ļ»æEpisode 42 - Twins with Dr Stuart Fischbein
Mel:
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson. I'm a clinical and research midwife with my PhD, and each episode I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth, and postpartum journey. Welcome everybody to this week's episode of the Great Birth Rebellion. Melanie Jackson here with you, I have a very special guest, Dr. Stuart Fishbane, who's joined me today from the US. Thankfully, it's his 6.30 p.m. and my 10.30 a.m., and it took me a long time to work out the time zones, and he was very patient with me in doing that, so I appreciate that. And I've invited Dr. Stu here today because he's somewhat of an expert on, well, reach and twin births but my main interest today is we want to talk about twin births so welcome to the podcast stew stewart however you want whatever you want to be called you
Stuart:
[1:09] Go by melanie or mel.
Mel:
[1:10] I go by mel but my my kind of instagram hashtag is melanie the midwife so either or again with me totally fine so
Stuart:
[1:20] It's the same with me uh thanks for having me on it is it is nice to glimpse the future you're 18 hours ahead of me so so now i know what tomorrow is going to be like.
Mel:
[1:29] Exactly it's so i i couldn't get my head around the fact that it's that you are in my yesterday and i am in your tomorrow yeah yeah it's what i just and it and
Stuart:
[1:40] It's your winter and it's my summer.
Mel:
[1:42] Right i mean okay yes but today we're gonna look into the evidence on twitter i
Stuart:
[1:50] Got i got you all flustered it's good.
Mel:
[1:51] I know i love it keep me on my toes super important so i have some questions for you but firstly i want i want to introduce you to our audience we're here in australia you're in the u.s and i've specifically invited you because you really uh embody the ethos of this podcast the great birth rebellion because one of your claims to fame claim to fame's claims to fame is that you attend twin births at home. And that piqued my interest because I'm also a home birth midwife who doesn't have the skill to attend twin births at home. And so while I've supported families who are having twins, it's always been in hospital. So I am super keen to delve into your knowledge about twin births at home, the evidence, but also not disregarding and really acknowledging what knowledge is generated by pure experience. And what you witness in twin births that really has possibly not been shared in literature and in mainstream discourse about births.
Stuart:
[3:01] So a lot of our wisdom has to come from experience. This is, you know, you can't do certain things by reading a textbook. Yeah, so I was fortunate because I trained in an era when twin birth, breech birth were considered normal. I'm old enough to have lived in that era. And so I trained in the early 80s when I worked at Cedars-Sinai Medical Center in Los Angeles. And as part of my residency training, we spent three or four months at LA County. That's Los Angeles County, USC, which is University of Southern California, Women's Hospital, which at that time in the early 80s was the busiest hospital in the United States, doing about 22,000 births a year. Which if you break that down is about 65 babies a day and so we got exposed to everything and we got exposed to it in large volume and intensity because we were working every other day for 24 hour shifts they don't do that to young doctors anymore but they did it you know back in the day i sound like my father sometimes when i talk about yeah my father used to walk uphill 12 miles to school in the snow barefoot both ways. So that's, that's a story that he used to tell. So I, I, I sound a little bit like that, but that's the way training was in those days that you can't get that training anymore.
Stuart:
[4:28] So I'm really concerned that the skill of breach delivery and twin delivery and forceps delivery and internal pedallic version and breach extraction are going to disappear and everything is going to be resolved by the scalpel, which is.
Stuart:
[4:46] Has so many downsides to it what we've done to the human female and the species by this all the interventions that that i thought were normal when i came out of my training i mean i came out of my training like any other young doctor comes out of the training think i know everything about, obstetrical care and maybe i did but but but only about 10 or 15 percent of women needed obstetrical care. The other 80 to 90% did not. And I didn't know anything about them. So again, like I said, I was lucky to do that. And so I see that skill disappearing and it troubles me.
Stuart:
[5:25] And my career has led me down a path where initially I started off working like any other doctor does in the United States. In those days, you just hang up your shingle and you hustle to build a practice.
Stuart:
[5:36] Now, most doctors coming out of training are just going to get a job working for somebody, corporate medicine has been taken over pretty much corporate or government medicine takes over everything and doctors just are employees working shifts which by the way is much better for their life and their lifestyle but not better for the women that we're supposed to be serving because this is one of those specialties that's not designed for shift mentality you know if you're going to the er and you have a broken leg and you have a doctor and that doctor goes off shift another doctor comes out and that's probably okay but there's so much in the regarding obstetrics that is personal and it's a journey and feeling safe and secure and as your your countryman sarah buckley likes to say quiet safe and unobserved is the way for women to labor and you don't feel safe if there's strangers popping in all the time or people that you don't know or don't like interrupting you all the time. So we have this model that is not beneficial to the system. And so we're not learning these skills. We're going to end up intervening. We've got rising rates of cesarean, or at least it's plateaued, but at a very high level. You have rising rates of chronic childhood illnesses.
Stuart:
[6:51] You have lots of high rates of dissatisfaction and, and postpartum depression and, and other, other things that, that are, that are often really, really unnecessary.
Stuart:
[7:03] And so my, my role in the world right now, you said I, I deliver twins at home. I have stopped delivering after 40 years, war on me after a while. It wears on your ability to sleep and your physical health. And being on call, you know, is again, it's, it's an honor, but it's also a burden because even though you don't get called every night, you never go to bed, not knowing if you're going to be called. And, you know, to do that for as many years as I did that in this, in some of my, honorable granny midwife colleagues have done that i i respect them greatly for that but, it was time for me to to go off on a different tack so i will occasionally tend to birth somebody who i know or a legacy client or something like that but other than that now i travel around the country and around the world and i teach breach and twin skills i have a seminar that i teach, and then i also do online consultation i.
Mel:
[8:00] Hear you with that you know have being on call and doing continuity of care has a time limitation as you said on our physical social well-being and the health of our families having done it for 15 years i get it you know you every night i put out a bag and clothes and i make sure my car is full of petrol and you know is there somebody going to be here when the kids wake up it's the whole rigmarole that is
Stuart:
[8:26] Is yeah you can't live your whole life with adrenal fatigue like that where you're i mean your cortisol and your adrenaline are constantly on high alert. It's not a good way to live. I'm fortunate. I'm healthy. I've got great genetics and constitution. And I didn't quit because I had a medical problem. I quit because I didn't quit. I slowed down because I really wanted to try a new chapter. This is the third chapter of my life. It's the third and final chapter.
Stuart:
[8:56] And I want to spread the word and try to make bigger changes. I'm not ready to sit down on the farm and retire and do nothing. I want to speak to the world. I want, if I can only change small groups or families at a time, that's fine. Because every act has a ripple effect downstream that's going to change the course of that family or that group of midwives or birth workers. And that's what I want to do. You know, I sometimes feel sad and depressed a little bit about what's happened in my profession and my colleagues who are stuck in what I call the hamster wheel of medicalized birth and never look outside the wheel to see that what they're doing isn't doing well. And yet they continue to do it. And not only do they continue to do it, but then they ridicule people who do something different.
Stuart:
[9:50] And for that, you know, for today's discussion, we can talk, we're going to, you know, we can apply that to twins and what it shows is what can be done.
Stuart:
[10:00] With confident women and a skilled practitioner in any setting where twins are not treated as you know danger from the moment they're discovered and fear because fear is what motivates everybody it's used as a manipulative tool and the medical model is drenched in it, and from the beginning from the very first thing that happens when you go to see your OB for your first appointment is that you have what they start what's called a problem list.
