Progress in Obstetrics from 19th to 21st Centuries: Perspectives from KK Hospital, Singapore - the Former World's Largest Maternity Hospital
K Tan, S Chern
Citation
K Tan, S Chern. Progress in Obstetrics from 19th to 21st Centuries: Perspectives from KK Hospital, Singapore - the Former World's Largest Maternity Hospital. The Internet Journal of Gynecology and Obstetrics. 2002 Volume 2 Number 2.
Abstract
KK Maternity Hospital, Singapore was the former world's largest maternity hospital from 1950s to 1970s. This article presents the history of KK Maternity Hospital in Singapore, the changes in KK Hospital over the years from 19th century up to the 21st century and the last decades where the changes became more rapid.
Introduction
Our generation at the edge of this new millennium has witnessed the rapid advance of new technologies. With this we saw rapid development and advancement in all aspects of our lives at home, at work & at leisure, and at a breathtaking pace, not experienced by or even dreamt of by our forefathers. The rapid advancement in technology is also felt in the medical industry and the obstetric speciality is not spared either from the relentless changes induced by the advancing technology. This article presents the history of KK maternity hospital in Singapore, the changes in KK Hospital over the years since 19th century up to the 21st century and the last decades where the changes became more rapid.
History Of KK Hospital, The Former World's Largest Maternity Hospital
Kandang Kerbau Hospital (KK Hospital), the birthplace of over 1.2 million Singaporeans, was the largest maternity hospital in the world from the 1950s to the early 1970s.1 It was named after the district where it was located. The Singapore district around the crossroads formed by Serangoon Road, Selegie Road, Bukit Timah Road and Rochor Road was known in Malay as “Kandang Kerbau” (“Buffalo Enclosure”, because in the old days, there was a buffalo pen in the locality). In Teochew and Hokkien (dialects of spoken Chinese), it was known as “Tek Kah” and in Mandarin as “Zhu Jiao” (“below the clumps of bamboo”, because in the early days, clumps of bamboo grew on the hillocks in the district). The hospital, commonly known as “KK” or “Tek Kah” served as the national maternity hospital of Singapore from 1924 to 1997.
The old KK Hospital has a long tradition of service to the people of Singapore. It was first built in 1858 to function as a general hospital. In 1905, it expanded to accept female pauper patients from Tan Tock Seng Hospital and later housed female lepers and poor children. It eventually became the Pauper Hospital for Women and Children. On 1 October 1924, led by Professor J S English, the first Professor of Obstetrics and Gynaecology (O&G), KK Hospital was converted into a free maternity hospital with 30 beds. On that momentous first day, five babies were born – three Malays, one Chinese and one Japanese. A new block containing 120 beds was completed by 1934. In that year, there were 2, 575 births, a figure which continued to climb steadily over the years. Another new block was erected and opened in July 1940 bringing the total number of beds to 180. In that year 6,184 births were recorded.
During the period of Japanese hostilities in 1940-41, the Hospital became an Emergency General Hospital providing 500 beds. After the fall of Singapore and during the Japanese Occupation (1942-45), the hospital served as the Civil General Hospital and was known as Chuo Byoin (Central Hospital). Dr B H Sheares, who became Malaya's first local Professor in O&G in 1951 and the Republic of Singapore's Second President in 1971, was its Deputy Medical Superintendent then. After the war, KK Hospital remained the Civil General Hospital until 1 July 1946, when it resumed as the only O&G hospital serving the country.
The post-war years witnessed high birth rates, with the number of obstetric births increasing from about 10,000 in 1948 to a historic high of 40,000 in 1966 (Table 1).
In 1955, a new Extension Wing, at Hampshire Road and linked to the old Wing across Buffalo Road, was added to cope with the demand (Photos 1-6). The main building of this New Wing which used to house the admission, two obstetric theatres and 3 floors of labour wards, witnessed a record of just over one million births from 1955 to 1997. This unique “one million babies” building of the New Wing (and also the old Wing of old KK Hospital) still stand today as part of the offices of Singapore's Land Transport Authority. Visitors can easily view this historical building, as the old (Old and New Wings) as well as the new KK Hospital are very accessible and are just adjacent to the Little India train station of Singapore's latest Mass Rapid Transit (underground subway) North East Line (which also occupies part of old KK Hospital's site). Perhaps no intact building in the world has witnessed as many obstetric deliveries as the main building of the New Wing of old KK Hospital.
