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Multiple pregnancy

About

What is covered

This pathway covers the management of twin and triplet pregnancies in the antenatal period. The incidence of multiple births is rising, due mainly to increasing use of assisted reproduction techniques. Multiple pregnancy is associated with higher risks for both mother and babies. Because of this, women with multiple pregnancies need more antenatal contact with healthcare professionals than women with singleton pregnancies. In addition, their higher risk of preterm delivery places greater demand on specialist neonatal resources.
This pathway should be used in conjunction with the NICE pathway on antenatal care for uncomplicated pregnancies. The multiple pregnancy pathway specifies the care that women with twin and triplet pregnancies should receive that is additional to or different from routine antenatal care for women with singleton pregnancies. For many women the twin or triplet pregnancy will be detected only after the first (booking) appointment in routine antenatal care. Women should then be offered the specialist antenatal appointments described in this pathway.

Updates

Updates to this pathway

30 September 2016 Pathway updated to include full guideline recommendations.
19 November 2015 Link to NICE pathway on preterm labour and birth added.
26 February 2015 Link to NICE pathway on safe midwifery staffing for maternity settings added.
17 September 2013 Multiple pregnancy quality standard added to pathway.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on managing multiple (twin and triplet) pregnancies in the antenatal period in an interactive flowchart

What is covered

This pathway covers the management of twin and triplet pregnancies in the antenatal period. The incidence of multiple births is rising, due mainly to increasing use of assisted reproduction techniques. Multiple pregnancy is associated with higher risks for both mother and babies. Because of this, women with multiple pregnancies need more antenatal contact with healthcare professionals than women with singleton pregnancies. In addition, their higher risk of preterm delivery places greater demand on specialist neonatal resources.
This pathway should be used in conjunction with the NICE pathway on antenatal care for uncomplicated pregnancies. The multiple pregnancy pathway specifies the care that women with twin and triplet pregnancies should receive that is additional to or different from routine antenatal care for women with singleton pregnancies. For many women the twin or triplet pregnancy will be detected only after the first (booking) appointment in routine antenatal care. Women should then be offered the specialist antenatal appointments described in this pathway.

Updates

Updates to this pathway

30 September 2016 Pathway updated to include full guideline recommendations.
19 November 2015 Link to NICE pathway on preterm labour and birth added.
26 February 2015 Link to NICE pathway on safe midwifery staffing for maternity settings added.
17 September 2013 Multiple pregnancy quality standard added to pathway.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Multiple pregnancy: twin and triplet pregnancies (2013) NICE quality standard 46

Quality standards

Quality statements

Determining chorionicity and amnionicity

This quality statement is taken from the multiple pregnancy: twin and triplet pregnancies quality standard. The quality standard defines clinical best practice for multiple pregnancy and should be read in full.

Quality statement

Women with a multiple pregnancy have the chorionicity and amnionicity of their pregnancy determined using ultrasound and recorded between 11 weeks 0 days and 13 weeks 6 days.

Rationale

If fetuses share a placenta, there is a greater risk of complications. Determining chorionicity and amnionicity allows women to be assigned the correct plan of care for their pregnancy.
Pregnancy risks, clinical management and subsequent outcomes are different for monochorionic and dichorionic twin pregnancies (and for monochorionic, dichorionic and trichorionic triplet pregnancies). Therefore, accurate determination of chorionicity is important.

Quality measure

Structure
Evidence of local arrangements to ensure that women with a multiple pregnancy have an ultrasound scan between 11 weeks 0 days and 13 weeks 6 days to determine and record the chorionicity and amnionicity of their pregnancy.
Data source: Local data collection.
Process
The proportion of women with a multiple pregnancy who receive an ultrasound scan between 11 weeks 0 days and 13 weeks 6 days to determine and record the chorionicity and amnionicity of their pregnancy.
Numerator – the number of women in the denominator who received an ultrasound scan between 11 weeks 0 days and 13 weeks 6 days to determine and record the chorionicity and amnionicity of their pregnancy.
Denominator – the number of women with a multiple pregnancy of greater than 14 weeks' gestation.
Data source: Local data collection. The Maternity Services Secondary Uses Data Set, once implemented, will collect data on:
  • Offer status – dating ultrasound scan (global number 17201960).
  • Gestation – dating ultrasound scan (global number 17202010).
  • Number of fetuses – dating ultrasound scan (global number 17202020).
Outcomes
Determination of chorionicity and amnionicity.
Data source: Local data collection.

What the quality statement means for each audience

Service providers ensure that systems are in place for women with a multiple pregnancy to have an ultrasound scan between 11 weeks 0 days and 13 weeks 6 days to determine and record the chorionicity and amnionicity of their pregnancy.
Healthcare practitioners ensure that women with a multiple pregnancy have an ultrasound scan between 11 weeks 0 days and 13 weeks 6 days to determine and record the chorionicity and amnionicity of their pregnancy.
Commissioners ensure that they commission specialist services that provide ultrasound scanning between 11 weeks 0 days and 13 weeks 6 days for women with a multiple pregnancy to determine and record the chorionicity and amnionicity of their pregnancy.

