Christine Stewart-Fitzgerald 0:01
We're hearing more and more about the choices that women have in giving birth, their hospital birthing suites, birthing centers, and even home births. But do all these choices go out the window when you're having multiple babies? If we want something other than a hospital birth for twins. how do we determine what is possible? Today we're here to talk with Dr. Stuart Fischbein of Birthing Instincts and learn what may be possible for twin births including giving birth at home. This is Twin Talks.
Christine Stewart-Fitzgerald 0:57
Welcome to Twin Talks. Twin Talks is your weekly online on the go support group for expecting a new parents of twins. If you'd like to listen to our show on the go, be sure to download the Parents on Demand app. And it's available on Apple and Android. Not only can you hear our show, but you'll also discover more great podcasts geared towards parents and twins. Well, let's introduce everyone who is joining our conversation today. So I'm your host, Christine Stewart-Fitzgerald. And I'll say I've got twin girls who are now well, almost 10 years old identical girls and a singleton. So we are a girl family. And I gotta say this, this, these 10 years have flown by so I I'm always surprised as we hear more and more about twins and just how the topic sometimes they're the same and sometimes it's totally different. But if you're Sunny our producer,
Sunny Gault 1:50
Yeah. Hi, guys. So glad that you're joining us on Twin Talks today. I'm Sunny and I'm a mom, I have four kids. My last two were surprised twins. Not so surprised. I found out at about 11 weeks, but they're identical girls like Christine have got identical girls. And they're now five and a half. I think. And yeah. I think yeah, because the Okay, so my older son just turned nine. And I don't know, it always throws me off when one of my kids changes ages then I got to think about all of them. It totally throws me off. Yeah, I know that. They were born in November. So five and a half or so month. years. Yeah. And so yeah, like you. They're constantly changing. And the moment I have their personalities, quote, unquote, figured out, they change on me and then you know, and it's tough to because people will come up to me and be like, Okay, how do you tell them apart? Right? And I'm in it is difficult because are identical. And so I usually go towards the personality like, Well, this one is more than but then when they change on you then I don't even know what to tell other people. I'm like, you just have to figure it out. I don't know how to help you. What are you gonna do? The life of twins.
Christine Stewart-Fitzgerald 3:04
Alright, and with that, we're gonna take a break.
Sunny Gault 3:12
Okay, guys, so today we are going to do a segment called News Headlines. And we like to find interesting twin triplet related stories. And you know, Christina and I were talking before today's show, and it's been hard to find stories that haven't been kind of on the sad side with twins. And so Christine and I were kind of racking our brains, but we found one that we thought was positive and uplifting, which is what we want to bring to you guys. And this is just fantastic. So this twin mom, she is 23 years old. Her name is Montoya Majore. And she moved from Florida to Alabama. And her goal was to pursue a dual degree program from a university and right about that time that she had moved, she discovered she was pregnant. Not only was she pregnant, but you guys know the story here. She goes in, and she finds out she's pregnant with twins. And she's really honest. In this article, we're we found the article on Yahoo. But there may be other places where you can find the article. But you can you can imagine what she felt like like she was like the first in her family to go to college. She's think she's on the right path, data da, and then finds out she's pregnant. And she feels like you know, that could totally change her life. And she finds out it's more than one baby. She doesn't have any family around her. But the beauty of this story is that she ended up graduating and I don't know there's just these amazing pictures of her with her beautiful babies that again, it's really hard to tell them apart. But like I'm looking at this picture and she's got her graduation cap on, and her little girls are right next to her and they have like little graduation shirts on and I just think this is such a beautiful story of just how what is that? Can you guys hear that too? Video?
Stu Fischbein 5:08
It's Whitney Houston, let it play. Let's listen.
Sunny Gault 5:13
So this article that I have up on the website, there's a little video that just started playing.... I'm gonna leave that in the show, because that's just hysterical when you used to and singing for this mama too, because she's amazing. Because I just think that this is such a beautiful picture.
Christine Stewart-Fitzgerald 5:31
Oh my gosh, I mean, beautiful mom, beautiful twins. And it says that she got her degree in cardiovascular monography. And what was the other thing I'm just looking on here? I mean, like, do older, I'm like, okay, just just doing dual degrees in of itself, that is just a bear. And I couldn't even imagine being pregnant. I mean, I know what it was like to just, you know, towards the end walking around, waddling around, and can you imagine, like having to get yourself up and go to class, and then she's doing, you know, clinical rotations and just the physicality of it, I count I do that.
Sunny Gault 6:09
I don't know. I mean, she had to have some sort of help maybe she had to pay for, I mean, what I mean, seriously, like, she's by herself, she had to take the kids somewhere in order to, you know, kind of keep doing all this. But it doesn't go into, you know, a ton of in depth information about all that. But just the fact that she was able to do this, and then Oh, her twins names, because I know you guys are dying to know, McKenna and McKinley, which we've talked about baby show in the past, and I have a feeling she's gonna mix that up quite a bit. Let's just leave that right. And it's cute, too, because her name is Montoya. So she's definitely sticking with this M theme. And we'll see where that takes her. has more kids and she sticks with that. But again, just a beautiful story.
Christine Stewart-Fitzgerald 6:55
Congrats to her on so many different levels. And and that's just such an inspiration. And you know, and I just want to say that she just said that. She you know, she wanted mothers to know that you can get an education with children. And she said she had so many friends are people I know who are told to drop out of school, or actually dropped out of school because they're expecting a child and told there would be no way for them to finish. I wanted to prove to everyone in society that it is possible. No, it won't be easy, but it is possible. I'm like, wow!
Sunny Gault 7:26
I know. So inspirational. And we don't always hear those kinds of stories we hear, oh my gosh, you're pregnant with twins. What are you going to do? Your whole life is like over kind of thing. And she just took this and just made something really beautiful out of it. She's obviously an inspiration, which is why we wanted to share with you guys today and hopefully just uplift you a little bit today.
Christine Stewart-Fitzgerald 7:51
We're here with birthing advocate, author, educator and fellow podcaster. Dr. Stuart Fishbein, Dr. Fischbein, provides full service prenatal and birth services to families both in and out of hospital. He's LA's only OBGYN specializing in natural breech twin and VBAC vaginal birth after cesarean birth. And today, we're talking about birth choices for twins, including giving birth at home. Well welcome Dr. Fischbein, I gotta say, I am so excited to have you on the show today. I've been following I've been kind of a fan for for several years now. And you know, and I love seeing your posts, when you've you've showed the families that you've been serving over the years and the twin bursts. And it's just, it's so beautiful and so inspiring. So I just thought, Okay, we have to have you on the show. So thank you.
