Identical twins induced routinely at 37 weeks? - Mothering Forums

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#1 of 19 Old 05-22-2012, 05:51 PM - Thread Starter
 
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I know it's a little early to worry about this... But, because I was induced at 42 weeks with my daughter (ended up in a C/S)... I am.

I was told by my perinatologist that they deliver twins at 37 weeks.
Period. He said that the reason is because stillborn rates increase after this point with identical twins.

I am 21 weeks with mono/di twins. I know it would probably be more appropriate to worry about premature labor, or TTTS or something... But, I'm afraid of being induced. I really want a vbac, and I want to go into labor naturally, since I never got to do that last time.

I was wondering if anyone here had researched this at all, and how valid the perinatologist's concerns are. Has anyone read any studies they could recommend? Even personal experience where they declined an induction in a similar situation?

Thanks ladies!
-C
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#2 of 19 Old 05-23-2012, 06:11 AM
 
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I am in the exact same boat.  My peri wants them out, no question, at 36 weeks for the same reason!  I told him in my last appt that unless there was evidence of an emergency, ttts, or other immediate problem with one or both of the twins, I would absolutely decline induction.  He raised his eyebrows at me and of course told me that he really doesn't recommend that, etc.  I have been researching this as much as possible and the study that the doctors are basing most of this on was done in the Netherlands in 2008.  I will try to find the link again and post, but essentially they did find an elevated risk of still births when mono-di twins are carried past 36 weeks. I read the study and it examines women between 1994 -2003 (I believe).  I am not a doctor, but I didn't' find the study or evidence to be overwhelming.  I felt like there were a lot of variables that didn't seem to be taken into consideration...especially the years they were monitoring.  U/S technology wasn't as advanced as it is now.  The study did say, that they are not able to foresee the complications that could cause a still birth, therefore getting the baby out sooner is recommended.  For a woman who doesn't mind an induced labor and most likely C-section, I suppose that's fine.  But I am doing everything in my power to have a natural vaginal birth and being induced so early would surely take that chance away.  I feel strongly about this, but everyone has to make their own decision, because there is a higher risk.  I am very anxious about getting to 36 weeks and having to deal with the doctor's pressure and scare tactics.  I wonder if I'll be able to stay strong.  We all of course, ultimately, want health babies.  Sigh....such a hard decision.  I would also love to hear some other ladies input on this.  

 

Oh, I found the link, here it is:

 

http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2007.01556.x/full


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#3 of 19 Old 05-23-2012, 07:32 AM
 
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I'm not in the same situation - my twins are di/di - but I also concerned about ending up with a induction, because I was induced last time at 41 weeks for low AFI. I still don't know how I feel about that decision. I did end up having a vaginal birth and an overall positive birth experience, and my son did have some signs of postmaturity (my pg was dated by early u/s, not LMP), but I strongly question whether it was necessary. My OB practice won't induce by a certain week (maybe they do for twins sharing a placenta, I don't know), but they won't let me labor unless both babies are vertex. I'm trying not to think about it too much because chances are they will be, but am starting to prepare mentally for different scenarios. I know there is a European study (I need to look it up) that showed better outcomes for Baby B breech with a section, and several studies (also need to look those up) that show optimal outcomes for twins born either at 38 or 39 weeks. I wonder if all the twins included in those studies were di/di - that might be significant.

 

I really want to avoid an induction, and I really REALLY want to avoid a c-section. So I would definitely consider waiting until I was in active labor to roll into L&D with one breech, but that may not be feasible if that doesn't happen until 41.5 weeks and they're giving me NSTs daily from 39 weeks or whatever. I will say, my skepticism of the medical establishment is reasonably high, but my risk tolerance is pretty low, and DH's is lower. I don't have a problem going AMA to a degree, but for all my respect and support for HB, we won't choose it for ourselves. So that's why I really need to think this through, otherwise I will panic and accept the induction/section. Maybe I will anyway, but I don't want it to be automatic. So I too would love to swap ideas!


