I mentioned in a previous blog that the twins were a bit "unusual" in that they were monochorionic monoamniotic (or MCMA, or MoMo) twins.  What this means is that both twins were sharing a single amniotic sac.  To say that they are unusual is probably an understatement.  Worldwide stats show that MCMA twins happen along once every 35,000 pregnancies - or, to put it in a different perspective, on average there will only be a single MCMA pregnancy in the nation of Singapore in any given year.

Starting from 28 weeks, our docs asked us to come for CTG recordings every two days.  The reason was pretty straightforward.  Having MCMA twins is a bit like putting two kids in a swimming pool, and separately tying both to one of the sides of the pool.  They swim round and round, but to be safe they never tangle their lines, because with kids in a pool, tangling lines could make swimming difficult.  With MCMA fetuses sharing a sac, blissfully unaware of concepts like "dangers", they swim round and round - and here, the very real risk is that they could tangle umbilical cords.  Entanglement in this way could lead to cord compression, which will cut off the flow of oxygen to the baby, and one or both babies will demise in a sudden acute event.  The mortality rate of MA twins runs at about 40% as a result.  We knew this from the counselling we received from our excellent hospital staff early in pregnancy, and had worked to stay somewhat detached, just in case - but reaching 28 weeks radically changed that.

We found out at 22 weeks using a Doppler scan that the cords had been entangled.  This was evident because we could see blood flowing in different directions in the cords, and could hear what they call "galloping" - you could hear one heartbeat, and a second heartbeart shadowing the first (like the sound of a horse galloping), telling us that they cords were bunched together.  The babies though were alive - meaning that although they were tangled, they weren't tangled tightly enough to compress the cords and cut off oxygen to the fetuses.

At 28 weeks, the docs asked us to come in for CTG recordings every two days.  CTG recordings will monitor a baby's heart rate, as well as for possible contractions.  Usually they are used to look for distressed babies when their mum is in delivery.  In our case, we were looking for a sudden deceleration of the kids' heart rates, which would indicate that perhaps the cords were tangled badly enough to compress, pointing towards emergency extraction if it happened repeatedly.

The first couple of scans were 100% clear, problem-free.  The heart rates of both babies ran at between 140 and 160 beats per minute, and were strong throughout.  The third scan was the one on Friday 7 September.  Near the end, it showed an inconclusive blip.  Our doc was appropriately concerned and admitted Stacey for the night, for eight hours of CTG monitoring.  The next morning though, after reviewing the results (I took a crash course in reading the trace that comes from the CTG machines) it was again perfectly clear.  They let us go but asked us to change to daily monitoring.

The next week, the first two scans on Monday and Tuesday were again clear.  We began to relax. On Wednesday 12 September, we came in again for what had become our routine.  Looking back, it literally brings tears to my eyes when I realise how a few lucky coincidences combined to bring our two kids into the world, and how close we were to missing that.

On the Wednesday, the labour ward was packed - mums and dads delivering in every room - and the nurses (who by now knew us very well and considered us competent enough to let us get on with it) put us in a back room, usually used for storage, but with a bed.  The CTG scans go for 30 minutes - but that day, because of the crowds delivering, they left us for an hour and a half.  That day, just over an hour in, there was a clear deceleration.  Unlike the previous Friday though, this time the deceleration was accompanied by a very weak contraction - so weak that Stacey felt nothing.  Clearly though the contraction had distressed the baby.  Her heart rate had plummeted from the usual 150-160 beats to 100 beats per minute for the duration of the contraction (about one minute).

Our doc took one look and admitted us.  She was concerned enough that she wanted twice daily monitoring, starting that same afternoon.  Stace and I were trying to keep it in perspective - we'd been in the same place last Friday - this was clearer evidence, but not solid enough to take the babies out.

We really didn't want to take the babies out.  Taking babies out at 29 weeks is not an easy decision.  They are at a critical period of system development, in ways that we don't fully understand and can't predict.  The babies are viable, we knew that, but it is going to be a long road.  To help them, one of the things you can do is give the babies a steroid to help their lung development.  This gives them a short term boost and means they *may* be able to breathe unassisted when they come out.  Problem is, you only get one shot at this and it last for about seven days.  Beyond seven days, the babies return to the curve of expected development.  If you give the steroid again, it leads to all kinds of issues down the track.  So, to be effective you need to give the shot less than one week before delivery.

