Transcript: Preparing For Your Twin Vaginal Birth
Twin Talks
Preparing for Your Twin Vaginal Birth
[00:00:00]
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[Theme Music]
DR. TEVY TITH: Having a vaginal delivery for multiples is not always the first thought for expectant moms but it can have its advantages. If you do decide you’d prefer a vaginal delivery for your twins, how can you prepare for it and how is it different from a singleton delivery. I’m Dr. Tevy Tith of the San Diego prenatal center, here to discuss how you can prepare for a vaginal birth for your twins. This is Twin Talks.
[Theme Music/Intro]
CHRISTINE STEWART-FITZGERALD: Well welcome to Twin Talks, broadcasting from the birth education center of 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. Have you heard about the Twin Talks club?
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Another way for you to stay connected is by downloading our free Twin Talks app and it’s available for most smart phones. Well before we get started, let’s introduce our panelists and everyone who’s here in the studio and I’ll introduce myself, I’m Christine Stewart-Fitzgerald and I’ve got almost 5 year old identical girls and they are headed off to kindergarten soon so I’m excited. And then I do have a 20 month old singleton who is now officially weaned and on her own so I’m very happy.
SUNNY GAULT: Oh my goodness. Yehey!
CHRISTINE STEWART-FITZGERALD: Yehey! So yeah let’s go around and let’s see Sunny…
SUNNY GAULT: Yeah.
CHRISTINE STEWART-FITZGERALD: Can you tell us about you?
SUNNY GAULT: Absolutely okay. Hey everyone I’m Sunny. I’m the owner of New Mommy Media which produces Twin Talks, Parent Savers, Preggie Pals and The Boob Group and I’m a twin mommy as well, I actually have four children now. My oldest is 4 and that’s a boy and my middle guy is 2 and then I have identical twin girls who are now 7 ½ months I think.
CHRISTINE STEWART-FITZGERALD: Wow.
SUNNY GAULT: Yeah.
CHRISTINE STEWART-FITZGERALD: Time flies.
SUNNY GAULT: Full house.
SHELLY STEELY: I’m Shelly. I’m a high school history teacher and I’m also the producer here at Twin Talks. I have two children, identical twin boys who are going to be 2 next month and I’m currently pregnant with my third just one this time though…
CHRISTINE STEWART-FITZGERALD: Yehey!
SHELLY STEELY: And we’re expecting a girl. So I want to give you guys a little heads up about our virtual panelists program. If you’re not able to join us here on the studio, you can follow along at home. You can follow us on Facebook or Twitter with Twin Talks or you can use the #twintalksvp to be a panelist from the comfort of your own home.
CHRISTINE STEWART-FITZGERALD: Alright.
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CHRISTINE STEWART-FITZGERALD: And today we have a question from Annie in New Port Rhode Island. She’s asking about solid food. She says “my 8 month old fraternal boys, they seem to be doing you know fairly well and trying new foods. I give them a lot of mush up vegetables and mix in some fruit. But lately I’ve notice that one of my boys seems to be much pickier than the other and refuses the food I’m offering. So how do I handle this? Do I need to prepare different food for each of them?”
NATALIE DIAZ: Hey Annie, this is Natalie Diaz author of “What to Do When You’re Having Two” and founder twiniversity.com and multiplicity magazine. Just so you know you are not alone on your frustration to solid feeding your twins. It’s very common that one twin will have a preference of the foods that they like while the other are the more of the kind of I will called the other one [inaudible] I don’t know if I’m the only one who thought them would be old school but that’s what I think of.
There is always going to be – you shouldn’t say always, its usually one child who’s the better eater. So how do we overcome this? Do you need to have two separate meals? It depends you know if one kid is totally going on strike and want to eat nothing but sweet potatoes and they’re really just giving you a lot of problems, you may have to but I’m going to tell you old school mom style even now to this day my 9 year old know that we should we have a rule on our house that this house isn’t a diner.
You eat what’s on the table and that’s that. Not saying you should apply this rule for your 8 month old. I am saying that you got to figure out a way that they’re going to eat what they have. So I wish I knew specifically what food they were eating. Do they not want to eat meat? Do they not want to eat veg? Do they not want to eat fruit? If it’s a problem that they want to stay with the sweet, just gradually mix in some vegetables and go you know 90% fruit 10% vegetable and next day go 20% vegetable and did I say that right?
Well you know what I mean. Just gradually increase the amount of vegetable that are in the fruit until you are getting a nice 50/50. If that doesn’t seem to be working and you do feel comfortable with having two separate bowls for your twins then of course go ahead and do that. Feeding kids and parenting twins is not a one size fits all. You have to do whatever you feel is the best for your twins.
If you think that it’s an issue with texture, let’s say they don’t want to eat chunk or something you may want to speak with your pediatrician about it that you should always speak to your pediatrician if you really have a concern. But as far as having a picky eater, you could just have picky eater you know. Not every twin would just eat whatever put in front of them.
So try tomorrow start a little bit to a lot of fruit a little veg. Try to change that. Try to give them what they want alternating with something that they don’t want. So let’s say you blended up some chicken soup and then they love having mash carrot. Get them one spoon of the chicken soup, one spoon of the mash carrot. You can keep it on separate bowl. Try that. See how it goes. And you know there is actually a ton of resources on twiniversity.com in regards to feeding your multiples. So you may want to check that out.
There is a lot more specific you know questions and answers up there but on short you get back to the New Mommy Media team like a follow up. I’d be more than happy to help more than ever and whenever you need me. Have a good day, take a deep breath and try not to get frustrated. If you get frustrated, the babies will sense that and they’re going to shut down and shut their little mouth. So take a deep breath, put on some great music and just make eating time a fun time. Good luck! I hope today everybody eats everything that’s in their dish. Bye bye.
[Theme Music]
CHRISTINE STEWART-FITZGERALD: Today’s topic is preparing for a vaginal birth and today we’re talking with Dr. Tevy Tith who is here to help us understand what and expectant twin mom needs to know to plan for a vaginal delivery of her babies. So thanks for joining us.
DR. TEVY TITH: Thanks for having me.
CHRISTINE STEWART-FITZGERALD: Yeah so I know you see a lot of twin moms in your practice…
DR. TEVY TITH: I do.
CHRISTINE STEWART-FITZGERALD: And if she decides just “you know hey I really would like to try for a vaginal birth”. What makes her a good candidate to try for that?
DR. TEVY TITH: There are definitely several things that make her an excellent candidate. The first thing we always have to consider is her safety as well as the safety of the babies. So like I tell all my moms, baby A always determines which way the party goes. So first and foremost baby A is head down.
The second thing is to really figure out which what kind of twins they are so if they don’t share a sac that’s also the best kind of twins to have vaginally. We ideally would like for the twins to be at least 3 plus pounds each. So 15 hundred grams is usually our cut off for having twins vaginally.
We don’t want for there to be a discrepancy in the size of the twins so hopefully they’re about the same size. Anything over 15% to 20% makes it a little bit more unsafe particularly if baby B is the bigger one. And then finally if they’ve had a vaginal birth before, that’s just a bonus but it’s not necessary. So those are the most important things in determining having a…whether or not it’s safe to have vaginal delivery for twins.
CHRISTINE STEWART-FITZGERALD: And it sounds like these are mostly factors about the babies themselves and on for the mom on the maternal health side of it, are there anything that relates to I mean either her health I mean like if you know let’s say if she’s overweight…
DR. TEVY TITH: Yeah.
CHRISTINE STEWART-FITZGERALD: Or does that make a difference or…
DR. TEVY TITH: So we use the same criteria for even a singleton mom. So if she’s had a prior vaginal delivery if it’s in a horizontal direction, she could potentially be a candidate for a trial of labor for twins. I’ve done that before. If she’s had a C-section in a different direction then she may not be. So it’s the same criteria that you would use for singletons. If she has certain cardiac or pulmonary problems then she may not be a candidate just for her own health. So we would again use just similar criteria that we would use for twins.
SHELLY STEELY: What about those common complications? I guess like we have preeclampsia or gestational diabetes, the things that are more common with twins. How those affect her likelihood of being able to deliver vaginally?
DR. TEVY TITH: Again generally the success rate is usually the same for both for gestational diabetes or for somebody who has preeclampsia but for somebody who has preeclampsia for instance you have to make sure that the safety of the mom is ensured and with preeclampsia cure is that the cure for preeclampsia is delivery so if you don’t think you can expedite a delivery of twin pregnancies in a you know in a quick fashion then you may have to she may really be a candidate for a C-section instead. So…
CHRISTINE STEWART-FITZGERALD: And then I mean is there you know anything that a mom can do during her pregnancy if she says “okay you know I really like to have a vaginal delivery”. Is there anything she could prepare for on I don’t know health wise for herself?