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#4 of 19 Old 05-23-2012, 11:08 AM
 
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I read this thinking it was sounding VERY familiar and realized that you posted on the Naturally Parenting Twins fb group :)  I replied there but for people who may not be part of that group, here's my 2 cents:

 

Our hospital had a policy to induce at 38 weeks and I refused the induction. I did have an ultrasound to check on the babes and the placenta (I also had mono/di). I went into labour spontaneously at 38w2d. I think it depends on the individual situation. If there is no good medically justified reason to evict the babies, why do it, just because of a hospital policy? And as I was told later - 37 weeks is still preterm!


Married to my love love.gif since 08/12/10, mama to E REPlaySkateboard04HL.gif04/06/01 and twin girls M and Z slingtwin.gif 01/08/11

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#5 of 19 Old 05-23-2012, 11:40 AM
 
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I know there is a European study (I need to look it up) that showed better outcomes for Baby B breech with a section, and several studies (also need to look those up) that show optimal outcomes for twins born either at 38 or 39 weeks. I wonder if all the twins included in those studies were di/di - that might be significant.

 

I live in Europe.

 

Second, I would love to read those studies too!

 

I also am expecting (fraternal dd/ds) twins. The 'traditional' policy here if you go to a hospital is that they will induce if you have not delivered by 38w. One hospital in town will only do vaginal births if both twins are the same size more or less and both have to be head down. The other hospital in town will allow you to try a vaginal if Baby A is head down, regardless of if Baby B is breech.

 

DS1 was born naturally at 42w but I really had to fight for that to happen and agreed if he was not here by 42.5w I would induce.. it literally came down to a few days for me or I would have had to have the induction.

 

With that being said, I am 31w and baby B is still in a very ugly transverse breech. Baby A is slight smaller then Baby B but head down.. I seem to cook them late and Im really nervous if they aren't 'on time'

 

I will have to make the decision basically in mid-June if the baby has not flipped what to do/which hospital I want and if I can afford the 'natural' hospital as its not covered by my gov insurance (and will cost about 10k USD to give birth in which we just don't have the money for right now. . .) I've been preparing myself for the reality of a c-section and coming to peace with the positives I can find. . .

 

Sadly there are no midwives in our little town who are willing to do a twin homebirth nor does my DH support it.. so Im stuck at the hospitals.. woah tangent. . sorry :)
 


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#6 of 19 Old 05-23-2012, 01:01 PM
 
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I was very reluctant to induce. That study convinced me that we needed to induce in week 36. You have to look at the data you have and talk to your doctor and your partner and decide what makes sense for you.

 

That said, induction isn't monolithic. Induction can include acupuncture, herbs, walking, prostoglandins, etc, before pitocin. And I felt this wasn't useful:

 

"For a woman who doesn't mind an induced labor and most likely C-section, I suppose that's fine."

 

I very much minded an induced labor, but it, in the end, felt like the right thing to do. And an induced labor increases the chance of c-section, and shouldn't be done lightly, but it doesn't mean you will most likely have a c-section. Many many people induce and go on to have vaginal births without other interventions, as I did. It's not all or nothing.

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#7 of 19 Old 05-23-2012, 01:49 PM
 
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Originally Posted by ithappened View Post

Quote:
I know there is a European study (I need to look it up) that showed better outcomes for Baby B breech with a section, and several studies (also need to look those up) that show optimal outcomes for twins born either at 38 or 39 weeks. I wonder if all the twins included in those studies were di/di - that might be significant.

 

I live in Europe.

 

Second, I would love to read those studies too!

 

I also am expecting (fraternal dd/ds) twins. The 'traditional' policy here if you go to a hospital is that they will induce if you have not delivered by 38w. One hospital in town will only do vaginal births if both twins are the same size more or less and both have to be head down. The other hospital in town will allow you to try a vaginal if Baby A is head down, regardless of if Baby B is breech.

