The multiple pregnancy antenatal care service at St George's Hospital, London provides an example of a multidisciplinary integrated antenatal clinic where women with multiple pregnancy have all aspects of their care, including ultrasound scans and antenatal appointments at the same visit.
These women are looked after by the core team and supported by the enhanced team. The core team consists of two specialist midwives, two senior sonographers and a fetal medicine consultant who provide continuity of care following the antenatal pathway recommended by NICE.
The enhanced team includes specialists in perinatal mental health and safeguarding, a dietician, physiotherapist, bereavement midwife and breastfeeding specialist. Our recent survey has revealed that the level of awareness of the NICE guidance is poor. To address this, we have organised an educational meeting that specifically targets multiple pregnancy, supported by the Royal College of Obstetricians and Gynaecologists (RCOG).
This example was originally submitted to demonstrate implementation of NICE guideline CG129. The guideline has now been updated and replaced by NG137. The example has been reviewed and practice described remains consistent with the updated guideline.
- Twin and triplet pregnancy (NG137)
Aims and objectives
- To implement a multidisciplinary approach, including both the core and the enhanced teams, to the management of women with multiple pregnancy.
- To introduce an integrated antenatal care pathway, as recommended by NICE, detailing the timings, frequency and content of antenatal appointments and ultrasound scans at the same visits.
- To improve the level of knowledge and awareness, of healthcare professionals involved in the care of these women, on the NICE guidance on multiple pregnancy.
- To optimise the pregnancy outcomes of these women. Twin pregnancy is associated with a much higher risk of complications for both mother and babies. The woman is at increased risk of medical complications such as pre-eclampsia (high blood pressure), diabetes of pregnancy and anaemia, as well as suffering more from general symptoms such as backache, heartburn etc. The greatest risk to the babies is of being born prematurely (around 50% deliver before 37 weeks' gestation), with all of the consequent complications, but they are also more likely to have a genetic abnormality or impaired growth while still in the womb (intrauterine growth restriction).
- To improve women's experience and respond to the public demand. Women value continuity of care and being looked after with respect and dignity by competent healthcare professionals, who are passionate about the care they provide.
Reasons for implementing your project
Multiple pregnancies (twins and higher order) represent 2-3% of all conceptions, but the rate is rising, largely due to the increasing use of assisted conception techniques such as IVF. Multiple pregnancy is associated with increased maternal and perinatal mortality and morbidity. The maternal mortality is 2.5 times higher in twin, compared to singleton, pregnancies. The stillbirth rate in multiple pregnancy is 2-3 times that of singleton pregnancies. Furthermore, almost 50% of twin pregnancies deliver before 37 weeks' gestation.
In more than 90% of NHS maternity hospitals, women with multiple pregnancy are not looked after by a specialist multiple pregnancy team. The women are often seen by non-specialists, who might lack the knowledge and experience required. A recent survey by Twin and Multiple Birth Association (TAMBA), where more than 1,000 participants responded, showed that only 1 in 5 of those women (after NICE guideline in 2011) was seen by a specialist midwife and only 1 in 3 was scanned by a specialist sonographer.
Those who develop complications are referred to the tertiary level centre, who might provide excellent ultrasound scanning and fetal management, but ignore the other, equally important, aspects of their antenatal care. Many clinicians who are confident when managing complicated singleton pregnancies feel uneasy caring for women with multiple pregnancy. Subspecialist training has led to reduced exposure of the majority of trainees who received general core training to these complex cases. Our recent survey has shown that the level of awareness of the NICE guidance on "Antenatal Management of Multiple Pregnancy" among healthcare professionals was poor. These included midwives and doctors of varying grades, both consultants and trainees. Almost 60% were unable to identify the correct indications for referral to a tertiary unit. Approximately one third did not know the correct method of screening for Down's syndrome in multiple pregnancy. Half of the respondents did not realise that antenatal interventions such as bed rest, progesterone, cervical cerclage and oral tocolytics, are ineffective in reducing the risk of preterm delivery. Similarly, 50% failed to specify the correct timing of birth
How did you implement the project
We have adopted a multidisciplinary approach to the care of these women and their babies. The core team includes a specialist Fetal Medicine Consultant, two specialist midwives and two senior sonographers, enhanced by the extended team including specialists in perinatal mental health and safeguarding, a dietician, physiotherapist, bereavement midwife and breastfeeding specialist. The core team are responsible for the care of all women in the clinic, while the enhanced team are involved in the care, when needed.
