Twin pregnancy birth injury claims

We tend to think of twins as identical or non-identical. However, during pregnancy, twins are classified by whether the babies share the placenta and its membranes. The type of twins determines the risk and the level of specialist care that the mother should receive throughout her pregnancy, labour, and delivery. There are three types of twins:

• DCDA or dichorionic diamniotic twins. DCDA twins each have their own placenta with its own separate inner membrane (amnion) and outer membrane (chorion). All non-identical twins and one third of identical twins are DCDA. DCDA twins have the lowest risk of all twin pregnancies.
• MCDA or monochorionic diamniotic twins. MCDA twins share the same placenta with one outer membrane (chorion) and two inner membranes (amnion). Around two thirds of all identical twins are MCDA. Twins who are MCDA  are at greatest risk of developing twin-to-twin transfusion syndrome (TTTS). MCDA twins need more frequent scans and monitoring than DCDA twins. Women who are expecting MCDA twins may be referred to a fetal medicine centre for specialist care during pregnancy.
• MCMA or monochorionic monoamniotic twins. Only 1% (1 in 100) pairs of identical twins are MCMA. MCMA twins share both the inner and outer membranes. MCMA twins need specialist care, frequent scans and close monitoring during pregnancy, as they have a higher risk of life-threatening injury to the babies from cord entanglement.  

Parents can find out which type of twins they have at the antenatal ultrasound scan appointment between 11 and 14 weeks of pregnancy.

Having twins, triplets or other multiples increases the risk of developing many of the complications of pregnancy. These complications include:

• Premature birth - Premature newborn babies’ organs may not have fully developed at birth, increasing their risk of injury from serious conditions which require early diagnosis and treatment, such as blindness from retinopathy of prematurity (ROP). They need help with breathing, feeding, controlling their body temperature or fighting infection, and usually need specialist care in a neonatal intensive care unit (NICU or SCBU).
• Anaemia in pregnancy can be caused by lack of iron but may be treated with changes in diet or supplements, such as iron tablets and folic acid. Untreated anaemia increases the risk of life-threatening injury to the mother and unborn baby from harmful conditions, such as IUGR (intra-uterine growth restriction), infection, heart failure and bleeding.
• Intrauterine growth restriction (IUGR) - Babies with IUGR don’t grow at the expected rate for their gestational age (number of weeks of pregnancy). It is normal for twins to be slightly smaller than single babies, but IUGR can be life-threatening for unborn twins if it is caused by problems with the umbilical cord or the placenta. 
• High blood pressure (hypertension) in twin pregnancy increases the risk of detachment of the placenta (placental abruption).
• Pre-eclampsia - If a pregnant woman has signs of pre-eclampsia she must be monitored carefully and treated to avoid serious injury to herself and her baby/babies. Treatment for pre-eclampsia usually involves admission to hospital, bed rest, medication and careful monitoring, to bring the mother’s blood pressure down to safe levels.
• HELLP syndrome is a life-threatening atypical form of pre-eclampsia which takes its name from key features of the condition: Haemolysis (breakdown of red blood cells), Elevated Liver enzymes and Low Platelet count (affecting blood clotting). HELLP develops late in pregnancy and is often misdiagnosed, delaying urgent treatment to deliver the babies and give the mother a blood transfusion. If HELLP is left untreated, the mother may become critically ill or die from liver rupture or stroke. The unborn babies may be stillborn or suffer brain injury from placental failure or abruption.

Gestational diabetes refers to when a woman develops diabetes in pregnancy. In severe cases, the mother may need tablets or insulin injections to keep her blood sugar within safe levels. Gestational diabetes must be diagnosed, monitored and kept under control as it increases the risk of developing other complications of pregnancy, such as high blood pressure, pre-eclampsia, shoulder dystocia, stillbirth, prematurity, and respiratory difficulties, neonatal hypoglycaemia and jaundice for the newborn baby.

Twin-to-twin transfusion syndrome or TTTS is a serious complication of twin pregnancy which occurs when abnormalities in the blood vessels of the placenta allow more blood to flow to one twin than the other. The twin who receives less blood (the ‘donor twin’) is left undernourished and anaemic. The twin who receives too much blood (the ‘recipient twin’) may suffer heart failure from their cardiovascular system becoming overloaded, and complications from too much amniotic fluid.

When TTTS is suspected in a twin pregnancy, frequent ultrasound scanning must take place to monitor the babies’ growth and health. The mother may need to be referred urgently to a fetal medicine centre for specialist treatment. Any delays in diagnosis of TTTS or referral to a specialist fetal medicine centre for treatment can result in death or brain injury to the unborn babies.

When an unborn baby is positioned with their bottom or feet down (instead of head down) in the last weeks of pregnancy, this is known as a breech presentation.

In twin or multiple pregnancies, it is important that the method and timing of the babies’ delivery is carefully planned in advance with the mother and an experienced obstetrician. Twin births should be managed in hospital under the care of a multidisciplinary maternity team including midwives, an obstetrician and paediatricians. Throughout labour and delivery, the unborn twins must be monitored carefully with electronic fetal heart monitoring.

Twin births are often recommended to take place by caesarean section, especially if the first twin is in the breech position or the second twin is in transverse position. Vaginal breech deliveries of twins need careful management by obstetricians who are skilled in handling the complications of multiple births and vaginal breech delivery.

Severe brain injury to babies and birth injury compensation claims commonly arise from maternity emergencies in which inexperienced or unskilled junior obstetricians are left to manage unplanned vaginal breech deliveries.

Birth injury compensation claims arising from negligent maternity care during twin pregnancy and birth  often involve one or more of the following mistakes:

• failing to inform the mother about options, risks and benefits of different types of care;
• failing to plan the method and timing of a twin birth with the mother and senior obstetrician;
• inadequate antenatal monitoring, scanning or other tests;
• delay or failure to diagnose, monitor and treat complications (e.g. TTTS, gestational diabetes, IUGR, hypertension, pre-eclampsia);
• delaying or failing to refer a mother with TTTS for specialist review;
• delay in delivery;
• failure to arrange or carry out a caesarean section, where needed;
• negligent management of breech delivery;
• negligent resuscitation or neonatal care of premature or twin babies;
• failure to diagnose, monitor and treat premature or newborn twin babies for neonatal conditions (e.g. retinopathy of prematurity (ROP), hypoglycaemia, jaundice);
• birth trauma to the mother from birth injury or twin pregnancy complications (e.g. pre-eclampsia, HELLP).

Our experienced birth injury solicitors investigate the cause and full extent of each client’s injury carefully, to ensure that our client receives their full entitlement to compensation. This includes ensuring that the long-term consequences of their injury, such as future developmental or increasing disability, are understood and taken into account when assessing their future needs and the value of the claim.

Birth and neonatal injuries which often lead to twin pregnancy negligence compensation claims include:

• brain injury, cerebral palsy or neurodevelopmental disability;
• epilepsy;
• blindness from retinopathy of prematurity (ROP);
• brachial plexus injury/Erb’s palsy;
• stillbirth or neonatal death;
• maternal birth trauma, psychological injury or death.