 

There was a French study that I can't track down right now, it suggested that vertex/breech vaginal delivery was fine as long as the breech twin was turned by an attendant skilled in external version. The people at my hospital were not enthusiastic about version, so I made a conclusion they didn't have the skills or the motivation. (And even if some were super at it, where's the guarantee they would be on duty that day.) Countries and studies are fine, but I felt what mattered was what was available in my particular city.

 

A French study -

Modes of delivery of first and second twins as a function of their presentation. Study of 614 consecutive patients from 1992 to 2000.

 

Another French study -

[Modes of deliveries of twins as a function of their presentation. A study of 371 pregnancies].

 

Israeli study (their medical system is modeled after the USA, as far as I know)

- Vaginal delivery of vertex-nonvertex twins: a fading skill?

 

Swedish article:

Influence of mode of delivery on neonatal mortality in the second twin, at and before term.

 

Delivery of the second twin.

 

Canadian study:

Occurrence and predictors of cesarean delivery for the second twin after vaginal delivery of the first twin.

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#8 of 19 Old 05-24-2012, 05:58 PM
 
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Heres my story w/studies included. My boys are now 6 months old

http://nicole-journeyofapregnantrunner.blogspot.com/2011/10/countdown-begins.html

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42 year old runnerjog.gif, hiker. Mom to DS(6/28/08) smile.gifand married to my best friend. Cloth diaper and plan to homeschool. Love my life in the mountains. Identical twin boys born 11/3/11 selectivevax.gifgoorganic.jpgbfolderchild.gifnocirc.giffambedsingle2.gif

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#9 of 19 Old 05-25-2012, 07:57 AM - Thread Starter
 
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Thanks, mamas. 

 

Mamlove3X - I think you may have been the one who told me about the Naturally Parenting Twins FB group in another thread! :) Thanks for sharing your story - I think I would be ok going to 38+ a little... but, I would be lying if that one study didn't scare the bejeezes out of me.

 

Gindugirl - I had some of the same responses to the study as you did... in addition to the timeframe (starting nearly 20 years ago), I have a concern with the number of people included in the study. I was surprised to see only ~1300 twin sets included, and this called a 'large' study. Of the 1300, only 128 of the sets were MC. Of the 7 infants that died during that 10 year study - 6 had signs of TTTS, some at 32-33 weeks and some not until labor. 1 was unexplained. I just wish that there were more studies out there. I'm going to talk to my peri about the size and age of the study at my upcoming appointment. 

 

rinap - You are correct, there are many different modes of induction. Being a VBAC, some methods of induction - mainly prostaglandins are off of the table (fine with me), others are ok with some doctors, or in some cases they aren't ok with any forms of induction (except maybe stripping of membranes). Some VBACs may feel that the risk of uterine rupture is too high for them to feel comfortable with any type of induction (even herbal), in these cases, they may feel like they would be safer to have a repeat c/s, instead of an augmented labor. I think that may be why the 'all or none' comment came up. If I was a second time mom, with a previous successful vaginal delivery, induction wouldn't scare me as much. My peri said "you can do pretty much anything to a second time mom (with a proven pelvis) and things will turn out ok." He went on to explain that first time mom's, or VBAC mom's... not really the same thing. Although I have heard of first time moms being induced, given an epidural, and things turn out just fine. They just didn't for me.. and for a lot of people I know. This is why induction is a huge fear for me. 

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#10 of 19 Old 05-25-2012, 09:13 AM
 
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EONjourney it is SO great to run into another mom (no pun intended) who has/was very active both during/before/after your twin pregnancy. I read your blog and it gives me so much hope for my own c-section (next month). I was starting to think it would be MONTHS until I could run/hike/bike again.. this gives me such great hope. thank you.
 


