Involvement of emergency medical services at ...

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Review

Involvement of emergency medical services at unplanned births before arrival to hospital: a structured review Gayle E McLelland,1 Amee E Morgans,2 Lisa G McKenna3 1

School of Nursing and Midwifery, Monash University, Frankston, Victoria, Australia 2 Department of Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia 3 School of Nursing and Midwifery, Monash University, Clayton, Victoria, Australia Correspondence to Gayle Elizabeth McLelland, School of Nursing and Midwifery, Monash University, PO BOx 527, Frankston, Victoria 3199, Australia; [email protected] Received 21 December 2012 Accepted 18 January 2013 Published Online First 16 February 2013

ABSTRACT Objective While infrequent, unplanned births before arrival (BBAs) are clinically significant events at which, conceivably, paramedics will be the first health professionals in attendance. This review aims to demonstrate that paramedics not only attend and transfer birthing women, but also use critical clinical and decision-making skills. It further proposes strategies that will support paramedics manage out-of-hospital obstetric emergencies. Design The bibliographic databases EMBASE, MEDLINE, CINAHL and Maternity and Infant Care were searched from 1991 to 2012 for relevant English language publications using key words and Medical Subject Heading (MeSH) terms. Data were extracted with respect to study design, incidence of BBAs, attendance of paramedics, complications and recommendations. Results Fourteen studies were selected for inclusion arising from the US, UK and Europe. While all studies acknowledged paramedics attend BBAs, seven reported the incidence of BBAs attended by paramedics, and two discuss issues specifically encountered by paramedics. Paramedics attended between 28.2% and 91.5% of all BBAs. While the articles reviewed noted that most of the births encountered by paramedics were uncomplicated, they all reported maternal or neonatal complications. Eight articles reported the most common maternal complication was excessive bleeding after birth, and nine reported the most frequent neonatal complication was hypothermia regardless of gestation. Conclusions Paramedics need to be adequately educated and equipped to manage BBAs at both undergraduate and graduate levels. Protocols should be developed between health and ambulance services to minimise risks associated with BBAs. A dearth of information surrounds the incidence of BBAs attended and the management performed by paramedics highlighting the need for further research.

INTRODUCTION

To cite: McLelland GE, Morgans AE, McKenna LG. Emerg Med J 2014;31: 345–350.

Unplanned births before arrival (BBAs) to hospital are uncommon, but are significant clinical events encountered by ambulance paramedics. Compared with in-hospital deliveries and planned home births, the outcomes for mothers and babies after BBAs are reportedly poorer, especially for newborns.1–10 Conceivably, the paramedic will be the first healthcare professional to provide clinical support to women experiencing BBAs. Due to limited education and clinical exposure, paramedics report a lack of confidence in their ability to manage these women in a clinically optimal way.11

McLelland GE, et al. Emerg Med J 2014;31:345–350. doi:10.1136/emermed-2012-202309

A BBA is defined as either: (1) a birth that occurs in an inappropriate location, usually outside a health facility, regardless of whether there is an appropriate health practitioner present3 7 9 12 or (2) a birth that occurs without a midwife or medical practitioner, regardless of location3 4 7 9 12–14 (eg, emergency department). The definition of ‘BBA’ adopted for this review is the occurrence of a birth prior to arrival at hospital and without the presence of a planned midwife or medical practitioner.6 15–17 A recent discussion paper from the Australian Department of Health and Ageing, aiming to examine and improve existing Australian maternity services, highlights the importance of interprofessional collaboration in the provision of maternity services.18 However, this report neither acknowledges the occurrences of BBAs nor paramedics as legitimate emergency maternity care providers for women during childbirth. While their attendance at BBAs is occasionally reported in the media, very little is actually known about the incidence of births attended and clinical management undertaken by paramedics. This paper presents the findings of a structured literature review which was conducted to identify the incidence and clinical presentation of BBAs attended by paramedics. It further explores the complications encountered and the interventions performed by paramedics. Finally, it outlines the paramedic-specific recommendations within the literature. This paper concludes with recommendations for paramedic education and practice relating to BBAs to optimise clinical management and patient outcomes.