Figure 1
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Figure 6
The record number of births or ‘birthquakes' earned KK Hospital consecutive entries in the Guinness Book of Records from the 1950s to the 1970s as the world's largest maternity hospital in the era where home deliveries were still common in many parts of the world. The 1975 edition of the Guinness Book of Records recorded ‘The largest maternity hospital in the world is the Kandang Kerbau Government Maternity Hospital in Singapore. It has 239 midwives, 151 beds for gynaecological cases, 388 maternity beds and an output of 31,255 babies in 1969 compared with the record “birthquake” of 39,856 babies (more than 109 per day) in 1966.’ Indeed it was the melting ethnicity pot of Singaporean women. It was also a vehicle and a powerful symbol of racial harmony where many women, irrespective of races, laboured and delivered their babies side by side. The ‘new' Extension Wing of the old KKH, which opened in 1955, comprised the familiar Admission entrance, the Outpatient Clinics, the medical students' & house-officers' quarters, antenatal & postnatal wards and above all, the Labour wards. Known fondly as KK or Tekka, it was also a national focal point known to countless Singaporeans and their families as it was the humble birthplace of over a million Singaporeans.
KK Hospital also witnessed remarkable improvement in maternal and perinatal mortality rates, quite unmatched in the history of obstetrics of the world. The maternal mortality rate dropped dramatically from 760 per 100,000 births in 1930 to 7 per 100,000 births in 1987 and the perinatal mortality rate decreased from above 50 per 1000 births in 1940s to less than 5 per 1000 births in 1990s, achieving world class standards. KK Hospital was the centre of Singapore's pioneering feeder system of Maternal and Child Health Clinics (MCHC) with 66 MCHCs in 1964. Singapore was awarded the Kettering Shield for having the best Maternal and Child Health Service in the Commonwealth in 1955. It was also the centre of O&G and reproductive medicine research in South-East Asia and was world famous for research on trophoblastic disease (molar pregnancy) and prostaglandins (used for induction of labour). It was the birthplace of Asia's first IVF baby in 1983 and was Singapore's most important teaching and training centre for midwives and obstetricians & gynaecologists from 1924 to 1997.
The old KK Hospital being the world's largest maternity hospital had an unsurpassed wealth of clinical material. It became an international focal point and an important hub of O&G activities of the world. It was here that important research on molar pregnancies, prostaglandins, contraception and assisted reproductive techniques were performed and benefited the world greatly.
The activities and talents of the world converged at KK Hospital from the 1950s to 1970s. These influences included those from: the USA (Prof McKelvey, Britain (Prof English and expatriate members of the Royal College of Obstetricians and Gynaecologists); Taiwan and Japan (Dr HT Choo); Uganda (Prof Sultan Karim); Malaysia (notably from Penang); Australia; Sweden; Sri Lanka and other countries. Some of them returned to their country of birth or migrated elsewhere while others like SS Ratnam, Tow Siang Hwa, Lean Tye-Hin, SM Goon and HT Choo stayed and contributed even more.
On 1 April 1990, the KK Hospital ended its 132-year history as a government hospital and embarked on a new chapter in its history as a restructured hospital. O&G units at Alexandra Hospital and Toa Payoh Hospital were closed and transferred to KK Hospital. In 1997, KK Hospital moved to its new premises nearby at 100 Bukit Timah Road with 888 beds and was renamed KK Women's and Children's Hospital. Besides O&G, the new hospital assumed an additional role as the first Children's Hospital in Singapore, bringing together the paediatric services of the Singapore General Hospital, Tan Tock Seng Hospital and Alexandra Hospital. KK Women's Hospital opened its doors on 10 March 1997; while KK Children's Hospital admitted its first patient on 9 May 1997.
