I do not consider myself irresponsible nor did I feel that I put my babies at risk. I presented with a presentation that would have gotten me immediate surgery in the hospital but I was lucky enough to be at home and gave birth to both babies without serious incident.
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Old 12-01-2009, 06:29 PM
 
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my twin 1 was ventilated and twin 2 was not, but twin 1 made a quicker recovery overall (preemies) - i wonder how much is intervention full stop rather than letting things take their course. cord cutting/not makes a difference. so many factors to take into consideration. MZ/DZ makes a difference in some cases.

position-wise twin 2 suddenly has lots of space which means he/she can skipity about and get into awkward positions, but equally he/she can line up perfectly.

i'd ask her about the details of their births tbh, out of curiosity. ultimately they might be a twin, but each has their own birth, which can be just as varied as singletons.

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Old 12-01-2009, 08:20 PM
 
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I think that the practice of immediate cord clamping after Twin A is born has a lot to do with the need to resuscitate Twin B's and them having a lack of oxygen.

The clamping of the cord signals to your body that it is finished with the placenta and it will start to detach. With Twin B still in there, I am sure that they are then being deprived of oxygen.

We are going to be delaying cord clamping for at least a few minutes. But we also know that both babies have separate sacs and placentas. In the case of identical twins, this wouldn't be safe obviously if the are sharing a placenta, but...

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Old 12-01-2009, 09:48 PM
 
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My twin A needed CPR at birth and had horrible apgars. He was also hospitalized for two weeks. Twin B had good apgars. Twin B has many issues but I don't think any of them had to do with his birth.
A greater percent of twins will have issues no matter the birth order.

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Old 12-01-2009, 11:24 PM
 
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My twin A needed help too, due to her very fast breech birth. She was a bit 'wet' and grunty and they gave her some O2 and suction. Baby B had zero issues but was also vertex (flipped after A was born).
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Old 12-02-2009, 12:41 AM - Thread Starter
 
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Wow. Thank you all so much! I really appreciate you taking the time to answer my question!

OGirlieMama, I think you hit the nail on the head with this:

Quote:
Originally Posted by OGirlieMama View Post
It's very easy for someone who is not deeply educated in the details to take a little bit of data (reading an article about a study showing poorer outcomes for twin B) and then a little bit of personal experience (2-3 twin Bs with several developmental issues) and draw a conclusion like that.
Except that I don't know that she's even read an article. She's not a HCP, she manages the case workers there. She's easily swayed by anecdotal evidence, at least that which backs up her "mainstream" ideas. (I know that word can cause trouble here, I just don't know how else to describe it - she generally agrees with whatever most docs would recommend: hospital birth, c/s for breech, etc.) She's not one to question "authority" or research for herself and potentially change her mind. She actually told me she'd have to stop talking to me if I decided not to vax (we do selective/delayed). Anyway, getting WAY off topic!

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Originally Posted by Intertwined View Post


I think it's probably true that the second baby has a higher risk of issues (although I wonder if that's innate or the rush to get him/her out that's the problem) and I can see how your friend might jump to the conclusion that a c-section is safer. In reality, it's a case by case basis. For sure, sometimes there is a better outcome with surgery. In some cases, it's safe to deliver both babies vaginally (and we probably all know the significant benefits of vaginal birth for both mother and babies).

I gave birth to my twins at home. I do not consider myself irresponsible nor did I feel that I put my babies at risk. I presented with a presentation that would have gotten me immediate surgery in the hospital but I was lucky enough to be at home and gave birth to both babies without serious incident.
The bolded part is a good point. Isn't that part of why breech can be so dangerous, twin or not, since HCPs panic and start messing with things that should be left alone?

Also, I hope you didn't misunderstand me: I wasn't saying that I think homebirth is irresponsible, just that she does. I think it's great you were able to be at home!

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Originally Posted by shukr View Post
i'd ask her about the details of their births tbh, out of curiosity. ultimately they might be a twin, but each has their own birth, which can be just as varied as singletons.
This would be interesting. Though I don't know if she even has that information, nor would it sway her in any way, unfortunately.

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Originally Posted by rachel65655 View Post
I think that the practice of immediate cord clamping after Twin A is born has a lot to do with the need to resuscitate Twin B's and them having a lack of oxygen.

