So one of the advantages of working as a midwife in a hospital is that I get to participate in many births that I wouldn’t have the opportunity to experience in private practice. If I were working as a private practice midwife, and as a homebirth midwife in particular, there is no way I would be able to assist at a delivery of preterm twins. But, in a hospital such as mine, especially since there are no residents, we midwives often find ourselves helping and working with many of the high-risk women. Today was a case in point. This woman had been admitted early last week with preterm premature rupture of membranes (PPROM) at only 24 weeks gestation, which is never good news in singleton pregnancies, and even more worrisome in twin gestations because the babies are even smaller since they’re sharing a womb. She was admitted and given steroids to help develop the babies lungs, and put on bed-rest in an attempt to slow down the labor; we also gave her prophylactic antibiotics since PPROM is often caused by infection, and with ruptured membranes, infection is always a risk. Luckily we were able to get all of the steroid doses on board before the delivery of the babies, and she stayed on the antepartum unit for nearly a week before the labor continued to progress, going from 24 to 25 weeks gestation in the process–and every day was a blessing in a case like this, since every day helps.
Even so, 25 weeks is extremely premature, right on the cusp of viability. She was moved to L&D this morning because she had begun to contract regularly again, and was feeling increased pressure. We were able to hold her off for most of the day, but one of the doctors did a sterile speculum exam towards evening in order to visually assess the cervix (vaginal exams are avoided as much as possible when a woman has broken her water, since they tend to increase the risk of infection), and all the doctor saw was a head of hair, without any cervix covering it at all. A vaginal exam afterwards quickly confirmed what she had suspected: the patient was nearly fully dilated, and the first twin had moved far down into the pelvis, to nearly +1 station. Initially we thought she might need a cesarean, but a sonogram quickly confirmed the first twin was vertex (obviously…this was the twin that was presenting) and that the second twin was very nearly vertex (more transverse, but with the head still sloping downward). After consulting with the MFM and attending pediatricians, the decision was made to attempt a vaginal delivery, since one of the risks of extreme prematurity is cerebral hemorrhage in the fetus, and pushing a tiny, head-first twin back up through the bony pelvis in order to deliver through the abdomen was sure to cause more damage, rather than less. Nevertheless, she was taken to the OR for the delivery just in case a cesarean was needed after all.
All hands were on deck, and the OR was packed. The attending OB physician was there, the back-up attending was also there, and I was there. We were the delivery team. Two attending pediatricians, 3 pediatrician residents, and 2 neonatal nurses were also there, divided into two groups–one for each tiny twin. We had two warmers ready for the twins, two isolettes, two laryngoscopes, two sets of everything. The anesthesiologist was present and on standby in case we needed to put the patient under general anesthesia for an emergency cesarean. There were also 3 L&D nurses on hand; one scrubbed and ready to assist in a stat cesarean, and the other two as runners/ circulating nurses. And a medical student, who was observing (with the patient’s permission)–and holding her hand, and feeding her ice chips.
She was nervous, naturally. This was her first pregnancy, she’d never pushed before, and she still wasn’t feeling the contractions very strongly (one of the hallmarks of preterm contractions is that they tend to be painless). We set the sonogram machine next to the patient, and the back-up attending used it throughout the birth to help assess the position of the second twin (twin B), as well as the fetal hearts of both twins throughout the pushing. We gave her reassurance, helped hold her legs, got her into a good position, and then asked her to push. Amazingly (well, not really, given how small these babies are, and how low in the pelvis the first twin already was), it took only a few strong pushes before the tiny little head was starting to crown in the vagina. Before we knew it, the first tiny twin was out, a red little girl weighing only 1 lb 6 oz. I helped deliver the head and quickly clamped and cut the cord; the attending OB handed the tiny baby to the waiting peds team, and they instantly got to work, intubating and ventilating her tiny little lungs. She never cried, but she was nice and pink, and waving her little arms and legs around. Within minutes she was intubated and stabilized, and the team quickly moved her to the NICU. Meanwhile, we were concentrating on twin B.
The back-up physician was applying steady fundal pressure on the uterus, helping to hold twin B in a vertex position and guide her into the pelvis. After a few more contractions, the uterus began to close around twin B and push her down into the pelvis. Once she was engaged, the OB attending broke the second amniotic sac, and we asked the mom to begin to push again, which she did with renewed energy (having gotten a brief rest after the delivery of twin A). About 10 minutes later, twin B was also crowning, and again, we quickly delivered the baby, clamped and cut the cord, and handed the twin to the second peds team. She as another tiny little girl, this time 1 lb 8 oz, and again, doing as well as could possibly be hoped for at only 25 weeks gestation. Once she as stable, she too was moved to the NICU, and the OR began to clear out a bit.
It’s quite an amazing sight, to see two umbilical cords presenting. We waited for awhile, and slowly the cords began to lengthen as the placenta separated from the uterus. About 15 minutes after the delivery of Twin B the placenta came out–much larger than a singleton placenta, with two cords and two separate amniotic sacs (di-chorionic/ di-amniotic). Once the placenta was out, we all breathed a sigh of relief. A quick exam showed that the woman was intact (not surprising, given how tiny the babies were). We cleaned her up, took out the foley catheter we had put in just in case she needed a cesarean, and transferred her to the recovery room, where her family was waiting. And there you have it: a remarkably straightforward vaginal twin delivery at 25 weeks gestation. Not exactly something your average midwife gets to see everyday, but certainly something I felt very lucky to have been able to experience.