A fellow doula supported a lovely lady in her wish to have a normal vaginal delivery with her twins. What follows is the mother's article written for and published by Midwifery Matters. I am so inspired by her strength and courage in the face of what seemed insurmountable odds, and wanted to share it with you:
The purpose of this paper is –
1 To place on my file a record of my experience at the hospital during my second pregnancy.
2 To remind the Medical Staff that having twins is not an illness to be treated, or a disease to be cured, particularly when all tests throughout the pregnancy are within normal limits. Incessant quoting of “worst case scenario” is neither positive nor encouraging for any expectant mother.
3 To encourage the development of a supportive policy for normal vaginal birth (NVB) of twins in those women with normal results throughout who choose this path.
INTRODUCTION
Being pregnant with twins has inherent risks, certainly more than a single pregnancy.
However, a review of multiple studies of uncomplicated twin pregnancies shows clearly that the vast majority of women (90%-95% dependent on the twin type) remained just that, “uncomplicated”, throughout gestation and birth. It can therefore be surmised that the majority of women have the capability of safely going to full term and birthing vaginally, resulting in positive physical and emotional benefits to the mother and her babies.
From the very first visit to the hospital being immediately referred to as a “High Risk Patient” does not assist the expectant mother in feeling optimistic or excited about the impending arrival of twins. This can have a profound and damaging effect on the mother’s mental health for the duration of the pregnancy.
A safe and trouble free arrival of healthy babies is the desire of every mother and it is accepted that understanding risk factors is very important. However, when regular monitoring demonstrates normal results in every aspect, in both mother and babies, a normal vaginal birth (NVB) of twins with minimal, to no, intervention should be a supported option - and an option that includes a supportive, skilled and well-trained hospital staff.
When the research outcomes are still inconclusive, caesarean section at 34 – 38 weeks gestation should not be standard policy. Surely, with all that modern technology has to offer, development of more detailed monitoring practices should be the first step and preferable to an intentional delivery of premature babies. It comes as no surprise that there is a high caesarean rate given the almost robotic recommendation given as a “cure all” procedure for twin pregnancy by all but one obstetrician we met. Not once were the risks of caesarean sections discussed, especially for future pregnancies, and as far as can be determined those risks seem more probable than those faced by attempting a NVB of twins.
At the hospital, three out of four senior obstetricians refused to participate in a normal vaginal delivery of my twins and they attempted to undermine my preference for NVB by making unconstructive comments. Apart from making a twin pregnancy a completely negative experience for the mother, pregnancy no longer seems to be viewed as a normal female process. There is an obsessive fear of litigation that over-rules natural birthing. When everything is progressing normally there appears to be a lack of knowledge, skills, expertise or patience to let nature take its course for the benefit of the mother and babies. The entire management is based on medical intervention and associated administrative efficiency.
FOR THE RECORD
In broad terms my medical history is:
Age 37
My first child was born in the Birth Centre with no drugs or intervention weighing in at 3.7 kgs
My twins were naturally conceived and monochorionic diamniotic (MCDA)
There was no evidence throughout the pregnancy of twin-to-twin transfusion
All blood tests were normal
Blood pressure was normal
Glucose test was normal
Weight and size increase was normal
I am physically fit, having played competition hockey for 25 years and have been practicing yoga for 10 years.
My weight for height ratio is within normal limits.
I go to the doctor for regular pap smears.
I have never taken antibiotics.
I have no relevant medical or obstetrical history.
On May 31 2007 my G.P. confirmed my pregnancy and I was sent for a “dating scan”.
10 weeks – Dating scan showed a twin pregnancy of 10 weeks gestation.
My partner and I then set about reading as many articles as we could find regarding twin pregnancies, including the foetal risks and associated delivery options.
12 weeks – GP offers to do Shared Care if that helps me into the Birth Centre. An
ultrasound and a Nucal Translucency test were done. All normal. A phone call to the hospital established that giving birth at the Birth Centre was not available as an option due to automatic “High Risk” classification of a twin pregnancy.
13 weeks – First trip to hospital. Staff booked me into antenatal Clinic. It was noted that I wanted Shared Care and I asked about a NVB. The midwife told me she would try to get me Shared Care, but doubted it was possible. She also said that “I would have a fight on my hands” to get a NVB without intervention.
17 weeks – My request for Shared Care was brushed aside and I was again booked into the clinic. Health well.
19 weeks – Ultrasound showed normal results. The Sonographer noted how close in size the twins were and that we had two healthy growing boys. It was the first time anyone had said anything positive.
