Identifying Preterm Labor with Twins
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DOCTOR WADE SCHWENDEMANN: If you’re pregnant with twins or higher order multiples, hopefully you’ve had a discussion with your health care provider about the risk of pre –term labor. But do you know what pre-term actually means? Can you identify the signs of pre-term labor and what they look like? And what can you do to guard against it. I’m Doctor Wade Schwendemann, perinatologist at the San Diego Perinatal Centre in Caswell, here to shed some light on pre-term labour in twin pregnancies. This is twin talks.
CHRISTINE STEWART-FITZGERALD: Welcome to twin talks. We’re broadcasting form the birth education centre from San Diego. Twin Talks is your weekly online on-the-go support group for expecting and new parents of twins. I’m your host Christine Stewart-Fitzgerald. And have you heard about the twin talks club?
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Let’s introduce everyone who’s in the room and on the phone with us today. As your host, I’ll say I’ve got identical girls who are five years old. Thankfully carrying them full term so I got lots of questions here today for our folks and our panellist. I do have a singleton who is now two years old. So, we got all girls
SUNNY GAULT: And those are full term baby too right?
CHRISTINE STEWART-FITZGERALD: Full term baby as well yes
SUNNY GAULT: So, I’m Sunny. So I’m producing today’s show. I’m also the owner of new mommy media which produces this show as well as Parent savers, Preggie Pals and The Boob Group. And I have four children of my own. I have a four year old boy, a two year old boy and identical twin girls who just turned one
CHRISTINE STEWART-FITZGERALD: Alright. And let’s see on the phone with us, Regina, tell us about your self
REGINA DRURY: Hi my name is Regina Drury and I am a mom of eight year old triplet girls. They are fraternal. And I host a weekly podcast called multiple personalities. I interview parents and doctors, people that are part of a set of multiples. I’ve had people with twins, triplets, I’m getting ready to interview a quad mom next week so come over and check it out when you get done listening to Twin Talks.
SUNNY GAULT: Awesome
SUNNY GAULT: Hey twin talks we have a special comment from one of our listeners that I like to read to you today and this comes from Melissa. And Melissa says: Hi, thank you so much for the segment on mothering multiple multiples. I found out this week that I’m expecting my second set of twins, first identical, next likely fraternal. As there’s no history of twins in my family, shock doesn’t begin to describe my feeling right now. It’s been very difficult to find resources on what it’s like to parent multiple multiples so I’m incredibly grateful for your podcast with the three wonderful mothers with several sets of twins. And then she goes on to say “Can you put me in touch with some of those mommas?” which we did. And Melissa, thank you so much for writing this and congratulations. It’s such an awesome thing. You even have one set of twins so you’re doubly blessed and we really appreciate you listening to our show.
CHRISTINE STEWART-FITZGERALD: Okay. Well, today’s topic is pre-term labour with twins and we’re talking with Doctor Wade Schwendemann who’s here to help us understand what preterm really means and how to identify it. So, thanks for joining us Doctor Schwendemann.
DOCTOR WADE SCHWENDEMANN: Thanks for having me, of course.
CHRISTINE STEWART-FITZGERALD: Well, we’ve read recently that the definition of term, the word “term” has changed. So can you help us understand what term and what preterm actually means?
DOCTOR WADE SCHWENDEMANN: Sure. What you’re referring to is the kind of the re-classification of full terms specifically. It used to be what we considered full term to be thirty seven weeks and beyond. And now what we’re looking at is, you know, what we call an early term which be thirty seven to thirty nine weeks. And then term which is thirty nine to forty one, and then post term which is after forty one weeks to pregnancy.
Those are new definitions by the American College of OBGYN. The rationale for changing those definitions comes from primarily from the singleton literature where it’s ideal to deliver after thirty nine weeks if everything is medically safe. Doesn’t necessarily apply it to multiples, those definitions are definitely different and a little bit fuzzier when it comes to multiple pregnancies.
