Vol. 6 •Issue 26 • Page 29
Multiple Births/Multiple Challenges
Anticipating the birth of several babies from one mother requires planning and multidisciplinary input
Multiple births present multiple challenges for all involved. The most recent birth of quadruplets at Lankenau Hospital in August — actually two sets of identical twins — was designated as a one in a million event.
However, multiple births are not a rare event at Lankenau. In 2003, 69 sets of twins and 9 sets of triplets were delivered at the 351-bed Wynnewood, PA hospital, part of Main Line Health System (MLHS). In past years quintuplets as well as quadruplets have been cared for in the NICU there. One of the more challenging times recalled by the NICU staff was when two sets of quadruplets were delivered within the same 24-hour period.
The challenge of caring for multiple pregnancies begins in the prenatal period. Nutritional requirements are greater with multiples and extra calories, as well as calcium, iron and folic acid are recommended. Office visits are more frequent and may even be weekly. Monthly ultrasounds follow the progress of the pregnancy and monitor for complications including premature cervical dilatation. Bedrest may be instituted if complications arise but is not necessarily ordered as a matter of routine. The mother will be hospitalized for closer observation and care if complications such as hypertension or preterm labor develop. Neonatology is informed of patients with known complications.
Otherwise, announcements of quadruplets or quintuplets to the obstetrical and neonatal staffs are made as the pregnancies approach viability at around 22 weeks. It is at this point that interdisciplinary meetings commence to develop a comprehensive plan of care for the delivery and postnatal care of the mother and babies.
Although twin and triplet deliveries require special coordination, planning is even more challenging when delivery of quadruplets or quintuplets is expected. Representatives from the obstetrical, neonatal and respiratory staffs meet to outline a plan for the delivery and to set up communication with other departments that may be involved. Evaluation of the patient’s status is communicated 3 times a week and may increase in frequency if complications arise.
The general plan for delivery calls for a care team for each infant comprised of a doctor or neonatal nurse practitioner, an RN and a respiratory therapist. Also, a unit secretary is invaluable to assist with the admission process. Due to space and equipment requirements, two rooms are utilized to stabilize the babies. As soon as they are born, infants A and B are taken to waiting teams in an adjacent labor/delivery/recovery while infants C, D (and E) are stabilized, each on their own warmer in the delivery room.
Other departments included in the planning prior to delivery include admissions, lab, pharmacy, radiology and public relations.
The hospital’s computer system allows for routine admission of up to three babies to one mother. Special assistance is required of the admissions department to admit four or five babies to one mother.
Since no lab work or pharmacy orders can be filled until the baby is admitted into the system this is an important step. The lab is alerted that multiple specimens will be arriving with the same last name and must be processed as labeled A, B, C, etc.
Pharmacy is notified that numerous orders will need to be filled simultaneously when the babies are born. Advanced planning allows the pharmacy to prepare standard IV solutions for each baby ahead of time. These are kept in the NICU refrigerator and replaced every 3 days until the babies are delivered. Also, an adequate supply of calfactant, intratracheal suspension — a sterile, non-pyrogenic lung surfactant — and other medications routinely used for premature infants is assured.
Radiology must also be prepared to provide required services once the babies are admitted to the NICU. Finally, public relations will need advance notice as multiple births often attract media attention.
Adequate Equipment, Supplies
Much thought and planning goes into providing adequate equipment, supplies and space. This is often impacted by current census and acuity conditions in the NICU. Adequate radiant warmer beds, isolettes, multi-channel IV pumps, syringe pumps, ventilators and respiratory supplies must be available.
In the planning weeks the staff begins to set aside the needed equipment and supplies anticipated for each baby while trying to balance the needs of the current patient population in the NICU. Main Line Health has the advantage of being able to borrow and lend equipment among the three acute care hospitals in its system, which provides an extra source of needed supplies. However, it is still sometimes necessary to rent equipment to assure that all is readily available when needed.
Another challenge is that of working within the space limitations of our NICU. It is sometimes necessary to cap census at 16 until the multiple delivery occurs to assure adequate beds. This measure would have a domino effect on antepartum services and require that maternal transports from outside be diverted. If census still climbs we must be ready to transport current NICU infants to another MLHS hospital — Bryn Mawr (PA) Hospital or Paoli (PA) Hospital — if needed to accommodate the multiple delivery.
And Most Importantly, Staffing
A major challenge is that of staffing for the big event. A variety of strategies are employed to assure adequate personnel not just for the delivery but for the shifts immediately following when census and acuity may be unusually high. First, a voluntary on-call system of NICU staff is set up and maintained by the nurse managers and all per diem and supplementary staff are utilized. In addition, nursing staff is shared across the three MLHS NICU’s on a shift-to-shift basis as needed (Schindler, M. 2004).
Also, many of the mother/baby nurses at Lankenau are cross-trained to care for transitional infants in the NICU. The flexibility of staffing provided by all of these resources serves well in delivering the nursing care necessary to accommodate sudden fluctuations in census and acuity with multiple deliveries.
During the remainder of their hospital stay additional services are incorporated into the infants’ care. Social service staff assists the parents in acquiring whatever benefits might be available to them including referrals to support groups for parents of multiples. Speech, physical and developmental specialists may be involved in their care as well.
One important area that also must be considered is bereavement care in the event that one, more or all of the babies do not survive. Obviously, death of a newborn is always difficult, but additional considerations apply when multiples are involved.
The Ultimate Challenge
While these are many of the challenges involved in the planning and care of multiple deliveries, they are not the “ultimate challenge.” That belongs to the parents — in the days after discharge as they encounter the reality of caring for multiple newborns at home!
Schindler, M. (2004, Sept. 27). Keeping baby safe: Updating communication and safety initiatives made Main Line Health NICUs a unique place to nurse. Advance for Nurses, 6(21), 37-38.