Stu Fischbein 8:42
Well, I'm honored. I'm honored to be here. And it's I'm always happy to talk about this topic, because there's so much misinformation out there. I just want to say a couple of things. I was listening to you guys through the introduction, the thing about remembering the ages of your kids. I when I married my wife, she had three little boys, including two twins, that were three years old. And now my twins, my twin boys are 26 years old. And I always have to think about it for a second as to when it is true when one of them changes ages. You have to then remember, well, no, are they four years apart? Are they only three and a half years?
Sunny Gault 9:16
Thank you. You totally validated me and I so appreciate that.
Stu Fischbein 9:21
Yeah, no, it is true. And then of course, and then of course you don't hear from him for a long period of time. You can't remember, you know, they grow, they grow up and they go off and do their own thing. And then they are not they're not real responsive because they are boys and boys tend to I think be less responsive to their parents needs than the baby daughters are when the daughters grow up and get past that.
Stu Fischbein 9:43
Okay, now I have to ask when they were in college and did they come home and did you have like, double the laundry on the weekends?
Stu Fischbein 9:49
Well, I was living separately from them at the time. They actually went to college locally, so they technically they lived at their mom's house.
Christine Stewart-Fitzgerald 9:57
Okay, but they were I'm sure come home It's just it's like, you know, we hear about kids coming home from college and it's the hurricane right? I can only imagine with two Yeah, college.
Stu Fischbein 10:06
Oh, yeah. I mean, again, I have a daughter too and and she has like a lot more laundry than the boys do. I just think that the boys wear the same pair of pants all week. And so anyway, listen, so it's really good. I love the twin stories. I've had a couple recently myself, I don't know if you've been following on our on my podcast, but we had a really good set of twins. I just like to direct your listeners. Before we get into it. today. I'd like to direct your listeners to Dr. Stu's podcast number 148. We did a interview with Dr. Emiliano Trevira, who's a godsend here in Los Angeles, who does breech and twin birthing in the hospital setting. And he occasionally will take a transport from home and give them the outcome that they really wanted. Whereas most cities in the country do not have a choice of me or anybody like Dr. Trevira.
Christine Stewart-Fitzgerald 10:55
So yes, no, that is that is amazing. And you know, and really go and going on that. I mean, we know that by far. I mean, really, the standard is for for twins to be born in a hospital. And and in fact, you know, we're talking about that. Okay, there there are other options is is very, very non standard. So, why is it that it's just so common for most doctors to still encourage women to have either cesarean delivery or, you know, give birth in a hospital? I mean, why why isn't it even talked about that there are other options.
Stu Fischbein 11:27
For a long time now that the skills of taking out a breech delivery and, and even a second twin breach are not being taught. So younger physicians do not have the training or the skill. And what's going to be very hard is to bring that back because there just isn't enough volume of twins in the current teaching model for any doctor to really come out of training, feeling comfortable with breach extraction or breach first twin or anything like that. So, whenever a twin whenever twins are not vertex vertex.
Christine Stewart-Fitzgerald 12:00
Let's explain so vertex vertex is basically head down, head down, right?
Stu Fischbein 12:04
Correct about 40. Statistically speaking, remember, statistics are, are useful for projecting but they're not useful in any individual case, because they don't apply to the individual. But just for teaching purposes, about 44% of twins are head down, head down, and about 27% are about our head down, reach. Okay, in about 13%, our breach head down, and about 13%, our breach breach, and at least about three or 4% before other things like transverse lie, which are pretty rare. So we need to get back to the question of why why section default position. There's so many reasons on that. And I promised I wouldn't monologue because I know we have time that's limited. But the reasons are, are a lot are poor training, little reward for the system, the way the system is designed, current hospital policies generally will say if twins are in labor, the doctor who's responsible for them has to be there, and the doctor doesn't get paid more to be there for 14 hours than he does. If he's there for 45 minutes doing a C section, it's exactly the same, there's probably more liability.
Stu Fischbein 13:14
What happens is, as doctors are fearful of these things, their fears begin to project onto the nurses around them on to the patients themselves. And so it's not a good setting for success. Even when you have a physician who wants to do that sort of thing. Plus, he's got big brother watching over his shoulder. And if something were to go wrong in that setting, there'll be hell to pay. So a lot of doctors just just say, forget it, I'm just going to do a C section. And it's not the right thing to do, it's certainly not the ethical thing to do, you know, the decision really doesn't belong to them. But so often, information is skewed in a direction to get the client to do what you want them to do. And if they start planting seeds of fear and anxiety, which is more projection than anything else, then the women become scared and nervous. And eventually, you know, they're told that if they have a C section, they you know, everything will be safe, it'll be great, blah, blah, blah. And they don't talk about the downsides of the C section, the downsides, the babies the downside to the mom. They don't often talk about downsides to the future babies that mom might want to have. So when there is an advocate like me in the hospital, what happens is and almost every physician I know who has stopped doing twins, or has left the hospital to do what I do has done so because they've been beaten up by the hospital system. Wow, they've been brought in for peer review. They've been brought in, they've been picked on by the anesthesia department and they're making trouble and then the administration just wants everybody to be happy. And if there's one person that's stirring the pot, that one loud person is the one that gets beat up on and on.
Christine Stewart-Fitzgerald 14:43
Right, right. And so I think what you're saying is that there, there are other doctors and other providers who would like to offer more either vaginal births or other choices, but it's just a lot of policies within the institutions themselves that are really preventing them from executing that are right commending it to their patients?