Stuart:
[10:34] And a really good example of how the medical model thinks is a story that happened to me a few years back after all these years of taking a history on a new consult women would come in and you take a history you ask them what their chief complaint is and you ask them about the about the symptoms of that and then you go through past medical history and past surgical history and family history and review of systems. And sort of in general, that's how you take a history. And so when I got to past medical history, as I'd done it thousands of times before, I asked this woman, do you have any other medical problems? Which is something that we ask every person that comes in. And she looked at me and for the first time in my career, she said to me, what's the first one? And I realized that even me, after almost eight or nine years of doing home birthing and practicing for 30, 35, 38 years was still considering pregnancy to be the first medical problem. It was ingrained inside of me. It's not anymore because she woke me up and I just, boom, it was like a light bulb went off. And I realized that, yeah, you don't have a problem.
Stuart:
[11:38] Until you do. I mean, some pregnancies will become a problem, but pregnancy in and of itself is not a problem. Yet the medical model is constantly looking for problems.
Stuart:
[11:48] And they'll tell you things that don't even matter. Like, oh, you're over 35 or, oh, your hips are small. Oh, your husband's too tall. Oh, you know, oh, you're, you know, your last pregnancy, your, your baby was only six pounds. So we have to watch your baby grow. I mean, they're just vomiting seeds of doubt upon you. And some of them are going to stick and they're going to make and i don't know about your country as much as mine but i know that most women in my country have a lot of have have dread and fear, when it comes to pregnancy not our clients because it takes special people to decide to do home birthing and and have twins or breaches or whatever at home most women could never do that my own family members who have babies i just became a grandpa last week for the first time thanks. It was great. But I was, you know, my son was, my son was texting me like, oh, now they're, they're checking her again. And she's two centimeters and, oh, they're checking her again. And she's three centimeters. And then she says, now she's five centimeters. Now she's seven centimeters. And I'm saying to myself, why do I need to know this? How do they, why do they need to know? How many, how many badge exams are you going to do? She, and she's a multiparous woman. So she you know so she didn't need any of this but they didn't you know she had an iv she couldn't eat.
Stuart:
[13:09] When she was complete and felt like pushing came really quickly as sometimes it does the doctor wasn't there yet they told her to not push okay and i and i'm hearing the story i'm not saying anything because it's not my place you know people think that because i do what i do that all my family members would want me at their birth it's like no that's not the way it works in my family so you know and so that's a sense of me and we and why don't we take it to where you want to go because i could i could really ramble for the entire hour i just love it well i love i love talking about birth i am a birth junkie i was lucky i fell into something that i really love to do and i found a way to make myself love it because i know that most of my ob colleagues, from talking to them, they're not, they're not thrilled about being on call. They don't really want to get up at night and come in. They're a little nervous when they have someone in labor. That's no way to live.
Mel:
[14:06] No. Well, I'm curious to know, I had a look at your profile online and you in 2016, you won an award for being most, the most audacious.
Stuart:
[14:18] Yeah. It's sitting, it's right over there.
Mel:
[14:20] I love it. It's like Ina Mae Gaskin won an award in the Countercultural Hall of Fame. And I was like, those are the type of awards I'd love to win, that most audacious practitioner award. I just think, what was the tipping point? Training in the way that you did under an obstetric model in that philosophical framework, what moved you into believing that doing twin and breeches and all these births at home was a good and reasonable idea. I'm saying this tongue in cheek, but how do you go from that to a complete flip in philosophy and understanding of birth?
Stuart:
[15:02] Yeah. I mean, some people, a lot of my midwife friends will have an epiphany. They'll have an event in their life. They'll watch their sister being born or whatever. And they say, I want to be a midwife. Well, that wasn't the case. For me, it was a very slow transition. As I said, I went to a standard residency program, which was very medicalized. And I came out knowing a lot about problems, but nothing about normal. So I came out very medicalized. I was the guy fully dressed in a hazmat suit. Having you in lithotomy position, telling you to blow, okay,
Stuart:
[15:38] well, I, so that I could get you the drapes on your legs to cover you with the blue drapes. And then I could wash off your vulva with a little bit of betadine because it's got to be sterile, right? Birth is supposed to be a sterile procedure, right? Every other mammal has a sterile birth, right? Lions and tigers and bears. Oh my, no, they, they, they don't, but we did. The baby would come out. I would immediately grab the baby in my left hand because I'm right-handed. I would grab two clamps. I'd put a clamp on a clamp on, cut the cord immediately. I'd show the baby to the mother and this beautiful thing that she just accomplished. And then I'd walk it across the room and set it down in the warmer.
Stuart:
[16:18] And this is what I thought was normal. And I only began to think it wasn't normal when I was approached by some midwives in the community and asked to take their transports from home. And when you're a young physician in the 80s, you didn't, like I said earlier, you didn't get a salary. You ended up trying to hustle. So you covered emergency rooms, you covered other guys when they were on vacation, you assisted surgeries, that sort of thing, free clinics. So I said, sure, I'll take your transports because I just was looking at it as a revenue generation thing. I'm sure I thought home birth was stupid and I really knew nothing about midwifery. And this would have been 1986, 87. And over the next five to 10 years, I began to spend a lot of time with the midwives because they'd transferred to me. I became very popular because I was very supportive of what they were doing and honoring the woman's birth plan, fully aware that the birth plan has been altered because you had to come to the hospital, but not, you know, invading their space completely. And there'd be a lot of downtime. The woman would get an epidural and she'd get Pitocin and we'd be sitting in the lounge. and we'd be talking and I'd hear a whole other way of doing things. And I realized that the women that these midwives were caring for were really intelligent. And in Southern California, they were, you know, they were doctors and lawyers. They were Hollywood people.
Stuart:
[17:35] Very bright. And I began to see another way of doing things. And I began to realize that I didn't know anything about normal.
Stuart:
[17:42] And I was open to that. And then they began inviting me to their open houses or their, to come speak or to come listen early on to these things. And I became part of a birth center situation. And I opened up a collaborative midwifery practice with two certified nurse midwives in a hospital setting. And for 15 years, we did really good, really good things. And I began, you know, I realized that, that I'm really good at taking care of the problems and the midwives are really good at taking care of the normal stuff. And it's a great collaboration. I don't mean to be doing pap smears, but if someone has, you know, cancerous cells on their pap smear, I'm the person to do the colposcopy, the biopsy, the leap procedure, whatever. That's me. Someone needs surgery. Someone has a breach delivery. If someone needs forceps, if someone needs a third or fourth degree laceration repaired, that's what i'm good at so it worked we had a great relationship but we were never accepted in the community because there was a bunch of good old boy doctors who wanted to didn't ever want their apple cart overturned and so eventually we sort of got into a administrative hassle where they weren't going to renew my privileges and i could have fought them legally or not it wasn't because of any bad outcomes or anything like that it's because we made them all nervous we made especially the anesthesiologists and the pediatricians were really nervous around our patient because they didn't want epidurals and they wanted to go home early and they didn't want hepatitis vaccine and, and they just didn't know what to do.
Stuart:
[19:12] And so I eventually started to go to home births because I had a choice of fighting them legally and probably losing because that's they're big and I'm little. And fortunately the home births I went to were beautiful. And a lot of my clients who were due after the, the date where my privileges were not going to be renewed, they came to me and said, we don't want to go to the hospital. We'll stay home. You come to our house. And what's really funny, Melanie, is after 25 years of backing midwives, I had yet to be at a home birth. So I was like most OBs who've never seen it. I had opinions about home birth having never been to work. I was that guy.
Mel:
[19:49] Yes. And I take midwifery students with me to home birth sometimes and you can see their brain change when a baby comes out at home and they see how simple it is and they go oh my gosh what have we been doing to women in hospital if birth can be like this how far have we moved away from that and they don't realize how far it is until they see a baby come out uninterrupted. With very little, if any, assistance whatsoever. And you can see all these new neural pathways going, like firing in their brains. And I say to them, I'm sorry, I've ruined you forever. You will never, ever be satisfied with seeing birth in an institution ever again. Once you see a baby come out at home.
