ACOG and SMFM have released new guidelines...

ElTrain5 · February 2014

Be patient, think critically, avoid cesarean at all costs, and hire a doula! For those of you who follow, or whose practitioners follow, evidence based care models...this is BIG!! Yay Science! Check out their joint statement here:

https://www.scienceandsensibility.org/?p=7958&fb_action_ids=10202354795206058&fb_action_types=og.likes&fb_ref=.UwUz7509LkV.like&fb_source=other_multiline&action_object_map=%5B277819429043885%5D&action_type_map=%5B%22og.likes%22%5D&action_ref_map=%5B%22.UwUz7509LkV.like%22%5D

ncbelle · February 2014

This is a great step in the right direction!

MrsP419 · February 2014

This is definitely really good for a LOT of moms, but is making my decisions so much harder. I had two med-free labors for DD and DS, so I am definitely supportive of low-intervention labors and births. But having a spontaneous labor (not med-free, just going into labor on your own), or an induction, and a vaginal delivery with twins terrifies me. I am SO afraid of having a difficult labor with my limited labor options (have to birth in an OR, can't use water, most likely will need pitocin, will need an epidural, etc), and then ending up needing an emergency C anyway, or (my worst nightmare) one vaginal and one C-section. My OB is totally supportive of an elective C-section for twins because he thinks that risks are there in both types of delivery. With twins, if you have a scheduled c-section, you know what you are getting into in most cases, and the recovery is not as bad as an emergency one. But this article implies that even with twins a C-section should be avoided. It is SO hard to wrap my brain around since a C-section was never really anything but an emergency option for me. Now, I am kind of hoping that circumstances push me into having no choice.

ElTrain5 · February 2014

caitykate said:

I can't say I'm thrilled. I hope this doesn't make my CDMR more difficult to get.

There are a lot of valid reasons why a cesarean would be performed. These guidelines mostly urge doctors to give laboring moms more time and to trust more in the natural process. They are also a major update to include a lot of research that has been done over the past few decades that had shown previous guidelines were no longer the safest practices. (i.e. following Friedman's Curve from the 1950's, putting mom's on a strict timetable for dilation, etc.)

If you have a medical reason for needing a C-section, this most likely wouldn't effect you at all (unless that reason is something like "failure to progress" or something else that these new guidelines help to re-define).

For purely elective C-sections (i.e. I want to have my baby on Valentines day/I'm just not interested in having a vaginal birth.) without any medical indication whatsoever (and again, there are a ton of good reasons your doctor may recommend a C-section), those types of operative deliveries were never recommended by either of these organizations even before these latest guidelines (that's not to say they aren't done, they just aren't recommended by these groups).

ElTrain5 · February 2014

@mrsp419 Having twins is still a perfectly valid medical reason for having a scheduled C-section, these new guidelines mostly just help to open up the options for moms who want to deliver vaginally, but may be stuck with a doctor who refuses due to previous ACOG recommendations. If you're doctor was on board with doing a C-section before, I can't imagine why anything in this update would change their minds.

Edit: words today...for reals

MrsP419 · February 2014

ElTrain5 said:

@mrsp419 Having twins is still a perfectly valid medical reason for having a scheduled C-section, these new guidelines mostly just help to open up the options for moms who want to deliver vaginally, but may be stuck with a doctor who refuses due to previous ACOG recommendations. If you're doctor was on board with doing a C-section before, I can't imagine why anything in this update would change their minds.

Edit: words today...for reals

It probably won't change my Dr's mind at all; he has been an OB for a long time and is the best surgeon in the practice. It is just giving ME pause as I consider my options. For example, in regard to twins the official press release states that a C-section is not advisable as the first resort for twins where Baby A is head down (even if B is breech). I don't think my practice would even consider delivering twins vaginally if EITHER is breech (it is pretty 50-50 from what I read; some practices are OK with a breech baby

. But I am considering a C-section even if both are head down, even if there are no other complications. I am sure I will have no trouble getting my doctor to agree to that, but if I pay attention to the articles, I should re-think that option.

ElTrain5 · February 2014

The part that I love most about these new guidelines is the statement that fetal heart rate decelerations are a normal physiological response to contractions, not "the baby not handling the contractions well" or "being in distress". That makes a lot of sense when you look at it in conjunction with the benefits of intermittent oscillation as opposed to continuous monitoring.

amwangel · February 2014

Inductions before 41 weeks lead to more c-sections - I hope my doctor takes note! I really really hope these are implemented - what a difference they'll make!

Aaward1658 · February 2014

@mrsp419, they also gave recommendations about vag delivery of at least the first multiple if in appropriate position as well as performing positioning maneuvers rather than going to a cesarean birth for malpositions.

