Caesarean section birth – first babies, twin girls.

It quickly became obvious to me that my birth story is part of a trilogy that begins with my pregnancy, continues with the birth and goes on to the saga of early breastfeeding.

Part I – Pregnancy

I learned I was expecting twins early. I had a scan at seven and a half weeks and the gynaecologist said, “There’s two”, and I replied, “I was expecting that”, thinking he meant the two fibrial cysts that had been among the difficulties I faced in getting pregnant in the first place. Then it dawned on me that the sonographer was measuring a hazy baked bean within each sack of fluid and not the sack itself, and that meant… The shock slowly hit me.

During my pregnancy people constantly asked, “Do twins run in your family?” Initially I interpreted this as “Do twins run in your family or did you use fertility drugs?” and found it overly invasive. Later on I figured out they might be asking, “Am I in danger too?” or “Were you as surprised as I’d be?” and found it easier to answer. For the record, I had twin Great-Aunts who were probably identical, and I did use fertility treatment. At one now memorable visit to the fertility clinic I was asked flippantly, “How do you feel about quads?” Then even one pregnancy seemed so improbable that quads was an unimaginable risk. Looking back, knowing there were four developing follicles in my ovary at that time, it seems like a terrifying close shave.

I went on two overseas trips in the first couple of months of my pregnancy. My main memory of them is sleeping. At every break during a conference in Seattle I would pop up to my hotel room, set the alarm clock to wake me in 25 minutes, and be asleep in moments. In Brisbane I napped on park benches between sightseeing.

Everything I read during my pregnancy made me determined to get as close to full term as possible. I wanted the best start for my babies and I wanted to exclusively breastfeed them (more about that later). I believe sustaining pregnancy is about three things: luck, genetics, and good management. Luck was out of my control. Genetics seemed mostly on my side: I have a strong family history of singleton pregnancies going to 42 weeks. Good management was about focussing on what I could do to improve my chances. Eating well, eating lots – particularly protein. Drinking lots of water. Listening to my body. Sleeping lots – napping frequently. Reminding myself that resting earlier at home would save me from being forced to rest later in hospital.

Two books were particularly helpful regarding self-care during pregnancy: Mothering Multiples by Karen Kerkhoff Gromada (available from the La Leche League), and Holistic Midwifery Vol I by Anne Frye which I got on interloan through the Wellington City Library.

More than anything else, my advice to anyone pregnant with twins is to reduce stress, and for me that meant taking maternity leave from my high pressure job at 14 weeks. I was very tired and didn’t seem to have the kind of brain I was used to doing my job with anymore. I felt I was letting my team down. I talked to my midwife, who was very supportive of me leaving early. She talked about the increased risk of complications if I pushed myself too hard. Having a medical certificate meant I was still eligible for the usual amount of leave after the babies’ birth. I am due back 46 weeks after their due date.

I had been a support person for my sister at the birth of my niece, and attended Birth Wise antenatal classes with her, so when I first found out I was pregnant I felt terrifically well prepared – until I found out it was twins. I decided to go to Birth Wise classes again because I felt that my partner could best learn from them how to support me in being a stroppy patient.

I also chose the same group of midwives as my sister, Domino, because their positive natural birth philosophies suited me and the group’s ability to tap into one another’s experience appealed. I wanted my midwife as LMC but I was advised I would need an obstetrician, and I chose to go private with a particular obstetrician who would only take me if he was LMC. Nevertheless my midwife was extremely important during the pregnancy and birth. I was pleased with the combination of a natural-birth-oriented midwife and an obstetrician very experienced in delivering twins. I had alternate visits with each.

Part II – The Birth

I was due on February 16th. Throughout my pregnancy I told everyone, “They’re not allowed out until February.” It was my mantra against premature labour, my answer to all the many people who told me twins are always early, and my best maternal advice to the two inside.

On January 26th I had the first sign that the birth was approaching – a pink watery discharge and some very tiny red clots. Fortunately my waters weren’t breaking, but it was an unusual ‘show’. Unfortunately blood tests showed my liver was no longer coping so well. I had slightly raised ALT levels although not so high they were a definite problem. The obstetrician talked to me about induction but we settled on monitoring in hospital every other morning. The ‘show’ continued and I had some definite contractions which petered out at night.

Then at 5pm on January 31st  I looked in the mirror and thought, “It’s going to be tonight.” I promptly ignored my intuition. But I started to take it more seriously as the evening went on. As the contractions got stronger I found that I was most comfortable sitting very upright on the sofa pushing my back very hard against a cushion. (Later this position made the drive to hospital much easier than I expected). I closed my eyes to ride the contractions and held my partner’s hand to stay anchored. The wind raging outside seemed the perfect accompaniment to something so natural and primal.

At 1am I was 4cm dilated with bulging membranes and the first baby seemed correctly positioned. I felt very successful. At 3am I felt ready to go and get settled in hospital. Delivery Suite at Wellington Women’s was quite full so they put us straight in a theatre. Another disappointment followed as my obstetrician advised against a bath – something I’d been looking forward to. I found it frustrating that the midwife talked to the obstetrician on the phone and I couldn’t argue with him.

Through the night my labour progressed slowly. My sister says I slept between contractions, but I only remember holding Damon’s hand and thinking that it was amazing it still worked as my anchor even though he was dozing. Meanwhile my sister was trying to keep monitoring two separate heartbeats with all her determination and focus.