Stu Fischbein 15:01
Yeah, I think there are some, I don't know that those a lot. I think a lot of doctors at this point, have been pretty beaten up by what's happened to them in medicine, you know, all the outside forces that take away the ability to practice medicine the way that you want to, because you're always being told by your administrator, your insurance company or pharmaceutical company, what you can prescribe what you can do, how many things you can do at one visit. I mean, I just saw a sign yesterday, that was, let me just actually read it to you because it was pretty impressive. But then when you think about it, it actually makes a lot of sense. The sign says this, it's on the door of a doctor's office, and it says to decrease wait time due to our volume of patients, we will only be addressing the issues you scheduled your appointment for any other issues will require another appointment. Not first, that sounds rather cold. Right? All right. But I actually feel pity for the physician. Because the way reimbursement works is if you have somebody comes in, and you've scheduled them for an annual visit, or an OB visit, and suddenly they've got other problems. All right, you're not going to get paid extra, if that visit takes 10 minutes or an hour and 10 minutes, right? No, they have to they have to do that. But but the way it's written, it just sounds very impersonal, I think doctors have sort of just surrendered. And when it comes to twins and breaches, they've really surrendered, there's no doubt upside for them to be doing them. And they have really, really lost that intellectual curiosity, to even learn how to do it once they leave their residency program.
Christine Stewart-Fitzgerald 16:28
Now, you also talked a little bit about just kind of that the fear that's been instilled. And you know, and I have to say, as a twin mom, you know, there's there's tons of Facebook groups and you know, in the twin community about, oh, my gosh, I'm high risk, and I, you know, I might have this condition, and, you know, the different types of twin types, and there's all these scary things that are out there. And sometimes it's it's evidence based, and sometimes it's not. But I think one of the things that does come up, is this, this idea that oh, well, you know, if my twins aren't in both the vertex, you know, both head down, and once one's in breach or you know, in less favorable position, oh, I might be, and we can't flip them. I might have the the dreaded, you know, the two way birth of, you know, like, oh, I might have to, you know, give birth to one badly, and then the other one by cesarean section. And you know, and so there's this looming thing where, you know, I see moms talk about, well, you know, one of them hasn't flipped yet. And I don't know if I should try to do to do badly, I should just schedule the C section. And so I think you said that didn't in having one breach is I think you said 30%. of where you have one is vertex and one is one is breach?
Stu Fischbein 17:41
Well actually actually, about 53%. Of all twins will have at least one of them breach.
Christine Stewart-Fitzgerald 17:49
Wow. So it is very high. Okay. Right. So I can see then it's just this, this whole discussion about where breach really comes in, or the ability to deliver breach is is huge, because if 50% of births are essentially a breach have at least one breech presentation, then that means then, either it's either what the doctor being able have the skill set to do it or a C section, right?
Stu Fischbein 18:14
Yeah. Even if a doctor has the skill set, if the doctor has is fearful or anxious about it, that's going to be projected all the way through the last trimester of pregnancy. And, and even even early on. I mean, even early on, I see patients in consultation who've already been told, you know, at 14 weeks that the likelihood is they're going to end up with a C section, because that's just what happens with twins, and no one's delivering twins vaginally anymore. I mean, I can't tell how many times I've heard that silliness. And you know, so there's a lot of dishonesty out there. And again, we don't have the opportunity and in at least Western civilization right now to have exposure to enough because there are no twins centers, there are no breach centers would be ideal. And the way to bring this back into training would be to have in Los Angeles would be a perfect example, because it's a huge city is to have one major hospital say okay, we're gonna have a twin and breech training program. And that means that people who are going to deliver, say, in Long Beach will say, Well, I'm going to just drive up to say Cedars Sinai and go to their breech clinic. And that way there'd be enough volume for for residents in any program locally, or even across the country to come and spend a couple months on that breech or twin unit and get enough experience where they would feel comfortable doing them outside. Because quite frankly, I was lucky I was I trained in an era where it was considered normal and most twins do not have a problem. The problem is the the risk of twins having a problem is higher than the risk of singleton. So we tend to focus on that rather than the fact that most twins end up coming out normally, if you if people know what they're doing.
Christine Stewart-Fitzgerald 19:46
So now also, I mean, if so, if they're in a breach, we you know, I'll talk to us about flip or inversion. And is that one of the choice I've made so if moms are you know, coming, let's say halfway or you know, they've got, you know, another four to six weeks to go or, you know, they're they're coming towards their due date, let's just say and one is not in the perfect position. What are the choices? I mean, it's breech, I mean, a safe way of giving birth. I mean, should they try inversion or, you know, what are the different options available?
Stu Fischbein 20:14
Well, a couple things. First of all, there are anecdotal stories about people being able to turn one twin. Early in my career, I tried it a couple of times, I was not successful at trying to turn one twin. And now I have no reason to turn one two in any way. Because as long as twin A is what I call a stable longitudinal lie, which means either in a good head down position, or a normal breech position, I don't have a problem with that person going into labor. The problem, of course, is that if any baby is breech, even if it's the second baby, which should be no problem at all, any skilled OB GYN, as part of their core learning, should learn how to do a breech extraction on a second twin, it's really not hard to do, right. But they're not teaching it anymore. And that's where you end up with these women who have a vaginal delivery for A and then B turns sideways or something, and people don't know what to do. And then they do a C section for B, I can't even imagine that scenario happening. If a comes out, B will come out if even if you have to reach up and get it. And you know, you prepare when I do these breaches. I mean, when I do these twins at home, we have these long talks about possible scenarios that can occur. And as long as you know, the criteria for for safe breech delivery, whether at home or in the hospital, is that the babies tend to be growing concordantly Alright, which means that they need to be within 10 to 15 to 20% of each other. But ultimately, they could be even further apart than that if they're both growing at their normal rates. Unfortunately, a lot of stuff that we learned in medicine is very rigid. And if you fall outside of the rigid thing, there's no thinking outside the box, right? There's very little thing they don't know what to do with and they don't know how to individualize care. And there's very little incentive, as I said earlier, financially medical legally expedient ways to actually individualize care. A great example of what I what happens when something gets out of the ordinary in the typical hospital setting. And again, I'm not trying to bash hospitals, I would I will bash academia....
Christine Stewart-Fitzgerald 22:08
Those darn professors, right?
Stu Fischbein 22:14
They're not teaching the core skills that make an obstetrician unique. They're not teaching that. So if an obstetrician can't do forceps, if an opposition can't do breech, it's an obstetrician can't do breech extraction. What good is he explained that to me, what good is he he can do a vaginal delivery? Well, midwives can do a vaginal delivery. He can do a C section. Well, surgeons and family practice doctors can do a C section he can do a pap smear. Well, you know nurse practitioners can do a pap smear. Now you've got GYN oncologist, you've got GYN endocrinologist. You've got GYN urologist, you've got maternal fetal medicine specialist. So what is the generalist OBGYN job? Wow, other than to compete with midwives? Right? If he's not learning these special skills, anyway, the thing that reminds me of when you see the hospital getting all panicky, because something isn't exactly as there used to or protocol, is, if you've ever seen A Bug's Life, I don't know if you've ever seen the movie A Bug's Life?