Regardless of the new recs, hopefully providers will jump on board with them. Their fear is delivery of a healthy baby and avoiding litigations, these new guidelines and recommendations don't prevent lawsuits!

MrsP419 · February 2014

Aaward1658 said: @mrsp419, they also gave recommendations about vag delivery of at least the first multiple if in appropriate position as well as performing positioning maneuvers rather than going to a cesarean birth for malpositions. Regardless of the new recs, hopefully providers will jump on board with them. Their fear is delivery of a healthy baby and avoiding litigations, these new guidelines and recommendations don't prevent lawsuits!

________
I don't think I would even attempt a vaginal for baby A if it was absolutely unlikely that Baby B would be delivered the same way. If both are favorable for a vaginal delivery, awesome- that I would consider, but if it looks like B most likely is going to need a C-section anyway, I would not choose to heal in two places. Newborn phase is going to be hard enough with twins without having to worry about a C-section recovery AND a vaginal one. My recovery from my first was so so painful. But I am not sure if that was what you were referring to. I am definitely going to ask the next OB I see if these standards would push them toward a vaginal delivery if baby A was head down.

edit: quote fail

ElTrain5 · February 2014

Aaward1658 said:

@mrsp419, they also gave recommendations about vag delivery of at least the first multiple if in appropriate position as well as performing positioning maneuvers rather than going to a cesarean birth for malpositions. Regardless of the new recs, hopefully providers will jump on board with them. Their fear is delivery of a healthy baby and avoiding litigations, these new guidelines and recommendations don't prevent lawsuits!

I'm a little confused by this too. To your first point, the new guidelines state that "Perinatal outcomes for twin gestations in which the first twin is in cephalic presentation are not improved by cesarean delivery" So basically, in that specific situation, a cesarean would not improve the outcome, that doesn't mean that the outcome wouldn't be the same, it's just not a "definite improvement", hence, giving it a shot vaginally, if that's mom's and doctor's choice, is equally as likely to be successful.

As for your comment "Their fear is delivery of a healthy baby and avoiding litigations, these new guidelines and recommendations don't prevent lawsuits!" ....I'm confused as to what you're trying to say...why would a doctor fear delivery of a healthy baby and avoiding litigation? Healthy babies and avoiding lawsuits are both positive things... and the new guidelines are certainly not meant to "prevent lawsuits", they are to recommend what they believe to be the best practices to physicians and practitioners based on evidence.

ElTrain5 · February 2014

@mrsp419 very good point about not wanting to recover from both types of birth. If I was in your shoes I would feel exactly the same way. I'm glad it sounds like you've got a rockstar doc to help you through

MrsP419 · February 2014

ElTrain5 said:
I'm a little confused by this too. To your first point, the new guidelines state that "Perinatal outcomes for twin gestations in which the first twin is in cephalic presentation are not improved by cesarean delivery" So basically, in that specific situation, a cesarean would not improve the outcome, that doesn't mean that the outcome wouldn't be the same, it's just not a "definite improvement", hence, giving it a shot vaginally, if that's mom's and doctor's choice, is equally as likely to be successful.

----another quote fail

I am curious though...is this necessarily saying that the risk with a c-section is much higher? Or kind of equal to a vaginal delivery? My OB says there are risks for both, and multiples births are one of those situations where it is not cut and dry "Vaginal is most likely safer." There are risks to either, even if the risk is that attempting a vaginal with twins has a higher risk of an emergency c-section, and a planned c-section is safer than an emergency one.
Thanks for all the support, @Eltrain5 , I appreciate it. :-)

ElTrain5 · February 2014

@mrsp419,

From the official release:

Twin gestations
Perinatal outcomes for twin gestations in which the first twin is in cephalic presentation are not improved by cesarean delivery. Thus, women with either cephalic/cephalic-presenting twins or cephalic/noncephalic presenting twins should be counseled to attempt vaginal delivery.	1B
	Strong recommendation, moderate quality evidence

the study that the guidelines reference in relation to their twins recommendation can be found here: https://www.nejm.org/doi/full/10.1056/NEJMoa1214939#t=article

Here's a little excerpt that seems to sum up their findings in relation to your question:

"In conclusion, we found no benefits of planned cesarean section, as compared with planned vaginal delivery, for the delivery of twins between 32 and 38 weeks of gestation, if the first twin was in the cephalic presentation."

Basically it sounds like they are contradicting a previous recommendation that said "C sections are always safer in these scenarios", and presenting their reasoning as to why that's not true, without saying that its more dangerous...just not guaranteed to produce better results, so it shouldn't be the automatic go-to.