The Singapore O&G Advances
The practice of Obstetrics and Gynaecology (O&G) in Singapore has come a long way. The improvements of O&G care in Singapore, as evident in higher female life expectancy and lower maternal mortality & perinatal mortality rates, make Singapore one of the safest places in the world to be a woman and to have a baby. This process of improvement has over the years, produced a large pool of trained midwives, nurses, general practitioners and O&G specialists to serve our nation.
Singapore maternity care-providers evolved from the untrained traditional birth attendants “bidans” and midwives to trained and registered midwives, general practitioners and O&G specialists. In 19th century and the early years of the 20th century, home deliveries were the mode and family planning & antenatal care were not in the layman's vocabulary. At that time perinatal and maternal morbidity & mortality were high. Where previously a general practitioner (up to the 1960s) would usually take care of all aspects during pregnancy and delivery, there are now O&G specialists, and besides them other specialists like the neonatologist and obstetric anaesthetist to enhance the care of the mother and the baby.
Professor JS English and colleagues brought into Singapore (in the 1920s to 1940s), a proper system of control and training of the midwives, with a better understanding of the principles of aseptic and antiseptic midwifery They also spread health consciousness amongst the expectant mothers, so as to avail themselves to the benefits of ante-natal and post-natal care, in the 1920s to 40s. The contributive roles played by general practitioners, including Dr SR Salmon of the Salmon Maternity Home and Dr Paglar of the Paglar Maternity and Nursing Home should not be forgotten.
In the 1940s to the 1960s, Professor BH Sheares and colleagues raised the standards of O&G care, medical student & postgraduate teaching and research, despite the lack of staff and resources. Professor Sheares imbibed modern and progressive O&G ideas readily. He introduced modern obstetric practice to Singapore and popularized the lower segment Cesarean section during the Japanese occupation period. Cesarean section is a routine and common procedure now and the current cesarean section rate (almost all of them are lower segment Caesarean section) is more than 20 % of the total deliveries in Singapore.
Professor SH Tow and Clinical Professors TH Lean & SM Goon further improved standards of antenatal and gynaecological care as well as O&G research in KKH in the 1960s. They were instrumental in obtaining local accreditation for MRCOG training, facilitating the training of more O&G specialists locally. Their good works were continued by pioneers like Dr YM Salmon, Dr HT Choo and Prof SS Ratnam from the 1970s onwards. Dr CS Oon was a pioneer in O&G specialist private practice from 1959. Despite its initial difficulty, the private O&G practice has progressed very rapidly over the last 40 years. More than half of the deliveries in Singapore are performed in the private sector and there are more O&G specialists in the private sector, with a ratio of 156 (private) to 77 (public) O&G specialists in 2001. The contributions made by our dedicated nursing community in Midwifery including Matron IL Aeria were crucial. The various midwifery schemes including the municipal and rural maternal and childcare system were started in 1910s and 1920s respectively. The domiciliary delivery & after-care and the KKH midwifery wards, introduced in the 1950s and 1960s, were manned by the midwives. They were essential in keeping maternal and perinatal mortality rates low, during the earlier era of high birth rates and overwhelming patient load. Placing the care of women and babies above self, the O&G pioneers' hard work and dedication have now become a source of inspiration and motivation to over 230 O&G specialists, 40 O&G trainee specialists and the O&G nursing community in Singapore currently.
From Third World to First World
Improvements in maternal and perinatal mortality and standards of obstetric care of a country go hand in hand with improved socio-economic levels and female literacy. Therefore, the contributions of Singapore's former Prime Minister, Mr Lee Kuan Yew, and his government, during the 1950s to 1980s need to be recognized as well. Today, Singapore has one of the highest standards of living and female literacy in Asia and in the world.
Singapore doctors have opportunities for training and advancement and they have also easy availability of facilities, equipment and technical support. In addition, Singapore has a national population base where people are educated, socio-economically adequate and understood the need for early antenatal care. These assets have enabled the range of O&G services in Singapore to expand and the standard of care to improve markedly. With a better staffing ratio and training opportunity, our obstetric standards of care and service have improved tremendously.