Stuart:
[20:46] No, a lot of labor and delivery nurses and doulas have talked to me and other midwives, I've heard through them too, that they really don't want to work in the hospital anymore because they can't watch what goes on there. It's just too painful for them to watch. Anyway, so I started doing home birthing. And as the years went by, I got bolder. And I said, you know, I was doing breach in the hospital.
Stuart:
[21:08] Why can't I do breach at home? And why don't I do twins at home?
Stuart:
[21:13] And so I just started doing other things. And then I don't like to write too much, but I wrote a book.
Stuart:
[21:19] I'm not an academician. I'm a practitioner. But I did write a book called Fearless Pregnancy, and then I published a paper on home birthing, my first 135 home births, and then I published a paper on breech home birthing. And then I had something very interesting happen with a set of twins. I had that thing that they tell you you're supposed to be scared of, but actually the paper shade never happens, and that's where the two heads, head of A, breech, and B, vertex, get tangled. I call it head entanglement it's not like locked heads or something like that and I was able to solve the problem right then and there because of my breach experience and my knowledge of the spatial relationships of what's going on inside and putting my hand up and fixing one head out of the way and getting the other head to come down so I published a paper on that a case report, and then now I have this new paper coming out and it's on twin home birthing and when people say things like twin home birthing is dangerous that's what's called opinion because there is no data because no one's ever done any data on twin home birthing so all they're doing is they're they're projecting their own anxieties and fear about twin hospital birthing on home birthing and how can you do that at home because what if something happens or what if something goes wrong.
Stuart:
[22:40] And not realizing that most of the things that go wrong in the hospital are iatrogenic. They're caused by the way the hospital manages the patient in the first place. The immobilizing, the starving, the interrupting, the anesthetizing, the hyper-stimulating, baby's not tolerating labor, thank God that we had an operating room, what would you have done if this had happened at home? None of those things would have happened at home. You know, and, and, um, with twin birthing, it's the same thing. It's just a baby. Followed by another baby.
Mel:
[23:18] I love that.
Stuart:
[23:19] If you properly, if you properly select your, you know, your clients appropriately, I mean, not everybody with twins should be having vaginal births or home births, but many, many women with twins could.
Stuart:
[23:33] There was a practitioner that's skilled available to assist them.
Mel:
[23:37] Yes. And this is where I want to go next because the reality in the system, And I feel like Australia is tracking quite similarly to the trends in America. But essentially, if you have a twin pregnancy, you're in a high-risk clinic with obstetric care, you're most likely to end up with a cesarean section. If you do opt for a vaginal birth option, you'll be encouraged to have an epidural. And it's an incredibly medicalized approach to birth because there's two babies. And so that's the reality the reality is is in in australia and i imagine in america yeah if you've got twins the most likelihood of what's going to happen to you is highly medicalized management lots of ultrasound and a cesarean section birth with your babies being separate from you afterwards
Stuart:
[24:29] Right you're going to be you're going to be receiving, signals of anxiety and fear the entire pregnancy from your doctor the nurses in your doctor's office from the maternal fetal medicine specialist that they'll send you to not always again when we discuss things we're talking in in in general there's always exceptions there's beautiful maternal fetal medicine specialists and there's really bad midwives and then it works both ways But for the most part, you're setting somebody up for being anxious the entire pregnancy. Now, not only is that bad for your developing baby to be soaked in those maternal hormones all the time, but it's also detrimental to the pregnancy and labor. Because mammals that are anxious or in fear will not go into labor or it'll be dysfunctional. And that's a survival mechanism.
Stuart:
[25:34] This is nature's way of protecting the future generations. And only when it's safe does it make sense for nature to allow these things to proceed normally. So if you're drenched in anxiety all the time, as my colleagues generally are caught and then therefore carry on the tradition of anxiety for twins from the very first visit.
Stuart:
[26:01] You're taught all about the things that might happen down the road.
Stuart:
[26:06] Sanitas are too low. They're too attached. There could be this, you know, pre-term labor is a problem. There's higher risks of preeclampsia. Yeah, that's true. But what is the actual risk and how do we prevent that? In the medical model, they don't. They watch for things and then they try to fix them once they happen. In the midwifery model, you're going to eat more protein. You're going to get some help at home. You're going to take good care of yourself. You're going to exercise. I have people who have twins or something, and their doctor tells them, well, you can't pick up your two-year-old anymore. There's no book anywhere that says that.
Mel:
[26:41] No. And so I'm curious, how do you, and this is where I'd love to dive into your information because there's lots of different types of twins, but is there criteria, evidence-based or not for selecting which twins would be best suited to vaginal birth and which might benefit from being born by cesarean section
Stuart:
[27:04] Yeah that's before we talk a little bit about that i just want to comment on the term evidence-based we talked about it off the air before we started and i have a problem with evidence-based the term because it implies that the evidence that the that the information is based on is good evidence. And a lot, as we've seen over the last few years, the world has seen, and a lot of us have known this for a long time. If you read Suzanne Humphrey's book, Dissolving Illusions, you know, that's been going on for a hundred years and probably long before that, that what current trends are and then what the current information is or the current evidence is may be wrong.
Stuart:
[27:44] And it may not be the only evidence, but it's the evidence that's used to skew you, the path that they want you to take. But you've got to be really careful about how good the evidence is. And that's a whole different conversation.
Mel:
[27:59] What I sometimes call culture-based care. So if you enter into a hospital, every hospital has a different culture around what they might do for twins and breeches and VBACs and all these things. And depending on which hospital you're in will determine what type of care you get based on the culture and opinion of the people in that facility rather than actual.
Stuart:
[28:19] That's a really good point. We call that in our country, we call it standard of care. And standard of care is, again, is another term that doesn't mean anything. Because who decides? Your local community, your national organization, the hospital's risk management lawyers, insurance company, the medical executive committee who i mean who decides and so it really doesn't mean anything again these terms are used to convince you that what they're saying is right or or also it's a bit of cognitive dissonance on their part to convince them that what they're doing is right because the alternative that what they've been doing all these years is wrong.
Stuart:
[29:07] Is really unthinkable because these are not mostly bad people the system is bad the people are not yeah okay so twins corian corianicity of twins embryology is simple embryology a baby when it's conceived is inside an amniotic sac inside a chorionic sac so the the bag of waters that we talk about toward term when that ruptures it's a two-layered sac with the chorion on the outside the amnion on the inside everybody's heard of the amnion because they've heard the word amniocentesis but the chorion is not necessarily something that people have heard.
Stuart:
[29:50] So chorionicity is looking at how many sacs they have and whether or not there's a chance that there's a problem with the placentas that they can communicate. So the most common type of twin is diamniotic-dichorionic twins, which means each twin has its own amnion and its own chorion, often called fraternal twins or non-identical twins. Now, a small percentage of di-di twins can be identical. They just split before they implant it. Those twins' placentas have zero chance of ever communicating, and they don't have any of this risk of these rarer things, which, well, it's not that rare. It's about 15%, 17% of monochoriatic diamniotic twins have this thing called twin-twin transfusion syndrome, or some of the lesser...
Stuart:
[30:42] Blood flow problems called taps and traps and we're not going to go into those but but tts is a real is a real thing and we'll talk about that in a second so identical twins depending on when they split generally have two amnions but they're in one chorion so those babies share a placenta and there's a small chance that like i.