Because of the previously clear scans, we had all agreed to give the steroid at 31 weeks and hold out to deliver at 32 weeks (beyond that, the risk of cord compression just got too great).  On that day though, our doc said we really had no choice but to administer the steroid.  I mentioned earlier that there was some luck - in some respects though, the successful arrival of our babies had nothing to do with luck.  Here was experience and expertise, a professional correctly reading weak signals and making the right calls.  We agreed to the earlier-than-planned steroids and had them at noon, and with hindsight it was a great call from the doc.  Two doses are required though, and they had to be taken 12 hours apart - they didn't really take effect until 24 hours after the first dose.  Again with hindsight, it was unfortunate we didn't have them any earlier.

The second scan for the day took place at 6pm or so, a little later than planned.  Dr Thong came in on her rounds and looked at the scan, and the anomaly in the scan had re-occured.  A very weak contraction, and one of the babies heart rates had plummeted for the duration.  For her that was enough - she put us straight into the labour ward for 24 hours continuous monitoring.  The best case was that we would hold on until 2pm the next day, to give the steroids a chance to work.

Stacey and I were still hopeful that everything would settle down.  They started to give her drugs to stop the contractions.  We turned on the television and settled in to wait.  Stace's mum was in town (mother's premonition had caused her to fly up to Singapore only two days previously) and she joined us in the hospital.

At about 7.30pm we were in the delivery room, waiting, waiting.  If you asked me everything that could possibly have happened next, I would not have predicted an earthquake, but quake it did.  An 8.4M earthquake off the coast of Sumatra rocked the towers in SIngapore.  We were on the 8th floor (very auspicious to have your babies on the 8th floor!) and the whole room was shaking.  Evacuation wasn't necessary, but I can tell you it did nothing for my nerves.

Again, luck was on our side later that night.  Dr Thong was delivering a baby naturally next door.  That bub was expected earlier in the day but was refusing to come out.  Eventually the mum was induced, and afterwards at midnight Dr Thong came by to check the CTG trace before heading home.  She took one look, and immediately made the call that we had to deliver without delay.  The contractions had been happening hourly since 6pm, and by now both babies were now in distress.  The drugs to stop or slow the contractions had had no effect.  Dr Thong felt that was enough evidence to suggest that the cords were increasingly tangled, and as the contractions took place, more and more pressure was being placed on the cords, tightening the tangle.  It had become very real very quickly and we realised that these babies were in grave danger.  There was no time for the second dose of steroids - Stace was rushed to the OT and the babies were to be pulled out.

People have asked if I cut the cords, kept my scrubs, enjoyed the birth experience, so on and so on.  But it was nothing like that.  Because they had no idea what they would find inside when they went in, Stace was put under GA.  I wasn't allowed in the OT.  I'm sure it must be wonderful to have a regular birth and to participate in the process, but for me the experience was two lonely hours with Stace's mum outside the OT in an empty waiting room, from nearly one to three AM.  Not fun.

Sometime after 1am, two teams of docs came out pushing trolleys with the two tiniest human beings I had ever seen.  It was Tessa and Georgia.  They said both were alive and ok but had to be rushed to the neonatal intensive care unit.  Stace's mum and I resumed our wait.

About 2am, a nurse came out to show me the placenta.  Two umbilical cords were connected very close to the centre.  Right above where they were connected were two true knots in the cords.  Beyond that, the cords were braided.  Those knots would have been terminal for the kids.  The right decisions had been made.  Never had I seen anything that scared me as much as those knots.

Around 3am, the docs came out with Stace.  She was just revived from the GA and asking about the babies.  I had very little news.  We went up to our ward room and waited.

Sometime later, our neo-natologist (Dr Tan MC) called me into the NICU (Stace was unable to come in as she was recovering).  The babies were ok he said, and a good size for 29 weeks.  One needed tubes to the lungs so that surfactant could be put put in; the other was beathing with CPAP alone.  They had other tubes going in everywhere - mouths, arms, feet.  It was overwhelming, I was exhausted, but the doctor was reassuring.  He suggested rest, the next day would be a big one; I didn't argue and passed out in our ward.