DR. TEVY TITH: So you know just like with a singleton pregnancy we really want to encourage mom to increase her caloric intake. So what’s recommended for singleton is above baseline about 300 calories a day. For twins it’s probably more along the lines of 3 to 5 hundred extra calories a day. And again that’s not empty calories. You have to be healthy.
CHRISTINE STEWART-FITZGERALD: Right. I remember eating lots of protein.
DR. TEVY TITH: Yes. Exactly. And then just educating and counselling patients extensively about nutrition, keeping stress levels low…
CHRISTINE STEWART-FITZGERALD: So there are some positive things that you know we can do if we said “hey we do really like to have” that’s great. Now just in making that decision I mean let’s say a mom has really they said “well you know I’d like to have a vaginal delivery but I’m not sure”. What are some of the pros and cons of each delivery type?
DR. TEVY TITH: Well looking at it from a maternal aspect first, definitely the pros of having or the advantages of having a vaginal delivery include shorter hospital stays, typically if you were problems with anaesthesia so if you were anaesthetic complications usually it’s less of a blood lost if everything goes very well. There are some studies that I’ve looked at breastfeeding initiation rates being higher after a vaginal delivery but when you look at it downstream 3 months 12 months down the line there isn’t really a difference between a C-section and vaginal but initiation rates appear to be a little bit higher.
CHRISTINE STEWART-FITZGERALD: And that means that’s basically starting breastfeeding immediately…
DR. TEVY TITH: Yeah.
CHRISTINE STEWART-FITZGERALD: After birth.
DR. TEVY TITH: Yeah. Exactly.
CHRISTINE STEWART-FITZGERALD: Okay. Okay.
DR. TEVY TITH: Exactly.
CHRISTINE STEWART-FITZGERALD: Yeah. So the moms who have the twins vaginally might have a better success rate of getting the baby…
DR. TEVY TITH: Starting.
CHRISTINE STEWART-FITZGERALD: Starting…
DR. TEVY TITH: Yeah.
CHRISTINE STEWART-FITZGERALD: To breastfeed and I think that’s probably the most critical time periods. . .
DR. TEVY TITH: Definitely the immediate postpartum bonding experience. So yeah…From some of the disadvantages obviously you know there’s always a small risk of conversion to a C-section for patients who start vaginal who have a planned vaginally delivery first and then it ends up getting converted to a C-section for usually for fetal indications.
CHRISTINE STEWART-FITZGERALD: Then when they are converted, I have also heard of in some cases were a woman was able to deliver one vaginally and then for some reasons the second one…
DR. TEVY TITH: Yeah.
CHRISTINE STEWART-FITZGERALD: Isn’t in the position or something happens were the second one need to be delivered surgically. How often does it happen?
DR. TEVY TITH: About 4% of the time give or take.
CHRISTINE STEWART-FITZGERALD: Okay.
DR. TEVY TITH: You know there was a really large study that was recently published in the New England Journal of Medicine and the study took over 10 years and many, many countries to participate in but I’m glad the study was done because it has provided so much good useful information for us. And it look up the safety of vaginal twin deliveries versus plan C-section then they it show that vaginal delivery was just as safe as C-sections.
CHRISTINE STEWART-FITZGERALD: I know I mean and that’s good to know. So that’s something that’s pretty rare and I think for woman who kind of you know considering her options like well that’s probably not a big likelihood that that would happen but…
DR. TEVY TITH: No. No it’s just something that you would want to remind mom that could possibly happen.
SHELLY STEELY: Is there anything that would make it more likely that you could be aware or make it more likely that you would have to deliver one each way?
DR. TEVY TITH: Yeah. You know interestingly the in terms of having to convert sort of midway through the delivery, the one thing that sort increases that likelihood is waiting too much or waiting for too long to deliver the second twin. So there are definitely studies that have shown that if you actually after the delivery of the first twin immediately go and try to deliver the second twin, your success rates are much higher. And whether that’s vaginal or whether that’s vertex or doing like a pretext extraction, it’s actually much more successful if you immediately try to go and deliver the second one.
SHELLY STEELY: And with that size discrepancy you talked about, will that increase the likelihood?
DR. TEVY TITH: Hopefully you would know that ahead of time you know with ultrasound at least the week within the week of delivery so that you could try to prepare yourself for that but definitely if twin B is significantly bigger than twin A then that is definitely a possibility.
CHRISTINE STEWART-FITZGERALD: And we talked about having them delivered within a time frame I mean is there are time frame I mean we’ve heard of deliveries being within 10 minutes, 45 minutes, I mean…
DR. TEVY TITH: You know it’s funny you generally we say we would like to deliver the second twin within an hour. Some other authorities may say within half an hour. But you know I’ve done this before and I like to have them delivered hopefully within 10 minutes of each other.
CHRISTINE STEWART-FITZGERALD: Wow.
DR. TEVY TITH: But it’s not always possible. It’s definitely not always possible and I’ve definitely sat there for an hour waiting for the second twin especially if the second twin is vertex and the cervix hasn’t close and then I’m happy to give it time and to wait for the second one.
CHRISTINE STEWART-FITZGERALD: Sounds like I mean it sounds like there are just a lot of variables in the timing and you know the moms health and…
DR. TEVY TITH: Yes.
CHRISTINE STEWART-FITZGERALD: I mean I can say in having done a VBAC myself I mean it’s a lot of work pushing a baby . . .
DR. TEVY TITH: That’s why they call it labor.
SHELLY STEELY: Well then what kind of support could you recommend? So we all know with twins there’s they have their own plan so even the best laid plans for vaginal delivery don’t always go well but is there anything that has been proven to improve chances? I mean is there like more support person or other things that she could do?
DR. TEVY TITH: You know I think that definitely having a really good support person is really important in the delivery process? One of the bigger differences in terms of delivering vaginally for twins is also the fact that you when we push we usually will push on the operating room instead of the labor room and usually when you’re in the labor room with a singleton you can have a lot of family around.
When you’re pushing in the OR you can really have one other family member around and it’s partly because the ORs are a lot smaller and if we have to quickly convert to a C-section for instance then you would want to just be have to usher one person out instead of a whole family member or instead of a whole family.
So that is definitely one big difference but that support person is very key, is very integral but also you know having the provider explain everything that is going on and who everybody is really important too and what processes are taking place. So for instance after the delivery of the first one we usually do an ultrasound, we’ll do an exam and we’ll tell mom what we’re seeing and if we need her to push or to bear down or something then she could be an active part of the whole process.
SHELLY STEELY: And so some hospitals will let twin moms deliver in a regular labor in delivery room. So that would be I guess you need to look at when you’re choosing your hospital if you wanted to have a support person like a doula or something like that.
CHRISTINE STEWART-FITZGERALD: It sounds like it depends on the medical provider…
DR. TEVY TITH: Yeah.
CHRISTINE STEWART-FITZGERALD: So within your practice that’s probably a standard…
DR. TEVY TITH: Yeah.
CHRISTINE STEWART-FITZGERALD: Procedure and then some hospitals might have different policies in place.
DR. TEVY TITH: Yeah.
CHRISTINE STEWART-FITZGERALD: You have to ask around.
DR. TEVY TITH: Yeah.
CHRISTINE STEWART-FITZGERALD: Right. Yeah.
SUNNY GAULT: I have a question when it comes to the space that is available to do that. So if you laboring in a OR room, so I had two caesareans and one vaginal birth, my twins were caesarean so this doesn’t quite apply to me but the question would be I know how valuable like that OR space is and you can be in labor. I mean with my first I was in labor which end up being a vaginal delivery for like 14 hours. I mean not being crazy…
DR. TEVY TITH: Yeah.
SUNNY GAULT: So is it fair?
DR. TEVY TITH: Oh.
SUNNY GAULT: I mean so I mean how does that work?
DR. TEVY TITH: Oh.
SUNNY GAULT: On what point will they take them in there?
DR. TEVY TITH: Yeah.
SUNNY GAULT: Yeah.
DR. TEVY TITH: It’s not it’s definitely not for the whole labor process…
SUNNY GAULT: Okay.
DR. TEVY TITH: At all.
SUNNY GAULT: Okay.
DR. TEVY TITH: No. no. no. It’s actually just at the very end when…
SUNNY GAULT: Once they reach 10 or something?
DR. TEVY TITH: Once they’re even once even past 10 like once they’re starting to push.
SUNNY GAULT: Okay.
DR. TEVY TITH: Once they started to push then we’ll usually bring them to the OR…
SUNNY GAULT: Okay.
DR. TEVY TITH: But not definitely not during the whole labor process because that can take a while.
SHELLY STEELY: So somebody who wanted to have like a doula or another support person…
CHRISTINE STEWART-FITZGERALD: Yeah.
SHELLY STEELY: then they’d still be…
CHRISTINE STEWART-FITZGERALD: Oh yeah.
SHELLY STEELY: Able to have after the process?
