Twin home birth: Outcomes of 100 sets of twins in the care of a single practitioner

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This study evaluates the outcomes of twin pregnancies entering care with a single practitioner in a community setting. Methods: This is a retrospective observational cohort study of 100 consecutive twin pregnancies planning community births during 12 years with a single obstetrician. Outcomes measured included mode of delivery; birth weights; Apgar scores; ante-, intra-, and post-partum transports; perineal integrity; delivery interval; blood loss; chorionicity; weight concordance; and other maternal or neonatal morbidity. Results: Of the 100 twin pregnancies who entered into care, 31 (31%) transferred to a hospital-based clinician prior to labor. The remaining 69 sets of twins were still in the obstetrician’s care at the onset of labor. Of those 69 pregnancies, 79.7% (n=55) were di-amniotic-di-chorionic and 21.3% (n=14) were mono-di. The vaginal delivery rate was 91.3% (n=63) including 16/21 primips/TOLACs (76.2%) and 47/48 multips (97.9%); 6 mothers (8.7%) had in-labor cesareans (1 multip and 5 primips). Rates of vaginal delivery did not vary significantly by chorionicity; 91.4% (53/58) of di-di and 90.9% (10/11) of mono-di twins gave birth vaginally. There were 8 transports in labor (11.6%) with 2 birthing vaginally and 6 via cesarean. Average gestational age was 39.0 weeks (range 35-42). Compared to primiparas, multiparas had less perineal trauma and higher rates of community, vaginal, and spontaneous vaginal birth. One twin infant and one mother required postpartum hospital transport. Of the babies born in a community setting, there was no serious morbidity requiring hospital treatment. Conclusions : A community birth leads to high rates of vaginal birth and good outcomes for both mothers and babies in properly selected twin pregnancies. Community twin birth with midwifery style care under specific protocol guidelines and with a skilled practitioner may be a reasonable choice for women wishing to avoid a cesarean section—especially when there is no option of a hospital vaginal birth. However, this study is underpowered to calculate uncommon adverse neonatal outcomes. Training of future practitioners in vaginal twin and breech birth skills remains an imperative. Twins Chorionicity Home birth Birth center Out-of-hospital birth Physiological birth Autonomy Informed consent vaginal breech birth breech Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Background This paper examines maternal and neonatal outcomes of a series of 100 twin pregnancies supported by an obstetrician who has been attending home births exclusively since 2010, and prior to that 24 years of hospital practice attending breeches, twins, and VBACs. His decision to attend home births was driven by breech, twin, and VBAC bans and limited options at his local hospitals. In California, midwives are not allowed to attend twin births at home or in birth centers, leaving this physician as one of the only options for a community (home or birth center) birth in the entire state with a population of 39 million people. Around 120,000 babies are born as twins every year in the US, representing 3.2% of all births [ 1 ]. As of 2013, the last year in which the data has been published, the C-section rate for twins was 74.8%, slightly lower than the 2009 peak of 75.3% [ 2 – 4 ]. With decreasing skill and experience in vaginal twin births, providers are relying more heavily on cesarean delivery [ 5 ]. However, this presents a difficult situation for women who strongly desire a vaginal birth. If there are few or no hospital options for their twins, a home birth may be their only way to avoid unwanted surgery. American women are increasingly turning to home birth for many reasons including increased comfort, lower intervention rates, greater feeling of safety, lack of acceptable hospital options, and recently, concerns over Covid-19 infection and/or Covid regulations at their local hospitals [6-101]. In the USA, home births rose 19% between 2019 and 2020, largely due to the Covid-19 pandemic and the associated hospital restrictions [ 11 ]. For women with multiple gestations, hospital options are even more restricted than for those with singleton cephalic pregnancies. Where a vaginal hospital twin birth is still possible, the process is often medicalized (common practices include induction at a set gestational age, vaginal birth in the OR, epidurals as mandatory or strongly encouraged, mother in dorsal lithotomy position, and strict time limits for delivery interval). Some women find this medicalized approach unacceptable and choose to give birth outside the medical system [ 13 – 14 ]. With ACOG contraindicating multiple births at home and some state regulations forbidding community midwives from supporting twin pregnancies, the options for a vaginal birth decrease even further. Very little data exists on outcomes of twin births in a community setting. Obstetrical societies such as the ACOG list twin birth at home as contraindicated, due to (short-term) safety concerns for the neonate. However, systematic, detailed data are not available for twin home births, particularly data that take into account provider skill and experience levels, chorionicity, selection criteria, or type of presentations. The CPM 2000 study of planned home births briefly mentions 13 sets of twins with no neonatal deaths [ 15 ]. In the MANA Stats 2.0 and 4.0 data sets, there were 138 twin pregnancies intending to birth at home, representing 0.3% of births out of a total of 47,394 women planning home or birth center births [ 16 ]. This study includes more detailed information on outcomes, such as Apgar scores, NICU stays, and maternal injuries or PPH, although it still lacks information on provider skill level, chorionicity, selection criteria, gestational age, or birth weights. Of the twin pregnancies, 19.6% ended in intrapartum transfer, with an overall cesarean rate of 18.1% (indicating that most transfers ended in cesarean). Compared to planned singleton home birth, twin pregnancy was not associated with higher rates of neonatal transfer, perineal trauma, or neonatal death. On the other hand, twin pregnancy was associated with higher rates of intrapartum transfer and maternal or neonatal hospitalization (modest); of postpartum transfer, cesarean section, low 5-minute Apgars, and NICU admission (elevated); and of very low 5-minute Apgars (substantially elevated)—again, compared to planned singleton home birth. A small number of studies outside the USA mention twin community births, but with few details about the pregnancies or about the outcomes. Bastian et al [ 17 ] analyzed self-reported data on home births in Australia and reported a perinatal mortality rate of 1:7 for the twin births. This study did not note how many twin pregnancies were included in the data. A few other studies looking at the role of “high-risk” home births (including multiple gestations) have found an increased rate of adverse outcomes in the high-risk groups, but the role of twins was not parsed out separately [ 18 – 20 ]. A PhD dissertation examining more than a half-million home and hospital births in the UK’s SMMIS registry from 1988–2000 found no cases of perinatal mortality among the planned twin home births; there were 13,263 multiple pregnancies overall in the SMMIS registries, of which some (likely a small percentage at most) were planned home births [ 21 ]. There is a wide disparity between evidence and practice regarding mode of birth for twin presentations [ 22 – 23 ]. A large body of hospital-based research indicates that there is no benefit to routine cesarean section for twins, regardless of whether twin A or B is cephalic or breech. The 2013 Twin Birth Study was a randomized controlled trial comparing planned vaginal birth with planned CS for cephalic-first “low-risk” twins, enrolling 2804 women in 106 centers between 32 + 0 and 38 + 6 weeks’ gestation. It likewise found no benefit to planned cesarean section [ 24 ]. A large prospective observational study of twin birth outcomes in France and Belgium, called JUMODA, found no benefit to cesarean for cephalic first twins [ 25 ]. JUMODA was designed with identical exclusion criteria as the Twin Birth Study to enable cross-comparison of a low-risk population. (JUMODA is a sister study to PREMODA, which examined outcomes of singleton breech births in maternity centers in France and Belgium and found no benefit to planned cesarean section for breech presentation.) A sub-analysis of the JUMODA data by Korb [ 26 ], looking at breech-first twins, found no benefit to cesarean for those presentation, echoing similar findings by Blickstein, Goldman, and Kupferminc in 2000 [ 27 ], Bourtembourg et al. in 2012 [ 28 ], and Ghesquière et al. in 2022 [ 29 ]. Despite strong evidence that a planned vaginal birth should be offered and supported for most twin presentations, clinical practice in the USA and many other countries strongly favors planned cesarean section. In many places in the USA, women cannot access planned vaginal birth at all, even when both babies are cephalic. This lack of choice is difficult to overcome due to the deskilling of practitioners [ 26 , 30 ]. Given this medical and cultural context—with evidence supporting vaginal birth for most twin pregnancies, but with clinical practice, hospital protocols, and state regulations making vaginal birth either impossible or untenable for most women—we find it beneficial to analyze outcomes of planned twin births at home with a skilled, experienced practitioner. In many locations in the USA, community birth may be a woman’s only way to achieve a vaginal birth if she has twins, particularly breech-first twins. Methods This paper is a retrospective review of 100 consecutive twin mothers who entered care for a community birth with a single practitioner over a 12-year period from March 2011 to January 2023. Seven TOLACs were included in the review; a mother without a previous vaginal birth was considered a functional primipara. The women in this series were all in good health and received prenatal care with an obstetrician, a midwife, or a collaboration of both. Most of the twin clients self-selected the option of home birth at an early gestational age; they were highly motivated and experienced continuity of care throughout their pregnancies. Prenatal visits were individualized based on history, social factors such as distance, and chorionicity. Dichorionic/Diamniotic twins without concerns were seen about every 4 weeks through 28 weeks, then every 2 weeks until 35–36 weeks, and then weekly or as needed. Monochorionic/Diamniotic twins were seen more often in the second trimester for surveillance. This was again individualized but usually every 2 to 3 weeks unless more often was clinically indicated. Ultrasound surveillance was also individualized based on clinical setting and parental desire with recommendations for closer monitoring based on chorionicity and growth. The women in this review were selected and accepted to labor based on simple criteria as follows: Greater than 35 weeks gestation Di-di or mono-di chorionicity Twin A in a stable longitudinal lie Both twins growing consistently on their own growth curves with EFW of smallest twin > 2000 gm No gross anomalies or significant maternal medical issues Labor starting spontaneously Fetal and maternal tolerance to labor Right parental mindset for community-based birthing These were used as general guidelines, not as strict selection criteria. Each case was individualized per our model of care and ethical considerations. The birth team consisted of an obstetrician (SJF), two licensed midwives, one or two midwifery students, and often a birth doula. Duties were discussed ahead of time as to who had primary responsibility for Twin A, Twin B and the mother as the delivery progressed. Assistants and students were in charge of setup, cleanup, and documentation. Equipment brought to each birth included IV fluids and tubing, sterile gloves, gauze, pads, betadine, urinary catheters, suture material, and appropriate surgical instruments. The birth team also supplied an inflatable birth pool. Medications included antibiotics, lidocaine, oxytocin, misoprostol, oral methylergonovine (until it became unavailable), tranexamic acid (TXA), vitamin K, Rhogam, smelling salts, and oxygen. In this series SJF also carried a portable GE ultrasound, a Masimo pulse oximeter, handheld Doppler, a Mityvac vacuum, Piper forceps, Simpson forceps, and Tucker-McLean forceps. All licensed practitioners were certified in neonatal resuscitation and cardio-pulmonary resuscitation. Women in our cohort were not excluded for conditions that were unlikely to affect labor such as diet-controlled gestational diabetes, mild chronic hypertension, IVF pregnancy, or age over 35. The data were not analyzed prior to completion of the 100th twin birth. The midwifery model of care encourages settings where women feel “private, safe, and undisturbed” to encourage the proper release of birth hormones involved in physiological birth: oxytocin; beta-endorphin; catecholamines (adrenaline and noradrenaline), and prolactin [ 31 ]. Breech and cephalic labors were managed identically. Women were encouraged to eat and drink, ambulate, change positions, and choose their birth location and position. Women had the option of a shower and tub for labor analgesia; water birth for breech births was not the preferred mode due the higher likelihood of assistance but choice remained with the laboring woman. Fetal monitoring was performed intermittently with a Nicolet Elite 200 Handheld Doppler. Auscultation was individualized but the usual protocol practice was every 30–60 min in active labor, every 15–30 min in transition and every 5–10 min in the second stage. Vaginal exams were only done with maternal informed consent and kept to a minimum, often withheld until maternal guttural vocalizations signaled an urge to push. Portable ultrasound was used sparingly mainly to confirm position and