Twins - Twice

By Beverley Lawrence Beech

Women who are expecting twins are often persuaded to submit to obstetric management and undergo a caesarean section in the belief that this is safer for them and their babies. Since there have been no randomised trials there is no evidence that caesarean operations are safer for the babies than vaginal births and it is always likely to be less safe for the mother.

Birth of twins at home on the South Coast

Mr and Mrs Jones decided that they wanted their babies to be born in the safety of their own home and were unwilling to take the risk of a hospital delivery. Having experienced a hospital birth for the first baby, eleven years ago, an experience she remembers with distress, Mrs Jones's second and third babies were born at home.

When she became pregnant for the fourth time and a twin pregnancy was diagnosed, Mrs Jones approached her community midwife who was supportive, but was honest about her lack of experience in twin births and breech births if either of the babies decided to come bottom first. Mrs Jones approached an independent midwife practising in the area, and engaged her. What followed was a lovely example of how the NHS and independent practice can work together for the safest outcome for a woman and her babies.

Mrs Jones booked the independent midwife A, when she was 25+ weeks. The twins were due in early July. Midwife A discussed the case with the Supervisor of Midwives (SOM) who was helpful and supportive. Following discussion Mrs Jones decided that if she laboured before 36 weeks she would have the babies in hospital. An honorary contract was arranged for the independent midwife to provide midwifery care in hospital. If labour was after 36 weeks Mrs Jones planned to birth at home. Midwife A discussed this with the Supervisor of Midwives (SOM) and said that in her opinion there should be three competent practitioners at the birth. The SOM approached the NHS midwives employed by the Trust and it was agreed that midwives could be on call and those who wanted to should put themselves on a rota to attend the births with Midwife A who was very pleased that eight NHS midwife colleagues put themselves forwards to help. A rota was arranged to cover three weeks.

Mr and Mrs Jones met the Consultant Obstetrician who was described by the couple as being really nice and they were assured them that if they elected to come to hospital they could labour in the same way and with the same team that they would at home? This enabled them to feel that a planned hospital birth was a real option and they did consider this, but decided to continue to plan for home. They felt that if there was a problem that the obstetrician was there for them and they would transfer happily if necessary.

Midwife A met with the team of volunteers and planned the births and the equipment that would be needed. They thought about the worst possible scenarios and what they would do and what they would need, and the best possible scenario, and what each person's role would be. Mrs Jones had agreed to have one scan and this confirmed what was felt on palpation, well grown babies, the presenting twin head down, the second a breech. The placentae were separate. Mrs Jones preferred to have a physiological third stage but would accept active management if the midwives felt that to be best.

Saturday night at 23.30 the phone rang - Mrs Jones's waters had just gone -38 weeks - the liquor was clear and no contractions as yet. Midwife A's equipment was in the car and she made a quick call to the labour ward as she got dressed, 'would the co-ordinator please page the midwives on the rota?' -She arrived at the Jones's at 0015 Mr Jones was at the door as she drew up. "Any contractions yet?" She asked 'Yes every four minutes and strong', he said. While he brought in the midwife's gear she went upstairs and found Mrs Jones leaning on her window sill having strong contractions. She quickly listened to the fetal hearts, both were fine and the blood pressure was OK. There wasn't much time between contractions. Mrs Jones didn't want a vaginal examination and there really was no indication to do one. She didn't want to be touched or disturbed in any way and said she would tell Midwife A when she wanted to push. The two NHS midwife colleagues arrived. The midwives set out the room as quietly and unobtrusively as they could, listening to the fetal hearts when Mrs Jones could let them. The heart rates remained satisfactory.

At 1.04 A definite pushy noise from Mrs Jones. The midwives assisted her to the all fours position on a prepared pad beside her bed and Midwife A just got her gloves on in time for a large grapefruit sized bag of membranes to emerge. She felt the head was at the vulva and ruptured the tough membranes with an amni-hook (first time she had ruptured membranes since 1993!) and twin one was born at 01. 07. She was in very good condition with an Apgar score of 9. Midwife B checked her and was available to help twin one if necessary - It wasn't.

