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Twins and breech presentation

Women expecting twins have some additional things to consider when thinking about birth choices, including the position and size of the babies and whether to have a planned caesarean. In twin pregnancies it is common for one or both babies to be in breech position (bottom first rather than head first).

One mother had expected to have a caesarean because both babies were breech, but her latest scan showed one had turned. She had to reconsider whether to try a vaginal delivery. In her area special antenatal classes had been run for people expecting twins, and she would have liked to attend, but the person running them had left.

 

She was expecting a caesarean because both her twins were breech, but now one has turned and she...

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Age at interview: 38
Sex: Female
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So what are your plans for birth at the moment? You said you'd moved away from the caesarean as a kind of..?

Well, I had always assumed that I would have a caesarean, really. And so I was quite shocked when the last scan was that the baby had turned round. And that was quite alarming really, because I hadn't psychologically prepared myself yet [laughs] for a natural birth. But, and again I'd sort of taken the approach that, that whatever, I didn't have a sort of particularly strong view against a caesarean or in favour of a caesarean. But that the reality was that however the babies were going to be placed, that was going to dictate what it was. There was nothing I could do about it. But I had in the back of my mind always thought because it was twins that I probably would have a caesarean. So I've had to sort of re-think now, and get my head around the idea that it's not. And that's kind of quite a difficult thing, because the advice that the consultant's given me now is that a vaginal delivery would be, would be fine even if the second baby is breech, so long as the first one's head down. 

But that I should have an epidural, because there are, there's likely to be intervention with the second baby, either to turn her if she's not the right way or to, if she's going to be born breech they'll have to have, they usually have a forceps delivery. And so that all sounds a bit horrendous, but again I'm going for an, to see the consultant next week on Monday, where we'll get a better idea. Although ironically having had all of these scans up until now, she said that I don't need to have another one, which would seem like, now I feel very indignant about it because I've got used to having them. And at this crucial stage she's telling me I don't need to know how they are and what they're growing like and everything. 

Because the information they give you is obviously again to say that they're, that everything's going fine, but they also can tell you how much they weigh, which is quite a sort of factor with twins because of the risk that they might be small. And so I'll feel that when I go on Monday I'm going to say, 'You know you said I don't need a scan - can I have one?' [Laughs] Just to, just to see how they are. But, yeah.

Right, so all a bit up in the air at the moment.

Yeah, up in the air, that's the best way to describe it.

Has that made it difficult to kind of discuss like in antenatal classes with other parents what you might do, knowing that you've got these special circumstances?

Not really, no. Well, I mean, I suppose I've only, I've been to two classes and I also went to yoga, one session of yoga, antenatal yoga, where we had a lot of discussion about what was what, and up until, and all of that was before the baby had turned. So I've always had the discussions with people on the basis that I was assuming I'd probably have a caesarean. And most people that I've spoken to are very, are keen to have a natural birth, whereas I've been much more ambivalent, so. And especially in the yoga class, the teacher there was very keen to sort of, to be saying, 'You know, you don't need to be too anxious about births, and they do have successful twin deliveries at the hospital', and she was aware of people who'd recently had twins there without any difficulty.

 

There used to be special antenatal classes locally for women expecting twins, but the person...

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Age at interview: 38
Sex: Female
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And I was surprised at the extent to which there isn't really very extensive provision of antenatal classes. Because I had thought that you would go to classes for quite a long time, and that would be your opportunity to meet other mums and things like that, because having, I mean, working full time, I don't know a lot of local people in that kind of way. And I certainly don't know many people who live locally with children. But it seems that quite a lot of antenatal classes don't take place. And they don't have the staff to run them and they've had no specific availability of any antenatal classes about twins, because the person that they had, has gone, is not there anymore who was doing twins. And I think that's a bit of a shame. I think that that does mean that there is more of a gulf for me in terms of it being a medical process, as opposed to something more sort of normal and part of, just part of your life, because there's quite a gap. 

Another mother had two terminations because of a serious genetic abnormality and then conceived twins using pre-implantation genetic diagnosis and IVF. The safety of the babies was more important to her than whether or not she had a natural birth. She went into labour four weeks early, and had a caesarean when the first baby got stuck and the second baby's heart rate started to slow down. She was offered forceps for the first baby but the second would have needed a caesarean anyway.

 

She discussed birth choices with her doctor for her IVF twins. Their safety was the most...