heart rate of twin B after delivery of twin A. Pushing only began when maternal urge became irresistible; pushing was spontaneous rather than coached. Breech-first twin mothers were encouraged to labor down before active pushing began. Passage of pasty meconium was considered a positive sign of descent with a breech. Breech twin mothers were counseled about the benefits of upright and hands-off techniques. On-the-back positioning for breech was used on an as-needed basis and with maternal informed consent. Optimal cord clamping (usually done after the placenta was birthed) and immediate and uninterrupted skin-to-skin were routine. This project received approval from the University of Michigan IRB (HUM00209968). Patient informed consent to participate was waived by the IRB as this was a retrospective chart review using de-identified data. Statistical analysis was done using unpaired t-tests. Results A total of 100 women planning a community-based birth with either dichorionic-diamniotic (79%) or monochorionic-diamniotic (21%) twins entered into care with a single obstetrician over an twelve-year period from March of 2011 to January of 2023 (see Fig. 1). Antepartum transfer of care (TOC) occurred with 31 of the women. Of the antepartum women whose care was transferred to a hospital-based practice, 19.4% (6/31) were mono-di and 80.6% (25/31) were di-di. Similar to the overall percentage in the cohort. There were 4 cases of twin-twin transfusion syndrome (TTTS) diagnosed in the mono-di twins (19%) all of whom are included in the antepartum group. (See Fig. 1 and Table 1 .) Figure 1: Flowchart of 100 sets of twins Table 1 Reasons for antenatal transfer of care to a hospital-based provider Primip twins n = 19 Multip twins n = 12 > 41 weeks, NIL (not in labor) 3 Cholestasis 2 SPROM < 35 weeks 2 2 Preterm labor < 35 weeks 3 4 Gestational hypertension/preeclampsia 3 1 IUGR 1 Funic or footling prior to labor 2 2 TTTS 2 2 Non-reassuring FHT, NIL 1 Twin A breech (early in SJF’s home birth practice) 1 Total antenatal transfers 19/40 (47.5%) 12/60 (20.0%) The remaining 69 women went into spontaneous labor. Of these, 8 women (11.6%) were transported in labor, one emergently and 7 non-emergently (see Table 2 ). Of these transfers, 2 went on to deliver vaginally with a supportive hospital practitioner and the other 6 had cesarean sections. The overall cesarean section rate in the cohort planning home birth at the onset of labor was 8.7% (5 primips & 1 multip). Table 2 Indications for in-labor hospital transfer of twins Indication for transfer Primip twins (includes VBACs) n = 7 Multip twins n = 1 Arrest of active labor (> 7 cm) 2 1 (B/B) Audible decelerations in early labor 1 Maternal complaint of incisional pain (TOLAC) 1 SPROM, prolonged latent labor, maternal fatigue 3 Total in-labor transfers by parity 7/21 (33.3%) 1/48 (2.1%) Of the remaining 61 clients who delivered at their desired location, there were 14 primiparas (including first-time VBAC moms) and 47 multiparas. Vaginal delivery was achieved in 97.9% (47/48) of multiparas and 76.2% (16/21) of primiparas who entered labor, with 66.7% (14/21) of primiparas giving birth vaginally in the community setting. (See Fig. 2.) For a video of a community home birth with SJF, please see Additional File 1. Figure 2: Vaginal twin birth rates by parity For those 69 women who planned a community birth, the presentation of the twins broke down as follows in Table 3 and Fig. 3. Table 3 Type of presentations and vaginal birth rates Presentation % N Vaginal birth rate Vertex/vertex 50.7% 35 97.1% (34/35) Vertex/breech 24.6% 17 94.1% (16/17) Vertex/transverse* 4.3% 3 66.7% (2/3) Breech/vertex 14.5% 10 80% (8/10) Breech/breech 5.8% 4 75% (3/4) * One converted spontaneously to vertex/vertex after baby A, another had an IPV (internal podalic version) and breech extraction due to separation of placenta A and heavy maternal bleeding. The third transported in labor and had a cesarean section. Figure 3: Fetal presentations in twin labors Close to half of the pregnancies had at least one twin presenting breech at the onset of labor (44.9%, 31/69). Of the 35 total breech presentations, 12 were frank, 19 were complete, 3 were incomplete, and 1 was footling. Of the 11 breech-first twins that birthed vaginally, 2 (18%) required more extensive maneuvers, such as freeing entangled heads and an extraction for terminal decels. Of the 19 breech second twins that birthed vaginally (not including the transverse lie that ended with IPV and extraction), 9 required more extensive maneuvers (extraction) (47.4%). For a description of the 8 in-labor transports, please see Additional File 2. We had one TOLAC mother who began having suprapubic pain of a concerning nature at 10cm. She was transported via ambulance to a hospital, and no uterine scar dehiscence was found at repeat cesarean. She recovered without further sequelae. Timing of Delivery: Our model of care supports waiting for natural labor to occur, given the benefits of spontaneous labor and the risks of induction. We did not routinely induce twins as per ACOG guidelines [ 23 ]; instead, we provided individualized care, weighing the risks and benefits that each mother thought suited her. Mean gestational age for home twin labor was 39.0 weeks (range 35–42 weeks). See discussion section. Twin-to-twin delivery interval and estimated blood loss (EBL): Overall, the twin-to-twin interval averaged 35.1 minutes. Early in the series, the birth team practiced less active intervention and waited for the spontaneous return of labor. When a trend appeared showing that longer inter-twin interval was related to increased blood loss, we began recommending AROM (artificial rupture of membranes) after 30–45 minutes if labor had not returned. We have EBL data on 51/61 successful community births. Overall EBL average was 760.5 ml (range 150–1900). There were 16 twin mothers who had a EBL of ≥ 1000 ml (30.8%); of those 16, half had an EBL ≥ 1500 ml (15.3%). None of these women required transport or received a blood transfusion. Of the 16 mothers with an EBL of ≥ 1000 ml, we found the twin-to-twin interval to average 62 minutes (range 8-259) whereas in births with EBL < 1000 ml, the interval averaged 24.7 minutes (range 2-135). Comparing mothers with an EBL above or below 1500 ml, the average twin-to-twin interval was 24 minutes for EBL < 1500 ml (n = 43) and 85 minutes for EBL ≥ 1500 ml (n = 8). (See Fig. 4). Age, parity, total fetal weight, length of active labor or gestational age did not appear significantly related to blood loss. Figure 4: Delivery Interval and EBL Most women with excess blood loss received bimanual uterine massage, herbs, and homeopathy. In a few cases with a history of excessive blood loss, active management with IM Pitocin was given shortly after the delivery of twin B. When clinically indicated, excessive bleeding was treated with IM Pitocin, IV fluids, IV Pitocin, rectal misoprostol and occasional IV tranexamic acid infusion. Early latching was encouraged as it enhances uterine contractions. We do not have data on the length of the third stage of labor, but our practice was to wait for spontaneous separation and expulsion of the placenta unless intervention was clinically indicated (manual removal for excessive bleeding). We did not have a structured time limit for delivery of the placenta. Perineal integrity: The majority of twin mothers birthing in a community setting had no perineal lacerations, with only one 3rd-degree laceration (repaired at home). As expected, perineal lacerations are more heavily skewed towards primiparous mothers. There was also one 3rd-degree laceration among a primip who transported in labor and had a spontaneous vaginal birth for baby A and vacuum delivery for baby B. We do not have perineal outcomes for the other in-labor transport that ended in a vaginal birth. No episiotomies were performed in the community setting over a total of 122 vaginal births. See Table 4 and Figs. 5 & 6. Table 4 Perineal lacerations and parity in completed twin home births Perineum Overall n (%) Primips Multips Intact 39 (63.9%) 3 36 1st degree 17 (27.9%) 8 9 2nd degree 4 (6.6%) 3 1 3rd degree 1 (1.6%) 1 0 Figure 5: Perineal outcomes of vaginal twin births Figure 6: Perineal outcomes of vaginal twin births by parity The only maternal postpartum transport was for an eclamptic seizure which occurred about one hour postpartum. She recovered without further sequelae (see Additional File 3). Neonatal outcomes: For deliveries that occurred in the community setting, the average birth weight of twin A was 2835.5 g (n = 61, range 1814–4337). The average birth weight of twin B was 2836.8 g (n = 61, range 1644–4224). Discordance between twins averaged 11.8% (n = 95, range 0–46%). Apgar scores at 1 minute averaged 8.0 for twin A (range 3–10) and 7.0 for twin B (range 3–9); this difference was statistically significant (p = 0.0005, unpaired t-test). At 5 minutes there was no significant difference in Apgars, with twin A averaging 9.0 (range 7–10) and twin B at 8.8 (range 6–10) (p = 0.13, unpaired t-test). Cord gasses were not collected in this setting. We found no significant differences in 1 or 5 minute Apgar scores for twin B in relation to the delivery interval, whether above or below 10 minutes, 30 minutes, or 60 minutes (unpaired t-test, p values were all > 0.05). See Fig. 7. Figure 7: Intertwin Delivery Intervals and Apgar Scores There was one non-emergent newborn transport of a twin A for persistent tachypnea and desaturation which resolved at the hospital within 48 hours and was attributed to be most likely transient tachypnea of the newborn (TTN, see Additional File 2). There was one case of short-term neonatal morbidity: a broken humerus on a second twin with a difficult breech extraction. The baby remained at home and healed without issue. IVF results : There were 15/100 women who had IVF. Four transferred care prior to labor. Three women with IVF had preterm labor or PPROM (21.4%) and one went to 41 weeks and chose a C-section. Of the 11 who began labor still under SJF’s care, delivery by cesarean occurred in four (36.4%) with the remaining 7 having a vaginal birth, one after transport and 6 at home. Two women had IUI with both delivering vaginally at home. Discussion In our study we found high rates of vaginal birth in the community setting of term twins, independent of chorionicity or fetal position. The overall vaginal delivery rate was 91.3%. This was especially evident in multiparous women with a success rate of 97.9% for those still under SJF’s care when labor began (47/48). Primiparas were less likely to birth vaginally but still had an overall rate of 76.2% (66.7% in the community setting and the remainder after hospital transport). Our vaginal birth rate was higher than the MANA Stats data by Bovbjerg at al., which had an 81.1% overall vaginal birth rate in a planned community setting [ 16 ]. The vaginal birth rate is markedly higher than large hospital-based studies such as the Twin Birth Trial [ 24 ], JUMODA [ 25 ], or the breech-first twin subset from JUMODA [ 26 ] (with the caveat that these are less direct comparisons than the MANA Stats data, see Fig. 8 and Table 5 ). Table 5 Comparison of vaginal birth rates Data set N planned vaginal births Presentation Vaginal birth rate (n) primips (n) multips (n) Fischbein 69 all 92.3% (63) 76.2% (16/21) 97.9% (47/48) Bovbjerg (MANA Stats 2.0 & 4.0) 138 all 81.1% (112) unspecified Cephalic-first twins Fischbein subset 55 cephalic first 94.5% (52) 82.4% (14/17) 100% (38/38) Twin Birth Study (vaginal group) 1406 cephalic first 56.2% (790) unspecified: cohort was 61.5% multips JUMODA planned vaginal group 5915 cephalic first 80.3% (3583) unspecified Breech-first twins Fischbein subset 14 breech first 78.6% (11) 60% (3/5) 88.9% (8/9) Korb 2020 298 breech first 62.1% (185) Bourtembourg 2012 54 breech first 53.7% 32% 68.8% Blickstein 2000: at least 1500g 286 breech first 63.6% n = 53 Rate unspecified n = 129 Rate unspecified Ghesquière 2022 116 Breech first 72.4% (84) 62.0% (31/50) 80.3% (53/66) Figure 8: Reported success rates of twin labors intending a vaginal birth During consultations, teaching, and/or clinical practice, the authors have noted that most women are told a cesarean is best when one or both of the twins are breech or when twin B is in an unstable lie. We believe this has more to do with lack of expertise or willingness on the part of practitioners rather than evidence showing poorer outcomes with vaginal births [ 26 – 29 ]. This is reinforced by a comment from Korb et al [ 26 ], whose article analyzed outcomes of breech-first twins: “despite the lack of solid evidence, planned vaginal delivery [for breech-first twins] has been progressively abandoned, resulting, as in the delivery of breech singletons, in a loss of expertise in the delivery of twin pregnancies with a first twin in breech presentation.” Commenting on Korb’s analysis, Aviram et al. [ 30 ] wrote in 2022: “a more recent publication based on the JUMODA dataset suggested that there is no difference in neonatal outcomes between planned CD and planned VD in twin pregnancies in which the first twin is in breech presentation. However, given the worldwide decrease in expertise in singleton breech deliveries, it is unlikely that this publication will change current practices.” We call this the “shrug” effect: an observation of a problem but no concerted efforts to fix it despite well-supported evidence. In essence, practitioners and hospital administrators shrug their shoulders and allow the overuse of cesareans to continue. We urge practitioners to abandon the current obstetric practice of counseling women that breech-first twins are too dangerous to be delivered vaginally. The absence of data showing better outcomes with cesarean section for breech-first twins should be clearly communicated to both practitioners and parents. As Korb et al note in 2020 [ 26 ]: “the absence of neonatal benefits associated with planned cesarean delivery in this study further emphasizes the reported increase in short-term and long-term maternal