METHODS Search strategy A literature search was conducted using EMBASE, MEDLINE, CINAHL, Science Direct, ProQuest and Maternity and Infant Care. The following keywords and MeSH terms were used: ‘unplanned birth before arrival (BBA)’, ‘unplanned out of hospital birth’, ‘unplanned delivery’, ‘unattended out of hospital birth’, ‘accidental out of hospital birth’, ‘out of hospital deliveries’, ‘out of hospital birth(s)’, ‘childbirth’, ‘birth’, ‘ambulance’, ‘paramedic’ ‘EMS’ and ‘EMT’. The search included publications from 1991 to 2011, and identified a total of 78 articles of potential relevance. The titles and abstracts were screened for context of study and year published. The remaining 25 articles were scrutinised for inclusion of paramedic involvement and provision of care. These screening criteria left 14 articles for 345


Review Figure 1 Flow diagram for study selection process.

review, all of which were quantitative studies included in this review (figure 1).

Search results A total of 14 relevant articles from 1991 to 2011 were identified for review and are presented in table 1. Two studies6 19 provide specific descriptive information on the types of BBAs attended by paramedics; six studies2 3 7 9 10 20 state the number or incidence of births attended by paramedics, with only three studies6 7 9 clearly identifying paramedics’ point of arrival relative to birth. Although vague about the incidence of births attended and the clinical management performed by paramedics, the remaining studies3 5 16 17 21 were included because overall they made a valuable contribution to the descriptive perspective of paramedic involvement in BBAs. Data were extracted from each paper including study design; overall incidence of BBAs and incidence attended by paramedics; presence of paramedics at birth; and finally, any paramedic-specific recommendations given by the authors. These results are presented descriptively. When available, complications encountered, as well as any interventions performed by paramedics, were also extracted. While all were quantitative studies, no meta-analysis was attempted due to their heterogeneity.

RESULTS Of the 14 studies retrieved for this review, there were six retrospective case-controlled studies,1–3 7 10 15 including two random controlled cases.3 15 Also included were five retrospective reviews,9 10 16 17 19 one prospective case series study6; one computerised prospective review5 and one retrospective audit.20 Three of the studies15 17 21 used multiple methods to meet their research goals. To determine the perinatal deaths associated with BBAs, Bateman et al15 used a case-control study followed by a statistical summary review produced by hospital records. The remaining two studies17 21 performed detailed retrospective reviews of maternal hospital records and analysed the trends of the annual incidence of BBAs during their respective study times. For all the articles retrieved, both the incidence and actual number of BBAs are small. While all articles retrieved describe paramedics’ attendance at BBAs in varying degrees, only two 346

articles, by Verdile et al19 and Moscovitz et al,6 focused primarily on clinical management. Seven studies2 6 7 9–10 15 20 reported the number of dispatches to BBAs, and six6 7 9 10 15 20 included the incidence of those actually attended and managed by paramedics. One article2 reported on both paramedic and flying squad attendance at BBAs, but was included in the review as it clearly demonstrates the numbers that occurred, and the proportion requiring care in an inappropriate location. Four of the studies6 7 9 15 clearly indicate paramedics’ point of arrival before or after the birth. Although they clearly identified that paramedics provided emergency care to birthing women, six articles1 3 5 16 17 21 gave negligible detail about either the number of BBAs attended or care provided by them, but make an important contribution in regards to outcomes and recommendations (refer table 1).

The incidence of BBAs and the proportion attended by paramedics Compared with in-hospital births, the reported overall incidence of BBAs is low, ranging from 0.08%3 to 1.99%.15 While all the studies fulfilled the inclusion criteria, it is clear the differing health contexts influence the incidence of BBAs. Studies performed in similar health contexts, such as the UK,1 2 7 10 17 20 Ireland5 9 21 and the USA,15 16 reported comparable incidence of BBAs. While difficult to compare, an apparent increase in the incidence of BBAs over time is evident, especially in the UK (refer table 1). This assertion is supported by two studies17 21 that reported the incidence of BBAs had more than doubled17 or tripled21 during the period of their respective studies. Six articles6 7 9 10 15 20 report the proportion of BBAs attended by paramedics with the range varying from 28.2% to 91.5%. Although context may influence the incidence of BBAS attended by paramedics, it is difficult to ascertain individual predisposing factors. However, the country in which they occur may have some bearing. Two studies from the USA6 15 reported relatively high attendance of paramedics at BBAs, whereas studies from Ireland 9 and UK7 10 20 are more variable. A further five studies clearly demonstrate paramedics do attend BBAs, but not their precise numbers. Three studies1 3 21 noted some births occurred in ambulances, one study17 identified paramedics as