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#11 of 19 Old 05-25-2012, 09:19 AM
 
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Caitlyn- I agree those are the very same issues I took up with this study.  It's a VERY small group to be considered large study.  When you talk to your doctor I would be very curious to find out if there is another study out there these OB's are referring to.  I haven't found it, but my Peri did mention there was a huge OBGYN conference this past year 2011, in the U.S., where this was discussed at length.  Without going into details, he mentioned the overall theme of this conference was to get mono-di twins out by 36 weeks.  So I am really curious as to what motivated this and what "extended" research they're talking about, because that study sure doesn't do it for me. Also, I didn't know that about VBAC moms and that second time moms don't have as many problems with induction.  That's very interesting.  btw- how do you join the FB natural twins group?

 

Rinap- I do want to apologize for my comment, ""For a woman who doesn't mind an induced labor and most likely C-section, I suppose that's fine."  I was definitely making a sweeping generalization.  It comes from the fact I've been on my normal twin boards for some time now and it's been very frustrating for me b/c over there every time I try to discuss this subject, most of the ladies (and I mean 98% of them) react very strongly to me not wanting an induction or a C-section.  The majority of those women are truly fine with a C-section and actually prefer them and are scheduling them without evidence of needing to.  So I meant, most of those women couldn't understand my aversion to induction in any way, hence my generalization.  I just joined this site for the first time b/c I was seeking out like minded women who I could bounce ideas off of.  But I think I'm still in the defensive mode I was in on those boards, where I was kind of the black sheep.  I realize now, this is a very different forum (thank god!) and many of you have done the research and have tried alternative methods to get the birth you want.  I don't judge how anyone delivers their baby (that is a very personal choice), I just wanted more balance in weighing different options.  I really appreciate you saying you were induced and still had a vaginal delivery.  That makes me hopeful.  However, I also should note I also am worried b/c I am extremely sensitive and deathly allergic to fentanyl (one of the drugs in epidurals), so I am declining any type of pain meds, including an epidural.  And I have heard/read that when you're induced your contractions are much stronger and difficult to endure if you have been given an epidural.  Did you get one and if so did you find this true?

 

For the ladies who were talking about breech deliveries, I faced that problem too.  I searched all over NYC to find a doctor that was willing to deliver baby b breech.  He was only one of 3 I found in the whole city!  He also said something interesting:  he would rather baby b be breech or transverse, b/c he said it is easier and safer for him to do a breech extraction of baby b, instead of waiting for my contractions to bring a vertex baby b down and then deliver.  He said that he found there to be more risk of the placenta detaching and causing problems, than if he just reached in and extracted baby b breech while my cervix was nice and open.  I had never heard this and was actually pleasantly surprised.  He is much older and said he used to do breech deliveries all the time and it was never a big deal.  I think the high risk of delivering baby b breech comes b/c many OB's now are simply not trained to do it.  It's kind of a lost art form and so if they are at all inexperienced and nervous about doing it, it would make sense that a c-section is safer in that situation.  I feel the more we seek out and request doctor's still trained in breech deliveries, the more the medical establishment will heed our wishes and maybe (possibly, a far off wish) to begin training breech deliveries to residents again.  


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#12 of 19 Old 05-25-2012, 09:25 AM
 
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Eonjourney- wow your story is amazing!  I'm a light runner (12-15 mpw) and I can barely walk two blocks in this pregnancy!  I did run with my singleton pregnancy, but my body just said NO with this one from 8 weeks on.  


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#13 of 19 Old 05-25-2012, 10:01 AM
 
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Thank so much to everyone for sharing their experience and research, they are really helpful to me! I promise I will look into the studies I mentioned. I'm going to be offline for a few days but hopefully I'll be back with some more links/info. Can I just say how wonderful it is to share information and ideas with women who are honest, smart, respectful, open-minded, and kind? Um, and impressive, hello marathon-running mamas! The only kind of running I do is after my kiddo. I'd also be interested in joing the FB group but I couldn't find it. I will probably wait just a little longer anyway, because there are a few people close to me I have not told personally yet about my pg (they live far away from me and I get very little phone time with DS) and I like to do that.