and infant risks associated with planned cesarean deliveries.” Twin pregnancies seem to have a different proportion of breech presentations compared to singleton breeches. While approximately two-thirds of term singleton breeches present frank breech [ 32 ], nonfrank breeches in twin pregnancies are much more common (67.6%) than frank breeches (32.4%). Vaginal breech birth of twin A or B and extraction of twin B, when indicated, should be core obstetric skills taught to all obstetric and family practice/OB residents as well as midwives. On average, more than half of twin pregnancies involve at least one breech presentation: 53% of twin pregnancies in a 2009 study [ 33 ]. Obstetricians currently in practice should seek out breech training to ensure they can safely support all twin births and uphold maternal autonomy [ 34 ]. Midwives have shown a much keener interest in retaining this skill as represented by their high rates of attendance in vaginal breech trainings conducted throughout the US and Canada beginning in 2019 [ 35 ]. In our population, 31 (44.9%) of the women in labor had at least one twin in a breech position and 87.1% (27/31) of those had a successful community-based vaginal birth. There were 35 breech babies overall among the 31 mothers; 4 mothers had breech/breech twins. Of those 31 breech babies born with SJF, 35.5% (11/31) were assisted by breech extraction, 31% (10/31) were assisted with simple maneuvers often associated with non-upright positioning and 10 breech babies were born spontaneously (31%). One of the three transverse presentations also required internal version and breech extraction. This suggests the need for breech skills training for any practitioner attending vaginal twin births, due to the high percentage of breech presentations and to the occasional need for maneuvers, major or minor. One set of breech/vertex twins had head entanglement, an extremely rare event estimated to occur in 1:1000 twin births overall [ 36 ]. In other studies, Korb [ 26 ] cites one case of interlocked twins out of 298 planned breech-first twins, while Blickstein [ 27 ] had no cases of entanglement among the 286 planned vaginal births of breech-first twins. The entanglement became evident after baby A was born to the chest with no further progress and unsuccessful attempts to maneuver the baby. Reaching inside past baby A’s head and using his hand as a fulcrum, SJF was able to successfully unlock the two heads and deliver both babies promptly with good outcomes [ 37 ]. Knowing the mechanics of breech birth and having the skill and experience to understand what was happening, SJF was able to resolve a situation that is rarely encountered. Chorionicity: Chorionicity should be determined as early as practical so as to outline a best plan of action and counseling for mono-chorionic, di-amniotic twins who are at risk of TTTS & TAPS (twin anemia polycythemia sequence) [ 38 ]. When in our care, mono-di twins began surveillance at 14–16 weeks with follow-up scans every 2 weeks until 28 weeks. SJF’s experience is that TTTS becomes much less likely if there is no evidence by 28 weeks. However, TTTS can occur at any gestational age for mono-di twins [ 38 ], so ongoing monitoring for TTTS would be discussed with the parents. Four of our twin mothers developed TTTS over the period of our study. All four reached the level where fetal laser surgery was indicated between 20–25 weeks. We are fortunate in our community to have local options for this procedure. All four had successful ablation of the communicating vessels and all eight babies survived. Three delivered by cesarean from 29.5 to 33 weeks and one mother delivered vaginally (vertex/vertex) at the hospital at 33 5/7 weeks. With di-di twins we recommended growth scans every 4–6 weeks unless there were predisposing factors indicating need for more frequent surveillance. We encouraged all twin clients to have a 20-week structural survey ultrasound. To induce or not to induce?: The average gestational age at delivery in our population of laboring women was 39 weeks (range 35–42 weeks). This differs significantly from how most hospitals manage twin pregnancies, with induction or C-section several weeks earlier than our population’s average [ 22 – 23 ]. The relative rate of stillbirth rises for twins beyond 35 weeks, hence the recommendation that all twins should be delivered by 37–38 weeks. (The relative rate of stillbirth rises for singletons beyond 35 weeks, as well.) Our clients’ preference for low intervention births was one of the main reasons they sought a community rather than hospital location. In our population we did not recommend induction simply based on gestational age. We believe that counseling based on relative risk alone is not helpful and even sometimes deceptive and that absolute risk should be discussed. This sets the risks in context of how common or rare they are. We also trust the evidence and predictive value of fetal surveillance [ 39 ] and generally follow ACOG guidelines when recommending its initiation after thorough informed consent counseling. During the informed consent process, we rely on the information from Page et al. [ 40 ], which shows the risk of PND/NND for twins at each gestational age. In twins, excluding those complicated by gestational diabetes, hypertension, and IUGR, there is almost a 7-fold increase in the risk of IUFD between 37 and 40 weeks (relative risk). On the other hand, there is a 99.93% chance of not having an IUFD at 37 weeks and a 99.53% chance of not having an IUFD at 40 weeks (absolute risk). When counseling patients, practitioners should explain the risks in an unbiased way and state absolute, not relative risk. The American Medical Association (AMA) code of ethics states, “Rational, informed patients should not be expected to act uniformly, even under similar circumstances, in agreeing to or refusing treatment.” [ 41 ]. It is a basic tenet of medical ethics that when people are given the same information, they will not all reach the same conclusions [ 42 ]. It is not surprising then to understand why many in our population were willing to wait for spontaneous labor despite the small increase in the absolute risk of stillbirth. For our population, the risks of induction or cesarean section outweighed the risks of awaiting labor. We did offer (but not require) fetal biophysical profile testing beginning in the 38th week to reassure the family, the team and the potential hospital transport practitioner. Care during labor: Care during twin labors in a community setting differs significantly from how most twins are managed in a hospital setting [ 43 , 23 ]. The care practices that our population finds objectionable include moving the mother to an operating suite for a vaginal delivery, having a room full of staff, most of whom are strangers to the woman; lithotomy positioning; coached pushing; epidurals (often mandatory); immediate cord clamping; separation of mother and newborn; and AROM and immediate delivery of twin B within just a few minutes of twin A. In contrast, we support the mother in a safe, private environment where she is surrounded by people she knows. She is free to move at will, to eat and drink, to birth in whichever positions she finds most comfortable, most often to await the birth of baby B, and to have uninterrupted skin-to-skin contact with her baby after the birth. Delivery interval: We believe that a short, actively-managed delivery interval is a routine born of impatience and convenience. We acknowledge that the literature shows some associations between delivery interval and lower cord gasses in twin B [ 44 – 45 ]. However, we also see the benefits to letting the labor unfold without intervening for a specific indication. Hastening the birth of twin B should be only done in the rare indications where immediate interventions for twin A & B are medically indicated. Women should be free to move about and push and deliver in whatever position feels best to them. Babies should have immediate skin to skin and optimal cord clamping (defined as waiting until the cord is limp, white, and flat before clamping & cutting the cord). In mono-di twins with no evidence of TTTS, we saw no reason to alter our practice of optimal cord clamping. Baby A can be put to breast to help stimulate contractions for Baby B. We recommend respectful, silent waiting for at least 30 minutes, intermittently monitoring Baby B’s heartbeat, to let mom and her uterus do what nature intends before suggesting an intervention. Like so much of the medical model, these routine habits are done without concern for downstream consequences and the desires of the mother. Third Stage Management: In clients with no risk factors for postpartum hemorrhage, we discussed but did not demand active third stage management. Patients were given informed consent about the increased risk of blood loss after a twin delivery and their decision to accept or decline routine postpartum Pitocin injection was respected. While some women were accepting of immediate IM Pitocin after delivery of twin B, many of our patients preferred to avoid pharmaceuticals, which is common in the community birthing population. EBL levels in our population are higher than in reported hospital studies, but with lower rates of blood transfusion. For example, in the Twin Birth Study [ 15 ], 2.3% of the planned vaginal births had EBL ≥ 1500 ml and 5.4% received blood transfusions, while our cohort had a rate of EBL ≥ 1500 ml of 15.3% but with no blood transfusions needed. Some of this may be complicated by the accuracy of estimating blood loss, and some may in part be our population’s preference for physiological third stage and for longer average delivery interval times (the JUMODA study interval averaged 5 minutes in the planned vaginal birth group [ 26 ], while our population averaged 35.1 minutes). Limitations: While our dataset has detailed information on the pregnancies and births, it is too small to accurately calculate the incidence of rare events, such as severe neonatal morbidity or mortality. We are aware of home birth practitioners in the US who have attended over 500 sets of twins, but their data has never been analyzed.[1] We strongly encourage all practitioners, whether community- or hospital-based, to collect and publish their data on planned vaginal births of twins. Conclusion Properly selected, motivated twin mothers can successfully birth in a home setting, if they have a supportive environment, a skilled practitioner, and a competent team of birth workers. Properly selected term twin vaginal birth, regardless of which twin is breech, is a reasonable option with excellent success rates in skilled hands and should be offered to all women with twin pregnancies. Residency training programs should reinstitute the teaching of these skills to ensure women desiring hospital births are not pushed outside the system. Professional medical organizations and state legislatures should recognize the value and dedication of midwifery care in the community and stop limiting choices, under the guise of safety, that rightfully belong to the pregnant woman. The midwifery approach to term twin pregnancy is significantly different from the obstetric medical model, and women seek it out despite obstacles of cost, relocation, and social disapproval. Most twin mothers entered into our practice early in gestation, but some transferred or relocated later in the pregnancy, usually due to lack of birth options in their community. The midwifery approach supports physiology and strongly supports vaginal birth in the context of the woman’s individual values and preferences. A medicalized approach to multiples sees twin birth as hazardous and relies heavily on algorithmic managing of the prenatal period, following a high-risk protocol of consults and ultrasound, and then managing the birth process via cesarean section or induction of labor. In SJF’s experience attending births for over four decades in both hospital and community settings, this approach causes anxiety and fear in the women and their families, with the anxiety often originating from the practitioner. In contrast, when a woman is confident and feels supported, her prenatal experience and labor are more enjoyable. While alertness and vigilance are appropriate, a fear-based defensive approach to twins is unwarranted and detrimental. As opposed to the pre-ultrasound era, when half of all twins were discovered in labor, most women discover a twin pregnancy early on. We know that around half of all twins will have at least one baby in the breech position [ 33 ]. Many obstetricians have no training or experience in vaginal breech birth; breech extraction may be the only skill they learn and the only tool they have, limited to twin B. Without vaginal breech skills, practitioners cannot be considered experts in twin birth because they lack the skills for an event (breech presentation) that occurs almost half of the time. We argue that obstetricians should not be taking care of twins if they cannot or will not support vaginal breech births, since roughly half of all twins involve one or more breech presentations. However, they continue to do so and rarely refer their twin clients to someone skilled and confident in twin vaginal delivery. But this is exactly what must be done if we are to honor our code of ethics as maternity practitioners. We also propose some common sense suggestions for less experienced practitioners attending twin births: Seek out breech training and practice the associated maneuvers monthly Adhere to reasonable selection criteria, honoring one’s personal comfort levels Gestational age of 35 weeks or greater (in a community setting) Multiparous mothers Diamniotic/dichorionic twins and relative concordance (due to a need for more frequent surveillance and consultation with discordant growth and mono-di twins) As skill and comfort levels increase, practitioners can offer more expansive options such as primiparas and uncomplicated mono-di twins. Instead of creating an ever-expanding list of contraindications to home and birth center births–including twins–we propose that we contraindicate restrictions on maternal choice of practitioner or birth setting and contraindicate restrictions that limit providers in both community and hospital settings from supporting vaginal twin or breech births . Contraindicating certain choices is paternalistic, assuming the doctor, obstetric society, or regulatory committee knows better than the woman herself. It also ignores individual values, beliefs, and preferences, seeking to impose a one-size-fits-all maternity care experience that may benefit some while harming others. The goal should be to create a nurturing environment, where each woman is treated with dignity, compassion, and respect by a skilled twin practitioner and where her choices are not just tolerated but enthusiastically supported. List Of Abbreviations AROM artificial rupture of membranes EBL estimated blood loss IPV internal podalic version IUFD intrauterine fetal demise IUGR intrauterine growth restriction FHT fetal heart tones IUI intrauterine insemination IVF in vitro fertilization NICU neonatal intensive care unit NIL not in labor SPROM spontaneous premature rupture of membranes TAPS twin anemia polycythemia sequence TOC transfer of care TOLAC trial of labor after cesarean TTN transient tachypnea of the newborn TTTS twin-twin transfusion syndrome VBAC vaginal birth after cesarean Declarations Ethics approval and consent to participate: This project was approved by the University of Michigan IRB (HUM00209968). The IRB waived the requirement for patient informed consent to participate in this research project since it was a retrospective chart review using de-identified records. Consent for publication: We have informed consent from the family to link to their birth video for this publication. Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: This project had no institutional or private funding. Authors' contributions: SJF collected and collated the data and authored the abstract, methods, and results sections. RF wrote the background section, created the images, and performed the statistical analyses. SJF and RF together wrote the discussion and conclusion sections. Acknowledgements: Our paper would not have been possible without the dedication and collaboration of the Southern California community based midwives, doulas, students and other birth workers who supported the author and the families throughout the pregnancy, labor and postpartum. It is with great appreciation and gratitude we acknowledge their contribution. Authors' information: RF has a PhD from the University of Iowa and is the founder and president of Breech Without Borders, a 501(c)3 nonprofit dedicated to breech training, education, and advocacy (breechwithoutborder.org). She is the co-author of A Guide to Physiological Breech Birth (2022), a chapter in the 2020 book Birthing Outside the System: The Canary In the Coal Mine , and several articles about vaginal breech birth and home birth. SJF (MD, FACOG) has been a practicing clinical obstetrician for over 40 years in both hospital and community settings. He is a published author and now travels around the world teaching seminars on breech and twin skills via Birthing Instincts (www.birthinginstincts.com). References Martin JA, Hamilton BE, Osterman MJK, Driscoll AK. Births: final data for 2019. National Vital Statistics Reports. 2021 March 23;72(2). Bateni ZH, et al. Trends in the delivery route of twin pregnancies in the United States, 2006–2013. 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Borah T, Das A. Locked twins: a rarity. Ann Med Health Sci Res. 2012;2(2):204. 10.4103/2141-9248.105676 . Fischbein SJ. A maneuver for head entanglement in term breech/vertex twin labor. J Case Rep Images Obstet Gynecol. 2018;4:100042Z08SF2018. Kilby MD. Bricker L on behalf of the Royal College of Obstetricians and Gynaecologists. Management of monochorionic twin pregnancy. BJOG. 2016;124:e1–e45. American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Obstetrics. Antepartum fetal surveillance: ACOG Practice Bulletin, Number 229. Obstet Gynecol. 2021;137(6):e116–27. Page JM, Pilliod RA, Snowden JM, Caughey AB. The risk of stillbirth and infant death by each additional week of expectant management in twin pregnancies. Am J Obstet Gynecol. 2015;212(5):630.e1-7. 10.1016/j.ajog.2015.03.033 . E. Riddick FA Jr. The code of medical ethics of the American Medical Association. Ochsner J. 2003 Spring;5(2):6–10. Sokolec J. Respect for patient decision making: Mr. Douglas's choice of treatment. Virtual Mentor. 2005;7(1):23–42. Schmitz T, Bernabé C, Azria E, Goffinet F. Intrapartum management of twin gestations. Obstet Gynecol. 2007;110(3):712; author reply 712. 10.1097/01.AOG.0000280282.83266.15 . Stein W, Misselwitz B, Schmidt S. Twin-to-twin delivery time interval: influencing factors and effect on short-term outcome of the second twin. Acta Obstet Gynecol Scand. 2008;87(3):346–53. 10.1080/00016340801934276 . Suh YH, Park KH, Hong JS, Yoon BH, Shim SS, Park JS, Jun JK, Syn HC. Relationship between twin-to-twin delivery interval and umbilical artery acid-base status in the second twin. J Korean Med Sci. 2007;22(2):248–53. 10.3346/jkms.2007.22.2.248 . Footnotes For example, Cynthia Caillagh, a Certified Professional Midwife in rural Wisconsin, attended 561 vaginal breech births and 527 sets of twins in a community setting over her 50-year career as a midwife. In the past decade, she had a 97+% vaginal birth rate for her breech and twin births. She was compiling her breech and twin data for RF to publish when she died of cancer. Additional Declarations No competing interests reported. Supplementary Files AdditionalFile1.docx Additionalfile2.docx AdditionalFile3.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3290533","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":232963229,"identity":"14f33959-7e04-4e14-8112-410004e9bfd1","order_by":0,"name":"Stuart James Fischbein","email":"","orcid":"","institution":"Birthing Instincts","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Stuart","middleName":"James","lastName":"Fischbein","suffix":""},{"id":232963233,"identity":"ff5068ad-355c-4c1f-b9d5-cabe2f2183d5","order_by":1,"name":"Rixa 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7","display":"","copyAsset":false,"role":"figure","size":138268,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eIntertwin Delivery Intervals and Apgar Scores\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure7intervalApgar.png","url":"https://assets-eu.researchsquare.com/files/rs-3290533/v1/1a640433294617dbfe225b51.png"},{"id":43372491,"identity":"12683c3b-b7e0-420d-884e-70b167be9a4e","added_by":"auto","created_at":"2023-09-19 15:45:36","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":205004,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eReported success rates of twin labors intending a vaginal birth\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure8VBrates.png","url":"https://assets-eu.researchsquare.com/files/rs-3290533/v1/974cf16ec90f6275b20a8e09.png"},{"id":47088412,"identity":"3a2a2623-55e5-47f7-aa95-56395c750337","added_by":"auto","created_at":"2023-11-26 06:37:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1666752,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3290533/v1/0b955ae0-cf52-461b-9fb3-0f182cf020ff.pdf"},{"id":43372487,"identity":"8863dd87-05b6-4273-b78b-88640062b592","added_by":"auto","created_at":"2023-09-19 15:45:36","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":12853,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-3290533/v1/72b136fba6a7672a5fca882e.docx"},{"id":43372725,"identity":"0a018a4d-b783-486e-a759-5e413f59fc54","added_by":"auto","created_at":"2023-09-19 15:53:36","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":15010,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-3290533/v1/dada2622fb59e03d0099c3e6.docx"},{"id":43372720,"identity":"eba88ec0-2d09-4bdf-ac01-c8c615ef643b","added_by":"auto","created_at":"2023-09-19 15:53:36","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":14186,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile3.docx","url":"https://assets-eu.researchsquare.com/files/rs-3290533/v1/1db9cc9db52b6f1dbf309094.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Twin home birth: Outcomes of 100 sets of twins in the care of a single practitioner","fulltext":[{"header":"Background","content":"\u003cp\u003eThis paper examines maternal and neonatal outcomes of a series of 100 twin pregnancies supported by an obstetrician who has been attending home births exclusively since 2010, and prior to that 24 years of hospital practice attending breeches, twins, and VBACs. His decision to attend home births was driven by breech, twin, and VBAC bans and limited options at his local hospitals. In California, midwives are not allowed to attend twin births at home or in birth centers, leaving this physician as one of the only options for a community (home or birth center) birth in the entire state with a population of 39\u0026nbsp;million people.\u003c/p\u003e \u003cp\u003eAround 120,000 babies are born as twins every year in the US, representing 3.2% of all births [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. As of 2013, the last year in which the data has been published, the C-section rate for twins was 74.8%, slightly lower than the 2009 peak of 75.3% [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. With decreasing skill and experience in vaginal twin births, providers are relying more heavily on cesarean delivery [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, this presents a difficult situation for women who strongly desire a vaginal birth. If there are few or no hospital options for their twins, a home birth may be their only way to avoid unwanted surgery.\u003c/p\u003e \u003cp\u003eAmerican women are increasingly turning to home birth for many reasons including increased comfort, lower intervention rates, greater feeling of safety, lack of acceptable hospital options, and recently, concerns over Covid-19 infection and/or Covid regulations at their local hospitals [6-101]. In the USA, home births rose 19% between 2019 and 2020, largely due to the Covid-19 pandemic and the associated hospital restrictions [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. For women with multiple gestations, hospital options are even more restricted than for those with singleton cephalic pregnancies. Where a vaginal hospital twin birth is still possible, the process is often medicalized (common practices include induction at a set gestational age, vaginal birth in the OR, epidurals as mandatory or strongly encouraged, mother in dorsal lithotomy position, and strict time limits for delivery interval). Some women find this medicalized approach unacceptable and choose to give birth outside the medical system [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. With ACOG contraindicating multiple births at home and some state regulations forbidding community midwives from supporting twin pregnancies, the options for a vaginal birth decrease even further.\u003c/p\u003e \u003cp\u003eVery little data exists on outcomes of twin births in a community setting. Obstetrical societies such as the ACOG list twin birth at home as contraindicated, due to (short-term) safety concerns for the neonate. However, systematic, detailed data are not available for twin home births, particularly data that take into account provider skill and experience levels, chorionicity, selection criteria, or type of presentations. The CPM 2000 study of planned home births briefly mentions 13 sets of twins with no neonatal deaths [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In the MANA Stats 2.0 and 4.0 data sets, there were 138 twin pregnancies intending to birth at home, representing 0.3% of births out of a total of 47,394 women planning home or birth center births [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This study includes more detailed information on outcomes, such as Apgar scores, NICU stays, and maternal injuries or PPH, although it still lacks information on provider skill level, chorionicity, selection criteria, gestational age, or birth weights. Of the twin pregnancies, 19.6% ended in intrapartum transfer, with an overall cesarean rate of 18.1% (indicating that most transfers ended in cesarean). Compared to planned singleton home birth, twin pregnancy was not associated with higher rates of neonatal transfer, perineal trauma, or neonatal death. On the other hand, twin pregnancy was associated with higher rates of intrapartum transfer and maternal or neonatal hospitalization (modest); of postpartum transfer, cesarean section, low 5-minute Apgars, and NICU admission (elevated); and of very low 5-minute Apgars (substantially elevated)\u0026mdash;again, compared to planned singleton home birth.