June 23, 2010
Volume 12, Issue 13
Midwifery Today E-News
“Twin Pregnancy”
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In This Week’s Issue:

Quote of the Week

“The better the obstetrician, the more like a midwife he or she becomes.”

Nancy Wainer Cohen

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The Art of Midwifery

Avoid Wrist Fatigue

When a birthing woman is using the "all fours" position, have her put her hands into fists, keeping her arms and hands entirely vertical, to avoid wrist fatigue.

Carla Hartley
Excerpted from Tricks of the Trade, Vol. I
Tricks of the Trade, Vol. I is out of print. You’ll find the rest of the Tricks books here.

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Jan’s Corner

Dating a Pregnancy—Hands-on Care

Ultrasound tests are not accurate and are dangerous to the baby. Some babies even try to get away from the onslaught of sound waves. It isn’t cute. It isn’t funny. It is serious business, and the effects of ultrasound can possibly last a lifetime for the baby. So many mothers are getting failed inductions for being "overdue," but I wonder if the ultrasound is accurately dating these pregnancies. Are these mothers really at 42 weeks? Often they are not. And many of these inductions lead to cesareans.

So, how do we date a pregnancy without ultrasound? The Dubowitz test of gestational age is done at birth. It involves looking at the amount of vernix on the newborn (a lot may indicate an early baby; none may mean a late baby); size of fontanel, development of genitalia, cartilage in ears, size of breast buds, whether or not the testes have descended, creases in bottom of feet, length of fingernails and so on. Here is a link to the test: https://www.cebp.nl/vault_public/filesystem/?ID=1307 (opens a PDF) Many women undergo a cesarean for a too-late baby only to find their baby has been ripped from them too early. MIDIRS (Midwives Information and Resource Service, http://www.midirs.org) reports that the midwife’s hands, combined with the woman’s knowledge, date a pregnancy more accurately than ultrasound.

How to date your pregnancy (your midwife will hopefully know this; your doctor may not know this or may not tell you):

First, determine the length of your cycle: Start with the first day of your last period, but remember: the length of your cycle is important. How many days are between your periods? The standard 40-week pregnancy is based on a 28-day cycle, so if you have 35 days between your periods you might go two or three weeks over the 40-week mark and not be overdue at all. (Or, if the women in your family all delivered three to four weeks overdue, you may go past the typical 40-week date.) Likewise, if there are 26 days between your periods, and you ovulate at a nonconventional time, you may have a full-term baby one to three weeks earlier. Don’t wait until you’ve had an “unnecesarean” and the Dubowitz scale lets you know that your baby wasn’t late. From conception, it is approximately 266 days to birth, and 280 from last menstrual period. Midwives: Remember to listen to women. Often, they can pinpoint the exact day of conception.

First movement: Many first-time moms feel their baby move (fluttering, not hard kicks) at approximately 20 weeks. Sometimes thin moms will feel movement sooner than 20 weeks. Dating a pregnancy this way can be way off, as some moms feel first movements much later than 20 weeks, but it gives another parameter when you need to figure out if this baby is early or late. Monika, my midwife partner, and I once had a woman go into labor a full month early. We analyzed all of our charting, and we asked and noted all of the types of things you are reading about right now. We finally figured out that this mother wasn’t early—she actually was right on time. She went into labor and we were comfortable that she was not 36 weeks. She had a lovely birth and a baby that was not early.

First FHT: Note when you first heard heartbeat with a fetoscope, not a Doppler. Dopplers are ultrasound and should only be used when necessary. You will generally be able to hear the FHT (fetal heart tone) between 18 and 22 weeks, give or take a bit. We used to use a Leff scope, which is shaped like a small saucepan but is heavier. I think we were able to hear the FHT sooner with this tool—often at 18 weeks. You may not be able to hear the FHT with the Pinard or other fetoscopes until later than 18 weeks.

Growth of uterus: Midwives will often perform a bimanual test to determine uterus size. If the uterus is the size of an orange, the mother is approximately 8 weeks. If it is grapefruit-size, she is approximately 12 weeks. Fundal height is measured by charting the distance from the top of the pubic bone to the top of the uterus. It is much more accurate if measured by the same person each time. Many of us liked using our fingers to measure fundal height. When the uterus can be felt at the umbilicus (bellybutton), you are at 20 weeks. You add another two weeks for every finger width past the umbilicus, so if the top of the uterus is four finger widths above the umbilicus, you are approximately 28 weeks. If you are measuring with a measuring tape, figure one centimeter for each week, so four centimeters past the umbilicus would be approximately 24 weeks. This measurement also may clue you into a twin pregnancy. Monika and I missed a twin pregnancy once. Looking back over the chart we might have suspected it had we looked harder. Oh well, sometimes things turn out better than we could have planned. You should have seen our faces when this “big baby” was so small and our mother birthed twins—on Valentine’s Day!

