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  • HSIB - Management of preterm labour and birth of twins (25 August 2022)

    Article information
    • UK
    • Investigations
    • Pre-existing
    • Original author
    • No
    • Healthcare Safety Investigation Branch
    • 25/08/22
    • Everyone


    The purpose of this investigation by the Healthcare Safety Investigation Branch (HSIB) was to consider the management and care of preterm labour and birth of twins. Preterm birth—defined as babies born alive before the completion of 37 weeks of pregnancy—is one of the main causes of death, long-term conditions and disability in under-fives worldwide, and 60% of twin pregnancies result in premature birth.

    The reference event for this investigation was the case of Sarah, who was pregnant with twins and was overseen by an obstetrician during her pregnancy. Sarah was assessed as having a higher-risk pregnancy as she had had previous medical intervention on her cervix and was pregnant with twins. Shortly after having been discharged from a hospital with a specialist neonatal unit following suspected early labour, she went to her local maternity unit at 29+2 weeks with further episodes of abdominal tightening. Her labour did not progress as expected and a caesarean section was required to deliver the babies at 29+6 weeks. The twin girls were born well, but 23 days after their birth a scan revealed brain injury in both babies.

    The investigation identified several findings to explain the experience of the mother in the reference event, including the lack of scientific evidence or specific guidelines and the uncertainty associated with the clinical decision making in this scenario. This highlighted the need for further research into preterm labour as a recognised risk factor for twin pregnancies.

    As part of the investigation, HSIB identified that since 2019 a large volume of national work and research in the area of twin pregnancy and preterm birth has been undertaken. The investigation report sets out the work currently in progress and seeks to understand if it will address gaps in knowledge.


    HSIB was notified about potential patient safety issues by Sarah, who was concerned about the care she had received when her babies were delivered. The investigation used interviews, observations of the maternity unit and reviews of guidelines and organisational documents in order to understand the system-wide factors that contributed to Sarah’s experience and the decisions made by staff. The evidence suggested that the process of decision making in the context of Sarah’s care was relevant to this investigation, so the investigation has summarised the key factors that appear to have influenced the decision making associated with her care and the delivery of her babies


    • There are currently no proven treatments available to reduce the risk of preterm labour for twin pregnancies.
    • There are gaps in scientific knowledge and challenges to completing research in the field of preterm labour and birth. This creates a challenge for the development of detailed guidelines to support clinical decision making.
    • Guidelines and equipment recommended for managing and monitoring singleton (one baby) and full-term pregnancies are used to assist with clinical decision making about preterm twin pregnancies; some interventions within the guidelines are unproven for use in preterm twin pregnancies.
    • Research and national improvement initiatives, such as the British Association of Perinatal Medicine perinatal optimisation care pathway and NHS England and NHS Improvement ‘Saving babies’ lives care bundle version two’ and the Maternity and Neonatal Safety Improvement Programme are improving the standardisation and implementation of evidence-based interventions.
    • Intelligence from national data gathered by maternity units can support the learning on preterm labour and birth in twin pregnancies.

    Safety observations

    • It may be beneficial if further research aimed to generate additional knowledge to predict and prevent preterm labour for twin pregnancies among different groups of women/pregnant people.
    • It may be beneficial to increase awareness among the public and healthcare professionals of the limitations of interventions for the prevention of preterm labour of multiple births.
    • It may be beneficial to regularly analyse data on multiple births so the interpretation of this data can inform learning and research.

    Safety actions

    Following stakeholder feedback received during an update of the guideline for preterm labour and birth, the National Institute for Health and Care Excellence decided to delete the recommendation relating to milking the cord and amend the subsequent recommendation on clamping of the cord to wait at least 60 seconds before clamping the cord of preterm babies unless there are specific maternal or fetal conditions that need earlier clamping.

    HSIB - Management of preterm labour and birth of twins (25 August 2022) https://www.hsib.org.uk/investigations-and-reports/management-of-preterm-labour-and-birth/
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