\u003c/p\u003e \u003cp\u003eA small number of studies outside the USA mention twin community births, but with few details about the pregnancies or about the outcomes. Bastian et al [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] analyzed self-reported data on home births in Australia and reported a perinatal mortality rate of 1:7 for the twin births. This study did not note how many twin pregnancies were included in the data. A few other studies looking at the role of \u0026ldquo;high-risk\u0026rdquo; home births (including multiple gestations) have found an increased rate of adverse outcomes in the high-risk groups, but the role of twins was not parsed out separately [\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. A PhD dissertation examining more than a half-million home and hospital births in the UK\u0026rsquo;s SMMIS registry from 1988\u0026ndash;2000 found no cases of perinatal mortality among the planned twin home births; there were 13,263 multiple pregnancies overall in the SMMIS registries, of which some (likely a small percentage at most) were planned home births [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere is a wide disparity between evidence and practice regarding mode of birth for twin presentations [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. A large body of hospital-based research indicates that there is no benefit to routine cesarean section for twins, regardless of whether twin A or B is cephalic or breech. The 2013 Twin Birth Study was a randomized controlled trial comparing planned vaginal birth with planned CS for cephalic-first \u0026ldquo;low-risk\u0026rdquo; twins, enrolling 2804 women in 106 centers between 32\u0026thinsp;+\u0026thinsp;0 and 38\u0026thinsp;+\u0026thinsp;6 weeks\u0026rsquo; gestation. It likewise found no benefit to planned cesarean section [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. A large prospective observational study of twin birth outcomes in France and Belgium, called JUMODA, found no benefit to cesarean for cephalic first twins [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. JUMODA was designed with identical exclusion criteria as the Twin Birth Study to enable cross-comparison of a low-risk population. (JUMODA is a sister study to PREMODA, which examined outcomes of singleton breech births in maternity centers in France and Belgium and found no benefit to planned cesarean section for breech presentation.) A sub-analysis of the JUMODA data by Korb [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], looking at breech-first twins, found no benefit to cesarean for those presentation, echoing similar findings by Blickstein, Goldman, and Kupferminc in 2000 [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], Bourtembourg et al. in 2012 [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], and Ghesqui\u0026egrave;re et al. in 2022 [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite strong evidence that a planned vaginal birth should be offered and supported for most twin presentations, clinical practice in the USA and many other countries strongly favors planned cesarean section. In many places in the USA, women cannot access planned vaginal birth at all, even when both babies are cephalic. This lack of choice is difficult to overcome due to the deskilling of practitioners [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGiven this medical and cultural context\u0026mdash;with evidence supporting vaginal birth for most twin pregnancies, but with clinical practice, hospital protocols, and state regulations making vaginal birth either impossible or untenable for most women\u0026mdash;we find it beneficial to analyze outcomes of planned twin births at home with a skilled, experienced practitioner. In many locations in the USA, community birth may be a woman\u0026rsquo;s only way to achieve a vaginal birth if she has twins, particularly breech-first twins.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis paper is a retrospective review of 100 consecutive twin mothers who entered care for a community birth with a single practitioner over a 12-year period from March 2011 to January 2023. Seven TOLACs were included in the review; a mother without a previous vaginal birth was considered a functional primipara. The women in this series were all in good health and received prenatal care with an obstetrician, a midwife, or a collaboration of both. Most of the twin clients self-selected the option of home birth at an early gestational age; they were highly motivated and experienced continuity of care throughout their pregnancies.\u003c/p\u003e \u003cp\u003ePrenatal visits were individualized based on history, social factors such as distance, and chorionicity. Dichorionic/Diamniotic twins without concerns were seen about every 4 weeks through 28 weeks, then every 2 weeks until 35\u0026ndash;36 weeks, and then weekly or as needed. Monochorionic/Diamniotic twins were seen more often in the second trimester for surveillance. This was again individualized but usually every 2 to 3 weeks unless more often was clinically indicated. Ultrasound surveillance was also individualized based on clinical setting and parental desire with recommendations for closer monitoring based on chorionicity and growth.\u003c/p\u003e \u003cp\u003eThe women in this review were selected and accepted to labor based on simple criteria as follows:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eGreater than 35 weeks gestation\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDi-di or mono-di chorionicity\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTwin A in a stable longitudinal lie\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eBoth twins growing consistently on their own growth curves with EFW of smallest twin\u0026thinsp;\u0026gt;\u0026thinsp;2000 gm\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eNo gross anomalies or significant maternal medical issues\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eLabor starting spontaneously\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eFetal and maternal tolerance to labor\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eRight parental mindset for community-based birthing\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e These were used as general guidelines, not as strict selection criteria. Each case was individualized per our model of care and ethical considerations.\u003c/p\u003e \u003cp\u003eThe birth team consisted of an obstetrician (SJF), two licensed midwives, one or two midwifery students, and often a birth doula. Duties were discussed ahead of time as to who had primary responsibility for Twin A, Twin B and the mother as the delivery progressed. Assistants and students were in charge of setup, cleanup, and documentation. Equipment brought to each birth included IV fluids and tubing, sterile gloves, gauze, pads, betadine, urinary catheters, suture material, and appropriate surgical instruments. The birth team also supplied an inflatable birth pool. Medications included antibiotics, lidocaine, oxytocin, misoprostol, oral methylergonovine (until it became unavailable), tranexamic acid (TXA), vitamin K, Rhogam, smelling salts, and oxygen. In this series SJF also carried a portable GE ultrasound, a Masimo pulse oximeter, handheld Doppler, a Mityvac vacuum, Piper forceps, Simpson forceps, and Tucker-McLean forceps. All licensed practitioners were certified in neonatal resuscitation and cardio-pulmonary resuscitation.\u003c/p\u003e \u003cp\u003eWomen in our cohort were not excluded for conditions that were unlikely to affect labor such as diet-controlled gestational diabetes, mild chronic hypertension, IVF pregnancy, or age over 35. The data were not analyzed prior to completion of the 100th twin birth.\u003c/p\u003e \u003cp\u003eThe midwifery model of care encourages settings where women feel \u0026ldquo;private, safe, and undisturbed\u0026rdquo; to encourage the proper release of birth hormones involved in physiological birth: oxytocin; beta-endorphin; catecholamines (adrenaline and noradrenaline), and prolactin [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Breech and cephalic labors were managed identically. Women were encouraged to eat and drink, ambulate, change positions, and choose their birth location and position. Women had the option of a shower and tub for labor analgesia; water birth for breech births was not the preferred mode due the higher likelihood of assistance but choice remained with the laboring woman. Fetal monitoring was performed intermittently with a Nicolet Elite 200 Handheld Doppler. Auscultation was individualized but the usual protocol practice was every 30\u0026ndash;60 min in active labor, every 15\u0026ndash;30 min in transition and every 5\u0026ndash;10 min in the second stage. Vaginal exams were only done with maternal informed consent and kept to a minimum, often withheld until maternal guttural vocalizations signaled an urge to push. Portable ultrasound was used sparingly mainly to confirm position and heart rate of twin B after delivery of twin A.\u003c/p\u003e \u003cp\u003ePushing only began when maternal urge became irresistible; pushing was spontaneous rather than coached. Breech-first twin mothers were encouraged to labor down before active pushing began. Passage of pasty meconium was considered a positive sign of descent with a breech. Breech twin mothers were counseled about the benefits of upright and hands-off techniques. On-the-back positioning for breech was used on an as-needed basis and with maternal informed consent. Optimal cord clamping (usually done after the placenta was birthed) and immediate and uninterrupted skin-to-skin were routine.\u003c/p\u003e \u003cp\u003e This project received approval from the University of Michigan IRB (HUM00209968). Patient informed consent to participate was waived by the IRB as this was a retrospective chart review using de-identified data. Statistical analysis was done using unpaired t-tests.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 100 women planning a community-based birth with either dichorionic-diamniotic (79%) or monochorionic-diamniotic (21%) twins entered into care with a single obstetrician over an twelve-year period from March of 2011 to January of 2023 (see Fig.\u0026nbsp;1).\u003c/p\u003e \u003cp\u003eAntepartum transfer of care (TOC) occurred with 31 of the women. Of the antepartum women whose care was transferred to a hospital-based practice, 19.4% (6/31) were mono-di and 80.6% (25/31) were di-di. Similar to the overall percentage in the cohort. There were 4 cases of twin-twin transfusion syndrome (TTTS) diagnosed in the mono-di twins (19%) all of whom are included in the antepartum group. (See Fig.\u0026nbsp;1 and Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.)\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 1: Flowchart of 100 sets of twins\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eReasons for antenatal transfer of care to a hospital-based provider\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimip twins\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;19\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMultip twins\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;12\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;41 weeks, NIL (not in labor)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCholestasis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSPROM\u0026thinsp;\u0026lt;\u0026thinsp;35 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreterm labor\u0026thinsp;\u0026lt;\u0026thinsp;35 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGestational hypertension/preeclampsia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIUGR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFunic or footling prior to labor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTTTS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-reassuring FHT, NIL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTwin A breech (early in SJF\u0026rsquo;s home birth practice)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal antenatal transfers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19/40 (47.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12/60 (20.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe remaining 69 women went into spontaneous labor. Of these, 8 women (11.6%) were transported in labor, one emergently and 7 non-emergently (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Of these transfers, 2 went on to deliver vaginally with a supportive hospital practitioner and the other 6 had cesarean sections. The overall cesarean section rate in the cohort planning home birth at the onset of labor was 8.7% (5 primips \u0026amp; 1 multip).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIndications for in-labor hospital transfer of twins\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndication for transfer\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimip twins (includes VBACs)\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;7\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMultip twins\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArrest of active labor (\u0026gt;\u0026thinsp;7 cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (B/B)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAudible decelerations in early labor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaternal complaint of incisional pain (TOLAC)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSPROM, prolonged latent labor, maternal fatigue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal in-labor transfers by parity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e7/21 (33.3%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e1/48 (2.1%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOf the remaining 61 clients who delivered at their desired location, there were 14 primiparas (including first-time VBAC moms) and 47 multiparas. Vaginal delivery was achieved in 97.9% (47/48) of multiparas and 76.2% (16/21) of primiparas who entered labor, with 66.7% (14/21) of primiparas giving birth vaginally in the community setting. (See Fig.\u0026nbsp;2.) For a video of a community home birth with SJF, please see Additional File 1.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 2: Vaginal twin birth rates by parity\u003c/b\u003e \u003c/p\u003e \u003cp\u003eFor those 69 women who planned a community birth, the presentation of the twins broke down as follows in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and Fig.\u0026nbsp;3.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eType of presentations and vaginal birth rates\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresentation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eVaginal birth rate\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVertex/vertex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e97.1% (34/35)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVertex/breech\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e94.1% (16/17)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVertex/transverse*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66.7% (2/3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreech/vertex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e14.5%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e10\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e80% (8/10)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreech/breech\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e5.8%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e75% (3/4)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e* \u003cem\u003eOne converted spontaneously to vertex/vertex after baby A, another had an IPV (internal podalic version) and breech extraction due to separation of placenta A and heavy maternal bleeding. The third transported in labor and had a cesarean section.