CHRISTINE STEWART-FITZGERALD: And as far as the definition goes then, so you’re saying that the multiples may, I mean preterm or early term might be a different range when it comes to multiples
DOCTOR WADE SCHWENDEMANN: Right. And the rationale for that, the reason for that is that there’s really just a difference of when the ideal time for delivery is. And so for multiple pregnancies, the ideal time is going to vary greatly, it’s going to vary based on the presentation or the way that those multiples are divided if they each have their own placenta or if they have to share one. Or in case of triplets or more if two of them share a placenta or not, babies, when we’re talking about twins specifically, babies that each have their own placenta, generally the ideal time is approximately thirty eight to thirty nine weeks for delivery. When we’re talking about babies that have to share a placenta, then we’re looking at thirty six to thirsty seven weeks as the time when ideal delivery is going to occur
SUNNY GAULT: I know when I was taking treatment, you know, my perinatologist, I wanted to push it as long as possible and I had, my babies were sharing the same placenta. I remember telling her “oh I want to push it, I want to push it” and I was trying to push it to thirty eight weeks. And we knew it was going to be a scheduled cesarean that was the plan, Mother Nature kind of had other plans. My twins decided to come at thirty five weeks instead and so, you know being the middle of November when they arrive I wanted to go as long as possible. But I remember her saying “that’s kind of, I understand that’s kind of your dream, but that’s probably not going to happen” and she was right
CHRISTINE STEWART-FITZGERALD: Oh yeah
SUNNY GAULT: So listen to your perinatologist
CHRISTINE STEWART-FITZGERALD: Right. Right. Well you know it’s interesting because I think often, you know, we do hear “okay well twins come early” so you know like doctor Schwendemann you’re talking about “okay here’s sort of the ideal range” but then reality is often much earlier.
So, what are the standards as far as you know early, you know, are there particular, you know, weeks in which “hey this is really critical”, you know, what’s the viability, you now the earliest viability or you know what are these kind of significant numbers that
DOCTOR WADE SCHWENDEMANN: So, what we consider the threshold viability meaning the gestational which babies have a real shot to survive is somewhere between twenty three and twenty four weeks of pregnancy. Science is advancing all the time. Used to be always twenty four was our number and that was when we would really try to resuscitate these babies and really try to give them a chance. Sometimes we’re having success at twenty three weeks now in some institutions. You got to be in the right hospital with the right level NICU and all that but twenty three weeks is possible. Twenty four weeks is still the threshold of viability though. The average delivery time for twins across the country is thirty six weeks. The average delivery time for triplets across the country is thirty three weeks. And if you get higher orders than that, higher order multiples than that, it goes down even more substantially. Quadruplets is going to be somewhere between twenty and thirty weeks as an average. There are just not so many of them that we have a lot of good data on that
CHRISTINE STEWART-FITZGERALD: And I think Regina, I think you had said with your triplets, you delivered at, it was at thirty three weeks, is that correct?
REGINA DRURY: thirty three weeks, three days yes
DOCTOR WADE SCHWENDEMANN: So, right on schedule
REGINA DRURY: Yeah. When I was in the hospital for twenty eight days
CHRISTINE STEWART-FITZGERALD: Oh, so you were, you’re on the bed rest. And I was curious, we’re your doctors telling you that that was probably what you should expect? Or what were your expectations around this?
REGINA DRURY: Well they made me stop working at twenty four weeks. And so, I was going to go home and be on bed rest. And I was going to go visit them once a week and have them check everything out. And on my first visit, after I stopped work, he was checking everything out and my cervix was thinning while I was in the office while he was checking it. He checked it like five times and it kept thinner and thinner.
So, he said “not to alarm you, go home, get something, you now clothes to change in to [inaudible]” So I went to the hospital, they got all that straightened up, they gave me a steroid shot, you know for the lungs and everything, and I never left. He just kept me there
CHRISTINE STEWART-FITZGERALD: Wow
REGINA DRURY: I had contractions for the whole two months I was there so yeah
CHRISTINE STEWART-FITZGERALD: Oh wow, but you kept them in till thirty three weeks which is, which is great
DOCTOR WADE SCHWENDEMANN: I’d say it’s always incredibly common Regina. Moms with triplets, what you’re talking about are what we call a dynamic cervix where it’ll kind of shorten and lengthen while we’re watching it with ultrasound. And that’s only, that’s only because of the contractions that you’re experiencing and it’s, when we think about the size of the uterus and what it’s supposed to do, it’s supposed to carry one baby to forty weeks. While when you’re carrying triplets at twenty four weeks, that’s essentially the size of may be, I don’t know a thirty two or thirty three week baby, maybe thirty four even. Between all the placenta and all the fluid that’s in there and all the baby that’s in there.
So it makes sense that you’re going to have some preterm contractions in preterm labour. And see some cervical change in that. And that cervical change is why you got sent to the hospital
CHRISTINE STEWART-FITZGERALD: Wow
REGINA DRURY: Right
CHRISTINE STEWART-FITZGERALD: And are there any other sort of critical milestones, I mean, sometimes I’ve heard like there’s a thirty week milestone, I mean , in terms of just development?