Stuart:
[31:04] Said 15 18 percent will have a problem with there's a shunt in the placenta and one baby will end up acting like the pump for the other baby and it can be lead to real problems and in the days before they came up with this really creative medical solution to it mortality in that situation was very high for both twins now they have the thing where they can do a laser to the vessels a laparoscopic they actually poke a hole and go inside and they're actually working on doing it with high frequency ultrasound where it could be non-invasive in the near future and i in my paper that i did had we had four sets of tts and all four of them had the procedure done and all four of them had their babies make it to viability so we had eight surviving babies from this where you know 30 years ago a likelihood that any of those babies were to survive might have been quite small so medicine does do things that are wonderful sometimes right you know we we talk a lot about how the you know in our model there's a lot of interventions that that are unnecessary but sometimes they can be really necessary so that's a brilliant one so that's monochorionic diamniotic twins and then on the and i would say that di-di twins are about 80 of twins i'm rounding and mono di twins are probably about 17 and the other 3% are generally either mono.
Stuart:
[32:31] Mono twins where they're identical and they're in the same sack.
Stuart:
[32:35] And that has a high mortality rate because there's placental issues and also cord entanglement.
Stuart:
[32:41] The little babies are flipping around each other. They tie themselves into a knot. So that's really rare. And that's something that would almost never make it except by a misdiagnosis to term. Because those babies should be delivered early in a hospital, almost always by cesarean section. And then you have the rare things like what we lovingly call conjoined twins or Siamese twins. But again, very, very, very rare. So let's just talk about the two most common, which are di-di and mono-di. If mono-dye twins develop TTTS, they obviously need to be referred to a high-risk center where they're probably going to get this procedure done. I'm sure there are places in Australia that do it. And they're going to generally go into preterm labor or deliver prematurely after that procedure, but they'll usually make it to viability. Those people aren't, those moms are not candidates for any sort of midwifery care, home birth, that sort of thing. Well, there's still good candidates for midwifery prenatal care because you guys do such a great job of nurturing and keeping the people calm and happy and healthy, but not for home birthing. And that's what we're talking about. But if that doesn't develop, in my experience, if it doesn't develop by about 28 weeks, it's probably not going to happen.
Stuart:
[33:55] So that's a very reassuring thing. You're never 100% out of the woods, but the likelihood it goes down significantly if you haven't had any evidence by 26 to 28 weeks. What I have found is if that doesn't happen, then monodye twins and dye-dye twins are no different as far as success rates, going into labor, allowing them to deliver, delayed cord clamping, success, exactly the same. The statistics, I mean, again, my number's not big enough in a lot of the categories to reach statistical significance. So it's an observational paper, but you can draw conclusions from an observational paper. Like I said, about 80% of twins or 70 to 80% of twins are going to be die-die. They're not going to have that risk. So what other risk factors are involved with twins? Well, there is a risk of asymmetric growth. Now twins can grow asymmetrically and as long as they're growing okay on each of its own growth curve i don't think i came out of my mouth with good english but but if they grow appropriately for their own growth curve because the way the growth curve is designed the closer you get toward term the further apart things are so a baby that's growing on the fifth percentile a baby it's growing on the 70th percentile, they're not going to be that far apart at 20 weeks. But by 35 weeks, they're going to be more than 20%, 30% discordant.
Stuart:
[35:22] The medical model looks at a number like 20% discordance and thinks that that's gold, not gold, but lead, because anything over that, that scares them. But it's not the absolute number that's important. It's how are the babies growing on their own growth curve, and how were they doing early on, and how are they doing now? And you're more likely to find a baby, partly because there's two babies in there, where you see intrauterine growth restriction. True intrauterine growth restriction, not mislabeling of intrauterine growth restriction. Another thing that's important to note is that a lot of measurements that are done on twins use singleton graphs and charts. The Hadlock graph, which is the graph that you use, is not really designed for twins. So they'll say, oh, your baby's only in the 7th percentile. Well, that's probably fine for twins because twins generally overall are slightly smaller.
Stuart:
[36:13] I can tell you that my average breech baby was between 3,100 and 3,200 grams at term, and my average twin baby was about 2,800 grams at term. And my average twins went to 39 weeks with a range of 35 to 42 weeks. So we did not induce our twins simply because they had twins. We looked at each individual woman clinically, and if she had an indication that she needed to be delivered early, then we would transfer their care and deliver them early. But otherwise, we let them go to whenever they went into labor because we felt that was best. And the average was 39 weeks. So think about that. If we have some women that went into labor at 35 and a half, 36 weeks, we had to have some that went to 41 and 42.
Stuart:
[36:59] And so that brings you to the risk of stillbirth, which is another scary thing that they'll throw at you. The rising risks of stillbirth in twins after 36 weeks. Well, the truth is, is the risk of stillbirth rises in all pregnancies after 36 weeks. It's not the fact that it rises that matters.
Stuart:
[37:16] It's the actual rise that matters. And this is something that most of my colleagues, again, don't know. How do I know they don't know it? Well, one, I hear stories, but two, I didn't know it either. I had to dig deep to look this up. I was not taught this. I was always taught that twins should be delivered. They're monody twins they should be delivered by 36 weeks and if they're die die 37 to 38 weeks and they should be induced then the induction process is just as you described earlier you know nothing to eat prophylactic epidural iv you know pitocin in the or 14 people in there that you don't know, Five minutes between twins because they can't keep everybody waiting for an hour or two between twins. So they immediately go up and around. That's how they do it in the hospital setting. That's not how we do it at home.
Mel:
[38:09] No.
Stuart:
[38:10] And we're free to do what we want at home because we don't have risk managers and administrators who haven't practiced in 20 years telling us how to practice. One of my biggest pet peeves, Melanie, is a midwife goes through years of training. An OB resident goes through medical school residency that's eight years of his life or her life to be highly trained. They get a certificate that says you finished your residency program. They get licensed by the state. They take their boards and they get board certified. And then they go to work someplace and people who aren't practicing are telling these people how to practice so why did i spend eight years of my life or you as a midwife four years five years whatever it was and all the apprenticeships and all that hardship and up all night long only to then finish and then be told what you can prescribe and and how many how many minutes you get to see a client and you know that we at kaiser don't let anyone go past 41 weeks so you have to skew your counseling to tell that woman that she can't go past 41 weeks, and so we are free in the home birth model to do what we want go ahead i'm sorry yeah.
Mel:
[39:31] Oh no it just it sounds like and this was my would flow into what you're talking about is obviously you you're using ultrasound to assess these twins and
Stuart:
[39:44] I do. Yes. That you can't, you can't get all the doctor out of the, out of me. Of course. So yes, but there are many midwives out there who do not, if their clients don't want ultrasound for twins, they don't do it. I, you know, and again, most of the time it's going to be fine.
Mel:
[40:02] Yeah. So when your ultrasound, this was my question is when, what's your usual ultrasound schedule for twins?
Stuart:
[40:09] Okay if early on you discover you're having twins say you're 11 weeks 12 weeks and you find out you're having twins at that point it's very easy to find so if you discover that they're mono dye twins where they have one chorion and two amyons then you should probably be scanning that person starting at around 16 17 weeks about every two weeks until about 28 weeks because ttts can occur at any time it's pretty obvious it can come on fairly quickly so you you i think that ultrasound is important in that because and partly because i've i picked up four cases yes out of you know 20 some monody twins whatever whatever 17 was so you i don't know that's one in six so about 24 it must have been about 24 women and so i think it's important with di-di twins.
Stuart:
[40:59] I think every four to six weeks is reasonable or not you know i i again because i still have a medical side to me i kind of like clients to have a 20-week scan i like to know that the twins are growing well i like to know that there's no anomalies i like to know where the placentas are i like to know the the that there's no with twins you're more often to see weird cord insertions Now, again, this is another fear-based thing. If you find a velamentous cord insertion, which where the cord inserts off the placenta and the vessels splay out a little bit, you're going to make the woman nervous. You're going to tell her all about these. But most velamentous insertions are found when?