Hope this helps with your research

amwangel · February 2014

MrsP419 said:
I don't think I would even attempt a vaginal for baby A if it was absolutely unlikely that Baby B would be delivered the same way. If both are favorable for a vaginal delivery, awesome- that I would consider, but if it looks like B most likely is going to need a C-section anyway, I would not choose to heal in two places. Newborn phase is going to be hard enough with twins without having to worry about a C-section recovery AND a vaginal one. My recovery from my first was so so painful. But I am not sure if that was what you were referring to. I am definitely going to ask the next OB I see if these standards would push them toward a vaginal delivery if baby A was head down.
edit: quote fail

Disclaimer: I have never had more than one baby in my uterus at a time and I am not a doctor.

However! My SIL and a friend both had twins where the baby closer to the exit (heh) was head down and the other baby was transverse. After the first baby was born, the contractions pulled the other baby into position so it could exit as well.

So maybe it's hard to tell if the second baby is in the "right" position for a vaginal birth? I can't imagine birthing vaginally AND having a c-section, though! Eek.

But it sounds like you would be most comfortable with a c-section, so that might be a moot point!

edit quote fail too

curlylocks3 · February 2014

MrsP419 said:

ElTrain5 said:

@mrsp419 Having twins is still a perfectly valid medical reason for having a scheduled C-section, these new guidelines mostly just help to open up the options for moms who want to deliver vaginally, but may be stuck with a doctor who refuses due to previous ACOG recommendations. If you're doctor was on board with doing a C-section before, I can't imagine why anything in this update would change their minds.

Edit: words today...for reals

It probably won't change my Dr's mind at all; he has been an OB for a long time and is the best surgeon in the practice. It is just giving ME pause as I consider my options. For example, in regard to twins the official press release states that a C-section is not advisable as the first resort for twins where Baby A is head down (even if B is breech). I don't think my practice would even consider delivering twins vaginally if EITHER is breech (it is pretty 50-50 from what I read; some practices are OK with a breech baby

. But I am considering a C-section even if both are head down, even if there are no other complications. I am sure I will have no trouble getting my doctor to agree to that, but if I pay attention to the articles, I should re-think that option.
---------------
Honestly, it comes down to your doctors skill set. Some doctors just don't have the experience to do a breech extraction- and when I asked my OB about it they said it's fairly regional as in on the coasts twins are an automatic c-section.

Don't write off the vaginal delivery for twins though. Twin B might flip into position once A is out (and there is space!). I fully get that the concept of a breech extraction is scary. It really calms me down knowing that the recovery will be much easier, especially when I'm dealing with two newborns.

b48kate · February 2014

Back in nursing school the hospital where I did my L&D rotation had a pretty uniform "3 strikes and your out" policy when it came to late fetal heart rate decels. Always struck me as a bit too one size fits all...

As a person who fully intends on having a "medicalized" western birth (pass the epidural, please) I was still very excited to see these new reqs come out. Mainly because I want to be able to labor many, many hours if necessary without having the labor distocia flag thrown!

I can't stress enough that we all have the right to informed consent and the right of refusal. It makes me really sad when I hear ladies on here say that they feel pressured or unheard by their medical professionals, because it means the system is failing you. I work in that system, although not in OB, and know it can be near impossible to navigate.

That's why I think it is so important to take a look at these findings/recommendations and be prepared to site them when working with your doctor. You are in charge of your care and deserve to feel empowered when making decisions! [exiting soapbox]

@MrsP419 I won't even pretend to know what is best in the twin situation. All I know about multiples is that they are rare in large, long-lived mammals and therefore really should be treated on a case-by-case basis. This makes you an automatic SS in the natural world!

margaritachikita · February 2014

Internationalkate said:

I can't stress enough that we all have the right to informed consent and the right of refusal. It makes me really sad when I hear ladies on here say that they feel pressured or unheard by their medical professionals, because it means the system is failing you. I work in that system, although not in OB, and know it can be near impossible to navigate.

That's why I think it is so important to take a look at these findings/recommendations and be prepared to site them when working with your doctor. You are in charge of your care and deserve to feel empowered when making decisions! [exiting soapbox]

This!!! Informed consent is so important and so often overlooked. Informed consent should be based on evidence based care, glad to see the new guidelines support this. I really hope they are quickly adopted.

katekat8721 · February 2014

@MrsP419 The "double whammy" is my worst nightmare too. I totally understand. I'm hoping and praying and calling on all good karma that I can do both vaginally, but if not, that we have a c-section. No vaginal and cesarean deliveries. Ah, horrifying!

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