In the morning dilation paused at about 7cm. I agreed to the rupture of the membranes of the first baby – lots of nice clear fluid but no change in my labour. No progress so I agreed to having a gradually increasing dose of syntocinon to increase the strength of the contractions, but no epidural. By 1pm I’d been on the highest dose of syntocinon for an hour. The contractions were very intense but I still felt able to cope with each one without pain relief. However, an exam showed that although I’d reached 9cm my cervix was now a thick rim as the first baby was facing my front and not providing the even pressure I needed.

The obstetrician told me he advised a caesarean and I remember collecting every ounce of composure I had to ask calmly, “What are the alternatives?” In this surreal situation with my body still intent on each crashing wave I still demanded to make my own informed choice.

For me what tipped the balance was the safety of the second baby – I might have been prepared to continue a difficult anterior birth for a singleton (like my own birth) but then that would mean a dangerous delay for the second baby.

The next hour was the roughest of my life – the syntocinon was off but my body didn’t know the labour wasn’t needed. From welcoming each contraction as a move toward birth, now they were unnecessary. I now tried (as unsuccessfully as you can imagine) to ignore them and sort my head out. I had put everything I had into it and it hadn’t been enough. My sister reminded me of the three things I’d written at the end of the birth plan:

“No plan survives contact with the enemy.”

“The birth is not the important thing; the family it creates is.”

“All mothers are heroes; it is not necessary to be the most heroic, there are no medals.”

The caesarean was a whirl and I was euphoric when the babies arrived. Two big girls: Heather first (7lb 2oz), and then Kay (7lb 11oz). They were so beautiful. In recovery I just wanted to hold them both against me. The recovery midwife was worried I was too tired to be safe with them. I cuddled them and fed them and couldn’t bear to give them back.

Part III – Beginning Breastfeeding

I was extremely confident about breastfeeding. My mother and sister had both breastfed successfully with ample milk supplies. While I was pregnant, I'd read about breastfeeding, been to a couple of La Leche League meetings and talked to Maggie Morgan, the Wellington Hospital Lactation Consultant. Whenever I read that most women can fully breastfeed their babies I took it for granted that I would be able to. I knew that many (some say most) breastfeeding problems can be resolved through correct latching, good support and persistence.

Things started well. The babies latched on in recovery and were eager to feed. A couple of days later however things weren’t looking so good. Heather and Kay were very unsettled and they suckled constantly but I didn’t seem to have much colostrum. I kept hoping that everything would be okay when my milk came in. It started to sink in that a caesarean or a difficult birth can delay that.

Three days after the birth, no milk yet and only minute amounts of colostrum. Both babies had lost more than ten percent of their birth weight and were very hungry. I didn’t want them to have formula and after discussions with my midwife, Maggie Morgan and a paediatrician, we agreed to “top up” using a lactated-like arrangement with my sister’s expressed breast milk. So my sister, who was breastfeeding my one year old niece, starting pumping for my twins. It was a tremendous gift. She pumped at the hospital and at home, her husband delivered milk at all hours.

Still at the hospital that night we got the midwife from hell. At 3am she decided to start an argument about our decision making and independence. We requested not to have her again and when I made sufficient fuss this happened (it helped that what she had written in my notes backed up our complaints). I think they save them for the night shift when you’re at your lowest ebb.

Next day I vomited and continued to be nauseous for a few days. After some trial and error I discovered I could only eat dairy products and bland stuff I couldn’t smell (e.g. white bread).

Day 6, finally, MILK. I was over the moon and convinced that it was only a matter of following the advice to increase my supply. But when I gradually stopped supplementing, my babies stopped growing. I fed almost constantly. I even slept propped up so I could sleep while tandem feeding through the night. My milk supply simply could not meet the demand even following all the advice available to increase it.

There have been some case studies published that suggest that insufficient milk supply can be a symptom of Polycystic Ovarian Syndrome (PCOS) which was one of my barriers to conception in the first place.

Heather and Kay were exclusively breast milk-fed until they were 15 days old. Nine months on they are still primarily breastfed, I top-up three feeds a day with about 75ml of formula and they are also on solids. This is an impressive success given the problems we faced but it still looks like failure when they are sucking on a bottle.

The hardest thing to deal with was the grief I experienced. For months thinking about feeding would make me cry. Writing that my babies were hungry tears at my heart. I will never know if I should have done things differently. Breastfeeding IS best and sometimes it takes persistence to get it established. If I had formula fed earlier or topped up more maybe I would never have established as much supply as I have.

I found it hard to get good information about mixed feeding. The La Leche League is focussed on exclusive breastfeeding and can seem to have the perspective that any formula feeding will inevitably lead to early complete weaning. This misses an important message – if you do mixed feed the more breast milk the better. The women I know with twins of similar age are all mixed feeding but all of us do it differently for a variety of different reasons.

The best advice I can give about breastfeeding is to keep trying, get as much help from family as you can and talk to a lactation consultant if you have a problem. The lactation consultants at the Plunket Family Centre are available free or you can contact Maggie Morgan through the hospital. There are also private lactation consultants who will come to your home. The La Leche League can provide a friendly ear. Support from my partner and family has helped me more than I can say.

Birth Wise