Twin A breech, Twin B vertex--undeliverable? - Page 2 - Mothering Forums

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#31 of 40 Old 05-18-2007, 06:29 PM
 
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Originally Posted by torio View Post
Hi, another twin positioning question. We've made small (but inadequate) progress moving our son's feet off my cervix so our daughter, who's vertex can get into position. Our midwife has said that if they don't move substantially within the next 1.5 to 2 weeks (I'm at 37 wks now) we'll have to accept an c/section.

Does anyone have experience with this? Is the combined position of Twin A breech and Twin B vertex always undeliverable? The midwife has mentioned that their chins can lock.

Our twins are fraternal and placentas have not fused. Both are facing in toward the center with their backs at the sides of my uterus. The boy (thus far called Twin A) is a complete breech with his feet dangling over my cervix. The girl is vertex, but a bit off to my left side with her head toward my cervix (boy's feet are in her way).

We've been doing the head below knees exercise as seen on spinningbabies.com for 5-10 min. a day, also a supported bridge pose with DH massaging babes toward the positions they need to be in for delivery.

Any advice or shared experience would be welcome.

Thanks.
Tori
I wouldn't attempt it. And if Twin B is a boy I would definitely not attempt it.
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#32 of 40 Old 05-18-2007, 10:30 PM
 
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How do you/we know this?

I could find no relevent studies about outcomes of Breech Twin A (Doctors have to allow the event to take place to be able to study the outcome!).

Even in my own situation (Twin A vertex, Twin B double-footling breech) I couldn't find relevent studies. We were open to our doctor's recommendation of immediate total breech extraction of Twin B if objective evidence supported it, but not simply on the basis of "just because that's how we do it". Our OB was pretty desperate to convince us: and the best she could come up with were the studies that compare vaginal vs c-section for vertex-vertex twins, and a study of outcomes of singleton breech babies in developing countries in Africa.

I'm not picking on you Oliviabolivia. I just think we need to be very careful when we are claiming it's superior to interrupt nature's processes - unless we have carefully-conducted, scientific evidence to support.

Just think back to so many birth interventions that have come and gone: I'm pretty sure that when moms were getting knocked out in "twilight sleep" and having drug-dazed babies dragged out with forceps that doctors were telling women it was because it was better/safer.
Notice my language. I never said a C-section was safer for breech/vertex presentation. The type of breech makes a huge difference in safety. That's what I've been saying over and over in this thread. You are correct. The studies don't exist because doctors don't allow these types (i.e. footling/complete breech first twin) of births to happen - because the risks are too great.

There was a time not too long ago - even before 'moms were having drug-dazed babies' - when mothers and babies died during childbirth. And presentations like first twin footling/complete breech carry that risk to a significant degree.

As dangerous as it is for mothers to sit idly by while the medical establishment 'claims its superiority over nature's processes' it's equally as dangerous to not recognize that in some cases, we're better off with medical advancements available to us.

And while I can't present studies on the above scenario because studies don't exist, I can tell you that in singletons, cord prolapse occurs in 10-25% of footling breech presentations, and in 5-10% of complete breech presentations, and since the risks of cp can be reduced oxygen supply, resulting in neurological damage and/or death, the risk of attempting a vaginal birth with those presentations outweighs the risk of C-sections. And this doesn't even take into account the risks of head entrapment and interlocking twins.

http://www.emedicine.com/med/topic3272.htm

And in your situation, vertex/breech, I would have attempted a vaginal birth, with full support of my doctor, in a heartbeat. And I would have attempted a breech/vertex birth with his support also, had my dd not been footling.