Struggled with being in hospital Clinic, knowing that the clinic policy negated my desire to have a NVB if all is progressing well. I sought the advice of a Consultant Midwife and cried when she explained the negative reality of what we would have to do in order to have a normal vaginal birth of twins without intervention in the hospital environment. It was very upsetting to hear how hard it would be and I commented what a “mistake it was to have twins”. She gave a list of options:
1 Try another hospital
2 Find an accommodating private obstetrician
3 Find an independent midwife
I called a number of private obstetricians and quickly discovered that many were on Christmas leave or fully booked when the babies were due. A locum for one of the reportedly more sympathetic obstetricians said he would surgically remove the babies at 34 weeks gestation because he would be concerned about one dying. I found this to be an appalling over reaction to the perceived risk.
20 weeks – In view of the ongoing negative response from obstetricians to my desire for a NVB, I chose to meet with an Independent Midwife for emotional support. She listened to us and completely understood what we were hoping to achieve. Finally, someone positive to talk to.
21 weeks – Noted that all progressing normally. Discussion with doctor regarding High Risk Status caused me to comment, “Carrying twins in this hospital is like being a terrorist with a bomb on board”. The doctor responded: “No, two bombs”. I was really upset and decided I wasn’t going back to the clinic. On the way out, I booked myself into the Midwives Clinic for a more rational and nurturing approach.
25 weeks – Visited Midwives Clinic. I ask them about moving from this particular doctor’s Clinic. The response was they would see what they could do.
26 Weeks – Meeting with Independent Midwife for emotional support and check.
27 Weeks – Still in this doctor’s clinic and never having met him, I again asked to change. The midwives said they would try another senior obstetrician. Ultrasound showed that all was progressing normally.
28 Weeks – Met with a senior obstetrician. He was completely against my plan to have a NVB without intervention and was not prepared to handle my case. He offered to pass around my file to see if there was someone who would take it. This made my spirits very low. I felt totally rejected and very depressed.
The next day I received a call from the Clinical Midwife Consultant (CMC) of the High Risk Pregnancy Unit telling me she had found my file on her desk with a post-it note on it and my phone number. My file had been seen by a female obstetrician (who I had tried to book with privately and had been recommended by many staff members in the preceding weeks). The CMC asked firstly if I was “okay?”. Since the file had landed on her desk, she said she could only imagine what I had been through in the system so far and she apologised. She asked if I was looking for a natural birth. I said “yes” and when she told me that was okay, I nearly burst into tears. She made an appointment for my partner and me for the following week, gave us her number and told us to call if there was anything we needed.
Blood and Glucose Test – No information was given regarding the possibility of adverse reactions to the GTT. I vomited for 12 hours after drinking the glucose mixture at a time when I had work commitments that could not be postponed. I was to find out later that similar reactions to the test were reported by other women. Had I been informed there might be such an extreme reaction, I would have taken the test at another time. I believe a brochure with relevant information should be given to every woman required to take this test. Results – No Gestational Diabetes.
29 Weeks – Meeting with the CMC and Obstetrician. Finally, after nearly 17weeks in the system we had found an obstetrician who looked at the file and all my results and treated me as normal, healthy and well… AND was prepared to support a NVB. What a relief!! Our spirits were buoyed.
31 weeks – High-Risk Clinic – all results normal.
32 weeks – Independent Midwife – all normal.
34 weeks – High-Risk Clinic – noted that I declined an Induction of Labour
– Independent Midwife – all normal.
36 weeks – High-Risk Clinic – noted that I declined an Induction of Labour
- Independent Midwife – “Strategies ” meeting to enable NVB in hospital labour ward if all progressing normally.
37 weeks – High-Risk Clinic – all normal. No scan.
38 weeks – Independent Midwife – all normal. She was very encouraging that we had reached this great milestone.
High-Risk Clinic – Obstetrician on leave. All normal and babies in good position for birth. The CMC later called to say that she felt bad that we had been left without an obstetrician we could put a face to so she organised a meeting for that afternoon.
A terrible meeting ensued with a very senior obstetrician. All available monitoring had continued to show the pregnancy to be uncomplicated at this stage and from my position all I wanted was to be allowed to have a NVB with the support of a skilled medical team available IN CASE something went wrong.
On expressing my desire to the obstetrician to have no intervention immediately upon hospital arrival, I was told that “if I was his wife, he would make me have an epidural” followed by “I’ve been delivering babies for 20 years and you haven’t”. (Interestingly the Independent Midwife who was offering emotional support had been delivering babies, including many sets of twins, for over 30 years both here and overseas.)
At 38 weeks +3 days I was being attacked with total disdain because my babies were still in utero 10 days before my due date. He then asked, “At 40 weeks what will you do?”, followed by “I am not concerned with litigation” (A totally unsolicited statement the relevance of which I am still trying to figure out.) From the beginning, having done my research and with everything progressing normally, reaching my due date had been my goal as it would maximise the benefits pre and post birth for my babies.
