Shared learning database

Liverpool Women's Foundation Trust
Published date:
September 2013

The Multiple Pregnancy Service (MPC) at Liverpool Women's Foundation Trust provides the additional care that women with multiple pregnancies should receive. It also provides tertiary level care for women with higher risk or complicated multiple pregnancies. Women are cared for by the clinical team within the service as per Statement 3 in the NICE Quality Standard. This team is made up of a Consultant in Fetal and Maternal Medicine, a Professor of Obstetrics and Gynaecology, Specialist Midwives and a Midwife Sonographer.

When twin pregnancy is already known before booking, women are allocated to book as per normal booking routine and attend the Multiple Pregnancy Clinic (MPC) within 3 weeks of booking.

When twin pregnancy is diagnosed at booking or later at the dating scan, care is transferred to the MPC. The woman is seen in the clinic within 3 weeks of diagnosis.

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

To set up a service which meets the additional care needs of women with multiple pregnancy. To deliver a service from a multidisciplinary team with knowledge and expertise in the management of uncomplicated and complicated multiple pregnancy ensuring optimal care and outcomes. The key performance indicators established to help measure whether the correct care is delivered were:
- Documentation of antenatal discussions re place, timing and mode of birth (completion of Place, Timing and Mode of Birth Discussion checklist- appendix 5 of the attached document)
- Offer of birth from 37 weeks gestation to all uncomplicated dichorionic and from 36 weeks to all uncomplicated monochorionic twin pregnancies.
- Review by or discussion with Consultant member of the MPC team if the woman requests Caesarean section and there is no clinical indication.
- Arrangements for offering women USS before 13+6 weeks to assess viability, chorionicity and nuchal translucency combined screening.
- Antenatal clinic schedule as per guidance (based on chorionicity and amnionicity)
- Management of twin to twin transfusion coordinated by a consultant member of the MPC team or by a consultant in fetal medicine.

Reasons for implementing your project

The incidence of multiple births has risen in the last 30 years. In 1980, 10 women per 1000 gave birth to multiples and in 2011 there were 16 per 1000 births. This increase in multiple births is due mainly to the use of assisted reproduction techniques including in vitro fertilisation (IVF). Older women are more likely to have a multiple pregnancy and as the average age at which women give birth is rising this is also a contributory factor. Multiple births currently account for 3% of live births.

Multiple pregnancy is associated with higher risks for the mother and babies. Maternal mortality associated with multiple births is 2.5 times that for singleton births. The risk of preterm birth is also considerably higher in multiple pregnancies than in singleton pregnancies, occurring in at least 50% of twin pregnancies .The significantly higher preterm delivery rates in twin and triplet pregnancies result in increased demand for specialist neonatal resources.

Risks to babies depend partly on the chorionicity (number of chorionic (outer) membranes and amnionicity (number if amnions (inner) membranes) of the pregnancy. Feto-fetal transfusion syndrome, a condition associated with a shared placenta, can occur in monochorionic pregnancies and accounts for about 20% of stillbirths in multiple pregnancies. Additional risks to the babies include intrauterine growth restriction and congenital abnormalities.

Because of the increased risk of complications, women with multiple pregnancies need more monitoring and increased contact with healthcare professionals during their pregnancy than women with singleton pregnancies, and this will impact on NHS resources. An awareness of the increased risks may also have a significant psychosocial and economic impact on women and their families because this might increase anxiety in the women, resulting in an increased need for psychological support.

The multiple pregnancy service in Liverpool was set up to ensure optimal consistent care. Before this service, women were seen in general clinics and care was inconsistent. The service guideline was written and modified upon publication of the NICE guideline, to ensure that what needs to be done at each visit is documented. To deliver optimal care, a specialist service is required.

How did you implement the project

A guideline for the provision of antenatal management of multiple pregnancies was drawn up for use in Liverpool Women's Trust. This is in line with the NICE guideline and quality standard. This details the additional care that should be provided at each step and is summarised below. The guideline and appendices are attached to this submission.
- Chorionicity, amnionicity, viability and assessment for any major congenital abnormalities should be determined at the first / dating scan.
- All women should be offered the following information in addition to routine booking information: Multiple Pregnancy booklet, a flier with the dates and agenda for Parent Education Evenings held for multiple pregnancies, TAMBA details & membership form, TAMBA helpline details, Liverpool support group contact & useful e-mail addresses, Multiple Births Foundation details & Publication list, Breastfeeding workshop details, Library information, information about preterm labour signs and symptoms and 'what to do'.
- The clinic schedule in appendix 1-4 of the attached (depending on chorionicity and multiplicity) should be used as a basis of care, following individual risk assessment and consultation with the woman.
- Clinical management where screening is abnormal should be coordinated by the MPC consultant team.
- The ultrasound scanning protocol will depend on the chorionicity, amnionicity and multiplicity.
- At all scans, the twins should be mapped as left and right OR upper and lower OR upper left or right and lower left or right.
- Place, timing and mode of birth should be discussed and documented ideally around 32 weeks if it has not been discussed beforehand.
- The Place, Timing and Mode of Birth Discussion checklist in Appendix 5 of the attached should be completed for all women with uncomplicated multiple pregnancy by 33 completed weeks gestation where appropriate.

Key findings

The clinic has been running for a long time, i.e. is probably the longest running dedicated multiple pregnancy service in the UK and therefore it is difficult to demonstrate before and after outcomes. An audit undertaken in 2011 showed that there was good compliance with the NICE guideline in terms of the ensuring the different elements of the care plan occur as follows:
- chorionicity determination
- screening tests - NT and AFP
- anomaly and serial growth scans
- MPC attendance
- CTG and Doppler 3rd trimester

In that cohort audited the preterm delivery rate was 40% but there were no fetal or neonatal deaths.

A more recent audit of documentation of discussion around place, timing and mode of delivery showed this could be improved and we therefore introduced the checklist and subsequent audit has shown good compliance.

When we attained CNST level III in 2010, multiple pregnancy was introduced as a pilot criterion and given that we had care plans, pathways and a dedicated service in place, we were able to achieve compliance easily for that criterion.

Key learning points

Convincing other clinicians (doctors and midwives) that it is more efficient and consistent to look after women under umbrella of one service or clinic. Some still want to look after these women in general clinics and feel affronted if they cannot.

Providing cover 52 weeks a year. To overcome this the service at Liverpool has 2 consultants and 2 midwifes. This ensures that if one is on leave there is another available. We are big enough in terms of numbers to justify this. If numbers are small, justifying resource for a separate clinic or service may be challenging - but I would argue this may be more reason for one team to be leading as it ensures expertise is not diluted.

Positives include:
We make sure that women get their scans at the same time they are seen for their antenatal checks. Furthermore, that they are scanned by the right person with the appropriate expertise - i.e. MC twins / triplets and complicated DC twins need scanned by the consultants or the midwife sonographer whereas DC twins that are not complicated are scanned in the dept before they come through to clinic. Women like it. They meet other women having multiples and like that their care is consistent and there is continuity (get to know the team).

Makes it easier to ensure all guideline elements are covered and therefore easier to audit etc. We know a number of women choose to come to us for their multiple pregnancy care when they find out we have a dedicated clinic. For example if we are referred a complicated multiple pregnancy and intend to only see them once they opt to continue coming. If the hospitals who referred to us had specialist clinics they would feel happier to go back to local care.

Contact details

Dr Leanne Bricker
Consultant in Fetal and Maternal Medicine and Multiple Pregnancy Clinical Lead
Liverpool Women's Foundation Trust

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