VBAC & Twins

[{sarah}]

I'm just wondering if there is more risk attempting a VBAC with twins? What extra risk would there be? The reason I ask is that we're in the discussion stage as to whether we put one or two embryos back in when we have our transfer in August.

So hit me with it girls....

[Cherie]

For a regular vaginal birth of twins, I think it depends on the position of the lowermost baby - breech or vertex. From memory, it's considered safe if the first twin is vertex, even if the second is breech.

But I'm not sure if there are extra considerations for a VBAC. I wonder if the risk of uterine rupture is the same?

[{sarah}]

The risk of uterine rupture from everything I've read is moreso in the final weeks of pregnancy rather than during the actual labour, so maybe a twin pregnancy would carry more risk anyway ????

[Loula]

Sarah - i would say a MP (multipul pg) would carry LOTS more risks have you read what willow and Jo posted in your other thread?

Maybe with your first cycle you would consider one embie then go from there also are you doing day 2/3 or blastie? i guess your Fs will help you to decide on the day.

[{sarah}]

Yep I have read the other thread Lou, I'm just going through everything at the moment so we can make the most informed decision.

[Loula]

Good on you Sarah, i do the same every time and then just as were about to go ahead , 1, 2, 1, 2, 1 ok one .............F it 2 lol

[{sarah}]

LOL, I can imagine we're going to be the same!

[diva det]

twin pg as so high risk that you will be hard pressed to find a Ob to deliver twins unless the presenting twin is head down - esp when its a VBAC
the chances of having a cs are alot higher with twin than a singleton
caution tends to be of the upmost with multiple births - but speak to your OB and get their opinion if that helps

[BellyBelly]

Sarah will email you found some info, here is a little of it:

Twin VBAC (vaginal birth after caesarean)
Here is a summary of all the research I have found on VBAC for multiple births, together with some links, and full copies of the Medline abstracts of the studies in question.

If you know of any more research on this subject, or of relevant birth stories, please email me on angela@horns.freeserve.co.uk

Summary of research
[1] This study looked only at mothers with a prior caesarean who were expecting twins, and compared trial of labour to elective repeat section. 21 mothers attempting VBAC were compared to 15 mothers having elective repeat sections. 80.9% of the mothers attempting VBAC delivered vaginally. Comparing trial of labour to elective repeat section, there were no differences in outcomes for the babies. However, for the mothers, elective repeat section produced worse outcomes. Blood transfusions were received in 9.5% of the group which attempted vaginal birth, and 26.6% of the group having elective repeat sections. Postpartum infections were recorded in 9.5% of women in the group attempting vaginal birth, and 46.6% of those having elective repeat sections. Average hospital stay was 4.4 days after attempted vaginal birth, and 8.0 days after elective section.

[2] 19 women carrying twins and attempting VBAC were compared to 57 women carrying single babies and attempting VBAC. Women carrying twins were actually more likely to deliver vaginally than women carrying single babies - 84.2% of them, as opposed to 75.4% of the single baby VBAC attempts. There were no other differences in outcome.

The authors conclude that: "The option of VBAC for twin pregnancy (TP) appears to be safe and shares a similar likelihood of success as a singleton pregnancy. In view of the lack of increased complications, this option should be offered to patients with TP who are eligible for VBAC.

[3] 25 twin pregnancies where VBAC was attempted were compared to outcomes for VBAC attempts with a single baby. 21 mothers of twins had a VBAC (84% success rate). No difference in outcome for babies compared to singleton babies. One scar dehiscence occurred in amother with two prior caesareans who had a full breech extraction.

[4] small study - 10 out of 12 women attempting VBAC with twins delivered vaginally. No difference in outcomes compared to women delivering twins with no prior caesarean, except a longer average stay in intensive care for the second twins. No suggestions made in the abstract for reasons.

[5] looked at 1,000 women attempting VBAC, but it doesn't tell us how many were carrying twins. However, "Successful trial of labor was observed in 75% of twin pregnancies".

[6] This study looked at vaginal birth of triplets. One set of triplets was born vaginally to a mother with a past caesarean.

Twin birth is safe. You just need to surround yourself with people who are in the right model of care and supportive. As you know I have been to vaginal twin birth before

[BellyBelly]

Twin VBAC not associated with increased risk of rupture
OB/GYN News, March 1, 2005

RENO, NEVADA -- Attempting vaginal birth after cesarean section in twin deliveries may be no more risky than attempting VBAC in singleton pregnancies, according to a review of almost 25,000 deliveries.

The review found that women with twins who had a prior C-section were less likely to attempt a vaginal birth but that they had the same rate of VBAC failures and no higher rate of maternal complications, Alison Cahill, M.D., and her associates wrote in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Women with twins should not be discouraged from making a VBAC attempt if that is their desire, according to data reported by Dr. Cahill of the University of Pennsylvania, Philadelphia, and her colleagues.

The study's subjects were patients from 17 different tertiary and community hospitals who were delivered between 1996 and 2000, and who were identified by coding in their pregnancy records as having had a previous cesarean section.

Of the 24,842 deliveries identified, 535 were twin pregnancies.

A total of 33% of the mothers with twins chose to attempt VBAC, compared with 55% of the women with singleton pregnancies.

The VBAC failed in 24% of the attempts of both groups.

Uterine rupture occurred in 2 of the twin pregnancies (1% of those who attempted VBAC), and 125 of the singleton pregnancies (also 1%).

Twin VBAC not associated with increased risk of rupture
OB/GYN News, March 1, 2005
RENO, NEVADA -- Attempting vaginal birth after cesarean section in twin deliveries may be no more risky than attempting VBAC in singleton pregnancies, according to a review of almost 25,000 deliveries.

