Shared learning database

 
Organisation:
The Newcastle upon Tyne Hospitals NHS Foundation Trust
Published date:
September 2013

The Multiple Pregnancy Service at Newcastle upon Tyne Hospitals Foundation Trust provides the additional care that women with multiple pregnancies should receive. This care is based on best practice and best available evidence in keeping with the National Institute for Health and Care Excellence (NICE) Multiple Pregnancy Clinical Guideline and Quality Standard and the Northern Survey of Twins and Multiple Pregnancy (NorSTAMP) Standards of Care (Public Health England).

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

Example

Aims and objectives

To set up a service which meets the additional care needs of women with multiple pregnancy. The organisation of care at unit level should be as follows:
- All women with a multiple pregnancy will be seen by a dedicated multi-disciplinary team for multiple pregnancies in the multiple pregnancy clinic. This is in line with NICE quality statement 3.
- The core team includes a named lead consultant obstetrician, a team of specialist multiple pregnancy midwife and sonographers with an interest in the care of multiple pregnancies as per NICE quality statement 3.
- The multi-disciplinary team also has access to fetal medicine specialists, the perinatal mental health team, women's health physiotherapy and a dietician if necessary.
- The care of women with medical problems in pregnancy but also with a multiple pregnancy will be shared between the lead obstetrician for multiple pregnancies and a maternal medicine consultant as indicated by statement 6.
- The service will ensure continuity of care and provide consistent support and advice throughout the whole pregnancy.

Reasons for implementing your project

An increased maternal mortality rate associated with multiple births in the previous two triennia has been maintained (CMACE 2011). Compared with singletons, fetuses in a multiple pregnancy have a higher risk of complications during and after pregnancy, including discordant growth, pre-term birth and increased mortality rate. It has been shown that the rate of cerebral palsy is at least six times higher for twins and 18 times higher for triplets than for singleton babies (CMACE 2009). This is also supported by the claims data held by the NHS Litigation Authority. In a study of claims relating to stillbirth conducted by the NHS Litigation Authority there were a number of twin pregnancies. This service was set up following the results of an RCT here in Newcastle measuring the care given to women expecting multiple pregnancy and how it impacts on the outcome of the chance of developing post natal depression. The study highlighted that women with twins or more may be more prone to postnatal depression and that mothers receive better care from a dedicated clinic with a core team.

How did you implement the project

A guideline for the provision of antenatal management of multiple pregnancies was drawn up for use in Newcastle. This defined the roles and responsibilities of midwives, obstetricians and sonographers involved in the care of women with multiple pregnancy. The antenatal care which should be provided is summarised below:
First multiple pregnancy clinic visit: Discuss and ensure the appropriate visit schedule is in the hospital and patient hand held notes as per quality statement 4. Provide women with the team contact details and inform them of the parenting sessions they can attend during their pregnancy (refer to leaflet in supporting information). We provide 10 hours of education sessions to prepare parents for all eventualities.

Information, Education and Support: Information to support women in planning for birth should be given. This includes the advised place of birth and the risks and benefits of different modes of delivery. The likely timing and mode of delivery will also be discussed. The NUTH 'Multiple Pregnancy leaflet' will be given to support these discussions. Document in the hospital notes (multiple pregnancy documentation) that the above information and NUTH leaflet has been given. Parents to be offered dedicated antenatal classes/education for twin's and higher order multiple pregnancy.

The 11+0 - 13+6 week ultrasound scan for multiple pregnancy: Determine number of fetuses, gestational age, diagnose and document chorionicity and amnionicity, determine the position of each fetus as per quality statements 1 and 2. If chorionicity is not ascertained at 10 - 13 weeks, a further scan should be arranged. Following this women have a care plan which specifies the timing of appointments appropriate for the chorionicity and amnionicity of their pregnancy.

Indications for referral to Fetal Medicine: Monochorionic monoamniotic twin, triplet or higher order pregnancy. Triplet or higher order pregnancy. Pregnancy complicated by discordant fetal growth. fetal anomaly, fetal death, suspected TTTS.

Planning for delivery: Place, timing and mode: Women with a multiple pregnancy have a discussion by 32 weeks about the timing of birth, possible modes of delivery and agree a birth plan. This is in line with statement 8.

Key findings

- All women are seen once per week and their care plan is reviewed at each visit.
- Parents report that they are better prepared with all having access to 10 hours of education. All classes have been evaluated positively.
- When the service was set up we cared and provided education classes for about 90 women per year. Now we have about 200 per year with mother travelling from the surrounding areas to receive their care here.

Key learning points

-One challenge we found when implementing the service was that it required a change to normal practice in that women with multiple pregnancy are to be referred to the specialised service. Sometimes, Doctors are resistant to change or to letting go of their patients. However specialised services ultimately improve patient satisfaction as those providing their care have greater knowledge and expertise. The service in Newcastle is centred on the women's experience.
-A GP referral pathway has been set up to make it easier for GPs to refer women into the service.
-The service in Newcastle has a midwife for multiple births in post to provide coordination and specialised support.
-Parents are part of the decision making process meaning that all aspects of care are jointly agreed.

Contact details

Name:
Sandra Bosman
Job:
Specialist midwife for multiples
Organisation:
The Newcastle upon Tyne Hospitals NHS Foundation Trust
Email:
sandra.bosman@nuth.nhs.uk

Sector:
Primary care
Is the example industry-sponsored in any way?
No