Oh, and I don't feel like you're picking on me.
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#33 of 40 Old 05-18-2007, 11:51 PM
 
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Thank you, Oliviabolivia: This link you've posted is interesting on several points:
http://www.emedicine.com/med/topic3272.htm

"Cord prolapse occurs in 7.5% of all breeches. This incidence varies with the type of breech: 0-2% with frank breech, 5-10% with complete breech, and 10-25% with footling breech. Cord prolapse occurs twice as often in multiparas (6%) than in primigravidas (3%). Cord prolapse may not always result in severe fetal heart rate decelerations because of the lack of presenting parts to compress the umbilical cord (ie, that which predisposes also protects)."

Bold emphasis is mine - I'm glad to see this was acknowledged in a study. "Cord prolapse" always seems to be a dread phrase in North American obstetrics. But from the reading I've done, there is more tolerance for it in Britian. Midwife Mary Cronk has some good pieces online about breech, especially commenting on the situation that while some breech presentations carry higher risk of prolapse (complete and footling) these same presentations have increase protection over the prolapse actually causing a serious problem.

"A frank breech presentation is preferred when vaginal delivery is attempted. Complete breeches and footling breeches are still candidates, as long as the presenting part is well applied to the cervix and both obstetrical and anesthesia services are readily available in the event of a cord prolapse."

This seems to contradict the suggestion that Oliviabolivia and some others have made: that first twin in a non-frank-breech presentation is a situation where a c-section is definitely called for.

"In 1983, Gimovsky et al randomized 105 women in labor with term nonfrank breech presentations to a trial of labor versus elective cesarean delivery. In this group of women, 47 had complete breech presentations, 16 had incomplete breech presentations (hips flexed, 1 knee extended/1 knee flexed), 32 had double-footling presentations, and 10 had single-footling presentations. Oxytocin was allowed for dysfunctional labor. Of the labor group, 44% had successful vaginal delivery. Most cesarean deliveries were performed for inadequate pelvic dimensions on radiographic pelvimetry. The rate of neonatal morbidity did not differ between neonates delivered vaginally and those delivered by cesarean delivery, although a higher maternal morbidity rate was noted in the cesarean delivery group."
(bold emphasis mine)

A fourth comment that interested me in the study summary was:
"Green et al compared perinatal outcome for term breeches prior to 1975 (595 infants, 22% cesarean delivery rate for breeches) with those from 1978-1979 (164 infants, 94% cesarean delivery rate for breeches). Despite the increase in rates of cesarean delivery, the differences in rates of asphyxia, birth injury, and perinatal deaths were not significant."

On the historical note. . .

It is certainly true that back in "the good old days" more women and infants died relating to complications in childbirth than is the case today. However, from what I've read on the matter, the vast majority of this improvement seems to have come from better hygiene, better management of post-partum hemmorhage, and better nutrition (eg. problems were sometimes caused by rickets, which is diet-related).

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#34 of 40 Old 05-19-2007, 12:42 AM
 
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Whoa, wait a minute. You missed my point entirely. I specifically said that in the case of undesirable breech presentations, i.e. complete/footling, a C-section has less risks. That is undeniable fact. Regardless of the findings of a study of 105 women (24 years ago), the risk of harm to the mother or baby(ies) during a C-section is statistically less than the risk of a mother attempting a vaginal delivery with an aforementioned presentation. Besides, the findings of the study did not refer to how many of the successful breech births were frank or otherwise. They could have all been frank with as much information as that study provided. A position we are not debating here.

That being said . . . of course, many women have successfully delivered breeches in those dangerous positions. I never said it couldn't be done. And I linked the article knowing full well that you would bring up the fact that not all cases of cp result in brain damage or death. This does not deny the presence of a significant risk. The issue is whether it is safe to take the risk when the risks involved with a surgical birth are so much less.

I'm not compelled to comment on the study you cited that is almost 30 years old. It's outdated and not relevant, imo. Can we please stay on the topic of comparing risks of surgical v. vaginal birth for nonfrank breech presentations, please?
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#35 of 40 Old 05-19-2007, 01:44 AM
 
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Originally Posted by oliviabolivia View Post
I specifically said that in the case of undesirable breech presentations, i.e. complete/footling, a C-section has less risks. That is undeniable fact.
When you say, "less risks" do you mean that a c-section for this type of delivery will result in fewer possible problems and those problems will be less severe/dire in nature? Or do you mean that while there are a greater variety of possible complications with a c-section, those complications are generally not as severe/dire as the complications that can arise with a complete/footling vaginal Twin A?