Mel:
[41:40] After bed.
Stuart:
[41:41] After bed. Oh, the placenta comes out and everybody goes, oh, wow, look at that.
Mel:
[41:44] Yeah.
Stuart:
[41:45] Okay. So it doesn't mean anything. so i'm a little i'm a i have a i have a ying and a yang when it comes to ultrasound because there's very valuable information from it but the way the ultrasound is done these days is it's it it's so detailed it picks up things that don't mean anything yes well i think.
Mel:
[42:07] We're doing things like twins at home you know and i and i attend women who are having v-backs at home and one thing that I ask is I say, look, there is a very small risk that your placenta's implanted somewhere that wouldn't be safe at home. If we could find that out, that may increase the safety of you doing VBAC at home. Just like if we're going to attend twins at home, having a collection of information that's helps you to make a decision about the best place for birth because we can't always deal with every single complication at home in the same rapid way that we could in hospital yeah that's kind of where i sit with the ultrasounds i
Stuart:
[42:52] Think yeah well patient selection patient selection for all of us in the home birth world and even in the hospital but the home birth world especially is very important and that you know the criteria for twin birthing isn't that my criteria isn't that complicated it's essentially term so you have to get to at least 35 weeks i consider 35 weeks even if somebody was 34 weeks and five days and in labor would i make them go to the hospital no i wouldn't if the babies needed a little bit of respiratory assistance afterwards more than i could handle then the babies could go to the hospital but at least she would get the nice vaginal home delivery that she wanted. So term, relatively concordant. I don't have a number, but just so that they're growing concordantly. What I like to see is baby A in what I call a stable longitudinal lie, which is a fancy way for saying either head down or in a proper breech position. A lot of people say, oh, breech-first twins is dangerous. It's not. As a matter of fact, most of the world literature on breech-first twins supports that there's no evidence that breech-first twins more than 1,500 grams, which is about 3 pounds, 5 ounces, that there's no benefit to cesarean section over vaginal delivery for those twins. But you wouldn't know that by talking to obstetricians. They immediately would say that you can't do that because they're afraid of breech, partly because they were not taught it and partly because they were taught to be afraid of it.
Stuart:
[44:16] No gross anomalies for the twins. And then laborers should start spontaneously. Babies obviously have to tolerate labor as does mom. And then when the most important thing for home birth workers is, is the, that the parents have the right mindset.
Stuart:
[44:31] You can't take somebody that was planning to have an epidural at the hospital and scared of birth and suddenly finds out she's having twins and doesn't want a C-section. But if they're in the wrong mindset, then they're going to be that mammal that's on high alert and that's not necessarily conducive to our model of care. Now, maybe we can convert them over time. It just depends. But a mindset is really important. And that's really about it.
Mel:
[44:58] Yeah. Well, you answered a lot of my other questions in that response as well, because I was curious about your perspective on ultrasounds for twin pregnancies, which I feel like you've answered that. And also, and thank you for that amazing description of the different types of pregnancy, of twin pregnancies and all the differences with the Corion and the Amnion. And just as a side note, anybody on the mailing list for this podcast gets access to all the resources that we use to create each podcast. Episode so i will absolutely be putting your papers in the in the group file for people to access and also a little diagram for those of you who are in the assembly of rebellious midwives which is another little option for the listeners in this podcast a little diagram of what it looks like with those mcda mcma and mcda twins just so you can get a visual of what she's talking about with the different structures that twins can take on?
Stuart:
[45:57] I was going to say, when I talk about position of twin A, I purposely didn't mention twin B. Because ultimately for a skilled practitioner, it doesn't really matter what position twin B is in. Yes. It could be breech, it could be head down, it could be sideways. It doesn't matter. Because anybody that's supporting twin vaginal delivery should know how to reach up and do a breech extraction if it's necessary. And you can always i shouldn't say always because i never say always but even though i say always all the time you you can almost always you know if you have to because there's an emergency you can reach up and you can grab those baby's feet and you can pull it down even if it's sideways or even if it's head down you can push the head out of the way it's called an internal pedallic version something i teach at the reteach breach seminars we teach breach extraction we teach internal pedagogy version. We use the Sophie and her mom breech trainers, and they're really pretty good trainers. So you can do all those things, and you can do them without anesthesia. Another thing that a lot of my colleagues would go, well, you know, we want to have an epidural just in case. Just in case what? I mean, it's almost like you're setting them up. If it, well, in case I have to reach up and get, well, yeah, it's very uncomfortable.
Stuart:
[47:22] But sometimes the epidural isn't activated enough anyway, and you're still going to have to do that. And when you have good communication and you have continuity of care with your clients all through the prenatal period, there's a trust that develops. And you can discuss these things. And you said, listen, there's a small chance that if this happens, I may have to reach up inside and my arm's going to be up this far and it's going to be really uncomfortable. It may take 10 to 20 seconds to do it. And I'm going to, you know, and we'll talk about, you know, focusing on your partner or, whatever, but you know, we'll have to do this, you know, and if people are, can't handle that sort of thing, then they're probably not a good candidate to stay home.
Mel:
[48:04] Yeah. And proponents of, you know, people who propose that maybe every single twin birth should be aided by the use of an epidural, I think forget the impact that an epidural will actually have on the labor and how you're probably more likely to set up a complicated scenario by having the woman lying down with an epidural than if she was moving and upright and actively involved in the birth process, you're less likely to create the complications that you're worried about needing to intervene for. And so, yeah, like you said before, there's not necessarily ā€“ The thought process doesn't go so far as to actually assess what complications we're introducing by recommending things like routine epidurals and routinely inducing babies early. What other risks are you offering the woman by doing that?
Stuart:
[49:03] The medical model doesn't see those as risks. They see the baby in the bassinet
Stuart:
[49:06] as the only outcome that matters. And you are so right about the epidural. I have a whole talk about epidurals and how they disconnect the mother from the baby. The mother and the baby are in communication constantly throughout the entire pregnancy through hormones. You're happy, the baby gets a waft of your dopamine and your oxytocin. You're scared, the baby gets a waft of your adrenaline. Baby and mom are communicating constantly. The minute you give a woman an epidural, she's disconnected because she's no longer discomfort. She's no longer secreting things like she would be otherwise. So it interferes with it everything that you do as bliss my co-podcast co-host likes to say walking in the room is an intervention because you're disrupting the flow mammals again sarah buckley i can't can't say it enough safe quiet unobserved the minute you walk in the room you're bringing the woman out of her primitive brain and you're bringing her into her cortical brain and the cortical brain has nothing to do with labor. It actually can only interfere.
Stuart:
[50:15] Labor is, for those of people who haven't heard this before, labor is a primitive bodily function like breathing or digestion. We don't have to think about it. Thank God we don't have to think about it. Oh, breathe in, breathe out. I got to remember to do that. No. Or digesting your food. But when you start to think about it, say you have to give a speech or say you have a test, you may hyperventilate, you may get diarrhea. Yeah. Your cortical brain is causing your body to screate things that affect your primitive brain functions. I can't say it in a simpler way. And so when you intervene in any way, shape, or form, but an epidural is one thing. Having a woman on her back is another. Having her starved is another. The idea that we can't eat in labor because you might aspirate, that's the whole point, is anesthesia is afraid that you might aspirate. What are we talking about here? Right. Yeah. For those of you listening, her head just exploded.