CHRISTINE STEWART-FITZGERALD: Oh yeah.
DR. TEVY TITH: Yeah. No. Exactly. I’m what I’m really referring to is really just that last part…
SUNNY GAULT: Yeah.
DR. TEVY TITH: Kind of the last part Hoorah of the marathon before you know the pushing.
SUNNY GAULT: Right.
CHRISTINE STEWART-FITZGERALD: And you know earlier you talked about the position of the babies as being one factor of you know the success of you know having a vaginal delivery and you know I know I see questions all the time from moms who say “well you know I’m 36 weeks and I’ve got you know baby A head’s down and baby B is you know breech or transverse and you know when they’ll going to flip and you know I mean how important is that factor and then you know once they do get to labor if that second baby is not head down I mean you know what can be done as far as you know you know moving the baby around?
DR. TEVY TITH: For having a twin vaginal delivery the real important part is really just having twin A down. Because in the end even if they’re both head down after delivery of twin A, baby B can flip. So…
CHRISTINE STEWART-FITZGERALD: So baby B could be head down…
DR. TEVY TITH: Yup.
CHRISTINE STEWART-FITZGERALD: And then you know baby A is born and is like baby B is like “hey I’ve got lots of space”…
DR. TEVY TITH: Yeah. Yeah.
CHRISTINE STEWART-FITZGERALD: “Let’s do some flips or gymnastics”
DR. TEVY TITH: Yes.
CHRISTINE STEWART-FITZGERALD: “I’m having fun and hey I got the place for myself”.
DR. TEVY TITH: Yeah. Exactly. I’ve definitely seen that happen. I’ve definitely seen twin B who was breech the entire time suddenly flip to vertex. So what’s most important is really the position of twin A.
CHRISTINE STEWART-FITZGERALD: And if baby B does flip then you know what type of procedures can be done?
DR. TEVY TITH: There are definitely a couple of different options, typically if you, if baby B has flip and is now breech, you can actually going to do a or is either breech or is a transverse you can actually going to do what we call an internal podalic version and it just means that you go in and you grab one or both feet and you bring it down to the cervix or you bring it out of the vaginal canal and deliver baby B breech.
CHRISTINE STEWART-FITZGERALD: Oh okay. Now on when you said when you’re grabbing on to the feet, are we talking about a footling breech delivery or you just kind of…
DR. TEVY TITH: It is essentially a footling breech. It’s essentially a breech delivery.
CHRISTINE STEWART-FITZGERALD: Okay.
DR. TEVY TITH: You grab one foot, the other foot will follow and you will deliver the baby backwards or feet first which they use to do all the time actually a long long time ago even for singleton deliveries. But presumably if baby A has pass through the vaginal canal then they’ve made space and room they’ve paved the way for baby B and you should be able to deliver baby B.
SHELLY STEELY: Wow. Wow.
SUNNY GAULT: Wow.
CHRISTINE STEWART-FITZGERALD: I mean it sounds like that’s kind of an art form too I mean I know in medicine you’ve got sort of the science but then looking at the situation you figure well…
DR. TEVY TITH: Yes you…
CHRISTINE STEWART-FITZGERALD: Different opportunity.
DR. TEVY TITH: You definitely have to have a provider who is very comfortable with those types of manipulations inter partum. You also we are blessed in that we also have the technology to see all of the ultrasound as well. So I will usually use ultrasound. A lot of providers will use ultrasound to help diagnose what position the babies are in and then to follow and to use their hands to flip the baby.
CHRISTINE STEWART-FITZGERALD: And I think the woman would want to have a discussion about you know sort of here are some different scenarios and what are my options and find out about the provider and their philosophy as well during that during the you know prenatal checks.
DR. TEVY TITH: Absolutely. So anybody who in our practice is diagnosing with twins and is a candidate for having a vaginal delivery, we always have the discussion of mode of delivery. What are we planning on doing when she goes into labor or you know or around the time of her due date? So really we have to truly council the patient and we can’t really make a definitive plan until a little bit later when we know where the babies are going to settle.
CHRISTINE STEWART-FITZGERALD: Well you know talking about the sort of the delivery actually kind of taking a step back when moms are you know just arriving getting at the hospital from the kind of the point of active labor, how do you approach the delivery process? I mean you know from a monitoring stand point, you know frequency of cervical checks, I mean how much different is it to you know give birth to twins as oppose to a singleton? What would the moms expect especially those who’ve maybe they‘ve already had a singleton birth?
DR. TEVY TITH: So if they come in in labor, that’s usually a good sign and increases their chance of success but for the most part, they would come into triage. They would be evaluated for labor if they’re diagnosed with active labor and they’re usually admitted to labor and delivery. We will monitor the twins closely so the real big difference is monitoring your you’ve got two of them in there so a lot of times because of their movement the monitors just have to be adjusted more frequently. The frequency of the cervical checks aren’t any different, you still try to follow the same labor curve until the babies deliver.
CHRISTINE STEWART-FITZGERALD: It’s pretty much the same but…
DR. TEVY TITH: Yes.
CHRISTINE STEWART-FITZGERALD: You got a little bit more equipment going on in here.
DR. TEVY TITH: Yes. Exactly.
CHRISTINE STEWART-FITZGERALD: When it comes to pain management, are there any differences in terms of the pain management and you know getting epidural or any types of other you know drugs and you know should moms be concerned in anyway of you know what they’re using for pain management?
DR. TEVY TITH: No. So the pain management is usually managed about the same way. We do recommend for moms to get epidurals who have who were planning to have a vaginal delivery of twins. A large part of this is really for the delivery part or in the event that we would have to do something very rapidly. So something like an internal podalic version for instance is not the most comfortable thing to have to go through. So we would recommend for moms to be comfortable just in case it’s something we have to do very quickly. Either that or you know again in cases where we would in rare instance where we would have to convert to a C-section rapidly we would want to have moms at least have their epidural, their anesthesia available already.
CHRISTINE STEWART-FITZGERALD: And I think included with that so we talked about having an epidural I mean I’ve heard of different types of I’ve heard of a walking epidural as well, is that an option?
DR. TEVY TITH: You know it’s probably an option at different hospitals. So I think that that’s probably a discussion that you want to have with the anesthesiologist as you what level they could have the block at and what options would be available you know.
SHELLY STEELY: [inaudible] to have an external fetal monitoring. Is that because I know I started with an induction and I know that when you are induced with epidosin you have to have both monitors. So is that all twin deliveries pretty much is at standard, they have to have external fetal monitoring?
DR. TEVY TITH: They should again one of the main risks that we worry about with the twins is actually a risk of we call an abruption with the placenta that separates prematurely after delivery of the first one and so a lot of times after you deliver the first one there’s a rapid decompression of the uterus and that can potentially cause some separation of the placenta and the uterus which you don’t want to have especially if baby B is not ready to deliver yet. So usually we do recommend having monitoring during the delivery.
SHELLY STEELY: And how common is internal fetal monitoring? So I had my boy’s heartbeats were identical so it was really hard and they were in the same position very close to each other so it was really hard for them to ensure two heartbeats on the monitor so I actually had one an internal and one an external. Is that common or is that unusual?
DR. TEVY TITH: You definitely can have that especially with if you were dilated enough and baby A is well applied to the cervix or engaged in the pelvis. You can definitely monitor baby A internally and then baby B externally that’s definitely possible.
SHELLY STEELY: Is it common or is it kind of not?
DR. TEVY TITH: You know I think the practice is variable with different practitioners. We generally try not to put too many instruments into the vagina because of an increase a potential increase of an infection. If it’s necessary then we will typically do that. So I’d say its provider dependent.
CHRISTINE STEWART-FITZGERALD: When we come back we’re going to talk about what are you going to expect in the labor and delivery or the OR room, who’s there, who’s helping you out and what happen?
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CHRISTINE STEWART-FITZGERALD: Alright welcome back. Today we are talking with Dr. Tevy Tith and who’s helping us understand the vaginal delivery process and who are those medical providers and all the people wearing white coats that are in the room. We know in for the moms who are doing you know C-sections in the OR and there’s going to be this whole surgical team but what about when doing a vaginal birth and we know that there’s usually there’s often be a lot of people on the support team. Who is that and what do they do?
DR. TEVY TITH: Why I think the most important support team that you have will be your family or whoever you bring to the labor room with you. They provide support and comfort and encouragement throughout the whole labor process. Another really very integral part of the team is your labor and delivery nurse and she’s really with you with the entire time that you’re laboring.
She’ll explain everything that is going on, what sort of medications you have or what medications you need. She’ll give you options in terms of pain medications and then obviously your doctor who is also there to support you and to help provide a safe delivery. And then the anesthesiologist is important as well and hopefully you’ll be able to meet them before you do your or before you have an epidural or whatever anesthesia you end up deciding to go with.
