Mar 30
Yesterday I saw the BEST Twin talk video which I will put at the end of this post..
But first….. I wanted you all to have a look at some luscious twin breastfeeding photos I found on Google. I am in a twin mood today.
This has had over 2 million hits on YouTube!
Nov 17
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Jun 16
~I’ve reason to be a little proud of the care given this week.
I hope this is a continuing trend of attention to detail, utilizing evidence-based practices and compassion, listening to our patients and providing them with options and the best possible care…. I’ll give you a few details about each as you read on… In summary, this week we have had the following situations:
Whew! We have a lot of busy weeks but they don’t always have this intensity or variety! I feel proud because there may have been a few things done differently due to recent conversations I’ve had…Plugs I’ve made… and I keeping putting in little plugs to try to gently increase awareness & educate. I am an Instructor in Neonatal Resuscitation and Lactation.. sometimes the troops listen when I talk about other topics…. I’m no expert but I try to be current, correct and compassionate in care. (My 4 c’s)
Okay… the details for the first 3… stay tuned for the others…..
~25 Week gestation walk-in~
She came in with mild cramps and pressure. She didn’t report any fluid leakage but did C/O pink vaginal mucus. We had her in an exam room pronto. She had a gentle speculum exam which revealed hour glassing membranes thru an approximate 4-5 cm cervix..visually. Hour-glassing means that the intact amniotic sac has protruded thru the partially dilated cervix and expanded like a bubble in the vagina. She went right into trendelenburg. The transfer teams were called. It was soon clear she would deliver here and the baby would need to be stabilized and transferred. The NICU team contacted us back they would be flying up to retrieve. The nurses caring for her were tremendously supportive. All procedures explained, options offered and decisions honored. They got her records faxed over from her OB’s office so we had a little history.
Like a well oiled machine (from all of our drills), all the emergency equipment was readied, pediatrician in attendance, roles clarified. Once he was born almost without warning, precipitously, all at once, about 30 minutes later. He was quickly assessed, wrapped in plastic, ventilated, then intubated. We had a peripheral IV in place in case he needed meds or fluid volume. He had a chest xray and a blood culture/blood count sent. He was kept warm, ventilated and appropriately oxygenated and had stable glucoses. He weighed in at about 700 gms (about 1 1/2 lbs). The team arrived when he was about 30 minutes old. They checked all labs, xrays and his IV line. They gave him Surfactant and pretty quickly and carefully, loaded him in the transport incubator then got him out to his mommy for a visit before he was transferred. They answered all her questions before they left and we helped her deal with it all. The doctors discharged her shortly after that so she could get down to her baby. At last report, he was doing just as expected for 25 wks, no other complications often seen at that gestation, for ELBW (Extremely Low BirthWeight) had come up. He was actually improving each day! So happy for everyone!
~Twins!~
She came in to the hospital already in very active labor at 37.5 weeks gestation. Her twins were both head down (vertex/vertex). She labored quickly, uneventfully and delivered Twin A at about 1 pm. With the ultrasound machine in the room, they scanned over her still pregnant belly to see where Twin B was and if he was still in position. Turns out that once Twin A had vacated the womb, baby B had a lot of room and he had moved into a transverse/breech position. That means he was more bottom first than head first anymore. Most Ob’s now don’t attempt a breech delivery even with the second twin. They are quick to do a C/S…. This day, however, …. the Ob in charge called over an associate to ask his opinion. They brought the mom into the OR and prepared to do a C/S if they were unable to get the baby in proper position. The point is they were at least going to TRY! With the U/S scanner and 2 assistants, they did an external version and worked Twin B back into a head down vertex position without complication. He delivered vaginally about 1 hour and 45 minutes after his brother! The staff kept the first twin in the room the whole time so they could all be together. I spoke to the Ob later and congratulated him on a great job.. he said to me that he remembered what we had talked about awhile ago (when I had written the post about a C/S for the 2nd twin), and had researched it himself. I was happy that any little plug I had made had sparked interest in researching the topic and possibly even influencing a decision towards better care! I am happy to report that both babies went home with mommy on day 2!