Studies selected for review

Authors and country Bateman et al15 USA Beeram et al16 USA Bhoopalam and Watkinson 1 UK Di Benedetto et al3 Italy Ford and Pett17 UK

Haloob and Thein2 UK

Number BBAs paramedics called to

Number delivered in presence of paramedics

1.99% (n=61)

Ambulance called to 54 cases

22 of 54 birthed with paramedic

1.8% (n=151) 0.44% (137)

Not given Total number of ambulances called not stated Total number of ambulances called not stated Not stated

Not given Not given, but 24 born in an ambulance

Research design

Overall incidence/number of BBAs

Two studies: 1. 1-year case-controlled 2. 5-year retrospective review of medical records 4-year retrospective review of medical records 2 studies in 1 year: 1. Random control 2. Case-controlled Random case-control study 1 year

0.08% (n=22)

Increasing trend from lowest 2002 to highest 2005. 0.22%–0.7%. Incidence for 2006 not stated, but n=29

2 studies1. Analyse BBA incidence trends from 2000–2007 2. Retrospective review of BBAs in one year—2006 5-year retrospective case-controlled study

0.51% (n=26)

1-year retrospective audit of maternity records

0.8% (n=44)

None given

Not stated, but paramedics were second most frequent birth attendant

Documentation by paramedics and midwives need improvement

Not stated

All paramedic staff need to be adequately trained in all birth emergencies

26 out 44 birthed with paramedics

Ambulance and maternity services should develop a plan to manage BBAs

35 women birthed with paramedic present

Training in delivery of 3rd stage should be provided for ambulance personnel

51 of 78 birthed with paramedic present

Paramedics should have periodic education in the management of labour and birth to reinforce recommended protocols Childbirth education should be provided for all emergency services. Health services need a plan for BBAs Teach prevention of newborn hypothermia to women and attendees (including paramedics) None given

Loughney et al10 UK 5-year retrospective review of medical records

0.52% (n=124)

Moscovitz et al6 USA

3-year prospective case series

91 BBAs Total births not stated

Rodie et al7 UK

50-month retrospective case-control

Incidence 0.6% (n=117 but 2 sets of twins)

Ambulances called to 50 cases

33 of 50 birthed with paramedics present

Scott and Essen9 Ireland Spillane et al5 Ireland

3-year retrospective case review of hospital records for BBAs 3-year prospective review of hospital records for BBAs.

Incidence 0.31% (n=14)

Ambulances called to 12 cases Not stated

Unterscheider et al21 Ireland

Prospective analysis of antenatal and postnatal details in a retrospective review of BBAs from 2005 to 2009. 4-year retrospective review of BBAs in the care of prehospital providers.

Average Incidence 0.36% (n=142 with 1 Not stated set of twins). Trend doubled, 0.26%– 0.5%, 2005 to 2009 Not stated Ambulances called to 81 births (incidence unknown)

5 of 12 birthed with paramedics Number not stated, but paramedics present at portion of 58 births Not stated, but 33.3% of births occurred in the ambulance

Verdile et al19 USA

71 of 81 birthed with paramedics

Ongoing paramedic education in the management of birth and neonatal resuscitation Paramedics require education programmes in normal and complicated vaginal births Development of protocols to assist paramedics with transport and destination decisions

347

Review

BBA, births before arrival.

