Twins who are born vaginally have fewer complications and are less likely to die than those born via cesarean, say the authors of a recent large-scale French study. The researchers recommend that vaginal delivery be the birth method of choice between 32 and 37 weeks gestation when the first twin has a cephalic (head-first) presentation.

This recommendation was recently echoed by the American College of Obstetricians and Gynecologists (ACOG). In their “Obstetric Care Consensus” statement released in 2014 and reaffirmed in 2016, the ACOG clearly states: “Perinatal outcomes for twin gestations in which the first twin is in cephalic presentation are not improved by cesarean delivery. Thus, women with either cephalic/cephalic-presenting twins or cephalic/noncephalic-presenting twins should be counseled to attempt vaginal delivery.”

Given this overwhelming evidence in favor of vaginal delivery, why are 75 percent of twins born via C-section in the U.S.?

 

A culture of fear

According to Dr. Mary Mirto, who has been a private practice obstetrician for 15 years, the reasons behind the trend away from the vaginal delivery of twins are multifaceted.

“Twin pregnancies are high-risk pregnancies,” she says. “They require higher levels of surveillance, usually obtained with more visits and more ultrasounds. They have an increased risk of preterm labor, preterm delivery, and complications during the labor and delivery process. Many physicians believe that by recommending cesarean delivery for all patients with high-risk pregnancies, they’re reducing their risk for complications and liability.”

In fact, our lawsuit culture has created a climate of fear that has transformed the very way obstetricians are trained and expected to perform their duties.

“In some [obstetrician] training programs, vaginal twin deliveries aren’t encouraged, so the physicians may not be adequately trained to be comfortable managing them,” says Dr. Mirto. “And for physicians with smaller practices, having enough twin and high-risk pregnancies to maintain skills such as breech delivery for a second twin may not be possible.”

The ACOG couldn’t agree more. Their statement reads, “In order to ensure safe vaginal delivery of twins, it is important to train residents to perform twin deliveries and to maintain experience with twin vaginal deliveries among practicing obstetric care providers.”

Dr. Mirto believes the division of responsibility with other care providers is another key factor in the high rate of C-sections for twins. “Having support services such as anesthetists or specialists for the infants [on hand] may determine whether a provider feels comfortable caring for and delivering twin pregnancies,” she says. “When these services are not readily available, a scheduled cesarean can ensure adequate personnel are present.”

Time pressures can also push OB/GYNs to recommend a speedy operation over an unpredictable delivery. “When a physician is juggling the responsibilities of the office and hospital coverage, waiting for the second twin to deliver may not be seen as an efficient use of time,” says Dr. Mirto.

Finally, some women may balk at the idea of delivering two babies vaginally. “All patients aren’t willing to deliver their twins vaginally, especially once they’re aware that even if the first twin delivers vaginally, the second may require a cesarean delivery,” says Dr. Mirto. “This leads some patients to request a scheduled cesarean section.”

 

Seeking a patient-centered approach

All the reasons cited by Dr. Mirto – and echoed by other obstetricians off the record – are based on protecting the interests of the doctor rather than those of the patient. Even women’s refusal to attempt a vaginal birth comes from obstetricians projecting their fears onto expecting mothers and stripping them of their power and self-belief, says one California OB/GYN.

Thankfully, there is a counterculture within the OB/GYN community that still believes that their patients’ interests should be front and center, but the fear of stirring the pot in the organized medical world often prevents them from voicing their dissent. This is especially true for doctors who work in large hospitals, which often follow very strict protocols.

Dr. Mirto feels very fortunate to have found a practice where she can help women pursue the birth experience they truly want. “I work for OB/GYN North, a collaborative practice employing OB/GYN physicians and Certified Nurse Midwives in Austin, Texas,” she says. “We are very supportive of natural, or unmedicated, childbirth. Many women come to us for a low-intervention approach to pregnancy and childbirth when it’s appropriate. But we are also supportive of our patients who choose to use pain medication and epidurals in labor at the hospital.

“Our practice and protocols are evidence-based. We have a Birth Center attached to our office space where the midwives are the primary caregivers. All the physicians are able to serve as consultants and assistants in the Birth Center, but they’re rarely needed. The physicians manage the hospital patients, which include low- to high-risk pregnancies. Our midwives also work at the hospital so they can help provide patient care there as well, but because of the high risks during the delivery, the midwives can’t manage twins in labor.

“As employees of the practice, our work doesn’t determine our income. As a general rule, this means that we’re comfortable allowing our care to be patient-centered, not focused on completing tasks or deliveries for billing before we leave for the day.”

 

More women are fighting for the birth experience they want

Jessica Finley was so adamant that she would give birth to her twins naturally that she traveled from Denver to LA to have them delivered by an obstetrician who was experienced in vaginal twin births.

“I had a complete meltdown when I found out about the laws and regulations of Colorado twin birth,” she says. “Not only do mamas have to deliver in a hospital, but in the O.R. with a team of people waiting to give you a C-section. It’s completely ridiculous. I found my doctor online and he said that if I was willing to birth in LA, he would be happy to see me. So my daughter, husband and I traveled to LA when I was 35 weeks, and I ended up having a home birth at 39 weeks and 5 days.

“My second son Devon was footling breech [the feet are born first instead of the pelvis], so his birth was a bit more difficult than Miles’, but had I been in a hospital there’s no way I would have avoided a C-section. Plus, I had the freedom to get up and move and birth in whatever position felt good to me at that time. I would definitely choose to do a home birth again.”

 

How to find an obstetrician who is experienced in vaginal twin birth

Dr. Mirto has a few pointers for women who want to deliver their twins the good old-fashioned way.

“You’ll usually have more success finding a physician willing to support your choice by seeking one who works at a medical center or a teaching hospital [rather than a regular hospital],” she says.

This is particularly true if you want to attempt a drug-free birth. “While a completely drug-free twin birth in a hospital setting is possible [if both babies are presenting head-first], many obstetricians will encourage their patients to have an epidural for pain management due to the possible need for breech delivery or cesarean delivery for the second twin.”

Dr. Mirto also suggests seeking information from twin parent groups about their experience with local physicians. Once you’ve found an obstetrician you think might fit the bill, make an appointment and ask all the questions you want before making a final decision.

“Be sure to ask if they’re experienced and comfortable with vaginal twin deliveries, how often they have successful vaginal twin deliveries, and whether the physicians they share call coverage with also support and perform twin vaginal deliveries,” says Dr. Mirto. “You should also ask under what conditions the provider would recommend a cesarean delivery.”