~A Heroin/Cocaine addict~
We are attempting to put together some consistant protocols for drug screening so that we don’t miss the opportunities to protect a newborn in need…. Some may not understand how important it is to sometimes screen the healthy and innocent to weed out those with problems…. They don’t always present in an obvious way. From my perspective, those individuals who are hiding something are very difficult to identify from outward appearance only. We identified a heroin/cocaine addict recently who was a very beautiful, well groomed, well nourished, affluent (seemed wealthy) woman who stated she was just visiting in our area, and had no prenatal care info or records with her…. she was in rip-roaring very active labor at 36 1/2 weeks with heavy vaginal bleeding and fetal distress. We thought we were headed to the OR but the baby had other ideas. We had little time to get more information before the baby was born. There was a small abruption but luckily, the baby was vigorous and did not seem to have suffered blood loss. The admitting nurse had collected a urine sample with a catheter insertion and sent it for drug screen. It came back positive for Opiates, Cocaine and THC. The baby’s urine also tested postive for Opiates, Cocaine and THC. Because we knew, we were able to start the NAS (Neonatal Abstinence Scoring) for signs of drug withdrawal and identify the signs quickly. If the baby is unable to be comforted by swaddling or holding or if we had 3 scores of 8 or higher, there are protocols set up for medicating the baby. The baby did require medication within 24 hrs. Once medicated, she was such a happy sweet little girl. The nurses named her “Molly” and we all loved her. She stayed with us all week until the pediatrician released her andChildren’s Services placed her in a foster home experienced with this kind of care. Unfortunately, some of the big drug problems have hit my area. Our local paper just did a big series of stories on local Heroin addiction problems. Apparently it is cheap and accessible.
I am going to publish this part tonite and tell the other two stories soon…
May 21
I was talking to one of my on-line Twitter friends @onefinebreeder about twin delivery. I was telling her about how things used to be.. how vertex-nonvertex twin gestation’s were always delivered vaginally ….. and she commented on how it was sad that some of the old OB skills have been totally lost to surgery… So Very True!
I got to thinking about the first combination Twin delivery I had witnessed back in the very early 80’s. This was actually one of our own (hospital employee) nurses . She was a multip…. around 37-38 weeks and healthy…no complications during pregnancy. Twin A delivered spontaneously, vaginally with a generous episiotomy as they often performed at that time… The baby , a girl, was about 6 pounds, vigorous and had no problems. We were all marveling at the first baby, checked fetal hearts on the second twin and started waiting for him to get in position. Still before consistent ultrasound, we were not worried. However, we had a newer doctor who was attending this birth. He began to get concerned after 5- 10 min when contractions slowed and he was worried that if this baby was breech, he would have difficulty with the “after-coming” head. Up to this point, all I had learned was this can be a real concern if the smaller feet or buttocks present through a cervix which is not fully dilated. Much research was done later on but at the time, I did not know about it. He began to ask us to call the OR for a C/S. This was unheard of in my limited experience at the time…. my 70’s world. I thought.. how can they do a C/S now when one baby was already born??? I tried to be an advocate… (my early days… )”We have Piper forceps…” I said meekly… “Have you tried to grab a large part and help bring the baby down… ?” This was my limited knowledge… all I knew to suggest. I kept wishing one of the other doctors was on duty that day.. or maybe we could call them???
In front of the mother, he said to me “I’m not going to have a bad outcome here!” By now it was 20 minutes or so. There was no cord prolapse, no drop in fetal hearts, no evidence of immediate trouble… the baby was seeming to work itself into breech position…. To the mother he said “Your baby is in serious danger and the best thing to save him is to take you for a Cesarean now!” “I’ll sew your episiotomy together while we are in the OR.”
I was in shock. She signed, scared to death of course. So we prepped her for the OR. She went up for a C/S of her second twin and repair of her generous episiotomy. Her second baby was delivered frank breech… a beautiful boy about the same size and was also vigorous and healthy. I remember I felt as though she was almost assaulted. I remember feeling that this was a true rare event if it every happened before. There was no immediate access to information like today.
Luckily mom and babies did fairly well in the postpartum period even though healing from both the episiotomy and the C/S was difficult for her.
" Psst-- How can I get out if I'm not head 1st ??"
I wanted to see how much research I could find on this topic. I had gone to the green journal (OB & GYN) website but then it locked me out. (You can only look at abstracts anyway unless you want to purchase the article. You are on your own for that.) I had some luck with the abstracts at PubMed so I have put a few here.
I decided to take a look across time…….
