Telling Secrets

I have found that trying to explain why we made the choice to come to Utah to deliver these babies is up there in the "potential for misunderstanding" category along with explaining why I believe what Jesus said over, say, what Joseph Smith said. My claim that Jesus is The Savior is, in the ears of many listeners who don't share the same conviction, also a statement that what they believe is worth nada. Whether or not I actually think this about them doesn't matter. I've already been pegged as a Jerry Falwell clone. Saying that my first son's home birth was the most incredible experience and that I couldn't imagine having a hospital birth could peg me as a doctor hating, granola munching Boulderite who would rather live off the grid completely and overthrow the Medical Establishment without a moment's thought.

Well, I have said this and I have been pegged like that. It's as if the choices I have made define other people's lives, or at least threaten them. If I had that kind of power, believe me, I could use it now. At the same time, there's some truth to the accusation. Any claim of exclusivity by definition excludes other beliefs. I think that Christianity has it in spades over Mormonism, Buddhism, and the rest. There are lots of great things about the other religions that I learn from, but ultimately I think Christianity makes the most sense. I'm not judging other people who think old Joe is the best, I just don't agree for lots of good reasons. I think that home, when the baby and mom are healthy, is the best place to give birth. I'm not judging other people who choose hospital births, I just wouldn't do it for lots of good reasons.

It's not that I hate Medicine either. I don't think that doctors are evil for prescribing drugs or for taking prudent steps to cover their well-trained asses from a lawsuit happy, consequence-avoiding society. I think that doctors are extremely valuable and handy when you need them.

And that's the big question, isn't it? “When do you need them?”

We were planning to have a homebirth again with our second pregnancy, right up to 32 weeks when we discovered we were having twins. This introduced a whole set of questions like, "What the fuh?!" and "Are you serious?" After the news settled in, other questions formed: "What do we do now? Any midwives in town willing to put their licenses on the line to deliver twins at home? Are midwives allowed to deliver anywhere else in the country? Is that really a good option? Aren't twins scary to deliver?"

The answer to the last question if you ask just about anyone is "yes." We talked with a truly wonderful OB who, after offering us an elective C-section, gave us statistics like "75% of twins born (in our hospital) are delivered by section" and "prolapsed cord and breech presentations are common and serious complications of delivering twin B." Experience-wise, she delivers one set of twins a year, about average for all the other OB's. She said that the doctors at our hospital like to think that they are prepared to do nothing and everything. But she gave every indication that they would most likely go ahead and do everything because "we don't sleep well when something goes wrong and we lose a baby or a mom. We really don't."

We also talked to a bunch of midwives about it and none of them were concerned. After hearing about our uncomplicated pregnancy and that the babies were both already over 4 pounds, the most common statement they made was, "No problem!" and "If mom is eating right and babies are healthy, you should go to term." All the midwives we talked to went through a fairly extensive screening process to make sure that any potential client expecting twins was healthy and eating the way she should. As a result, all of their twin births were successfully delivered vaginally at home or in the birth center with no emergency transports to the hospital. One midwife we considered seeing in Texas said that the key was diet. The clients (5 of them) who stuck with her throughout the pregnancy and ate the way she told them to all went to term (40 weeks) with their twins and delivered safely in the birth center. The clients (another 5) who didn't stick with her transferred their care to an OB, didn't stick with the diet she suggested, and all of them delivered pre-term and by Cesarean.

Different stories, different experiences. One perspective was fearful, the other confident. Knowing that Angela and the babies were as healthy as could be, we just couldn't swallow the enormous "high risk" pill, but we also couldn't accept the almost too easy "no problem" answer. How to choose? Our OB suggested I do the research on my own using the access I had through work to every medical journal and textbook available.

The conclusions I found were illuminating. Here are a few that were in the obstetrics textbook:

From Gabbe’s Obstetrics, 4th edition, 2002
"…In the series by Chervenak et al.,[261] 81.2 percent of the vertex-vertex twin gestations were delivered vaginally. These investigators, and several others cited in their article, believe that when both twins are in vertex presentation, a cesarean delivery should only be performed for the same indications applied to singletons...

…At birth weights above 1,500 g, there were no neonatal deaths or documented intraventricular hemorrhages and only three cases (5 percent) of 5-minute Apgar scores of less than 7 in the group of second twins delivered vaginally by breech extraction. Chervenak et al.[266] state that their data do not prove vaginal breech delivery of the low-birth-weight second twin to be more damaging than cesarean delivery…On the other hand, if a second twin weighs between 1,500 and 3,500 g and the criteria for vaginal delivery of a singleton breech are met, this series suggests that vaginal breech delivery is an acceptable option…

…The authors, therefore, suggest that primary breech extraction of the second nonvertex twin weighing more than 1,500 g is a reasonable alternative to either cesarean delivery or external version…

…Regardless of the estimated weight, they suggest that an attempt be made to convert the second twin to a vertex presentation by performing an external version after the first twin has been delivered. If this proves successful, a vaginal delivery can be anticipated. If the attempted version is unsuccessful and the EFW is between 2,000 and 3,500 g, a breech extraction can be performed unless the other criteria for a singleton vaginal breech delivery are not satisfied. Recent reports support these recommendations and have documented the efficacy and safety of either external cephalic version[272] or total breech extraction [273] , [274] for the delivery of second nonvertex twins weighing more than 1,500 g…"

At 32 weeks we knew that our babies were vertex/breech and weighed more than 1500 grams. These conclusions are also mostly the same as the ones I found in the other studies I read. There are problems with all the data presented in the textbook and in the studies, the most blatant being the age of the studies - many of them are 20 to 30 years old. Some of the data used was around 40 years old! They also don't extract healthy versus unhealthy pregnancies, IVF treatment (which carries increased risk of complications all around for twins), diet, etc. Also many of the studies draw from very small sample populations.

