HSIB’s latest investigation report, Management of preterm labour and birth of twins, has highlighted the need for better national guidance to help maternity teams manage the care of mothers expecting twins during preterm labour and birth. Key facts and figures from HSIB’s report on premature labour and birth of twins Around 8 out of every 100 babies are born preterm (before 37 completed weeks of pregnancy). Twins are at higher risk of being born prematurely with 60% of twin pregnancies ending in preterm birth. In the UK, twin pregnancies account for approximately 1.5% of all pregnancies. The UK has higher numbers of preterm births than other European countries, which is concerning, as preterm birth is known to be one of the main causes of death and neurodevelopmental disability in babies and children under the age of five worldwide. In the UK, 75% of stillbirths and 71% of neonatal (newborn) deaths are related to preterm births. Although in recent years there has been a reduction in the rate of stillbirths and neonatal deaths for twin pregnancies, twins have nearly double the risk of stillbirths and more than triple the risk of neonatal death than single babies. Premature birth is associated with high levels of morbidity (long-term health conditions), mortality (death) and long term disability from conditions such as intraventricular haemorrhage (IVH or bleeding within the brain), brain injury from periventricular leukomalacia (PVL) and cerebral palsy. Intrauterine infection (or chorioamnionitis) of the membranes which surround the baby in the womb is also common but difficult to diagnose in preterm labour. Babies who are born prematurely often need specialist care in SCBU or a neonatal unit (NNU) or neonatal intensive care (NICU) unit. If the mother shows signs of imminent preterm labour, if her cervix has started to open and she is having contractions, she may be offered steroids or magnesium sulphate medication: Steroids are given to help the unborn baby’s lungs to mature. It is recommended that steroids are given between 24 and 48 hours before birth but no longer than 7 days before birth. Magnesium sulphate is thought to help the development of the baby’s brain and prevent conditions associated with preterm brain injury. Magnesium sulphate is given to the mother as an initial dose (bolus) and then by IV for at least 4 hours and within 24 hours of the birth. The mother should be closely monitored as magnesium sulphate can also reduce the strength and frequency of contractions. HSIB’s reference event – the patient’s experience HSIB’s investigation followed concerns expressed by a mother of twins who both suffered brain injuries after a preterm birth. The mother’s twin pregnancy, previous surgery to her cervix and a complex vaginal tear from her previous pregnancy increased her risk of a preterm labour. Her care was overseen by an obstetrician and she was advised about the implications of her twin pregnancy and the risk of preterm labour and birth. During pregnancy she was treated with antibiotics for a urine infection. A scan revealed that her cervix was reduced in length and a consultant obstetrician discussed possible options with her, including no intervention, cervical cerclage (a stitch around the cervix to prevent preterm labour), or a progesterone pessary which she accepted. She attended the maternity unit with tightenings (which can indicate the start of labour), a green vaginal discharge and bulging membranes. A scan showed the babies were positioned head down (cephalic), tests for infection were negative and the babies' heartrates were normal. Steroid treatment was started and she was admitted to a hospital with a more specialist NICU. Whilst in hospital her cervix was noted to be ‘open’ but she had no contractions. A consultant neonatologist advised her that preterm birth could lead to the babies suffering severe disability, respiratory and digestive problems and IVH. Bed rest was advised and she was discharged a few days later after the unborn babies’ scans and heart rates were normal, except for one possible deceleration on a CTG, which the obstetrician decided was no cause for concern. Two days later she reattended her local maternity unit with tightenings and was treated with magnesium sulphate, steroids, and antibiotics for a urine infection. She began to show signs of imminent preterm labour, but contractions reduced in strength after further doses of magnesium sulphate. There were concerns that the lowest baby’s head position could be obstructing delivery and the uterine stimulant oxytocin was administered in increasing doses. She was transferred to theatre for an examination under anaesthesia and finally had a caesarean section. The newborn premature twins were ventilated and transferred to the neonatal unit. Cord blood tests after birth showed no sign of oxygen deprivation, but scans three weeks later revealed both had signs of PVL brain injury. HSIB’s investigation of this family’s experience highlighted a number of issues that are commonly found in twin pregnancies at risk of preterm birth, including: There is uncertainty in the scientific evidence and guidance relating to the use of interventions, such as progesterone pessaries or cervical cerclage in twin pregnancies. Although progesterone pessary is commonly used, HSIB found that evidence suggested that progesterone pessaries were ineffective for twin pregnancies, and NICE recommended further research on the use of progesterone pessaries in mothers with risk factors for preterm labour. The use of a cervical cerclage was not recommended for use in twin pregnancies. The mother’s recommended bed rest was not supported by the guidelines. There was a lack of relevant guidance on recognising signs and symptoms of preterm labour, particularly in relation to infection risks from prolonged cervical dilatation, and the contraction-weakening effects of magnesium sulphate. There were difficulties identifying intra-uterine infection (chorioamnionitis) during labour and lack of guidance to help clinicians decide on augmentation and timing of birth, given the need to balance the risk of harm to the babies from infection with the risks of premature birth. Staff numbers, workload, capacity and staff handover may have influenced decision-making in relation to the timing or need for a caesarean section when the mother’s cervix is fully dilated in preterm labour. There were difficulties with identifying and correctly interpreting both twins’ heartrates on the CTG monitor. NICE guidance has also questioned the effectiveness of CTG monitoring in improving outcomes in multiple preterm births. There is a lack of guidance on the dose and duration of oxytocin (syntocinon) in second stage of labour. The obstetrician expressed stress and difficulty in attempting vaginal delivery of the poorly positioned baby in a preterm, potentially obstructed labour. Key findings from HSIB’s report Despite the known complications and risks associated with twin preterm labour, HSIB found that there is no single guideline which details the management of preterm labour in the context of twin pregnancies. Clinical decisions related to monitoring and managing twin pregnancies are often made on the basis of guidelines and equipment recommended for single pregnancies, but some interventions within the guidelines are unproven for use in preterm twin pregnancies. There are currently no proven treatments available to reduce the risk of preterm labour for twin pregnancies. HSIB’s investigation of the reference event and their additional findings highlight the need for further research into preterm labour as a recognised risk factor for twin pregnancies, but there are also challenges in researching this area. HSIB identified that since 2019, when the referenced family’s experience took place, a large amount of research and other work has begun in the hope of developing, implementing and assuring the effectiveness of evidence-based interventions to improve the management of preterm labour and birth. With this research underway, HSIB made no further formal recommendations. Twin pregnancies are complex and mothers expecting twins deserve good quality, consistent, evidence based care as well as clear and compassionate information about their pregnancy and labour and its known potential risks. HSIB’s findings are concerning, as was the pregnancy, birth and neonatal experience of this family which shines a light on so many of the issues which currently affect multiple pregnancy and preterm birth care. The lack of clear guidance for junior doctors and midwives makes it all the more important that women and birthing people are properly advised, and their pregnancies and births managed by experienced, senior obstetricians, in maternity settings with the necessary resources and experienced staff to provide safe care for mother and babies when complications arise. 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