Mel:
[51:26] I did. I just mind-blowing. I agree with you that we starve women just in case they need a cesarean section, just in case that cesarean section needs to be done under general. Because really so the scenario is so unlikely yet you create these scenarios by not feeding women we create all these risk factors that are going to increase the chance of women ending up in this scenario that you're trying to avoid
Stuart:
[51:58] Does anyone listening really believe that one third of of human females cannot give birth as nature dictated name another mammal other than french bulldogs for the yes other than you smart asses out there name another mammal okay that has a c-section rate of anything i mean occasional racehorses probably because they have half a million dollar foals inside of them but and even then it's probably stupid it's probably better for that foal to be born vaginally we don't yeah but we but we but we're we're accepting of the fact that one in three female humans can't have their baby as nature does they grew a baby inside of them that that only obstetricians can save it's the hubris and the idiocy well i guess they always go together hubris and idiocy tend to tend to go together so when you know so back to twin birthing so you know that's those are the basic things about twins but there's other things including like what's the ideal twin to twin interval this.
Mel:
[53:07] Was my next question twin to twin intervals that you're following exactly my plan here on the on my screen you are just rolling
Stuart:
[53:16] Through it and i did not i don't have any notes i just it's amazing well this is i mean i'm going in chronological order of labor and delivery and stuff. So when a comes out, All right. Delayed cord clamping. Absolutely fine. Talking about home birthing twins. We know there's no TTTS or anything like that. Twin-twin transfusion syndrome. None of that. So baby's off, put on mom's chest. Occasionally with twins, you might have a short cord and the baby can't quite make it up to the chest. So you put the baby down here. That's fine. You have a teamwork set up where, you know, you have your first midwife is in charge of that baby and the midwife that's in charge of delivering or the doctor is now checking on baby B to make sure baby B's heart rate's okay. Maybe, maybe doing a vaginal exam just to see if it's head down or what position it is and maybe taking the Doppler out to listen to baby B. But if baby B is fine, just leave it alone and let mom and dad relish in the birth of baby A. Let baby A get its stem cells from optimal cord uh delay optimal cord management i guess it's not optimal cord clamping because we don't clamp the cord so yeah optimal cord management which is to just leave it alone.
Stuart:
[54:33] And if the baby is able to reach the breast then you can have the baby latch which can then help bring contractions back in the hospital you're going to see that most babies are only born anywhere from two to five minutes apart with twins vaginally because immediately after twin a comes up they go up and rupture membranes on twin b and either mom pushes twin b out or they do a breach extraction on twin b or whatever or put a vacuum on twin b what did they do that and the reason they do that is because two reasons one is no one's thinking and in other words it's the long habit of not thinking something wrong gives it the superficial appearance of being right and it's just the way it's always been done. And why has it always been done that way? Well, partly because of the fact that you've got 14 people in the room and you can't keep two sets of pediatric teams, an anesthesiologist, a couple of nurses tied up for an hour, hour and a half, waiting for the next baby B to come out. So that's the way it's managed in the hospital. At home.
Stuart:
[55:38] Initially when i started doing twins i i let things go as long as i felt comfortable, and as long as baby b was fine if baby b started to show signs of variable decelerations or a bradycardia then i would then i would expedite things as well but again we would have these conversations in the you know in the office during the prenatal period we talk about all the different scenarios so that they'd be fully aware of what the possibilities might be sometimes contractions will come right back and that's great and sometimes they don't and they just and they they space out and that's why breast pump or getting baby on the breast or but but there's no hurry to do that and the range that we had between babies was two minutes to four hours and 16 minutes in the home setting we had one set of twins that was transferred to the hospital that was almost six hours between twins now there's stories out there that you know oh twins were born 24 hours apart on two different days. And yeah, that happens, but that's not what we would normally do at home. And I have to say that, you know, I and my other team, we have some, a bit of impatience as well. It's hard sitting there for three hours knowing there's another twin inside.
Stuart:
[56:49] So, and what I have found and what the literature supports is one thing that literature says that the longer the interval goes between A and B, the more, the lower the pH of baby B will be. And a lower pH is translated into probably lower APGAR score at one minute at least, and possibly a needing of respiratory assistance. So that's pretty universal in the literature. That's not necessarily the reason to intervene right away. What I've also found in my own experience is that women who have a blood loss of over 1500 cc's, have an average twin-to-twin interval of 58 minutes.
Mel:
[57:30] So for people in Australia, 15,000 cc is 1.5.
Stuart:
[57:36] No, 1,500 cc. 1.5 liters. 1.5.
Mel:
[57:41] Liters. Yeah.
Stuart:
[57:42] Same as you. Same as you. We do the same. We use cc's in America. So, and then, and women that had less than 1,000 cc's, I believe, the average interval was 24 minutes.
Mel:
[57:53] And is that because the baby A's placenta has started coming away and being born?
Stuart:
[58:01] No, I think the uterus just is, I'll talk about the third stage in a second, but no, I just think that the uterus is extended for a longer period of time. And remember that the placenta, you've got two placentas on the uterus and you've got two placental beds. So blood losses, it's just one of those things that I didn't expect, but we just observed. Now, again, it doesn't reach statistical significance, so I can't draw a scientific conclusion. But what I did after the first five or six years of doing twins was I started to tell my twin clients that if 30 to 45 minutes goes by and nothing is happening, then I think we need to consider stepping in and maybe rupturing membranes and getting things moving. Some women would say sure, other women would say no, and we did what they wanted. But I think it's important to understand that the longer you go, all right, nature has a reason for that, and sometimes it's good, but it can lead to problems. So the question is, how often does it lead to problems?
Stuart:
[59:14] You know, it's not rare, but a postpartum hemorrhage is nothing that we can't handle at home. We're equipped for that. so it's just a it's just a individual thing now a lot of midwives are probably a little bit more hands-off than me i've got a lot of midwife in me but i can't get all the physician and obstetrician out of me so yeah so that's the thing but you know i've waited as long as four hours and 16 minutes between twins and of course what happened to that woman she had a postpartum hemorrhage so but i'm not saying that that's because of of that because we've had some postpartum hemorrhages when there's been, you know, 10 minutes between it, but just the trend, is such that that's the case. So that's just an important thing to note. And since that's one of the rare things that we as physicians can somewhat control, that we have the option of discussing that with our clients so we can control the twin-to-twin interval. And because of the risk of acidosis and the risk of bleeding that I've found, it's a discussion that should be had with the moms.
Mel:
[1:00:21] Yeah. And so for women who are listening and wondering what this twin-to-do-in interval is, is if you do go to the hospital for your birth, here in Australia, I've seen in the hospital that i usually transfer to they say no more than half an hour
Stuart:
[1:00:37] That's good because the united states we rarely see half an hour yeah.
Mel:
[1:00:42] And so that's so what we're talking about is the time between the the birth of the first baby and second baby is often sped up in hospital and stew's talking about the the difference in how that would be managed at home versus in hospital which is very hands-on
Stuart:
[1:00:59] Yeah we tend to leave baby b alone as long as baby b is fine and we'll you know we'll listen to baby b every few minutes initially you know we try not to disturb the the the beautiful time with baby a but part of me believes that baby b starts to sometimes develop d cells, and i know that this doesn't make any sense simply because it's missing its twin oh.
Mel:
[1:01:24] It's just sad
Stuart:
[1:01:25] It's suddenly like, where did he go?
Mel:
[1:01:28] Yeah. Oh, I think that's completely possible.