I guess I'm just having a hard time with the 'undeniable fact' that a c-section has 'less risk'. When discussing medical procedures, efficacy is the chance that a given measure will make things better, risk is the chance that a given measure will make things worse. The risk of having anesthetic drugs in your body, and having your abdomen cut open and temporarily rearranged is 100% with a c-section. The risk of adhesions following a c-section is up to 70%.

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Originally Posted by oliviabolivia View Post
I'm not compelled to comment on the study you cited that is almost 30 years old. It's outdated and not relevant, imo.
Information doesn't become irrelevant just because it's 30-years-old (or older). I was interested to see how many people responded to this thread with information of their own (or their twin's) safe arrival as a breech Twin A. Their safe arrivals don't become insignificant just because they are now adults. Practices go in and out of obstetric vogue. By the time these changes cycle through the medical community, one may very well have to consider older information.

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Originally Posted by oliviabolivia View Post
The issue is whether it is safe to take the risk when the risks involved with a surgical birth are so much less.
Yes, I agree that the question is whether a vaginal delivery or a c-section is safer - but in the sense that 'safety' is a value judgement that can be made only by that individual who is going to undergo the procedure. (a la Marsden Wagner). It's a scenario of evaluating a) how many (variety of) complications are possible in either method of delivery, b) the likelihood (rate) of said complications, and c) the severity of them.

For one person, the 'safe' choice would be to accept the guaranteed downsides of a c-section (eg. post-operative pain/recovery) in hopes of avoiding more serious problems (eg. baby with compromised neurological function due to prolapsed cord w/ compression).

For another person, the 'safe' choice may be to pursue a vaginal delivery which may be prone to greater extremes (ie. things go really great, or really terribly).

This isn't an example of one of these people being right and one being wrong. It's two different approaches. There are many situations in life where we see individuals choosing between "hedging bets" or not.

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#36 of 40 Old 05-19-2007, 02:38 AM
 
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For one person, the 'safe' choice would be to accept the guaranteed downsides of a c-section (eg. post-operative pain/recovery) in hopes of avoiding more serious problems (eg. baby with compromised neurological function due to prolapsed cord w/ compression).

For another person, the 'safe' choice may be to pursue a vaginal delivery which may be prone to greater extremes (ie. things go really great, or really terribly).
Once again I am putting myself out here stating an unpopular opinion...In my first post I stated I did not have a C-section but wished I had. (and yes, I heard immediately from ManitobaMom ) From my reading it sounds like many mothers on this site have had successful complicated twin vaginal deliveries. I'd like to mention the other side:

I felt the 'safe' choice was having more pain/recovery for myself and avoid injury to my children. My doctor disagreed and felt a vaginal birth was fine; she delivered similar situations all of the time. (32 week twins, my son was transverse) I was at a respected hospital with a doctor who was considered one of the best in Chicago.

I suggest you go with your gut. I will never forgive myself for not standing up to my doctor. She, and everyone else who argued with me about wanting a c-section, was not around when I was dealing with my son's brain damage, seeing physical, occupational, developmental, and speech therapists weekly. They do not understand the lifetime of worry; never knowing how his traumatic birth and brain injury will affect him throughout the years.

It sounds as though you are informed and have researched your situation. Problems can arise in any delivery. IMO you need to make the decision you feel in your gut and you will be able to live with - no matter the outcome.
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#37 of 40 Old 05-19-2007, 03:54 AM
 
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Once again I am putting myself out here stating an unpopular opinion...In my first post I stated I did not have a C-section but wished I had. (and yes, I heard immediately from ManitobaMom )
I hope I'm not being overly-sensitive but this is sounding like a bit of a shot of some sort. My apologies if I've misconstrued.