Mrs Jones leaned back against Midwife A and Midwife C palpated and found the lie of the second twin to be longitudinal. The FH was heard about 100 bpm then 110. Twin one's cord ceased pulsating at 01. 13 and it was clamped and cut at the baby side. The maternal end was not clamped but allowed to drain. Another contraction and a foot and buttocks were at the vulva Mrs Jones pushed, the buttocks emerged, rotated, and the trunk was born followed by the arms and Midwife A flexed the head and assisted it to be born 01.17. Midwives B and C were there immediately with bag and mask and a stethoscope as twin two was slow to breathe.. "Heart's fine" - What lovely words. Five breaths with bag and mask and twin two joined his sister in a screaming competition. Apgar scores 6 and 9. The twins weighed 7lbs 4ozs and 7lbs 1 oz.

When Mrs Jones had got her breath back she was assisted to her prepared bed and she cuddled her babies. A gentle hand on her abdomen demonstrated a high hard round fundus. The placentae had separated. There was practically no blood loss. Ten minutes, or so, later a contraction then a minute later another and Mrs Jones pushed out her placentae one after the other. Twin one's placenta came first but the second one was just behind it. Blood loss with the placentae was about 250 mls then it stopped. The uterus was firmly contracted. The pulse and blood pressure were checked and both were OK, so the midwives went off to the bathroom to check the placentae and then having checked the blood pressure and pulse again went to the kitchen to make the tea and to start the form filling leaving the Jones's to cuddle their babies in privacy.

The three midwives drank their tea and realised that it wasn't even 2am. It had been a best possible scenario!

Delivery of twins in a private obstetric unit

Peter and Laura Touche after eighteen months of marriage found that Laura was expecting twins. Her pregnancy was trouble free, as would be more likely of a 31 year-old woman with a well to do background. They originally booked to have their babies in Chelsea and Westminster Hospital but because they wanted regular monthly scans they changed their booking to the Portland Hospital. (Perhaps no-one explained to them that monthly scans are of no benefit and can be risky as scans have been shown to reduce babies' weights and increase the risk of early labour and miscarriage).

We presume she was advised to have her twins delivered by elective caesarean section. The operation was uneventful and the twins were born at 10.25pm, a rather strange time of day for an elective caesarean section. One wonders how tired the surgeon and attending staff were. Shortly afterwards Laura Touche was complaining of a headache and feeling ill. By 4.20am her speech was slurred, she was vomiting and having fits and, because the Portland Hospital does not have the facility to cope with complications, she was transferred to an NHS Hospital, the Middlesex. She was later moved to the National Hospital for Neurology and Neurosurgery, and died nine days after the birth.

Mr Touche requested an inquest, which the coroner, Dr Stephen Chan, refused, on the grounds that the cause of death was natural and an inquest was unnecessary. Although he admitted that Mrs Touche's post natal care was 'wholly inadequate'.

Mr Touche appealed to the High Court. On the 23rd June 2000 Lord Justice Kennedy and Lord Justice Morison overturned the coroner's decision stating that, 'It seems to us that if the coroner did not adopt an approach which was correct in law - and the documentation does not clearly indicate otherwise -then he reached a conclusion which was irrational'. Lord Justice Kennedy drew attention to the anaesthetist's report that described the failure of the hospital to monitor Mrs Touche's blood pressure as astonishing and the level of neglect as starkly apparent.

Philip Havers, QC, who represented Mr Touche in court, said that he had received a letter from the hospital that confirmed that there were no adequate procedures to give proper care to women after their caesarean operations.

After the ruling Mr Touche said, 'The treatment afforded to Laura that night did not reach even the minimum NHS standards of care'. Or even, for that matter, the care that should be given by competent midwives. It seems to us that there are questions that need to be asked of the midwives on duty. It was said that the Portland had no protocols for post-natal care. Competent, registered, midwives should know that a woman's blood pressure should be monitored after a birth or delivery whether that takes place in a modest home or in a costly private establishment. What were the midwives doing?

Beverley Beech

Links

Can a Twin Birth be a Positive Experience? by Jane Evans, on the Association of Radical Midwives website.

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