Empowered Birthing: A Doula’s Perspective on Supporting a Vaginal Twin Birth

Thanks to Nurturing Birth doula Sally Carter, who shares her experience of supporting a vaginal twin birth with us...

The decision to work with a doula is made for many different, often personal, reasons. However, ultimately, it is more often about ‘stacking the odds in your favor’ by ensuring that you can benefit from the type of person-centered, empathetic, independent, non-medical, continuity of care that only a doula can bring.

This was especially true of clients I supported earlier this year through the pregnancy, birth & immediate postpartum experience of welcoming twins!

For reasons I won’t go into, this pregnancy had already been labeled ‘high risk’ even before it was discovered to be a twin pregnancy. For these other reasons this couple had decided long before conception that they would like to work with a doula & we had therefore met & discussed all this, when they decided to start planning for another baby.

In planning & preparing for this pregnancy the client had decided they would like to plan for homebirth. She had also recently been diagnosed with ADHD & was now able to recognise that staying in her own environment where she would feel safe & in control, as well as be able to better manage her anxiety & sensory needs, would have a really positive impact on her overall experience of birth this time around & could help to avoid a traumatic birth.

It was unsurprising then, to be contacted early into the pregnancy & asked to officially be their doula. It was at this point that they had just discovered they were expecting surprise twins - this came as a massive shock & really was quite the curveball to get their heads around, especially as they both had quite different reactions to the news & understandably needed time & support to process this.

We were fortunate that we already knew one another & had started to build a relationship, so they felt confident in reaching out to me early for emotional support. I was able to meet with them (remotely on this occasion) & use my active listening skills & core conditions of counseling to create a safe non-judgmental space where they could both talk openly about their thoughts, feelings & concerns. I was then able to signpost them on to other services & resources that could also help them, which included, at that time a local trusted Independent Midwife.

One of the potential benefits of hiring a doula earlier on in pregnancy is that the client(s) have access to the doula’s support, knowledge, signposting, etc… sooner & for longer. I, like many doulas, am more than happy for expectant parents to pay me via an agreed payment plan, so again, the earlier you hire me the longer period of time you have to spread those payments, making the financial cost of having a doula much more affordable too.

Pretty much as soon as it was discovered to be a twin pregnancy everything had changed. As far as the hospital were concerned a potentially already high-risk pregnancy was now definitely considered as such: they would need to be seen by the Fetal Medicine Team; The Twin Consultant; & of course these babies would be born early & on labour ward. If by some miracle they avoided premature birth then labour would be induced at 37 weeks. Oh and if twin 1 isn’t head down at 36 weeks they would be booked for a cesarean!

There was no discussion, no question of what the parents would like, or even any real evidence-based reasoning or explanation as to why things should happen this way: simply, “this is the way we manage twin pregnancies & ‘deliveries’.” (NB: Pizzas are delivered, babies are born!)

That was it - goodbye homebirth, goodbye pool… at this particular hospital they even transfer you to the operating theatre for the second stage of labour (‘pushing’), ‘just in case’...

I don’t know about you, but that sounds far from the relaxing, oxytocin filled environment we know to be most conducive with physiological labour!?

Why? What is it that makes the birth of twins need to be a much more medicalised event?

In these early months of our doula relationship there was a LOT of emotional & informational support as I helped them to navigate the medical system as a whole, as well as the particular policies & procedures at this hospital. When every medical appointment feels like a fight, where you feel belittled & spoken down too, treated as if you have no autonomy or are foolish & reckless to want to go against what the Doctors think you should do, it’s so hard to hold your own & not let this affect you. The amount of pressure & negativity my clients faced during this time, purely because they wanted to try & achieve a physiological birth experience supported by midwives only, was immense, & meant that Mum in particular found managing her stress levels & mental health even more difficult!

However, researching together & separately, they learned how to make themselves heard. They asked questions & challenged the path being set out for them by the obstetric team. It soon became clear that when it comes to twin/multiple birth in particular, there is a considerable lack of specific data/research. The evidence that was being shared with them was all based on singleton births & the assumption that having more than one baby made things ‘higher risk’ & often even that evidence was being mis-quoted or misinterpreted… The hospital policies seem to all have been written with a fear of litigation being the driving force, e.g. we’d better over medicalise & be in control of everything, so that, should the worst happen, we can say we did everything we possibly could to ‘save’ this parent &/or baby(ies). But this approach completely disregards the woman or birthing person’s autonomy, overall experience, recovery & mental health.

How is anyone supposed, not only to recover fully, but also be able to respond to & parent a child well, if they have been traumatised by their birthing experience?

The clients realised that a home birth could still be an option & they began reaching out to specific hospital staff to have conversations about having their wishes taken into consideration to broaden their birthing options. I supported them at meetings with Consultant Midwives & things slowly began to change & feel more positive. In fact, the response from the midwives we went on to work with was really positive. With the support of one particular Consultant Midwife they were able to move forward with a birth plan that they felt comfortable with & confident in!

Initially, this was to plan for a home birth, supported by a selected team of midwives who all felt confident in supporting a physiological twin home birth. The twins were the most common & least risky type of twins: DCDA or DiDi twins, which basically means they were two separate embryos, each with their own placenta & amniotic sac. Twin 1 was head down & twin 2 was breech; this is common & something everyone was aware of & prepared for.

