An extremely concerning report from the Twins and Multiple Births Association (Tamba), commissioned by the Department of Health, has revealed that key recommendations to ensure the safety of multiple births are not being followed by many hospitals.
Five years ago, NICE (National Institute of Health and Care Excellence) recommended key steps to reduce the risk for multiple pregnancies, perhaps the most important of which was that women should be supervised by a specialist twins team who could spot early problems and the likelihood of prematurity to then put in place the right emergency care.
But the Tamba audit of 30 hospitals found that only just over half (58%) of larger maternity units were properly following the guidelines, falling to 38% of smaller units.
Currently in the UK, twins are two to three times as likely to die in the womb or in the first weeks of life, with pregnant women facing a lottery of luck as to whether they are cared for by a specialist team during the antenatal period and labour.
Britain still has one of the highest stillbirth rates in the West and the report advocates that to prevent the harrowing deaths of too many babies, staff must be better trained to improve care and to learn from mistakes.
I am acting for a family where one twin – C – was born at Whipps Cross Hospital and suffered permanent renal failure after having health problems neonatally that were not managed appropriately. Their case unfortunately illustrates the terrible impact of poor planning of twin births.
C's mother was admitted to Whipps Cross Hospital, part of Barts Health NHS Trust, in 2014 for induction of labour. CTGs were normal but when C was born by the use of ventouse and forceps the cord was wrapped tightly around his neck. C was reported to have spontaneous respirations at birth and a good cry but at one minute of age, breathing deteriorated and C appeared pale and cyanosed (blueish). At 20 minutes of age it was decided to transfer C to the neonatal unit for specialist care, including being given oxygen to help with breathing, but unfortunately the transfer was delayed because the neonatal team had to attend another delivery. C was not checked again until 40 minutes old, at which point he was in a very poor condition. Once transferred to the Neonatal ICU, signs and symptoms of abnormal blood pressure were not acted upon resulting in damage to both kidneys.
In the opinion of our expert witness, C's initial presentation was probably because of an insufficient oxygen supply at birth and, as a result, blood pressure and fluids should have been much more urgently monitored. There should have been earlier intervention and treatment, which would likely have avoided or significantly reduced level of renal injury.
Due to the injuries he suffered, C will need permanent nephrology care, will have to take medication for life, and there is a high chance he will need a kidney transplant in the future, with all the associated risks of such surgery.
Prompt and appropriate treatment at birth would have avoided these injuries, if the unit had been fully prepared for one of the twins to be in difficulties and had the resources to adequately monitor the baby. We were also critical of the antenatal care provided to C's mother and whether the pregnancy was properly risk assessed, including whether the risk of Twin-to-Twin Transfusion Syndrome was picked up.
Cases like this are too common; there will always be cases of medical emergencies which cannot be predicted but in this age of technological advances in scanning, tests and hugely skilled expertise in managing tricky pregnancies, it is vital that the NHS be able to uniformly deliver high level care in twin pregnancies across the UK.