A mother holds the feet of premature twin babies.

Management of preterm labour and birth of twins

HSIB legacy content

HSIB legacy content

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

National investigation

Preterm birth is one of the main causes for under-five mortality (death) and disability worldwide. 60% of twin pregnancies result in premature birth.

Premature birth is associated with high levels of:

  • morbidity (long-term health conditions)
  • mortality
  • long-term disability

Preterm is defined as babies born alive before the completion of 37 weeks of pregnancy. There are sub-categories of preterm birth, based on gestational age (length of pregnancy):

  • extremely preterm (less than 28 weeks)
  • very preterm (28 to 32 weeks)
  • moderate to late preterm (32 to 37 weeks)

This investigation considers the management and care of preterm labour and birth of twins.

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

We've identified that since 2019 a large volume of national work and research, relevant to the field of preterm labour and birth, has been commenced. This investigation report sets out the work currently in progress and seeks to understand if it will address gaps in knowledge identified by the investigation.

Reference event

Sarah was pregnant with twins. During her pregnancy her care was overseen by an obstetrician - a doctor who specialises in care for women/pregnant people during pregnancy, labour and birth. She was assessed as having a higher-risk pregnancy. This was because it was a twin pregnancy and because she had had a previous medical intervention on her cervix which had implications for the pregnancy.

When she was 26 weeks and 4 days pregnant (26+4 weeks), Sarah visited her local maternity unit with abdominal tightening, which can indicate the start of labour. She was transferred to and treated at a hospital with additional neonatal facilities that could support the babies if they were born at this time. At 29 weeks pregnant she was discharged home under the care of her local maternity unit. Sarah then went to her local maternity unit at 29+2 weeks with further episodes of abdominal tightening. Her labour did not progress as expected. A caesarean section was required to deliver the babies at 29+6 weeks. The twin girls were born well; however, 23 days after their birth a scan revealed brain injury in both babies

Investigation summary

HSIB was notified of a patient safety concern relating to preterm labour in the context of a twin pregnancy. The notification was made by Sarah who was concerned about the care she had received during the delivery of her babies. The investigation used a range of methods to gather information, for example, interviews, observation of the maternity unit and reviews of guidelines and 7 organisational documents.

The evidence was analysed 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. Therefore, 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.


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