Jan Tritten, mother of Midwifery Today

Jan Tritten is the founder, editor-in-chief and mother of Midwifery Today magazine. She became a midwife in 1977 after the amazing homebirth of her second daughter. Her mission is to make loving midwifery care the norm for birthing women and their babies throughout the world. Meet Jan at our conferences around the world, or join her online, as she works to transform birth practices around the world.

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Consider chiropractic care for safer, easier births.

Our doctors offer special care for pregnant women and infants. Specialties include the Webster technique for optimal fetal positioning and gentle cranial and spinal techniques for your baby. Visit www.icpa4kids.org.


Researchers investigating the disproportionate rate of perinatal morbidity in twin pregnancies concluded that paying attention to "twin-specific nutrition" could help lower these rates and result in healthier twin pregnancies. Recommending nutritional intake beyond that found in a typical prenatal vitamin, the authors recommended that mothers pregnant with twins be on a carbohydrate-controlled diet and supplement their diet with iron, folate, calcium, magnesium and zinc at a rate above that normally recommended for a singleton pregnancy.

"Antepartum lactation consultation can also improve the rate of postpartum breastfeeding in twin pregnancies," the authors added.

— Goodnight, W., R. Newman and Society of Maternal-Fetal Medicine. 2009. Optimal nutrition for improved twin pregnancy outcome. Obstet Gynecol 114(5): 1121–34.

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Considerations for Twin Birth

Why do so many multiple births happen prematurely? The medical theory is that multiple pregnancy not only causes added stress on the maternal system but that over-distention of the uterus causes premature contractions and labor. If that is so, then why do so many very large babies (over 9 pounds) often go to term—or even overdue? I have seen some very over-distended abdomens, which not only carried large babies but a surplus of amniotic fluid as well, with fundal heights often measuring up to or greater than 45 centimeters. These women carried to term, some went overdue, and had completely normal labors and deliveries. I sincerely believe most twins are born prematurely because they are suffering from starvation in utero, and come out early so that they can be fed!

Several important considerations should be noted when anticipating a twin delivery. These include: the mother’s commitment to her nutrition and general health; the type of twins (fraternal, monozygotic, etc.); the placental attachment site; the position of the babies and their growth and development. It must be noted that monozygotic twins have a greater likelihood of having fetal anomalies and are at risk for developing twin-to-twin transfusion. For this reason, I strongly advise clients to have at least three ultrasound examinations during the course of the pregnancy.

The first should be done at the time the multiple gestation is suspected or diagnosed. In my experience, this is usually between 16 weeks and 20 weeks. At this time, the gestational age and the type of twins expected are most easily diagnosed. Hopefully, even if only one placenta is seen (it is possible that two placentas have fused early in pregnancy), individual amniotic sacs will be identified. If both babies are within one amniotic sac, the delivery risk is very high, as the babies, and most important their umbilical cords, may become entangled. Many of the twins in this category do not survive pregnancy.

The second ultrasound should be done at about 30 weeks, so results can be compared with the first scans. At this time, problems such as intrauterine growth restriction (IUGR) may be diagnosed in one or both babies due to placental insufficiency. Or, any life-threatening anomalies in one or both babies can be identified so that preparations and plans can be made as to mode and place of delivery. An ultrasound at this time may also detect a discrepancy in size and estimated gestational age, which is possible when there is a separate conception date (rare) for the babies.

Also at the 30-week mark, if twin-to-twin transfusion is taking place, the babies will be remarkably dissimilar in size and weight, and the mother should be referred for high-risk care. In this case, the babies will be monitored closely and delivered as soon as they have reached sufficient maturity. Interestingly, the baby most at risk is the larger one, who has received a surplus of blood. This baby must be handled very delicately as its internal organs have been stressed. Often, the suffused baby will require one or more exchange transfusions to first reduce and then to supplant red blood cells. The smaller, anemic baby can simply be given extra blood.

Valerie El Halta, CPM
Excerpted from "Twins: A Very Special Occurrence," Midwifery Today, Issue 39, Fall 1996
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Q: Have you assisted with an at-home twin birth? Tell us what you learned.

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