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Age at interview: 37
Sex: Female
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They were born by caesarean because there were difficulties with the labour. I had considered an elective caesarean and had discussed this at length with my doctor. She had been very supportive of that because I'd had such a very poor, it says 'POOR OBSTETRIC HISTORY' in capital letters on the front of my file, I saw it at the hospital. And, which was good because it made people read my file, because the number of times nobody has read your file and you have to explain everything to them is quite frustrating. But she had said she would quite willingly book me in because I was, I had effectively had a labour and had a dead baby and I, at the back of my mind was the thought that that could happen again. And I think also I know caesareans carry their own risk with them, but it seemed a medical intervention risk rather than letting nature take its course. And letting nature take its course hadn't got me very far, and medical intervention had got me to the point where I was going to have healthy babies. So she was quite willing to do that but made the point that twins quite often come early. That she would not book in an elective caesarean a month prior to delivery date, she wasn't prepared to do that which, she said there's no point in taking them out before they're ready. But it, they made it very clear in my notes that, that there was to be no risk taken and at the end of the day I wanted a healthy baby, well, two healthy babies.

 

She went into labour early and had both babies by emergency caesarean. She did not like the sound...

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Age at interview: 37
Sex: Female
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I went into labour and my daughter, her head became stuck and couldn't get her out, and while her head was stuck my son's heartbeat went into, it would, it kept going up and down...

So the delivery was by caesarean section and was very efficient. The doctor came to me at 11'30 and said, he actually gave me the option. He said, 'Could you,' one of them could be born vaginally but that would have to be with ventouse or with those horrible big metal stretchy..

Forceps?

Forceps, that's it, forceps. And, no, I'd seen those, they'd shown me those at an NCT lecture. They'd shown me forceps and I just thought, no, that's not good, don't really want that. And the other one would have to be born by caesarean anyway, and to be honest, to be messed about in both areas seemed a bit unnecessary. So it was decided to do a caesarean. That was 11'35. I remember looking at the clock and my daughter was born at 12'00 lunchtime and my son was born at 12'02. And they were reasonable sizes, my daughter was 4lbs 10, my son was 5lbs 10.

When a single baby is breech, doctors may wait to see if turns spontaneously or may try to turn it, using external cephalic version (ECV). If the baby remains in breech position, women may be offered a choice between trying a vaginal birth or having a planned caesarean, but most women are advised to have a caesarean, as evidence suggests this is safer for the baby.

 

An obstetrician turned the baby from breech position to head down using external cephalic version.

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Age at interview: 33
Sex: Female
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Okay this is your second pregnancy isn't it? 

Mm hmm.

Do you want to tell me a little bit about the first pregnancy and delivery? 

Right. The first pregnancy was fine, actually. I mean, it was through the summer so it was quite hot and I was quite large. It was always going to be a big baby so, you know, I felt really quite sort of encumbered by it, but it was fine. I had slightly high blood pressure, but nothing out of the ordinary. And then at about thirty weeks it was discovered that the baby was breech so then there was quite a lot of anxiety because I desperately didn't want to have a caesarean, and I knew that was sort of the natural outcome of having a breech baby, so I did lots of things to try and turn the baby myself, like lots of scrubbing floors and lots of exercises. And as it got closer and closer to the due date I spent quite a lot of money seeing lots of people like acupuncturists and chiropractors and people like that, who all thought they could do something to move the baby, but nothing happened. And then we had an ECV treatment at the hospital and that was successful, and that was very straightforward.

Tell me about the ECV?

It was basically where, it was all, it was quite straightforward. The obstetrician just literally put her hands on my tummy and moved the baby round like this.

What does ECV stand for?

It stands for I think it stands for external cephalic version, I think. Meaning it's a turning of the baby from, from outside. And it was quite manual, we were in the delivery suite and I was all hooked up and things so it seemed it was, that was sort of hi-tech but the actual procedure itself was just literally the hands of the obstetrician, that was it. And she managed to move the baby round.

One mother was advised that ECV in late pregnancy could cause the placenta to separate from the uterus (placental abruption), so she had a caesarean. (The most recent evidence-based guidance is that in the hands of appropriately trained professionals ECV is a safe procedure). During the operation the baby's position caused some problems, but it was generally a good experience.

 
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She had a planned caesarean because her baby was breech and she was told it was risky to turn the...

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Age at interview: 29
Sex: Female
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We'd gone into the hospital for your 34 week appointment and after the midwife had felt my stomach she decided that the baby was lying breech, which basically means that its bottom's down instead of its head being down. And she decided that it would be advisable to have a scan just to confirm it, because sometimes they can get it wrong. Apparently the bottom and the head both feel the same. So we went for a scan and it was confirmed that my daughter was lying breech and she also had her legs extended, which kind of means that her legs were up beside her ears as well as her bottom being down. And it wasn't recommended that they try to turn her, but what they did was, they actually brought me back 2 weeks later and scanned me again just to see if she'd turned naturally. And it wasn't until at that point they then said that really it would have to be a section that I would have, and a date was arranged for the section. And they left it until 4 days before my due date to book me in for the section because they obviously want to let you go as far as possible to reduce any risk to the baby, so.

