National Women’s Hospital Flying Squad

First conceived of by Professor E. Farquhar-Murray in 1929, the organisation and use of the Obstertric Emergency Service was first established on a practical basis in Newcastle-on-Tyne in 1935. Since that time units have been developed in all parts of the world. Originally the aim of such a service was largely to render a woman temporarily fit to withstand the ambulance journey hospital. Of the first 27 women suffering from loss of blood and brought into hospital after restorative measure, 9 died in a state of shock.

This frightful mortality was due principally to inadequate resuscitation to withstand travel. (No blood banks then.) This state-of-affairs led to the evolving of a highly skilled service including a senior obstetrician and a senior anaesthetist so that operative obstetrics was undertaken on the spot and in most cases the patient was never transferred to hospital. This principle is still adhered to in Newcastle-on-Tyne.

With the greater availability of blood, more recently developed services have tended to aim at good resuscitation then transfer to a base hospital for further treatment.

Although the Newcastle-on-Tyne Emergency Obstetric Service operates in a region where the domicilary confinement rate is still approximately 50%, it does not mean that we here in New Zealand with an almost 100% hospital delivery rate, can do without an emergency service – unless all women can be kept in hospital from ‘coitus to confinement’.

In the last 20 years there has been a marked reduction in the number of neglected cases and mismanaged cases such as failed forceps or grossly exsanguinated women. But antenatal emergencies such as eclampsia, antepartum haemorrhage and haemorrhage from abortion still occur in the patient’s home and general practitioner units still require the services of prompt specialised assistance and access to blood, for urgent transfusion.

Practical aims of an emergency service in New Zealand

1. To provide prompt expert assistance including facilities for urgent blood transfusion.

2. To ensure that the patient is made fit enough to safely withstand transfer to hospital where this is indicated.

3. Where transfer to a base hospital is still considered dangerous despite resuscitation, to provide the means of dealing with the problem on-on the-spot.  This means the provision of a competent anaesthetic service manned by experienced anaesthetists.  Due to a lack of adequate cover this service is being closely looked at the moment.  The week-end and night cover consists of Senior Anaesthetist who covers National Women’s hospital and St. Helen’s Hospital pus Registrar at each hospital.  Should the Registrar go out on a Flying Squad call for several hours this seriously depletes the hospital team.  Such conditions as post partum haemorrahage and retained placenta may thus be dealt with in the maternity hospital of origin, the anaesthetist and blood being taken to the patient instead of vice versa.

4. Every effort should continue to be made to sustain the dignity and standing of the summoning practitioner with his patient.

5. Keep a full record of all cases attended, as this gives an indication of the current standard of obstetric practice in the region.

Practical tips for the summoning practitioner

1. Summon assistance early – to anticipate trouble is the ideal.

2. If the call is to a private house give simple and explicit instructions on how to find the place.

3. Give the patient’s blood group over the ‘phone – remember that it is safer to transfuse uncrossmatched blood of the same ABO group and Rh neg. than it is to give O Neg.

4. Send a sample of blood for urgent crossmatch by the handiest local transport – the messenger to return with the blood. In this way the giving of uncrossmatched blood may be considerably reduced.

5. Erect an intravenous infusion while the patient is still fit enough to provide easy access to veins (If the G.P. is out of practice in erecting drips he should desist in his attempts before ruining all the available veins.) The blood volume may thus be temporarily maintained using reconstituted dried plasma but remember that this is futile beyond the temporary replacement of two pints.

6. Never hesitate to give oxytocics in cases with postpartum haemorrhage and retained placenta because You think that it may make manual removal more difficult.

7. The G.P must remain with his patient until assistance arrives.

8. Always summon the flying squad for a woman whose general condition has been affected by blood loss, or obstetric manipulations. Never transfer an undelivered woman who is still bleeding no matter how good her condition appears to be.

List of situations when Flying Squad should be summoned

1. Abortion – very seldom is flying squad required.

2. Antepartum conditions:

• Eclampsia or imminent eclampsia.
• Antepartum haemorrage – A woman should never to sent on an ambulance journey, however good her condition, if she is still bleeding. If her general condition has been affected by blood loss, then the general state must be returned to normal before travel even though bleeding may have ceased (temporarily).

3. Intrapartum conditions:

• Breech presentation when labour is advanced.
• Twins – Delay with a previously unsuspected twin.
• Failed forceps.

4. Third stage difficulties:

• Haemorrhage and retained placenta.
• Haemorrage after delivery of placenta. If severe enough to require transfusion the uterus should be explored.
• Simple retained placenta – Remember that a bungled attempt to deliver a retained placenta is worse than no attempt at all.A woman should never be sent on an ambulance journey with the placenta undelivered.
• Inversion of Uterus.

