Ep 201: Everything You Wanted to Know About Twins with Dr. Nathan S. Fox

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Aren’t twins so fascinating? Today we have Dr. Nathan (Nate) Fox here to tell us all about them! He’s a maternal fetal medicine specialist, also known as a high-risk pregnancy doctor or a perinatologist, which is an OB/GYN that works with more complex pregnancies. 

The truth is a lot of doctors don’t have much training or experience with twins and as a result, you might not get the level of care you need or have all the birth options open to you. You want doctors on your team who know which screenings/tests to do, how often you should be seen, and what your nutrition should be like (it’s different for twins). You also want doctors who feel confident offering vaginal birth instead of just going straight to cesarean, which happens more than it should. Whether you are pregnant with twins or just want to learn more about twins, this episode is a must listen.

In this Episode, You’ll Learn About:

  • What it means to be a maternal fetal medicine specialist
  • How common it is to have twins
  • What some of the risk factors are for having twins
  • What distinguishes different kinds of twins from each other
  • How the prenatal care for single babies and twins differ
  • What the models of care are for twins
  • Why you should consider seeing a specialist
  • How a high-risk doctor works with other perinatal care providers
  • What additional risks come with twin pregnancy
  • How perinatologists approach (the almost inevitable) early term twin birth
  • How much more important Dr. Fox says weight gain is in twin vs. singleton pregnancy

Links Mentioned in the Episode

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Dr. Nicole (00:00:00): This episode with Dr. Nate Fox, OBGYN, and maternal fetal medicine specialist is a must listen if you are pregnant with twins or just want to learn more about twins, welcome to the All About Pregnancy and Birth podcast. I'm Dr. Nicole Calloway Rankins, a board certified obgyn, who's been in practice for nearly 15 years. I've had the privilege of helping over 1000 babies into this world, and I'm here to help you be calm, confident, and empowered to have a beautiful pregnancy and birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer@drnicolerankins.com slash disclaimer. Now, let's get to it.

(00:00:56): Hello there. Welcome to another episode of the podcast. This is episode number 201. Whether you are a new listener or you've listened before, I am so glad that you are spending a bit of your time with me today. In today's episode of the podcast, we have Dr. Nathan (Nate) Fox. He is an OBGYN maternal fetal medicine specialist practicing in New York City. He's also a clinical professor at Mount Sinai and a managing partner at Maternal Fetal Medicine Associates and Carnegie Imaging for women in New York City. Dr. Fox is the creator and host of his own podcast called The Healthful Woman Podcast, and you definitely should take that out. And when not practicing medicine. You can find Nate running, walking his dogs or embarrassing his wife and four children, including a set of twins. By the way, now speaking of twins, this episode is all about twins, and you are going to learn so much in our conversation today, including how common twins are, the different types of twin pregnancies and general people.

(00:02:00): Think of twins as identical and non-identical. We think of twins in a completely different way, and you're going to learn that in the episode we'll learn about the important ways prenatal care should change. If you have twins, what are some concerns or complications that can occur? We'll talk about the timing of birth for twins as well as the way twins are born, vaginally versus cesarean. He has some really insightful information about that. Also, the difference in nutrition for twins. I was surprised about this. I learned something here in this conversation, and I know you're going to learn a lot in this conversation too. Dr. Fox has a great way of explaining things in a way that makes these topics very clear, easy to understand, tons of useful information. You're going to enjoy it. Now, before we get into the episode, one of the things that doesn't really change about twins is the type of test you get during pregnancy. And if you're curious about all of the various prenatal tests that should happen during pregnancy, then check out my free guide to prenatal test where I explain what tests are done. I break it down by trimester, explain what it's for, the results, all of that good, great stuff. You can grab this free guide at drnicolerankins.com/prenatal. Again, that's Drnicolerankins.com/prenatal. All right, let's get into the conversation with Dr. Nate Fox.

(00:03:29): Thank you, Dr. Fox for agreeing to come back on the podcast this time for a solo episode. And I am super excited to have you come back. And today we're going to chat about twins.

Dr. Fox (00:03:39): Love it. Game on. Let's do it.

Dr. Nicole (00:03:41): All right. So why don't you start off by telling us a bit about yourself and your work and your family.

Dr. Fox (00:03:46): Yes, so I am, I'm a Midwesterner. I was born and raised in Chicago, Illinois, which is where I got my pleasant disposition, and then I got transplanted out to New York City, which is where I lost it. And no, I came here for college and I met my wife. We got married young. I went to medical school here in New York, and then my OBGYN residency here in New York City at Mount Sinai. At the same time, my wife was getting her doctorate, her Sci D and school and child and clinical psychology. And at the same time, this is when I was in med school, we were having our own twins, all right. Who were born my third year in med school. That was very exciting. And then I went on to do my fellowship in maternal fetal medicine at Cornell where we had our third kid.

(00:04:38): So I had two in medical school. Sorry. Oh my God, I got that all wrong. I had two in medical school. See now, just showing my age. Then I had one in residency that was my third, and I was a resident, and my fourth was in fellowship at Cornell. Wow. So I like to say we had, as I progressed in my own training about childbirth, we practice what you preach. So we had kids in every stage of my training. And then I've been in practice. Yeah, I've been in practice in New York City since then. It's a private group in that we're not employed by the hospital, but since by the nature of what we do, we deliver our babies at the hospital, and that's at Mount Sinai. But our main group is called Maternal Fetal Medicine Associates, which is a very clever name for a bunch of maternal fetal medicine doctors.

Dr. Nicole (00:05:26): Well, speaking of maternal fetal medicine, why don't you tell us what exactly that means to be a maternal fetal medicine specialist? And then there are other names like Perinatologist or High-Risk Doctor, and I think it kind of confuses people sometimes. So tell us exactly what that means.

Dr. Fox (00:05:41): Yeah, it's intentionally confusing and makes us sound smarter than we are, but basically a maternal fetal medicine specialist is someone we do. We go to medical school, so we're doctors, and then we do training in obstetrics and gynecology. We're trained as obstetricians. You take care of pregnant people and deliver their babies and gynecology, so that's exams and gynecologic problems and surgery. And then we do an additional, nowadays it's three years of training, what we call a fellowship, and that is essentially focused on several things. It's focused on care of high risk pregnant women. So that could be someone who, let's say, comes into pregnancy with a high risk condition, like let's say she has diabetes or hypertension, or she has a history of cancer, whatever it might be, or she's healthy, but develops a condition in pregnancy like pre-eclampsia or preterm labor or bleeding.