DOCTOR WADE SCHWENDEMANN: There are. Every week that you can gain between twenty three and twenty eight substantially increases the chance for each baby survival. And for survival without long term neurologic problems. Once you get to twenty eight, the next real goal is thirty and then thirty two, then thirty four.
And so each of those milestones is a substantial, substantial and permanent. If you get to thirty two weeks at our hospital for example, the chance for survival for a baby is approximately ninety nine percent
SUNNY GAULT: Wow
DOCTOR WADE SCHWENDEMANN: Ninety nine plus percent the chance for survival without long term neurologic problems is over ninety percent. And so once you get to thirty two weeks, you’ve really reached a major milestone in my opinion. Those babies are of course going to be in the intensive care unit for several weeks like Regina’s did to feed and grow and get bigger, get, and you know healthy. But long term, they’re going to do really well in almost all cases
CHRISTINE STEWART-FITZGERALD: Wow, so switching gears a little bit, you know we talked about labour and I think in our sister show Preggie Pals, you know we’ve talked about you know just generally signs of labour. But I don’t know I want to ask, is it different to have signs of labour earlier on in the pregnancy. In that either late, you know, second trimester or early trimester, does it feel differently, what would we expect?
DOCTOR WADE SCHWENDEMANN: Well the signs for preterm labour definitely a little more mild or can be more mild that their counterparts in you know the new term. Pregnancies, the issue becomes really what we’re talking about is now there’s a, the signs are so much more subtle; you can confuse them with regular pregnancies signs. Low back ache and back pain, pelvic pain and pressure, vaginal, you know, vaginal pressures that can kind of mimic be the same as almost like a round ligament type pain that a lot of women experience. Menstrual type cramps that are just mild. And so, if you have some of these signs and symptoms you don’t want to just ignore them.
If you’re at twenty six weeks and you’re feeling a little bit, if it doesn’t feel right, trust your instincts, at least call your doctor, be evaluated in someway
CHRISTINE STEWART-FITZGERALD: Well, so in other words if, you know we think of regular, in your term, signs as being very, I don’t know, say big you know having you know, significant cramps or really, you know like a lot of pressure or the water breaking. And so I think what I’m hearing is that if it’s, it’s much earlier on it’s going to be able just a lot more subtle and you might think “oh I’m just feeling a little bit achy today” or there’s just some sort of shift you know going on that within the pelvic region that might need some attention
DOCTOR WADE SCHWENDEMANN: That’s absolutely right. And I’m not trying to advocate for people to call their doctor every time they have a particular amount of pressure or a single cramp in their lower back but if it’s persistent if it’s continuing after, long after you think it should have gone to try some, say for example, you’re having back pain and you try some Tylenol and it doesn’t really seems to take it away to that level, then I would, then I would call your doctor’s office and be evaluated. You’re absolutely right, the signs of pregnancy, of labour, at term or near term are big things. You know, your water breaks, which of course can happen early too and if that does happen then you just go straight to the hospital. But you know if your water breaks or if you have regular powerful painful contractions you know every three to five minutes apart. Well, when you’re talking about preterm, you want to look at are you having contractions that are six in an hour. That’s a number that, if you have more than six contractions in an hour, you should be calling your doctor’s office even if you think they’re Braxton Hicks. You need to be seen to make sure
CHRISTINE STEWART-FITZGERALD: That’s good play. We’re going to take a break and when we come back we’re going to talk about some of the things that you should be doing if you think you’re experiencing preterm labour
CHRISTINE STEWART-FITZGERALD: Well welcome back, today we’re talking with Doctor Wade Schwendemann about preterm labour with twins. So we were just kind of mentioning some of the different signs that of preterm labour and you know what women might be experiencing.
And so if she’s experiencing consistent contraction, I think you said six contractions within an hour then that’s something she should definitely call her doctor and get attention. And if she goes to her doctor and says you know I’m concerned about this and there and confirm that it’s preterm labour, what can be done?
DOCTOR WADE SCHWENDEMANN: Well, first you want to confirm that it is preterm labour or not. So the way to do that, there are a lot of things that we can do to look at whether this is actually preterm contractions, preterm labour or not. And so, the important thing to understand is that a lot of women have preterm contractions which are just contractions that occur every so often and those don’t necessarily cause change in the cervix right? But for women who have a preterm labour we’re going to see some sort of effect on the cervix itself. Whether that be dilation or shortening or softening.
Something that’s telling us, these contractions are actually causing a change and if they aren’t stopped could lead to early delivery which is obviously what we like to avoid in all cases. Now things that we can do to assess that would include an ultrasound of the cervical length which may or may not be done. Not all these are going to be done by every doctor or every triage areas so don’t.