5. Injuries to Genital Tract – Severe lacerations, especially those involving the rectum.

6. Secondary postpartum haemorrhage.

Revised Flying Squad procedures

• Requests for the Flying Squad must be given top priority by all involved.The telephone line 686-404 is reserved for the Flying Squad and no other calls must be made or received on this line.
• The call should be directed to the Obstetrical and Gynaecological Registrar on Second Call or the Paediatric Registrar, who will be summoned by a double bleep on his locator.  The double bleep must only be used for Flying Squad or other emergency calls.  If the registrar does not arrive immediately any available registrar should be called.
• The registrar will be responsible for determining whether there is a real need for the Flying Squad toout whether it would be preferable for the patient to be transferred directly into hospital.  If agreement cannot be reached with the referring doctor his wishes must be respected.  In general once a decision has been made about sending the Squad it should not be changed.  The Registrar should obtain the patients full name and date of birth, and if possible home address, together with precise details as to the locality where the squad is required.

N.B. If you are not sending the Squad make certain who is responsible for calling the ambulance and ensure that a suitable escort for the patient will be provided.

• The Registrar should telephone the St. John Ambulance Station himself (Phone No.111) and request suitable transport for the Flying Squad or give instructions about brining the patient into hospital.
• The Registrar should notify the Switchboard Operator that the Flying Squad has been called giving the patient’s name, date of birth, if possible her home address, diagnosis, and stating what additional help he requires, e.g. presence of anaesthetist.
• The Switchboard Operator on being informed that it is a Squad Call will ignore all other calls and will notify the persons requested by the Registrar; e.g. Anaesthetist, and will then automatically notify the following:

1. The nursing Supervisor
2. Delivery Suite or Ward 11A
3. Admitting Office giving them details of the case.
4. The other Obstetrical and Gynaecological Registrar on call if one Obstetrical and Gynaecological Registrar is leaving the hospital.

• The Registrar dealing with the Flying Squad should notify the consultant, under whose care the patient will come, of the details.

• Personnel going on the Flying Squad must assemble in Delivery Suite Office with all possible haste.

NOTE  If there is a delay or if you are in doubt as to whether the right message has been given ring Delivery Suite on the Direct Hot Line 686-581. NO calls can be transferred from this number.

Flying Squad calls from 22/10/76–9/10/77

4/11/76     Papakura Hospital – Failure to Progress.

Easy Keillands Rotation. Left at Papakura.

18/11/76  Waitakere Hospital – Retained Placenta.

Manual Removal under General Anaesthetic. Left at Waitakere.

19/11/76  Papakura Hospital – Post Partum Haemorrhage

Twenty minutes delay contacting flying squad. No change. Mother and baby transferred to National  Women’s Hospital.

26/11/76  Papakura Hospital – Breech Delay 2^nd stage.

              Patient delivered on arrival. Not transferred.

28/11/76  Papakura Hospital – ??Fit.

      Neurological examination normal. Transferred National Women’s Hospital.

3/12/76   Papakura Hospital Cord Prolapse.

      L.S.C.S at National Women’s Hospital.

9/12/76  Waitakere Hospital – Retained Placenta.

      General Anaesthetic, Manual Removal at Waitakere. Post Partum haemorrhage, 500 mls.

             Mother and baby transferred to National Women’s Hospital.

16/12/76 Bethany Hospital – Sev H.O.P 190/130 in Labour.

     Semi-Conscious – Hydrallazine. Transferred National Women’s Hospital. Forceps delivery.

18/12/76 North Shore Hospital – Post Partum Haemorrhage. 700 mls.

     No. I.V. in situ. Transferred National Women’s Hospital observation.

31/12/76 Papakura Hospital – Severe H.O.P in labour – 150/110

            Sodi Gardinal, Valium, Pethidine. Transferred National Women’s Hospital. Forceps delivery.

2/1/77   North Shore Hospital – Post Partum Haemorrhage, 1.000 ml.  BP. 120/80.

   Transferred National Women’s Hospital – observation.

7/1/77  Waitakere Hospital – Premature 26-27/40 R.M

           Transferred National Women’s Hospital. Berotec steroids.

7/1/77 Howick Hospital – Retained Placenta

          General Anaesthetic, Manual Removal at Howick. Left at Howick.

7/1/77 Papakura Hospital – Ante Partum Haemorrhage 32/40

  No active bleeding. I.V Fluids – National Women’s Hospital.

9/1/77 Home- Ante Partum Haemorrhage. 18/40 aborted.

         ?1000 ml Blood. EUA, D&C Transfused.

9/1/77 North Shore Hospital HOP 150/100 Delivered.

         Valium, Hydrallazine. Transferred to National Women’s Hospital.

8/2/77 Papakura Hospital – Post Partum Haemorrhage B.P 70/30 ?700mls loss.

         Plasma, Hartmas. Transferred National Women’s Hospital.

12/2/77 Papakura Hospital – Ante Partum Haemorrhage 36/40.

           Normal Delivery at National Women’s Hospital.

17/2/77 Howick Hospital – Retained Placenta.