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 3: Fetal presentations in twin labors\u003c/b\u003e \u003c/p\u003e \u003cp\u003eClose to half of the pregnancies had at least one twin presenting breech at the onset of labor (44.9%, 31/69). Of the 35 total breech presentations, 12 were frank, 19 were complete, 3 were incomplete, and 1 was footling. Of the 11 breech-first twins that birthed vaginally, 2 (18%) required more extensive maneuvers, such as freeing entangled heads and an extraction for terminal decels. Of the 19 breech second twins that birthed vaginally (not including the transverse lie that ended with IPV and extraction), 9 required more extensive maneuvers (extraction) (47.4%).\u003c/p\u003e \u003cp\u003eFor a description of the 8 in-labor transports, please see Additional File 2. We had one TOLAC mother who began having suprapubic pain of a concerning nature at 10cm. She was transported via ambulance to a hospital, and no uterine scar dehiscence was found at repeat cesarean. She recovered without further sequelae.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eTiming of Delivery:\u003c/h2\u003e \u003cp\u003eOur model of care supports waiting for natural labor to occur, given the benefits of spontaneous labor and the risks of induction. We did not routinely induce twins as per ACOG guidelines [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]; instead, we provided individualized care, weighing the risks and benefits that each mother thought suited her. Mean gestational age for home twin labor was 39.0 weeks (range 35\u0026ndash;42 weeks). See \u003cspan refid=\"Sec8\" class=\"InternalRef\"\u003ediscussion\u003c/span\u003e section.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eTwin-to-twin delivery interval and estimated blood loss (EBL):\u003c/h2\u003e \u003cp\u003eOverall, the twin-to-twin interval averaged 35.1 minutes. Early in the series, the birth team practiced less active intervention and waited for the spontaneous return of labor. When a trend appeared showing that longer inter-twin interval was related to increased blood loss, we began recommending AROM (artificial rupture of membranes) after 30\u0026ndash;45 minutes if labor had not returned.\u003c/p\u003e \u003cp\u003eWe have EBL data on 51/61 successful community births. Overall EBL average was 760.5 ml (range 150\u0026ndash;1900). There were 16 twin mothers who had a EBL of \u0026ge;\u0026thinsp;1000 ml (30.8%); of those 16, half had an EBL\u0026thinsp;\u0026ge;\u0026thinsp;1500 ml (15.3%). None of these women required transport or received a blood transfusion.\u003c/p\u003e \u003cp\u003eOf the 16 mothers with an EBL of \u0026ge;\u0026thinsp;1000 ml, we found the twin-to-twin interval to average 62 minutes (range 8-259) whereas in births with EBL\u0026thinsp;\u0026lt;\u0026thinsp;1000 ml, the interval averaged 24.7 minutes (range 2-135). Comparing mothers with an EBL above or below 1500 ml, the average twin-to-twin interval was 24 minutes for EBL\u0026thinsp;\u0026lt;\u0026thinsp;1500 ml (n\u0026thinsp;=\u0026thinsp;43) and 85 minutes for EBL\u0026thinsp;\u0026ge;\u0026thinsp;1500 ml (n\u0026thinsp;=\u0026thinsp;8). (See Fig.\u0026nbsp;4). Age, parity, total fetal weight, length of active labor or gestational age did not appear significantly related to blood loss.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 4: Delivery Interval and EBL\u003c/b\u003e \u003c/p\u003e \u003cp\u003eMost women with excess blood loss received bimanual uterine massage, herbs, and homeopathy. In a few cases with a history of excessive blood loss, active management with IM Pitocin was given shortly after the delivery of twin B. When clinically indicated, excessive bleeding was treated with IM Pitocin, IV fluids, IV Pitocin, rectal misoprostol and occasional IV tranexamic acid infusion. Early latching was encouraged as it enhances uterine contractions. We do not have data on the length of the third stage of labor, but our practice was to wait for spontaneous separation and expulsion of the placenta unless intervention was clinically indicated (manual removal for excessive bleeding). We did not have a structured time limit for delivery of the placenta.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003ePerineal integrity:\u003c/h2\u003e \u003cp\u003eThe majority of twin mothers birthing in a community setting had no perineal lacerations, with only one 3rd-degree laceration (repaired at home). As expected, perineal lacerations are more heavily skewed towards primiparous mothers. There was also one 3rd-degree laceration among a primip who transported in labor and had a spontaneous vaginal birth for baby A and vacuum delivery for baby B. We do not have perineal outcomes for the other in-labor transport that ended in a vaginal birth. No episiotomies were performed in the community setting over a total of 122 vaginal births. See Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and Figs.\u0026nbsp;5 \u0026amp; 6.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePerineal lacerations and parity in completed twin home births\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerineum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrimips\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMultips\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39 (63.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1st degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17 (27.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2nd degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (6.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3rd degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (1.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 5: Perineal outcomes of vaginal twin births\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 6: Perineal outcomes of vaginal twin births by parity\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe only maternal postpartum transport was for an eclamptic seizure which occurred about one hour postpartum. She recovered without further sequelae (see Additional File 3).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eNeonatal outcomes:\u003c/h2\u003e \u003cp\u003eFor deliveries that occurred in the community setting, the average birth weight of twin A was 2835.5 g (n\u0026thinsp;=\u0026thinsp;61, range 1814\u0026ndash;4337). The average birth weight of twin B was 2836.8 g (n\u0026thinsp;=\u0026thinsp;61, range 1644\u0026ndash;4224). Discordance between twins averaged 11.8% (n\u0026thinsp;=\u0026thinsp;95, range 0\u0026ndash;46%). Apgar scores at 1 minute averaged 8.0 for twin A (range 3\u0026ndash;10) and 7.0 for twin B (range 3\u0026ndash;9); this difference was statistically significant (p\u0026thinsp;=\u0026thinsp;0.0005, unpaired t-test). At 5 minutes there was no significant difference in Apgars, with twin A averaging 9.0 (range 7\u0026ndash;10) and twin B at 8.8 (range 6\u0026ndash;10) (p\u0026thinsp;=\u0026thinsp;0.13, unpaired t-test). Cord gasses were not collected in this setting.\u003c/p\u003e \u003cp\u003eWe found no significant differences in 1 or 5 minute Apgar scores for twin B in relation to the delivery interval, whether above or below 10 minutes, 30 minutes, or 60 minutes (unpaired t-test, p values were all \u0026gt;\u0026thinsp;0.05). See Fig.\u0026nbsp;7.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 7: Intertwin Delivery Intervals and Apgar Scores\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThere was one non-emergent newborn transport of a twin A for persistent tachypnea and desaturation which resolved at the hospital within 48 hours and was attributed to be most likely transient tachypnea of the newborn (TTN, see Additional File 2). There was one case of short-term neonatal morbidity: a broken humerus on a second twin with a difficult breech extraction. The baby remained at home and healed without issue.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eIVF results\u003c/span\u003e: There were 15/100 women who had IVF. Four transferred care prior to labor. Three women with IVF had preterm labor or PPROM (21.4%) and one went to 41 weeks and chose a C-section. Of the 11 who began labor still under SJF\u0026rsquo;s care, delivery by cesarean occurred in four (36.4%) with the remaining 7 having a vaginal birth, one after transport and 6 at home. Two women had IUI with both delivering vaginally at home.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn our study we found high rates of vaginal birth in the community setting of term twins, independent of chorionicity or fetal position. The overall vaginal delivery rate was 91.3%. This was especially evident in multiparous women with a success rate of 97.9% for those still under SJF\u0026rsquo;s care when labor began (47/48). Primiparas were less likely to birth vaginally but still had an overall rate of 76.2% (66.7% in the community setting and the remainder after hospital transport). Our vaginal birth rate was higher than the MANA Stats data by Bovbjerg at al., which had an 81.1% overall vaginal birth rate in a planned community setting [\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]. The vaginal birth rate is markedly higher than large hospital-based studies such as the Twin Birth Trial [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e], JUMODA [\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e], or the breech-first twin subset from JUMODA [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e] (with the caveat that these are less direct comparisons than the MANA Stats data, see Fig. 8 and Table \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e).\u0026nbsp;\u003c/p\u003e\n\u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eComparison of vaginal birth rates\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eData set\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN planned vaginal births\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePresentation\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVaginal birth rate (n)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eprimips\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e(n)\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003emultips\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e(n)\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFischbein\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eall\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e92.3% (63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e76.2% (16/21)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e97.9% (47/48)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBovbjerg (MANA Stats 2.0 \u0026amp; 4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e138\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eall\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e81.1% (112)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eunspecified\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"6\"\u003e\n \u003cp\u003e\u003cstrong\u003eCephalic-first twins\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFischbein subset\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ecephalic first\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e94.5% (52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e82.4% (14/17)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e100% (38/38)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTwin Birth Study (vaginal group)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1406\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ecephalic first\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56.2% (790)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eunspecified: cohort was 61.5% multips\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eJUMODA\u003c/p\u003e\n \u003cp\u003eplanned vaginal group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5915\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ecephalic first\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80.3% (3583)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eunspecified\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"6\"\u003e\n \u003cp\u003e\u003cstrong\u003eBreech-first twins\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFischbein subset\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ebreech first\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e78.6% (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e60% (3/5)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e88.9% (8/9)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKorb 2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e298\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ebreech first\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62.1% (185)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBourtembourg 2012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ebreech first\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e32%\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e68.8%\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBlickstein 2000:\u003c/p\u003e\n \u003cp\u003eat least 1500g\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e286\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ebreech first\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003en\u0026thinsp;=\u0026thinsp;53\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eRate unspecified\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003en\u0026thinsp;=\u0026thinsp;129\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eRate unspecified\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGhesqui\u0026egrave;re 2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e116\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBreech first\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e72.4% (84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e62.0% (31/50)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e80.3% (53/66)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 8: Reported success rates of twin labors intending a vaginal birth\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring consultations, teaching, and/or clinical practice, the authors have noted that most women are told a cesarean is best when one or both of the twins are breech or when twin B is in an unstable lie. We believe this has more to do with lack of expertise or willingness on the part of practitioners rather than evidence showing poorer outcomes with vaginal births [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e]. This is reinforced by a comment from Korb et al [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e], whose article analyzed outcomes of breech-first twins: \u0026ldquo;despite the lack of solid evidence, planned vaginal delivery [for breech-first twins] has been progressively abandoned, resulting, as in the delivery of breech singletons, in a loss of expertise in the delivery of twin pregnancies with a first twin in breech presentation.