Recently I supported my client, Scarlett to have a natural twin birth. Completely outside NHS guidelines. The twins were Didi, (they had their own placentas and amniotic sacs). They were born at 39 weeks and 3 days. Twin one was a cephalic presentation, head down, twin two was a complete breech presentation, bottom down, arms and feet curled up.
No induction. No caesarean. No epidural. No routine vaginal examinations. No continuous foetal monitoring. No IV cannula. No routine monitoring of mum or her babies. No episiotomy or coached pushing. Using a birth pool. With no time restriction of 30 minutes between the birth of twin one and twin two.
Scarlett has a little boy, now nearly three years old. His planned for home birth was sabotaged by an unreliable home birth team who would not commit to supporting Scarlett prior to and during her labour. It took three attempts at calling the home birth team, over a protracted period, to have midwifes attend her at home. The stress and anxiety she endured resulted in her labour stalling and thus transferring to hospital when 9cm dilated. Forceps where then used to help her birth her baby boy.
Her baby boy’s birth ultimately influenced her decisions around how to and where to birth her twins.
But first, how was this possible when the societal norm for a twin pregnancy and breech pregnancy is to have a Caesarean booked for around week 36 or 37?
Research, persistence, self-advocacy, education, knowledge of birth rights, sheer determination and mental strength from Scarlett.
Research, education, reading, and undertaking a course on Breech babies, by me.
Over 50 Emails were sent to the Consultant Midwife. Several in person and zoom meetings took place. Birthrights.org.uk and Dr Stuart Fischbein from @birthinginstincts, as well as an Obstetrician from another trust, gave their support.
It wasn’t easy for Scarlett. The process put untold stress on her and her partner.
An initial meeting with the Consultant Midwife, when Scarlett was 20 weeks pregnant, went well. Scarlett felt optimistic that their birth choices would be supported.
However, this initial positive start was short lived. Appointments with a Specialist Multiples Pregnancy Midwife didn’t materialise. My client had to chase her appointment only to have it with someone else. My client had to repeatedly request her MATB1 form too. The promised follow up appointment with the Consultant Midwife, 4 weeks after the initial meeting, was not arranged. Eventually, the Consultant Midwife emailed to say she had been on Annual Leave and Study Leave, and put forward a date for the next meeting, 10 weeks after the first. Scarlett was now 30 weeks pregnant. This meeting was arranged and then cancelled. The Consultant Midwife was also going to speak with an Obstetrician from another trust who had experience of women birthing twins naturally. The idea being to get some support with the documentation, (PCSP*) and to exchange her experience. This never happened. Eventually, after I emailed the Consultant Midwife myself, expressing concern for Scarlett’s mental wellbeing being affected by the lack of a definitive care plan, a meeting was arranged. This in person meeting took place more than 3 months after the original meeting!
Scarlett had also had a scan prior to this meeting and had discovered twin two was breech.
The meeting went well.
After more than twelve weeks of poor communication, frustrating silence, initial optimism and then a complete lack of trust in the maternity system, the birth plan that Scarlett and her partner had written themselves, was signed off by the Consultant Midwife and her team. This meant that Scarlett’s choices should be respected and her birth for her babies she be left to unfold as she wished.
(*When a woman wishes to have antenatal care, and a labour and birth outside of the hospital’s guidelines or policies, a PCSP, (Personal Care and Support Plan), is usually written by the lead Obstetrician or Midwife, and gone through with the pregnant woman. It lists all the perceived risks and hospital guidelines and what ultimately the pregnant woman is planning to do during HER labour and baby’s birth.)
The Birth Plan
Scarlett wrote three separate plans. One for a Home Birth. Her first choice.
One for birthing on the Midwife Led unit.
One for a Caesarean Birth.
I encourage all my clients to consider all scenarios when writing their birth plans/preferences. Labour and birth are unpredictable. But having a voice and a choice in all scenarios helps to have a positive birth experience, even if the birth doesn’t go to the original, first choice, plan.
A summary of each plan follows. I have listed the main points.
Home Birth
Scarlett hoped for a hands-off physiological birth with minimal interruptions. The environment was to be kept calm, and she was going to use movement, aromatherapy, water, massage and partner support to help her manage her labour.
Vaginal birth was planned for both twins, including twin two who was breech. No rush to birth twin two, with twin one still attached for at least 15 minutes. Physiological third stage, (birth of placentas).