Christine Stewart-Fitzgerald 23:03
I think, right? Yes, I think we have. It's been awhile.
Stu Fischbein 23:07
Well, if you have kids, you're gonna probably watch, it's worth watching. At the very beginning, there's a scene where all the bugs are carrying the little food to the basket, and from the tree above them comes to this leaf comes down, okay? And all the answer in this line, like you always see ants in your kitchen in line, you know, going to the candy left in the sink by mistake. Alright, so they're online and the leaf falls down on top of the line. So the ants behind the leaf begin to panic. What do we do? What do we do? They don't know where to go? They don't know, you know, they're all in a panic. Oh, my God, oh, my God, what do we do? What do we do? And one of the ants climbs up on a rock and he looks at the answer in a panic and he raises his hands and he goes, calm down, we'll go around the leaf.
Christine Stewart-Fitzgerald 23:48
Around is an option.
Stu Fischbein 23:50
Yeah, calm down. Take each individual problem separately. You know, you've got to if you have so much fear, every time you're in the delivery room, you need to find another profession. Birth is something that needs respect. It's sometimes difficult. Rarely is it dangerous, but you cannot sit there and be in fear the whole time. Or you will project that on to the women you care for. And therefore they will have pregnancies where they're nervous all the time. And I don't know what that does to the developing embryos and fetuses over time.
Stu Fischbein 24:21
Right? We need less stress for all the twin mamas out there who are pregnant. That's a that is a really big thing, right? We need less stress. We want to have happy Mama's happy babies healthy baby. So I am totally....
Stu Fischbein 24:34
And from the very beginning finding a practitioner who is knowledgeable in twins and supportive twins and doesn't read you all the things that can go wrong with twins at your very first twin prenatal visit or even having prenatal care along with your doctor with a midwife for somebody else. Getting concurrent care so that you get a calm sense of self along with all the things that can go wrong and we should talk briefly about the the....
Christine Stewart-Fitzgerald 25:01
The midwife, yes. In fact, you know what we're gonna take a break. But when we come back, we're going to talk about the birth choices and what it means to follow the midwifery model of birth that I know you've been talking about.
Christine Stewart-Fitzgerald 25:18
Well, welcome back. Today we're talking with Dr. Stu Fischbein, about the choices that women have and giving birth to twins. So we've turned the talking about just the kind of the process and what both women and physicians are faced with. And that kind of our current model of care seems to push women towards giving birth in a hospital because of a lot of, let's just say, regulations and standards and fear and just a lot of crazy stuff. But I know Dr. Stu, you've talked about following a midwifery model. So what exactly is that? Can you tell us you know about it?
Stu Fischbein 25:54
Yeah, I can. And I want to just say one other thing, just to finish up with the last segment was that there are issues about twins, which makes somebody probably not a good candidate for a natural type twin birth. And a lot of it has to do with something called Corinicity. Which means are the babies in their separate sex or the sex in separate sex? Are they all in the same sack? And I won't get into that today. But some of your listeners...
Christine Stewart-Fitzgerald 26:17
We do have another I say we have another episode about twin types where we talk about yes, they're sharing a placenta twinning, twinning. How does it happen in twin types? Absolutely, yes, we and that is different levels of care.
Stu Fischbein 26:32
For the rest of the rest of the podcast, we'll make the assumption that everything is going swimmingly in normal. And that's great. So the midwifery model of care, whether it's for twins or singletons or whatever, is just a model of care where much more is spent on preventative health care, much more the philosophy is such that birth is wellness, and is a normal function of the woman's body, the medical model or the medical model of care, the obstetric model of care, focuses on pathology, that's the way that residents are taught that every woman is with a little bit of hyperbole as a potential walking time bomb, and that the job of the physician is to prevent anything bad from happening. Even though those are the rare times maybe about 15% of the time in pregnancy, something requires medical attention, and about 85% of the time it doesn't, but all 85 Of those, all 85% of those women are being treated with a medical model by somebody who was talking them all the time about the baby might be getting too big, or there might be too much fluid, or if you go too far overdue, then this is going to happen. And you know, there's increased risks of stillbirth or increased risk of that. And they talk mostly about relative risk and not about actual risk. And people don't know the difference...
Christine Stewart-Fitzgerald 27:43
Oh, my gosh, totally, you know, okay, I have to say, I felt that in my own pregnancy, when when I was getting the care. That is exactly what happened to me. I mean, I was 37 when I get that birth, so okay, geriatric, right.
Stu Fischbein 27:58
Which means, which means absolutely nothing a normal normal practice, but, but your label it a category of high risk. And, and if you if you label somebody high risk, I always have this theory that that actually makes them high risk, because they are now worried, right? Just because you just because you labeled them that way.
Christine Stewart-Fitzgerald 28:15
Right? Exactly. And so everybody, I remember going through the care, and they you know, they were lying, you know, laying everything out and saying, Oh, well, you know, you know, once you reach 35, and this is the risks are significantly higher, blah, blah, blah, and oh, by the way, having twins, so you got this double high risk. And I'm thinking really, I mean, it was my first pregnancy. And in my case, I've been pretty healthy. I've been fairly fit, you know, my whole life, and I just, I have a healthy lifestyle. And so I've personally never been worried about my twins. And I'll just say, I did end up carrying them to 39 weeks and five days. And of course, nobody believed, you know, they were just in shock that I carried twins that long. And so I to your point about perceived risk versus actual risk. I mean, I think that really, really needs to be honed in that, you know, I'm not a walking statistics. And and I think each and every patient when they, you know, when they're having the discussions with the with the doctors should be looking at, well, what is this patient's lifestyle choices? I mean, what's their? I mean, what's their, you know, prior history? What are their their current, you know, what's their, their diet with their exercise, you know, what are the the risk factors instead of just saying, Okay, you're this age, you're, you know, you're having twins is the twin type pregnancy and Okay, well...
