Delayed Interval Delivery

What is Delayed Interval Delivery?
Delayed Interval Delivery (DID) is a medical procedure that can be done for multiples who are not sharing a placenta or amniotic sac, such as fraternal twins. It is the intentional act of delaying the birth of the remaining multiples after one has to be born either before viability or after viability up to about 28 weeks.

When is Delayed Interval Delivery an option?
DID is typically an option when the multiple closest to the cervix (Baby A) has had their water break or has already begun birthing with water intact. It has also been done when Baby A has a placental abruption but other multiples have properly intact and attached placentas. It is often needed when the mother has some degree of Cervical Insufficiency that causes her cervix to open prematurely, which occurs more often with multiple pregnancies.

When is Delayed Interval Delivery not an option?
DID is not attempted for twins sharing an amniotic sac or placenta. It will not be done if any of the remaining multiples have ruptured membranes. It would not be attempted if the remaining baby or mother is already showing signs of infection. It is usually not attempted if there is significant vaginal blood loss suggestive of placental abruption or if there are signs of fetal distress or serious congenital defects with the remaining multiples. There may be other factors that a doctor would consider as excluding a patient as a DID candidate.

How does Delayed Interval Delivery work?
The specifics of every DID situation are different, but the basic premise is that the first multiple is delivered and then the surgeon cuts the umbilical cord as high as possible so that the cord retracts into the uterus and the delivered baby's placenta does not detach (which helps "trick" the body into not thinking the remaining multiples need to be delivered). Typically, tocolytic drugs are administered to try and stop or control any uterine contractions. Often, for patients before viability, a cerclage is placed immediately after or in the days shortly after the delivery of the first multiple. An antibiotic regimen lasting for a week or two is typically prescribed to help the body fight any potential infection. And then it is just a waiting game to see when uncontrollable labor occurs with the remaining multiples or other complications develop that require the birth of the remaining babies.

How effective is Delayed Interval Delivery?
Much of the time, even when DID is attempted, the doctors are unable to prevent the the delivery of the remaining multiples. Even when it is successful, roughly half of delay attempts last less than 3 weeks. Once you've made it through the first few weeks, there is a wide distribution of interval lengths from 3 weeks to as long as 4 to 5 months, with a very small percentage making it past 100 days. There have even been 2 reported intervals over 150 days, including the current record of 158 days. Many studies have shown that delaying the birth of the remaining multiples when the first is born prior to 28 weeks is associated with improved outcomes for the remaining babies without creating significant additional risks to the mother, as long as the pregnancy is properly managed and monitored.

What can you expect after the first baby is born?
Depending on the circumstances of the birth of your first multiple, general anesthesia may be required for surgery. If you are not yet at viability, the first baby will not be resuscitated. If a previable baby has survived birth, they may be able to survive anywhere from a few moments to a few hours. If you are beyond 23-24 weeks and the first baby is considered viable, your doctors will attempt to save the baby and likely take them directly to a NICU. The doctors will then attempt to stop your labor via tocolytic drugs and if you are pre-viability, they will usually place a cerclage to help the cervix remain closed for the remaining multiples. You may continue having contractions as your uterus shrinks to the size needed for one less baby. You will likely be put on some degree of bedrest, at least for the first few days or weeks, and in many cases you may be on some degree of bedrest until the remaining babies are born. If you have not already received them, you may be given a dose of corticosteroids to help with fetal maturity (at or after week 24). You will likely be put on an antibiotic regimen for about a week to help prevent an infection. Drugs such with a tocolytic effect such as Indocin, Motrin, Procardia, Progesterone, and others may be prescribed to help you remain pregnant and stable as long as possible. Eventually, when your remaining multiples are born, you will deliver the placenta of the first baby as well.

What can you share from your experience?
DID is an incredibly difficult thing for everyone involved. The idea of having to grieve for one baby or deal with a micropreemie struggling in a NICU while still pregnant and hoping to remain that way as long as possible is not a normal situation. Ultimately, Laurie ended up doing weekly sessions with a psychiatrist until we reached viability to help her deal with the emotional gravity of the situation. Personally, we decided that after we spent a few hours grieving for Thomas, we couldn't fully reopen those wounds until after Milo was born. Others may prefer to cope with their situations differently. It is an intensely personal decision and experience. For us, focusing exclusively on getting Milo here safely was the best way to cope.

What other information is out there about Delayed Interval Delivery?
Part of our reason in creating this blog was to spread more information about DID, because so little exists out there currently other than academic papers in medical journals. Below are links to a few sites that I found helpful during our pregnancy.
Delayed Interval Delivery website
CLIMB (Center for Loss in Multiple Births) Delayed Interval page
MOST (Mothers of Supertwins)
Jess and Jared's Blog - Their son Wyatt is a DID success story
An excellent free to view scholarly paper on Delayed Interval Delivery

I (or someone I know) is currently experiencing a Delayed Interval Delivery. Can you help?
While we aren't doctors, we are parents who have been through Delayed Interval Delivery and are happy to share our experiences with others. You can email us at danshapiroDID@gmail.com. We're happy to answer any questions we can about Delayed Interval Delivery and provide whatever support we possibly can.