April is International Caesarean Awareness month. an event organised by ICAN – The International Caesarean Awareness Network. ICAN is a non-profit organisation whose mission is to improve maternal-child health by reducing preventable cesareans through education, supporting cesarean recovery, and advocating for vaginal birth after caesarean (VBAC).
This guest blog from Ruth, mum of four children aged 8 years, 6 years, and 21 months (x2) shares her positive c-section birth with her twins.
When I found out I was pregnant with twins, in amongst the multitude of thoughts whizzing around my head was the question: will I get to have a positive birth experience? Also amongst those thoughts was whether I’d be able to tandem carry in slings. As it turns out, both were entirely possible.
I’d had two extremely positive births with my singletons before. They were spontaneous and fast labours, no pain relief and no interventions, delivering in a beautiful midwife led birth centre (well the second one was almost in the car, but we just about made it inside!) I really enjoyed giving birth. I feared that I wouldn’t get this again with twins inside. Throughout the pregnancy I really hoped that I’d at least get to give birth vaginally, even if it was in a hospital surrounded by doctors, monitors and medication. But this wasn’t meant to be, and I ended up with an elective caesarean birth.
The problem was the twins’ positioning relative to each other and to my cervix. At our final growth scan at 36 weeks, twin 1 had been breech, which meant the consultant wouldn’t consider induction, though was happy to support a breech birth if all happened spontaneously, quickly and without complications. They often help deliver a breech twin 2 once twin 1 has paved the way so to speak. Initially a 37 week elective caesarean date was suggested (as the hospital policy is that DCDA twins should be delivered by 37+6), but I chose to give the twins another week to arrive spontaneously, having done my research on risks and knowing that the pregnancy had been uncomplicated. I agreed to go in for a pre-op appointment at 38+3 and to give birth via elective caesarean at 38+4 if the positioning was still risky.
The agreed date came around and I wasn’t feeling very positive about the prospect of a caesarean, I was terrified of surgery. I honestly thought that labour would have started by now and I wouldn’t be in the position of having to make such a big decision about how the twins would be born. So we arrived at the hospital at 7:30am. We were called in first (I’d been told that twin mums get priority on the elective list for the day). A midwife did some obs on me and strapped two foetal heart rate monitors to my bump – all was fine.
Then an obstetric registrar came in with an ultrasound machine to check the positions, as I had requested. She looked closely at which twin was nearer the cervix. She said it was very close, but that the breech one was probably just slightly closer. Both were presenting very low in my pelvis, which doesn’t always happen with twins – often one is higher than the other. Without me asking, she then went on to have the conversation I was hoping to have about whether a caesarean was necessary. She was of the opinion that it depended how much I was keen to have a vaginal birth, to which I replied very keen! She talked about the possibility of a gentle induction – no hormone drip, just an internal examination with membrane sweep to see how far off labour I was, and possible breaking of waters if I was dilated enough. This sounded positive to me, and I was glad that she was open to the possibility of not just ploughing ahead with a caesarean regardless. However, she said she needed to run this all past a consultant, who then picked up on something that she hadn’t thought of – the risk of “interlocking heads” in a vaginal birth. This is when the breech twin comes out first, with its bottom presenting first, but as the head comes past twin two, the chin of twin one locks onto the chin of twin two, which is near the cervix as it is presenting head down. As our twins were both so low, the risk of this head lock occurring was higher than if one twin was sitting higher up than the other in the uterus. If this head lock situation were to happen, it would mean a very fast emergency caesarean, and even then the outcome statistics aren’t good at all. I looked this up myself from respectable sources I found online whilst we were still being monitored.
With this information, I decided that I didn’t want to take this risk, and that a caesarean was the best option for us in this circumstance. I felt that it was meant to be that I hadn’t gone into spontaneous fast labour with them in this position, because if we had have found ourselves accidentally staying at home, or worse still in the car, the consequences of head lock could have been far worse than at the hospital with an operating theatre down the corridor.
Once the decision was made, it was time to get prepped. I got changed into a gown and compression stockings and my husband into scrubs. A midwife showed us down the corridor and into theatre. Everyone in there introduced themselves. There were lots of people, mainly because with twins they need two of some types of staff! But it was a bigger room than I was imagining, so it didn’t feel overcrowded.