(00:06:39): So that's one facet of the high risk training. The second is we do a lot of ultrasound, so we're sort of like the radiologists of pregnancies, so we learn to do a lot of ultrasound that's predominantly of the fetus of the baby, although there is some maternal anatomy that we look at, the cervix, the ovaries and whatnot. So we do a lot of that. And then the third aspect is generally research related. So we learn with research and doing and publishing and reading and teaching and whatnot. And then when we finish, we have a lot of options. So some of us continue to do prenatal care and deliveries, and some of us don't. And the ones who don't generally will be doing ultrasounds and consultations and maybe procedures. There are even some maternal fetal medicine doctors who still do general gynecology. I don't personally, it's few and far between.

(00:07:28): Sure. A lot of it's hard to be the master of so many things. So I would say in the US, the majority of maternal fetal medicine specialists don't do deliveries. They certainly don't do a lot of them. I'm one of the rare birds who still doing deliveries and staying up at night and being a part of that part of the pregnancy journey. And so that's what I do. And yes, it's sometimes called perinatology not to be confused with neonatology, which is the newborns. And then high risk is a kind of a vague term, but yes, people call us that as well. People call me a lot of names, but of the good ones, maternal fetal medicine or MFM as usually the most precise.

Dr. Nicole (00:08:10): Thank you. That was very a great explanation because I see a lot of people get confused because they think that they're MFM doctors going to be at the delivery, and I'm like, I don't think your doctor knows how to do that anymore. Yeah. See,

Dr. Fox (00:08:25): I have patients, say to me, I just want to make sure, because our practice is actually mixed. We have maternal fetal medicine specialists, we have obstetrician gynecologists, we have obstetrician gynecologists who only do gynecologist. We have a whole, sure. There's a lot of us. And sometimes one of the patients will say to me, oh, I just want to make sure that one of the MFMs does my delivery. And I'll be like, I don't think so, because some of them haven't done a delivery in 30 years, and maybe you don't want them doing your delivery. Yes. So yeah, it is. That is a misconception or misperception. There's actually nothing about the high risk training. The fellowship in maternal fetal medicine that's really specific to deliveries, being good at providing care for someone in labor deliveries, C-sections, all that stuff is really a function of experience. People who do a lot of it tend to be very good at it, and people who do very little of it might be good at it, but might not. And so if you have a maternal fetal medicine doctor who does a lot of it, then yeah, they'll probably be pretty skilled. Or if you have an obstetrician gynecologist who does a lot of labor and delivery, they'll probably be very skilled, and it's much more so that than the specific designation if they did the fellowship or not.

Dr. Nicole (00:09:40): Yes. Yep. Love it. Great information. So let's talk about twins. Love it. So first off, how common are twins?

Dr. Fox (00:09:48): So in the upper East side of Manhattan, everybody,

Dr. Nicole (00:09:54): They're all getting IVF or what? I mean, is it,

Dr. Fox (00:09:57): I don't know. It's in the water. God bless. In the US the typical quoted rate is somewhere between two and 3% of births are twins. And that number would definitely be higher for someone who's having fertility treatments. It can go up, and that's true if you're having fertility treatments that are sort of lower intervention, taking certain medications or injections. In fact, when the Octo mom and sort of you hear these stories as someone's pregnant with eight babies, it's actually not ivf typically. It's not like an IVF doctor put an eight babies. It's usually someone got loaded up with hormones and then just went home and got pregnant. Right. Okay. So that's one risk factor. Having IVF would also increase your risk, particularly if they put in two embryos. But that's actually done a lot less nowadays. That's much more uncommon for good reason. It's just using one embryo at a time tends to be a lower risk way to go about it.

(00:11:00): But even one of the things that a lot of people don't realize is that if you have ivf, you have an increased risk of identical twins where it's not two separate embryos, but one embryo splitting in two in nature. That happens about one in 300 times. And that's true in every population on earth, which is remarkable having

(00:11:22): Oh, that's crazy. Yeah.

(00:11:23): Yeah. Identical twins, they don't run in families. They're not related to age. They're not in certain geographies. It's like about one in 300 everywhere. But if you have ivf, it's like two to 3%. For whatever reason, mucking around with that embryo makes them more likely to split. Interesting. So all the risk factors for twins are much more related to having non-identical twins, two separate eggs, two separate sperms. So things like my mother had twins, or it's more common as you get older. You see it's sometimes certain populations have a higher concentration of twins, but that tends to be the non-identical twins.

Dr. Nicole (00:11:59): Gotcha, gotcha. So you talk, people tend to think of twins as identical or non-identical, however, we think about them a very different way. So how do you, we talk about the different types of twins and specifically placenta, amnio, all that stuff. Yeah.

Dr. Fox (00:12:16): So it's a really important distinction. Like you said, when the babies are born and they become children and adults, we think of twins. Again, like you said, the two types. There's identical and non-identical. Or the fancy term for that would be monozygotic would be the identical. Sometimes they're called maternal twins, which isn't really a medical term, but that's used versus non-identical or di zygotic or fraternal twins. And the difference between those two is identical twins is one egg plus one sperm, making one little embryo, and then that embryo splits in half and well, not really in half, but whatever it sort of replicates. Sure. And so then you get two embryos that are identically the same. So identical twins will have the same dna, right. If you look at them, and those are the ones that typically look very much alike, and they can think back and forth each other and all the communication and all that very interesting stuff.

(00:13:11): Interestingly, they don't have the same fingerprints, which is fascinating how that happens. That fingerprints is something that happens after your DNA's coded in utero. It's very fascinating. Interesting. And then non identical or fraternal or dizygotic is basically two eggs and two sperms. They're basically siblings who are come out at the same time, who are housed in the uter at the same time, come on at the same time. So that's sort of what you think of them. But in pregnancy, the biggest issue in terms of which types of twins is really whether or not the twins share a placenta or they each get their own placenta. So identical twins, or I'm going to turn it around. If we see twins with one placenta, there's only one placenta and there's two twins. Each of them are attached by the umbilical cord to that placenta. They are by definition identical.

(00:14:06): They are identical twins. Now, those types of twins usually each have their own water bag, so they're not swimming in the exact same room, but whatever they share a placenta, think of it, whether you share a room or whether you share a refrigerator. So the placenta's like the refrigerator. So they each share a, share a refrigerator, but they each have their own room. So that's what we call monochorionic, which means one placenta, and then we say di amniotic, which means two water bags, or we sometimes call them mono di. Now, if there are two placenta, which is the more common situation, usually they're not identical, but they can be identical. So you don't know for sure. But either way, it's a lower risk twin pregnancy compared to having one placenta. And if they have two placenta, we call it dichorionic, and then they're in two water bags as well.

