1. Twins transported to New Cross NNU Mr S Manning Dr B Muhammed (consultant)

2. Maternal information 32 years old 1999 NVD at 40 weeks 2002 NVD at 30 weeks 2011 NVD – gestational age not recorded 2 children live with aunt, 1 with maternal grandmother.

3. Maternal information History of depression Previous OD attempts Admitted to Psychiatric hospital at 16 weeks of pregnancy – reason not recorded. Social services were made aware of this hospital admission

4. Presentation on 19/9/2013 24 +3 gestation twin pregnancy Taking folic acid - no other drugs recorded Antenatal screening bloods unremarkable Presented in labour, given dexamethasone x2 last at 1720 No PROM, No pyrexia Foul smelling liquor noted during delivery

5. Twin 1 Cephalic presentation, spontaneous vaginal delivery born at 1959 into plastic bag. Weight 620g 5 inflation breaths given + IPPV H/R 90 bpm Intubated - 2.5mm ET tube 5.5cm to lips

6. Twin 1 Good air entry, L=R HR >100. Sats remain 40- 50% on 100% O 2 Curosurf given - 25mins of age Improved with bag ventilation Consultant present from 2015 Transfered to NNU at 2040

7. Twin 1 Sats remain poor with ventilation CMV 23/6 at rate of 60/min on 100% O 2. With bag ventilation improved to 80-90% Re-intubated by consultant, 2.5mm ET tube, 6 cm at lips Air entry improved. Sats >90% HR 136 good chest movements.

8. Twin 1 Access obtained – UVC and UAC Started IV fluids – 0.9% saline bolus and 10% dextrose 1.5ml/hr Later started on dobutamine and dopamine Given vitamin K Benzylpenicillin Gentamicin

9. Twin 1 ET Tube dislodged late evening Re-intubated by consultant ETT 2.5cm, 6 cm at lips.

10. Twin 2 Breech presentation spontaneous vaginal delivery into plastic bag at 2000. Weight 600g Moderate condition. APGAR 3 at 1 minute IPPV used, HR 80-100, Sats in 30s Intubated - 2.5mm ET tube, 5.5cm at lips, tube became dislodged during securing – repeat intubation 6.5cm to lips

11. Twin 2 HR now >100 Sats 50% Given 120mg surfactant Sats improved >95% HR 130 Venous gas pH7.05. lactate 15.5 On SIMV 18/5 Rate 60/mi FiO 2 40% TV 2.3ml sats 99%

12. Twin 2 Mean BP 20 IV access obtained, fluid bolus given 10ml/kg 0.9% saline Started on IV benzylpenicillin and gentamicin Moved to NNU at 35mins UAC and UVC inserted by SpR at 2245 Started on dopamine and dubutamine

13. Twin 2 ETT tube dislodged en route to transport Mask ventilation used Re-intubated size 2.5mm tube 5.5cm at lips

14. Both babies Neonatal consultant called New Cross NNU consultant at around 2145. Informed of gestation and condition – space identified at New Cross NNU. Contacted NTS team around same time. Details given Estimated arrival time of team 45 minutes

15. Both babies Parents spoken to twice during time at Walsall by neonatal consultant Told twin 1 struggled initially but showed some sign of improvement Both are in very critical condition Extremely premature Parents made aware of gaurded prognosis.

16. Both babies were taken by the transport team to New Cross Hospital Neo Natal unit for further intensive care.