How did you feel when they said that you wouldn't be able to have a natural delivery?

I was a bit disappointed. My initial reaction was kind of disappointment because you've built yourself up over the past 9 months for this, you know, big event and the delivery, but at the end of the day, my husband and I spoke about it, really the safe arrival of a baby is the ultimate and that was what was most important to us. And you just have to sort of change your views about your delivery and go for what's been advised by the medical staff, as they know best and they're delivering so many babies a year. And therefore we kind of just relied on their opinion to help us along. But they do sort of tell you all about your birthing plan and everything else and I was just going, [laughing] my birthing plan was very short in that it was to be a section and that was the end of it. So yeah.

When they discovered that your baby was breech, did they give you a choice about what to do or did they say, 'Look, you have to have a C-section'?

Right, the, the medical profession advised that I had the C-section because it would be very difficult to turn a baby that late into pregnancy and the risks that were involved in it then. They said that they recommended that the section would be the best option for us both.

What did they say the risks were of trying to turn the baby?

The risks involved in trying to turn the baby that late into pregnancy are that your placenta, I think it's called 'abrupts' or something, and it can cause the baby to die that late into your pregnancy. And it can also cause the Mum to be very ill and involves the Mum, in a lot of cases, having to have a blood transfusion because she loses so much blood. I, I assume that it would probably be a ruptured placenta that it would cause. So, yes, I decided not to opt for that because the risks involved were just too, too high to both of us and went with the medical professional man and opted for the C-section.
 
 
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During the caesarean the baby's position caused some problems, but it was generally a good...

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Age at interview: 29
Sex: Female
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I was booked in for the, the C-section and we went along and my husband actually got to be in the operating theatre with me, which was quite nice in that he was there for the birth, because it had been something if I'd had a natural birth that was quite important to us, that he was there as well. So he got to come along too, and my daughter was, was born on, in the afternoon. It took them quite a long time to actually get her out, just because of the way that she was lying. Her head was trapped under my diaphragm which was, [laughing] seems a bit strange. She came out with two nice big lines on the back of her head,  which quickly disappeared. But yeah, that was, everything went fine. And the surgeon was very nice and everybody certainly involved in the operation, for such a - I think what surprised us most was, I mean, it's a major operation. I think a lot of people forget just how big an operation it is and, you know, there was kind of eleven people all involved in the operation in this theatre, but they actually kept it quite informal, which was quite nice. You know, it wasn't all sort of medical talk and things like that. They made you sort of feel like a human being as opposed to just a number which was, it was nice, yeah.
 

In some cases the baby's position becomes apparent only during labour. One mother had an emergency caesarean when this happened, because doctors thought her pelvis would be too small to allow a vaginal birth.

 

During her first labour it was discovered the baby was breech. She was advised her pelvis was too...

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Age at interview: 30
Sex: Female
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I went in on the Monday and I had to have a heart trace of the baby, and they said, “Oh, can you go up to the delivery suite, please?” So I went up to the delivery suite and I went up there, I stayed there until 5 o'clock in the morning and then they said, “Oh, it's fine, you know, you haven't started your labour, so we'll keep you in.” Sent my husband home at 5 o'clock in the morning and then he came to pick me up the next day. And then they told me to come back on the Wednesday for another heart trace; came back on the Wednesday, they sent me back up to delivery and then they then started me off because - which I didn't know at the time, I only knew when I was 8cms dilated - that the baby had been in distress on the Monday and on the Wednesday. And then when I was 8cms dilated they realised that my daughter was coming out bum first, breech, double breech instead of her head, obviously. The surgeon came in to see me, asked me what size shoe I was, so..

What size shoe?

Shoe, because apparently your shoe size is the size of your pelvis.

Is that true?

Yes. And because I was only size 3, anyone who's a size 5 and above could bring a breech baby. Anyone who's below has to have a section and I was a, only a 3, a size 3, so I've only got little feet. And I went in, I got, he done like a scan and showed me, you know, that it was bum and everything. But she was breech at 5 months and I did try to tell them quite a few times that she hadn't turned round but, you know, according to the midwife and everyone else she had, you know, but she didn't. I went in, I had an epidural, which was fine, because I was sitting talking to my husband while I was getting it done. It was quite strange, it quite surreal, actually, lying there talking to my husband while, you know, obviously they'd cut me open and what have you and then woke up in recovery. I was okay the next day, I wasn't too bad, but it was, she was, she was great and I was great. We went home 3 days later, the midwife came out to visit us, took the stitches out after so many days and she was perfectly fine.

Guidelines on caring for women with a baby in breech position can be found on the Royal College of Obstetricians and Gynaecologists website (See also 'Looking back - caesarean birth').

For further links see our pregnancy resources.

Last reviewed May 2017.
Last updated August 2010.

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