Twins, a Breech & the Pitfalls of Policies: Some Evidence against Evidenced Based Medicine
Life is complicated. Medicine is complicated. Obstetrics is complicated. When we are young these truths don’t register and the world is an oyster. As we grow older, and supposedly wiser, we understand the daunting tasks we face and we begin to dream up ways to simplify our personal world. Sometimes we follow the ostrich theory of life and live in denial or, even worse, we just conform to the establish norms and accept our fate. Or as my colleague, Elke, in Kodiak Alaska writes to me about her community:
“I am constantly fighting persecution/slander, trying to get paid, and not having a back-up midwife and all of the other stressors of being the only midwife within 12 hours. I have battles of my own just trying to stay in practice, without stirring the pot. I frankly do not have the energy to stage a campaign. I think I have come to peace about letting VBAC go for now.”
The battle against entrenched but misguided policies can be hard and lonely. It’s simpler to give in and give up.
One of the methods commonly used to simplify life‘s tasks is to establish routines. Wake at a designated time to get to the gym and grab a coffee before heading to work. Avoid peak traffic times and using the WAZE app to navigate. Shop online because it’s easier and use popup reminders to tell us when to pay our rent and whose birthday is coming up. Coming home at night and placing the keys on the hook and the shoes neatly in the closet. We find comfort in these routines. Knowing things will be right where we left them, every time. These are coping mechanisms we use to control what we can because there is so much we cannot. And we believe in rules and the authority of the law, even at times when we disagree. Adapting to these norms helps a busy society run smoothly and avoids chaos.
But there are occasions where following the rules verbatim or staying silent are not always the wisest path. For those that make the rules are not always the wisest people. Just take a look at Sacramento for a minute. We have SB277 and AB1308 as examples of rules that defy common sense and mandate one size fits all behavior. Many of you, I know, prefer individual liberty and autonomy in decision making when it comes to your personal and professional lives. Those in favor of control will always quote evidence of safety. Blindly following any policy supposedly based on evidence is a fool’s errand unless we know the quality of that evidence. Because it is just so complicated these days to look into all the data and separate the wheat from the chaff we most often surrender to the expedience of the lemming.
In the obstetrical world twin and breech birthing are considered high risk scenarios. All the different types and situations often lumped together. Physicians are taught about strict guidelines and hospitals often institute strict policies that apply to all pregnancies. Many of these decisions are attributed to evidence based medicine, ACOG guidelines and so called best practices. But are they really based on the best science or simply decided by expediency and consensus opinion? And what is the experience and motivation of those who render these consensus decisions? How can any one person see the forest through all those trees? See how complicated this is getting? Just wait, here’s more…..
There are pretty rigid guidelines taught to physicians about the prenatal care and the mode of delivery for twins. Some have great value, others have no value. The key is to know the difference and make the time to explain these differences to a client. A discussion of all here is not possible but a few key points are worthy of mention. Knowledge of chorionicity is very important. Mono-chorionic twins do have more risk factors than di-chorionic twins. Discordance and twin to twin transfusion syndrome (TTTS) are more likely to occur and lead to a complication.
Most practitioners are taught that having twins more than 20% discordant is dangerous. Irrespective of the reason and without concern about the cause, a woman is then labeled as higher risk in what doctors already consider a high risk pregnancy. More testing and intervention must occur. Breech second twins are scary to most obstetricians who lack training and confidence and, these days, a breech first twin is always considered an absolute indication for a cesarean birth. Fear and ignorance are powerful motivators.
Evidenced based medicine would suggest prematurity in twins is more common therefore strict standardized instructions and recommendations for surveillance beginning in the second trimester of all twin pregnancies is considered the standard. It is noted that neonatal death rates begin to rise after 36 weeks and so doctors counsel clients to expect induction with all twins by 38 weeks. Practitioners are discouraged from individualizing care or offering options outside these establish parameters for fear of retribution from authority figures, often of the Monday morning quarterback variety. No real thought is given to another choice because the current obstetrical model offers no incentive and only detriment to do so. But what if the evidence for many of these things was shaky at best? What would it look like if physicians individualized their care and offered alternative options so that the client could decide? What might that look like?