Stuart:
[1:01:32] Yeah. I loved getting kicked in the head, and now I'm not getting kicked in the head anymore. So I'm going to complain, and my only way I have to complain is to have a variable D-cell. No, I don't really know. And of course, with twins, of course, cord prolapse is a little more common, especially with twin B. But cord prolapse with twin B is not the same as cord prolapse with a vertex singleton pregnancy if cord if the if twin a is out and twin b's membranes rupture and the cord falls out that's not a reason to do surgery that's a reason to reach up find the feet and do a breech extraction on twin b but i can't tell you how much i cringe when i hear stories of a woman who says, yeah i had i delivered twin a but then i had to have an emergency c-section for twin b and it's like.
Stuart:
[1:02:21] I can't even think of a situation that's ever happened to me, but I will tell you that that aggravates me because somebody who's not comfortable doing a breech extraction should not be taking care of you if you have twins. I might have said this earlier, but I feel very strongly more than half of all twin babies, twin pregnancies, will have at least one twin being breech. If your practitioner is not comfortable with a breech first twin or a breech second twin, or both twins being breech for that matter, then that physician is not a physician who should be taking care of twins. And an ethical thing for that physician to do would be to say, listen, I'm not an expert in twins, but the Susan Jones down the hall, she does twins all the time. You should go have a conversation with her and maybe she should be better. She's a better, but doctors have an ego. And doctors don't want to do that. And doctors figure they can coerce people into a C-section anyway. So that's what they do. But the idea that you have one vaginal delivery and then you end up with a cesarean for baby B should never happen. It really should never happen. People say, well, the cervix can close down a little bit. No, it doesn't. Even if it closes down to seven or eight centimeters, if you reach up, that cervix is really floppy.
Stuart:
[1:03:40] And you're not going to have that problem. We're not talking about preemies here. We're talking about all-term pregnancies. We're not talking about all twins. We're talking about the ones that we properly selected that we talked about earlier.
Mel:
[1:03:52] And I think this is the difference. Because my clients talk to me about breach. They're like, what about breach? Is it safe? I'm like, if you have a clinician who knows how to manage the complications of breach, then that's the safest person to be at your birth, regardless of whether or not you're at home or in hospital. It's not the location. You know, I've seen three breech births total because they accidentally came out bum first and they thankfully needed no assistance. But I'm very clear with my clients that I'm not of an era where we've been taught to be confident in breech vaginal births or been taught in a way that encourages us as midwives to attend breech births. So I'm not, although I believe in the capacity of women to give birth to breech babies and that I believe that they will come out and it's not an increased danger, your safety is linked to the experience of your clinician, which it sounds like that's the same situation as twins.
Stuart:
[1:04:51] Well, yeah. And let's talk briefly about this because very simple, it's very simple math. The, there is a slight increased risk to a baby being born breech. of an injury. The risk of neonatal death, which is everybody's nightmare, is statistically indistinguishable from a head-down singleton baby. The Royal College of OBGYN, England's equivalent of the American College, or ANZOG, which is yours, says that the risk of a neonatal death with a head-down baby, BRTX, at term is one in a thousand.
Stuart:
[1:05:33] And with a breach, it's one in five hundred. So it's essentially twice as risky but it's a but if you look at those numbers as not happening it's a 99.9 percent chance of it not happening with a head down baby and a 99.8 percent chance of it not happening with a breech baby if you told women that they have a 99.8 or 9 percent what's the difference that most women are going to say not much and it's certainly not a reason to have a C-section. But if you sectioned all breaches and you section all twins where there's a breach in there, you may save one in 2000 babies, but you've created more risk for that baby that you just saved. You create more risk for that mother from the surgery itself. And there's morbidity and mortality from C-section. And if that woman ever wants more children, All you've done is push the risk downstream and now you've put all her future children at more risk because you were afraid to do a breach delivery or to tell a woman, I'm not comfortable with breach, but there's somebody down the hall that is comfortable with breach. You should go have a consult with that person. And one of the questions that's really interesting when you find out you have twins or breach, and I do a consult on these women, this was another epiphany for me, was...
Stuart:
[1:07:03] 100% of the time when I asked this question, I got the same answer. And that was your primate, you got a breach or your primate, you got twins, your doctor's recommending a C-section. Did your doctor ever ask you if you want more children? And the answer is universally no, the doctor never even brought it up because again, it's the live baby in the bassinet in this pregnancy thing that that's all that matters. I don't mean that in a callous way. I just mean that that's the way it works and they're not thinking about your future babies but the ideal situation is to avoid that first cesarean section and whether that's for a singleton breach or twins or twins with a breach baby or two a skilled practitioner is what we need and the and the shame in my profession is that is that the torchbearers of my profession the academics who run the residency programs are not teaching this core skill that makes my profession unique and the true torchbearers of it are the midwives who seek this out.
Mel:
[1:08:03] Yeah. So much nuance to consider when we consider the impact of interventions versus leaving things alone.
Stuart:
[1:08:12] And the beauty of our model of care is that we have time to think about these sort of things.
Mel:
[1:08:17] Can you briefly talk us through as well placental birth for twins?
Stuart:
[1:08:22] Yeah. So I always thought that placentas of twins don't come out until after the second baby comes out, until it happened to me once where Quinn A came out, and then there was this huge gush of blood. And I examined a woman, and I only felt placenta. And I said, well, she can't have a placenta previa because the baby just came out. And I realized it was baby A's placenta that came out separately. And then baby B came out. Baby B got in trouble at that point, so we hustled baby B out too. But generally what happens is twin A comes out, whenever twin B comes out, blade cord cramping on twin B. Eventually, you know, mom will hear the gush of blood or that cramping that, you know, that placental separation cramping that they get. And the placenta will generally just come out on its own. You need to be prepared to do a placental, a manual extraction of the placenta. Don't rarely do you have to, but you should have that skill.
Stuart:
[1:09:19] Anybody who does home birthing should have that skill actually of any kind. And then you should be ready for, you know anticipate increased blood loss with twins simply because you have a bigger distended uterus with two wounds on it and so have your agents available we don't i in my practice because i'm anti-use of pitocin because i think it interferes with the natural thing i have to have a conversation with sarah buckley about this because sarah thinks they're the same molecule and And even though she's not for Pitocin, she doesn't think it's as maybe as detrimental as I do. So, but I carry Pitocin, I carry misoprostol, I carry TXA, tranexamic acid. And I believe in teaching the mother fundal massage.
Stuart:
[1:10:10] I do believe in, you know, shortly after birth, within the first five minutes, doing one bimanual exam. Am i know that a lot of my midwife colleagues are going to cringe when i say that but a lot of times what happens is you find that there's 500 cc's of clot in the lower uterine segment and if you don't get that out of there then a lot of blood builds up inside the uterus and then you get a uterus that becomes floppy and you then you end up chasing your tail and trying to get ahead of the of the hemorrhage so you know funnel massage is annoying but that's why i try to teach the mom to do it herself. I say, if you do it, we don't have to. I did not ever have to transfer a single one for postpartum hemorrhage. So I'm proud of that, but I probably have done a lot of mashing on uteruses that.
Stuart:
[1:10:58] Would make a lot of my colleagues cringe, but I, but I, I don't want them after all that great work to have those babies at home and then have to call an ambulance because mom is passing out.
Mel:
[1:11:08] Well, I think actually the medicine and cause I carry, so you carry Pitocin, we call it Sintimetrin or Sintocin on here in Australia, same medicine, different name, but you know, and I talked to my clients about, I'm like, actually these medications work, you know, if you're having a bleed they absolutely work and that's probably why transfer for postpartum hemorrhage is so rare
Stuart:
[1:11:31] Yeah we carry that and and i never when i go to a birth i have a team that consists of me for twins and two two other licensed midwives i like to have you know just because on the small chance that you have a mother who's bleeding and two babies that need attention you need three trained personnel there could you do it with two yeah you could probably do it too but i never wanted to spare i wanted to pay people you know a fair wage to come and be there for those twins so me two midwives usually we had a midwife student and a doula and you know that's that was our team and we would often do we wouldn't do drills but we would talk about who's going to take care of baby a who's going to take care of baby b what's my responsibility as the catching physician if if if it's a midwife's client and i'm there because california law says i have to be there then the midwife can catch both babies and i'll just i'll be the midwife and i'll i'll just keep an eye on baby a or something like that i can do that too so but we have assigned roles and it's just it it goes very smoothly and it's nothing's more beautiful by the way than after that happens and the twins are out and you've, everybody's seen the Instagram photos of the parents with their twins. And it's just, it's amazing. Cause you compare that.