Stu Fischbein 29:34
Right, and what are their what are their? What are their future fertility plans? What are their future family planning, right? They want more children, they want more children, we should do everything we can to avoid that initial cesarean section, so that those things don't come up in the conversation very well. And the midwifery model deals with that sort of thing because the the prenatal visits are generally 30 to 60 minutes long. And I know that most of your listeners who go to an OB I would say that most of the OB visits if The last more than five or six minutes are pretty darn pretty darn good. Because and you can't possibly get into preventative health care in five or six minutes. You can't ask them about their diet or diet recall, you can't ask them about sleep. You can't ask them about stress reduction in house things with your with your partner and you can't ask them about their birth plan or what their concerns are fears are you essentially go in, you take your tape measure, you measure the belly, listen to the baby, say God, things look looking great, your blood pressure is fine, I'll see you in two weeks. And that's sort of the typical prenatal visit in the in the medical model.
Stu Fischbein 30:35
The midwifery model is also different in labor to is that they're much more attentive, but they're attentive in a way that leaves you alone. So they're not interrupting normal mammalian birth, I have a big talk on this about how every other mammal gives birth by going off to a quiet place by themselves uninterrupted, and they're allowed to eat, or they eat and drink as they feel like it. When they're ready to give birth, they give birth and nobody else bothers them. That whole period of time. And anytime they are interrupted, or a predator approaches, or whatever, or they're starved or whatever else labor, their labor stops, they get up, they run away. And so what we do human female is antithetical to about everything that's typical for normal, normal mammalian birth. Whereas midwives tend to honor that space much more than the medical model I, for the life of me can't figure out why my colleagues don't understand that, that everyone needs to be monitored everyone's vital signs. I mean, how often in labor does a blood pressure with it's normal on admission? Does it actually change to a pathological amount yet they have policies or protocols that mean that blood pressure cuff on your arm has to blow itself up every 30 minutes. And you know, it tends to interrupt whatever you're doing, and then they have to come in and you know, you can't get up, you can't walk around, you can't get in the shower. You can't get on all fours, because we have to have those belts on.
Stu Fischbein 31:47
And how was I was just curious, you need and you talked about in the prenatal, like in the midwifery model, you know, the fact that in OB GYN office, they're not being able to talk about preventative care. And do you see more preventative care emphasized using the midwifery model for for prenatal care?
Stu Fischbein 32:03
Yeah, I think it's more personalized preventive care. I think in doctor's offices, they may give you a handout.
Christine Stewart-Fitzgerald 32:08
Right? Here's the paper, read it. Read it right here. Here's the here's the list of vitamin supplements you should be taking. Right?
Stu Fischbein 32:15
Right. But the midwife will go over all those things with you, right? And they will ask you what, you know why you're not taking them what's going on at home, blah, blah, and they and they just solve those problems. You're much more likely to get labor to come naturally without interventions and midwives are not, you know, they don't follow this thing where we we need to start testing your baby because you're over 35 We need to start testing baby at 38 weeks because your placenta is old and we'll give out. All right. I mean, the things that they say to people, your hips are too small. The fluid is low ish. I mean, what does that mean? lowish? Babies too big? How do you know the baby's too big? Right? I mean, women haven't delivered nine but nine and a half pound babies out of their pelvis before?
Stu Fischbein 32:55
Right now, you know, I was wondering, so I know a lot of women who have been maybe, you know, hearing about this and you know, looking at the midwifery model and desiring to give birth out of the hospital. How is it different? I mean, what what can women expect when they're giving birth outside of a hospital? What's that experience look like?
Stu Fischbein 33:14
Well, first, I mean, since it's a focus on twins, let's try to focus just on twins. Obviously, the recommendation from organized medicine is that any home birth is inappropriate, and they consider breech twins and VBAC to be absolute contraindications to out of hospital birthing. I'll state that categorically that that's what it says in their guidelines. I will also say categorically that they freely admit that these guidelines are what are called level C evidence, which is, which is consensus opinion, there's no data or good science that says that probably because there just isn't enough data. So their consensus opinion and what consensus opinion would you expect from people whose consensus opinion is that homebirth sucks. So you're not going to get that? No twins are, I think twins and breaches of all things being equal, be better and safer. Safer is a very loaded word, but I'll use it here right to be delivered in the hospital setting. The problem is all things aren't equal. And you're and you're not going to get the success rate of birthing in the hospital is less than the success rate at home. And the end, the intervention rate in the hospital is higher than it is at home, which then leads to outcomes that may not be so good. So I would tell you that as as an expert in normal labor, and working with midwife colleagues for all these years, because they're experts in normal labor, they're very, they're expert at recognizing when labor isn't normal, and then you can be quick to transport and when you rarely see the rapid deterioration of fetal status that they talk about in the hospital where, you know, the baby's heart rate went down and did a craftsy section. Thank God they saved the baby. Yeah, but they saved the baby from the fact that I atherogenically, they'd caused all this problem in the first place by epidurals and over pitting and it mobilizing and starving the mother for 20 hours.
Stu Fischbein 35:00
So we don't see that at home, when we see things happening at home, that well trained practitioner can actually see things coming from plenty of time away. And it's very rare that we have a 911 sort of call from home the most common reasons why we call 911. And I would say it's less than one or 2% of all births is actually for postpartum problems like bleeding, or the or the, or the baby's breathing, but it's breathing a little fast, and where we don't like the color, and we think the baby should go get evaluated, but we're not going to put the baby in the car seat to do that. We're going to call it ambulance, that sort of thing. It's very rare to have an ambulance come to take a mother away in labor. It does happen. Of course, it happens, right? But the success rates of twin birth breech birth VBAC birth, at home are significantly higher than the success rates in the hospital. And that's simply by the model by which women are cared for. And the fact that there's a trusting of the process that's going on, with with, especially with with twin birthing, because nobody's going to do twin birthing out of the hospital that isn't really confident with twin birthing. So you're guaranteed a confident practitioner, if you're having a twin birthing experience outside of the hospital.
Christine Stewart-Fitzgerald 36:12
And how about like at birth centers, because I mean, a birth center is sort of a quasi kind of in between, right? I mean, compared to how well....
