Friday, September 18, 2009

Birth Plan for twins

Readers may have seen recent posts on my villagemidwife blog about complex negotiations that have gone into planning for birth of twins, and a summary from the birth.

My purpose in telling this story publicly, with the support of the mother, is to highlight basic midwifery knowledge, that even in complex situations, the physiologically normal processes in birth can be, and often is, the best. The only way to reach physiological birthing in today's world is for the mother to have the confidence to refuse all offers to actively manage the birth. When a midwife and a woman have established a partnership based on trust, respect, and reciprocity, the midwife is able to support the woman as she negotiates complex and unpredictable decision-making.

In this particular case the mother had initially planned homebirth, but on my recommendation, after the twin pregnancy was diagnosed, agreed to change that plan to hospital birth. The mother was pressured and coerced in an attempt by the hospital to achieve compliance and agree to elective caesarean. She listened and discussed what was on offer, yet she believed that the safest way for her to proceed was to wait for spontaneous onset of labour, and to proceed without surgery or anaesthesia. This is what she did.

In this blog we are sharing the framework of a birth plan. This birth plan was prepared at about 36 weeks' gestation. Ultrasound scanning gave no indication of any specific reason which may have swayed the balance towards surgically managed birth, other than the fact that the first twin (A) was presenting as Breech. Size of babies and amniotic fluid around the babies were unremarkable.

Include statements such as:
• “I plan to give birth to my babies spontaneously unless there is a reason for me to change this plan.”
• “I understand that I have the right to refuse any intervention.”
• “I believe that my birth plan is the best way for me to ensure the safety of my babies and to protect my own health”.
• "I ask that all care providers respect my need for privacy in labour and birth. Please do not interrupt me without good reason. Please minimise the number of people who come into my room, and keep equipment brought into my room to a minimum."
• "If an intervention is recommended, please explain to me the reason and I will consider it, and discuss it with my husband and my midwife so that I can make an informed decision."

• Onset of labour – may be regular contractions, or breaking of water or both. [Contact midwife]
• Going to hospital – as labour becomes established. Usually labour for the first twin proceeds in a similar way to previous labours. [Discuss with midwife]
• Established labour – check babies are coping well with labour. [midwives will be watching for normal progress over time.]
• Birth of Twin A:
• Urge to push – find upright position
• If membranes have not ruptured when visible at the vaginal opening, midwife will break the sac
• As baby’s body emerges, allow it to hang, assisted by gravity
• No forceful manipulation of the body
• No touching unless absolutely necessary until neck is visible
• Gentle support as face is born
• Clamp and cut cord soon after birth to prevent the possibility of twin-twin transfusion
• Baby to mother, skin to skin, as soon as baby’s condition is good
• Mother rest and enjoy Baby A, while midwife checks condition of Twin B.
• Baby A to breast if mother wishes
• Mother may need to stand and walk, to bring Twin B into to the birth canal
• When contractions return, and mother needs to focus on the birth of Twin B, pass Baby A to father, who stays close by. As long as Twin B's condition is good, there is no reason to speed up the birth by breaking the baby's waters.
• Birth of Twin B:
• Second labour will usually progress quickly once baby is presenting well, as the cervix has been dilated.
• Third Stage: After pulsation of the cord for Baby B has ceased, proceed with administration of oxytocic and controlled cord traction.

[Thanks to English midwife Mary Cronk, for sharing her guidelines for the care of a woman expecting twins. These guidelines have informed me in advising several twin mothers over the past few years.]


  1. Thanks for sharing this.
    Is it not possible to proceed with physiological (unmanaged) third stage in a twin birth? Is there a reason that the administration of oxy and traction is necessary?

  2. Thank Tanja for this question.

    Yes there are some twin births where the mother and midwife would be very confident to proceed without active management of S3 - wait and see, and use the drug if indicated.

    However in this birth the mother accepted advice from me and from the medical people involved in her care to use the oxytocic. I have not focused on the reasons for this, including parity and previous birthing experience.


Thankyou for your comment, which will be emailed to me for moderation.