Support of twin two to avoid rotating to a transverse position, if necessary.
Immediate skin to skin and no hats or rubbing babies down.
Scarlett planned to breast feed but had harvested colostrum should it be needed.
Midwife Led Unit.
As above.
No cannula, no mentioning/offering of pain relief or epidural, no scan between babies.
ACCESS TO POOL! (Usually denied for a twin birth).
Caesarean Birth.
A caesarean birth would only be an option if there were concerns for Scarlett’s or her baby’s health. A true clinical reason.
In this scenario, she would want a Spinal block, not an epidural. No morphine analgesia. Both her partner and I in theatre with her. The option to have immediate skin to skin, placentas to remain attached and cords cut by their dad.
Microbiome seeding was planned too.
Colostrum to be given, if necessary, not formula. If special care was needed, twins to remain together and to be co bedded.
So, how did the births unfold?
At 39 weeks and 3 days gestation, Scarlett’s waters broke at around 22.30 one evening. She had been having mild contractions on and off all day. She planned to stay in bed and try to get some rest.
At 23.23 I received a message to say that Scarlett was having stronger contractions, that felt different to the ones she had been having during the day, but they were manageable, and she was able to breathe through them.
She had a TENS machine and a hot water bottle at hand but felt she didn’t yet need them.
At 0100am, Scarlett’s partner messaged to say that she was progressing, with contractions now 3-4 in 10 minutes, long and strong.
It was decided I would make my way to their home.
I arrived at 02.20am.
Scarlett was leaning over her sofa. She had her TENS machine on. She was in the middle of a long, strong contraction.
Her partner had called the midwives and had been told there was no home birth team due to sickness. Despite promises of having staff available during the period Scarlett could go into labour. He was focused on prepping the birth pool in anticipation of going ahead with the planned home birth.
Between us, we decided to call the midwife back and question the fact they had no home birth team as we had been told only a few days before that staffing had been sorted to honour Scarlett’s birth plan.
The discussion I had on the phone with the Lead Midwife for home births did not change the situation. She implored me to advise Scarlett to transfer to the MLU. (Midwife Led Unit. My clients Plan B).
Meanwhile……
Scarlett was progressing quickly. I could hear from her vocalisations and see from her contractions. She was getting some urge to push. I could also see the Purple Line*.
In between contractions I made Scarlett aware that there was no home Birth Team and that her options were to either Free Birth, (stay at home and birth her babies without midwifes present). We had previously discussed this scenario, and my clients were going to make this decision if it arose. (They had full understanding that as a Doula, I couldn’t offer medical advice or support and if there was a medical emergency, Paramedics would need to be called.)
Or they could transfer to the MLU, a 20-minute car drive.
I also advised her that a decision needed to be made quickly as I was aware that there was a risk her first baby could be born on route!
It was decided that she would transfer in by Ambulance as labour was progressing fast.
I helped Scarlett to get ready. Within 5 minutes the paramedics arrived. This was around 3.30am. We went straight out to the ambulance. I travelled with my client. During the journey she declined any observations, and we tried to keep the journey quiet and as comfortable for her as possible.
Grandma was called to be with their older child. The Father waited at home for Grandma to arrive.
On arrival at the hospital, the lead midwife and two other midwives were waiting for us, and we were shown to a birthing room with a pool.
The Father arrived shortly after.
Despite a written birth plan that had been signed off, Scarlett was still asked if they could do some ‘quick monitoring’ with the CTG and asked her if she wanted an examination!
She declined both.
The pool hadn’t been filled despite our requests, so I advocated for this to be done straight away as Scarlett was very keen to get into the water!
It was said by one of the midwifes, despite having gone through it before, that the pool wasn’t recommended! So frustrating when everyone was aware of the birth plan! So again, I advocated for my client and said we were aware, and my client said rather forcibly, “I am getting in the pool!”
The pool filled quickly, and oh, the relief felt by my client when she got in!
There was no more questioning of Scarlett’s choices. She was left to labour, without interruptions, in the pool, her partner by her side and me offering encouragement.
Shortly after being in the pool, Scarlett hit transition and had a wobble. She really wanted an epidural, but her partner knew that if she requested one at this point, he was to tell her she didn’t want one really, it was just that she was close to birthing their first twin.
During her transition I was able to see in my pool mirror that there were signs baby was coming, so I knew it was too late for her to have an epidural!