(00:15:00): And so we call diamniotic, and sometimes you hear the term di, di twins, which sounds very morbid, but it's d i, not d i e, and it's not d y e, it's di like two. So di, di twins. And again, most of the time they're not identical, particularly if you see that they have different genitalia, one female, one male, then you'll know that they're not identical. But even if it's the same, it's usually not identical, but they can be actually have friends who are, everybody knows they're identical twins. These are two guys who look alike, think alike, talk alike, everything's the exact same. And they say, oh, no, no, we're not identical. I'm like, how the hell are you not identical? Like, oh, we had two placenta. I'm like, sorry, bub. Yeah. You know,

Dr. Nicole (00:15:41): Can still be identical.

Dr. Fox (00:15:43): So in pregnancy, and then the reason having one placenta makes it even higher is because since they share that refrigerator, there can be an uneven distribution. One of them takes too much and the other one gets too little. Whereas if you have two placenta, that does not tend to happen. You can't really get that, but one steals from the other because it's separate. And so all twin pregnancies are higher risk for a lot of complications, but there are some that are unique to having one placenta, and those have to be followed even closer than we normally follow twin pregnancies.

Dr. Nicole (00:16:14): Love it. Very, you explain things so well, and I never even thought about how we say di, di in our field. We know what that means, but I can understand how patients might hear that and be like, why are you saying my twins are dying and dying? Yeah, that's crazy. So

Dr. Fox (00:16:28): It's like Seinfeld when he has the joke about the restaurant in the airport. That's called the terminal restaurant. Yes.

Dr. Nicole (00:16:36): That's

Dr. Fox (00:16:36): That's not a place I want to eat.

Dr. Nicole (00:16:38): You. Yes, no, thank you. No, thank you. And then I guess the highest risk is if they're in the same sack.

Dr. Fox (00:16:44): Yeah. If they're in the same water bag, which is again, they would have to have one placenta, and then they have one water bag. So that's one placenta, mono amniotic, one water bagger, we call them mono mono, which sounds, I don't know, a Hawaiian dish made of pineapple and something. But so that is a very, very high risk situation because not only do they have the risk of twins, and not only do they have some of the risk of sharing one placenta, but since they're in the same water bag, their umbilical cords can tangle around each other because they're sort of swimming around. Fortunately, that kind of twin is quite rare, but it's a big deal to have that twin.

Dr. Nicole (00:17:25): Yes, it's scary.

Dr. Fox (00:17:26): Yeah, actually, it's a very high risk situation.

Dr. Nicole (00:17:28): Yeah. So let's talk about how prenatal care changes when you have twins. What does it look like?

Dr. Fox (00:17:35): So it should look different. I think that unfortunately, there are a lot of pregnant women, both in the US and abroad when they have twins and their doctors are taking care of them. They don't really do anything different because they're having twins. And I think most of that is either related to ignorance that maybe the doctors don't realize that, or sometimes just resources. Some of the stuff isn't available and they're doing their best, right? Sure. They know exactly what someone needs, but that just isn't available. But ideally, because in our practice, we see from the lowest risk to the highest risk, we see everybody, we sort of tailor their visits and what they need in this based on what's going on. So for us, we'll see 'em as frequently as we need to, as infrequently. So someone with twins, there's so many additional risks that come about.

(00:18:31): And since someone is literally double pregnant, they have so many more complaints. I don't make complaints in a bad way, but they have symptoms. My back hurts to this. I'm having all these things that come up in pregnancy are much more likely to happen in twins. And so they need more frequent visits just to be seen, to ask their questions. There's a lot going on. A lot of things have changed. So essentially the things we worry about with twins is there's an increased risk of delivering early preterm birth. That's a big one. I'm sure we'll talk about that. And then there's an increased risk of how they're going to grow. One or both can not perform well and how they're growing. And then there's also high risk of diabetes, of pregnancy and high blood pressure. But those are the main ones. And so when we're seeing more people more frequently, we have to see the babies more frequently.

(00:19:21): So there's a lot more in terms of ultrasound, measuring the fluid around the babies, measuring the baby's weights, measuring their health later in pregnancy. We can't always use the mom's subjective assessment of how are the babies moving? Because since there's two in there, it's hard to always know, oh, the boy's moving, but the girl isn't sure. It's hard. I mean, some people know that and they can figure it out, but most can't sort of like I, they're moving, but I don't really know. Right. And so there's that and the screening for preterm birth, and we have to see the mom more frequently, check her blood pressure, see how she's feeling, see how she's doing. So ultimately for twins, I would say an average, and it's different for every practice. If you're having one baby for most of the pregnancy, we're seeing you once a month until the end. And for twins, most of them we're seeing every two weeks until the end. So that's sort of a short way to think about it. Sure. It's not exact. You can get away with monthly visits in some of the situations and twins, but it's really a lot. And it's really just visits with the doctor, the midwife, whoever's seeing them, and the ultrasounds, that tends to be the more reason they're coming in more frequently.

Dr. Nicole (00:20:27): Sure, sure. Okay. So midwives take care of twins, you think?

Dr. Fox (00:20:31): Yeah. I mean, listen, midwives can take care of twins. Midwives can deliver twins. A lot of it is, like we said before, at the obgyn versus the mfm. It's based on experience. It's based on comfort level. And absolutely there's midwives who take care of twins. I think that most of the midwives aren't going to be doing the ultrasounds in their office and reading them and doing, and maybe there are the that do, I don't know. I'm not sure. So it's certainly possible. But for my practice, there's the twins who are coming to us for everything, prenatal care, delivery, and we do their ultrasounds. But a lot of our practice is consultative. We're someone else, one of the community doctors, whether it's an obgyn or a midwife or a combination, is seeing the patients for all their prenatal visits and for their delivery. But we're seeing them, usually it's for a consultation to talk about twins for their ultrasounds, and if anything comes up and they need further consultation.

(00:21:26): And I would say the more common model for twins in the United States that you have your obstetrician gynecologist or your midwife, and then you're seeing somebody for your ultrasounds or for consultation. And that could be maternal fetal medicine specialist. It usually is. But again, sometimes resources are scarce and sometimes the obgyn, particularly if they're very experienced, can do a lot of that in their own office. But that's a great question for someone. If you have twins, you have to really ask, do I need to be seeing a specialist? How often do you take care of twins? How many do you deliver? And again, it's going to vary. There's some OBGYNs who are amazing at taking care of twins, and they take care of a lot of them, and they're really good and they don't deliver them, and they're great. And there's others who do it once a year, and obviously anything generally you want to see the person who does it more than does it once a year, unless it's something that only happens once a year, obviously. Sure. But twins are common enough that people who take care of twins take care of twins.

Dr. Nicole (00:22:22): Yeah. Yeah, for sure. So you touched upon it briefly, and maybe you can talk a little bit more about how often the complications occur. But you said preterm birth, are the things you look out for growth issues and then diabetes, maybe preeclampsia? Are those sort of the big complications that we worry about?