 

Just wanted to add a quick note about my induction as a first-time mom - I was very fortunate to have a pretty good (vaginal) birth experience with it. To the surprise of my doctor, the cervical  softner they gave me (I forgot the name) actually kicked off my labor. They still augmented me (wonder if that could have been done differently - wonder if a doula might have helped there) and while I can't compare the contractions to natural labor contractions, obviously, they were not like what my books/childbirth class/mom described to me. They were smushed together, very little space between them from the very beginning, maybe 2 minutes for the first 1/2 hour and then 30 seconds, to almost constant. I am very confident that I could have managed the pain had I been able to move around and/or labor in a position other than on my back. The reason they wouldn't let me is because the baby monitor would fall off and with pitocin they did not want the baby off the monitor at all. I did end up with an epidural (probably during transition, in retrospect - again, should have gotten a doula!) and I hated it. I hated pushing without sensation and I got a terrible backache and felt weird for a day after. I also got a fourth-degree tear for which I blame the epidural and my positioning. (DS was an avg-size baby with a small head.) That being said, I felt very present during my l&d and remember it with great joy. So for those who've never heard a good (vaginal) outcome for a first-time induction - I hadn't before mine and I was very nervous about that - I did have one. I don't mean to minimize the more usual situation with inductions (I really hear you, Caitlyn), and I myself am trying to avoid one again if I can. BTW, interesting what your peri said about second-time moms, I didn't know that.

 

Gindugirl, if you don't mind, could I ask you to PM the name of your doctor in NYC? I'm in the metro area and I may travel if I end up in that situation. My doctor actually is experienced with Twin B breech, he reassured me that if I should go into natural labor with Baby B breech not to worry. However, the practice feels that outcomes are better with section for a breech B. I will do some serious reading/asking if I end up in that situation. I may end up with an induction or section, and that's okay, I just want to feel whole with it.


Me + DH + DS ('07) + after a long and bumpy road, thrilled that our twin boys are finally here (DS2 & DS3, '12)

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#14 of 19 Old 05-25-2012, 10:49 PM
 
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Gindugirl, glad to hear we're on the same page.

 

With induction, different forms have very different side effects. From what I have heard, Pitocin tends to cause very strong contractions. Good providers can give just the right amount to start labor, but it's very easy for it to be too much (or one to be too sensitive), and then the contractions can be overwhelming, which makes it more likely that one may decide on an epidural (and for some people that epidural means that they can have the vaginal birth they wanted, and would otherwise need a c-section, and for others it goes exactly the opposite)

 

I was lucky to not need pitocin. My doctor induced with prostoglandins, and that was enough to kick everything into a natural labor without pitocin. I wound up having an epidural placed at the very last minute (after half an hour of pushing, about 10 minutes before baby A was born) just in case of an emergency c-section (no drugs, just placement). Which is a tricky time to stay very very still.

 

So talk and talk and talk to your doctor about different induction methods. Because there are all sorts out there.

 

~Caitlyn~ yeah, I don't know a lot about VBAC in particular, as I've only had the one pregnancy. That does make things a lot more complicated.

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#15 of 19 Old 05-29-2012, 06:30 AM
 
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My twins are 17 years old, and even back when I delivered, there was no talk of induction at a certain time. I ended up having a C-section at 39 weeks (HELLP syndrome), but the babies were wonderfully healthy, 8 pounds each.

 

I did see a doctor 2 - 3 times a week at the end, DH took my blood pressure and I checked for protein in my urine every day. As long as everything looked good, my doctors liked my babies right where they were - growing inside me.

 

Good luck!


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#16 of 19 Old 05-29-2012, 06:48 PM
 
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I only have info based on my experience delivering my mono-di twins 10 months ago. Though I'll gladly share. :)

 

I was fortunate to have prenatal care at one of the best of the best maternity hospitals around, and I really valued how much information and research was available surrounding multiple pregnancies, births, etc. when I was going through my pregnancy experience. Those covering my care dealt routinely with twins and more, which was great. With that said, I was informed it was considered standard-drill to be induced at the 37 week mark, though this was strictly with identicals and surrounding the risk for Twin to Twin Transfusion. Long story short (and in very much layman's terms...), once they're shoe-ins to be viable on the outside, they get them out and then needn't worry about TTT.

