Shared learning database

East and North Hertfordshire NHS Trust
Published date:
April 2019

Implementation of a continuity of carer pathway for women with multiple pregnancies.

Our multiple pregnancy service has implemented 100% of the NICE Guidelines for multiple pregnancies. After undergoing an audit of our service by TAMBA in 2017 we received recommendations in relation to enhancing our service and as a result of this implemented a continuity of carer pathway.

When TAMBA returned to re-audit our multiple pregnancy service in 2018 we were identified as an outstanding service for multiple pregnancy.

To continue improving we completed their recommendations and subsequently identified other areas that would improve patient experience. This has shown a marked improvement on appointment compliance, enhanced collaborative team working, an enriched patient education programme for antenatal care and a better communication package.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

The TAMBA audit completed in 2017 highlighted recommendations to improve our compliance with guidance- we also wanted to evidence our work in relation to Quality Statement 3 of Quality Standard 46.

Project Aim: To implement a Continuity of Carer Model for Women with Multiple Pregnancies

This is a new model of care not currently available within the provision of the Trust multiple pregnancy service.

Reasons for implementing your project

The TAMBA audit completed in 2017 made recommendations related to NICE Quality Statement 3 of NICE QS46 which refers to women with a multiple pregnancy being cared for by a multi-disciplinary team.

At that time, not all women with a multiple pregnancy were seen by the multiple pregnancy specialist midwife and a recommendation from TAMBA was to implement continuity for all multiple pregnancies with the multiple pregnancy midwife.

East and North Hertfordshire NHS Trust have a 1.9% rate of multiple pregnancies which equated to 103 multiple pregnancies in 2017-2018.

The baseline for management of women with multiple pregnancies was previously a collaboration between the specialist multiple pregnancy midwife and the consultants, 70% of women experienced contact with the specialist multiple pregnancy midwife with some only experiencing 1 appointment.

Poor patient experience feedback was associated with the service specifically in relation to lack of midwifery contact and choice of place of birth.

How did you implement the project

A project plan was developed utilising Prince II and QI methodology. The plan was submitted to the life QI system and was also monitored using this system.

Engagement with key stakeholders was undertaken and new processes were implemented including:

Direct referral to multiple pregnancy specialist midwife directly from sonographer for any woman identified as multiple pregnancy at dating scan

Option for direct referral to multiple pregnancy specialist at booking via self-referral form if known multiple pregnancy

Supported by NICE Quality Statements 7 and 8, specific specialist midwifery contacts implemented with new clinics at 16 weeks and 32 weeks for all women with multiple pregnancy to firstly initiate the pathway, discuss personalised care plan, advise on  risks and signs of pre-term labour and birth and subsequently discuss birth plan. 

Planned attendance for 100% women undergoing Elective Caesarean (ELCS) as mode of delivery which was challenging due to the management of the caesarean section lists clashing with the new clinic template.

1st postnatal visit for each woman with a multiple pregnancy facilitated by the multiple pregnancy specialist midwife.

Multiple pregnancy specialist midwife establishment was increased from 0.2WTE to 0.8 WTE which had a financial impact.

Key findings

Improvement in patient experience as a direct result of increased midwifery provision within the multiple pregnancy service.

Increase in availability of diet and nutrition advice as a result of set 16 week appointment with specialist multiple pregnancy midwife.

Improved compliance with the pathway due to development of personalised care plan with every woman expecting a multiple pregnancy at 16 weeks.

Improved choice due to information provided at birth planning discussion with multiple pregnancy specialist midwife at 32 weeks.

Benefits of continuity of carer model due to relationship building and communication during pregnancy.

Increase in breastfeeding rates and colostrum harvesting.

Improved support network due to the provision of external resources to all women experiencing multiple pregnancies by the specialist multiple pregnancy midwife.

Key learning points

From a patient experience perspective, the continuity of carer pathway has generated a large amount of positive feedback from the women.

Increased collaboration initially with the neonatal service would have increased the potential effect on the admission rate to Neo-natal Unit (NNU) for multiples.

The development of the project plan is a necessity in order to have clear vision of the direction of travel for the project including what is in and out of scope.

Contact details

Pam Langford
Multiple Pregnancy Specialist Midwife
East and North Hertfordshire NHS Trust

Primary care
Is the example industry-sponsored in any way?