The clamping of the cord signals to your body that it is finished with the placenta and it will start to detach. With Twin B still in there, I am sure that they are then being deprived of oxygen.

We are going to be delaying cord clamping for at least a few minutes. But we also know that both babies have separate sacs and placentas. In the case of identical twins, this wouldn't be safe obviously if the are sharing a placenta, but...
I knew that it was important to delay cord cutting in general, but I guess I hadn't thought about it in the case of twins.

Thanks so much for all your info mamas! Like I said, I know I have no hope of changing my friend's mind, but it was something that made me wonder. Thanks!
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Old 12-02-2009, 01:49 AM
 
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Also, I hope you didn't misunderstand me: I wasn't saying that I think homebirth is irresponsible, just that she does. I think it's great you were able to be at home!
Oh no, not at all! I was totally directing that at your 'friend'. Who doesn't sound like much of a friend if your intensely personal vaxing decisions are cause for her to stop speaking to you.
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Old 12-02-2009, 04:09 AM
 
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In a word, no. I have had twins twice. Baby B did better than A both times for me (in one Baby A died due to severe birth defects). The midwives I have worked with do twins at home. We like mamas to be upright on stool or standing and the birth asst. hold the outside of the belly as baby A comes out and keeps Baby B from switching to a transverse position or flipping around. Sorry for the fast post. I can describe better if you need.
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Old 12-02-2009, 08:19 AM
 
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Rena (twin B) had was in major distress right before birth. Her first APGAR was 4. Thank G/d she was descended enough they could just vacuum her out and after a few minutes she was fine (2nd apgar was 8). She has had no lasting health affects.

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Old 12-02-2009, 03:36 PM
 
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This has always been a grey area for me. From my research I believed that homebirthing Baby A was as safe as a singleton. Mixed results on Baby B.

My twins were born at home by one of the midwives Lorrie mentioned above. Both had perfect apgars.

FWIW - My Baby B was a pound lighter and had no vernex, which her sister was still covered in. I induced labor at 39 weeks with castor oil. Don't know whether home induction was the right call. I think Baby A needed to come in her own time, maybe a week or two later. I think Baby B was ready to be born. Who really knows. But my girls were born upright with no problems to Baby B. She was secure in her unbroken sac all through labor and delivery of Baby A. Perfect heartbeats all through. Nursed right away.

I loved having a homebirth, and know there's plenty of research supporting the benefits to vaginal twin birth.

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Old 12-03-2009, 01:34 AM - Thread Starter
 
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In a word, no. I have had twins twice. Baby B did better than A both times for me (in one Baby A died due to severe birth defects). The midwives I have worked with do twins at home. We like mamas to be upright on stool or standing and the birth asst. hold the outside of the belly as baby A comes out and keeps Baby B from switching to a transverse position or flipping around. Sorry for the fast post. I can describe better if you need.
Oh I am so sorry for the loss of your baby. I really appreciate your sharing with me.

I really appreciate all of the stories and ideas you've all shared. Gena 22, that's something I've wondered too: if sometimes 1 twin is ready but the other is not yet. Interesting...
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Old 02-12-2010, 03:38 PM
 
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Ran across this study today and remembered the post on vaginal birth and twin B:

http://www.nature.com/jp/journal/v22.../7210752a.html
Comparison of the Perinatal Morbidity and Mortality of the Presenting Twin and Its Co-Twin, Journal of Perinatology, July/August 2002, Volume 22, Number 5, Pages 391-396

"....Our study is one of the largest from a single center comparing twins A and B for a multitude of outcome variables. It shows that in the 461 twins studied, the outcome of twin A seems to be similar to that of twin B, irrespective of the mode of delivery or presentation. In our series, there was no significant difference in gender, birth weight, or incidence of cord prolapse between twins A and B. Abnormal presentation was more common in twin B, which has been previously reported;15,21 however, when comparing twins A and B in vaginally delivered vertex/nonvertex, no significant difference in outcome was detected and significant trauma occurred infrequently.
* * *
Differences in the outcomes of our cases became more evident when taking into consideration pregnancies where only one twin was affected disregarding pregnancies where both members were affected for that variable. Thus, the probability of twin B for having low Apgar scores at 1 and 5 minutes, for requiring intubation and mechanical ventilation, for developing respiratory distress syndrome, and for neonatal death was significantly higher than twin A. In addition, the probability of neonatal death of only twin B was also found to be significantly higher for smaller birth weights in twin B (<1500 and 1500-2500 g). This is in agreement with previous reports.1,2,3,4,5,10,14 However, the probability for hyperbilirubinemia, phototherapy, necrotizing enterocolitis, and sepsis was higher for twin A. The higher susceptibility of twin A to infection and its related complication (necrotizing entercolitis) may be due to the fact that twin A is more prone to acquire ascending infection due to its proximity to the birth canal.