I had to look up your first post to see what you were referring to. Respectfully, I must say that you didn't "hear from me". I was the following poster, replying back to the originating question of the thread.

What I thought was very interesting was that you ended up in exactly the sort of dangerous situation that my husband and I were very keen on avoiding: the agressive interventions of the doctor very likely caused long-term health problems for your child. You and I had the same goal: happy, healthy baby. You felt that your best way to reach that goal was through have a c-section. I felt that my best way to reach that goal was through having a vaginal delivery without any "facilitating" by the attending physician unless it became obvious that a bonafide problem had already developed.

I certainly agree with your sentiment that it is a question of deciding what you can live with.

Given that this seems to have taken a personal turn, I will be leaving this thread now.

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#38 of 40 Old 05-19-2007, 12:28 PM
 
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I hope I'm not being overly-sensitive but this is sounding like a bit of a shot of some sort. My apologies if I've misconstrued.

I had to look up your first post to see what you were referring to. Respectfully, I must say that you didn't "hear from me". I was the following poster, replying back to the originating question of the thread.

What I thought was very interesting was that you ended up in exactly the sort of dangerous situation that my husband and I were very keen on avoiding: the agressive interventions of the doctor very likely caused long-term health problems for your child. You and I had the same goal: happy, healthy baby. You felt that your best way to reach that goal was through have a c-section. I felt that my best way to reach that goal was through having a vaginal delivery without any "facilitating" by the attending physician unless it became obvious that a bonafide problem had already developed.

I certainly agree with your sentiment that it is a question of deciding what you can live with.

Given that this seems to have taken a personal turn, I will be leaving this thread now.
I am so sorry...
After re-reading my post it does sound harsh. It wasn't an attack. I was just making the point that you and I had already both posted about a similar topic - with different ideas.

Please accept my apology. I will be more careful about my typing w/o thinking or re-reading.
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#39 of 40 Old 05-20-2007, 09:53 PM
 
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Originally Posted by ManitobaMom View Post
What I thought was very interesting was that you ended up in exactly the sort of dangerous situation that my husband and I were very keen on avoiding: the agressive interventions of the doctor very likely caused long-term health problems for your child. You and I had the same goal: happy, healthy baby. You felt that your best way to reach that goal was through have a c-section. I felt that my best way to reach that goal was through having a vaginal delivery without any "facilitating" by the attending physician unless it became obvious that a bonafide problem had already developed.

I certainly agree with your sentiment that it is a question of deciding what you can live with.

Given that this seems to have taken a personal turn, I will be leaving this thread now.
I share your sentiment, ManitobaMom. The very reason *I* chose an out-of-hospital birth with my twins was to avoid (potentially harmful) over-management of their birth--of which the whole breech factor was one small piece.

Each mom has to do that evaluation for herself and follow her heart.
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#40 of 40 Old 05-20-2007, 10:20 PM
 
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What an interesting discussion.
I have a total phobia of locked twins, so if this was me, I would be all over the hospital birth, and wouldn't hesitate to have a section if the babes didn't shuffle a bit during labour or if it wasn't very, very clear that their chins were nowhere near each other. As a midwifery student, I am still missing a lot of training and experience, but, at this point, I would say that I think I would be comfortable with home, vaginal births of twins in many combinations, breech or not. Just not when twin A is a footling breech and twin B is vertex. But, again, this is a personal phobia.
There's still time, Mama, and one of the pps had a good point about allowing labour to work a bit. Your body knows what it is doing, and may very well be able to shuffle those babes into a slightly better position. Locked twins are very rare, so the odds are in your favour, really. Do you trust your midwife, and feel a connection and lots of respect in the relationship? I think that's the most important part here.

Many, many good wishes for an awesome vaginal birth.
Katia

For greater things are yet to come...

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