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Best Practice Example

Pam Langford, Fetal Medicine and Multiple Birth Specialist Midwife

Questions regarding continuity of care and caring for multiple birth pregnancies

1. What is the team called?

Multiple Birth Team

2. How many of you are there? 

There is myself, the multiple pregnancy midwife Band 7, two twin consultants and sonographers, with support from physio, screening and Fetal Medicine Team.  My role is 7 ½ hours a week and I see all the multiples, excluding the higher order multiples as they are seen in the Fetal Medicine Department (which I do see – but in my other role as the fetal medicine specialist midwife).

3. How many mothers do you see overall and how many of these are expecting multiples?

We specialise in women experiencing a multiple pregnancy and we see approximately 104-110 pregnancies per year. I see the dichorionic diamniotic twins (babies which have their own amniotic sac and placenta) every four week in the multiple birth clinic and the monochorionic twins (identicals who share a placenta) every two weeks in the Fetal Medicine Clinic.

4. What other populations do you focus on?

We don’t see any other specialist teams however every now and again I work with the diabetic team if we are doing shared care of a multiple with diabetes.

5. Did the team exist already?

There was a multiple pregnancy midwife before me but since I have joined things have expanded and grown organically. One of the biggest problems previously was trying to do too much/travel between sites in the contracted hours. So when I joined I suggested staying at one unit for a whole day, thus making the process more streamlined and allowing me to spend as much time as necessary with families within the time allocated to fetal medicine.

This allowed me to increase the connect time from 20 minutes to up to one hour. The mums have their scan and get growth measured then I take their blood pressure etc. and answer any questions they might have, provide advice and give them practical information. So in essence they get a more individualised care pattern. If clinic runs over it doesn’t matter as I am on site all day.

6. What did you do to identify the needs of multiple birth mothers? And how did you bring about a change?

My role has aided reviewing old guidelines and instigating change to policy and practice. Since being in post I have completed an audit reviewing caseload from 1st April 2016 to 31st March 2017 to assess compliance with the NICE (National Institute for Health and Care Excellence) Quality Standards. We were 100% compliant in all 8 statements. The improvements made since the last audit were a decrease in lower segment caesarean sections for Twin 2 following spontaneous vaginal delivery for Twin 1 to 3% compared to 17%.

DoH maternity slider 2All women who are expecting multiples will be referred to see the multiples team after their dating scan. I then insert the patient information planning document and highlight this to the women with her schedule of care and scan appointments depending on chronicity (whether they are identical or non-identical babies).  I feel this works well and has clear and up-to-date evidence based department guidelines. A letter is dictated to be sent to their GP informing them.

We have a dedicated team of sonographers who have an interest in multiples. These sonographers only see multiples; however all our sonographers can do the first trimester scan. The dedicated core team comprises five sonographers who learn on the job and have development opportunities in the unit.

The sonography policy for multiples is very detailed and comprehensive. They are fully staffed and do not use a locum. This is attributed to the ‘grow your own’ attitude resulting in a stable department with development opportunities.  Two midwives were able to be trained on the stand alone training at City University Birmingham for 6 months so they can carry out the extra scans. The introduction of fortnightly scans for monochorionic (identicals) was also a hurdle which they managed to overcome.

All monochorionic are scanned in the fetal medicine centre and the dichorionic go on the sonographer list.  GROW (Gestation Related Optimal Weight) and CRIS (Case Register Interactive Search) databases are used and two midwives are being trained to be midwife sonographers to accommodate the increased need for scans due to GROW.

Our sonographers feel that the introduction of the NICE guidelines and Quality Standards and the Royal College of Obstetricians and Gynaecologists Guidelines have made caring for women much easier and ensure quality care. They are clear guidelines and since these, they have been able to put a business plan into the directorate which was accepted and implemented. The unit pathway now adheres to NICE Guidelines and RCOG. 

We have also changed our policy and now do not bring every woman into theatre for birth and every year an audit is carried out ensuring compliance for CNST (Clinical Negligence Scheme for Trusts) and now with NICE. Improvements are made from this.

We also have monthly audit and review meetings and a designated multiples clinic. We also hold Fetal Medicine multidisciplinary team meetings every Thursday.

The current guidelines/policy for multiples date issued in June 2014 and valid until June 2017 is being ratified along with the patient information leaflet (our multiple pregnancy leaflet). We also have a multiple pregnancy counselling pro forma.Proud new parents

7. Does mum see one midwife throughout her pregnancy, birth and postnatally?

Pregnancy yes, they see me as the Multiple pregnancy midwife and again me if they get seen in Fetal medicine (By chance I do both posts). Postnatally mum sees the community midwife.

8. Does mum see one clinician throughout the same period?

If the woman is told she is expecting multiples from the dating scan they are referred to see the screening midwife, usually on that day to discuss the implication of combined screening (nuchal) to ensure the woman is fully informed. The woman will be counselled and then have a 24 hour cooling off period, the screening midwife will organise the nuchal with scan department and that is usually accommodated within the recommended time frame. (The nuchal translucency screening tests measures the thickness of fluid build-up at the back of the babies’ head. If this area is thicker than normal, it can be an early sign of Down’s syndrome, trisomy 18 or heart problems).

The multiples are always booked in with one of two clinicians depending on where they live. They only reason they wouldn’t see the same one each time is if that particular clinician was on holiday when the appointment was due.  If that does happen then most women tend to have their scan then come and see me at the other site to go through anything else.

9. What choices are parents given in terms of where and how they receive their antenatal care, intrapartum care and postnatal care?

They are allowed choice with regards to birth and care but care is mostly done in-house as it is an easier pathway to continue seeing me. We do discuss all birthing options (Home and Hospital) with them and recently had one lady request a homebirth. This was facilitated with the consultant, myself and our Consultant Midwife. The lady is having a Doula at home, her community Midwife and the Consultant Midwife is going on call as a second support. All of our women having a normal vaginal delivery are offered mobilisation throughout the labour with a telemetry fetal auscultation (a wireless ‘belt’ around mum’s tummy which monitors fetal heart rate) to allow them to walk around the room. They are also offered and regularly use a birthing pool to labour in and to deliver the first baby. On the second twin they get out for stabilisation of the second twin and are encouraged to deliver upright.

At 32 weeks the parents have a birth planning appointment and see both myself and the consultant separately to go through options, book their induction or caesarean section, cover aspects of labour and care for their babies post birth.

Parents see the community midwife postnatally.

10. What is the feedback they have received from parents on the service?

No there hasn’t been any formal feedback mechanisms specific to the twins but there is a patient feedback iPad that all patients complete on leaving the postnatal ward.

Patients are finding the longer one-to-one time much more beneficial. Before they didn’t quite know what to expect but now they have my mobile number and email and can contact me at any time. Once they have seen their community midwife at 16 weeks I become the constant as they see me from that point onwards.

Complaints have stopped and we have received some extremely positive feedback since operating this way. I feel it creates proper relationships and the families feel they have support the whole way through.  I regularly receive cards and photos which is lovely.

11. Has anyone else in your maternity network (or beyond) expressed an interest in learning more about the service you provide? / copying your model?

Not as yet no. Implementation was tricky due to scan slot times and consultant clinic times.


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