In conclusion, although the outcome of first-born twin seemed to be similar to that of second-born twin regardless of the mode of delivery, presentation, or birth weight, differences in some neonatal outcome parameters were evident when pregnancies with only one affected member were analyzed separately. This information is helpful in counseling women with twin gestations...."
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Old 02-13-2010, 05:52 AM
 
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Thus, the probability of twin B for having low Apgar scores at 1 and 5 minutes, for requiring intubation and mechanical ventilation, for developing respiratory distress syndrome, and for neonatal death was significantly higher than twin A.

However, the probability for hyperbilirubinemia, phototherapy, necrotizing enterocolitis, and sepsis was higher for twin A. "
This is exactly the case with my twins. My Twin A had jaundice and needed phototherapy, and my Twin B needed help getting start breathing (and then was fine). For once... we fit a mold!
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Old 02-13-2010, 03:03 PM
 
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There are so many different variables...my twin B was breech and we still attempted a vaginal delivery. However, I'm glad I was in the hospital- as we ended up needing to do a c-sec. to get her out after 4 hours. Overall- she was never in danger, never had heart rate issues and did not require any special care. Both of my twins were born at 38 weeks. And- if we had been at home, we would have had time to get to a hospital.

I think you just have to do what feels right and know that everything will be OK...you have no control anyways so you have to just make the best decision for yourself without allowing others to judge or sway your decision. Good luck to you!
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Old 02-13-2010, 04:15 PM
 
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An anecdote: My twin A was in tough shape when born at 30 weeks- needed oxygen, etc. Twin B came out breathing room air just fine. I know the nurses were bracing themselves for twin B to come out in poorer shape than twin a, and that wouldn't have been good news, if you catch my drift. They assumed so b/c in their experience twin a was often in better shape at birth.

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Old 02-13-2010, 06:28 PM
 
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This is exactly the case with my twins. My Twin A had jaundice and needed phototherapy, and my Twin B needed help getting start breathing (and then was fine). For once... we fit a mold!
That's us, too, in a nutshell. (And I HAD the c-section.) Twin B (my DS) was high and transverse, and very difficult to deliver as a result. He didn't breathe on his own for three hours after birth. I think the transverse positioning was the problem, though, for DS.

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Old 02-14-2010, 11:58 PM
 
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My twin B was breech, and my OB still allowed me to attempt a vaginal delivery. I was happy to have a hospital birth, and thankfully I did. Twin B's heart rate dropped to 60, and they pulled her out in the nick of time. There was a knot in the umbilical cord.

Also, I had severe post partum hemorraging and also required a blood transfusion.

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Old 02-17-2010, 01:36 AM - Thread Starter
 
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Freeman - Thanks for sharing the article. But, I'm confused (I'm way out of practice reading stuff like this). Is the article saying that there's no difference between A and B, except when you look at twins where they had diffrerent outcomes? A and B are the same except when they're diffrerent? Hopefully I'm just too tired right now!
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Old 02-17-2010, 10:14 PM
 
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Hi boysmom2, I interpreted the findings to be that in general, there were no significant differences in outcomes between A & B. However, when one only one twin was affected by certain adverse outcomes, as opposed to both being affected, then it was more often twin A or B, depending on the particular adverse outcome. In other words, if only one twin had low Apgar scores, for example, it was more likely to be twin B than twin A. If only one twin had phototherapy, it was more likely to be twin A than twin B, etc. Hopefully I'm interpreting correctly!
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Old 02-17-2010, 11:41 PM - Thread Starter
 
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Hi boysmom2, I interpreted the findings to be that in general, there were no significant differences in outcomes between A & B. However, when one only one twin was affected by certain adverse outcomes, as opposed to both being affected, then it was more often twin A or B, depending on the particular adverse outcome. In other words, if only one twin had low Apgar scores, for example, it was more likely to be twin B than twin A. If only one twin had phototherapy, it was more likely to be twin A than twin B, etc. Hopefully I'm interpreting correctly!
That makes so much more sense! Thank you!
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Old 02-18-2010, 09:20 AM
 
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I just read an article that compared c/s to vag birth for 2nd twins and there was no difference in outcomes.
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Old 02-23-2010, 11:22 AM
 
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In the case of identical twins, this wouldn't be safe obviously if the are sharing a placenta, but...
I'm not sure that one can say this is "obvious".

