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If You're A Woman In Labour And In Trouble Don't Count On Emergency Air Transport

10th September 2019

MSP Rhoda Grant is calling on the Health Secretary to launch an urgent review into the availability and suitability of emergency air transport for pregnant women across the whole of the Highlands and Islands.

Her plea comes after her further investigation into the case of a Caithness mother who went into labour at 30 weeks with twins. The babies were born 50 miles apart in a dash of over 100 miles by a road ambulance to Raigmore Hospital. One twin was born in Golspie, Sutherland and the other in Raigmore, Inverness.

Mrs Grant asked NHS Highland, the Scottish Ambulance Service (SAS) and Health Secretary, Jean Freeman, further questions after receiving an edited version of a Significant Adverse Event Review into the incident. She previously asked First Minister Nicola Sturgeon to investigate.

She repeated her call for a full risk assessment to be carried out on such emergency transfers and that a suitable craft can be made available for airlifts.

"After receiving the responses, I would sum up the situation as this - for any woman in labour and needing emergency help going by road ambulance is really the only option and air transfer is almost a non-starter," said Mrs Grant, who represents the Highlands and Islands.

"Whatever the officials and Government say, most people believe that an air ambulance is still an option when the truth is that it can hardly ever be used due to the constraints of the helicopter and the risks associated with giving birth in the air.

"I'm now calling on the health secretary to instigate a review, to ensure that any emergency aircrafts can be large enough to carry medical equipment and be able take at least one qualified medic on board, particularly to cater for women in labour.

"I realise that pregnancy and labour are risks but we really do need to ensure that everything that can be done is being done to cover eventualities."

Mrs Grant discovered that the ScotSTAR service, run by SAS and used to fly in medical experts in emergencies to locations across Scotland, does not have obstetric/midwifery staff and she is now asking Ms Freeman if this gap can be filled.

She wrote to Brian Johnson, Chief Executive of the Maritime and Coastguard Agency, which runs search and rescue helicopters, to find out its policy on being called to pregnant women.

He said transfer requests in relation to pregnancy rested with the ambulance service but also said: "our crews and aircraft are prepared and equipped to respond to deal with maternity care and obstetric emergencies".

Mrs Grant commented: “This appears to be at odds with what the health authority and ambulance service are telling me so I've written back to him for clarification."

The MSP stressed front-line staff involved in the twins' case were excellent and coped with a very difficult and serious situation, but she was worried about the implications for other pregnant women.

The mother of the twins, who wants to remain anonymous, is supporting Mrs Grant's campaign for a review.

The mum believed the health service mentioned air transport as a back-up when the maternity service in Caithness was changed to a midwife-led unit and at-risk mothers were sent to Raigmore to give birth.

“Why if the NHS is saying that the helicopter is not suitable for premature labouring women did the team in my case spend two hours trying to get a helicopter when I had already had given birth to one twin?" said the mum.

“A helicopter was sent out but was unable to land. If it's stated it's not suitable then it should have never been sent or requested!

“I've supported Rhoda investigating this further because I don’t want any other mother going through what I went through, although the staff who helped me at the time were fantastic.”

Caithness health campaigners, CHAT, fully support Mrs Grant in calling for an urgent review into air transport for expectant mothers in the Highlands.

“Following Mrs Grant's intervention, it is now apparent, that in an emergency situation, pregnant mothers cannot rely on air transportation or help from the ScotSTAR service,” said vice-chair, Ron Gunn.

“The only option left is a two-hour transfer by road ambulance. Living in Caithness we are all too familiar with the many problems associated with driving on the A9, especially as we come closer to winter. Caithness women need to know they can get help quickly and efficiently when they or their baby needs it.”

Mrs Grant’s questions also revealed that some SAS pilots were not trained in the use of night vision goggles which meant they could not fly at night - the ambulance service said the search and rescue helicopter could respond in these cases.

Mrs Grant has asked Ms Freeman to grant the ambulance service extra money to ensure air staff get the significant additional training for night work.

The MSP also asked about the plan for delivering babies in Caithness if transfer by road and air was impossible and was told that midwives and the emergency teams at Caithness General undertake regular training in the management of emergency obstetric cases and neonatal resuscitation. In addition, NHS Highland said there was support from consultants using VC from Raigmore Hospital.

“However, I do believe the expertise available in Caithness has to be investigated again,” said Mrs Grant.

“I believe there is still a lack of obstetric and neonatal expertise there adding to the limitations and deficiencies in the current system for transferring mothers and babies.”

Extracts from the NHS Highland and Scottish Ambulance letter:

RG: You say that “the air ambulance helicopter is a highly unsuitable environment for the delivery of a baby”. So, what aircraft is suitable? Where is the suitable craft based? Who runs the service? If not the ambulance service, then does the ambulance service have to pay for its use? If road transfer is impossible i.e. closed roads/weather conditions what air craft can be used to transfer pregnant women?

Response: In general, in bad weather, the roads would remain open beyond the point when air resource is unable to fly.

The limits of flight safety are a decision for the pilot and must consider the safety of the aircraft and crew. Thus if the road is closed for weather reasons it is highly likely that air resource is unable to fly.

The Scottish Ambulance Service (SAS) Air Ambulance resources fly under Civil Aviation Authority (CAA) restrictions. Search and Rescue (SAR) helicopters are significantly larger and can fly in poorer weather conditions (i.e. at some times when SAS helicopters are grounded).

