Twins- How do you deal with them in your practice? - Mothering Forums
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#1 of 10 Old 04-05-2011, 03:01 PM - Thread Starter
 
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Regarding attending twins-

Would you automatically risk out monoamniotic twins?

What about twins in unusual presentation?- examples both breech, first twin breech with second vertex,  one baby transverse etc.?

What about twins for a first time mom?

How frequently do you recommend ultrasounds?

 

Are you legally allowed to do twin births where you practice?

If it is legal how do you decide they are clients you are willing to take?

Do  you have any positive twin homebirth stories to share from your own practice?Thanks

 

 

 

 

 


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#2 of 10 Old 04-06-2011, 10:41 AM
 
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My understanding of monoamniotic twins is that they are at risk for TTTS because they share the placenta, and that there is more chance of complications during birth and statistically significant chances of one or both dying before birth. If they are monoamniotic, then around here the OB standard is to do very close monitoring during the pregnancy to make sure they are growing appropriately, and then have them delivered by 34-36 weeks, generally by planned c-section because of risks of cord entanglement, compression, or prolapse. I am only a doula, but based on what I know from reading and from two sets of friends with twins, I would say the mo-mo is definitely not a good candidate for a homebirth.


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#3 of 10 Old 04-06-2011, 06:06 PM
 
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I agree- the B/V twins could go either way. It would depend on the exact circumstances- how close to the hospital, mom's previous birthing experiences, the midwife's experience, etc etc. It sounds like the midwife you are working with has a lot of experience with twins, so who knows. However, the mo/mo twins are extremely, extraordinarily high risk. If she is lucky enough to make it to term, the twins are still at a high risk for life threatening complications during labor- and for that reason a planned c/s is usually the standard of care.

 

No offense to your preceptor, but I would seriously question her judgement if she is accepting a client like this into her practice. I think that certain experienced midwives can, in some situations,  provide safe care for moderate risk women at home (breech, twin etc), but it is very important for midwives to accept the limitations of a homebirth practice. I just can't see how mo/mo twins could be monitored safely in a homebirth setting. I would not be comfortable attending that birth, as either a student or a midwife.  


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#4 of 10 Old 04-06-2011, 09:45 PM
 
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I think there is a point in "studenthood" where a student starts to morph into the midwife she is going to be.  That takes standing back and assessing the situation with your personal midwife skills rather than those of your preceptor. 

 


By the end of your apprentiseship, you'll be doing that pretty much continuously as you get to practice under the supervision of another midwife. That said, I wouldn't attend a homebirth of mo/mo twins or breech/vertex twins under any circumstances.  My presence would be some sort of suggestion that I think it's a reasonable situation.  However, I fully support the mother's right to choose that, just as I would choose not to attend her, and look askance at whoever attends her.


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#5 of 10 Old 04-07-2011, 03:38 PM
 
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I recommend that you find a midwife student group for discussing these kinds of situations. Does your preceptor know you posted this here? You may be giving more information than she would like posted on the internet, especially in a forum that's not really designed for birth professionals to ask each other about clinical questions in front of the general public.

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#6 of 10 Old 04-08-2011, 06:45 AM - Thread Starter
 
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Yes my preceptor knows I post here. I was looking for experience from experienced midwives. Hopefully positive stories, as I said in my first post. I do trust my preceptor. She knows what she is doing with 30 years of experience and over 1500 births, including numerous twins and breeches. I just wanted some other opinions from midwives who have attended similar births. That is not something I would find on a student group. She also isn't a complete fool. The momoamniotic mom is also consulting with an OB and having regular ultrasounds and will be risked out if she finds it appropriate. The midwife has handled unusual lie situations before so she is not that worried. It is difficult to find stories of twins such as these born at home. I feel blessed to be the student in these situations where I can learn while someone else decides appropriate risk factors. Sorry if you think it was an inappropriate question. I don't think I shared enough information to cause any potential problems for the families.


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#7 of 10 Old 04-08-2011, 07:18 AM
 
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Quote:
Originally Posted by completebeginnings View Post

I don't think I shared enough information to cause any potential problems for the families.



Two things:

1.  It is not that difficult to put information about you together enough to figure out who you are and where you are, and from there, to figure out who your clients are.

2.  It doesn't matter how trivial or innocuous you think the information is, unless the patient authorizes you to discuss it, it should stay private.  Privacy law and professional confidentiality are intended to give clients and patients an assurance of control over information about themselves.  Your judgment about what information might or might not cause a problem for them is irrelevant, the factor that matters is whether you have the patient's permission.  HIPPA allows for consultation between professionals, but did not contemplate those consultations taking place in public forums.

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#8 of 10 Old 04-08-2011, 09:12 AM - Thread Starter
 
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Edited the original question so that I can actually get feedback that I am looking for. I never meant to violate any ones rights. Please see the intended questions I was trying to ask but didn't word correctly in the first place. Gee Wiz.