The era of “harassed overworked stern midwife keeping watch over 6 labouring women in the same room, with many more waiting outside on the hard benches along the corridor” is gone forever. Singapore's obstetrics standards have even surpassed many countries in the West in terms of female life expectancy and maternal & perinatal mortality rates. Singapore has arrived from the Third World to the standards of the First World in obstetrics.
Singapore Timeline of Obstetrics
This Obstetrics Timeline (Table 2) stretching from AD 1297 to 2003, chronicles the important events relating to obstetrics and gynaecology in Singapore. It juxtaposes the important events, achievements and milestones of Obstetrics of Singapore with the important national events. It keeps track of the setting up and the closure of various O&G departments and hospitals in the history of Singapore since 1865 where patients were admitted for gynaecological complaints and childbirth in the General Hospital at Kandang Kerbau District.
The first Maternity Hospital (8 beds) in Singapore opened at the junction of Victoria Street and Stamford Canal in 1888. The Maternity Hospital at Victoria Street closed on 20th November 1908 and the new Maternity Block at the General Hospital at Sepoy Lines was completed and received patients from 1 Dec 1908. The old Maternity Hospital at Victoria Street was reopened in September 1914 as a Free Maternity Hospital of 12 beds. On 1 October 1924, Kandang Kerbau Maternity Hospital (KK Hospital) was opened with 30 beds and 12 children's cots, replacing the Maternity Hospital at Victoria Street.
It records the progressive number of deliveries in the maternity hospital at Victoria Street and later in KKH, from 1915 with 174 deliveries, leading up to KKH being the world's busiest maternity hospital since the 1950s with a peak of 39,835 deliveries in 1966, a record which was maintained till 1975.
It traces the evolution of Singapore O&G health care providers from the untrained traditional birth attendants, the “bidans” and midwives to trained and registered midwives, general practitioners and O&G specialists. It shows the growth of the local O&G fraternity since Dr Benjamin Henry Sheares became the first local obstetrician to hold the specialist diploma of MRCOG (Membership of the Royal College of Obstetricians and Gynaecologists) in 1948. This has grown to 233 O&G registered O&G specialists in Singapore.
It documents the improvements of O&G care in Singapore through the increasing Female Life Expectancy and the decreasing Maternal Mortality Rate and the Infant Mortality Rate and later Perinatal Mortality Rate, over the years. The maternal mortality dropped dramatically (by 100 fold) from 750 per 100,000 births in 1932 to 7 per 100,000 births in 1987. The perinatal mortality decreased by more than 10 fold from above 50 per 1000 births in 1948 to 5.1 per 1000 births in 1994. Standards of maternal, perinatal and infant care are intimately related to socioeconomic factors and health care policies of the government.
Rapid Changes over the Last Decade of the Millennium
Obstetrics
Within the short 10-year span, the obstetric specialty witnessed many changes in the way we practice obstetrics. The changes over the last decade are much more dramatic than all previous decades. The major advance in obstetrics namely ultrasound (pioneered by Ian Donald in 1958 in Scotland) only became routine and prevalent in the 1990s, changing the concepts & standards of care and protocols in many ways.
In this short span, KK Hospital witnessed the plastic Amniohook replacing the Kocher's forceps in performing ARM (artificial rupture of membranes) and plastic cups eg Kiwi cup with self inflate hand pump, replacing rubber (silicone) or metal cup in vacuum extraction. Reusable or autoclavable items (glass, metal or cotton material) are fast giving way to single-use paper or plastic disposable items eg gloves, syringes, paper towels and sterile drapes, gowns, caps, paper masks with plastic shields, speculums, amniohooks, Kiwi vacuum cups, infusion bottles and vacuum blood collection tubes. Our nurses no longer need to powder the rubber gloves that were recycled, to pack glass syringes or to fold cotton towels in the back room of the labour ward. Automation brings changes in O&G practice. The Doptone & the CTG (cardiotocography – fetal heart rate monitor) machine (which in the 1980s and early 1990s were scarce items reserved for use according to priority and severity of cases) had almost completely replaced the Pinard fetal stethoscope. Each of the 32 labour rooms of KKH delivery suite has a dedicated CTG machine. Automated and calibrated drip infusion sets for titration of drip regimes in exact mils per minute instead of the inaccurate drops per minutes for oxytocin, salbutamol, antihypertensives, were introduced. Continuous pulse oximetry was introduced. Automatic blood pressure sets became common. No longer does the house officer need to sit by a severe preeclamptic taking blood pressure every 5 to 10 minutes manually.