          General Anaesthetic, Manual Removal at Howick. Left at Howick.

18/2/77 Howick Hospital – ?Placenta Praevia – Breech.

           I.V Drip – Scan Xray – Normal Delivery at National Women’s Hospital.

19/2/77 North Shore Hospital – Server H.OP. B.P. 220/130 in Labour

           Hydrallazine Valium.  Epidural Monitor Syntocinon. Forceps Delivery at National Women’s Hospital.

21/2/77 Waitakere Hospital – Retained Placenta.

    Placenta sitting in vagina. Removed. Remained Waitakere.

24/2/77 Waitakere Hospital – Avulsed Cord.

           General Anaesthetic. Manual Removal – adherent. Not transferred.

4/4/77 Pukekohe Hospital – Premature Labour 32-34/40 ion Labour.

         Berotec steroids. Breech Delivery National Women’s Hospital.

14/4/77 Warkworth Hospital – Failure to progress 2^nd Stage.

  N.B lift out at Warkworth. Remained Warkworth.

15/4/77 Middlemore Hospital.  Severe H.O.P 200/140 35/40

   Hydrallazine. Transferred to National Women’s Hospital. ?outcome.

3/4/77 Middlemore hospital – 34/40 Fully Dilated.

   Steriods Berotec. Normal Delivery at National Women’s Hospital.

6/5/77 Auckland Hospital – Severe H.OP. 28/40, B.P. 220/120.

         Valium hydrallazine. Transferred National Women’s Hospital I.U.D.

10/5/77 Waitakere Hospital – Ante Partum Haemorrage. 36/40 R.M. Fetal Distress

           Delivery before arrival. Left at Waitakere Hospital.

14/5/77 Papakura Hospital – Retained Placenta.

           Manual Removal General Anaesthetic. Transferred National Women’s Hospital. Babe 11A.

18/5/77 Mater Hospital – Inverted Uterus – Gynae Operating Theatre.

18/5/77 Pukekohe Hospital – Patient Collapsed. ? Pulmonary Embolus.

           D.O.A at Pukekohe. P.M heart Failure.

5/6/77 Home of Compassion – Post Partum Haemorrhage ?700 ml.  Patient Lifeless.

  B.P. OK 2^o Plasma. Transferred National Women’s Hospital.

6/6/77 Papakura Hospital – Post Partum Haemorrhage. 1,000ml B.P OK.

          I.V. Drip. Syntocinon. Left at Papakura.

10/5/77 Howick Hospital – Post Partum Haemorrhage. 600 ml.

    EUA D & C at National Women’s Hospital.

7/7/77  Pukekohe Hospital – Post Partum haemorrhage 2,000ml 60/0.

           Plasma, Blood.  General Anaesthetic. Transferred National Women’s Hospital.

10/7/77 Warkworth Hospital.  Post Partum haemorrhage.  800mls +

   Blood Plasma. EUA at Warkworth pieces membrane removed. Left at Warkworth.

21/7/77 North Shore Hospital. Post Partum Haemorrhage 200 mls. B.P. 90/60

           Blood, transferred National Women’s Hospital.  EUA.

25/7/77 North Shore Hospital.  H.O.P Abruption 32/40 IUD.

          Induced at National Women’s Hospital. Delivered.

28/7/77 Waitakere Hospital. Ante Partum haemorrhage 28/40 Minimal loss.

           Transferred National Women’s Hospital – Ward 5.

5/8/77 Warkworth Hospital. Ante Partum Haemorrhage. 800ml loss 42/40.

         Placenta Praevia. LSCS at National Women’s Hospital.

21/8/77 Papakura Hospital.  Post Partum Haemorrhage. 1,00ml B.P. 80/60.

          Blood Plasma. General Anaesthetic. Placental tissue removed. Remained Papakura.

24/8/77 Waitakere Hospital – Retained Placenta.

           Placenta in vagina.  Pethidine, Valium – Placenta removed. Remained at Waitakere.

25/8/77 Home Midwife – Retained Placenta. Blood loss 1,000ml.

           I.V Sytocinon. Transferred National Women’s Hospital. Manual Removal under General Anaesthetic.

3/9/77 Warkworth Hospital – Retained Placenta.

         General Anaesthetic. Removal. Blood loss 800mls. Patient remained at Warkworth.

10/9/77 North Shore Hospital – H.O.P Post Partum. 200/140.

           B.P on arrival 120/90. Transferred National Women’s Hospital – observation.

19/9/77 North Shore Hospital – Post Partum Eclampsia 140/95 (Twins).

          Paraldehyde, Valium. Transferred observation.

29/7/77 North Shore Hospital – Retained Placenta. Post Partum Haemorrhage.

B.P 60/0. 2000 ml. Haemacel Blood Plasma. General Anaesthetic. Manual Removal. Transferred  National Women’s Hospital. Observation.

Paper written by G.E.Stimpson. Started 1971.