 

In my situation, I had a textbook twin-pregnancy, and through all my weekly ultrasounds they were sharing immaculately well, I was healthy, no BP issues, etc. so they allowed me to continue on and extra week. I ended up induced at 38 weeks, which I likely could've fought with little issue as things were still healthy, and going extremely well, though I hit a mental wall of "oh my god I'm huge and can't function anymore- get them out of me!".

 

So in this case, in this hospital, under this doctor's care, I likely could've gone longer again if I so chose. Get lots of opinions, and fight the good fight if you're really against induction. If any signs of TTT arise, or any other major issues, obviously things change. But please only pass that bridge if it comes. You know your body, and many people carry multiples in such a healthfully way and they're born as healthy, thriving babies, just as many singletons are.

 

And in hind sight- I would've shot down the induction. I was very fortunate to give birth vaginally in my labour circumstances- though I didn't give birth in a natural, unmedicated way, which was very important to me initially, and in not having that natural experience for myself and my babies I have had to go through a certain grieving period. In labour land, often medical interventions beget more medical interventions, and so starting off with an induction can lead a woman down a slippery slope. 

 

A healthy mom and healthy babes in the end is most important though- go with your gut, don't settle for anything you don't believe in, and enjoy your multiples!!


 

"Be content with what you have; rejoice in the way things are. When you realize there is nothing lacking, the whole world belongs to you."

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#17 of 19 Old 08-26-2012, 08:35 PM
 
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Thank you for all these replies.  I just wanted to update everyone.  I ended going into labor on my own (well, with the help of sex, evening of primrose oil, and stripping membranes) when I was 37 weeks.  I pre labored for about 8 hours and then active labor for 6 hours.  I didn't use any drugs whatsoever and despite really mean nurses who seemed to want to undermine my natural labor, I was able to naturally and vaginally deliver identical twin sons on July 25, 2012.  Baby A was 5lbs 8oz and Baby B was 5lbs 3oz.  Baby A was head down, but after being born Baby A went into a pike position and was in a footling breech position, with a prolapsed cord presenting.  I was very lucky to have the OB that I picked, because anyone else would've done an immediate C-section.  He instead reached his arm inside of me and with the help of a towel grabbed baby B by one foot and pulled him out!  It was tough and very painful, but totally worth it.  I didn't even tear!  So I feel incredibly lucky and happy that I was able to have the birth I wanted despite all the negativity in the hospital and throughout my pregnancy. 


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#18 of 19 Old 08-27-2012, 04:19 PM
 
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Im expecting di/di twins, and my OB routinely induces at 38 weeks. She would let me go to 40 if I pushed, but Ill probably agree to 38. Honestly, my labor with DS went so fast last time, that Im more worried about going into preterm labor and not making it to the hospital than being induced. That being said, I think chances of labor progressing well is better with your second pregnancy than with your first after induction.

 

 

What is this secret facebook group? Do you have to be really cool to get in?


Holly and David partners.gif

Adaline love.gif (3/20/10), and Charlie brokenheart.gif (1/26/12- 4/10/12) and our identical  rainbow1284.gif  twins Callie and Wendy (01/04/13)

SIDS happens. 

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#19 of 19 Old 08-27-2012, 04:48 PM
 
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The fb group is called Naturally Parenting Twins.  Full of lots of really supportive and awesome mamas, you should definitely check it out :)


Married to my love love.gif since 08/12/10, mama to E REPlaySkateboard04HL.gif04/06/01 and twin girls M and Z slingtwin.gif 01/08/11

 We are a  slingtwin.gif  familybed2.gif cd.gif   nursex2.gif family!  Expecting #4 and #5 in September - what a surprise!

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