And then after the delivery or really before the delivery while you’re pushing there’s usually a larger birthday party that comes to the delivery room. A large part of who comes is dependent on the gestational age of the baby at delivery. So if we anticipate that the babies are less than 36 weeks and potentially at risk for respiratory problems, we will usually have the ALS team there which Advance Life Support team and that usually consist of a nurse and a respiratory technician and if there’s two, two babies you have to multiple everything by two.
CHRISTINE STEWART-FITZGERALD: Oh yes.
DR. TEVY TITH: So there’s usually a lot of people who are there and then there is usually auxiliary staff that help to circulate or to just help out the team with whatever they need.
CHRISTINE STEWART-FITZGERALD: So moms if you got a big crowd of people, what do you tell them? Just you know dim the lights as much as you can and close your eyes.
DR. TEVY TITH: Yeah you know we actually do you know when my patients or when we have patients pushing, we will often have the light’s dimmed just so that we can really focus on the baby and the mom. Most of the time I do warn moms and dads ahead of time that there would be a lot of people coming in right at the end. Their role is to make sure that the baby transition safely after the delivery and to make sure that the babies are stable.
CHRISTINE STEWART-FITZGERALD: And before we actually get to the end I mean during let’s just say the beginning of active labor to the point where you know the mom starts pushing. I know the labor and delivery nurse play such a major role. I mean I was in active labor for about let’s see 20 hours and she was my main contact…
DR. TEVY TITH: Yes.
CHRISTINE STEWART-FITZGERALD: And I mean it was we’re in the labor and delivery room for quite a while and my OB was not called in until I mean that you know…
DR. TEVY TITH: Yeah
CHRISTINE STEWART-FITZGERALD: Reaching the you know point zero and she was calling on the phone and saying okay you’re now at you know 8 cm dilated and here’s all the stats and you know giving the updates and…
DR. TEVY TITH: Yeah. She’s their main liaison to the rest of the team. So she again is your is a very good source of support but she is also a part of the medical team so she ensures your safety. She is typically the one who also perform the checks the cervical exams and will adjust the medications accordingly. She also makes sure that the doctors get there on time and has the right personnel around for your babies.
CHRISTINE STEWART-FITZGERALD: I mean that’s great that she’s she is really the ring master making everything happen. But it is important to know that in her role she’s managing all these different aspects from the let’s see the medical provider side. Now as a mom I think one think I learned is that I really could’ve benefited from a doula because I mean the doula’s role is really to be the support specifically for the mom. And you know managing pain and you know getting into positions that help you know further you know the opening of the cervix and descent and all of that and I know I was laboring I had well an un-medicated labor during that time. I was unsuccessful with the having a vaginal delivery but I look back and I think oh my gosh I really I think that was probably the one thing that I could’ve benefited from is having someone in the room who had knowledge of kind of helping me get into position but and give better position for descent. So I think that’s really important to understand some of the different roles that people play and not expect folks to…
SHELLY STEELY: Yeah you know so this came up recently I also in labor I was in active labor at probably the same time you were and I my cervix ended up swelling. So I got 6 cm and I just never progress. But in looking back at the labor process is I don’t think I mean like I said I don’t think I would’ve been able to move much at all and it was definitely I mean the swelling was a concern and that but - You know we talked about and yeah I had my husband there, I had my mom there, I had my aunties there, all these very supportive people. I had an amazing labor and delivery nurse so I felt very emotionally supported but I think that what a lot of people forget is that your mom and your husband and your aunty they are not trained in positioning…
CHRISTINE STEWART-FITZGERALD: Right.
SHELLY STEELY: Techniques etc. and well my husband was very supportive. He knows absolutely nothing about child birth…
CHRISTINE STEWART-FITZGERALD: Yes.
SHELLY STEELY: He went to every class with me. He read the books I asked him to read. I mean he’s very supportive and engage in the process but it was something that it didn’t occur to me to have that extra person there who could’ve helped with the in a twin delivery.
CHRISTINE STEWART-FITZGERALD: Let’s talk logistics for a moment so you know when we’re in the hospital room and we’re having the delivery, what’s actually happening? I know I mean we know we’ll there’s let’s say we give birth to baby A successfully and then there’s this time period where we are waiting it’s like wait a minute we have a one baby and then what do we do with that baby and then the mom needs to push the other baby and I think you use the instrument the ultrasound. So how does that all work?
DR. TEVY TITH: So after delivery of baby A, usually baby A as long as baby A is stable, dad can actually hold baby A and dad can actually do skin to skin with baby if he wanted to. If mom is still pushing and dad wants to be supportive of mom then the nurses can actually help take care of baby A while mom is pushing.
You know again depending on the position of the baby and you know if baby B has or rather depending on the position of baby B depending on if baby B is flip or not hopefully the time interval is less than 30 minutes to an hour to deliver baby B. And hopefully as long and really as long as baby B is stable and the heart rate is reassuring and mom’s vitals are reassuring then we can allow labor to progress.
Occasionally if the contractions have spaced out we might give mom a little bit of extra medication to help increase the frequency of contractions to expedite the delivery of baby B so that the cervix doesn’t close or so that the placenta doesn’t separate you know just to make sure that we deliver baby B vaginally successfully.
CHRISTINE STEWART-FITZGERALD: Oh that’s great so and that’s I guess another thing that we want to talk to our provider that sort of thinking ahead and planning what are the options.
DR. TEVY TITH: Right. Right.
SHELLY STEELY: You know I think when you tell people that you’re planning on a vaginal birth whether you wanted un-medicated birth with twins everyone just kind of roll their eyes and…
CHRISTINE STEWART-FITZGERALD: Right.
SHELLY STEELY: But I think that the more you can do to prepare the better but with still the understanding that even the best laid plans with two babies can kind of go array.
CHRISTINE STEWART-FITZGERALD: So what do you to the moms who are saying “I really, really, really want a vaginal delivery”.
DR. TEVY TITH: I think it’s great to want and I think that it’s imp… but I also think it’s important to realize that for the safety of both mom and baby things you know for things that are that happen unexpectedly in labor that it’s always a possibility that we may have to go the other route. So I do tell them that ahead of time.
SHELLY STEELY: I think it’s kind of hard because you don’t want to discourage moms that off on attempting a vaginal delivery.
DR. TEVY TITH: Absolutely.
SHELLY STEELY: Or be like a downer.
DR. TEVY TITH: Yeah.
SHELLY STEELY: Like this is a great plan that you have but good luck.
DR. TEVY TITH: Yeah.
SHELLY STEELY: You know I think it’s kind of I mean it is kind of a fine line because I wouldn’t say they didn’t warn me you know It’s not that I wasn’t aware. It was more like I just figured if I did ABC and D then everything would go fine.
CHRISTINE STEWART-FITZGERALD: Alright. Well thanks so much everyone for joining us today and for more information about preparing for a vaginal delivery or for more information about any of our speakers and panelists, you can visit our episode page on our website. This conversation continues for members of our Twin Talks club and after the show we’ll talk with Dr. Tith about how moms can find providers who are very supportive of vaginal deliveries. So for more information about the Twin Talks club, visit our website www.twintalks.com .
[Theme Music]
SUNNY GAULT: We have a comment from one of our listeners that we want to share with you guys before we wrap up today’s show and it comes from Amanda, one of our Facebook friends and Amanda says “I am so glad to have just found this podcast. I found out I was pregnant in February and I discovered Preggie Pals” and for those of you who don’t know Preggie Pals is our sister show all about pregnancy.
She says “and I’ve been listening to Preggie Pals constantly. I just found out tonight about Twin Talks and I couldn’t be more thrilled because we are having twins. Can’t wait to get through all those episodes of great twin info, thank you so much for creating a podcast just for twin moms.”
Well Amanda, thank you so much for listening to our show and please spread the word for those of you guys that are listening in the show and if it has help you please tell other twin parents about it. We’re starting to grow and that’s fantastic but word of mouth is always the best way for people to find out about resource like ours. So spread the word. We really appreciate it and thank so much Amanda for the comment.
[Theme Music]
CHRISTINE STEWART-FITZGERALD: Well, that wraps up our show for today. We appreciate you listening to Twin Talks.
Don’t forget to check our sister show:
• Preggie Pals for expecting parents
• Our show The Boob Group for moms who breastfeed their babies and
• Parent Savers, your parenting resource on-the-go.
So next week we’re going to be talking about preparing for caesarean birth. This is Twin Talks parenting times two.
[Disclaimer]
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.
SUNNY GAULT: New Mommy Media is expanding our line up of shows for new and expecting parents. If you have an idea for a new series or if you’re a business or organization interested in joining our network of shows through a co-branded podcast, visit www.NewMommyMedia.com .
[00:41:04]
[End of Audio]
Episode Transcript
Twin Talks
Preparing for Your Twin Vaginal Birth
[00:00:00]
Please be advised, this transcription was performed from a company independent of New Mommy Media, LLC. As such, translation was required which may alter the accuracy of the transcription.