What the quality statement means for patients, service users and carers

Women who are pregnant with twins or triplets (referred to as a multiple pregnancy) have an ultrasound scan between 11 weeks 0 days and 13 weeks 6 days of their pregnancy. This is to see whether the babies share the same placenta (chorionicity) and amniotic sac (amnionicity). This information is recorded in the woman's notes

Source guidance

Multiple pregnancy (NICE clinical guideline 129) recommendations 1.1.1.1 (key priority for implementation) and 1.1.2.1 (key priority for implementation).

Definitions

Multiple pregnancy
A multiple pregnancy is defined as a twin or triplet pregnancy.
Chorionicity
The number of chorionic (outer) membranes that surround the fetuses in a multiple pregnancy. If there is only 1 membrane, the pregnancy is described as monochorionic; if there are 2, the pregnancy is described as dichorionic; and if it is a triplet pregnancy with 3 membranes, the pregnancy is described as trichorionic. Monochorionic twin pregnancies and dichorionic and monochorionic triplet pregnancies carry higher risks because fetuses share a placenta.
Amnionicity
The number of amnions (inner membranes) that surround fetuses in a multiple pregnancy. Pregnancies with 1 amnion (so that all fetuses share 1 amniotic sac) are described as monoamniotic; twin or triplet pregnancies with 2 amnions are diamniotic; and triplet pregnancies with 3 amnions are triamniotic.
Ultrasound scan
An ultrasound scan is used to determine chorionicity based on the number of placental masses, the Lambda or T sign and membrane thickness.
Note: Antenatal care (NICE clinical guideline 62) recommends determination of gestational age from 10 weeks 0 days. However, the aim in Multiple pregnancy (NICE clinical guideline 129) is to minimise the number of scan appointments that women need to attend within a short time, especially if it is already known that a woman has a twin or triplet pregnancy (for example, as a result of IVF treatment).
Recording the chorionicity and amnionicity
The chorionicity and amnionicity of the pregnancy should be documented in the ultrasound report. An electronic copy of the ultrasound report and an ultrasound image (of Lambda or T sign) should be stored on the radiology reporting and picture archiving system. Hard copies of the report should be printed out and placed in the woman's hand-held maternity notes and their hospital notes.

Equality and diversity considerations

Some pregnant women have complex social needs and may be less likely to access or maintain contact with antenatal care services. Examples of women with complex social needs include, but are not limited to, women who:
  • have a history of substance misuse (alcohol or drugs)
  • have recently arrived in the UK as a migrant, asylum seeker or refugee
  • have difficulty speaking or understanding English
  • are aged under 20 years
  • have experienced domestic abuse
  • are living in poverty
  • are homeless.
It is therefore appropriate that professionals give special consideration to women with complex social needs. Pregnancy and complex social factors (NICE clinical guideline 110) includes recommendations on how to make antenatal care accessible to pregnant women with complex social needs and how to encourage women to maintain ongoing contact with maternity services.

Labelling the fetuses

This quality statement is taken from the multiple pregnancy: twin and triplet pregnancies quality standard. The quality standard defines clinical best practice for multiple pregnancy and should be read in full.

Quality statement

Women with a multiple pregnancy have their fetuses labelled using ultrasound and recorded between 11 weeks 0 days and 13 weeks 6 days.

Rationale

Labelling the fetuses and recording this in the notes at the dating scan, using left and right, or upper and lower, allows the fetuses to be consistently identified throughout the pregnancy. It also takes into account that the 'leading' fetus may change as pregnancy progresses and labelling by number can cause confusion, particularly with left and right fetuses.

Quality measure

Structure
Evidence of local arrangements to ensure that women with a multiple pregnancy have an ultrasound scan between 11 weeks 0 days and 13 weeks 6 days to determine and record the chorionicity and amnionicity of their pregnancy.
Data source: Local data collection.
Process
The proportion of women with a multiple pregnancy who have their fetuses labelled using an ultrasound scan and recorded between 11 weeks 0 days and 13 weeks 6 days.
Numerator – the number of women in the denominator who have had their fetuses labelled using an ultrasound scan and recorded between 11 weeks 0 days and 13 weeks 6 days.
Denominator – the number of women with a multiple pregnancy of greater than 14 weeks' gestation.
Data source: Local data collection.
Outcomes
Consistent identification of fetuses in multiple pregnancies.
Data source: Local data collection.

What the quality statement means for each audience

Service providers ensure that systems are in place for women with a multiple pregnancy to have their fetuses labelled using an ultrasound scan and recorded between 11 weeks 0 days and 13 weeks 6 days.
Healthcare practitioners ensure that women with a multiple pregnancy have their fetuses labelled using an ultrasound scan and recorded between 11 weeks 0 days and 13 weeks 6 days.
Commissioners ensure that that they commission specialist services for women with a multiple pregnancy to have their fetuses labelled using an ultrasound scan and recorded between 11 weeks 0 days and 13 weeks 6 days.