\u0026rdquo; Commenting on Korb\u0026rsquo;s analysis, Aviram et al. [\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e] wrote in 2022: \u0026ldquo;a more recent publication based on the JUMODA dataset suggested that there is no difference in neonatal outcomes between planned CD and planned VD in twin pregnancies in which the first twin is in breech presentation. However, given the worldwide decrease in expertise in singleton breech deliveries, it is unlikely that this publication will change current practices.\u0026rdquo; We call this the \u0026ldquo;shrug\u0026rdquo; effect: an observation of a problem but no concerted efforts to fix it despite well-supported evidence. In essence, practitioners and hospital administrators shrug their shoulders and allow the overuse of cesareans to continue.\u003c/p\u003e\n\u003cp\u003eWe urge practitioners to abandon the current obstetric practice of counseling women that breech-first twins are too dangerous to be delivered vaginally. The absence of data showing better outcomes with cesarean section for breech-first twins should be clearly communicated to both practitioners and parents. As Korb et al note in 2020 [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e]: \u0026ldquo;the absence of neonatal benefits associated with planned cesarean delivery in this study further emphasizes the reported increase in short-term and long-term maternal and infant risks associated with planned cesarean deliveries.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eTwin pregnancies seem to have a different proportion of breech presentations compared to singleton breeches. While approximately two-thirds of term singleton breeches present frank breech [\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e], nonfrank breeches in twin pregnancies are much more common (67.6%) than frank breeches (32.4%).\u003c/p\u003e\n\u003cp\u003eVaginal breech birth of twin A or B and extraction of twin B, when indicated, should be core obstetric skills taught to all obstetric and family practice/OB residents as well as midwives. On average, more than half of twin pregnancies involve at least one breech presentation: 53% of twin pregnancies in a 2009 study [\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e]. Obstetricians currently in practice should seek out breech training to ensure they can safely support all twin births and uphold maternal autonomy [\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e]. Midwives have shown a much keener interest in retaining this skill as represented by their high rates of attendance in vaginal breech trainings conducted throughout the US and Canada beginning in 2019 [\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eIn our population, 31 (44.9%) of the women in labor had at least one twin in a breech position and 87.1% (27/31) of those had a successful community-based vaginal birth. There were 35 breech babies overall among the 31 mothers; 4 mothers had breech/breech twins. Of those 31 breech babies born with SJF, 35.5% (11/31) were assisted by breech extraction, 31% (10/31) were assisted with simple maneuvers often associated with non-upright positioning and 10 breech babies were born spontaneously (31%). One of the three transverse presentations also required internal version and breech extraction. This suggests the need for breech skills training for any practitioner attending vaginal twin births, due to the high percentage of breech presentations and to the occasional need for maneuvers, major or minor.\u003c/p\u003e\n\u003cp\u003eOne set of breech/vertex twins had head entanglement, an extremely rare event estimated to occur in 1:1000 twin births overall [\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e]. In other studies, Korb [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e] cites one case of interlocked twins out of 298 planned breech-first twins, while Blickstein [\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e] had no cases of entanglement among the 286 planned vaginal births of breech-first twins. The entanglement became evident after baby A was born to the chest with no further progress and unsuccessful attempts to maneuver the baby. Reaching inside past baby A\u0026rsquo;s head and using his hand as a fulcrum, SJF was able to successfully unlock the two heads and deliver both babies promptly with good outcomes [\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e]. Knowing the mechanics of breech birth and having the skill and experience to understand what was happening, SJF was able to resolve a situation that is rarely encountered.\u003c/p\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003eChorionicity:\u003c/h2\u003e\n \u003cp\u003eChorionicity should be determined as early as practical so as to outline a best plan of action and counseling for mono-chorionic, di-amniotic twins who are at risk of TTTS \u0026amp; TAPS (twin anemia polycythemia sequence) [\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e]. When in our care, mono-di twins began surveillance at 14\u0026ndash;16 weeks with follow-up scans every 2 weeks until 28 weeks. SJF\u0026rsquo;s experience is that TTTS becomes much less likely if there is no evidence by 28 weeks. However, TTTS can occur at any gestational age for mono-di twins [\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e], so ongoing monitoring for TTTS would be discussed with the parents. Four of our twin mothers developed TTTS over the period of our study. All four reached the level where fetal laser surgery was indicated between 20\u0026ndash;25 weeks. We are fortunate in our community to have local options for this procedure. All four had successful ablation of the communicating vessels and all eight babies survived. Three delivered by cesarean from 29.5 to 33 weeks and one mother delivered vaginally (vertex/vertex) at the hospital at 33 5/7 weeks. With di-di twins we recommended growth scans every 4\u0026ndash;6 weeks unless there were predisposing factors indicating need for more frequent surveillance. We encouraged all twin clients to have a 20-week structural survey ultrasound.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003eTo induce or not to induce?:\u003c/h2\u003e\n \u003cp\u003eThe average gestational age at delivery in our population of laboring women was 39 weeks (range 35\u0026ndash;42 weeks). This differs significantly from how most hospitals manage twin pregnancies, with induction or C-section several weeks earlier than our population\u0026rsquo;s average [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e]. The relative rate of stillbirth rises for twins beyond 35 weeks, hence the recommendation that all twins should be delivered by 37\u0026ndash;38 weeks. (The relative rate of stillbirth rises for singletons beyond 35 weeks, as well.)\u003c/p\u003e\n \u003cp\u003eOur clients\u0026rsquo; preference for low intervention births was one of the main reasons they sought a community rather than hospital location. In our population we did not recommend induction simply based on gestational age. We believe that counseling based on relative risk alone is not helpful and even sometimes deceptive and that absolute risk should be discussed. This sets the risks in context of how common or rare they are. We also trust the evidence and predictive value of fetal surveillance [\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e] and generally follow ACOG guidelines when recommending its initiation after thorough informed consent counseling. During the informed consent process, we rely on the information from Page et al. [\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e], which shows the risk of PND/NND for twins at each gestational age.\u003c/p\u003e\n \u003cp\u003eIn twins, excluding those complicated by gestational diabetes, hypertension, and IUGR, there is almost a 7-fold increase in the risk of IUFD between 37 and 40 weeks (relative risk). On the other hand, there is a 99.93% chance of not having an IUFD at 37 weeks and a 99.53% chance of not having an IUFD at 40 weeks (absolute risk). When counseling patients, practitioners should explain the risks in an unbiased way and state absolute, not relative risk. The American Medical Association (AMA) code of ethics states, \u0026ldquo;Rational, informed patients should not be expected to act uniformly, even under similar circumstances, in agreeing to or refusing treatment.\u0026rdquo; [\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e]. It is a basic tenet of medical ethics that when people are given the same information, they will not all reach the same conclusions [\u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e]. It is not surprising then to understand why many in our population were willing to wait for spontaneous labor despite the small increase in the absolute risk of stillbirth. For our population, the risks of induction or cesarean section outweighed the risks of awaiting labor. We did offer (but not require) fetal biophysical profile testing beginning in the 38th week to reassure the family, the team and the potential hospital transport practitioner.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eCare during labor:\u003c/h2\u003e\n \u003cp\u003eCare during twin labors in a community setting differs significantly from how most twins are managed in a hospital setting [\u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e]. The care practices that our population finds objectionable include moving the mother to an operating suite for a vaginal delivery, having a room full of staff, most of whom are strangers to the woman; lithotomy positioning; coached pushing; epidurals (often mandatory); immediate cord clamping; separation of mother and newborn; and AROM and immediate delivery of twin B within just a few minutes of twin A. In contrast, we support the mother in a safe, private environment where she is surrounded by people she knows. She is free to move at will, to eat and drink, to birth in whichever positions she finds most comfortable, most often to await the birth of baby B, and to have uninterrupted skin-to-skin contact with her baby after the birth.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eDelivery interval:\u003c/h2\u003e\n \u003cp\u003eWe believe that a short, actively-managed delivery interval is a routine born of impatience and convenience. We acknowledge that the literature shows some associations between delivery interval and lower cord gasses in twin B [\u003cspan class=\"CitationRef\"\u003e44\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e]. However, we also see the benefits to letting the labor unfold without intervening for a specific indication. Hastening the birth of twin B should be only done in the rare indications where immediate interventions for twin A \u0026amp; B are medically indicated. Women should be free to move about and push and deliver in whatever position feels best to them.\u003c/p\u003e\n \u003cp\u003eBabies should have immediate skin to skin and optimal cord clamping (defined as waiting until the cord is limp, white, and flat before clamping \u0026amp; cutting the cord). In mono-di twins with no evidence of TTTS, we saw no reason to alter our practice of optimal cord clamping. Baby A can be put to breast to help stimulate contractions for Baby B. We recommend respectful, silent waiting for at least 30 minutes, intermittently monitoring Baby B\u0026rsquo;s heartbeat, to let mom and her uterus do what nature intends before suggesting an intervention. Like so much of the medical model, these routine habits are done without concern for downstream consequences and the desires of the mother.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eThird Stage Management:\u003c/h2\u003e\n \u003cp\u003eIn clients with no risk factors for postpartum hemorrhage, we discussed but did not demand active third stage management. Patients were given informed consent about the increased risk of blood loss after a twin delivery and their decision to accept or decline routine postpartum Pitocin injection was respected. While some women were accepting of immediate IM Pitocin after delivery of twin B, many of our patients preferred to avoid pharmaceuticals, which is common in the community birthing population.