Everyone started to get their bit ready, and soon the anaesthetist asked me to sit up on the operating table and curl forwards over a pillow so my spine was rounded. She sprayed a cold local anaesthetic on me, then apparently put the spinal block needle in, though I didn’t feel a thing. Pretty soon my feet started to feel warm and fuzzy. They then pulled my legs up onto the table and I lay down. The obstetricians set up the screen in front of me, whilst the anaesthetist talked through what she was doing with me – attaching a drip and blood pressure cuff. She then got a cold water spray, and sprayed some on my arm, then down on my abdomen, and asked me if it felt cold like on my arm. It didn’t feel as cold, which showed that the spinal block was starting to work. She also checked that I couldn’t move my legs, which was really weird – like my brain was trying to do it as I thought about it, but I couldn’t actually make them move! At the same time, one of the theatre staff put a catheter in, which I couldn’t feel. After a few minutes, the anaesthetist did more of the spray tests, until I could feel no cold right up to my chest, and also some pinching tests on my abdomen – I couldn’t feel a thing. We were good to go, as she put it.
It wasn’t long before I could feel the doctors rooting around inside me. A very odd sensation, I could tell they were in there, but felt no pain at all. The next thing I knew, there was a loud cry from a baby! We had made sure they knew that we wanted to discover the sex of each baby ourselves, and the midwives were brilliant in this respect. The baby was passed to them, and within a minute was brought around naked, still attached by cord to the placenta, to our side of the screen. A boy! He was taken back over to the baby table, and my husband was asked if he wanted to cut the cord when it had stopped pulsating, then baby was weighed.
Meanwhile I could still feel the doctors rooting around inside me, and pushing quite firmly on my bump. Then, two minutes after the first cry started, we heard the second cry. Again the baby was quickly brought naked to us – a girl! I couldn’t quite believe it when we were told her weight. It was in metric – 3.3kg, and although this doesn’t mean much to me, I did remember that my singletons had weighed roughly 3.4kg and 3.5kg, so I knew she must be about 7 and a half pounds! I was not expecting a girl twin to be almost the size of my boy singletons. But then I thought maybe in my anaesthetised state I wasn’t computing that properly. The midwives confirmed though that she was big for a twin.
Whilst the doctors stitched me up, the babies were brought to us to hold, wrapped in towels. My husband held the boy whilst I had the girl across my shoulder in my arms, supported by the anaesthetist who had remained by my head throughout and was great at explaining what was going on. Once I was ready, it only took a few minutes to transfer me to a bed. Meanwhile Tom went with the babies and midwives to the recovery room first, followed shortly afterwards by me. Within 10 minutes of birth, we unwrapped the babies and got them skin to skin, which the midwives actively encouraged. They both latched on brilliantly straight away. I was expecting this to be an issue if they’d been born smaller or earlier, so I was so happy that they were able to do this as quickly after birth as my singletons had done.
We were monitored for about an hour in the recovery room. I was losing quite a lot of blood, which is pretty normal for twins because the uterus has a long way to contract back down. But as a precaution the doctor who reviewed me wanted to keep me down on the delivery suite in a room so that I could have one to one midwife care for a few hours. I felt fine in myself, and was enjoying a constant tandem skin to skin cuddle.
We spent the afternoon just the four of us with occasional midwife visits to check all was well. It was a really lovely time to be able to chat about names and enjoy those first hours uninterrupted. We didn’t think that we’d get to have this in a busy hospital. And we hadn’t had this time after our singletons were born because it was the middle of the night and we were both tired so tried to rest in the birth centre. When we were moved up onto the postnatal ward, we had our first glimpse of what it’s like to have twins in public, as the midwives wheeled me on the bed holding the twins in my arms through the reception area to the lift, and we turned lots of heads and got several “ah twins” comments.
All in all it was a very positive experience, and one that I can look back on and feel that the twins were born in the best possible way for them given the circumstances. I still would have preferred a vaginal birth like my previous experiences, and I can’t deny that the unavoidable positions of the twins means I was a little disappointed at this, but I’m glad that modern medical techniques like the caesarean exist to help in cases where natural birth may lead to seriously poor outcomes. Also I was glad that I’d been through the surgery in a calm and planned manner rather than in an emergency. My recovery was neither longer nor more painful than after my previous births, just a different part of my body was affected.
I was especially pleased with the amount of uninterrupted skin to skin time we got, which is important for babies born via caesarean in terms of seeding their microbiome – vaginally born babies get their seeding of “good bacteria” as they pass through the birth canal, whereas caesarean born babies don’t, so we should try to make up for it in other ways such as being skin to skin with mum and breastfeeding.
The twins are now active, thriving 21 month olds. I can still remember their birth like it was yesterday, for all the right reasons.
When she’s not running around with her children, Ruth runs a business sewing reusables and babywearing accessories. These reflect two big interests of hers – keeping our impact on the environment as low as possible and carrying her children in slings. She occasionally finds time to write on her blog and go swimming. You can find her blog here: http://www.mixedbagofallsorts.co.uk/ and her online shop here: https://www.etsy.com/uk/shop/sewndownpurplelane She is also on instagram @twinslingingadventures