What the quality statement means for patients, service users and carers

Women who are pregnant with twins or triplets (referred to as a multiple pregnancy) have an ultrasound scan between 11 weeks 0 days and 13 weeks 6 days of their pregnancy to record the positions of their babies.

Source guidance

Multiple pregnancy (NICE clinical guideline 129) recommendation 1.1.2.2 (key priority for implementation).

Definitions

Ultrasound scan
An ultrasound scan is used to determine chorionicity based on the number of placental masses, the Lambda or T sign and membrane thickness.
Note: Antenatal care (NICE clinical guideline 62) recommends determination of gestational age from 10 weeks 0 days. However, the aim in Multiple pregnancy (NICE clinical guideline 129) is to minimise the number of scan appointments that women need to attend within a short time, especially if it is already known that a woman has a twin or triplet pregnancy (for example, as a result of IVF treatment).
Labelling the fetuses
Labelling of the fetuses should be documented in the ultrasound report. An electronic copy of the ultrasound report and an ultrasound image should also be stored on the radiology reporting and picture archiving system. Hard copies of the report should be printed out and placed in the women's hand-held maternity notes and their hospital notes.
The fetuses should be labelled using either the lateral orientation (left and right) or the vertical orientation (upper and lower). Labelling of fetuses should be carried out at all ultrasound scans to ensure consistent identification throughout the pregnancy.

Equality and diversity considerations

Some pregnant women have complex social needs and may be less likely to access or maintain contact with antenatal care services. Examples of women with complex social needs include, but are not limited to, women who:
  • have a history of substance misuse (alcohol or drugs)
  • have recently arrived in the UK as a migrant, asylum seeker or refugee
  • have difficulty speaking or understanding English
  • are aged under 20 years
  • have experienced domestic abuse
  • are living in poverty
  • are homeless.
It is therefore appropriate that professionals give special consideration to women with complex social needs. Pregnancy and complex social factors (NICE clinical guideline 110) includes recommendations on how to make antenatal care accessible to pregnant women with complex social needs and how to encourage women to maintain ongoing contact with maternity services.

Composition of the multidisciplinary core team

This quality statement is taken from the multiple pregnancy: twin and triplet pregnancies quality standard. The quality standard defines clinical best practice for multiple pregnancy and should be read in full.

Quality statement

Women with a multiple pregnancy are cared for by a multidisciplinary core team.

Rationale

Women with a multiple pregnancy should have their clinical care provided by a multidisciplinary core team because of the increased risks and complications associated with multiple births. Members of this team will have the expertise needed to provide high-quality care for women with a multiple pregnancy. It may be appropriate for the multidisciplinary core team to refer women to the community midwifery team for some of their additional antenatal appointments.

Quality measure

Structure
Evidence of local arrangements to ensure that women with a multiple pregnancy are cared for by a multidisciplinary core team.
Data source: Local data collection.

What the quality statement means for each audience

Service providers ensure that systems are in place for women with a multiple pregnancy to be cared for by a multidisciplinary core team.
Healthcare practitioners ensure that women with a multiple pregnancy are cared for by a multidisciplinary core team.
Commissioners ensure that they commission services for women with a multiple pregnancy to be cared for by a multidisciplinary core team.

What the quality statement means for patients, service users and carers

Women who are pregnant with twins or triplets (referred to as a multiple pregnancy) are cared for by a team of healthcare professionals with different skills and roles (for example, specialist doctors, specialist midwives and ultrasound operators).

Source guidance

Multiple pregnancy (NICE clinical guideline 129) recommendations 1.2.3.1 (key priority for implementation), 1.2.3.3 (key priority for implementation) and 1.2.3.4 (key priority for implementation).

Definitions

Multidisciplinary core team
A multidisciplinary core team of named specialists consists of specialist obstetricians, specialist midwives and ultrasonographers, all of whom have experience and knowledge of managing twin and triplet pregnancies.
A specialist obstetrician is an obstetrician with a special interest, experience and knowledge of managing multiple pregnancies, and who works regularly with women with multiple pregnancies.
A specialist midwife is a midwife with a special interest, experience and knowledge of managing multiple pregnancies, and who works regularly with women with multiple pregnancies.
An ultrasonographer is a healthcare professional with a postgraduate certificate in the performance and interpretation of obstetric ultrasound examinations.
The multidisciplinary core team should coordinate clinical care for women with twin and triplet pregnancies to:
  • minimise the number of hospital visits
  • provide care as close to the woman's home as possible
  • provide continuity of care within and between hospitals and the community; the community includes GPs in primary care, and community midwives and health visitors.
The multidisciplinary core team should offer information and emotional support specific to twin and triplet pregnancies at their first contact with the woman and provide ongoing opportunities for further discussion and advice including:
  • antenatal and postnatal mental health and wellbeing
  • antenatal nutrition
  • the risks, symptoms and signs of preterm labour and the potential need for corticosteroids for fetal lung maturation
  • likely timing and possible modes of delivery
  • breastfeeding
  • parenting.