Dr. George Malcolm Morley, a proponent of delayed cord clamping has written about how delayed cord clamping is beneficial even in single placenta pregnancies. (I looked quickly for the link and couldn't find it, but have only a few minutes right now).

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Old 02-28-2010, 04:52 PM
 
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I think that the practice of immediate cord clamping after Twin A is born has a lot to do with the need to resuscitate Twin B's and them having a lack of oxygen.

The clamping of the cord signals to your body that it is finished with the placenta and it will start to detach. With Twin B still in there, I am sure that they are then being deprived of oxygen.

We are going to be delaying cord clamping for at least a few minutes. But we also know that both babies have separate sacs and placentas. In the case of identical twins, this wouldn't be safe obviously if the are sharing a placenta, but...
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Quote:
Originally Posted by rachel65655
In the case of identical twins, this wouldn't be safe obviously if the are sharing a placenta, but...

I'm not sure that one can say this is "obvious".

Dr. George Malcolm Morley, a proponent of delayed cord clamping has written about how delayed cord clamping is beneficial even in single placenta pregnancies. (I looked quickly for the link and couldn't find it, but have only a few minutes right now).


I don't know what Dr. Morley has to say on the subject and when I was pregnant (monochorionic twins) I never got good answers about delaying or not delaying with Twin A's cord, but I was going to comment on Rachel's post, as well. Just to question whether the initial comment could INDEED apply to identical twins who share a single placenta. After all, if clamping the first twin's cord signals the placenta that it is "done" and can begin the process of detaching, and that is the only placenta, then it would seem that would increase the likelihood of complicating things for Twin B.

My babies were born thirty minutes apart. They shared a placenta. Late in those thirty minutes between babies, things got a little iffy with Baby B. I don't know if it was that they lost his heart tones (they did for a bit, at least) or if his heart rate was too low. But it suddenly went to a "must come out now" place.

I know they were mixing his heart rate up with mine (I remember them saying, "That's the mother's!"), or else they did have his but it was low enough that they thought what they heard was mine. The anesthesiologist who had just been sitting there got up, took my wrist, watched his watch and then reported my pulse rate. I remember hearing the number and I'm not sure if it matched what they had on the doppler (which meant they didn't have a fetal tone) or if the too-low rate doppler tone was the baby's after all (didn't match mine but was too low to be good.) At that point, I got down off my knees (I was upright to push for both babies) and we used the vacuum to get the baby out. Out he flopped. His color was pretty bad and he seemed dazed (this is how my husband remembers it; I just remember that he looked purple or gray or something and he was very still.) They cut/clamped and they were pretty rushed/intense with whatever they did (suctioning, I imagine), but my husband saw him move and he did begin to make some noise. I remember my husband was quick to assure me that the baby was "fine" after he saw him moving, which basically meant "alive."

I really don't know what happened with him, whether his dark coloring was basically within the range of normal, whether he was stunned from his sudden removal, what had happened with his heart tone, etc. I had ended up with the on-call OB and I never really thought to talk to nurses who were there. I was seriously low-energy from the postpartum hemorrhaging (and had already known that a blood test just before that weekend indicated my hg was much lower than I'd have liked, and that if I hemorrhaged I would likely need a transfusion, which I did), I was mostly focused on nursing them, and I just wasn't "on my game" in terms of asking questions about that second birth.

I have always wondered if cutting the first baby's cord immediately had a negative impact on baby B, in one way or another.

