Quintuplets named, to be buried in Migori at their father’s home

By  Hellen Shikanda

Health and Science Reporter

Nation Media Group

What you need to know:

• Mercy Kanini, their 28-year-old mother, was discharged from the Kenyatta National Hospital on Thursday evening.
• The family have asked for thorough investigations to establish what led to the deaths of the five babies.

In just 48 hours, quintuplets born in a rare vaginal birth at Thika Level Five Hospital died before becoming part of the history they had made.

The five children now named Bravin, Bravlyn, Bravelle, Bravina and Braelyn will be buried in Migori County at their father’s home, Evans Nyamhanga.

Mercy Kanini, their 28-year-old mother, was discharged from the Kenyatta National Hospital (KNH) on Thursday evening flanked by her family.

She walked out of the hospital, held by her husband Evans; both appeared distraught by the loss.

Mercy and Evans' families came bearing two bouquets of flowers and a fruit basket for the grieving parents.

Now, preparations are underway for the burial of the five children.

As the family struggles to come to terms with the children's death, Felix Muthama, their spokesperson, and two lawyers representing the family have asked for thorough investigations to establish what led to the deaths.

Although the family publicly said the pregnancy scan showed only four babies, they now need clear and documented evidence to support that.

High-risk delivery

Njoki Mwangi, the family’s legal representative on Thursday said there is need for clarity as to whether the hospital where the babies were delivered was ready for such a high-risk kind of delivery.

She also questioned whether there were enough incubators, oxygen, resuscitation equipment and specialist staff on hand for five premature babies.

The family is also seeking to establish whether the babies were properly stabilized before they were moved to KNH and what equipment and staff traveled with them.

In a press briefing on Thursday, the family through their lawyer also said there were delays in admission at KNH because of the need for registration of the children to the Social Health Authority (SHA).

"Emergency care must always come first, payment and registration, second," said Njoki.

Gideon Kinara, the uncle to the deceased babies said none of the baby girls had been registered for SHA, and that it was only Bravin, the boy, who survived but died on Wednesday, who had been registered.

Now, the family is seeking to have an independent medical review by experts who have no ties with the hospital and immediate safekeeping of the medical records, as well as a review by Parliament of how emergency care is being handled under SHA.

Evans, the father of the quintuplets said during the transfer to KNH, he was handed one child, the boy, and was advised to practice skin-to-skin care, also known as kangaroo care, while driving from Thika Level Five to KNH.

“The ambulance had only oxygen cylinders. In the ambulance that I was in, we had a nurse who took care of one of my children. Our ambulance was the last to get to KNH around 11pm, but even those that came earlier, had not been admitted,” he explained.

The family estimates that it took about 12 hours between the time of delivery to the time the babies were transferred to KNH.

A health expert for younger babies who sought anonymity because of the sensitivity of the issue now says that the system may have failed Mercy Kanini.

The expert explained that when a mother has such a high risk multiple pregnancy, saving both the children and the mother requires preparation before, rather than after delivery.

The expert said the ideal pathway of caring for such a pregnancy should have been through antenatal and that identification should have triggered a high-risk plan especially during, and immediately after a mother delivers.

"A quintuplet pregnancy is already at exceptionally high risk of extreme prematurity. Once it was established that this mother was carrying five fetuses, there should ideally have been a documented multidisciplinary plan involving maternal-fetal medicine/obstetrics, neonatology, anaesthesia and nursing, with a predetermined tertiary delivery centre and thresholds for admission," said the expert. 

The expert explained that at 25–26 weeks with five fetuses, the anticipated neonatal requirement isn’t simply “a hospital with a newborn unit.” 

There is more to that.

"You potentially need five simultaneous Extremely Low Birth Weight resuscitations, five thermal-care stations, five continuous positive airway pressure (CPAP) circuits and potentially several ventilators and surfactant doses, plus adequate skilled staff," said the expert. 

The current Respiratory Distress Syndrome guidance in the country recommends that mothers at risk of delivery before 28–30 weeks be transferred when the babies are still in the womb (or in utero), to a higher level facility with experienced in caring for extremely preterm infants. 

Extraordinary preparation

"This is probably the central systems lesson from the case, especially if labour had not progressed beyond the point where transfer was unsafe," said the expert.

The mother ought to have been transferred to KNH and then a delivery as the babies are immediately taken to the Neonatal Intensive Care Unit.

"The mother is, in effect, the safest neonatal transport system. In-utero transfer avoids transport-related hypothermia, respiratory instability, line problems and the enormous logistical difficulty of simultaneously transporting five extremely low birth weight infants" the expert said.

There is a caveat as to what may have led to the facility to allow her to give birth and later transfer the babies.

"Once she arrived in established advanced labour, transfer might have been unsafe."

However, there is no public information about Mercy's cervical dilatation, contractions or fetal status when she got to Thika Level 5 Hospital that can help experts to conclude that the hospital should have transferred her at that point. 

The expert insisted that the delivery itself required extraordinary preparation. 

Most importantly, you need separate skilled teams. The expert noted that five babies arriving within a short span, cannot realistically be managed sequentially by one neonatal resuscitation team.

“For infants less than 28 weeks, meticulous thermal management is particularly important. Current guidance recommends plastic wrapping under radiant heat, warmed/humidified gases where available, and other measures to prevent hypothermia,” said the expert.

“This case could actually make a very useful Kenyan perinatal mortality review, because it highlights something beyond CPAP availability: regionalisation of perinatal care and antenatal referral of pregnancies expected to produce extremely preterm infants,” the expert added.

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