[Theme Music]
DR. TEVY TITH: Having a vaginal delivery for multiples is not always the first thought for expectant moms but it can have its advantages. If you do decide you’d prefer a vaginal delivery for your twins, how can you prepare for it and how is it different from a singleton delivery. I’m Dr. Tevy Tith of the San Diego prenatal center, here to discuss how you can prepare for a vaginal birth for your twins. This is Twin Talks.
[Theme Music/Intro]
CHRISTINE STEWART-FITZGERALD: Well welcome to Twin Talks, broadcasting from the birth education center of 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. Have you heard about the Twin Talks club?
Our members get bonus content after each new show plus special giveaways and discounts. Subscribe to our monthly Twin Talks newsletter and learn about the latest episodes available.
Another way for you to stay connected is by downloading our free Twin Talks app and it’s available for most smart phones. Well before we get started, let’s introduce our panelists and everyone who’s here in the studio and I’ll introduce myself, I’m Christine Stewart-Fitzgerald and I’ve got almost 5 year old identical girls and they are headed off to kindergarten soon so I’m excited. And then I do have a 20 month old singleton who is now officially weaned and on her own so I’m very happy.
SUNNY GAULT: Oh my goodness. Yehey!
CHRISTINE STEWART-FITZGERALD: Yehey! So yeah let’s go around and let’s see Sunny…
SUNNY GAULT: Yeah.
CHRISTINE STEWART-FITZGERALD: Can you tell us about you?
SUNNY GAULT: Absolutely okay. Hey everyone I’m Sunny. I’m the owner of New Mommy Media which produces Twin Talks, Parent Savers, Preggie Pals and The Boob Group and I’m a twin mommy as well, I actually have four children now. My oldest is 4 and that’s a boy and my middle guy is 2 and then I have identical twin girls who are now 7 ½ months I think.
CHRISTINE STEWART-FITZGERALD: Wow.
SUNNY GAULT: Yeah.
CHRISTINE STEWART-FITZGERALD: Time flies.
SUNNY GAULT: Full house.
SHELLY STEELY: I’m Shelly. I’m a high school history teacher and I’m also the producer here at Twin Talks. I have two children, identical twin boys who are going to be 2 next month and I’m currently pregnant with my third just one this time though…
CHRISTINE STEWART-FITZGERALD: Yehey!
SHELLY STEELY: And we’re expecting a girl. So I want to give you guys a little heads up about our virtual panelists program. If you’re not able to join us here on the studio, you can follow along at home. You can follow us on Facebook or Twitter with Twin Talks or you can use the #twintalksvp to be a panelist from the comfort of your own home.
CHRISTINE STEWART-FITZGERALD: Alright.
[Theme Music]
CHRISTINE STEWART-FITZGERALD: And today we have a question from Annie in New Port Rhode Island. She’s asking about solid food. She says “my 8 month old fraternal boys, they seem to be doing you know fairly well and trying new foods. I give them a lot of mush up vegetables and mix in some fruit. But lately I’ve notice that one of my boys seems to be much pickier than the other and refuses the food I’m offering. So how do I handle this? Do I need to prepare different food for each of them?”
NATALIE DIAZ: Hey Annie, this is Natalie Diaz author of “What to Do When You’re Having Two” and founder twiniversity.com and multiplicity magazine. Just so you know you are not alone on your frustration to solid feeding your twins. It’s very common that one twin will have a preference of the foods that they like while the other are the more of the kind of I will called the other one [inaudible] I don’t know if I’m the only one who thought them would be old school but that’s what I think of.
There is always going to be – you shouldn’t say always, its usually one child who’s the better eater. So how do we overcome this? Do you need to have two separate meals? It depends you know if one kid is totally going on strike and want to eat nothing but sweet potatoes and they’re really just giving you a lot of problems, you may have to but I’m going to tell you old school mom style even now to this day my 9 year old know that we should we have a rule on our house that this house isn’t a diner.
You eat what’s on the table and that’s that. Not saying you should apply this rule for your 8 month old. I am saying that you got to figure out a way that they’re going to eat what they have. So I wish I knew specifically what food they were eating. Do they not want to eat meat? Do they not want to eat veg? Do they not want to eat fruit? If it’s a problem that they want to stay with the sweet, just gradually mix in some vegetables and go you know 90% fruit 10% vegetable and next day go 20% vegetable and did I say that right?
Well you know what I mean. Just gradually increase the amount of vegetable that are in the fruit until you are getting a nice 50/50. If that doesn’t seem to be working and you do feel comfortable with having two separate bowls for your twins then of course go ahead and do that. Feeding kids and parenting twins is not a one size fits all. You have to do whatever you feel is the best for your twins.
If you think that it’s an issue with texture, let’s say they don’t want to eat chunk or something you may want to speak with your pediatrician about it that you should always speak to your pediatrician if you really have a concern. But as far as having a picky eater, you could just have picky eater you know. Not every twin would just eat whatever put in front of them.
So try tomorrow start a little bit to a lot of fruit a little veg. Try to change that. Try to give them what they want alternating with something that they don’t want. So let’s say you blended up some chicken soup and then they love having mash carrot. Get them one spoon of the chicken soup, one spoon of the mash carrot. You can keep it on separate bowl. Try that. See how it goes. And you know there is actually a ton of resources on twiniversity.com in regards to feeding your multiples. So you may want to check that out.
There is a lot more specific you know questions and answers up there but on short you get back to the New Mommy Media team like a follow up. I’d be more than happy to help more than ever and whenever you need me. Have a good day, take a deep breath and try not to get frustrated. If you get frustrated, the babies will sense that and they’re going to shut down and shut their little mouth. So take a deep breath, put on some great music and just make eating time a fun time. Good luck! I hope today everybody eats everything that’s in their dish. Bye bye.
[Theme Music]
CHRISTINE STEWART-FITZGERALD: Today’s topic is preparing for a vaginal birth and today we’re talking with Dr. Tevy Tith who is here to help us understand what and expectant twin mom needs to know to plan for a vaginal delivery of her babies. So thanks for joining us.
DR. TEVY TITH: Thanks for having me.
CHRISTINE STEWART-FITZGERALD: Yeah so I know you see a lot of twin moms in your practice…
DR. TEVY TITH: I do.
CHRISTINE STEWART-FITZGERALD: And if she decides just “you know hey I really would like to try for a vaginal birth”. What makes her a good candidate to try for that?
DR. TEVY TITH: There are definitely several things that make her an excellent candidate. The first thing we always have to consider is her safety as well as the safety of the babies. So like I tell all my moms, baby A always determines which way the party goes. So first and foremost baby A is head down.
The second thing is to really figure out which what kind of twins they are so if they don’t share a sac that’s also the best kind of twins to have vaginally. We ideally would like for the twins to be at least 3 plus pounds each. So 15 hundred grams is usually our cut off for having twins vaginally.
We don’t want for there to be a discrepancy in the size of the twins so hopefully they’re about the same size. Anything over 15% to 20% makes it a little bit more unsafe particularly if baby B is the bigger one. And then finally if they’ve had a vaginal birth before, that’s just a bonus but it’s not necessary. So those are the most important things in determining having a…whether or not it’s safe to have vaginal delivery for twins.
CHRISTINE STEWART-FITZGERALD: And it sounds like these are mostly factors about the babies themselves and on for the mom on the maternal health side of it, are there anything that relates to I mean either her health I mean like if you know let’s say if she’s overweight…
DR. TEVY TITH: Yeah.
CHRISTINE STEWART-FITZGERALD: Or does that make a difference or…
DR. TEVY TITH: So we use the same criteria for even a singleton mom. So if she’s had a prior vaginal delivery if it’s in a horizontal direction, she could potentially be a candidate for a trial of labor for twins. I’ve done that before. If she’s had a C-section in a different direction then she may not be. So it’s the same criteria that you would use for singletons. If she has certain cardiac or pulmonary problems then she may not be a candidate just for her own health. So we would again use just similar criteria that we would use for twins.
SHELLY STEELY: What about those common complications? I guess like we have preeclampsia or gestational diabetes, the things that are more common with twins. How those affect her likelihood of being able to deliver vaginally?
DR. TEVY TITH: Again generally the success rate is usually the same for both for gestational diabetes or for somebody who has preeclampsia but for somebody who has preeclampsia for instance you have to make sure that the safety of the mom is ensured and with preeclampsia cure is that the cure for preeclampsia is delivery so if you don’t think you can expedite a delivery of twin pregnancies in a you know in a quick fashion then you may have to she may really be a candidate for a C-section instead. So…
CHRISTINE STEWART-FITZGERALD: And then I mean is there you know anything that a mom can do during her pregnancy if she says “okay you know I really like to have a vaginal delivery”. Is there anything she could prepare for on I don’t know health wise for herself?