Incidence 0.4% (n=106 with 1 set of twins)

Continued obstetrical training for paramedics especially in regards to basic care for a neonate after birth None given None given

Not given, but 2 were born in an ambulance

Ambulances attended 33% (n=19) Flying squad 12% (n=7) Total number of ambulances called not stated Total number of ambulances called not stated Ambulances called to 78 cases

Jones20 UK

Paramedic-specific recommendations



Table 1


Review the second most frequent birth attendant, and the remaining study5 clearly stated paramedics transported BBAs. Six articles6 7 9 15 19 20 quantified the incidence of paramedic attendance at the actual birth which ranged from 40.7%15 to 66%.7 Due to differences in the studies, such as methodology, location and dates performed, conclusions cannot be made about the factors influencing their attendance at BBAs. However, it is clear that paramedics do attend births. Although limited, the literature clearly indicates BBAs not only continue to occur, but may even be increasing in incidence with paramedics being key emergency health providers for birthing women.22 This apparent increase in incidence of BBAs may be due to a number of factors, such as the closure of rural hospitals,13 a greater number of non-English speaking immigrants21 and women being encouraged to stay home longer when they are in labour.7

Complications encountered by paramedics Only two studies,6 19 both from the USA, reported paramedics’ management of complications. After examining the cases of the 81 women managed by paramedics, Verdile et al19 noted 34% had complications. They noted the most frequent maternal complications were bleeding, which occurred in nine (11.1%) and hypertension in four (4.9%) of cases. Conversely, as Moscovitz et al6 reported the interventions performed by paramedics, they alluded to the complications rather than reporting the specific incidence. By recording that paramedics performed fundal massage on nine women (11.5%) and maternal fluid resuscitation for four (5.1%) women, they indicated that paramedics encountered maternal bleeding. They did not record any other maternal complications. Of more concern, both studies found that the neonate associated with a BBA encountered by paramedics was at increased risk. In accordance with other literature surrounding BBAs,5–7 15 19–21 both studies6–9 recognised a substantial number of premature neonates, including extreme prematurity. Verdile et al19 documented an average gestation of 30 weeks, but this may be skewed as four (4.9%) neonates were below 20 weeks. Moscovitz et al6 also found that paramedics encountered extreme prematurity, with six (7.7%) babies born after less than 25 weeks gestation. Other than providing the normal care for the neonate after birth, both Moscovitz et al6 and Verdile et al19 highlighted the need for paramedics to perform neonatal resuscitation, especially airway management, in 5 (6.4%) and 12 (14.8%) cases, respectively. While hypothermia has been documented as the most frequent neonatal complication following BBAs,1 5 7 9 10 15–17 only Moscovitz et al6 investigated this in the context of paramedic care. They noted that neonatal hypothermia for 37 (47.4%) babies and the presence of paramedics at the birth made no difference to the outcome. Other obstetric complications reported included 10 (12.4%) cases with cord around the neck, one (1.3%) baby born in the amniotic sac, one (1.3%) set of twins and two (2.5%) breech presentations not delivered in field.19

Management and interventions performed by paramedics Again, only these two studies6 19 specifically investigated the management of BBAs by paramedics. While both studies acknowledged paramedics predominantly encountered uncomplicated births, it was acknowledged that paramedics required the skills to manage the complications encountered. Both Verdile et al19 and Moscovitz et al6 confirmed paramedics performed complex clinical procedures, especially for the neonates, including assisted ventilation and intubation. Although only Moscovitz et al6 documented maternal interventions performed 348

by paramedics, including uterine massage and fluid resuscitation, Verdile et al19 clearly indicate paramedics managed a number of obstetric emergencies. Very little is known about the management provided by paramedics during the third stage of labour. While attendance of paramedics at births was identified in several studies, delivery of the placenta was documented in only two of these.2 6 Interestingly, both Moscovitz et al6 and Haloob and Thein,2 reported nearly one-quarter of third-stage management with 24.3% and 24.1%, respectively, being completed before hospital. While this highlights an obvious lack of information, it must be acknowledged that management during the third stage of labour, as well as conducting births, is equally important for paramedics. Generally, the effectiveness of paramedic management of birthing of women and neonates has been unexplored. Other than Moscovitz et al6 observations regarding hypothermia rates, generally the effectiveness of paramedic management of birthing women and neonates has been unexplored.