Care planning

This quality statement is taken from the multiple pregnancy: twin and triplet pregnancies quality standard. The quality standard defines clinical best practice for multiple pregnancy and should be read in full.

Quality statement

Women with a multiple pregnancy have a care plan that specifies the timing of appointments with the multidisciplinary core team appropriate for the chorionicity and amnionicity of their pregnancy.

Rationale

Women with a multiple pregnancy should have most of their antenatal appointments with a member of the multidisciplinary core team. The number of appointments and ultrasound scans a woman should have depends on the chorionicity and amnionicity of her pregnancy and any associated risk factors or complications.
Women should have a record of the expected number of antenatal appointments they should attend, who they should have them with and where they will take place.

Quality measure

Structure
a) Evidence of local arrangements to ensure that women with a multiple pregnancy have a care plan that specifies the timing of antenatal care appointments with the multidisciplinary core team appropriate for the chorionicity and amnionicity of their pregnancy.
Data source: Local data collection.
b) Evidence of local audit to monitor the completeness and accuracy of the antenatal care plan for women with a multiple pregnancy.
Data source: Local data collection.
Process
The proportion of women with a multiple pregnancy who have a care plan that specifies the timing of antenatal care appointments with the multidisciplinary core team appropriate for the chorionicity and amnionicity of their pregnancy.
Numerator – the number of women in the denominator who have a care plan that specifies the timing of antenatal care appointments with the multidisciplinary core team appropriate for the chorionicity and amnionicity of their pregnancy.
Denominator – the number of women with a multiple pregnancy.
Data source: Local data collection.
Outcome
Women feel informed about their care and know which healthcare professionals they should see and when.
Data source: Local data collection. Data will also be collected against NHS outcomes framework 2013/14 indicator 4.5 'Women's experience of maternity services'.
The Care Quality Commission's Maternity services survey 2010 collected data on singleton and multiple births and asked the questions 'Roughly how many antenatal check-ups did you have in total?' and 'Roughly how may ultrasound scans did you have in total during this pregnancy?'. The total number of respondents is also stated, although results are not broken down by singleton or multiple pregnancies.

What the quality statement means for each audience

Service providers ensure that systems are in place for women with a multiple pregnancy to have a care plan that specifies the timing of antenatal care appointments with the multidisciplinary core team appropriate for the chorionicity and amnionicity of their pregnancy.
Healthcare practitioners provide women who have a multiple pregnancy with a care plan that specifies the timing of antenatal care appointments with the multidisciplinary core team appropriate for the chorionicity and amnionicity of their pregnancy.
Commissioners ensure that they commission services that provide women who have a multiple pregnancy with a care plan that specifies the timing of antenatal care appointments with the multidisciplinary core team appropriate for the chorionicity and amnionicity of their pregnancy.

What the quality statement means for patients, service users and carers

Women who are pregnant with twins or triplets (referred to as a multiple pregnancy) have a care plan that has the dates and times of all their antenatal care appointments and details of who the appointments are with.

Source guidance

Multiple pregnancy (NICE clinical guideline 129) recommendation 1.1.2.11 (key priority for implementation) and recommendations 1.2.3.5, 1.2.3.6, 1.2.3.7 and 1.2.3.8.

Definitions

Multidisciplinary core team
A multidisciplinary core team of named specialists consists of specialist obstetricians, specialist midwives and ultrasonographers, all of whom have experience and knowledge of managing twin and triplet pregnancies.
A specialist obstetrician is an obstetrician with a special interest, experience and knowledge of managing multiple pregnancies, and who works regularly with women with multiple pregnancies.
A specialist midwife is a midwife with a special interest, experience and knowledge of managing multiple pregnancies, and who works regularly with women with multiple pregnancies.
An ultrasonographer is a healthcare professional with a postgraduate certificate in the performance and interpretation of obstetric ultrasound examinations.
Care plan
A care plan should be provided at determination of chorionicity, which specifies the frequency and timing of antenatal care appointments. The care plan should contain the recommended schedule of specialist antenatal appointments according to the chorionicity and amnionicity of a pregnancy, as detailed in NICE clinical guideline 129: schedule of specialist antenatal appointments.
Women may be seen for additional antenatal appointments in the community with healthcare professionals outside the multidisciplinary core team, such as neonatal unit staff, community midwives and GPs. The scheduling of these appointments will be coordinated by the multidisciplinary core team.

Monitoring for fetal complications

This quality statement is taken from the multiple pregnancy: twin and triplet pregnancies quality standard. The quality standard defines clinical best practice for multiple pregnancy and should be read in full.

Quality statement

Women with a multiple pregnancy are monitored for fetal complications according to the chorionicity and amnionicity of their pregnancy.