Dr. Fox (00:22:39): I mean in terms of the most common, and I'm going to put cesarean on as a separate conversation, because whether you call cesarean a complication or not is based on your perspective, but fine in terms of what we traditionally would call complications. So preterm birth defined as delivery under 37 weeks is very common. In fact, if you're carrying one baby on average, you're going to deliver 39 to 40 weeks, which is the week of your due date. 40 weeks is your due date. If you're carrying two babies, on average, you're going to deliver 35 to 36 weeks. So that's one month early. So on average, twins deliver at 35 and a half weeks now.

Dr. Nicole (00:23:22): Yeah. I didn't realize it was that early. Yeah.

Dr. Fox (00:23:24): Okay. It's interesting. That's the national numbers, and that should be looked at. Our numbers we've taken care of over about 1300 twins. It's like exactly there, 35 and a half weeks. And there's a few things about that. First, it's a month early two, if the midpoint is a week and a half premature, the majority of twins are going to be born prematurely. That's a great number. That's the midpoint, which means half the babies are born earlier than that. Now, fortunately, the bulk of the preterm births of twins are between 32 and 37 weeks when generally not uniformly, but generally the babies do very well, particularly if they have good NICU care. So if I knew that someone's going to deliver 35 and a half weeks, sure, I'd prefer she be pregnant a couple weeks longer, but I'm not sweating so much. I'm like, you know what?

(00:24:15): These babies may or may not go to the nicu, but the long-term prognosis is excellent, and if it's not as good as a baby 37 weeks, it's really close. Right, right. The differences are very slight. Yeah. Only about 10% of twins are going to deliver under 32 weeks. And that's pretty reassuring because it's really the baby's under 32 weeks that are more likely to have complications, and particularly under 28 weeks, which is really only three or 4%, it's not a high percentage that are going to deliver in that crazy scary range where you're talking about life or death. They may or may not survive. I mean, it's terrifying, but it's really only three to four, maybe 5% fortunately in that group. And so we know this twins deliver early, and so we're on the lookout for it. The problem is, unfortunately, we're much better at telling someone you're at risk to deliver early than we are at preventing them from delivering early.

(00:25:12): We kind of suck at that, not because we don't try and not because we don't care, but nothing we found seems to work, which makes a lot of sense. I mean, if the body's ready to deliver, it's pretty like, what are you going to do? You know what I mean? Yeah. It's, I mean, think about it almost in a sense, if you've ever had that friend or even yourself who's like about to throw up, there is nothing you can do to make it stop nothing. That is very true that it's coming out. Close your mouth, close your nose, right? Lie, stand, it's, it's happening. And so that's what happens when the body goes into labor. It is. It's vigorous. The uterus has really contracting away. So there are things that sometimes work in this and we do, but ultimately in our practice, we do a lot instead of focusing on how do we prevent preterm birth, meaning do we give people medicines to stop contractions?

(00:26:01): Do we tell them all to go on bedrest? First of all, none those things work. So we don't do that. We not either way. We focus a lot on prediction. We do cervical length screening in our twins, which is somewhat controversial. Not everyone agrees with that. We do fetal fibronectin testing in our twins, which is these are two tests that you could do to predict the likelihood of preterm birth, cervical length, and fetal fibronectin. The first one's an ultrasound, the second one is a Q-tip, like vaginal swab. Interestingly, we developed a calculator that if you have someone's with twins, you can plug in their gestational age the length of their cervix and their FFN fetal fibronectin results and it'll pop out. What is your risk of delivery before 32 weeks? What's your average gestational agent delivery? It's pretty cool, actually, huh? It's on our website, mfmnyc.com/twin. Okay, thank you. If I'm wrong, then it's slash whichever is the slash you're

Dr. Nicole (00:26:52): Supposed to use. I'm online. I think it's backslash.

Dr. Fox (00:26:54): Yes. Back slash twin. So we do that, and I always tell people when I'm doing this, I am very unlikely to get you to deliver later than you're going to. But what's interesting is, and this is true for everybody, but with twins, there's a higher risk of delivering early. If I have two women who are both carrying twins, and let's say both of them are going to show up at 30 weeks of pregnancy and deliver both those twins the same day, they're going to break their water, go until they deliver the twins. And let's say vaginal, forget about C-section, right? We both can deliver the same day, but one of them, somebody taps me on the shoulder a week in advance and says she's going to deliver next week. Her babies are going to do better. And the reason her babies are going to do better is that there are medications, treatments we can give before a preterm birth that improve to the mother, that improve outcomes for the babies afterwards.

(00:27:44): Things like steroids, potentially magnesium, potentially antibiotics spends on the situation. And we're pretty lousy at timing these because a lot of women show up at 30 weeks and deliver, and you don't have enough time to give them because you need about two days. And so when we looked at our own data and compared it to people who don't do these screening tests in our practice, when someone delivered under 34 weeks, the likelihood that they did get the steroids before birth was over 90%. Whereas we looked at another major medical center that does not do these screening tests, and theirs was about 70%, and the national average is about 50%. And so yeah, we're doing a lot of testing and screening, and people give us crap for that because they say, we're overdoing it. We're fine, but we're pretty good at doing what we need to do.

(00:28:34): Sure. And the interesting thing is you would think, okay, maybe you're just giving it to everybody and so you'll get your numbers up. If you look at women who deliver a term after 37 weeks, the likelihood they got exposed to steroids, it was only 7%. Good meaning we were also good at predicting who's not going to deliver early. And that that's also very useful because if someone's carrying twins and they're Googling that, they're at increased risk of preterm birth and they're seeing a high risk doctors talking about preterm birth, they're freaking out, right? Sure. This is really worrisome. But if they come to the office and they say, Hey, your cervix is long, your fetal fibronectin is negative, you're doing great. Have a great time. Go to work. Right? Do what you want to do. Go play tennis. Everything is going well, come back in two weeks. Versus the percentage where I really need to tell them, Hey, your cervix is sore. This let's, let's put you on watch, let's do this, let's do that. And so it ends up working even though we're doing a lot of screening. So that's how we do it in our practice. Yeah. This

Dr. Nicole (00:29:28): Is interesting because I think, I personally think Vbac calculators are trash because they don't help you. They don't change anything. You can still try for it. You can have a 10% chance of vbac. And I've seen people that have a successful feedback. So it doesn't help to me really predict the outcome. But in this circumstance, it's different. You actually have people you're giving beta method. I mean, that's part of, its my, I know from my own personal experience, I mean I had a singleton, but I happened to get steroids the week before I delivered it 32 weeks and she came out and she didn't have to get intubated or anything like that. So in this case, you're using the information to try to take the best resources that we have to improve outcomes.