Whilst it is tempting to assume that flight times would be quicker than road travel we also need to consider the time to get the aircraft from base to the referring centre, any necessary arrangements for the landing site (overnight opening an airport or lighting a helipad etc.) and the necessary patient transfers (where a fixed wing plane is used we need to consider airport transfers). In many cases once all these are included the road transfer time will be quicker.

Space constraints mean that the back of a helicopter is not a suitable place to consider delivering a baby, certainly not a premature twin. There is simply not the space for the required equipment and personnel.

Clearly whilst a road ambulance can pull over and park during an emergency, this option is not available in a helicopter. Safety considerations for patient, baby and staff mean ‘in-flight delivery’ is high risk (hence the limitations on pregnant patients flying on commercial airlines www.nhs.uk/common-health-questions/pregnancy/is-it-safe-to-fly-while-pregnant ) and would be avoided if at all possible.

Helicopter transfer of a non-labouring, pregnant woman would be potentially reasonable; transferring a woman in premature labour would not. The road alternative would be safer.

If SAS Air Ambulance were unavailable / unable to fly but an air transfer was still required then Search and Rescue (SAR) resource can be requested. Whilst these are larger helicopters these would still not be a good environment for a labouring, pre-term mother to give birth in.

Where are the suitable aircraft based? SAS Air Ambulance has:

· Two helicopters (www.airbus.com/helicopters/civil-helicopters/light-twin/h145.html) Helimed 5 based at Glasgow airport and Helimed 2 at Inverness airport, these are both available 24 x 7

· Two fixed wing planes (King Airs) based at Glasgow airport (GKA) and Aberdeen airport (AKA) both available 24 x 7

· SAR (Bristow’s) has resource based at:

o Stornoway (S92)

o Sumburgh (S92)

o Inverness (AW189)

o Prestwick (AW189)

Use of these can be requested via the Aeronautical Rescue Control Centre (ARCC)

Who runs the service? ScotSTAR and Air Ambulance are part of the Scottish Ambulance Service (SAS). ScotSTAR comprises the retrieval services for critically ill adult, paediatric and neonatal patients; it does not include obstetric staff. Sea Air Rescue (SAR) is now provided by Bristow’s www.bristowgroup.com/uk-sar (it was formerly a military service).

RG: the constituent name redacted has told me that when the Caithness unit was changed into a midwife-led unit she believed air transport was mentioned then as a back-up in emergencies. She asks why this promise was made when it couldn’t be fulfilled.

Response: Air transfer is utilised in an emergency and pregnant women are (and have been) transferred by air. However, a pregnant woman immediately about to give birth would not be transferred as the risks associated with having a baby in a helicopter are high. The helicopter would have to land and may not be able to find a suitable landing site. There is limited space with no room for a midwife to provide escort services, so no trained midwife or obstetrician on board.

This would be an adult / in utero transfer so no neonatologist or paediatric support is available if the baby is born mid-flight and no specialist equipment is available on board. Air transfer of a non-labouring pregnant woman could use any of the air resources (if the transfer warrants this). However air transfer of a labouring patient is inadvisable and particularly in bad weather air transfer may not be a smooth, pleasant experience.

If an air transfer is required and SAS Air Ambulance is unavailable then a request can be made for Sea Air Rescue (SAR) resource. If required a ScotSTAR team can fly on either SAS or SAR resource, whichever transport platform is most appropriate case by case.

RG: Another point in this case is that “the pilot was not trained in the use of specialised night vision equipment so their ability to land between Wick and Inverness, should delivery proceed, would be limited”. This is quite shocking that an air ambulance pilot wasn’t full trained for all conditions - how could the pilot be called to any other operation, i.e. on the hills, if not fully trained. How is this being addressed?

· Response: Overnight air ambulance operations are generally restricted to ‘designated’ landing sites, i.e. previously surveyed, appropriately lit etc. (there are often local arrangements with the Coastguard or Fire Service to get the lights turned on when required).

As part of the improved funding from the Scottish Trauma Network the use of Night Vision Goggles (NVG) was made available to the SAS Air Ambulance, these went into operational use in November 2017.

Use of NVG requires significant additional training - both of the pilot and of the technical crew member (TCM). There will occasionally be nights where either pilot or TCM are not ‘current’ for NVG use, new staff or late shift changes etc. (most Air Ambulance services do not use NVG).

If occasion arises where NVG use is not possible then we would revert to the arrangements as prior to November 2017 and use SAR resource to respond.

RG: Finally, with staffing shortages and stress being reported in all health services, and in the ambulance service, there is obviously going to be more stress placed on staff because of this move to centralise at risk births in Raigmore.

Response: We have not seen an increase in maternity ambulance transfers since moving to the CMU model in Caithness and we have seen a significant decrease in Neonatal Air Transfers.

You also state in your letter that the Scottish Government needs to think about establishing a full neo-natal unit in Caithness.

It would be important, here, to point out that, since CGH is a Rural General Hospital, there has never been a neonatal unit in Caithness and this was also the position when the maternity unit was a consultant obstetric-level model.

Lastly, it would be important to note that, due to the unpredictable nature of childbirth, there will always be a small percentage of labouring women who do not reach hospital in time for the birth of their baby. NHS Highland maternity teams work with service users, SAS and nursing and medical colleagues to ensure training, patient education and emergency protocols are in place to support the safest management and best outcomes in these events.

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