We have developed strong links with national and local organisations that support women with multiple pregnancy, such as the Multiple Birth Foundation (MBF) and the TAMBA. We also provide specialist antenatal classes tailored to multiple pregnancy. The service has developed integrated care pathways to ensure that the highest level of care is delivered consistently; these pathways are tailored to the type of pregnancy (monochorionic twins, which share a single placenta; dichorionic twins, where each twin has its own placenta; and triplets).
In order to implement these changes, we needed support in service reconfiguration from the Director of the Fetal Medicine Unit, Obstetric Lead and the Clinical Director. Examples of the practical changes needed were the proximity of the clinic rooms to the ultrasound scan rooms, adjusting the timetable so that all multiple pregnancy scan appointments are scheduled on the days when the multiple pregnancy clinic is taking place, and approving the antenatal integrated care pathways with the associated financial commitments e.g. more ultrasound scans.
As the RCOG is considered the most important organisation in Obstetrics and Gynaecology in the UK, we approached it with our proposal to hold an educational meeting that specifically targeted the management of multiple pregnancy. As there were many healthcare professionals who were not even aware of the guidance, we addressed this both within our own trust and more widely in the South West region by highlighting the key messages in local meetings, and dedicating a regional study day to multiple pregnancy. We are also working closely with TAMBA on "Maternity Unit Engagement Project", which aims to raise awareness of NICE guidance.
This expertise delivered in an individualised way has led to clinical outcomes that rival the best in the world. Nationally and internationally, the stillbirth rate is around twice as high in twins compared to singleton pregnancies. However, we have achieved a significant reduction in this stillbirth rate, and it now matches the rate in singletons. At the same time, the Caesarean section rate in twins, which has been steadily rising both nationally and internationally, has fallen at St George's, and is now below 50%, significantly lower than other equivalent services.
Patient feedback is consistently excellent; the continuity provided by this specialist team is appreciated by the women - all scans and antenatal care takes place in a single, one-stop setting. We also see education as an important part of our role. This includes education for the public, and also of specialists and GPs. For example, we ran a Multiple Pregnancy Study Day which was very well received. Our proposal to set up an educational meeting that specifically targeted multiple pregnancy, had a very positive response and support by the RCOG, and took place on the 25th November 2013. The final programme is attached, which demonstrates an emphasis on the role of the multidisciplinary team. The RCOG has agreed to incur any costs.
St George's multiple pregnancy service is the referral centre at the Southwest Thames Obstetric Research Collaborative (STORK), a network of nine maternity units. We now care for more than 150 such pregnancies every year, which has enabled us to develop the highest level of expertise, including laser treatment for the management of complicated pregnancies such as twin to twin transfusion syndrome. We have also used STORK to develop a comprehensive research, as well as clinical, network. Using our expertise and large database, we regularly publish important original research papers to address the research recommendations highlighted by NICE. Recent examples include "Early fetal loss in monochorionic and dichorionic twins", "Weight discordance and perinatal mortality in twins", and "Crown-rump length discordance and adverse perinatal outcome in twins". This collaborative network continues to go from strength to strength, and we are currently developing regional guidelines with a view to standardising the care of these women more widely. As the literature suggests, patients participating in research tend to receive a better care and have a better outcome.
Key learning points
- Baseline assessment of the current situation allows you to provide evidence of potentially substandard care that is not in line with national guidance. It also provides a baseline with which you can compare after implementing the change.
- The involvement and support of the relevant key stakeholders were key to the success of our project. In our case, we had the support of the Director of the Fetal Medicine Unit, Obstetric Lead and the Clinical Director.
- We would have valued some pre-existing robust evidence demonstrating better multiple pregnancy outcomes when these women are cared for by a specialist team. Such evidence would have enabled us to convince the management team and the commissioners that a specialist service for multiple pregnancy is worthwhile.
- Awareness and knowledge are key first steps in implementing change. In our case there were many healthcare professionals who were not even aware of the guidance. We addressed this both within our own trust and more widely in the South West region by highlighting the key messages in local educational and risk management meetings, and dedicating a regional study day to the management of multiple pregnancy.
- Lack of resources in the NHS and reconfiguration of the service. These issues were addressed by the support from the Director of the Fetal Medicine Unit, Obstetric Lead and the Clinical Director.
The Royal College of Obstetrics and Gynaecology have agreed to incur any costs associated with the educational meeting to be held on 25th November 2013.