If they do want, then not the other, don’t think that they’re doing the wrong thing. They’ll want to monitor you for contractions as also monitor the baby’s heart rate if we’re at twenty four weeks or more. They’ll monitor, they may collect what’s called a [inaudible] test. This is a test that helps to tell us about who’s at risk for preterm labour and even more to tell us who’s not at risk for preterm delivery rather which is really useful. But they can only be done in certain, there’s circumstances in which you can’t do that test. You can’t always do it.
They may do a cervical exam with their hands or digital exam where they check and see if the cervix is opening or dilating. And those things are all kind of ways to the things that might happen to you if you going to be evaluated for preterm labour. They may also collect urine samples to make sure that’s not urinary infection that’s giving you symptoms that are similar to preterm labour, that kind of thing.
If a woman’s experiencing preterm labour though, generally, it’s going to require admission to the hospital or going to do exactly as it occurred for Regina. You’re going to get admitted to the hospital. You’re going to get what they called steroid shots to increase the baby’s maturity in case we can’t get things stopped. And your doctors may choose use a medicine to stop labour.
We have a few of those that we can use and different ones are used by different doctors for any number of reasons.
CHRISTINE STEWART-FITZGERALD: And so, and it sounds like things happen quickly as well. So I think like Regina, you know in your case, you said that she were visiting your regular, you know, your OB and then, he told you, “okay it’s time to go to the hospital” and you were there within just a few hours. Is that right?
REGINA DRURY: Yes. We stopped by the house and picked up some clothes and we went straight to the hospital half hour
CHRISTINE STEWART-FITZGERALD: Half hour, wow. That’s great and . . .
DOCTOR WADE SCHWENDEMANN: Most of the time I tell people to bring something to read because if you’re going to be in the hospital for a few days, it gets boring really fast. And TV gets repetitive quickly.
SUNNY GAULT: Yeah. Totally!
CHRISTINE STEWART-FITZGERALD: Yeah. So, I think it sounds like we, you now, one of the key factors is just you know, being close to your, your medical provider and getting those test quickly and just taking it seriously and acting quickly
SUNNY GAULT: When my girls are finally born, you know at thirty five weeks, one of the twins broke their water so that was an obvious sign to me that labour was starting. But if I were to kind of back up about, I mean what was it, I don’t know fifteen weeks earlier, I had a scare where I don’t even think I was quite twenty weeks yet.
And I was having cramping, which was very unusual for me. I never really did, you know had Braxton Hicks that I could tell. It was just, you know, if you’re really cramping, you’re in labour. That’s what my body is telling me based on my previous experiences. And so, but I called labour and triage and I kind of explain the situation and they say “well just come in and we’ll check you”.
But it was consistent and it felt like contractions you know. And, but they kind of hooked me up and looked at everything and determined that I was just dehydrated. And then I needed to kind of relax more and drink more water. And, but that was kind of a scare for me, my husband looked at me and he’s like “I told you, you need to relax”. You know, like what are you doing up late at night doing, you know because, you know being a parent a lot of times even with my other kids, you know being up late at night is the only time I could get stuff done.
But I wasn’t giving my body the relaxation that it needed and I wasn’t drinking enough water and I wasn’t doing all that kind of stuff. So, but I was glad that I went in and it really did change how I perceive and how I handle the rest of my pregnancy you know.
CHRISTINE STEWART-FITZGERALD: Yeah you know I have to say and I think that’s a really interesting point because I think I’ve heard that there are some doctors that prescribe bed rest, because of people like you.
SUNNY GAULT: I know right because you have to. . .
CHRISTINE STEWART-FITZGERALD: Because doing so much as okay I’m going to force you to relax and take it easy.
DOCTOR WADE SCHWENDEMANN: You know I think there are two things to that. Number one, we’ll talk about the bed rest a little bit more but don’t forget that, fifteen weeks before the middle of November is the heat of summer in San Diego. And so it’s not exactly hard to lose water and get dehydrated really easily.
And it’s actually, you know, here we’re fortunate that, that could actually happen year round for some of our patients. So you got to be very, very cautious about that sort of thing. It’s important to stay well hydrated.
When it comes to bed rest, there’s you know, there’s a lot of controversy and a lot of you know a lot of recent information has come out and says that bed rest is not effective for preventing preterm labour. And for women who are carrying a normal pregnancy, that’s probably true as long as things, things are okay.
But for women who are carrying more than one baby, we absolutely still recommend periodic rest, you know, multiple, at least an hour a day starting once we get to twenty four weeks. That’s not uncommon as a recommendation. And for women who are carrying even more than that, if you’re carrying more than twins, I wouldn’t be surprised at all to have doctors prescribe bed rest for you.
