Planned homebirth for twins is rare in the developed world, because of worries about the birth of the second twin. Where it does happen, it is normally under the care of a team of independent midwives who are highly experienced in twin birth.
On this page you can read some views for and against, and links to twin birth stories and discussions from midwives and mothers. I try not to take any personal stance here; what I aim to do is give you information, case studies, and the reasons underpinning some views on twin homebirth from sources I respect.
High Risk Birth - Justine Caines is the secretary of Homebirth Australia and a respected advocate of natural birth. She gave birth to twins at home in December 2005, and has kindly allowed an article about her decision process, and about risk and birth in general, to be reproduced on this site. The birth story of twins Majella and Rosie is also online.
by Karen Kerkhoff Gromada
Karen Kerkhoff Gromada is the author of "Mothering Multiples", and other books. She is a lactation consultant and La Leche League Leader, and had a planned homebirth for a singleton baby. This post about twin birth is reproduced with her kind permission. Karen lives in the USA, so some of her comments may not apply to readers in the Britain.
I'm in favor of homebirth for uncomplicated, full-term singleton pregnancies -- I've had such a homebirth myself. Research demonstrates that such births are as safe or safer than similar births in hospitals. However, I believe twin- and other multiple births belong in the hospital because the odds are not comparable for even full-term, apparently uncomplicated vertex/vertex twins. With twins the odds start going down. And I write this as someone whose 40 5/7 week term twin pregnancy/birth, especially twin B, was the easiest of my 5 deliveries. But that's just anecdotal; as the leader of a La Leche League multiples group for more than 25 years, I've seen the odds play out in varying ways for hundreds of expectant MOT (mothers of twins). Previous pregnancy history cannot be depended upon when it comes to a twin/multiple pregnancy.
The reason being that the uncomplicated, full-term singleton (and the first of full-term, uncomplicated, vertex twins) is engaged in the pelvis, so malpresentation, cord prolapse, etc. is astronomically unlikely. The same can NEVER be said for the second (and subsequent) of multiples; that baby canNOT engage in the pelvis until the birth of the one before. This is the reason that most midwives (and their professional associations) -- including those in countries where homebirth is common -- do not recommend and will not "preside" at births at home for twins or more.
Malpresentations occur fairly often for second/subsequent multiples; cord prolapse is usually the biggest concern -- and it doesn't have to be complete to cut off a baby's oxygen, immediately placing her/him in severe distress. Placental issues, e.g. partial abruption are also acute emergencies that profoundly affects both infant(s) and mother, and these are more common during multiple births. Placenta flow issues are more of a concern with monozygotic (MZ) twins, but they may also affect dizygotic (DZ) sets in which one placenta implanted in a less favorable spot or developed in a less favorable way. Postpartum hemorrhage (with mother-related consequences) is significantly more common with twin and higher multiple births.
The issues that may result in transfer during a singleton homebirth tend to be less acute than those that occur during the birth of twins. Problems arising during a twin birth, especially for the second twin, are more likely to be true emergencies with a 5-10 minute window of time for resolution to brain injury to death.
Certainly, the odds may still be in your favor, and I respect that only you (and babies' other parent) can decide how low you are willing to go. However, you really need to investigate those odds in order to make an informed choice about birth site because this is not only about you and what you'd like; you are making decisions (that can have lifelong impact) for two (or more) other persons.
If you choose a homebirth, I hope you have made certain that your midwife has delivered a number of twins in which things that went wrong as well as twin births where all went right. Be certain she has ACLS(NN) -- Advanced Certification in Life Support (Neonatal) -- and carries related equipment. Can she and does she have appropriate IV equipment and medications if you hemorrhage?
And be absolutely certain that she is comfortable with transfer. I've heard homebirth stories in which a MOT was either not transferred when she should have been (apparently related to midwife fear of legal liability or retribution) and others in which the laboring MOT was essentially abandoned by her midwives at the hospital doorstep -- probably related to legal concerns. Since the odds of transfer are higher and the related issues more likely to be emergencies, consider distance to the hospital, consider comfort -- and consider having optional plans in place that require an obstetrician's (OB's) care prenatally so you and the OB can come to mutual agreements regarding birth if hospitaliation is necessary, allowing you to maintain some control of the situation. If you are transferred without preplanning, you will probably lose more control of the overall situation.
One thing I do want to be clear about, though, is that although I am in favor of hospital births for twins or more, I am dead set against the "one size fits all" thinking that many OB care providers have for twin/multiple births. Unmedicated birth, maternal positioning and other parental preferences, etc. are very possible for otherwise uncomplicated term or near-term twin/multiple births. The research literature supports vaginal delivery of a seconnd twin in breech or other presentation. It may take "doctor shopping" -- and I'd start by asking midwives, LLL leaders, etc. -- to find an OB who understands that she/he is your partner in birth, understands you have a right to your preferences (all things being safe at the time) and is comfortable dealing with the variations that can present, but it is a shopping expedition worth investing in. And once you find that OB provider who respects you/your choices, you will probably feel more confident in his/her judgement if any complication should arise.
