At thirty weeks pregnant with her second set of twins CB found out during her growth US that Baby A had moved into a breech position. You can imagine her sadness and angst to find out that one of her biggest concerns she had all along with this pregnancy was coming to life. Baby A would be breech. CB is a long time patient of mine, actually CB was my first set of twins I cared for as a new midwife almost 4 years ago now. Her first spontaneous set of twins was relatively straight forward, aside from some slight elevations in blood pressure at 37 weeks in which we made the decision to induce. CB had very little complications with her last twin pregnancy. Fast forward three years later when CB found out she was pregnant again, imagine the shock to find out she was having yet another set of twins! I was not practicing at the time and although CB was seeking pregnancy care at the same place she was at with me formerly… she said something felt different. CB was looking for education, personalized care, time spent, and lastly the ability to have a trusting relationship with her provider that allowed for curiosity, questioning, and informed decision making. So as soon as my practice opened up CB came quickly over to establish care in her early second trimester. Over the last several months we have been cautiously excited that her twins were vertex/transverse, until they were not. As her provider I counseled her originally on what we would do if baby A went breech. In my traditional training I was always taught that if Baby A was not vertex, cesarean delivery was the only option I had to offer my patient. When I met with CB it was very clear that she was not only upset about potentially undergoing a major abdominal surgery but that she was also very concerned for how she was going to recover from surgery meanwhile caring for newborn twins and three year old twins on her own. Which made me think…. outside of the box. I really do try to play by the rules… but if we don’t get curious, if we don’t ask hard questions, if we don’t individualize care… what are we really practicing? Uptodate and protocols are a beautiful thing for us providers as a resource, but I have always feared that we will make so many algorithms or protocols that practitioners would loose the art of “practicing medicine or healthcare.” In order to give individualized care we need to know that women need options. What works for one is certainly not what works for everyone. Cookie cutter medicine is going out of style. Women are demanding better, thank goodness.
So i made a promise to my patient… that I would look outside of the standard of care in the US and I would see what the literature says world wide and what options my patient actually has, versus what options I can actually offer with my credentials and skill set.
I already comanage my patient with MFM so naturally this was the first place I went to seek counsel. I was met with great respect and curiosity but unfortunately there was very little outside of ACOG recommendations that he was able to offer our patient. So next I went to my supervising OB and asked what she thought about offering an ECV to this mother based off multiple RCTs that I found showing a 50% success rate and 0 emergency cesarean or fetal or maternal deaths. Let me start by saying that my OB is women centered and although she has never offered ECV to a twin gestation she agreed to counsel risk and offer the procedure if they patient desired or was willing to assume those risks. Can I just say this tickled my heart?!!! That she was willing to offer choices to my mama that 90% of the OBs I know and work with in this community would not have offered? I thought to myself...now we are getting somewhere. Choices… I went back to CB and I told her what options I had been able to secure thus far. After reviewing more literature I was able to see that in Canada, ECV and breech birth are offered to mothers of twins as the standard of care. After reading many RCTs I found that breech/breech delivery has better statistics for fetal outcomes as well as apgar scores vs babies that underwent ECV. But the problem still exists… who could I find to consult, give true informed consent, and have the experience to be able to offer this option to my patient? Luckily I know a few Obgyn's in the Valley. So I called up an Obgyn that practices out of Banner University, who is very well known for his informed/educated approach to offering all reasonable options within his skill set. And low and behold he agreed to meet, consult, and offer breech/breech delivery if my patient decided that the risk and benefits were clearly weighed and the patient was willing and comfortable to proceed according to those risks.
To say I felt elated is an understatement. Cesarean birth, breech, ECV, epidural, unmedicated… listen here, I have a love for all types of birth. But you know what I love more than anything? Being able to help a woman understand all of her options… and giving them to her even if I am not able to be the person providing that care. CB is not just my patient. She is a mother, daughter, wife, friend… and an individual. She deserves to make informed/educated decisions about what is best for her and her babies. I have no idea what’s to come for CBs delivery. Maybe we will luck out and that little girl will flip head down just in time for me to be able to deliver her. Maybe we will undergo ECV after good informed consent. Maybe she will decide the risk is too high for her comfort and we will do a gentle cesarean. Or maybe she will decide the benefits outweigh the risk and she will go for a breech twin delivery.
It doesn’t matter to me which decision my patient makes… just that she has support, information, and has the ability to choose what is best for her body and her baby. And you know where you will find me,despite whichever choice she makes? Right by her side. Because I made a commitment that these two kiddos will not enter the world without me right by her side again.
I hope that despite your opinions about breech, ECV, cesarean, or etc… that this helps to open your mind to a better way to care for any human being….Care that starts with education, knowledge, and choices. Choices that reflect the individual and the needs of the family unit. Stay tuned…. if CB lets me share, I will be ecstatic to get you the details about the birth of these sweet little babies!
With love always,
Modern Day Midwife