The closest thing I've read to anything on the subject (and this was about acute TTTS and whether or not to clamp the first twin in a mono/di vaginal birth) was a comment that clamping the first cord sort of "freezes" the transfusion as it is. The implication was that it would be negative to do so, but I'm not certain why, exactly. I guess retaining flexibility in a low-grade/undetected transfusion situation could be desirable, but it seems that if it is low-grade, then "freezing" it and removing any chance of increase/decrease wouldn't exactly introduce a transfusion problem (if there was no detectable problem before.) I can see that if a detectable transfusion was going in a bad direction, it could be bad to sort of cement it there, but I am not sure if there's a lot of flux in those acute situations, anyway, so that it would be "better" to keep both lines open.

It doesn't make a lot of sense to me. I've never been clear on it, at all. But aside from acute TTTS issues, it seems that if clamping could compromise placenta function, then that would/could negatively affect the remaining twin who needs that placenta.

For what it's worth, there was no diagnosis of acute TTTS in our situation. Their hemoglobin was tested and the first twin was at the low end of the range of normal (for iron) and the second twin was quite high, but still in the normal range. Neither could be diagnosed as truly anemic or polycythemic. So.....no talk of TTTS at the time. The second twin obviously "got everything" after his twin's cord was clamped, and I don't know if the placental flow shifts from dividing the goods to flooding them all in the remaining direction at that point. I guess that could have been a factor in the second twin's distress.

But no evidence to support a diagnosis of acute TTTS. However, at six months, twin A was severely anemic (although it was a totally non-clinical case. He seemed "rosy enough" to our doctor and he was active and strong, enough so that she was convinced that the very low numbers were a lab mistake. Not so.) And twin B had iron levels in the normal/expected range.

The explanation we got for that was that it wasn't a recent development-- that twin A's iron had been depleted for a long time, probably as a result off an undetected or fast-developing acute TTTS situation during labor/birth that left him starting out with little or no iron stores. He had been coping/compensating for a long time and did not present with any obvious symptoms.

So in that scenario (of acute TTTS), twin B would have been the recipient, and it's true that the first twin's cord was clamped right away. (Theoretically locking in twin B to whatever inequality or overload existed at the time.) I guess something about that could have resulted in B's eventual distress, instead of the placenta getting a confusing message and starting to shut down. I don't know.
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Old 03-01-2010, 12:11 AM
 
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Amy, I'm so glad you typed all that for everyone to read. I also could not find good, conclusive evidence of cord clamping (immediate vs delayed) with mono-di twins. I, too have thought about the transfer and TTTS during birth and whether cord clamping has anything to do with it. It just seems there are a lot of unknowns in this area, which aren't likely to change soon, seeing as how immediate cord clamping is the norm with all babies; I imagine that with twins a study on delayed cord clamping could be seen as 'risky' since it delays a baby getting monitored immediately postpartum as well as the unknown effect of delayed cord clamping of A on B. Anyway, babbling....

Mama to twin girls Adele and Nadia, born 5/2008
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Old 03-15-2010, 09:53 PM
 
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In the bit of poking around I've done, I came across this site: http://www.homebirth.org.uk/twins.htm#foragainst

The nutshell of the "anti" twin homebirth article is that, having given birth to twin A, your cervix is fully open before twin B can engage, and there is an increased risk of cord prolapse. Also something about the loss of pressure in the uterus after twin A's birth increasing the risk of placental abruption. There are no supporting stats given here, but both cord prolapse and placental abruption are extremely serious, life-threatening complications, and it's not out of the question that your friend actually does work with people who suffered brain injuries because of something like this.
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Old 03-19-2010, 11:43 PM - Thread Starter
 
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Quote:
Originally Posted by mojobot2000 View Post
In the bit of poking around I've done, I came across this site: http://www.homebirth.org.uk/twins.htm#foragainst

The nutshell of the "anti" twin homebirth article is that, having given birth to twin A, your cervix is fully open before twin B can engage, and there is an increased risk of cord prolapse. Also something about the loss of pressure in the uterus after twin A's birth increasing the risk of placental abruption. There are no supporting stats given here, but both cord prolapse and placental abruption are extremely serious, life-threatening complications, and it's not out of the question that your friend actually does work with people who suffered brain injuries because of something like this.
Thanks for sharing this. I agree that bad things certainly can happen, and it may be that something like this did happen to the people that she works with. It seems like it's hard to know how often things like this happen. Things can go wrong in any birth and if you or someone you know has had something bad happen to their child it can seem like the risks are just too high. It's just hard to get a clear idea of just how risky a particular choice may be.
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