DR. TEVY TITH: So you know just like with a singleton pregnancy we really want to encourage mom to increase her caloric intake. So what’s recommended for singleton is above baseline about 300 calories a day. For twins it’s probably more along the lines of 3 to 5 hundred extra calories a day. And again that’s not empty calories. You have to be healthy.
CHRISTINE STEWART-FITZGERALD: Right. I remember eating lots of protein.
DR. TEVY TITH: Yes. Exactly. And then just educating and counselling patients extensively about nutrition, keeping stress levels low…
CHRISTINE STEWART-FITZGERALD: So there are some positive things that you know we can do if we said “hey we do really like to have” that’s great. Now just in making that decision I mean let’s say a mom has really they said “well you know I’d like to have a vaginal delivery but I’m not sure”. What are some of the pros and cons of each delivery type?
DR. TEVY TITH: Well looking at it from a maternal aspect first, definitely the pros of having or the advantages of having a vaginal delivery include shorter hospital stays, typically if you were problems with anaesthesia so if you were anaesthetic complications usually it’s less of a blood lost if everything goes very well. There are some studies that I’ve looked at breastfeeding initiation rates being higher after a vaginal delivery but when you look at it downstream 3 months 12 months down the line there isn’t really a difference between a C-section and vaginal but initiation rates appear to be a little bit higher.
CHRISTINE STEWART-FITZGERALD: And that means that’s basically starting breastfeeding immediately…
DR. TEVY TITH: Yeah.
CHRISTINE STEWART-FITZGERALD: After birth.
DR. TEVY TITH: Yeah. Exactly.
CHRISTINE STEWART-FITZGERALD: Okay. Okay.
DR. TEVY TITH: Exactly.
CHRISTINE STEWART-FITZGERALD: Yeah. So the moms who have the twins vaginally might have a better success rate of getting the baby…
DR. TEVY TITH: Starting.
CHRISTINE STEWART-FITZGERALD: Starting…
DR. TEVY TITH: Yeah.
CHRISTINE STEWART-FITZGERALD: To breastfeed and I think that’s probably the most critical time periods. . .
DR. TEVY TITH: Definitely the immediate postpartum bonding experience. So yeah…From some of the disadvantages obviously you know there’s always a small risk of conversion to a C-section for patients who start vaginal who have a planned vaginally delivery first and then it ends up getting converted to a C-section for usually for fetal indications.
CHRISTINE STEWART-FITZGERALD: Then when they are converted, I have also heard of in some cases were a woman was able to deliver one vaginally and then for some reasons the second one…
DR. TEVY TITH: Yeah.
CHRISTINE STEWART-FITZGERALD: Isn’t in the position or something happens were the second one need to be delivered surgically. How often does it happen?
DR. TEVY TITH: About 4% of the time give or take.
CHRISTINE STEWART-FITZGERALD: Okay.
DR. TEVY TITH: You know there was a really large study that was recently published in the New England Journal of Medicine and the study took over 10 years and many, many countries to participate in but I’m glad the study was done because it has provided so much good useful information for us. And it look up the safety of vaginal twin deliveries versus plan C-section then they it show that vaginal delivery was just as safe as C-sections.
CHRISTINE STEWART-FITZGERALD: I know I mean and that’s good to know. So that’s something that’s pretty rare and I think for woman who kind of you know considering her options like well that’s probably not a big likelihood that that would happen but…
DR. TEVY TITH: No. No it’s just something that you would want to remind mom that could possibly happen.
SHELLY STEELY: Is there anything that would make it more likely that you could be aware or make it more likely that you would have to deliver one each way?
DR. TEVY TITH: Yeah. You know interestingly the in terms of having to convert sort of midway through the delivery, the one thing that sort increases that likelihood is waiting too much or waiting for too long to deliver the second twin. So there are definitely studies that have shown that if you actually after the delivery of the first twin immediately go and try to deliver the second twin, your success rates are much higher. And whether that’s vaginal or whether that’s vertex or doing like a pretext extraction, it’s actually much more successful if you immediately try to go and deliver the second one.
SHELLY STEELY: And with that size discrepancy you talked about, will that increase the likelihood?
DR. TEVY TITH: Hopefully you would know that ahead of time you know with ultrasound at least the week within the week of delivery so that you could try to prepare yourself for that but definitely if twin B is significantly bigger than twin A then that is definitely a possibility.
CHRISTINE STEWART-FITZGERALD: And we talked about having them delivered within a time frame I mean is there are time frame I mean we’ve heard of deliveries being within 10 minutes, 45 minutes, I mean…
DR. TEVY TITH: You know it’s funny you generally we say we would like to deliver the second twin within an hour. Some other authorities may say within half an hour. But you know I’ve done this before and I like to have them delivered hopefully within 10 minutes of each other.
CHRISTINE STEWART-FITZGERALD: Wow.
DR. TEVY TITH: But it’s not always possible. It’s definitely not always possible and I’ve definitely sat there for an hour waiting for the second twin especially if the second twin is vertex and the cervix hasn’t close and then I’m happy to give it time and to wait for the second one.
CHRISTINE STEWART-FITZGERALD: Sounds like I mean it sounds like there are just a lot of variables in the timing and you know the moms health and…
DR. TEVY TITH: Yes.
CHRISTINE STEWART-FITZGERALD: I mean I can say in having done a VBAC myself I mean it’s a lot of work pushing a baby . . .
DR. TEVY TITH: That’s why they call it labor.
SHELLY STEELY: Well then what kind of support could you recommend? So we all know with twins there’s they have their own plan so even the best laid plans for vaginal delivery don’t always go well but is there anything that has been proven to improve chances? I mean is there like more support person or other things that she could do?
DR. TEVY TITH: You know I think that definitely having a really good support person is really important in the delivery process? One of the bigger differences in terms of delivering vaginally for twins is also the fact that you when we push we usually will push on the operating room instead of the labor room and usually when you’re in the labor room with a singleton you can have a lot of family around.
When you’re pushing in the OR you can really have one other family member around and it’s partly because the ORs are a lot smaller and if we have to quickly convert to a C-section for instance then you would want to just be have to usher one person out instead of a whole family member or instead of a whole family.
So that is definitely one big difference but that support person is very key, is very integral but also you know having the provider explain everything that is going on and who everybody is really important too and what processes are taking place. So for instance after the delivery of the first one we usually do an ultrasound, we’ll do an exam and we’ll tell mom what we’re seeing and if we need her to push or to bear down or something then she could be an active part of the whole process.
SHELLY STEELY: And so some hospitals will let twin moms deliver in a regular labor in delivery room. So that would be I guess you need to look at when you’re choosing your hospital if you wanted to have a support person like a doula or something like that.
CHRISTINE STEWART-FITZGERALD: It sounds like it depends on the medical provider…
DR. TEVY TITH: Yeah.
CHRISTINE STEWART-FITZGERALD: So within your practice that’s probably a standard…
DR. TEVY TITH: Yeah.
CHRISTINE STEWART-FITZGERALD: Procedure and then some hospitals might have different policies in place.
DR. TEVY TITH: Yeah.
CHRISTINE STEWART-FITZGERALD: You have to ask around.
DR. TEVY TITH: Yeah.
CHRISTINE STEWART-FITZGERALD: Right. Yeah.
SUNNY GAULT: I have a question when it comes to the space that is available to do that. So if you laboring in a OR room, so I had two caesareans and one vaginal birth, my twins were caesarean so this doesn’t quite apply to me but the question would be I know how valuable like that OR space is and you can be in labor. I mean with my first I was in labor which end up being a vaginal delivery for like 14 hours. I mean not being crazy…
DR. TEVY TITH: Yeah.
SUNNY GAULT: So is it fair?
DR. TEVY TITH: Oh.
SUNNY GAULT: I mean so I mean how does that work?
DR. TEVY TITH: Oh.
SUNNY GAULT: On what point will they take them in there?
DR. TEVY TITH: Yeah.
SUNNY GAULT: Yeah.
DR. TEVY TITH: It’s not it’s definitely not for the whole labor process…
SUNNY GAULT: Okay.
DR. TEVY TITH: At all.
SUNNY GAULT: Okay.
DR. TEVY TITH: No. no. no. It’s actually just at the very end when…
SUNNY GAULT: Once they reach 10 or something?
DR. TEVY TITH: Once they’re even once even past 10 like once they’re starting to push.
SUNNY GAULT: Okay.
DR. TEVY TITH: Once they started to push then we’ll usually bring them to the OR…
SUNNY GAULT: Okay.
DR. TEVY TITH: But not definitely not during the whole labor process because that can take a while.
SHELLY STEELY: So somebody who wanted to have like a doula or another support person…
CHRISTINE STEWART-FITZGERALD: Yeah.