The truth is, TTTS is a risk in mono-chorionic twins but if these things have not occurred by late 2nd trimester they are unlikely to occur later. So the over-testing and the anxiety produced from this concern are often unnecessary. Discordance between twins is not always pathologic if both twins are growing normally on their own growth curve and their in utero environment remains healthy (BPP). Breech first twin vaginal delivery, when properly selected, is supported in ACOG’s own literature and breech extraction of second twins, when necessary, is safe in skilled hands. Twins often mature faster than singletons and can do well if born a little early (34-36 weeks). The actual risk of neonatal death from twins going beyond 40 weeks is very small (<0.2%). Informing clients in an honest manner with respect to their wishes and resisting the robotic conformity to standardized policies can change lives. This is the diminishing art of medicine.
This past week I had the good fortune to attend and assist the home birth of two sets of twins and one breech. They each had a unique story that would have been written so differently had the births taken place in the hospital setting. This is not a story of which is better or safer but is a tale of respect for shared decision making and personal responsibility. And that is a cause worthy of respect.
The Cases:
Sara was pregnant for the first time with IVF diamniotic-dichorionic twins. As early as 8 weeks there was obvious discordance. Baby boy A’s gestational sac was significantly bigger than Baby girl B’s sac. A fact remarked upon by her fertility specialist. Both babies continued to grow well on their respective growth curves. They had separate placentas which appeared proportional in size to the babies. By 35 weeks the discordance was suspected to be about 34%, well beyond the 20% “rule”. However, the BPP of both twins remained 10/10 at each weekly visit. Baby B also had a velamentous insertion of the cord seen on ultrasound early on. A discussion of risks and benefits ensued including the possible risk that baby B may not tolerate labor very well because of the vulnerability of her cord to compression. At any time, this mother knew a transfer of care to a hospital based practice was available but this is not the vision that she had and I could not tell her with any certainty that her babies were in peril. Now past the 38 week “policy” her babies remained vertex/vertex but her cervix was unfavorable. Relying on the biophysical profile twice weekly which is based on good evidence, gave us all the confidence to continue past 39 weeks and then to 40 and ignore the questionable, one size fits all indication for intervention .
Meredyth was pregnant for the second time with spontaneous monochorionic-diamniotic twin girls. Her pregnancy had been totally uneventful and she had planned a home birth with a local Orange County midwife prior to the discovery of the twins. Because of the blanket law in California preventing a midwife from caring for twins I came on board in collaboration. Also, I had a vacation planned in her 37th and 38th week so she did consult with an obstetrician who would assist her in the hospital as long as twin A remained head down. However, she really desired a home birth so when my vacation plans changed her confidence for her home birth returned. (As a side note, once her hospital based obstetrician found out that she might once again consider a home birth he disowned her and refused to continue seeing her. In my opinion, this is not very ethical behavior, and was very hard for us to understand.)
At 35 weeks and 1 day Meredyth called to say she might be leaking clear fluid. My usual policy is to see twins get to 36 weeks before agreeing to support birth at home but in the past I had already individualized care in twin pregnancies with a good result. It is important to remember that guidelines are simply meant to be guidelines. We discussed all her options and came to the conclusion that if she went into labor that day we would deliver at home. It is evidence supported that twin babies in spontaneous labor a little early often do quite well. And if they needed help they could always be transferred to the hospital less than a mile down the road but at least mom would have the labor and birth experience she desired. Instead, if she had a hospital birth at 35.1 weeks it would be in the O.R. and pediatric protocol would almost certainly require these babies to go to the NICU for observation. Individualization of care quite often violates hospital policies and is just too complicated to confront.
Megan was pregnant with her singleton, first baby and planning a peaceful home birth with her midwife. But her little one had other plans, turning frank breech at 39 weeks. A consult regarding an external version suggested unlikely success and none of the other usual breech turning methods were successful. Community best practices, a non-evidenced based California law and sometimes even hospital policy left her with cesarean as her only choice.
The Birth Stories:
Sara began having strong contractions on the morning of her 40 6/7 week. Her labor progressed well, although maybe not if you asked her! She put in the hard work to get to complete dilation and began to push when the urge set in. Both babies were head down and stable throughout labor. Second stage progress was slow and twin A did begin to develop some variable decelerations. After discussion a vacuum delivery of twin A was accomplished. Immediately after, an ultrasound showed twin B’s heart rate at 120 but then a minute later was in the 70s and remain there. Membranes were ruptured and an exam showed the baby to be vertex but at -3 station with a palpable hand close to the crown. During her prenatal care, we had discussed this very situation and what might need to be done. Since delivery was not imminent and the baby’s heart rate remained in the 70s, an internal podalic version and extraction was done without anesthesia, of course, with delivery in a matter of seconds. Given the urgency of the situation, a crash cesarean almost certainly would have been the decision in the hospital where the staff would have lacked training in these critical obstetric maneuvers. The midwife team knew exactly what to do to assist both babies transition to stability without incident.
