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Are clinical guidelines for multiple births being ignored?

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    A recent study by Tamba (Twins & Multiple Births Association) shows that fewer than one in five maternity units has implemented NICE guidelines in relation to delivery of twins and triplets. Is this failure putting lives at risk?

    By Simon Elliman

The risks of multiple births

It is reported by Tamba that while multiple births make up only 3% of births each year, they are responsible for a disproportionately high number of stillbirths (7.4%), and neonatal deaths (18.4%). Just as tragically and importantly, a baby born as part of a “multiple” birth is more than six times as likely as a singleton baby to have cerebral palsy.

The reasons for these statistics lie in the complications which may arise in delivering more than one baby, as well as in the inherently greater risks of a multiple pregnancy. Such conditions as pre-eclampsia, gestational diabetes and anaemia are more common in mothers who are carrying more than one baby, and these conditions can also carry risk for the babies.

“Multiples” are more susceptible to fetal growth restriction, and more likely to be born prematurely. More than 50% of “multiples” are born before 37 weeks, while 10% are born before 32 weeks. Prematurity carries considerable risk for the baby.

Other risks peculiar to twin pregnancies include twin to twin transfusion syndrome (TTTS) where one twin shares the other’s blood supply, and the risk that a second born twin might suffer oxygen starvation while the first is being delivered.

Guidelines

The National Institute for Health and Care Excellence (NICE), introduced new clinical guidelines in relation to multiple deliveries in 2011. Under those guidelines, mothers must be attended by a midwife trained and experienced in the delivery of multiple babies, sonographers must be skilled in scanning for twins or more, and an obstetrician should be available at all births.

A study by TAMBA (Maternity Services Survey Report 2014) has revealed that fewer than one in five maternity units has implemented these guidelines.

Increasing numbers of multiple births

Multiple births are on the increase. In 2013, there were 10,783 multiple births, compared to 8,549 twenty years earlier. Factors include greater reliance upon IVF, where usually more than one embryo will be implanted.

Keith Reed, the chief executive of Tamba, has pinpointed the increase as being an added reason why services need to improve, and implement the NICE guidelines, saying:

Too many units are putting twins’, triplets’, and other multiples’ lives at risk by failing to follow the latest clinical guidance.”

Alan Cameron, the vice-president for clinical quality at the Royal College of Obstetricians and Gynaecologists (RCOG), has also called for a “multi-disciplinary approach including input from midwives, obstetricians and ultrasonographers”, which he states “will help to ensure any complications are picked up and managed quickly and effectively.”

Our Experience

In the Clinical Negligence Team we have dealt with a number of cases where mismanagement of multiple births has led to the tragic death of a baby or a baby suffering brain damage leading to cerebral palsy.

Clearly it makes sense for all maternity units to heed and implement NICE guidelines, which are designed to improve patient safety, and to reduce the number of tragic incidents at birth which may lead to parents pursuing claims for compensation on behalf of severely injured children. Tamba are now working with maternity units across the UK to support them in implementing the NICE guidelines which will hopefully see a decrease in these injuries and deaths.

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