SHELLY STEELY: then they’d still be…
CHRISTINE STEWART-FITZGERALD: Oh yeah.
SHELLY STEELY: Able to have after the process?
CHRISTINE STEWART-FITZGERALD: Oh yeah.
DR. TEVY TITH: Yeah. No. Exactly. I’m what I’m really referring to is really just that last part…
SUNNY GAULT: Yeah.
DR. TEVY TITH: Kind of the last part Hoorah of the marathon before you know the pushing.
SUNNY GAULT: Right.
CHRISTINE STEWART-FITZGERALD: And you know earlier you talked about the position of the babies as being one factor of you know the success of you know having a vaginal delivery and you know I know I see questions all the time from moms who say “well you know I’m 36 weeks and I’ve got you know baby A head’s down and baby B is you know breech or transverse and you know when they’ll going to flip and you know I mean how important is that factor and then you know once they do get to labor if that second baby is not head down I mean you know what can be done as far as you know you know moving the baby around?
DR. TEVY TITH: For having a twin vaginal delivery the real important part is really just having twin A down. Because in the end even if they’re both head down after delivery of twin A, baby B can flip. So…
CHRISTINE STEWART-FITZGERALD: So baby B could be head down…
DR. TEVY TITH: Yup.
CHRISTINE STEWART-FITZGERALD: And then you know baby A is born and is like baby B is like “hey I’ve got lots of space”…
DR. TEVY TITH: Yeah. Yeah.
CHRISTINE STEWART-FITZGERALD: “Let’s do some flips or gymnastics”
DR. TEVY TITH: Yes.
CHRISTINE STEWART-FITZGERALD: “I’m having fun and hey I got the place for myself”.
DR. TEVY TITH: Yeah. Exactly. I’ve definitely seen that happen. I’ve definitely seen twin B who was breech the entire time suddenly flip to vertex. So what’s most important is really the position of twin A.
CHRISTINE STEWART-FITZGERALD: And if baby B does flip then you know what type of procedures can be done?
DR. TEVY TITH: There are definitely a couple of different options, typically if you, if baby B has flip and is now breech, you can actually going to do a or is either breech or is a transverse you can actually going to do what we call an internal podalic version and it just means that you go in and you grab one or both feet and you bring it down to the cervix or you bring it out of the vaginal canal and deliver baby B breech.
CHRISTINE STEWART-FITZGERALD: Oh okay. Now on when you said when you’re grabbing on to the feet, are we talking about a footling breech delivery or you just kind of…
DR. TEVY TITH: It is essentially a footling breech. It’s essentially a breech delivery.
CHRISTINE STEWART-FITZGERALD: Okay.
DR. TEVY TITH: You grab one foot, the other foot will follow and you will deliver the baby backwards or feet first which they use to do all the time actually a long long time ago even for singleton deliveries. But presumably if baby A has pass through the vaginal canal then they’ve made space and room they’ve paved the way for baby B and you should be able to deliver baby B.
SHELLY STEELY: Wow. Wow.
SUNNY GAULT: Wow.
CHRISTINE STEWART-FITZGERALD: I mean it sounds like that’s kind of an art form too I mean I know in medicine you’ve got sort of the science but then looking at the situation you figure well…
DR. TEVY TITH: Yes you…
CHRISTINE STEWART-FITZGERALD: Different opportunity.
DR. TEVY TITH: You definitely have to have a provider who is very comfortable with those types of manipulations inter partum. You also we are blessed in that we also have the technology to see all of the ultrasound as well. So I will usually use ultrasound. A lot of providers will use ultrasound to help diagnose what position the babies are in and then to follow and to use their hands to flip the baby.
CHRISTINE STEWART-FITZGERALD: And I think the woman would want to have a discussion about you know sort of here are some different scenarios and what are my options and find out about the provider and their philosophy as well during that during the you know prenatal checks.
DR. TEVY TITH: Absolutely. So anybody who in our practice is diagnosing with twins and is a candidate for having a vaginal delivery, we always have the discussion of mode of delivery. What are we planning on doing when she goes into labor or you know or around the time of her due date? So really we have to truly council the patient and we can’t really make a definitive plan until a little bit later when we know where the babies are going to settle.
CHRISTINE STEWART-FITZGERALD: Well you know talking about the sort of the delivery actually kind of taking a step back when moms are you know just arriving getting at the hospital from the kind of the point of active labor, how do you approach the delivery process? I mean you know from a monitoring stand point, you know frequency of cervical checks, I mean how much different is it to you know give birth to twins as oppose to a singleton? What would the moms expect especially those who’ve maybe they‘ve already had a singleton birth?
DR. TEVY TITH: So if they come in in labor, that’s usually a good sign and increases their chance of success but for the most part, they would come into triage. They would be evaluated for labor if they’re diagnosed with active labor and they’re usually admitted to labor and delivery. We will monitor the twins closely so the real big difference is monitoring your you’ve got two of them in there so a lot of times because of their movement the monitors just have to be adjusted more frequently. The frequency of the cervical checks aren’t any different, you still try to follow the same labor curve until the babies deliver.
CHRISTINE STEWART-FITZGERALD: It’s pretty much the same but…
DR. TEVY TITH: Yes.
CHRISTINE STEWART-FITZGERALD: You got a little bit more equipment going on in here.
DR. TEVY TITH: Yes. Exactly.
CHRISTINE STEWART-FITZGERALD: When it comes to pain management, are there any differences in terms of the pain management and you know getting epidural or any types of other you know drugs and you know should moms be concerned in anyway of you know what they’re using for pain management?
DR. TEVY TITH: No. So the pain management is usually managed about the same way. We do recommend for moms to get epidurals who have who were planning to have a vaginal delivery of twins. A large part of this is really for the delivery part or in the event that we would have to do something very rapidly. So something like an internal podalic version for instance is not the most comfortable thing to have to go through. So we would recommend for moms to be comfortable just in case it’s something we have to do very quickly. Either that or you know again in cases where we would in rare instance where we would have to convert to a C-section rapidly we would want to have moms at least have their epidural, their anesthesia available already.
CHRISTINE STEWART-FITZGERALD: And I think included with that so we talked about having an epidural I mean I’ve heard of different types of I’ve heard of a walking epidural as well, is that an option?
DR. TEVY TITH: You know it’s probably an option at different hospitals. So I think that that’s probably a discussion that you want to have with the anesthesiologist as you what level they could have the block at and what options would be available you know.
SHELLY STEELY: [inaudible] to have an external fetal monitoring. Is that because I know I started with an induction and I know that when you are induced with epidosin you have to have both monitors. So is that all twin deliveries pretty much is at standard, they have to have external fetal monitoring?
DR. TEVY TITH: They should again one of the main risks that we worry about with the twins is actually a risk of we call an abruption with the placenta that separates prematurely after delivery of the first one and so a lot of times after you deliver the first one there’s a rapid decompression of the uterus and that can potentially cause some separation of the placenta and the uterus which you don’t want to have especially if baby B is not ready to deliver yet. So usually we do recommend having monitoring during the delivery.
SHELLY STEELY: And how common is internal fetal monitoring? So I had my boy’s heartbeats were identical so it was really hard and they were in the same position very close to each other so it was really hard for them to ensure two heartbeats on the monitor so I actually had one an internal and one an external. Is that common or is that unusual?
DR. TEVY TITH: You definitely can have that especially with if you were dilated enough and baby A is well applied to the cervix or engaged in the pelvis. You can definitely monitor baby A internally and then baby B externally that’s definitely possible.
SHELLY STEELY: Is it common or is it kind of not?
DR. TEVY TITH: You know I think the practice is variable with different practitioners. We generally try not to put too many instruments into the vagina because of an increase a potential increase of an infection. If it’s necessary then we will typically do that. So I’d say its provider dependent.
CHRISTINE STEWART-FITZGERALD: When we come back we’re going to talk about what are you going to expect in the labor and delivery or the OR room, who’s there, who’s helping you out and what happen?
[Theme Music]
CHRISTINE STEWART-FITZGERALD: Alright welcome back. Today we are talking with Dr. Tevy Tith and who’s helping us understand the vaginal delivery process and who are those medical providers and all the people wearing white coats that are in the room. We know in for the moms who are doing you know C-sections in the OR and there’s going to be this whole surgical team but what about when doing a vaginal birth and we know that there’s usually there’s often be a lot of people on the support team. Who is that and what do they do?
DR. TEVY TITH: Why I think the most important support team that you have will be your family or whoever you bring to the labor room with you. They provide support and comfort and encouragement throughout the whole labor process. Another really very integral part of the team is your labor and delivery nurse and she’s really with you with the entire time that you’re laboring.
She’ll explain everything that is going on, what sort of medications you have or what medications you need. She’ll give you options in terms of pain medications and then obviously your doctor who is also there to support you and to help provide a safe delivery. And then the anesthesiologist is important as well and hopefully you’ll be able to meet them before you do your or before you have an epidural or whatever anesthesia you end up deciding to go with.