This first one is from 1981. . Quoted abstract from the PubMed site:
Cesarean Section for Delivery of the Second Twin
Evrard,JohnR.; Gold, Edwin M.Obstetrics & Gynecology. 57(5):581-583, May 1981.Four cases of combined vaginal-abdominal delivery of twins are presented, and an additional 5 cases from the recent literature are discussed. Malposition, malpresentation, and contracted cervix were the main indications for cesarean section for the birth of twin B. In the 9 cases presented, there were 2 perinatal deaths.
Interesting that this research was done during the same time frame as my experience above. I’d like to know more about those poor outcomes 😦
The next interesting article I found was researched over a 10 yr period, somewhat close to here in a larger facility, published 1997. THIS study examines the delivery of the second twin by utilizing external version vs breech extraction . 😉 The results are showing in favor of breech delivery vs version (those meeting exclusionary criteria ).. Versions were associated with higher a incidence of Cesarean and fetal distress. Neonatal outcomes no different and are stated below:
Method of delivery of the nonvertex second twin: a community hospital experience.
Smith SJ, Zebrowitz J, Latta RA. J Matern Fetal Med. 1997 May-Jun;6(3):146-50
Abington Memorial Hospital, Pennsylvania, USA.
The purpose of this study is to examine the incidence of cesarean section and fetal distress complicating the delivery of the second twin in vertex-nonvertex twin gestations in which the second twin underwent either breech extraction or external version. The intrapartum courses of 510 twin gestations delivered at a community hospital over a 10-year period were retrospectively analyzed. All vertex-nonvertex twin gestations were identified in which the second twin underwent attempted breech extraction or external version. Exclusion criteria included birthweight < or = 1,500 g, fetal anomaly, intrauterine demise, and monoamniotic twins. Of the 76 twin sets that met inclusion criteria, 33 underwent external version and 43 underwent primary breech extraction. The two groups had similar demographic characteristics. External version compared to breech extraction was associated with a significantly greater incidence of cesarean section (8/33 vs. 1/43, P = .008) and fetal distress (8/33 vs. 1/43, P = .008). There was no difference between groups in neonatal outcome for the second twin as measured by length of stay, 5-minute Apgar < 7, intensive care unit admissions, hyaline membrane disease, intraventricular hemorrhage, and traumatic birth injury. In conclusion, the increased incidence of cesarean section and fetal distress in patients undergoing attempted external version suggests that breech extraction may be the preferable route of delivery for the nonvertex second twin weighing more than 1,500 g
The next study was published a little later in 2001 and covered a 20 year span of time… during the 80’s and 90’s at a larger center in Nova Scotia, Canada. They noted an increase in their combination vaginal/cesarean twin births and documented some statistical data, looked at reasons for an operative second twin birth. I wish to read this study further some day to see if there is mention pertaining to mother/baby outcomes other than statistics outlined (even though that wasn’t their objective) in this abstract:
Combined Vaginal-Cesarean Delivery of Twin Pregnancies
Obstetrics & Gynecology . 98(6):1032-1037, December 2001.
Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada.
OBJECTIVE: To estimate the incidence and factors associated with combined vaginal-cesarean delivery in twin pregnancies. METHODS: We studied all twin births weighing 500 g or more during a 20-year period (1980-1999) at a tertiary care center. Major anomalies, monoamniotic and conjoined twins, and antepartum fetal deaths were excluded.
RESULTS: During this 20-year period, 105,987 women delivered, of whom 1565 (1.5%) had twins. Of these, 1151 twin sets fulfilled the study criteria. The mode of delivery was vaginal in 653 (56.8%), cesarean in 448 (38.9%), and vaginal-cesarean in 50 (4.3%). During the 20 years there was a statistically significant increase in combined vaginal-cesarean and elective cesarean deliveries, with a decrease in vaginal deliveries. Parity, gestational age, and birth weight discordance (>25%) were not associated with combined delivery. Compared with vaginal delivery, the nonvertex second twin was associated with a twofold higher risk of cesarean delivery (relative risk [RR] 2.3; 95% confidence interval [CI] 1.3, 3.8; P =.002); and an interdelivery interval of over 60 minutes with an eightfold higher risk (RR 8.2; CI 4.6,14.6; P <.001). Vaginal-cesarean delivery had a 22-fold higher use of general anesthesia compared with vaginal delivery (RR 21.8; CI 5.4, 88.5; P <.001). CONCLUSION: There has been a significant increase in combined vaginal-cesarean and elective cesarean deliveries among twin gestations, with a decrease in vaginal births. Vaginal-cesarean delivery is associated with nonvertex second twin and a prolonged interdelivery interval.