\u003c/p\u003e\n \u003cp\u003eEBL levels in our population are higher than in reported hospital studies, but with lower rates of blood transfusion. For example, in the Twin Birth Study [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e], 2.3% of the planned vaginal births had EBL\u0026thinsp;\u0026ge;\u0026thinsp;1500 ml and 5.4% received blood transfusions, while our cohort had a rate of EBL\u0026thinsp;\u0026ge;\u0026thinsp;1500 ml of 15.3% but with no blood transfusions needed. Some of this may be complicated by the accuracy of estimating blood loss, and some may in part be our population\u0026rsquo;s preference for physiological third stage and for longer average delivery interval times (the JUMODA study interval averaged 5 minutes in the planned vaginal birth group [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e], while our population averaged 35.1 minutes).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003eLimitations:\u003c/h2\u003e\n \u003cp\u003eWhile our dataset has detailed information on the pregnancies and births, it is too small to accurately calculate the incidence of rare events, such as severe neonatal morbidity or mortality. We are aware of home birth practitioners in the US who have attended over 500 sets of twins, but their data has never been analyzed.[1] We strongly encourage all practitioners, whether community- or hospital-based, to collect and publish their data on planned vaginal births of twins.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eProperly selected, motivated twin mothers can successfully birth in a home setting, if they have a supportive environment, a skilled practitioner, and a competent team of birth workers. Properly selected term twin vaginal birth, regardless of which twin is breech, is a reasonable option with excellent success rates in skilled hands and should be offered to all women with twin pregnancies. Residency training programs should reinstitute the teaching of these skills to ensure women desiring hospital births are not pushed outside the system. Professional medical organizations and state legislatures should recognize the value and dedication of midwifery care in the community and stop limiting choices, under the guise of safety, that rightfully belong to the pregnant woman.\u003c/p\u003e \u003cp\u003eThe midwifery approach to term twin pregnancy is significantly different from the obstetric medical model, and women seek it out despite obstacles of cost, relocation, and social disapproval. Most twin mothers entered into our practice early in gestation, but some transferred or relocated later in the pregnancy, usually due to lack of birth options in their community. The midwifery approach supports physiology and strongly supports vaginal birth in the context of the woman\u0026rsquo;s individual values and preferences. A medicalized approach to multiples sees twin birth as hazardous and relies heavily on algorithmic managing of the prenatal period, following a high-risk protocol of consults and ultrasound, and then managing the birth process via cesarean section or induction of labor. In SJF\u0026rsquo;s experience attending births for over four decades in both hospital and community settings, this approach causes anxiety and fear in the women and their families, with the anxiety often originating from the practitioner. In contrast, when a woman is confident and feels supported, her prenatal experience and labor are more enjoyable. While alertness and vigilance are appropriate, a fear-based defensive approach to twins is unwarranted and detrimental.\u003c/p\u003e \u003cp\u003eAs opposed to the pre-ultrasound era, when half of all twins were discovered in labor, most women discover a twin pregnancy early on. We know that around half of all twins will have at least one baby in the breech position [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Many obstetricians have no training or experience in vaginal breech birth; breech extraction may be the only skill they learn and the only tool they have, limited to twin B. Without vaginal breech skills, practitioners cannot be considered experts in twin birth because they lack the skills for an event (breech presentation) that occurs almost half of the time.\u003c/p\u003e \u003cp\u003eWe argue that obstetricians should not be taking care of twins if they cannot or will not support vaginal breech births, since roughly half of all twins involve one or more breech presentations. However, they continue to do so and rarely refer their twin clients to someone skilled and confident in twin vaginal delivery. But this is exactly what must be done if we are to honor our code of ethics as maternity practitioners.\u003c/p\u003e \u003cp\u003eWe also propose some common sense suggestions for less experienced practitioners attending twin births:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eSeek out breech training and practice the associated maneuvers monthly\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAdhere to reasonable selection criteria, honoring one\u0026rsquo;s personal comfort levels\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eGestational age of 35 weeks or greater (in a community setting)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMultiparous mothers\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDiamniotic/dichorionic twins and relative concordance (due to a need for more frequent surveillance and consultation with discordant growth and mono-di twins)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eAs skill and comfort levels increase, practitioners can offer more expansive options such as primiparas and uncomplicated mono-di twins.\u003c/p\u003e \u003cp\u003eInstead of creating an ever-expanding list of contraindications to home and birth center births\u0026ndash;including twins\u0026ndash;we propose that we \u003cem\u003econtraindicate restrictions on maternal choice of practitioner or birth setting\u003c/em\u003e and \u003cem\u003econtraindicate restrictions that limit providers in both community and hospital settings from supporting vaginal twin or breech births\u003c/em\u003e. Contraindicating certain choices is paternalistic, assuming the doctor, obstetric society, or regulatory committee knows better than the woman herself. It also ignores individual values, beliefs, and preferences, seeking to impose a one-size-fits-all maternity care experience that may benefit some while harming others. The goal should be to create a nurturing environment, where each woman is treated with dignity, compassion, and respect by a skilled twin practitioner and where her choices are not just tolerated but enthusiastically supported.\u003c/p\u003e"},{"header":"List Of Abbreviations","content":"\u003cp\u003eAROM artificial rupture of membranes\u003c/p\u003e \u003cp\u003eEBL estimated blood loss\u003c/p\u003e \u003cp\u003eIPV internal podalic version\u003c/p\u003e \u003cp\u003eIUFD intrauterine fetal demise\u003c/p\u003e \u003cp\u003eIUGR intrauterine growth restriction\u003c/p\u003e \u003cp\u003eFHT fetal heart tones\u003c/p\u003e \u003cp\u003eIUI intrauterine insemination\u003c/p\u003e \u003cp\u003eIVF in vitro fertilization\u003c/p\u003e \u003cp\u003eNICU neonatal intensive care unit\u003c/p\u003e \u003cp\u003eNIL not in labor\u003c/p\u003e \u003cp\u003eSPROM spontaneous premature rupture of membranes\u003c/p\u003e \u003cp\u003eTAPS twin anemia polycythemia sequence\u003c/p\u003e \u003cp\u003eTOC transfer of care\u003c/p\u003e \u003cp\u003eTOLAC trial of labor after cesarean\u003c/p\u003e \u003cp\u003eTTN transient tachypnea of the newborn\u003c/p\u003e \u003cp\u003eTTTS twin-twin transfusion syndrome\u003c/p\u003e \u003cp\u003eVBAC vaginal birth after cesarean\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e This project was approved by the University of Michigan IRB (HUM00209968). The IRB waived the requirement for patient informed consent to participate in this research project since it was a retrospective chart review using de-identified records.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e We have informed consent from the family to link to their birth video for this publication.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This project had no institutional or private funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e SJF collected and collated the data and authored the abstract, methods, and results sections. RF wrote the background section, created the images, and performed the statistical analyses. SJF and RF together wrote the discussion and conclusion sections.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e Our paper would not have been possible without the dedication and collaboration of the Southern California community based midwives, doulas, students and other birth workers who supported the author and the families throughout the pregnancy, labor and postpartum. It is with great appreciation and gratitude we acknowledge their contribution.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information:\u003c/strong\u003e RF has a PhD from the University of Iowa and is the founder and president of Breech Without Borders, a 501(c)3 nonprofit dedicated to breech training, education, and advocacy (breechwithoutborder.org). She is the co-author of \u003cem\u003eA Guide to Physiological Breech Birth\u003c/em\u003e (2022), a chapter in the 2020 book \u003cem\u003eBirthing Outside the System: The Canary In the Coal Mine\u003c/em\u003e, and several articles about vaginal breech birth and home birth.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSJF (MD, FACOG) has been a practicing clinical obstetrician for over 40 years in both hospital and community settings. He is a published author and now travels around the world teaching seminars on breech and twin skills via Birthing Instincts (www.birthinginstincts.com).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMartin JA, Hamilton BE, Osterman MJK, Driscoll AK. Births: final data for 2019. National Vital Statistics Reports. 2021 March 23;72(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBateni ZH, et al. Trends in the delivery route of twin pregnancies in the United States, 2006\u0026ndash;2013. 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J Korean Med Sci. 2007;22(2):248\u0026ndash;53. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3346/jkms.2007.22.2.248\u003c/span\u003e\u003cspan address=\"10.3346/jkms.2007.22.2.248\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e For example, Cynthia Caillagh, a Certified Professional Midwife in rural Wisconsin, attended 561 vaginal breech births and 527 sets of twins in a community setting over her 50-year career as a midwife. In the past decade, she had a 97+% vaginal birth rate for her breech and twin births. She was compiling her breech and twin data for RF to publish when she died of cancer.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Twins, Chorionicity, Home birth, Birth center, Out-of-hospital birth, Physiological birth, Autonomy, Informed consent, vaginal breech birth, breech","lastPublishedDoi":"10.21203/rs.3.rs-3290533/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3290533/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003eResearch on outcomes of community (home or birth center) twin birth is scarce. This study evaluates the outcomes of twin pregnancies entering care with a single practitioner in a community setting.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This is a retrospective observational cohort study of 100 consecutive\u003c/p\u003e\n\u003cp\u003etwin pregnancies planning community births during 12 years with a single obstetrician. Outcomes measured included mode of delivery; birth weights; Apgar scores; ante-, intra-, and post-partum transports; perineal integrity; delivery interval; blood loss; chorionicity; weight concordance; and other maternal or neonatal morbidity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Of the 100 twin pregnancies who entered into care, 31 (31%) transferred to a hospital-based clinician prior to labor. The remaining 69 sets of twins were still in the obstetrician’s care at the onset of labor. Of those 69 pregnancies, 79.7% (n=55) were di-amniotic-di-chorionic and 21.3% (n=14) were mono-di. The vaginal delivery rate was 91.3% (n=63) including 16/21 primips/TOLACs (76.2%) and 47/48 multips (97.9%); 6 mothers (8.7%) had in-labor cesareans (1 multip and 5 primips). Rates of vaginal delivery did not vary significantly by chorionicity; 91.4% (53/58) of di-di and 90.9% (10/11) of mono-di twins gave birth vaginally.\u003cstrong\u003e \u003c/strong\u003eThere were 8 transports in labor (11.6%) with 2 birthing vaginally and 6 via cesarean. Average gestational age was 39.0 weeks (range 35-42). Compared to primiparas, multiparas had less perineal trauma and higher rates of community, vaginal, and spontaneous vaginal birth. One twin infant and one mother required postpartum hospital transport. Of the babies born in a community setting, there was no serious morbidity requiring hospital treatment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: A community birth leads to high rates of vaginal birth and good outcomes for both mothers and babies in properly selected twin pregnancies. Community twin birth with midwifery style care under specific protocol guidelines and with a skilled practitioner may be a reasonable choice for women wishing to avoid a cesarean section—especially when there is no option of a hospital vaginal birth. However, this study is underpowered to calculate uncommon adverse neonatal outcomes. Training of future practitioners in vaginal twin and breech birth skills remains an imperative.\u003c/p\u003e","manuscriptTitle":"Twin home birth: Outcomes of 100 sets of twins in the care of a single practitioner","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-09-19 15:45:31","doi":"10.21203/rs.3.rs-3290533/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cf21a016-faf2-4952-bd82-b3ef3b561d7d","owner":[],"postedDate":"September 19th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-11-26T06:29:12+00:00","versionOfRecord":[],"versionCreatedAt":"2023-09-19 15:45:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3290533","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3290533","identity":"rs-3290533","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}