The obstetrician then told me that I was being “incredibly selfish and putting my babies lives at risk”.
My confidence was knocked, I knew now that regardless of the normality of the pregnancy and my knowledge and acceptance of the small risk, my preference for a NVB without intervention was totally abhorred by the system and the clinicians operating within it. I felt rejected, dejected and very depressed. How would I recover from this in time for a positive birthing experience?
To finish the interview, I was then told that he was about to write a card to twins who had been delivered with his assistance 8 years before and the parents had given him a bottle of wine. I asked him if it was a nice drop. He replied, “It was a bottle of Grange. It was very nice. The father was a barrister”. (Was this about expertise, barrister/litigation fear, economic status of the client …… or the kind of wine he expected from grateful parents?)
His very final comment was “Well, I’ve done all my shifts for this month, so it’s not likely you’ll get me”.
It would seem that these and similar comments are used as a method of control to ensure that women are silenced and accept and obey whatever the doctor dictates without question. There is no amiable discussion about the possibility of a normal intervention free delivery and how this might be achieved. Only the worst case scenario is ever mentioned and this totally dominates the treatment of the mother. Any suggested deviation from this recommendation is treated as a personal insult by obstetricians.
39 weeks – High-Risk Clinic – all well.
40 weeks minus 1 day - December 30, 2007. It is worth noting that the pre-labour and labour for my first child in 2006 lasted approximately 48 hours and she was born in water in the Birthing Centre.
This time there was no pre-labour, I had a very sudden onset of contractions at home at 1.30 am. As arranged, the Independent Midwife arrived around 2.45 am for support through the early stages of labour, prior to departure for the hospital. However, on examination, after just 1 hour and 15 minutes in labour, I was fully dilated and unable to move. She gave us a choice, call an ambulance immediately with the likelihood of having them on the way to hospital or have the babies at home. As I could no longer walk and after the treatment I had received at the hospital during my pregnancy, we made the choice to birth at home.
This crucial decision was no doubt subconsciously influenced by the confrontational manner and lack of understanding of some hospital clinicians, and as a result we were actually placed in a situation of potential risk because we didn’t feel comfortable in attending the hospital early in the labour for fear of being railroaded into a high intervention birth, or at the very least being involved in a “battle” as described by the hospital midwives.
So we ended up having them at home, which was not our preference nor was it what we had planned. At 3.12 am, Harvey Francis arrived weighing 3.96 kgs and at 3.41am, Nash William arrived weighing 3.74 kgs.
Akal (midwife), Jerusha (doula), Elizabeth, Damien (partner) and Harvey and Nash
For the record there was:
• No caesarean
• No induction
• No cannula
• No epidural
• No stirrups
• No episiotomy
• No ventouse
• No forceps
• No syntocinon
• No tearing
• No stitching
• No significant blood loss
• No fluorescent lighting
• No cast of thousands
• No removal of the babies from the parents arms
• No immediate clamping and cutting of the cords - the cords were not touched until the placenta ceased pulsating.
Ironically, I had the gentle birth I was endeavouring to have in hospital without the battle or the emotional distress. Whilst understanding and accepting that there was a small risk, I was one of the over 95% of the Monochorionic Diamniotic pregnancies that remained uncomplicated through to a natural and normal vaginal birth demonstrating (contrary to most medical recommendations) that successful outcomes are possible and probable. As a result my children and I continue to reap the considerable benefits.
CONCLUSION
After my very positive experience with the midwives in the Birthing Centre in 2006, the obstetricians involved in my twin pregnancy in 2007 at the same hospital, failed miserably. They were unable or unwilling to even consider my request for a normal birth experience. With the exception of one, my overall experience with the obstetricians was most distressing, negative and filled with rejection. An investigation is urgently needed into the current hospital practise that requires all mothers with uncomplicated twin pregnancies to have a pre-term caesarean section, or to be paralysed from the waist down with an epidural anaesthetic for a pre-term induced delivery of their babies. Such a policy can only result in short and (possible) long term morbidity being suffered unnecessarily by the mothers of twins and their premature babies. This policy also adds to the already too high national caesarean section rate and increases the financial burden on the health system.
RECOMMENDATION
1 That the positive mental health and welfare of the mother be recognised by obstetricians as an important and integral factor in the monitoring of a twin pregnancy.
2 That new and improved non invasive monitoring practices be developed for twin pregnancies in order to identify those in the <10% risk group.
3 That a supportive policy be developed for the normal vaginal birth of twins without medical intervention in uncomplicated pregnancies.
ELIZABETH TREVAN February 26 2008