Stuart:
[1:12:54] To the experiences of a hospital birth with twins. And they really are, it's night and day. It's just completely different.
Mel:
[1:13:02] That's right.
Stuart:
[1:13:03] Yeah.
Mel:
[1:13:04] And just on a final point to mention, if you're listening here in Australia, we've had situations where home birth midwives have been reported and deregistered for things like attending twin births. So, you know, you'd have to really check out your legal structures in your country around and your registration bodies around what you're allowed for registered practitioners in terms of attending twin births you know this is a golden situation that you've got where you're you're actually allowed to attend twin births at home well
Stuart:
[1:13:39] They are only allowed because i'm there.
Mel:
[1:13:41] Correct yes for i mean for us in australia it would be such a head turner to know that obstetrician is coming out to home births with midwives to help facilitate twin births like it's you know it's unheard of so like you know hearing your story just shows people what's possible that we don't have to be confined to the current discourse that medicine is offering us about twins is that just because they say it's true because they're in a position of authority It doesn't mean that it necessarily is and that there's a whole world of knowledge around twins that is unacceptable to the authoritative paradigm, but that still sits within what's true.
Stuart:
[1:14:28] It's quite a reasonable option and it's been known for a really long time. It's not for everybody. You know, as my friend Kimberly likes to say in the Breach documentary, home birth, Breach birth may not be for everybody, but informed decision making is. But you can't make informed decision making when you're given skewed information. And I feel for my colleagues. I mean, if my colleagues love going to the hospital every day and doing that every day and not realizing what they're doing is not a lot of detriment to it, you know, blissful ignorance, I guess we could call it. Then I, far be it for me to disrupt that. But if I, if any OBs are listening to this whatsoever, think about breaking away, thinking about doing something that's really necessary that you were trained to do. If you got the training, if you didn't get the training, go out and get the training. Where do you go? Take some courses. If you have to, you could go to, you have Andrew Bissitz in Sydney. He's a skilled practitioner. You have Frank Lewin in Germany,
Stuart:
[1:15:30] Anka Ritter in Germany. You have people where you could go, where they're training institutions. Just think what we could do to restore this honorable and necessary skill that women deserve.
Mel:
[1:15:44] Absolutely.
Stuart:
[1:15:45] And was always safe until cognitive dissonance and confirmation bias came into play. And a paper that was an outlier compared to all the other papers on breach that showed there was very little difference between breach vaginal breach by cesarean except for the term breach trial which came out and that was the one they picked to choose they choose to follow because it met the model by which they wanted to practice which was get in at 7 30 in the morning on a, and just do a c-section and go on to the next task yeah and they've lost their humanity they've lost the mission that that we should all be on which is to give babies and mothers the best start possible and it isn't a medicalized impersonalized birth and twins are no different i love it i mean And, but it, but this, you know, this, this success rate in, in just my home birth practice, again, 98% for multips.
Mel:
[1:16:52] It's incredible.
Stuart:
[1:16:54] 67% for primips, 74% overall, but 67% at home.
Mel:
[1:17:00] For twins.
Stuart:
[1:17:01] For, for twins, for primips.
Mel:
[1:17:04] Yes.
Stuart:
[1:17:04] So even, even though that's not great, it's still two out of three, almost all those women would have had a C-section in the hospital setting.
Mel:
[1:17:13] Yeah. That's what I was just thinking. I was like, well, but it's 70% better than what's happening in a hospital setting.
Stuart:
[1:17:19] Yeah. We had a C-section rate of 8.3%. And just think about this. 44% of our moms had at least one baby breach in almost every practice in the United States or in your country, all 44, all those moms, they're not 44, but 44%. So the C-section rate would have been at least 44% just on those moms. If everyone else delivered vaginally and we had an 8% C-section rate overall.
Mel:
[1:17:45] And when you consider that women with one baby going into hospital have got a 35% chance of a cesarean section, when you're looking at twins having a 8% chance of cesarean section, I mean, that gives you the stark contrast of how a different model of care and a skilled clinician can make a difference. The fundamental risk isn't with women and with their pregnancy.
Mel:
[1:18:13] The the outcome is so heavily skewed by where you're giving birth and who you're with rather than actually the woman's body and her baby so yeah thanks so much Stu for I mean that was an incredible amount of information in a very short period of time and I'm so grateful for the wealth of knowledge that you have and for the path that you've chosen with education and putting yourself out there. And I think it's going to be really inspiring. There are obstetricians who listen to this podcast, I know, because I get messages from them. And so if people want to discover what else you're up to in your career and life, where can they go for more info?
Stuart:
[1:18:55] They can follow us on the Birthing Instincts podcast on your podcast app. So that's Bliss and I. And then everything is Birthing Instincts. So birthinginstincts.com is my website and at birthinginstincts on Instagram.
Mel:
[1:19:09] Right.
Stuart:
[1:19:10] And that's enough for now. I do have a consultation service on my website. It's a tiny little banner at the very top. I've tried to make it a bigger banner, but for whatever reason, Squarespace, we can't figure it out. But if a midwife wants to have me available as a consultant, there's an annual membership fee. If a client wants to talk to me about her whole medical history and talk about twins, we have a consult fee for that. somebody has one question, there's a, there's a much lesser fee for that and they can go on there. And then they, you know, we have some videos, there's a lot of testimonials, my blog.
Stuart:
[1:19:46] Just storytelling. Yeah. And one of the best things, even what we didn't tell a lot of stories today, but one of the best ways to learn. And when I do my breach, reteach breach seminar, which is one other thing that people can take. And if they, if there's anybody in Australia that wants to try to host it, we have a page on my website and they can fill out a form and my, my assistant Emily will get ahold of them and we can work on setting up some seminars. Like you had breach without borders out there this year. I teach a slightly different style of class and, and it's much more personal because it's me and it's anecdotes and it's stories. And part of the way we learn is hearing stories. And I tell stories and then I hear your stories and those stories then get told at the next seminar. And it's spreading. It's, it's not spreading fast enough for my liking. I would like to see more women have the choices that they deserve, but I'm doing what I'm doing. I can, you're doing what we can. I mean, we have a great community and I'm really proud to be part of it. Yeah. I'm starting to mumble. I'm getting a little bit.
Mel:
[1:20:45] Oh, no, no, I love it. It's all golden. So all of that info about Stu, I'm going to put in the show notes as well. And if you've signed up to the podcast mailing list, every week you get an email with all the resources that we've used for every single podcast. And that'll be in the resource folder. So you can click that button. And if you're in the Assembly of Rebellious Midwives, you get access to way more information. so take advantage of that. Thank you so much, Stu, for being here. I'm so grateful for your time and knowledge and we will see everybody else in the next episode of The Great Birth Rebellion. To get access to the resources for each podcast episode, join the mailing list at melaniethemidwife.com and to support the work of this podcast, wear the rebellion in the form of clothing and other merch at thegreatbirthrebellion.com. Follow me, Mel, @MelanieTheMidwife on socials and the show @TheGreatBirthRebellion. All the details are in the show notes.
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