Dr. Fox (00:30:10): And for the record, I'm also not a big fan of the vbac calculators for a lot of reasons. Number one, I don't think they're that much more accurate than just a really good season. Obstetrician telling you what their best guess is, your chance of delivering vaginally is, right. And I tell people about 50%, about 75%, about 90%. The calculator's not that much better. And number two, it becomes self-fulfilling. Meaning if you use the calculator and tell someone, oh, it's 46%, and then she's like, well, my friend had 68%, so I must be awful. I'm not going to try right now, it's 0%. Right? And that's been shown to be true. And it's also been a real issue with what went into the calculator and then they put in race in there and it was a whole disaster and they had to redo the calculators.

(00:30:55): Right. I'm not a big fan of that. But for this, what I tell women is I liken this to, if I'm leaving my house in the morning and I check my weather app and it says it's going to rain, right? I'm not changing whether it's going to rain or not, but I'm going to grab an umbrella. Sure. Right? Sure. And that's different. And so I think a lot of people are so much focused on, you can't change the rain. No, I can't change the rain, but I'm going to definitely want to have an umbrella or wear's different shoes or whatever it might be. And so for the twins, it's the same thing. If I tell So you're increased risk, it's not because I'm trying to necessarily, although sometimes there's things we can do that help, but I'm not trying to necessarily prevent the rain from happening.

(00:31:39): I'm like, all right, if it's going to rain, don't go on that trip to Mexico in two days or something of that nature that might be helpful. Or you're worried about, can I go to Philadelphia for Thanksgiving because that's where my mother is and I see them on the Tuesday of Thanksgiving and their cervix is long and their fetal FiberNetin is negative. I'm like, listen, I can't promise you anything. But the data shows the chancellor delivering this week is less than 1%. Sure, sure, sure. That's a lot better than saying, oh, you got twins, you can't go anywhere. Absolutely. And so you try to, there's this concept called precision medicine. You try to be precise because if you give everybody the average, you're underselling it for half the people and overselling it for the other half. So you try to be as say, okay, I think you fall here to give them better information about this. But not even if you're not going to necessarily change the overall management. You could be prepared for something if you're at risk for it.

Dr. Nicole (00:32:34): Yeah, absolutely. Love that. Love that. And then as far as timing of the last question about preterm birth, you, you're, you're like not going to get to your due date with twins ever.

Dr. Fox (00:32:46): The due date is that's great term. So the due date is synonymous with the day you turn 40 weeks and zero days. Which is actually ironic because when you're 40 weeks and zero days, you've actually only been pregnant for 38 weeks and zero days for some strange reason. The day you conceive, we call two weeks and zero days. But we really do that to confuse people. But either way, 40 weeks is your due date and twins usually don't get to 40 weeks. But even if you would let them get to 40 weeks, generally they're going to be recommended to deliver earlier in our practice. For the most uncomplicated twins out there, we generally recommend delivery at 38 weeks and then earlier based on what's going on in the pregnancy or if they have other issues going on. And the reason is not because the babies will get too big because twins rarely get too big to deliver.

(00:33:37): But because there's, the placenta function tends to decline. And that's true in singletons, but in singletons it usually happens after 39 or 40 weeks. But in twins, it starts happening usually 38 weeks or earlier. And so we're very concerned that if someone stays pregnant past 38 weeks to 39 or 40 weeks, that there's going to be an increased risk of stillbirth by waiting. And so the benefit you gained seems to be outweighed by that. There are those who disagree, but the general recommendation is to deliver twins somewhere around that range or earlier. So yeah, I tell people, your due dates May 20th, but you're not going to see May 10th pregnant, whatever

Dr. Nicole (00:34:21): It is. Exactly.

Dr. Fox (00:34:21): This is the end of the line for you. Usually something happens before then anyways to sort of force our hand.

Dr. Nicole (00:34:26): Yeah. And so speaking of delivery, let's talk about vaginal versus C-section. What are your thoughts on that?

Dr. Fox (00:34:34): This is one of my passions. So in the US right now, if you're carying twins, the likelihood your babies are both going to be born by C-section is probably ballpark 80% or higher. And there's a lot of reasons for that. But one of the reasons for it is many doctors are uncomfortable, unable, or unwilling to deliver your twins vaginally. Now if they're unable, God bless them. You don't want them to try. Sure. Right. So this is not, if you're, listen, I'm, I'm not able to do a lot of things. My wife tells me that all the time, so you don't want me trying. Fine. Everyone has their limitations. And the reason is not so much labor and delivery of the first twin because that's pretty similar to how we labor and delivery a single baby, you're in labor, you're contracting, we break your water, you get Pitocin, you don't get Pitocin, and we monitor the baby, like all that stuff, you go, you push head like same thing as everyone else.

(00:35:34): And in fact, the babies tend to be smaller on average cause they're earlier, they're small. So meaning you don't have a lot of 10 pound twins coming out, it's usually 4, 5, 6 pounds. Big twins are like seven. The issue is twin B, the second twin, because after twin A comes out, twin B frequently is not head first. So twin B's either feet first or butt first or sideways or their head first. But the head is very high up and you can have a lot of issues. Number one, a lot of providers, doctors, midwives, whoever delivers babies are not comfortable delivering that second twin feet first, what we call a breach delivery because very few people deliver single babies breach anymore. That skill has been pretty much lost amongst general training of obstetricians, not just in the US but really around the world. And there's a whole other discussion whether that's good or bad, but whatever.

(00:36:27): That's the reality. And so because of that, if the second baby is not at first, they're frequently going to recommend a C-section. And it's well known that if both your babies start out headfirst, you're like, oh, great, I'll push out the first, push out the second. That's true. But if you look at the numbers in the us, if your first baby comes out vaginally, there is a five to 10% chance your second baby's coming out by. So sometimes that's called the combined delivery, which is a nice name for saying you had a vaginal birth, got all the swelling and tearing, and now you have a C-section. It's like getting kicked when you're down. Yes. I call it the dominal delivery, which I learned from my mentor Steve Chason at Cornell, which is a great term, but it's not great. I mean, listen, it's not going to kill anybody, but it's really not what you're looking for to have a vaginal birth and a C-section.

(00:37:21): And so that's the US data. Now, if you look at countries which have much more centralized care of twins, like France, France is sort of the classic where you have twins, you are going to a perinatal center that takes care of twins, and you go to one of the major, that's where you go. Gotcha. And that's like national. Everyone does that. Okay. So these are people who take care of twins, deliver twins know what they're doing. This is all that they do. The C-section risk for twins overall is probably 40 to 50%. And that's mostly because the first baby is head is not head down and the first baby's breach and they don't usually deliver them or there's some complication and the chance that the second baby's going to be born by C-section, if the first baby's born vaginally is under 1%. And why is that?