Rationale

Multiple pregnancies are associated with increased risk of fetal complications. Fetal growth restriction is more likely to occur in monochorionic and dichorionic multiple pregnancies. There is a risk of feto-fetal transfusion syndrome with monochorionic multiple pregnancies. Therefore, it is important to monitor monochorionic and dichorionic multiple pregnancies closely for fetal complications in order to manage them effectively should they arise.

Quality measure

Structure
Evidence of local arrangements to ensure that women with a multiple pregnancy are monitored for fetal complications according to the chorionicity and amnionicity of their pregnancy.
Data source: Local data collection.
Process
a) The proportion of women with a monochorionic multiple pregnancy who are monitored for feto-fetal transfusion syndrome using ultrasound from 16 weeks and fortnightly until 24 weeks.
Numerator – the number of women in the denominator who were monitored for feto-fetal transfusion syndrome using ultrasound from 16 weeks and fortnightly until 24 weeks.
Denominator – the number of women with a monochorionic multiple pregnancy and a gestational age greater than 24 weeks.
Data source: Local data collection.
b) The proportion of women with a multiple pregnancy who receive an estimate of fetal weight discordance using 2 or more biometric parameters at each ultrasound scan from 20 weeks.
Numerator – the number of women in the denominator who received an estimate of fetal weight discordance using 2 or more biometric parameters at each ultrasound scan from 20 weeks.
Denominator – the number of women with a multiple pregnancy and a gestational age greater than 20 weeks.
Data source: Local data collection.

What the quality statement means for each audience

Service providers ensure that systems are in place to ensure that women with a multiple pregnancy can be monitored for fetal complications according to the chorionicity and amnionicity of their pregnancy.
Healthcare practitioners ensure that women with a multiple pregnancy are monitored for fetal complications according to the chorionicity and amnionicity of their pregnancy.
Commissioners ensure that they commission services that monitor women with a multiple pregnancy for fetal complications according to the chorionicity and amnionicity of their pregnancy.

What the quality statement means for patients, service users and carers

Women who are pregnant with twins or triplets (referred to as a multiple pregnancy) are monitored to check the babies for any complications (for example, to check the babies' growth and blood flow) in a way that is appropriate for their pregnancy.

Source guidance

Multiple pregnancy (NICE clinical guideline 129) recommendations 1.3.4.2, 1.3.4.3 and 1.3.5.2.

Definitions

Fetal growth restriction
A difference in size of 25% or more between twins or triplets, known as fetal weight discordance, is a clinically significant indicator of fetal growth restriction. The number of scans women receive to monitor for fetal growth restriction is determined by the amnionicity and chorionicity of the pregnancy and should follow the recommended schedule of specialist antenatal appointments, as detailed in NICE clinical guideline 129: schedule of specialist antenatal appointments.
Fetal biometric parameters
Standard antenatal ultrasound measures to assess the growth and wellbeing of the fetus and monitor for fetal weight discordance, they include:
  • head circumference
  • abdominal circumference
  • femoral length.
Feto-fetal transfusion syndrome
Feto-fetal transfusion syndrome is a complication of monochorionic multiple pregnancies, in which shared blood vessels in the placenta cause an imbalance in the flow of blood from one fetus to another. The fetus with less blood is referred to as the donor, whereas the fetus with too much blood is called the recipient. There are significant risks to both fetuses. Feto-fetal transfusion syndrome is also referred to as twin-to-twin transfusion syndrome in twin pregnancies.

Involving a consultant from a tertiary level fetal medicine centre

This quality statement is taken from the multiple pregnancy: twin and triplet pregnancies quality standard. The quality standard defines clinical best practice for multiple pregnancy and should be read in full.

Quality statement

Women with a higher-risk or complicated multiple pregnancy have a consultant from a tertiary level fetal medicine centre involved in their care.

Rationale

Collaborative care between local services and tertiary level fetal medicine centres allows access to appropriate knowledge and expertise, and tertiary level neonatal and paediatric services when needed, while maintaining the focus on delivery of care locally.
A consultant from a tertiary level fetal medicine centre needs to be involved in some of the decisions about the care provided for women with a higher-risk multiple pregnancy, or if there are complications. It may be more suitable to involve the consultant in planning and managing care rather than referring a woman directly.

Quality measure

Structure
Evidence of local arrangements to ensure that women with a higher-risk or complicated multiple pregnancy have a consultant from a tertiary level fetal medicine centre involved in their care.
Data source: Local data collection.
Process
a) The proportion of women with a higher-risk multiple pregnancy who have a consultant from a tertiary level fetal medicine centre involved in their care.
Numerator – the number of women in the denominator who have a consultant from a tertiary level fetal medicine centre involved in their care.
Denominator – the number of women with a higher-risk multiple pregnancy.
Data source: Local data collection.
b) The proportion of women with a complicated multiple pregnancy who have a consultant from a tertiary level fetal medicine centre involved in their care.
Numerator – the number of women in the denominator who have a consultant from a tertiary level fetal medicine centre involved in their care.
Denominator – the number of women with a complicated multiple pregnancy.
Data source: Local data collection.
Outcome
Infant and maternal mortality and morbidity.
Data source: Local data collection. The Maternity Services Secondary Uses Data Set, once implemented, will collect data on neonatal death (global number 17209680). Mothers and babies: reducing risk through audits and confidential enquiries across the UK (MBRRACE-UK) collects data on: 'all deaths of pregnant women and women up to one year following the end of the pregnancy' and 'neonatal deaths'.