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#9 of 10 Old 04-11-2011, 07:10 AM
 
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Quote:
Originally Posted by completebeginnings View Post

Regarding attending twins-

Would you automatically risk out monoamniotic twins?

What about twins in unusual presentation?- examples both breech, first twin breech with second vertex,  one baby transverse etc.?

What about twins for a first time mom?

How frequently do you recommend ultrasounds?

 

Are you legally allowed to do twin births where you practice?

If it is legal how do you decide they are clients you are willing to take?

Do  you have any positive twin homebirth stories to share from your own practice?Thanks

 

 

 

 

 



I am not currently practicing (I am back in school for my CNM)-

BUT if I was.....

I would automatically risk out mo/mo twins. Even with an uneventful pregnancy, there is a high risk of emergent complications in labor- cord entaglement could cause death very quickly and could happen at any stage in labor.

I would not automatically risk out twins in unusual presentations. As it stands right now, I would not attend a woman who was B/V because I do not have enough experience to do so, and I may never feel comfortable attending that presentation OOH. V/B, I would do depending on my back up situation, etc etc. Basically, if baby A was head down and everything else was looking good (including a good relationship with the hospital/OB), I would feel comfortable giving it a go, especially if this was not the mom's first birth. If they were B/B, I would consider it if everything else was great.

Twins for a first time mom- if everything was picture perfect, then yes.

I am a fan of a routine 20 week u/s, but I have attended plenty of women who declined it. 

I was not legally allowed to attend twins when I was actively practicing, and I would not have gone outside my license to do so. I am currently pregnant with twins, so hopefully I will have a positive hospital birth story to share pretty soon!!!

 

I am a huge fan of homebirth- both of my kids were born at home and I would be having these twins at home if they were mine. However, the unfortunate fact is that midwives are not well integrated into the health care system here in the U.S. This makes it hard to safely attend moderate risk women at home- without a good transfer system in place, acceptable risks quickly become unacceptable.  When I was a SM, I was, frankly, blinded by the beauty and magic of birth. Almost all the time, birth goes perfectly well. Since we HB midwives (and students) carry a fairly low client load of mostly low risk women, we can go a looong time without ever seeing a major complication. I never saw a life threatening complication during my 4 years of school, and that includes my 2 week internship at a high risk SA hospital. Yes, I saw PPH,  NNR, 3rd degree tears etc- but it wasn't until I had my own license that I saw a cord prolapse, a true shoulder dystocia, and a maternal death (not my client- a close friend). That sh*t will scare you straight. 


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#10 of 10 Old 08-24-2011, 10:01 PM
 
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I wouldn't "automatically" r/o momo's but might proceed w extreme caution, if everything looked good. Would need an additional last minute US to confirm  everything  was still okay  at beginning of labor, if it  got that far. As others have said, so many things can get screwed up when they share a sac & placenta!

  As long as 1st baby head down, I don't care what position the 2nd baby is in, once the 1st is out of the  way, it has plenty of room to turn around. I've attended several  where 2nd baby was transverse until the 1st one came out.  Of course that is ideal for cord prolapse, so I would guard against and be watchful for  that.  If both are breech, that's okay, but if the 1st one  is breech & the 2nd is cephalic, I'd feel better if they came  between 36 & 38 wks. I'd let them go to 41 wks if both were cephalic. I would want them to birth in a  hosp. if earlier than 36 wks, though often things are still okay as early as 35 wks. 

My own dd had twins for her 1st time. 1st cephalic, 2nd transverse, then brought out  by  the feet. Why would twins for primip be any different than twins for a  multip?

I never recommend US before 20 wks & even then, not routinely, only when I suspect a problem or there is some  major discrepancy.  When I suspect twins, I do suggest an US, mostly to be sure they aren't  having TTTT issues. With my  dd, 1st one, cephalic,  was in front, so  couldn't hear 2nds FHT's. I knew SOMETHING else was in there, felt like a head on the left, and  a lesser bulge (butt) on the right, but wanted to r/o a tumor.

Midwifery is not regulated in my state, so as long as I don't use restricted items or procedures in my practice, it is legal. 

All my twin birth stories are great! I love doing twins! Never have had any of them anyway but natural! 

My  fav was this Amish mom... sitting on birth stool, we start to see just about a quarter size sliver of babies rump. I am poised, but not touching. Next ctx, whole baby shoots out, through my hands, onto the  floor! So, a little later, while waiting for  ctx to resume, mom is sitting in bed, nursing baby  A, when she gets this funny look on her face. She says, "Somebody take the baby, quick!" And with that baby B shoots out, heels 1st, onto the bed, as she plops baby A  onto the bed next to her.  At the one & only 21 wk US, both babies were cephalic, by 36 wks, One was breech  & one transverse, so they decide to come butt & footling! the DVD, "the  birth of Psalm & Zoya"  is great too! 

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