Management of important conditions in the delivery suite has also changed tremendously. Up to the early 1990s, the drugs valium, Librium and Nepresol (Lib & Nep drip) were used in our standard protocol for the treatment of severe preeclampsia and eclampsia. In 1995, the Collaborative Eclampsia Trial showed that magnesium sulphate was superior to diazepam and phenytoin in the treatment of eclampsia.2 This made the change towards the increasing use of magnesium. Anti-hypertensives have changed to sublingual Adalat and intravenous labetolol besides the usual Nepresol (hydralazine). Eclampsia, over the past 10 years has become very uncommon, through early antenatal care, optimum care and early delivery in preeclampsia. Similarly tocolytics for inhibition of labour have expanded from salbutamol (Ventolin) to GTN (nitric oxide donor) patches and Adalat.
Sultan Karim, who was the first O&G Research Professor of Singapore, was the first to successfully use prostaglandins for the induction of labour in 1968. The continued development of better and better prostaglandins pessary for induction of labour (eg Prostin) later made it popular in later half of 1990s. It reduced the need for us to struggle to rupture the membranes (for oxytocin induction) when the os was not favourable. The increasing popular use of prostaglandins was also in line with the research by Mary Hannah et al and review by Patricia Crowley that routine induction of labour after 41 weeks reduced perinatal mortality in the early 1990s.3,4 One in five obstetric patients has Prostin induction in KK Hospital.
In the recent past, many have the opportunity during my training in the early 1990s to learn a variety of instrumental and assisted vaginal deliveries including Kielland's forceps delivery, assisted breech delivery etc. The trend today however, is that we are moving away from these difficult vaginal manoeuvres towards Caesarean section. Such well established techniques mastered by our pioneers, some of which have formed the artistic aspect of our profession may soon be lost. Even before the Term Breech Trial, vaginal breech delivery was becoming more selective and reserved for those which were clinically assessed to be unlikely to have feto-pelvic disproportion. The Term Breech Trial in 2000 revealed that for term breech births, elective cesarean section posed less risks than vaginal delivery and hastened the end for vaginal breech delivery.5 Currently vaginal breech delivery are only a handful. The hospital's CS rate has increased from 16.9% in 1991 to about 24% in 2001 in KK Hospital. Except for rare circumstances, all were by lower segment cesarean section which healed very well. In fact one of us personally has never ever needed to perform a classical upper segment cesarean section in my career.
Similarly, the skin incisions in early 1990s were both midline vertical and lower transverse (Pfannenstiel). It was believed that the midline skin incision gave faster and better access. However it tended to heal poorly. In the late 1990s, performing a midline incision became uncommon. In KKH, even in a Crash (immediate) cesarean section, it is becoming routine to do a Pfannenstiel. A Pfannenstiel incision is also commonly performed even if there was a previous midline scar. Sutures used have evolved. Advancement in Material Sciences has given us stronger and better sutures like dexon, vicryl, monocryl and even staples. For episiotomy repair the familiar catgut is now replaced by vicryl. There is also now a trend of not closing up even the parietal peritoneum layer in the recent years as some research showed that it was of no benefit.6
Prenatal Ultrasound and Imaging
Most of all, ultrasonography have revolutionized obstetric practice, making deep seated changes. This was especially so in the 1990s when ultrasound machines not only increased in sophistication and resolution but also became more popular, less cumbersome, more portable and less costly. One of us (BC) recalled as the medical officer on duty that patients with vaginal bleeding in early pregnancy without much pain was assessed clinically without a scan as ultrasound machines were scarce and not routine. In most patients, an appointment was made to return for an ultrasound scan in a scheduled list by a radiologist. In recent years, with the advent of less costly ultrasound machines with higher resolution and with training, it is becoming more of a routine practice to perform ultrasound in the first instance for such cases. We are thus able to better utilize the ultrasound for diagnosis of bleeding in early pregnancy to confirm intrauterine viability or to exclude ectopic pregnancy. The increase use of serum beta HCG and the increasing speed of the availability of results (similar to the speed of getting results for other blood tests eg tumour markers) helped a lot. The routine and prevalent use of ultrasound in the practice of O&G has reduced the incidence of ruptured ectopic pregnancy with gross hemoperitoneum and shock.