Stu Fischbein 36:19
Surprisingly, birth centers don't have any more equipment in them than what we bring to a house. So birth centers are a compromise in for possibly proximity if somebody lives far away or up in the hills, or in the canyons here in Los Angeles, or if they have a house that you know, got three roommates in it and, and very thin walls, and they don't feel privacy there. A birth center is a really great option. percenters also have really nice tubs built in as opposed to the portable tubs. But that's a small reason. But most people, if I were to encourage somebody to have a out of hospital birth, I would strongly recommend they stay home, because then they never have to get in their car. And they never have to disrupt the normal thing they can stay in a place they're very familiar with. And if they have the baby there, they never have to baby put the baby in the car seat four hours later and drive a baby home. Right?
Stu Fischbein 37:06
They you know that that's so true. I gotta say, just going labor. I mean, we hear these crazy stories about just you know, getting in the car. And I mean, I can say from, from my experience, I mean, I was living about 35 minutes away from the hospital where we gave birth. And I remember Yeah, with my twin birth. I mean, that was, yeah, that in my singleton birth as well, like the most uncomfortable car rides, ever. I mean, I was having back labor. And it's just, I'm like, Yeah, I think that's, that's torture and of itself, to try to be strapped in a seat, right?
Stu Fischbein 37:39
Right. Many communities don't have the option that we have here in Southern California for for twin home birthing. But one of the things that people can do is if if they can find a practitioner at the hospital who's somewhat flexible, they could actually hire a midwife to do what's called monitor Reese work, which is, they could stay at home with them, they can listen to the babies stay at home with them and labor and get them to the hospital, when they're 7,8,9 centimeters dilated, as opposed to bringing them in, you know, at, you know, oh, I broke my bag of water. So come on, in, oh, you're one centimeter. And now you're one centimeter stuck at the hospital, you've got twins, and they're not gonna let you go home. And eventually, they'll start Pitocin. And the whole cascade of interventions will, will ensue. So people that have twins, again, finding a confident practitioner, is ultimately the best thing that you can do. So that you don't end up with the person who's telling you you're too old.
Stu Fischbein 38:36
Right, right. Now I have to bring Sunny in on this. So I don't know. Were you ever 35 when you had your twins? I mean, what was your experience? Were you getting sort of that the fear of getting the fear of having twins?
Sunny Gault 38:48
I was 35. And yeah, and they make you feel like you're an alien. Right when you go in there. And I think I'm trying to do they even know when do they do that? I think that I want to say that that whole experience where they ran down. Okay, here are you know, the things that could happen now that you're pregnant and 35 and older. I want to say that appointment happened before we knew they were twins. Is that possible? When do they typically do that?
Stu Fischbein 39:19
They would probably do it at the first visit around 10 weeks when they're talking to you about genetic screening.
Sunny Gault 39:24
Ah, so it did I think what happened if memory serves, I had a regular appointment with the OB/GYN that you know delivered my previous baby. And I even asked I said is it twins because you guys know that listen to Twin Talks. I always wanted twins. Just one of those weird people always want to twins. And she said no, they're not twins or it's a singleton and are just one baby maybe she didn't say singleton. And so my hopes were dashed and I probably scheduled another appointment where they walked me through everything because I'm you know geriatric, and you know instill the fear of God in me of what was going to happen during this labor and delivery experience. And I think that was another appointment where they actually did the ultrasound. And then they told me there was more than one. So but no, I'm very familiar with, again, where they run down all the potential things that could happen and just just scare you honestly, like, I'm sure they have to do that for some reason. But that that was not fun.
Stu Fischbein 40:25
No, they don't have to do that. For some reason. I think that that is, again, projecting their own fears and anxieties, to be sure. You know, there's ways of giving informed consent where you make people feel comfortable. And there's ways of giving informed consent where you scare the puppy. Yeah. The twin birth, the twin birth itself can be a really beautiful, beautiful thing. And you know, even doing it out of the hospital, it's different than doing it in the hospital. Because in certain in certain situations, you're allowed to be in different positions, you don't in the hospital, you're probably going to be on your back with with legs and stirrups, once baby comes out in the hospital setting, they often and this is the way I did it for years, that often then go right up and break the bag on twin B and deliver twin B within five to 10 minutes of twin A, because A part of me believes that's just the way they've done it for a long time. And part of me believes that's because they've got you know, 12 people standing in the room waiting to take care of the babies.
Christine Stewart-Fitzgerald 41:19
And they don't want to be sitting around twiddling their fingers for Baby B to come out. Right.
Stu Fischbein 41:23
Yeah, I mean, every every every twin hospital generally has the NICU team standing by for even if they're term babies, they, they call out the the National Guard for for every twin birth, because their anticipation you know, and I understand it, but maybe all these people could stand outside the room instead of inside the room and be a little less be a little less intimidating. But that's just it's not that the thought process is not that the thought process about birth is that the you know, the endpoint is having a good baby and a good mother, which is not, which is laudable. But on the other hand, there's so much more involved than the and this is a life changing experience for women and their husbands and their family members. And it's treated often as if you came in with a gunshot wound or you're having your appendix out, it's very mechanical. And when all you're taught is that twin pregnancy is dangerous. And that's sort of what's taught to residents. I didn't come out of my residency program thinking like I do now, it took a long time for me to evolve. And it all started with me covering midwives. As a backup physician, I had no intention of ever backing midwives. But they approached me and asked me to do it. And I was a capitalist at the time. Because building the business of practice was different in 1986. And it is now where people come out, usually, you know, sign with Kaiser or some other HMO and get a salary work certain hours. It's a better lifestyle for them, then that we have. I mean, they know when they're on call, they know when they're off call. It's a much better lifestyle.
Stu Fischbein 42:50
So you brought on midwives just because there was a financial opportunity, and then they ended up teaching you something in the process.
Stu Fischbein 42:58
Oh, yeah, for sure. I mean, I was very open minded to it. I enjoyed their company, I ended up going to some of their meetings. And that but I was lucky though I trained in your twin delivery was considered normal, and we learned to do breech delivery. I mean, I trained at a big hospital, LA County, USC, where they had 22,000 births a year, which is 65 births a day. And, you know, even if only 2% of births are one or 2% of births are twins. That means every day I was on call, there were at least two sets of twins on average. And you know, we get to do everything there. So that kind of training doesn't exist anymore. And so we do have to be more flexible. And that's why I think we need we need more collaboration between the midwifery model and the medical model rather than less and we need to stop belittling each other. And we to accept the fact that that midwives are trained to do twins. And then states passed laws preventing midwives doing twins but don't mandate that doctors do them. So it's a schizophrenics sort of approach that organized medicine and and state legislators have is that they want to protect patient safety by banning midwives from doing things they're skilled to do and then forcing women to have cesarean sections. And I'm not exactly sure how that improves patient safety.