(00:38:06): Because they're trained to deliver the second baby breach and they're trained if the first baby is head down but is not what we call engaged, it's very high up. And if you were to try to deliver head first, it's going to be like 12 hours of pushing, which is, we've been there, it's awful. They go in, they flip the baby and deliver the baby feet. First cult, internal podalic version of breach extraction. And they've demonstrated very, very good outcomes. In 2007, there was an article in the Green Journal, which is sort of our society's OBGYN journal, which is an editorial by a fellow in Wisconsin. I forgot his name, I think he was in practice a long, long time. And he, he was writing about delivery of twins and he wrote, internal Podalic version is something that nobody in the US is trained to do and is unsafe and shouldn't be done.

(00:38:58): And in 2007 was the same year that I signed on with, I signed my contract to work with this MFM group that I joined. And I remember talking to them and they were telling me how they deliver twins. And they were basically describing the French style. They're like, yeah, first twin comes out, then we deliver second twin breach if it's head first, but it's very high, we flip it and we do it. And I was like, wait a second, you're doing what this guy says no one's trained to do. And they're like, I dunno what he's talking about. We're trained to do it and we do it. And so that was one of my first publications was looking at our twins and the delivery rates and showing that it was very, very similar to the French, about a C-section rate overall of maybe 40, 50%.

(00:39:39): Again, most of which because either they weren't a good candidate, cause the baby A was feet first, or maybe they had multiple prior C-sections. And once the first baby comes out, head first less than 1% C-section rate for the second twin. And that was a very winded answer to your question, but basically twins can be delivered vaginally, not a hundred percent because it's not safe for everyone. But probably about 50% of twins more if you're young and healthy. We also have a higher risk population in general, let's say 50%. But it really comes down to does your doctor or midwife deliver twins? And so I always tell people, if you don't care how your babies are born and you don't mind having a C-section or you want a C-section or some people want a C-section or their twins, sure, God bless them, we'll do it.

(00:40:27): Sure, then fine. But if you care and you really want a vaginal delivery, you got to ask early in your pregnancy to your obstetrician, Hey, do you deliver twins? Do you deliver them vaginally? Would you deliver the second twin feet first? Do you know how to do this? How many times you do this? And they should be open with you. And if they say, yeah, I do this all the time. I was trained, I would do it. Great. You're probably in a really good hands and you'll probably have a high chance as high as possible with vaginal delivery. But they say, well, I don't really do it. I'm not so comfortable. I don't know if it's safe. You have two choices. Either you're going to have a C-section or you got to switch practices. And again, it's not always possible. It's not always feasible. It's not like there's a lot of logistics involved potentially, but you should know upfront and this should not be discovered in the middle of labor. Yeah. That's a bad time to find this out.

Dr. Nicole (00:41:15): Absolutely. Thank you. All such great information. It kind of makes me sad. This is one I of, I will do breach extractions of a second twin. It's not that many of us who do do that. And I feel like it's a dying skill if we're obstetricians because we have more skills like that. These are the things that we are supposed to be able to do. So we should be able to do complex vaginal births. So that's just like my soapbox.

Dr. Fox (00:41:45): And it's also, it's remarkable because it's, well, two things. Number one, it's not that complex, meaning it's doing a breach delivery is easier than doing a vaginal hysterectomy. And people trained to do that. It's easier than doing most surgical procedures. It's easier than a lot of things that we already do or people already do. And I agree, it became a lost art. But we're actually seeing somewhat of a comeback in our hospital. The rates of breach delivery of the second twin were going up. And the reason is there was a concerted effort to teach and learn it. So as practice I'm in, there's people are doing it. And so someone's like, oh, can you show me or can you help me with my twins? And then all things in training, we have this famous thing of C one, do one, teach one where you first see what it's like, then you do it, and then you teach it.

(00:42:36): Obviously there's usually more times you have to see it, more times you have to do it right or whatever the concept. And it's in our own practice. We have doctors who come and join us. Listen, I was not a skilled obstetrician at breach delivery, the second twin when I finished my fellowship and started practice to these guys. And I would've been someone who said, listen, I'm not the person to do your delivery of your twins vaginally. Sure. Cause I don't have those. I'd done a few, but I wouldn't feel comfortable. But I learned, I was trained. I went to X amount of deliveries with my partners and they took me through it step by step. And we did it and I got comfortable with it. And now I take others through it. And that's how medicine has been taught forever. And it just takes a concerted effort.

(00:43:22): I mean, that's really all it is that a lot of, when I give lectures and stuff, a lot of people ask me to talk about twins and delivery of twins. And when I tell them is, if you want to do this, it's not that complicated. Essentially every twin birth should be attended by someone who knows what the hell they're doing. And someone who's learning always, whether it's 12 in day or middle of the night, have those two people there. And then you will, your numbers of people who can do this will swell and it'll snowball. And that's what happens if people care. But if someone doesn't care and says, eh, we'll just do a C-section. Like what's the difference? Yeah, I mean fine. But that's not really good if someone wants a vaginal delivery and it's a easier recovery and you don't have major surgery. So I agree. It's sort of a shame that fell out of favor, but it can come back and in certain places it is coming back.

Dr. Nicole (00:44:14): Okay. Well that's hopeful. That's hopeful. And a couple last things I wanted to touch on activity level. You mentioned it a little bit earlier with bedrest doesn't help or anything, but do twin women pregnant with twins really have to change their activity level? Should they be sitting around not doing anything, all of that kind of stuff?

Dr. Fox (00:44:34): So the truth is we don't exactly know what is the ideal activity level for someone with twins or frankly for anybody who's pregnant. The, it's very difficult to study this, but I would say that anyone that has attempted to improve outcomes in twins by telling them not to do stuff, like to rest, to relax, not to work, not to have sex, whatever it is, it's never worked. And sometimes it's made things worse. And so what I tell my patients or someone else, not my patients twins, I don't restrict your activity any more so than I would anyone else who's pregnant. Don't do things where you can get hurt. Sure, don't ski. Sure don't horseback ride, whatever. But that's not related to twins. So I say, you can work, you be active, you can have a sex life, whatever it is you would normally do, you can do.

(00:45:31): If there's something I need you not to do, I will tell you, if you have a placenta previa or your cervix has did, whatever something comes up, I will instruct you what you know may not do. But normally the default is do what you'd like. I encourage my twins to exercise. Obviously there are somewhat more limitations physically because someone carrying twins, a just is going to be larger than someone of equal gestational age. But if you're 20 weeks with twins, you're sort of like someone who's 16 weeks with a single tin. So both could exercise, but there's that and there's also they retain some more water and they tend to be more tired and they have more nausea. I mean, some of the symptoms are also greater. It's not just about the girth, the physical size, but if someone's up to it, great. If someone normally goes to yoga, go to yoga.