Karen Kerkhoff Gromada
Karen Kerkhoff Gromada's website includes a twin/multiple birthplan which can be adapted for your own use, and articles on parenting and breastfeeding multiples (www.karengromada.com).
From Deborah Lam, a homebirth supporter in Northern Ireland:
While I would agree with many of Karen's individual points, I'm not sure I'd agree with her conclusion - that multiple births are safer in hospital - because I don't buy the underlying assumption that any kind of difficulty or complication is handled better in a hospital than at home.
If I were expecting twins, I would absolutely be planning a homebirth - because I believe that what would happen in a hospital (either procedures or battling against those procedures) would actually increase risk, rather than reducing it. Possibly there are some hospitals where that would not be the case - but if those exist, they are certainly a tiny minority, and none of them is near me.
Deborah
Justine Caines writes, in her article High Risk Birth,
"I progressed full steam with confidence that the only place to have my babies was at home full term. Instinctively I knew that home was the safest place to give birth (in the absence of medical complications or conditions). Importantly I had also proven clinically that it was also much safer for me to be cared for by midwives at home."
"How could my babies be safer with a routine induction at 38 weeks, when they were more likely to need resuscitation and medical care? How would constant foetal monitoring assist when studies have shown its routine use has seen no improvement in outcomes only an increase in caesarean section? How would my babies or I be safer with an epidural that would prevent me being upright, the proven best physiological position for normal birth? How would I be safer being denied deep water for pain relief? (Do you know of a hospital that will enable a woman birthing twins to use a birth pool for pain relief in labour and to give birth if she wishes?). "
Mary Cronk MBE is one of the UK's most respected midwives, with 45 years' experience. She has helped many mothers of multiples to have their babies, both at home and in hospital. She writes about the situations when she would recommend a transfer to hospital, as well as her general recommendations for antenatal care and health, in her Twins Guidelines
(www.marycronkmidwiferyservices.co.uk)
Angela's response an enquirer on the Homebirth UK email group:
You know by now that you have the right to insist on a homebirth, regardless of what your health authority's policies are. Your local NHS Trust will certainly put pressure on you to plan a hospital birth, or an elective C-section. To be fair, there are reasons for this, which you probably know about.
There is a higher risk that one or both of your babies will require resuscitation, or some form of intervention, than a singleton, but you would no doubt be encouraged to accept interventions which might expose your babies to other risks in themselves.
I have often mused over what I'd do if I found I was expecting twins... used to think an independent midwife in hospital would be a good option, but because of NHS anti-litigation schemes (CNST) this is no longer possible in most places. The withdrawal of this option means that some women feel that a homebirth is their only way of avoiding being subjected to great interference and risk of intervention in hospital, even if a homebirth might not be their first choice. Most forms of resus can be given at home, and you can of course transfer for intervention if needed, but this is a situation where delay in transfer can be critical.
So why not labour in hospital? The problem is that support for natural, gentle twin birth in hospital may be hard to find, because of lack of experience among the staff, and fear of litigation. Some women see planning a home birth as their only way of avoiding a caesarean for their twins' birth.
I certainly see the merits of caesarean birth for twins, but it is well established that caesarean delivery carries its own risks for babies - higher risk of breathing difficulties, possible changes in brain chemistry, and, unless the cord is allowed to pulsate after delivery (possible even at CS), the baby is at risk of a number of complications due to being deprived of up to a third of its normal blood volume when the cord is clamped early. See "Effect of caesareans on the baby" - UK Midwifery group discussions - for references and more information.
If you are planning a twin homebirth, it's vital that your midwives (and birth partner) are really on the ball, and have good communication with the hospital in case you do need to transfer. The problem you are likely to find on the NHS is that very few midwives will be confident or experienced enough in natural twin birth to feel qualified to attend you at home. I do believe that it is vital to have confident and experienced midwives - calm, but very vigilant.
Even if you can't afford an independent midwife, it's worth talking to some of them anyway. Occasionally they will take on clients for no, or very low, fee, especially when there are special circumstances and they believe that the NHS cannot support the family adequately. It may be that there are some IMs who would love the chance to attend your labour, and perhaps to bring a colleague who can learn from the experience. Experienced twin birth midwives may recommend working closely with the local NHS - for example, the local maternity unit might supply one or more midwives to assist the independent midwife. The local unit would normally be informed that you were in labour, so that they could be ready to help if you do transfer.
Angela Horn
High Risk Birth - Justine Caines is the secretary of Homebirth Australia and a respected advocate of natural birth. She gave birth to twins at home in December 2005, and has kindly allowed an article about her decision process, and about risk and birth in general, to be reproduced on this site.
Twin birth archive page from the UK Midwifery egroup
Mary Cronk's Twins Guidelines - respected independent midwife Mary Cronk's guidelines for twin antenatal care and birth, either at home or in hospital.
AIMS twins article - from the UK's Association for Improvements in the Maternity Services.
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