Multidisciplinary Preparation for the Delivery of Craniopagus Conjoined Twins

Abstract

Background: Craniopagus twins joined at the head are an uncommon malformation found once in 2.5 million live births. Beyond findings from the Joint Commission on Accreditation of Health Organizations (JCAHO), there is limited evidence to inform best practices for successful preparation for delivery and management of craniopagus twins. JCAHO identified several root causes related to perinatal death; including poor communication, failure to function as a team, and poor training processes. UC Davis Children’s Hospital successfully delivered and managed craniopagus twins.

Methods: Anonymous surveys were distributed post-delivery to a multi-disciplinary team. Ten of the 13-team members had previously participated in mock deliveries. In preparation for the delivery of craniopagus twins fetal MRI imaging was reviewed to understand and produce anatomically correct positioning. Neonatal training mannequins were fabricated utilizing existing mannequins and the findings of fetal MRI imaging. Preparation required proper identification of each baby. Babies were designated to indicate the location of skull fusion. Baby Orange being fused along its occipital bone and baby Purple fused along its parietal bone. Multidisciplinary delivery team members participated in mock deliveries lasting 2 hours each; completed 3 weeks prior to delivery. Teams were configured utilizing color coding to facilitate closed loop communication. Anticipated requirement of cardiorespiratory support including CPAP and intubation were included. Babies were born at 36 weeks gestation and transitioned to the NICU; Baby Orange, utilizing customized headgear required bubble CPAP and Baby Purple on room air. Post-delivery surveys and team debriefing were conducted. IRB exemption as well as family consent was obtained.

Results: Thirteen surveys were returned. Ten of the 13 (77%) team members participated in simulated deliveries. 100% of respondents agreed that color coding of teams was helpful to distinguish team members during resuscitation of the infants and helped facilitate good communication with less confusion. 100% of respondents agreed mock mannequins created for simulated delivery were accurate.

Conclusions: Multidisciplinary planning and simulation training for the delivery of craniopagus conjoined twins including mannequin representation was beneficial for preparation of the delivery team. The experience of UC Davis Children’s Hospital will serve as a guide for future craniopagus twin delivery preparation worldwide.