And then after the delivery or really before the delivery while you’re pushing there’s usually a larger birthday party that comes to the delivery room. A large part of who comes is dependent on the gestational age of the baby at delivery. So if we anticipate that the babies are less than 36 weeks and potentially at risk for respiratory problems, we will usually have the ALS team there which Advance Life Support team and that usually consist of a nurse and a respiratory technician and if there’s two, two babies you have to multiple everything by two.
CHRISTINE STEWART-FITZGERALD: Oh yes.
DR. TEVY TITH: So there’s usually a lot of people who are there and then there is usually auxiliary staff that help to circulate or to just help out the team with whatever they need.
CHRISTINE STEWART-FITZGERALD: So moms if you got a big crowd of people, what do you tell them? Just you know dim the lights as much as you can and close your eyes.
DR. TEVY TITH: Yeah you know we actually do you know when my patients or when we have patients pushing, we will often have the light’s dimmed just so that we can really focus on the baby and the mom. Most of the time I do warn moms and dads ahead of time that there would be a lot of people coming in right at the end. Their role is to make sure that the baby transition safely after the delivery and to make sure that the babies are stable.
CHRISTINE STEWART-FITZGERALD: And before we actually get to the end I mean during let’s just say the beginning of active labor to the point where you know the mom starts pushing. I know the labor and delivery nurse play such a major role. I mean I was in active labor for about let’s see 20 hours and she was my main contact…
DR. TEVY TITH: Yes.
CHRISTINE STEWART-FITZGERALD: And I mean it was we’re in the labor and delivery room for quite a while and my OB was not called in until I mean that you know…
DR. TEVY TITH: Yeah
CHRISTINE STEWART-FITZGERALD: Reaching the you know point zero and she was calling on the phone and saying okay you’re now at you know 8 cm dilated and here’s all the stats and you know giving the updates and…
DR. TEVY TITH: Yeah. She’s their main liaison to the rest of the team. So she again is your is a very good source of support but she is also a part of the medical team so she ensures your safety. She is typically the one who also perform the checks the cervical exams and will adjust the medications accordingly. She also makes sure that the doctors get there on time and has the right personnel around for your babies.
CHRISTINE STEWART-FITZGERALD: I mean that’s great that she’s she is really the ring master making everything happen. But it is important to know that in her role she’s managing all these different aspects from the let’s see the medical provider side. Now as a mom I think one think I learned is that I really could’ve benefited from a doula because I mean the doula’s role is really to be the support specifically for the mom. And you know managing pain and you know getting into positions that help you know further you know the opening of the cervix and descent and all of that and I know I was laboring I had well an un-medicated labor during that time. I was unsuccessful with the having a vaginal delivery but I look back and I think oh my gosh I really I think that was probably the one thing that I could’ve benefited from is having someone in the room who had knowledge of kind of helping me get into position but and give better position for descent. So I think that’s really important to understand some of the different roles that people play and not expect folks to…
SHELLY STEELY: Yeah you know so this came up recently I also in labor I was in active labor at probably the same time you were and I my cervix ended up swelling. So I got 6 cm and I just never progress. But in looking back at the labor process is I don’t think I mean like I said I don’t think I would’ve been able to move much at all and it was definitely I mean the swelling was a concern and that but - You know we talked about and yeah I had my husband there, I had my mom there, I had my aunties there, all these very supportive people. I had an amazing labor and delivery nurse so I felt very emotionally supported but I think that what a lot of people forget is that your mom and your husband and your aunty they are not trained in positioning…
CHRISTINE STEWART-FITZGERALD: Right.
SHELLY STEELY: Techniques etc. and well my husband was very supportive. He knows absolutely nothing about child birth…
CHRISTINE STEWART-FITZGERALD: Yes.
SHELLY STEELY: He went to every class with me. He read the books I asked him to read. I mean he’s very supportive and engage in the process but it was something that it didn’t occur to me to have that extra person there who could’ve helped with the in a twin delivery.
CHRISTINE STEWART-FITZGERALD: Let’s talk logistics for a moment so you know when we’re in the hospital room and we’re having the delivery, what’s actually happening? I know I mean we know we’ll there’s let’s say we give birth to baby A successfully and then there’s this time period where we are waiting it’s like wait a minute we have a one baby and then what do we do with that baby and then the mom needs to push the other baby and I think you use the instrument the ultrasound. So how does that all work?
DR. TEVY TITH: So after delivery of baby A, usually baby A as long as baby A is stable, dad can actually hold baby A and dad can actually do skin to skin with baby if he wanted to. If mom is still pushing and dad wants to be supportive of mom then the nurses can actually help take care of baby A while mom is pushing.
You know again depending on the position of the baby and you know if baby B has or rather depending on the position of baby B depending on if baby B is flip or not hopefully the time interval is less than 30 minutes to an hour to deliver baby B. And hopefully as long and really as long as baby B is stable and the heart rate is reassuring and mom’s vitals are reassuring then we can allow labor to progress.
Occasionally if the contractions have spaced out we might give mom a little bit of extra medication to help increase the frequency of contractions to expedite the delivery of baby B so that the cervix doesn’t close or so that the placenta doesn’t separate you know just to make sure that we deliver baby B vaginally successfully.
CHRISTINE STEWART-FITZGERALD: Oh that’s great so and that’s I guess another thing that we want to talk to our provider that sort of thinking ahead and planning what are the options.
DR. TEVY TITH: Right. Right.
SHELLY STEELY: You know I think when you tell people that you’re planning on a vaginal birth whether you wanted un-medicated birth with twins everyone just kind of roll their eyes and…
CHRISTINE STEWART-FITZGERALD: Right.
SHELLY STEELY: But I think that the more you can do to prepare the better but with still the understanding that even the best laid plans with two babies can kind of go array.
CHRISTINE STEWART-FITZGERALD: So what do you to the moms who are saying “I really, really, really want a vaginal delivery”.
DR. TEVY TITH: I think it’s great to want and I think that it’s imp… but I also think it’s important to realize that for the safety of both mom and baby things you know for things that are that happen unexpectedly in labor that it’s always a possibility that we may have to go the other route. So I do tell them that ahead of time.
SHELLY STEELY: I think it’s kind of hard because you don’t want to discourage moms that off on attempting a vaginal delivery.
DR. TEVY TITH: Absolutely.
SHELLY STEELY: Or be like a downer.
DR. TEVY TITH: Yeah.
SHELLY STEELY: Like this is a great plan that you have but good luck.
DR. TEVY TITH: Yeah.
SHELLY STEELY: You know I think it’s kind of I mean it is kind of a fine line because I wouldn’t say they didn’t warn me you know It’s not that I wasn’t aware. It was more like I just figured if I did ABC and D then everything would go fine.
CHRISTINE STEWART-FITZGERALD: Alright. Well thanks so much everyone for joining us today and for more information about preparing for a vaginal delivery or for more information about any of our speakers and panelists, you can visit our episode page on our website. This conversation continues for members of our Twin Talks club and after the show we’ll talk with Dr. Tith about how moms can find providers who are very supportive of vaginal deliveries. So for more information about the Twin Talks club, visit our website www.twintalks.com .
[Theme Music]
SUNNY GAULT: We have a comment from one of our listeners that we want to share with you guys before we wrap up today’s show and it comes from Amanda, one of our Facebook friends and Amanda says “I am so glad to have just found this podcast. I found out I was pregnant in February and I discovered Preggie Pals” and for those of you who don’t know Preggie Pals is our sister show all about pregnancy.
She says “and I’ve been listening to Preggie Pals constantly. I just found out tonight about Twin Talks and I couldn’t be more thrilled because we are having twins. Can’t wait to get through all those episodes of great twin info, thank you so much for creating a podcast just for twin moms.”
Well Amanda, thank you so much for listening to our show and please spread the word for those of you guys that are listening in the show and if it has help you please tell other twin parents about it. We’re starting to grow and that’s fantastic but word of mouth is always the best way for people to find out about resource like ours. So spread the word. We really appreciate it and thank so much Amanda for the comment.
[Theme Music]
CHRISTINE STEWART-FITZGERALD: Well, that wraps up our show for today. We appreciate you listening to Twin Talks.
Don’t forget to check our sister show:
• Preggie Pals for expecting parents
• Our show The Boob Group for moms who breastfeed their babies and
• Parent Savers, your parenting resource on-the-go.
So next week we’re going to be talking about preparing for caesarean birth. This is Twin Talks parenting times two.
[Disclaimer]
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.
SUNNY GAULT: New Mommy Media is expanding our line up of shows for new and expecting parents. If you have an idea for a new series or if you’re a business or organization interested in joining our network of shows through a co-branded podcast, visit www.NewMommyMedia.com .
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