As the pregnancy progressed Mum was able to manage & minimise her other ‘risk’ factors, but each step of the journey felt like an up-hill battle. One where she often felt unheard & consultants generally only wanted to focus on & re-hash all the perceived risks of birthing twins, rather than supporting her wishes for physiological birth. Given my client's ADHD, & the way she was being made to feel by (not all, but many) healthcare professionals, her anxiety was steadily increasing. To make things even more interesting the family also moved house too! The house move was a positive & went well, however, the house also needed work done to it (& I don’t just mean re-decorating).

The combination of all of these things began to weigh heavy & the client decided to talk to her midwife about the possibility of birthing on the midwife led unit in the hospital instead of at home. Unsurprisingly she did not meet the usual criteria for being able to access this unit but the consultant midwife & team helped to advocate for this & given a team was already in place to be ‘on-call’ anyway, then it was agreed that this would now be the plan (with a low tolerance for transfer to labour ward.) Meanwhile we continued to prepare for birth in all the usual ways, with me visiting them to refresh hypnobirthing techniques, share books, signpost them to other resources & discuss the practicalities of the birth & how Mum would like me to support & care for her & her partner on the day. What this couple really needed from me, as their doula, was emotional support & the belief that she could birth these babies on her terms.

In the later stages of pregnancy there was a new development. Although twin 2 was now head down, twin 1, was now breech; this change had the potential to completely derail my clients plans & a labour ward birth was now looking inevitable.

I guess, unsurprisingly, this particular hospital have also completely over-medicalised breech birth too - to the point where, if you are identified as having a breech baby after a certain point of gestation, you are presented with two options: 1) An ECV (stands for External Cephalic Version & contraindicated (not advised) in a twin pregnancy) where a doctor uses external pressure on the fetus to physically force them to turn head down in the womb; or 2) An elective cesarean (an operative birth, usually early, around 37/38 weeks to avoid labour). If you choose option one, but it is unsuccessful, then you will be booked in for a cesarean.

Unfortunately, just another example of how the ‘system’ is designed by fear & the idea that being ‘proactive’ by intervening to keep both parent & baby alive is the gold standard of care, rather than the baseline.

Anyway, once again, this meant that my client would have to fight for her autonomy & right to birth the way she wanted. As was the theme of this pregnancy, much research was done, many discussions were had, questions asked & processes challenged! Both she & I contacted Birthrights for some advice, & meanwhile she tried ALL the ‘tricks in the book’ to try & get twin 1 to turn: spinning babies exercises; treatment with a chiropractor; moxibustion etc... If twin 1 didn’t turn back head down then the hospital would withdraw the option of giving birth on the midwifery led unit. Leaving their options as: go back to pushing for a homebirth (which would potentially be an even BIGGER fight now) & one which my client had now decided wasn’t what she wanted; or give birth on labour ward.

Mum & I then had a long conversation about why the baby might be in that position & did it really matter…? She was finding it stressful, focusing so much time & energy on trying to get the baby to turn, who was she doing this for? Then she began to consider; what if this is the way the baby needed to be? Maybe there was a reason? After all, breech is simply a variation of the ‘norm,’ not a medical emergency. What if she trusted her body to be able to bring the baby safely skin-side, even if they were bum first!? So, she decided to lean into the experience, trust & focus on things that were within her circle of control: creating a positive mindset & looking forward to welcoming her babies, by utilising hypnobirthing techniques such as affirmations & grounding & visualisations.  

In the end, after speaking with the consultant midwife again, Mum was happy to make one compromise, which was to give birth on the labour ward of the hospital. She still intended to wait for spontaneous labour & wanted to be supported by the same team of midwives that had already agreed to be on-call for her, have access to the birth pool, & to aim for a physiological, vaginal birth for her babies.

At 37+5 Mum went into spontaneous labour. It was nighttime, so she tried to sleep. She managed ‘some’ rest, but after her waters broke in the wee small hours & contractions were consistent & building from the start, it wasn’t long before we were heading to the hospital.

I’m not going to share the details of my clients birth story with you: they are not mine to tell. But I will say it was one of the most awe-inspiring, amazing experiences of my doula career!

Supported by the pre-selected midwifery team (most of whom she knew), her partner & I - Mum advocated for herself, laboured & birthed successfully (& really quite quickly) in the right way for her. The babies arrived into this world, twin 1 - breech, swiftly followed by twin 2 - head down & had a physiological 3rd stage, followed by immediate & extensive skin-2-skin.

It was the most perfect juxtaposition of normal, natural, vaginal birth AND the most magical & powerfully positive achievement! The midwives were respectful & supportive: they helped to hold that birthing space so safely keeping the prying eyes of consultants wanting to interfere/intervene at bay & giving us, Mum’s birth-partners, space to fulfill our roles as her supporters, offering words of affirmation & encouragement, fuel for her body, massage, etc… 

I honestly felt that there was no doubt in that room: we all believed that she could birth these babies on her terms & she did. Two happy, healthy babies, both a good weight & not needing any support or interventions.

In the hours following the birth the family were quite the celebrities. They had many visitors that afternoon as everyone wanted to see the woman who had completely spontaneously & physiologically birthed her twins - especially as twin 1 was breech.

It was my honor & absolute privilege to support & bear witness to someone stepping into & owning their power. Someone, who understood & believed in the process of physiological birth & a demonstration of informed decision making at its best.

Sally x

(aka: DoulaSlingSally)
www.sally.solentparenting.co.uk