Now we come to 2008! There is a study here from Texas. This study looked a twins born by C/S after labor and twins who had cesarean birth of the second twin. they campared outcomes to see if the twin of a combined delivery had more problems. The most important pieces of information I gather from this abstract of results…. (again, having NOT read the entire study):
“Combined twin delivery may be associated with endometritis and neonatal sepsis when compared with a twin delivery where both are delivered by cesarean in twin pregnancies experiencing labor. More serious neonatal sequelae, including hypoxic ischemic encephalopathy and death, were not affected by the route of delivery of the second twin.” Hmmm
Cesarean Delivery for the Second Twin
Alexander, James M.; Leveno, Kenneth J.; ….et al:for the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units Network (MFMU) Obstetrics & Gynecology . 112(4):748-752, October 2008.
Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas, TX 75235-9032, USA. james.alexander@utsouthwestern.edu
OBJECTIVE: To examine maternal and infant outcomes after a vaginal delivery of twin A and a cesarean delivery of twin B, and to identify whether the second twin experienced increased short-term morbidity as part of a combined route of delivery. METHODS: Between January 1, 1999, and December 31, 2000, a prospective cohort study of all cesarean deliveries was conducted at 13 university centers. This secondary analysis was limited to women with twin gestations who experienced labor and underwent cesarean delivery. We compared outcomes of the second twin in women who had vaginal delivery of the first twin and a cesarean delivery of the second twin to those who had cesarean delivery of both twins. RESULTS: One thousand twenty-eight twin pregnancies experienced labor and underwent cesarean delivery; 179 (17%) had a combined vaginal/cesarean delivery. Gestational age at delivery was 34.6 weeks in both groups (P=.97). The rupture of membranes to delivery interval was longer in the combined group (3.2 compared with 2.3 hours, P<.001). Endometritis and culture-proven sepsis in the second twin were more common in the combined group, respectively (n=24, odds ratio 1.6, 95% confidence interval, 1.0-2.7; n=15, odds ratio 1.8, 95% confidence interval, 1.0-3.4). These differences were not significant after logistic regression analysis. There were no statistically significant differences in an arterial cord pH of less than 7.0, Apgar score less than or equal to 3 at 5 minutes, seizures, grade III or IV intraventricular hemorrhage, hypoxic ischemic encephalopathy, or neonatal death. CONCLUSION: Combined twin delivery may be associated with endometritis and neonatal sepsis when compared with a twin delivery where both are delivered by cesarean in twin pregnancies experiencing labor. More serious neonatal sequelae, including hypoxic ischemic encephalopathy and death, were not affected by the route of delivery of the second twin.
I gather from these studies that a combined delivery route leads to more problems.. however…there are probably more problems than breech presentation alone to lead the provider to make that choice. I believe that many newer providers of obstetrics in a hospital setting are more apt to do a scheduled C/S for any vertex-nonvertex twins they encounter. That is what is done in my facility today. The same for all breech presentation singleton gestation.
Where is that old-fashioned nurse when you need her?? How ’bout the old fashoined doc??? 😉
I am very interested in anyone’s story or experience either in healthcare or your personal birth. Please let me know if you know anything about this!
Thanks for reading!
May 12
One gorgeous lazy summer day in 1976– I got the call from the OB office (across the street) about 11 am.
Office Nurse: [matter of fact voice] “We’re sending over a woman with twins.”
Me: [Calmly] “Ok. Is she is labor?
Office: [still matter of factly] “She’s in very active labor, Dr. B just checked her and she’s 8cm.”
Me: [A little less calmly] “Whooo.. really?? We don’t have a doctor over here. Make sure Dr. B knows that. We’ll go get things ready. How far along is she?” (in the pregnancy)
Office:“She’s about 8 months maybe 35/36 weeks….. we aren’t quite sure, she just came into town– to the university — and this is actually her first visit”
Me: [Quickly] “Well — Ok- thanks, better get rolling! ”
We Hang-up
Me- To our group: “Guys- we’ve got twins in active labor coming from office right now- she’s already 8cm!”