Around 20 minutes later at 4.28am, Scarlett birthed her first Twin, whilst on all fours, into the pool and caught her between her legs. No one touched baby, just mummy and daddy. Perfect!
Scarlett’s contractions continued, and she used some Gas and Air to help with the pain. Twin one remained attached, and she stayed in the pool before getting out about 6 minutes after twin one was born.
Scarlett settled on the bed in the throne position. After 23 minutes, daddy cut twin one’s cord and had skin to skin. Scarlett’s contractions had slowed down, so intuitively she kissed and smelt twin one to boost her oxytocin.
Over half an hour passed. By now, according to hospital guidelines, an intervention would have been offered to speed up the birth of twin two. However, Scarlett wanted twin two to come in their own time.
Her contractions intensified and at 0545, twin twos foot was born!
Twin two was complete breech, but as she descended, her foot dropped. A surreal moment, seeing this little foot kicking outside of mummy whilst the rest of her was yet to be born!
At 05.58, 1.5 hours after twin one, Scarlett birthed twin two, with a little help from a midwife and an Obstetrician.
The obstetrician had been waiting quietly and unobtrusively behind a curtain, and although wasn’t needed, she supported the midwife at the time of twin two’s birth.
Both twins had skin to skin. Twin one was given colostrum that my client had harvested, whilst my client birthed twin two.
As Scarlett came back to earth from birthing two babies naturally, twin two was also given colostrum.
Scarlett opted to have an injection of artificial oxytocin, to birth the placentas. The placentas were born, together, at 06.05 am.
The girls weighed 6lb 9oz and 6lb 12oz.
Both girls latched and fed at the breast shortly after birth. Twins that are induced early are often slow to latch and feed and therefore many twin mums have a difficult time with feeding. Pumping, topping up, tube feeding, an endless cycle that negatively impacts the early days and weeks postpartum. Scarlet’s twins were allowed to decide when to be born, at term for them, (39 weeks and 3 days, over two weeks longer in utero than recommended.) which meant they were ready to feed.
Both girls and mum were home later that day. Scarlett did have a second-degree tear from birthing twin one and required some sutures. (Common in singleton births, around 35% of women will have a second-degree tear. Water can reduce the risk and severity of tearing.)
Scarlett’s recovery from her babies’ birth has been, in her words, easier than the birth of her first born. She is breast feeding both girls and they are thriving. Big brother adores them!
My thoughts.
I am delighted that Scarlett had a natural birth of both her babies. The births she worked so hard for. I hope that the sickness of staff, cited by the Lead Homebirth Midwife, as a reason for no Homebirth Team being available, was just unfortunate.
Women have been giving birth for millennia. Our bodies are designed to grow and birth babies.
Today’s societal norm of being risk adverse, has contributed to the over medicalisation of birth. Midwifes have become de-skilled in the support of twin births and breech births. Their autonomy has been taken away and midwives have no choice but to follow hospital policies and guidelines.
We asked three of the midwives who had looked after my client, how many breech births they had witnessed. Between them they had over 30 years’ experience. They had witnessed 5! 5!!!!
We are blessed with our gut instincts, and they are usually right. Therefore, I am a strong believer in trusting your gut. If my client feels well and that their baby/babies are well, then they probably are.
Women deserve to be heard, respected and trusted to make the right choices for them. They should not have to battle for the birth they want. They certainly shouldn’t have to go through what my client did to eventually have her birth plan agreed.
There is a lack of personalised care. There is a lack of continuity of care. Maternity services need to address this urgently. Women suffering from birth trauma is on the rise and will keep rising.
Birthing women are strong, capable, incredible and never cease to amaze me.
Let women be to labour as nature intended, birth as their body is capable and be empowered by the experience.
Your baby’s birth happens only once. The memory lasts a lifetime.
Doulas can make a difference. One, (two!), birth(s) at a time.
Scarlett shared these thoughts.
‘It is such a shame I had to spend most of my pregnancy arguing and fighting for something so basic as to be treated as an individual, with the risk assessment based on my pregnancy and not on generic guidelines for twins which assume everyone is high risk. I am happy with the outcome but do still feel disappointed it took such a fight to get there”.
#twins #naturaltwinbirth #breech #breechbirth #doula #birth #birthchoices #individual #pregnant #baby #essex #doulasupport #positivebirth
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