Meanwhile, Sara also required our attention. Her bleeding became heavy as placenta A was delivered but placenta B remained attached. IM Pitocin was given after a manual extraction of placenta B (felt to be complete). She experience intermittent but persistent heavy bleeding with clots over the next couple hours despite frequent bimanual fundal massage. An IV with Pitocin and rectal misoprostol finally did the trick. Although BP remained stable, mom was tachycardic and dizzy if upright so a Foley catheter was placed to keep the bladder empty and mom in bed for a better recovery. The option of transport for observation and possible transfusion was discussed and Sara declined at that time. The team of obstetrician, midwives, students and family members endured and worked hard but everyone did their job and the model of collaboration and camaraderie worked as it should.
Meredyth’s labor as a multip was quite different. Moving quickly with her 35.1 week head down twins she climbed into the tub when feeling pushy and shortly after gave birth to very concordant baby girls 8 minutes apart. Both babies transitioned normally, requiring minimal support, and were placed immediately skin to skin with delayed cord clamping. No separation, no NICU observation and a water birth to boot. Not exactly community standard but maybe we should ask the question, “Why not? “
Four days later, Megan thought she might be leaking some fluid, or not, now at 41 3/7 weeks with her frank breech baby. What? Breech? Leaking? Forty one and a half weeks? Planned home birth? OMG, OMG, OMG! How many standards and policies were being violated here? Well, let’s consider. There is substantial evidence for properly selected term breech birthing in the obstetric literature. Proper informed consent should include this option. Leaking fluid at term with a negative GBS culture and no exams adds little risk in waiting. There is certainly some evidence supporting better vaginal delivery rates in waiting for spontaneous labor. There is also some evidence supporting induction. Clearly then the choice belongs to the well informed mother. Normal fetal testing (BPP) at 41 ½ weeks is very reassuring and very much supported in the literature. The ACTUAL rise in the risk of NND by waiting is statistically miniscule. Planned home birth for breech is not currently evidenced based simply because no data yet exists. (Hopefully, my next project). However, in my practice primipara success rates are over 75%. Is there a choice in any hospital that approaches that?
Megan and her partner, being well informed and highly motivated, were comfortable with their decision to deliver at home. Early the next morning, labor picked up. Progress was evident by the frequency of her contractions, bloody show and her affect. Her hypnobirthing lessons were so clearly working. Baby’s heart rate with intermittent monitoring was reassuring. In the early afternoon she began to feel the pressure to push and less than 90 minutes later her little baby girl was caught by her dad and handed to mom on the bedroom floor. No separation of baby from loving parents, minimal bleeding and no repair required.
The individualization of care and honoring a woman’s autonomy to make decisions based on honest information is one of the biggest joys of my practice. While we all know that nothing is always or never in life or medicine, this model of care makes for a bond of trust that goes well beyond nine months. Three women with differing stories all had their birth choices respected. In doing so, how many standardized policies and supposed evidence based practices were violated? Hmmm, let’s count, shall we?
1) Home Birth
2) Home Birth of twins
3) Home birth of breech
4) Water Birth
5) Twins going to 40 6/7 weeks
6) Discordance > 20%
7) Home vacuum extraction
8) Twins at 35 1/7 weeks
9) Allowing client with SROM to stay home and I’m sure there are others
While all the outcomes here were good, there is never a guarantee in childbirth no matter the setting, the policy or who decides. As for me, I am not one to follow the ostrich theory nor am I one who conforms without good reasoning and applied common sense. The birthing of a human life is a complicated miracle. That miracle is the sum of all its parts and must include the feelings and desires of the woman. Safety is paramount but safety is not seen by all of us the same way. Respect for that truth is all too often lacking in the larger medical system that exists today. Women and their families deserve the best evidence and a full range of options, including options their chosen practitioner may disagree with or cannot provide. There are no perfect shortcuts or algorithms. Relying on one size fits all policies as a way to avoid responsibility or justify expediency will surely backfire on us in the long run. We have a moral duty to avoid these pitfalls.
Stuart J. Fischbein, MD FACOG
December 10, 2016
(Posted with permission)