Just because it, you know, the activity can, the more activity you are the more risk you’re taking.
CHRISTINE STEWART-FITZGERALD: Yeah. And I can speak for myself, you know, I didn’t have any prescribed bed rest. But I was working, I had an office job and at the time I was working for home and so I had the advantage. I could, you know, work on my computer, have my feet up and sit on a bed. And it was, I mean literally, I mean a form of modified bed rest.
So I think it, you know, I think as women we have to really find where our limits are and you know and maybe that just means you know taking an hour keeping our feet up and just being really conscious of how much activity we’re doing throughout the day and Sunny sleep.
SUNNY GAULT: Sleep, relax.
REGINA DRURY: I couldn’t move anyway so there wasn’t much point.
CHRISTINE STEWART-FITZGERALD: Oh yeah. And I think you know, I actually maybe, I mean hospital bed rest I mean is boring as it is, I mean at least you’re, you’re being attended to right?
DOCTOR WADE SCHWENDEMANN: Yeah. If there’s like for Regina’s case especially and for other, everybody else’s out there like that and anyone who might be listening who’s stuck in the hospital now, understand that the rationale for being in the hospital is really access to the things that we can use to stop preterm labour.
And so, if a moms at home with preterm labour and even she recognizes the signs very early and comes in to the hospital right away and gets admitted to the hospital and all that can take time. And we’re talking about a period of several hours that labour just continues without treatment versus the mom who’s in the hospital and bed rest where that treatment can occur pretty much right away. And so, it’s a lot better.
I don’t know Regina you probably were often on multiple different medications for preterm labour during your stay in the hospital and that’s not uncommon for us to use several different things to try and prevent that contractions or supress them if we can
REGINA DRURY: Yes. Yeah I did take several things and I also had gestational diabetes so they were pricking my finger four times a day too
DOCTOR WADE SCHWENDEMANN: Again very common, the more placenta that’s in there the higher the risk for diabetes in pregnancy. So, moms with twins and triplets incredibly common
CHRISTINE STEWART-FITZGERALD: Thank you so much for everybody for joining us today. And for more information about preterm labour with twins or for more information about any of our speakers and panellist, visit our episode page on our website. This conversation continues for members of our Twin Talks club. And after the show, Doctor Schwendemann is going to talk about other ways that we can help prevent preterm labour. So for more information about twin talks club, visit our website www.newmommymedia.com
SUNNY GAULT: Okay it’s time for a special segment that we like to call “We’re expecting what??” and it’s where we share all the funny moments that we had when we found out we were expecting twins. And this comment comes from Angela. Angela says: Once my son turned two, my husband and I talked about having another baby. With my job being unstable we decided to wait.
Once a solid job came about we began trying. I was disappointed when we didn’t conceive right away and I began to thank God for my three year old son and ask Him to change the desires of my heart if it wasn’t His will for us to have another baby. My sister then announced she was pregnant and I began to feel even worse.
A month later I took a test and it was positive. We went to the doctor when I was five weeks pregnant. I was filled with joy when the doctor said “okay there’s the first heartbeat, and there’s the second heartbeat”.
My husband on the other hand was horrified. I had to convince him just have one more since he’s a single child. I’ve always wanted three children. He gulped and asked the doctor “what? Are you sure? Twins? No way! Are you sure?” the doctor kept repeating himself as he showed us the two embryos on the ultrasound monitor.
God has a sense of humour because the babies are due on my husband’s birthday. Angela, that’s so funny I have a similar story and that is that my husband thought we were done after two kids but we had two boys and I really wanted a little girl. And so I convinced my husband to have baby number three and then we found out we were having babies three and four. And so, yeah, yeah, super funny. But thank you so much for sharing this story. It’s a good one.
CHRISTINE STEWART-FITZGERALD: That wraps up our show for today. We appreciate you listening to Twin Talks.
Don’t forget to check our sister shows:
• Preggie Pals for expecting parents
• The Boob Group for moms who breastfeed their babies
• Parent Savers, your parenting resource on the go.
This is Twin Talks, parenting times two or times two, times two. However many you have.
This has been a New Mommy Media production. Information and material contained in this episode are presented for educational purposes only. Statements and opinions expressed in this episode are not necessarily those of New Mommy Media and should not be considered facts. Though information in which areas are related to be accurate, it is not intended to replace or substitute for professional, Medical or advisor care and should not be used for diagnosing or treating health care problem or disease or prescribing any medications. If you have questions or concerns regarding your physical or mental health or the health of your baby, please seek assistance from a qualified health care provider.
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