Quality statement 6: Involving a consultant from a tertiary level fetal medicine centre

Quality statement

Women with a higher-risk or complicated multiple pregnancy have a consultant from a tertiary level fetal medicine centre involved in their care.

Rationale

Collaborative care between local services and tertiary level fetal medicine centres allows access to appropriate knowledge and expertise, and tertiary level neonatal and paediatric services when needed, while maintaining the focus on delivery of care locally.

A consultant from a tertiary level fetal medicine centre needs to be involved in some of the decisions about the care provided for women with a higher-risk multiple pregnancy, or if there are complications. It may be more suitable to involve the consultant in planning and managing care rather than referring a woman directly.

Quality measures

Structure

Evidence of local arrangements to ensure that women with a higher-risk or complicated multiple pregnancy have a consultant from a tertiary level fetal medicine centre involved in their care.

Data source: Local data collection.

Process

a) The proportion of women with a higher-risk multiple pregnancy who have a consultant from a tertiary level fetal medicine centre involved in their care.

Numerator – the number of women in the denominator who have a consultant from a tertiary level fetal medicine centre involved in their care.

Denominator – the number of women with a higher-risk multiple pregnancy.

Data source: Local data collection.

b) The proportion of women with a complicated multiple pregnancy who have a consultant from a tertiary level fetal medicine centre involved in their care.

Numerator – the number of women in the denominator who have a consultant from a tertiary level fetal medicine centre involved in their care.

Denominator – the number of women with a complicated multiple pregnancy.

Data source: Local data collection.

Outcome

Infant and maternal mortality and morbidity.

Data source: Local data collection. The Maternity Services Data Set collects data on neonatal death (global number 17209680). Mothers and babies: reducing risk through audits and confidential enquiries across the UK (MBRRACE-UK) collects data on: 'all deaths of pregnant women and women up to one year following the end of the pregnancy' and 'neonatal deaths'.

What the quality statement means for different audiences

Service providers ensure that systems are in place to ensure women with a higher-risk or complicated multiple pregnancy have a consultant from a tertiary level fetal medicine centre involved in their care.

Healthcare practitioners ensure that women with a higher-risk or complicated multiple pregnancy have a consultant from a tertiary level fetal medicine centre involved in their care.

Commissioners ensure that they commission services for women with a higher-risk or complicated multiple pregnancy have a consultant from a tertiary level fetal medicine centre involved in their care.

Women who are pregnant with twins or triplets (referred to as a multiple pregnancy) have an expert in fetal medicine involved in their care if their pregnancy is higher risk or if there are complications.

Source guidance

Twin and triplet pregnancy (2019) NICE guideline NG137, recommendation 1.7.1

Definitions of terms used in this quality statement

Multiple pregnancy

A multiple pregnancy is defined as a twin or triplet pregnancy.

[Expert opinion]

Tertiary level fetal medicine centre

A specialist regional (or supra-regional) fetal medicine centre that has a multidisciplinary team with the expertise and infrastructure to assess and manage complicated twin and triplet pregnancies. This includes providing complex fetal interventions or therapies, for example, fetoscopic laser ablation for feto-fetal transfusion syndrome; and selective termination of pregnancy using techniques such as fetoscopic cord occlusion or radiofrequency ablation.

[NICE's guideline on twin and triplet pregnancy, terms used in this guideline]

Involving a consultant from a tertiary level fetal medicine centre

Involving a consultant from a tertiary level fetal medicine centre can either be through seeking an opinion and then recording the discussion in the woman's notes, or referring a woman with a higher-risk or complicated multiple pregnancy to a tertiary level fetal medicine centre.

NICE's guideline on twin and triplet pregnancy recommendation 1.7.1 advises the seeking of a consultant opinion from a tertiary level fetal medicine centre for higher-risk multiple pregnancies or complicated multiple pregnancies.

Higher-risk multiple pregnancies are defined as:

  • monochorionic monoamniotic twins

  • dichorionic diamniotic triplets.

  • monochorionic diamniotic triplets

  • monochorionic monoamniotic triplets.

Complicated multiple pregnancies are defined as those with:

  • fetal weight discordance (of 25% or more) and an estimated fetal weight of any of the babies below the 10th centile for gestational age

  • fetal anomaly (structural or chromosomal)

  • discordant fetal death

  • feto-fetal transfusion syndrome

  • twin reverse arterial perfusion sequence (TRAP)

  • conjoined twins or triplets

  • suspected twin anaemia polycythaemia sequence.

[Adapted from NICE's guideline on twin and triplet pregnancy, recommendation 1.7.1]

Equality and diversity considerations

The woman's preferences should be taken into account when referring them for a consultant opinion at a tertiary level fetal medicine centre. An opinion may be sought from a consultant at a tertiary level fetal medicine centre if the centre is a long distance from the woman's home and it is clinically appropriate to do so.

Care should be delivered locally where possible to minimise inconvenience and anxiety for women and their partners. But anxiety caused by travelling further for an appointment needs to be weighed against the anxiety of an unclear diagnosis or prognosis.

Women from some cultural backgrounds may prefer to have their antenatal examinations undertaken by female members of staff. NHS maternity services are organised so that such preferences can be accounted for and have arrangements in place for female chaperones if needed.