I found one very recent study that wasn't as encouraging as the conclusions presented in the textbook:

From “Yang Q - Am J Obstet Gynecol - 01-MAR-2005; 192(3): 840-7”
“The risk of asphyxia-related neonatal deaths and morbidity was increased in the group in which both twins were delivered vaginally and the group in which both twins were delivered by cesarean delivery. The increase in neonatal death in the group in which both twins were delivered vaginally was stronger in the birth weight of < 1500 g. In contrast, in the group in which both twins were delivered vaginally and the group in which the second twin was delivered by cesarean delivery after the first twin was delivered vaginally, the increase in neonatal morbidity was greater in the group in which the birth weight was 1500 to 4000 g. CONCLUSION: The risk of neonatal death and morbidity in second-born twins is higher in the group in which both twins were delivered vaginally and the group in which the second twin was delivered by cesarean delivery after the first twin was delivered vaginally compared with the group in which both twins were delivered by cesarean delivery.”


The problem with this conclusion (without actually seeing the data, so I could be wrong) is that it doesn’t concede the increased risk of c-section for both twins or how much greater the risk is for vaginal and c-section after vaginal birth of twin A. Many studies I read did this. They begin by stating the current standard of practice which is pretty much "get ready for the inevitable c-section" and then present data that doesn't necessarily paint as bleak a picture. And they still don't tease out the healthy versus unhealthy pregnancies.

A big problem with these studies is they are replete with bias. I of course introduce my own bias when I read these studies because I'm coming from a different perspective. Bias is unavoidable if you're really honest. But I found myself encouraged by what I read. What I got from it all was that with as healthy as Angela and the twins were, their risks were not higher than a normal healthy singleton birth. And that meant that homebirth of the twins was fine, that we weren't taking any higher risk with the twins than we had with Malachi. With the perspective that home is a safer place to have healthy babies than the hospital, we were actually chosing the safest place for the twins to be born. Talk about counter-everything expected about twins!

The bottom line is that we met all the criteria for a safe vaginal birth of the twins, something we were pretty much assured no one at the hospital would be willing to do aside from letting Angela labor on a table in the OR "just in case," a great recipe for c-section. The natural birth community was more confident and offered the birth we wanted. Either way, we would be displaced.

So the question changed from "Is home birth safe for twins?" to "Who is more confident in their ability to deliver breech babies?" Gabbe's Obstetrics and many of the studies supporting vaginal delivery of twins warned that the delivery should only be performed by someone who was well-versed and comfortable with external version and breech extraction, otherwise you could end up with a life-threatening problem. Angela expressed this as her greatest concern too. Our OB said that breech extractions were becoming more common with the increase in twin births these days, but we had our doubts considering we would be in the OR prepped for Cesarean. Midwives deal with breech presentations a lot and have to be comfortable with version and extraction simply because there aren't any other options available, aside from going to the hospital.

Angela's comfort with midwives and lack of it for the OR was the deciding factor. Besides, we wouldn't be able to choose which OB would come to our birth - it would be a luck of the draw. Her anxiety around the very idea of the hospital predicted the downward spiral of interventions if we went that direction, skilled physicians or not.

So how did we end up in Utah? Angela first alerted the entire natural birth community of our problem and asked for suggestions. Then we turned to the First Lady of Midwifery, Ina May Gaskin, who salon.com credits as reintroducing midwifery to the United States after the highly patriarchal medical practice in the 1950's. She practices at The Farm in Tennessee. We were trying to figure out how to make this work when our midwife Christie suggested going to Dallas where she was trained. This was much closer to home, cheaper, and I had some family friends from when I lived there. Then, the midwife we chose there had a bad horse accident that took her out of commission. Simultaneously, a doula in Austin wrote Angela and suggested a midwife in Utah, where the laws were being re-written to make it possible for midwives to deliver twins at home. This was a much more appealing place to wait it out, closer to home, and even cheaper. Then someone else in the network said they just moved from Provo (where we needed to be) to Ohio and that we could stay in the double wide they were still trying to sell. From there, a cascade of people knowing people pulled everything together. We have furniture and dishes, my boss outfitted me with a computer so I could work long distance, some good friends sold us a mini-van for cheap, and on and on it goes.

We are sure it is all a sign that we are where God wants us. It should have been a Herculean effort to pull together so many details in just a couple of weeks, but it all fell together so easily.

Now if he would just kick start the labor for us. This has become the true test of our faith in God's hand and in the natural birth process.