What the quality statement means for each audience

Service providers ensure that systems are in place to ensure women with a higher-risk or complicated multiple pregnancy have a consultant from a tertiary level fetal medicine centre involved in their care.
Healthcare practitioners ensure that women with a higher-risk or complicated multiple pregnancy have a consultant from a tertiary level fetal medicine centre involved in their care.
Commissioners ensure that they commission services for women with a higher-risk or complicated multiple pregnancy have a consultant from a tertiary level fetal medicine centre involved in their care.

What the quality statement means for patients, service users and carers

Women who are pregnant with twins or triplets (referred to as a multiple pregnancy) have an expert in fetal medicine involved in their care if their pregnancy is higher risk or if there are complications.

Source guidance

Multiple pregnancy (NICE clinical guideline 129) recommendations 1.6.1.1 and 1.3.2.6.

Definitions

Tertiary level fetal medicine centre
A regionally commissioned tertiary level centre with the experience and expertise for managing complicated twin and triplet pregnancies.
Involving a consultant from a tertiary level fetal medicine centre
Involving a consultant from a tertiary level fetal medicine centre can either be through seeking an opinion and then recording the discussion in the woman's notes, or referring a woman with a higher-risk or complicated multiple pregnancy to a tertiary level fetal medicine centre.
NICE clinical guideline 129 recommendation 1.6.1.1 advises the seeking of a consultant opinion from a tertiary level fetal medicine centre for higher-risk multiple pregnancies or complicated multiple pregnancies.
Higher-risk multiple pregnancies are defined as:
  • monochorionic monoamniotic twin pregnancies
  • monochorionic monoamniotic triplet pregnancies
  • monochorionic diamniotic triplet pregnancies
  • dichorionic diamniotic triplet pregnancies.
Complicated multiple pregnancies are defined as those with:
  • discordant fetal growth
  • fetal anomaly
  • discordant fetal death
  • feto-fetal transfusion syndrome.
In addition, NICE clinical guideline 129 recommendation 1.3.2.6 advises women with twin and triplet pregnancies who have a high risk of Down's syndrome to be offered referral to a fetal medicine specialist in a tertiary level fetal medicine centre.

Equality and diversity considerations

The woman's preferences should be taken into account when referring them for a consultant opinion at a tertiary level fetal medicine centre. An opinion may be sought from a consultant at a tertiary level fetal medicine centre if the centre is a long distance from the woman's home and it is clinically appropriate to do so.
Care should be delivered locally where possible to minimise inconvenience and anxiety for women and their partners. But anxiety caused by travelling further for an appointment needs to be weighed against the anxiety of an unclear diagnosis or prognosis.
Women from some cultural backgrounds may prefer to have their antenatal examinations undertaken by female members of staff. NHS maternity services are organised so that such preferences can be accounted for and have arrangements in place for female chaperones if needed.

Advice and preparation for preterm birth

This quality statement is taken from the multiple pregnancy: twin and triplet pregnancies quality standard. The quality standard defines clinical best practice for multiple pregnancy and should be read in full.

Quality statement

Women with a multiple pregnancy have a discussion by 24 weeks with one or more members of the multidisciplinary core team about the risks, signs and symptoms of preterm labour and possible outcomes of preterm birth.

Rationale

The multidisciplinary core team have expert knowledge in managing multiple pregnancies. Women with a multiple pregnancy are at increased risk of maternal and fetal complications in pregnancy and preterm birth. It is important that they are given advice on the possible risks, signs and symptoms of preterm labour so that they know what to expect and who to contact quickly if such symptoms arise. Women should also be informed that a preterm birth is associated with an increased risk of admission to a neonatal unit.

Quality measure

Structure
Evidence of local arrangements to ensure that women with a multiple pregnancy have a discussion by 24 weeks with one or more members of the multidisciplinary core team about the risks, signs and symptoms of preterm labour and possible outcomes of preterm birth.
Data source: Local data collection.
Process
The proportion of women with a multiple pregnancy who have a discussion by 24 weeks with one or more members of the multidisciplinary core team about the risks, signs and symptoms of preterm labour and possible outcomes of preterm birth.
Numerator – the number of women in the denominator who have had a discussion by 24 weeks with one or more members of the multidisciplinary core team about the risks, signs and symptoms of preterm labour and possible outcomes of preterm birth.
Denominator – the number of women with a multiple pregnancy that is greater than 24 weeks' gestation.
Data source: Local data collection. NHS Maternity Statistics - 2010/2011:
  • 'Complications during non-delivery obstetric episodes, 2010/11 (Table 24).
  • Singleton, twin and higher order multiple deliveries by gestation and birth status, 2010/11 (Table 26).'
Outcome
Levels of satisfaction with support and confidence to recognise the signs and symptoms of preterm labour.
Data source: Local data collection. Data will also be collected against NHS Outcomes Framework 2013/14: indicator 4.5 'Women's experience of maternity services'.
The Care Quality Commission's Maternity services survey 2010 collected data on singleton and multiple births and asked the questions 'Thinking about your antenatal care, were you spoken to in a way that you could understand?' and 'Thinking about your antenatal care, were you involved enough in decisions about your care?'. The total number of respondents is also stated, although results are not broken down by singleton or multiple pregnancies.