(00:46:18): If you swim, swim, if you jog, jog, I mean you have to go slower but fine, go slower. And I think it's probably better to do those things than to be sedentary. Some people are just exhausted and beat and they just have to sit and put their legs up and God bless. You're carrying twins. I mean, my wife was carrying twins. My wife was five feet tall. She's not a big woman. By the end of pregnancy was, I mean, the poor, she could barely get out of bed. It was so it was hard physically. And so a lot of mercy on her. But if you feel up to it, great. On the other hand, I'm a big, big proponent of nutrition.

Dr. Nicole (00:46:55): Thank you. That was my last question. What about nutrition?

Dr. Fox (00:46:57): I am all over that.

Dr. Nicole (00:46:58): Yeah. So tell us

Dr. Fox (00:46:59): About that. Yeah. And I am not, well, I don't want to say I'm not that way with singleton pregnancies cause it's always good. I'm like, for everybody on earth, it's good to have good nutrition. But when I mean that with twins is if I see someone who's carrying one baby, I almost never comment on their weight gain. Right. Too little, too much just right. Because honestly, it doesn't really matter that much. There are data on it, but it's only in great extremes is it an issue? And ultimately what are you going to do? But for twins, I really encourage them. They have to be gaining weight and they have to eat more to gain weight. Interesting. And there's a lot of data to support this, that the twins who gain more weight, particularly in the first half of pregnancy, have much better outcomes than the backend of pregnancy.

(00:47:46): They have bigger babies and they seem to deliver later. And some of that we think is giving a lot of nutrients to the placenta or placenta early. Now, there aren't perfect studis on this. Some of it could be twins who are doing better, tend to feel better and eat more. It could be sort of like cause effect and effect cause, but I don't buy that. And we've done a bunch of studis on this in our own twins. Ultimately on average, twins generally need to gain a pound a week. And it's hard to do it in the first two months of pregnancy. Right? Fine. Give you a break. It's you're throwing up all the time. But really when that subsides or gets better, and that means intentionally eating, we have all of our twins see a nutritionist and we do talk about weight gain. We do go over high protein and this and all those things. The only exceptions, women who start out a lot heavier probably can gain a little bit less, but it's way more than they would in a singleton. And maybe the least it's going to be is a pound every two weeks. And we're very, very hyper focused on that. And it does not seem to cause any problems related to diabetes or preeclampsia. And most of the weight, no matter what they've done, tends to come off after they deliver. Cause a lot of it's just water, right?

Dr. Nicole (00:49:00): Fortunately. Right. Yeah. That's not something, I mean, I don't do prenatal care anymore, but even when I did prenatal care there, the nutritional aspect of twins isn't something that I feel like was really emphasized. So I think that's really important that you mentioned that going to a nutritionist and the difference in weight gain, because I agree for singletons at least you tell people to gain, eat as healthy as you can and some folks are going to gain 40 pounds and some folks Yeah, but you're saying it's just different twins. Yeah,

Dr. Fox (00:49:30): Singletons generally. My mantra is like, don't focus on your weight, don't focus on the scale. Focus on eating healthy foods, not being hungry and exercising. And in singletons, that's the data shows. So if you're eating healthy foods, you're not hungry and you're gaining too little weight, quote, fine. And if you're gaining too much weight, fine. You're not supposed to dit when you're pregnant and you're not supposed to force feed yourself again when you're with one baby. But twins, I say eat healthy foods, exercise, and if you're not gain weight, eat more healthy foods. Gotcha. Keep eating more. So you have to really be gain weight. Your body's telling you it needs more Awesome when you're carrying twins. All

Dr. Nicole (00:50:05): Right. So then as we wrap up, what is the most frustrating part of caring for folks with twins and twin pregnancies?

Dr. Fox (00:50:12): The most frustrating part of caring for folks with twins. I don't tend get too frustrated. I think it's awesome. I really actually get really excited about caring for folks with twins. I think that there's so much, it's so fascinating. Love that. Yeah. The fact that I have twins makes it so interesting. Also, I would say, I guess the most frustrating part actually you almost get numb to is how little control we have over so much of this. I mean, we can get real philosophical here. That's true in life, I think. And you sort of have to just accept certain things as realities. Sure. Someone who's having twins, a certain percentage are going to deliver them very early, despite really good patients taking care of themselves, really good health habits, really good eating habits, and they do everything and very good doctors and midwives and nurses, and everyone's doing everything perfect, perfect.

(00:51:05): Sometimes it just ends really difficult. And that is more, I would say, more sad than frustrating. Sure. I think it used to be more frustrating, but then you just sort of realize this is kind of how life is. As you get older, you learn to sort of accept that we're not driving the bus. Yeah, usually. But that is tough. And I think that's tough for a lot of people to swallow. And I think also the fact that there are things we don't have great data on is really frustrating sometimes for patients. What do you mean you don't know? I mean, I don't know. And I tell people, yeah, the bad news is, I don't know. The good news is nobody else knows either. Right. It's, there's just things we don't understand yet. And hopefully with time we will, but that is the waters we navigate through.

Dr. Nicole (00:51:52): Absolutely. So then on the flip side, what's the most rewarding part?

Dr. Fox (00:51:57): When I would say probably when either those twins are born or when they come home from the hospital. Look, a lot of twins, if they're born early, end up in the NICU a little bit. And I have so many mean, just last week, patient RS with twins and she was doing really well and she had a crazy complication. Water broke, then she had a cord prolapse and had an emergency C-section. Babies are born early and she was doing great. It was the perfect twin pregnancy and just she got hit by a bus type of thing. But then about four weeks later, three weeks later, when both those kids are home from the hospital and she sends me a picture of both of them, and I just know how exciting it is and it's like such an adventure having any kids and having one. And then when we have two, it's like, wow.

(00:52:40): Yeah, it's just awesome. And I'm really, listen, I'm really fortunate to be able to do this every day. I tell people all the time, I said, I love my job. I work really hard. I work really long hours. I come early, I stay late. I'm on call all the time. I never complain about work because I love what I do. I say I, I spend all day here and I'm happy. Yeah. I love my family. I come home, I'm happy at home too, but I'm happy at work. Whereas if I have to take one of my kids shopping for shoes after 20 minutes, I on want to hurl myself out a window, not the hour spent. I'm really fortunate to be able to do what I do and to have people trust me and care about what I think and what I say is very, it's humbling, obviously, and it's, it's really cool. Yeah,

Dr. Nicole (00:53:25): It is. It's good jobs for sure. Yeah, we do. We do. We do. So then what's your favorite piece of advice that you would give to families, to moms or who are expecting twins? And it can be favorite piece as a parent, favorite piece as an M F L. What's your favorite piece of advice?