Since ultrasonography became available, it has become one of the most useful non-invasive tools in obstetrics, such as in the early detection of multiple pregnancy, a low-lying placenta, missed abortion, intra-uterine fetal death, fetal abnormality, fetal maturity, intra-uterine growth retardation and multiple pregnancy. Many fetal abnormalities (but not all given the diagnostic limitations of ultrasound), fetal presentation/number and baby gender are diagnosed antenatally and thus delivery is now less of a surprise. An occasional scan or indicated scan in the antenatal period began to be replaced by routine scans - dating, screening and growth scans in the late 1990s. It is conceivable in the near future that all clinic consultation rooms may be equipped with an ultrasound machine each just like most O&G consultation rooms were now equipped with BP set, stethoscope or even the doptone.
Today ultrasound has become an extension of our hands, our eyes and our ears. Clinical palpation skills (eg to assess presentation) has become less relevant in the face of the more definite diagnosis by the increasing ubiquitous ultrasound. It has also minimized our efforts in trying to interrogate our pregnant patient on the precise date of her last menstrual period, the regularity of her period and the date when her pregnancy was tested positive, the date of quickening so as to more accurately estimate her EDD. A simple dating scan done in the first trimester would suffice in most cases, eliminating intensive and sometimes frustrating clinical interrogation . Examination in OT for suspected placenta previa has disappeared.
Ultrasound examination is safe and useful in pregnancy but still the most important fact about ultrasound which every patient should know is that there are limitations i.e. false positives and false negatives. It cannot detect all anomalies, may not be conclusive & indeed may cause much anxiety. Additional tests like amniocentesis with its attendant risks may be offered to the patient, to give added information. Costs are also involved.
The maternal age criteria for amniocentesis have changed. It used to be that karyotyping (usually amniocentesis) was offered for woman 40 years of age to exclude chromosomal abnormalities. It was reduced to 38 years of age then to 37 and to 35. Later it has been recommended to offer based on the computer calculation of risks from serum screening (at around 16 weeks) of some serum factors (like AFP, E3 and HCG) in conjunction with age. Now Nuchal Translucency (NT) measurement test at 11 to 14 weeks to estimate risks has come into the picture. Besides routine offering of antenatal maternal serum screening for Down syndrome, the HIV test is an additional blood test in the past few years that is now routinely offered.
In contrast to ultrasound, X-rays which was used extensively in the past for estimation of fetal maturity, detection of fetal abnormalities or multiple pregnancy, pelvimetry in cases of difficult labour and localization of the placenta, was generally restricted to only one indication in the early 1990s. This was to assess for pelvic disproportion electively eg in breech presentation, the short primip less than 150 cm or patient with previous cesarean section through a lateral X-Ray pelvimetry. Even this last indication is now obsolete for the past few years.
Obstetric Anaesthesia
The pattern of obstetric analgesia and anaesthesia has changed. Obstetric epidural for labour pains are rare in the beginnings of 1990s (less than 5% in KKH). Now it is a common practice (about more than half of ‘primips' in labour are on epidural). With that and with continuous CTG monitoring, second stage can be longer and the “supposed norms” of second stage of labour of 1 hour for ‘primips' and half hour for ‘multips' no longer hold. Similarly regional anaesthesia (RA - spinal or epidural or combined) was rare in the early 1990s where general anaesthesia (GA) held sway. Now the vast majority of operations are under RA even in cases like placenta previa or preeclampsia. This poses challenges for obstetricians also (eg sometimes the abdominal muscles may not be as relaxed as in GA). The standard for an elective section is now RA so much so that for a few patients who had morbid fear of being awake during the section, they had to ‘bargain' quite hard for a GA with the anaesthetist.