Christine Stewart-Fitzgerald 44:11
Right. So from you know, expected twin mom perspective. I mean, if she's looking to have a more natural doing a vaginal birth, and maybe she's not here in Southern California, she's another part of the country. I mean, what what's the process that she should go through to try to find out what options are available in her area?
Stu Fischbein 44:30
Well, I would I would stress the fact that if she's a multipurpose woman if she's already had one or two vaginal deliveries and she's got twins, and that first one is head down or even in a stable breech position, she should not have a cesarean section she should because that the success rate for her is going to be above 95%. Delivering vaginally and dissection all those mothers is a shame for Prime MIPS is a little different. The success rates about 74% In my experience with Primus but that's still better than 100% c-section rate.
Stu Fischbein 44:59
We say primace is having twins as the first pregnancy right?
Stu Fischbein 45:03
Correct. So So what can you do if you're not immune in a community that doesn't have any practitioners? Well, it's a tough one. Because relocating to a community that does is sometimes a big deal, especially if you have other kids. I've had three for three or four sets of twins that have, you know, moved to Los Angeles that 36 weeks, and lifted, got an Airbnb or lived with family, and Heather twins here with me. But that's, that's the exception rather than the rule. The problem is, is that most people can't afford to do that. They can't afford to be away from home that long. So and then many states have laws against midwives doing twin delivery. So you're, you're screwed, basically, I mean, sometimes you might have to drive 100 miles, if you can find a doctor at a university setting or that is willing to do twins, but then there's a chance that you go into that day, and that doctor is not on call.
Christine Stewart-Fitzgerald 45:49
That's wow. That's tough. So I think you're saying you kind of have to look to learn about what the regulations are in your state and your immediate area. And then look at options, look at maybe the surrounding area, and others other states and see what options are there, what providers are there? And if and if this is really important, consider doing a temporary stay. I mean, maybe that mean, if you've got family that you can stay with for a couple months, I mean, I mean, that might seem to you know, stay with the in laws, right to get birth. But, but if that's important, maybe maybe that's the thing that should be considered if you know, you want to have that natural calm at a hospital birth.
Stu Fischbein 46:32
Yeah. And then prop being properly selected. We didn't really talk about that, because maybe you talked about that in a previous podcast. But if you're properly selected the you know, my average twin goes to 39 weeks in one day, the average twin in the hospital will never make that because they're all induced between 37 and 38 weeks because they're told the rising risk of stillbirth.
Christine Stewart-Fitzgerald 46:51
Yes 38 weeks, you hear that.
Stu Fischbein 46:54
Even in singletons as the farther along you get, the more likely you are to have a stillbirth. But the number is so small that you to change your birth plan because of a number that's, that's, you know, twice a very small number. It's still a very small number, but they're not You're not sort of told that, from what I hear from third hand from when patients come to me as a second opinion. I don't think the doctors understand statistics very well either anymore. And I don't think they understand that ultimately, the choice doesn't belong there. They're ethisus, who think that if we think we know best, we're supposed to skew our counseling to give a recommendation, and make it more difficult for the woman to choose something outside of our recommendation. And they think that that is ethical. And they have a good argument for it. I just happen to disagree. And so too many of my colleagues that, you know, we we believe that women are intelligent enough to be given information, if they, if they want to know our opinion, to ask our opinion. And then to be able to make a decision and medical ethics, the kind that I follow dictates that given the same information, we shouldn't expect two people to come to the same conclusion. And therefore we should be respectful of any reasonable choice that they make. Now, some doctors may think that twin twinning, twin birthing out of the hospital isn't reasonable, and they don't have to support that. But to tell them that they're crazy, and the babies will die or whatever else that's unethical. Right? To tell them that, you know, I can't support you, but there are practitioners in the community who might, why don't you go talk to them and see what they say and then maybe come back and talk to me about it, we'll have a conversation. That is beautifully ethics.
Christine Stewart-Fitzgerald 48:27
So I think what you're talking about is just the idea of informed consent, that the women the expectant moms really need to have the wide range of information available to know what choices are whether or not the particular provider believes that, you know, they are the best they're gonna have their own personal opinion, but women need to be in some ways trusted to to look at information and do that decision making process themselves given, armed with with good, practical, real evidence based information.
Stu Fischbein 48:56
Exactly. And fighting for the birth that you want. Yeah, you really need to do that. Because bad things can happen at home and the bad things can happen in the hospital. The hospital is no guarantee that because you're there that you'll have a good outcome. All right. All right. It's matter of fact, a lot of times bad outcomes, or at least scary outcomes happen because you're in the hospital and because of the way that you were managed in the hospital and anyone that denies that is not being honest. And yes, bad things can happen at home. All right. This is you know, again, I I'd like to end on a positive note regarding 20 Because it's a it's just a beautiful experience when you're when you're involved with with twin with twin birthing. It's a lot of work for the mom, it's it's amazing how strong women are. And babies are designed for this and right and your practice. They are they're designed. They're designed to come out the vaginally and they're designed to the placenta designed to support two babies in the uterus through labor. And if they're not supporting it, well you can hear that and then you know that it's time to go so it's not like as I said, It's not like there's a sudden switch.
Christine Stewart-Fitzgerald 50:01
Right? So so I'm just wondering, maybe just share with us a little bit, what does it look like, from your perspective? What is a twin birth at home look like? And how is it just so different than a hospital birth, a twin birth at home?
Stu Fischbein 50:14
Well, quite frankly, when if it's a multiple twin birth, I, I'm enjoying myself pretty much the entire time. And when it's the primate twin birth, I too, have a little bit of hesitancy and anxiety that, that I may end up having to do stuff. And so we have these long talks beforehand, about me possibly having to reach up and get the second twin, and what that's going to feel like and what that's going to be like, and if you if you tell me no, when I'm trying to do it, then I have to stop. And if I have to stop, then in the baby's in trouble when we have to call an ambulance. And that's not a good thing. So I, I give them this information ahead of time, so they can think about it and decide is this something that I think I might be able to handle. But normally, this time, we don't have to really do anything, what we do is the first twin will come out, and sometimes that twins a little bit more stressed initially, but Mom will generally reach down like with a singleton birth and pull the baby up onto her belly, and then sit back and hold on to the baby. And one of the midwives from my team will assess that baby, well, we'll take a good look at Baby B, we I bring a portable ultrasound machine, it's not always necessary. A lot of midwives don't do that.