The review found that women with twins who had a prior C-section were less likely to attempt a vaginal birth but that they had the same rate of VBAC failures and no higher rate of maternal complications, Alison Cahill, M.D., and her associates wrote in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Women with twins should not be discouraged from making a VBAC attempt if that is their desire, according to data reported by Dr. Cahill of the University of Pennsylvania, Philadelphia, and her colleagues.

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The study's subjects were patients from 17 different tertiary and community hospitals who were delivered between 1996 and 2000, and who were identified by coding in their pregnancy records as having had a previous cesarean section.

Of the 24,842 deliveries identified, 535 were twin pregnancies.

A total of 33% of the mothers with twins chose to attempt VBAC, compared with 55% of the women with singleton pregnancies.

The VBAC failed in 24% of the attempts of both groups.

Uterine rupture occurred in 2 of the twin pregnancies (1% of those who attempted VBAC), and 125 of the singleton pregnancies (also 1%).

In addition, 3% of the women with twins who attempted VBAC had either a uterine rupture, uterine artery laceration, bladder injury, and/or bowel injury.

[BellyBelly]

VBAC Found Safe for Women with Twins

Vaginal birth after cesarean section is widely accepted as a safe alternative to elective repeat cesarean section. But is a trial of labor safe for women with twins? This study at the Los Angeles County/University of Southern California Women's Hospital reviewed 210 twin births to women with a prior cesarean birth between 1985 and 1994 and no obstetric contraindications to labor.

Fifty-six percent of the women had a repeat cesarean delivery without a trial of labor; the cesarean was for obstetrical problems in 85% and elective in 15%. The remaining 92 patients (44%) had a trial of labor, and 70% of these delivered both twins vaginally, with no uterine ruptures and no increase in maternal or perinatal morbidity or mortality. One woman who had a repeat cesarean without a trial of labor died from pulmonary embolism.

Comment: This study provides evidence that a trial of labor after cesarean section can be safe in women with twins, allowing 70% to avoid the risks of major surgery.

— PJA Hillard

Published in Journal Watch Women's Health October 1, 1996

Citation(s):
Miller DA et al. Vaginal birth after cesarean section in twin gestation. Am J Obstet Gynecol 1996 Jul 175 194-198.

Medline abstract

The Maternal-Fetal Medicine Unit cesarean registry: trial of labor with a twin gestation.
Varner MW et al Am J Obstet Gynecol. 2005 Jul;193(1):135-40
OBJECTIVE: The purpose of this study was to identify the success rates and risks in women with a twin pregnancy who attempt a trial of labor after cesarean delivery. STUDY DESIGN: Cases were identified in the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network's Cesarean Registry with a woman with a twin pregnancy who had had at least 1 previous cesarean delivery. RESULTS:
During the study period (1999-2002), 412 women fulfilled the study criteria, and 226 women had elective repeat cesarean delivery. Of the
186 women (45.1% of total) who attempted a trial of labor, 120 women were delivered successfully (success rate, 64.5%), and 66 women (35.5%) had a failed trial of labor. Thirty of the failed trials of labor involved a vaginal delivery for twin A and cesarean delivery for twin B.
Women who attempted a trial of labor with twins had no increased risk of transfusion, endometritis, intensive care unit admissions, or uterine rupture when compared with elective repeat cesarean delivery. Fetal and neonatal complications were uncommon in either group at>or=34 weeks of gestation. CONCLUSION: A trial of labor with twins after previous cesarean delivery does not appear to increase maternal morbidity.
Perinatal morbidity is uncommon at>or=34 weeks of gestation

[diva det]

i know that it is possible kelly and please don't take this the wrong way - but in reality it is hard to find a good OB who is willing to to a VBAC for twins - espec if twin is not head down
they are scared of the what ifs for them - not what is best for bubs and mums- if something goes wrong

[BellyBelly]

Thats why you get yourself a good private midwife. And yes I know the perils of Obs who are not comfy with vaginal twin birth Breech too, same thing really....

[Adnil]

Just wondering what happens if you go close to term? Don't they normally induce at 38 weeks? And for a VBAC, I know in my area they won't induce because of the added risk. Would they let you go over the 38 weeks?

[BellyBelly]

They prefer to induce twins, but I know plenty of women who have gone 40wks+. Yvette was nearly 40wks when they broke her waters, she had such a fight in the public system, it was horrible for her...

Sarah if you have twins, there is a great twin home waterbirth DVD by Davini Malcolm. Its also a lotus birth but still to see a twin homewaterbirth I think at 41w6d? Its awesome.... you can get it from the website of the international college of spiritual midwifery.

You just need to find the right Ob... as the above studies say, same with a VBAC singleton. Many obs have restrictions, but some are also supportive in nature taking it's course too. A common thing with twins is that Obs will feel more comfortable if you have an epidural. But you can say no or find an Ob who is fine without one. Or have a midwife

[Adnil]

Ah, OK. Well that's great then. It really is a matter of finding the right OB by the sounds of it. As with most things.

Good luck Sarah - I hope this discussion becomes a very real one for you very soon IYKWIM.

[{sarah}]

Thanks everyone I've been googling & have found lots of stories from mums that have had successful twin VBACs so it is possible, just gotta have the right people around as you say Kelly

[Inanna]

I've seen them successfully done too. If the Mama is determined and focused, supported well (as Kel said get a good midwife!) and you seek out a doctor who is comfy with a twin VB. It's a big decision for you Sarah and I think you are doing all the right things by seeking out independently information and making an informed decision. Good luck my love...
(great info there Kelly! )