In those days, twins were always expected to be delivered vaginally.. I never even thought to ask about which pregnancy this was, presentation, (head down? breech?), membranes ruptured?……. not that I had much time to gather any history…
We began to pull some supplies out and open up the delivery room…
The next call came in about 3 or 4 minutes—-
Office: [anxiously] “BRING EVERYTHING OVER HERE….QUICK ! THERE’S NO TIME…. SHE’S GOING TO HAVE THE TWINS HERE !” Hangs-up
We couldn’t all leave… One of the labor nurses grabbed a precip tray (small tray of emergency delivery items for a precipitous delivery) , put on a cover gown and ran down the steps to go over to the office.
The two most experienced nursery nurses grabbed two sterile newborn kits (these had sterile towels, washclothes, blankets, cotton balls, cord clamp, and a sterile shirt etc..) and a few other supplies needed to care for the babies… opened the lid of the 2 Armstrong heaters and threw everything inside. —These old heavy metal heated units would open from the top and were on small little wheels. We usually used them to transport smaller babies from the delivery room to the nursery. They were already old back then and were not real easy to push.
Armstrong Incubator/Transporter
This all happened very fast in a couple minutes. They were gone….headed down the elevator wearing their cover gowns pushing those old heated units filled with supplies.
I stayed behind with a couple other nurses to watch our other patients. We watched from the window over looking the street.
Both nurses, running on short chubby legs were pushing those Armstrong Heaters down towards the street. (Think Danny DeVito and John Belushi in scrub dresses and nurses caps!).
One of the general surgeons had just come out of the hospital, saw what was happening and ran ahead of them right out into the middle of the busy street, held up both her hands to STOP all traffic. (Think Jane Fonda in a lab coat!) If she had a whistle–she would have used it. From my window it seemed like the Keystone Cops.
They got into the office, huffing and puffing. They told me there were a lot of people already in the tiny exam room. Dr.B had already delivered 0ne squalling baby girl probably about 4 lbs, about 4 or 5 weeks early. She was pink with a lusty cry. Dr. B was always so calm.. he was telling everyone to calm down while he tried to explain to the mother and the very faint shocked looking father that there was ANOTHER baby coming! Remember this was her first visit to our doctors? Turns out, this was her first prenatal visit ANYWHERE!! You see….although Dr. B had told his nurses to call over to us a few minutes earlier with his findings, things happened so fast there in the office that he hadn’t QUITE really explained it yet to the parents. Twins were often a surprise in those days anyway, but this poor mom and dad had really just arrived in this country, let alone get in the door of the doctors office and promptly have TWINS!.
Back to the delivery. The second baby was coming frank breech. No worries, we did that all the time. They told me Dr. B asked the labor nurse who had arrived first to open up one of the sterile packs and use one of the sterile towels to help hold the baby’s feet while he skillfully delivered the arms & then head of the second squalling 4 lb baby girl! The 2 nursery nurses wrapped up the babies in the sterile towels and wisked them both right out of there in the Armstrongs, out of the office, back to the street. (I doubt they let the mother have any time with the babies. That’s how it was then…… 😦 ) Like a well rehearsed skit, our lovely lady surgeon was waiting and once again— held up traffic so the nurses and babies crossed quickly and safely.
I watched them coming back up the sidewalk and was waiting as they got off the elevator. They asked me to then help start the admission procedures in the isolation nursery. (They were born in that “dirty” office under unsterile conditions afterall!) At that time, babies delivered outside the “sterile” hospital were always watched in the Isolation Nursery.
The mom came over by ambulance up to the delivery room to deliver her placenta (one placenta- they were indeed confirmed identical). The father was scrubbed up, gowned up and finally allowed to really see his little baby girls. I was the one to bring him over to the heaters. He was crying so hard. He was really in a state of shock and so emotional.
I thought he was so shocked from the surprise of twins and the burst of frenzied excitement the birth had been……
This is when he told me that one year ago, in their country, his wife had suffered thru the birth of a stillborn baby girl ……… and now they had TWO healthy baby girls!!! Can you imagine??
This family continued to grow as they stayed in town, both studying at the university. Her next baby was 10 LBs and born by C/S….. that’s another story.
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