What the quality statement means for each audience

Service providers ensure that systems are in place for women with a multiple pregnancy to have a discussion by 24 weeks with one or more members of multidisciplinary core team about the risks, signs and symptoms of preterm labour and possible outcomes of preterm birth.
Healthcare practitioners ensure that women with a multiple pregnancy have a discussion by 24 weeks with one or more members of multidisciplinary core team about the risks, signs and symptoms of preterm labour and possible outcomes of preterm birth.
Commissioners ensure that they commission services in which women with a multiple pregnancy have a discussion by 24 weeks with one or more members of multidisciplinary core team about the risks, signs and symptoms of preterm labour and possible outcomes of preterm birth.

What the quality statement means for patients, service users and carers

Women who are pregnant with twins or triplets (referred to as a multiple pregnancy) discuss the risks and signs of an early (preterm) labour with one or more members of their healthcare team. The discussion should take place by 24 weeks of their pregnancy and also cover the possible problems associated with an early birth.

Source guidance

Multiple pregnancy (NICE clinical guideline 129) recommendations 1.2.3.4 and 1.7.1.4.

Definitions

The timeframe of 'by 24 weeks' is included based on expert consensus.
Preterm labour
The risk of preterm birth is higher in multiple pregnancies. About 60% of twins are delivered by 37 weeks and 10% before 32 weeks, and 75% of triplets are delivered by 35 weeks.
The benefits and risks of targeted corticosteroids for fetal lung maturation should be discussed when providing information about preterm labour.
The signs and symptoms of preterm labour include more frequent and regular contractions, ruptured membranes, unusual or severe backache or other pain.
The potential need for neonatal management and the role of neonatal networks, including the possibility of admission of babies to a neonatal unit after birth, should also be discussed. Where possible, staff from the neonatal unit should be involved in the discussion and women should be provided with appropriate information about the neonatal services.

Equality and diversity considerations

Information on the risks, signs and symptoms of preterm labour should be understood by all women so that they can feel fully informed. Information should be provided in an accessible format (particularly for women with physical, sensory or learning disabilities and women who do not speak or read English).

Preparation for birth

This quality statement is taken from the multiple pregnancy: twin and triplet pregnancies quality standard. The quality standard defines clinical best practice for multiple pregnancy and should be read in full.

Quality statement

Women with a multiple pregnancy have a discussion by 32 weeks with one or more members of the multidisciplinary core team about the timing of birth and possible modes of delivery so that a birth plan can be agreed.

Rationale

Most women with multiple pregnancies deliver by 37 weeks either spontaneously or electively. This discussion should include the risks and benefits of different modes of birth and how they are managed to enable women to make an informed decision about their birth preference. Women should also be informed that a preterm birth is associated with an increased risk of admission to a neonatal unit.

Quality measure

Structure
Evidence of local arrangements to ensure that women with a multiple pregnancy have a discussion with one or more members of the multidisciplinary core team by 32 weeks about the timing of birth and possible modes of delivery so that a birth plan can be agreed.
Data source: Local data collection.
Process
The proportion of women with a multiple pregnancy who have a discussion with one or more members of the multidisciplinary core team by 32 weeks about the timing of birth and possible modes of delivery.
Numerator – the number of women in the denominator who have had a discussion with one or more members of the multidisciplinary core team by 32 weeks about the timing of birth and possible modes of delivery.
Denominator – the number of women with a multiple pregnancy of 32 weeks or more.
Data source: Local data collection. The Clinical Negligence Scheme for Trusts (CNST) Maternity Standards 2013/14 includes requirements for services to have discussion on the timing and mode of birth:
'Standard 3: high-risk conditions – criterion 4: multiple pregnancy and birth:
Level 1: the maternity service has approved documentation for the management of multiple pregnancy and birth, which as a minimum must include the:
  • requirement for providing information on the risks and benefits of different modes of delivery to support women in planning for birth.
  • requirement to discuss the planned and agreed place and timing of birth.'
Outcome
Women feel well informed and able to make decisions that reflect what is important to them about the options for delivery.
Data source: Local data collection. The Maternity Services Secondary Uses Data Set, once implemented, will collect data on delivery method (global number 2016160) and gestational age at birth (global number 17206120). Data will also be collected NHS Outcomes Framework 2013/14: indicator 4.5 'Women's experience of maternity services'