Implications of High Patient Expectations
The medico-legal climate becomes more adverse, putting pressure on medical indemnity premiums of Singapore obstetric practice which rose from less than $1000 to about $10,000 per year within a decade. It is an odd irony that the higher the standards and the more efficient the services provided, the more our patients demand and complain (a sign that patient's expectations have increased tremendously, more than they can be satisfied). In contrast to earlier days, gratitude seemed to be scarce but complains abound. We are more likely to have an older patient who is grateful rather than a younger one. Perhaps now our younger & more ‘educated' generation, is fussier, less tough, less stoic and less able to bear the rigours and uncertainty of labour or disease than the older generation. Doctors and nurses have to adapt to this changed pattern of patient behaviour and high (sometimes unduly high) expectations from patients. At the same time, many of us living in developed countries, as patients or other roles, must not inculcate a habit of complaints but must allow our gracious & courteous side to develop, even in trying circumstances of our fast paced world. A word of compliment or thanks would definitely encourage health care staff and boost tremendously the morale of busy staff in the public service to perform better. A positive side for our new generation of patients is that they are more likely to come in early to consult us before a disease becomes late or end stage.
The pregnant women in Singapore now have a wide choice of hospitals to select for delivery. Despite medical legal concerns, competition has heated up in private obstetrics.6 However KKH still maintains a commanding lead, delivering 36 per cent of babies in Singapore currently. The delivery of obstetric outpatient care in KKH has also kept in tandem with changing expectations. Obstetrics outpatient clinics in evenings and at weekends (Saturday & Sundays), hitherto unthinkable for a restructured (government related) hospital, is available since 1995. An interesting aspect is that more and more babies are delivered by doctors rather than midwives over the decade. In fact, with the increase of private patients in KKH, the majority of babies in KKH are now delivered by medical staff rather than midwives (the converse is true in UK National Health Service system).
Code Green – Crash Section
The shifting of old KKH to the new KK Women's and Children's Hospital in 1997 allowed the establishment of a routine “Crash LSCS” protocol within our hospital in May 1997.7,8 This is an unique system probably the first of its kind in the world. It uses a public announcement system within our large hospital to mobilise the team when an emergency cesarean section is required anytime of the day. Each team member is required to be aware of their own specific roles in such an emergency and to respond appropriately. Once a decision for an emergency cesarean section is made, a “code green” is activated via the telephone operator through a public announcement system within the hospital– eg “Attention, All Medical Staff. Code Green for Delivery Suite Bed 30”. All team members receive the urgent message simultaneously as the audio announcement is broadcasted to all places and rooms of the hospital. This ensures the rapid assembly of all the necessary staff at the appropriate locations including the mobilisation of support midwives and personnel involved in the transfer of the patient to the operating theatre. In addition the theatre staff can begin the process of receiving the patient and preparing for immediate cesarean section.
Conclusions
The progress in obstetrics from the 19th century to the 21st century has been remarkable and has dramatically reduced maternal and perinatal mortality. The changes over the last decade at the turn of our new millennium have been more rapid. It is important for obstetricians and midwives to adapt to these rapid changes and to continue to promote progress in all relevant areas of Obstetrics to improve obstetric care as we face the new challenges of the new millennium.
All photos are courtesy of Obstetrical & Gynecological Society of Singapore.
Correspondence to
Dr Kelvin Tan Senior Consultant & Head Perinatal Audit and Epidemiology Department of Maternal Fetal Medicine Division of Obstetrics & Gynaecology KK Women's & Children's Hospital 100 Bukit Timah Road Singapore 229899 Tel: 65-63941323 Fax: 65-62991969 Email: kh@tan.net