Stu Fischbein 51:19
But I bring a portable ultrasound machine to check the position of the second twin, and the heart rate of the second twin, the heart rate is good, we just leave it alone. And with that mom and baby, Hey, have their time have delayed cord clamping do whatever they want. Eventually, at some point mom will start to make sounds again, like because their contractions are coming back. And she'll want to hand the baby off to somebody else. She's no, because she's now like uncomfortable again. At that point, we can either check we do a vaginal exam to check the position of the baby. And if it's the heads right there, we have a push. If it's not the head right there, we maybe take a look, look on ultrasound, if it's the feet, we talked about doing a breech extraction at that point. And just breaking the bag of waters going up getting the feet pulling the baby down, taking it out breech, which is for any any skilled OB is a very simple procedure that actually makes you feel like all those years of training, were worthwhile.
Christine Stewart-Fitzgerald 52:09
You get to be a hero. Yeah, you get to do something and...
Stu Fischbein 52:13
Well, you get to use your skill. I mean, it doesn't take a lot of skill to do a pap smear or a c-section.
Christine Stewart-Fitzgerald 52:18
I just think the moms being at home and you know, just from the the feeling and the sensation of being at home and being in your own bed. And just I've seen videos of the twin births. And it just seems like it's so calm compared to a hospital setting.
Stu Fischbein 52:35
Yeah, and there are there are groups on Facebook and other social media outlets that people who have twins can go to where they can speak to other women who've been in the same position. I actually have a list for my clients and what I call my twins moms list. It's other moms who've had twin births, who presented in my office with the same dilemma and had births at home. And some of them have ended up being transported. Some of them had babies at home. But I supply that list to the future moms so they can contact these women and share their stories and they can find out a little bit of how they did it and what was it like? And again, I'd be willing to share that those women would be willing to share that with any of your listeners who contact me through birthing instincts calm even though they're not my clients. I'm sure that my my twin moms list would people would love to talk to anybody.
Christine Stewart-Fitzgerald 53:20
Absolutely. Well, I just want to say thank you, Dr. Stu for for joining us today and just oh my gosh, all the insights and kind of new contrary information that we've been hearing today contrary to what we're normally hearing, it's it's refreshing and very thought provoking. So, thanks for having us. And yeah, I would encourage our listeners to check out Dr. Stu's websites birthinginstincts.com And with that, we'll be back.
Sunny Gault 53:52
Okay, so before we let you guys go, today, we have a segment that we like to do, where we just share some funny stories, um, that we find online that people are sharing, sometimes they email it to us. And sometimes it's from the perspective of a twin who's now an adult, and they are sometimes reflecting on funny things they did you know, with their other twin growing up, sometimes we share stories of just things that regular people have perceived other twins, you know, happening between other twins. Today I'm going to share two with you because both are kind of short. But the first one this is really funny. So this is the perspective of a twin who has a twin brother, so to two boys, okay. But he's he's basically reminiscing about their childhood. So this is what he says my twin brother was president of the class and I was Vice President, our junior year, which by the way, isn't that just interesting? Like I don't know if they ran on the same ticket or whatever. Vice President anyway, so he says he was vice president as junior when it came time for our school reelection speeches for senior year, my brother completely forgot and why Tony, I did my speech for vice president, then I borrowed a friend's T shirts, and made up a presidential speech for him on the spot. And here's the kicker, they both won. That's one thing you can do it. It's titled helping out, and which Yeah, I mean, he totally just got his brother reelected president. It's kind of fun. They were kind of helping each other out there. Here's another funny one. And now this is from the perspective of someone who worked with a set of twins, obviously, they had to be identical. So it's really quick. It says, The McDonald's manager often puts one twin on the pay window, and the other twin on the food window.
Christine Stewart-Fitzgerald 55:44
So the drivers are like, they go up and they pay and they're like, hey, great. And then they go to the next window, and they're like, Wait, did you just pay?
Sunny Gault 55:53
Or did you run over? Like, that would totally throw me off. If I was just having one of those weird days where like, nothing's going right. I'm like, what, but but I thought I just need and then they would even be crazier. If they're like, now can you please pay? Right?
Christine Stewart-Fitzgerald 56:08
You're probably they're wearing different name tags, right? I mean, everything exactly the same. Right? So my girls to do that, you know, their first jobs work at a fast food restaurant. Just to throw people out.
Sunny Gault 56:29
Yeah, that's right. Just have fun with it.
Stu Fischbein 56:31
I have a funny twin story too.
Sunny Gault 56:33
Okay, go ahead.
Stu Fischbein 56:34
My twins were trying out for I think it was ninth grade football at their high school and one of my twins was was slightly heavier, heavier than the other twin. Alright, and they had a weight limit. Okay, so you can see where this is going. So the lighter twin try, you know, cuz under the weight limit goes tries out or just gets weighed in and don't have to try out it was just a weigh in. Because if you're over certain weight, then you have to move up to a different class. Yeah. And they wanted to play the same. So you go to the way and gets weighed and he's fine, goes back to the car, changes his shirt, changes his shoes comes back to be Teddy's his brother. All right, gets weighed in and passes. So they could play on the same team even though his brother would have been outside the weight limit by about five or six pounds.
Sunny Gault 57:20
That's so funny. Yeah, so that's another example of helping out your twin. There's a good story. I don't know. I don't know. That's how we're supposed to be.
Stu Fischbein 57:28
I was not too pleased when I heard about that was not too pleased about the ethics of it. But I thought I thought you know what, it's pretty clever. Why not?
Sunny Gault 57:34
Say they get points for creativity and helping out your brother. Brotherly love.
Christine Stewart-Fitzgerald 57:42
Well, that wraps up our show for today. We appreciate you listening to Twin Talks. Don't forget to check out our sister show Preggie Pals for expecting parents in our show with The Boob Group for moms who breastfeed their babies. Parents Savers, your parenting resource on the go, and Newbies for new moms during the first year. This is Twin Talks- parenting times two!