What the quality statement means for each audience

Service providers ensure that systems are in place for women with a multiple pregnancy to have a discussion with one or more members of the multidisciplinary core team by 32 weeks about the timing of birth and possible modes of delivery so that a birth plan can be agreed.
Healthcare practitioners from the multidisciplinary core team ensure that the timing of birth and possible modes of delivery are discussed with women with a multiple pregnancy by 32 weeks so that a birth plan can be agreed.
Commissioners ensure that they commission services so that women with a multiple pregnancy have a discussion with one or more members of the multidisciplinary core team by 32 weeks about the timing of birth and possible modes of delivery so that a birth plan can be agreed.

What the quality statement means for patients, service users and carers

Women who are pregnant with twins or triplets (referred to as a multiple pregnancy) have a discussion with one or more members of their healthcare team about the timing of the birth and how they want their babies to be delivered. This discussion needs to take place by 32 weeks of their pregnancy and include agreement of their birth plan.

Source guidance

Multiple pregnancy (NICE clinical guideline 129) recommendations 1.7.1.1 to 1.7.1.7 and recommendation 1.7.1.8 (key priority for implementation).

Definitions

The timeframe of 'by 32 weeks' is included based on expert consensus and adaption of NICE clinical guideline 129 recommendation 1.7.1.1.
Based on their expert consensus, where possible, staff from the neonatal unit should be involved in the discussion and women should be provided with appropriate information about the neonatal services.

Equality and diversity considerations

Information on the timing of birth and possible modes of delivery should be understood by all women to enable them to make informed decisions. Information should be provided in an accessible format (particularly for women with physical, sensory or learning disabilities, and women who do not speak or read English).

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Schedule of specialist antenatal appointments

Type of pregnancy (uncomplicated)
Minimum contacts with core multidisciplinary team
Timing of appointments PLUS scans
Additional appointments (WITHOUT scans)
9 (including 2 with specialist obstetrician)
Appt + early scan (approximately 11+0 to 13+6 weeks, when crown–rump length measures from 45 mm to 84 mm)
and 16, 18, 20, 22, 24, 28, 32 and 34 weeks
8 (including 2 with specialist obstetrician)
Appt + early scan (approximately 11+0 to 13+6 weeks, when crown–rump length measures from 45 mm to 84 mm)
and 20, 24, 28, 32 and 36 weeks
16 and 34 weeks
and
11 (including 2 with specialist obstetrician)
Appt + early scan (approximately 11+0 to 13+6 weeks, when crown–rump length measures from 45 mm to 84 mm)
and 16, 18, 20, 22, 24, 26, 28, 30, 32 and 34 weeks
7 (including 2 with specialist obstetrician)
Appt + early scan (approximately 11+0 to 13+6 weeks)
and 20, 24, 28, 32 and 34 weeks
16 weeks

Glossary

the inner membrane that surrounds the baby – pregnancies with one amnion (so that all babies share an amniotic sac) are monoamniotic; pregnancies with two amnions are diamniotic; and pregnancies with three amnions are triamniotic
antenatal ultrasound evaluation of fetal wellbeing based on fetal movement, fetal tone, fetal breathing, amniotic fluid volume, and the nonstress test of the fetal heart rate (or cardiotocography)
the number of chorionic (outer) membranes surrounding babies in a multiple pregnancy, indicating whether babies share a placenta – in monochorionic pregnancies babies share one placenta; in dichorionic pregnancies there are two placentas; in trichorionic triplet pregnancies each baby has a separate placenta
one baby has a separate placenta and amniotic sac and two of the babies share a placenta and amniotic sac
in dichorionic triplets one of the babies has a separate placenta and two of the babies share one placenta; all three babies have separate amniotic sacs
dichorionic twins each have a separate placenta
feto–fetal transfusion syndrome occurs when blood moves from one baby to another – it is a complication of monochorionic multiple pregnancies arising from shared placental circulation (also referred to as twin-to-twin transfusion syndrome in twin pregnancies)
monochorionic diamniotic twins share a placenta but have separate amniotic sacs
twin or triplet pregnancies in which all babies share a placenta and amniotic sac
all three babies share one placenta. One baby has a separate amniotic sac and two babies share one sac
in monochorionic triamniotic triplets all three babies share one placenta but each has its own amniotic sac
obstetricians with a special interest, experience and knowledge of managing multiple pregnancies, who work regularly with women with multiple pregnancies
in trichorionic triplets all three babies have separate placentas and amniotic sacs
a regionally commissioned centre with the experience and expertise for managing complicated twin and triplet pregnancies
pregnancies are either monozygous (arising from one fertilised egg) or dizygous (arising from two separate fertilised eggs). Monozygous twins are identical; dizygous twins are non-identical

Paths in this pathway

Pathway created: November 2011 Last updated: November 2016

© NICE 2017

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