Dr. Fox (00:53:41): Yeah. I would say as an M F M, it would be really early on make sure you're getting high level care. You should be having an ultrasound very early to determine what type of twins you have. One placenta or two. The earlier you are, the more accurate it is. You should be having regular visits. They should be telling you about the difference between twins and singletons, and they should be telling you what are the options for delivery. And if they're doing those things, you're get, you're probably getting very good care. And if they're not doing those things, you should ask why. And if the answer is they have this day's look on their face, they don't understand why twins would need anything different from one baby, you probably should look elsewhere. And if they say, well, I'd love to send you to this person, but you've got to move to another city, and you decide I might move to another city and get better care, or I might say, I don't have an option, but really get a lot of that information early. Get high level information. Don't just go on Google. You'll get a lot of nonsense out there. Find something reliable, whether that's a good book, there are a lot of good books, whether it's a website, whether it's podcasts like yours, like mine, whatever it is, find good information that's trustworthy and speak to your doctor midwife very early about what's going to happen. And you can usually get a sense very quickly if they're full of it or if they know what they're doing. Yeah, it's not that hard. We're humans. We can't hide it very well.

Dr. Nicole (00:55:06): Very

Dr. Fox (00:55:06): Much so as a parent, just I marvel at how different twins can be there. These are two kids born to the same parents at the same time at the same place, eating the same things, doing the same things. One's tall, one's short, one is allergies, one doesn't, one is loud, one is quiet, one is, it is just unbelievable how much, even though we believe that we can make our kids amazing, how much nature kicks in and just they are who they are. Right. Yes. We can definitely screw up our kids if we try hard enough, but it's just fascinating to see how people develop just differently for unexplainable reasons.

Dr. Nicole (00:55:45): Yeah, yeah. For sure. For sure. So where can people find you and tell us about your podcast?

Dr. Fox (00:55:50): You can find me roaming the streets of New York City or my podcast is called Healthful Woman. That's like the word helpful, but health, one word woman in the singular, W O M A N, where everywhere you get podcasts. Wherever you're getting this podcast, I'm sure you can get my podcast. Yep. We have a website, healthful woman.com. We've done a lot of stuff. By the time this has dropped, you have already been on my podcast, which dropped or will drop in February, I'll say now dropped in February and yeah, that's how you find me. Awesome. I'm easily reachable.

Dr. Nicole (00:56:26): All right. And we'll link all that in the show notes. And if anyone is in New York and has twins, what's your practice again? You said?

Dr. Fox (00:56:32): We are called Maternal Fetal Medicine Associates or M F M N Y c.com, like maternal fetal medicine New York city.com.

Dr. Nicole (00:56:41): All right. Dr. Fox, thank you so much for coming on. This was incredibly helpful, so appreciate your time.

Dr. Fox (00:56:46): Thank you. I love what you're doing. Thank you for having me. Keep doing God's work there.

Dr. Nicole (00:56:57): Wasn't it a great episode? I know I learned a lot and I'm sure that you did too. Really, really helpful information for those of you who have twins. Now, after every episode when I have a guest on, I do something called Dr. Nicole's notes where I talk about my top takeaways from the conversation. And here are my takeaways for the conversation with Dr. Fox. Number one, I really like how he talked about a more, a personalized approach to prenatal care and birth and adjusting that for twins if needed. Really based on your own unique circumstances, period. We can't do cookie cutter prenatal care. It really should be something that takes into account your unique circumstances, your health history, your concerns, and adjust your care accordingly. And along those same lines, if that is something that you feel like you are not getting, someone who's not respecting that you're an individual, someone who is not paying attention to your unique needs, then that leads me to point number two, which is get another doctor.

(00:57:59): If you are not getting the care that you need, and the earlier you are able to find this out, the better. Okay? If you are not getting the care you need, you definitely want to find someone who is giving you the care that you need. And in the case of twins, you really want to know early on whether you have someone who can support you with the things that are important to you. Those questions, especially around the method or of birth, are going to be really crucial If you strongly desire a vaginal birth. Now, maybe vaginal work to cesarean isn't a big deal for you, totally fine. But if it's something that is important for you, then again, you need to find someone who can provide that for you. And that applies not just to twins, but to everyone having a baby.

(00:58:46): Okay. My next point is the point that experience can make a difference. Now, this doesn't mean that someone who doesn't have experience in birth or someone who doesn't have experience in twins can't provide great care, but experience matters. I know for my own experience, I am a much better obstetrician now than I was at the beginning of my career. Not that I was bad at the beginning of my career, but experience, especially in something that requires you to do something physically, it is going to make a difference and experience in taking care of twins as he demonstrated can make a difference. Now, again, that is not to say that people who don't have experience can't take great care of you because it is certainly possible and we all have to learn at some point. Ideally, what you want is if someone is not as experienced, that they have access to someone who is more experienced to help them and guide them.

(00:59:45): Also, on the flip side, sometimes people with experience get set in their ways. So you just don't want experience. You really want someone who has experience but with a learner's mind, meaning that they are still learning new things. They are open to change. They are open to adapt their practice if need be. So pay attention to experience. But also you want someone with experience who has an open mind. And if you don't have someone who has a lot of experience, you want to know that they have access to help if they need to. They have access to people who can provide that experience if necessary. And then the final thing I want to say is you can't change outcomes. I love his analogy about the weather. You check the weather on the way out the door. If there's going to be rain, you grab an umbrella, you can't change whether or not it's going to rain, but you can be prepared for the rain.

(01:00:40): And that is exactly what childbirth education can do. It can be that umbrella for you. Birth is unpredictable. It cannot be predicted. Anyone who says that, they can predict exactly what happens with birth cannot do it. If they predict the right thing is because they're lucky, not because they could do it. All right? Birth is unpredictable, and the way to manage that unpredictability is to be prepared, prepared for the possible things that may occur. You check the weather, which is the climate of your labor and delivery, the climate of the type of practice that you're in, and you bring that umbrella childbirth education to be prepared for that. All right? That's what great childbirth education will do. It will be your umbrella and the event that there is some rain, hopefully you won't need to use all of it, but if you do, you have it and it's there.

(01:01:24): Of course, I have a great option. The birth preparation course, that is my online childbirth education class that gets you calm, confident and empowered, especially for a hospital birth. You can check out all the details of the birth preparation course@drnicolerankins.com slash enroll. All right, so there you have it. Do me a solid share. This podcast with a friend sharing is caring, helps me to reach and serve more pregnant folks. Be sure to subscribe to the podcast wherever you are listening to me right now. It helps the show to grow. Leave a review an Apple podcast, or better yet, shoot me a DM on Instagram. I love to hear what you think about the show. I'm on Instagram at Dr. Nicole Rankins. All of the comments and warm fuzzies that I get about how people have found the podcast, my course or other resources helpful, just really warm my heart and help me to keep going on those days when sometimes it gets a little bit exhausting. So check me out on Instagram. I also post great information there too at Dr. Nicole Rankins. So that is it for this episode to come on back next week and remember that you deserve a beautiful pregnancy and birth.