Paramedic-specific recommendations Ten studies2 6 7 9 10 15 17 19–21 contain specific recommendations for paramedic management and training. The most frequent recommendation was review of undergraduate and ongoing paramedic education curricula to increase time devoted to childbirth.2 6 7 9 10 15 19 At a minimum, most studies2 6 7 9 10 15 19 advocate that education be focused upon basic care of mother and baby during birth. This is highlighted by the higher incidence of preventable neonatal hypothermia.1 3 5–7 9 10 15–17 More in-depth education around birth complications2 19 and associated documentation is also recommended by some.6 17 19 As BBAs constitute a small percentage of overall births, paramedics may encounter them infrequently. This suggests that protocols may provide further support for paramedics. Four studies6 7 19 20 recommend the development of protocols for specific paramedic clinical management of BBAs. To assist paramedics determine the best destination hospital, two studies6 19 suggest that protocols can provide a framework to support transport decisions and ease the transition to hospital. However, as recognised by both Rodie et al7 and Jones,20 protocols must be developed in collaboration between health service and maternity providers.

DISCUSSION This review identified that there is very little current literature on either the numbers of BBAs encountered, birth complications, interventions or the effectiveness of management provided by paramedics. While there appears to be an increase in the incidence of BBAs in Victoria,22 Australia, literature reveals that the incidence of births attended by paramedics during the previous two decades remains constant. Most births attended by paramedics were uneventful, but complications were potentially high-risk for both mother and baby. Even minimal risks associated with providing normal care of mother and baby, such as neonatal hypothermia, is exacerbated during a BBA. Although high-risk for all newborns, the incidence of hypothermia is far greater for BBAs1 5-7 9 10 15–17 which, if left untreated, deteriorates further, often requiring admissions to either Special Care Nurseries (SCN) or Neonatal Intensive Care Units (NICU). Compared with in-hospital births, admissions to SCN/NICU are twice16 to more than 6-fold2 7 greater for BBAs. Admissions to SCNs with common problems, such as hypothermia and hypoglycaemia, may be reduced



Review through correct management at birth. The most commonly reported maternal complications after uncomplicated BBAs include longer third-stage due retained placenta1–3 8 10 which can predispose a greater risk of postpartum haemorrhage. Unfortunately, the presence of paramedics at BBAs has been shown to have little effect on neonatal and maternal outcomes.6 As paramedics encounter birthing women, they are required to make clinical judgments, perform interventions for both mother and baby, and manage potential complications. Postpartum haemorrhage has been reported as the most common maternal complication that may require fluid administration. Neonatal complications are more numerous, but extreme prematurity has been cited in the literature even when the baby is at a non-viable age. Within the literature, some confusion exists regarding the gestation that would be defined as a neonatal death. However, in the state of Victoria, Australia, a neonate must be legally registered if its gestational age is above 20 weeks,23 24 although considered viable above a gestational age of 24 weeks. 25 In the out-of-hospital setting, it can be difficult to determine gestation of a neonate, so paramedics must assess and decide the degree of neonatal resuscitation required. The availability of suitabilitysized neonatal airway equipment will vary dependent upon the local neonatal resuscitation protocols, and ambulance services should review theirs for neonatal resuscitation resources. Furthermore, paramedics may need to manage neonatal death which, regardless of the gestation, can be a highly emotional situation. In this literature review, most births encountered by paramedics were uncomplicated vertex births. Only two studies reported breech presentations2 19 and four reported twins.5 7 19 21 However, Verdile et al19 cites health statistics26–28 that paramedics encounter and manage a range of obstetric emergencies in their work, including prolapsed cord, shoulder dystocia and breech presentation. Very little is known about BBA cases encountered by paramedics and whether they are adequately prepared to clinically and emotionally manage them. This warrants detailed exploration. Confounding the dearth of information about the care provided by paramedics for BBAs, associated documentation has also been found to be inadequate.6 19 Moscovitz et al6 found that up to one-third of cases had incomplete documentation, making determination of interventions performed difficult. Likewise, Verdile et al19 reported poor documentation after BBAs with omission of expected important information, such as neonatal assessment, including APGAR scores. Not only is thorough, accurate documentation of all interventions performed at BBAs critical to identify current practice and its effectiveness, there are also legal implications. In a descriptive review performed on litigation claims against the London Ambulance Service, Dobbie and Cooke29 found that obstetric cases comprised a quarter of the high-value claims, despite being a minor proportion of the overall caseload. This provides further evidence of a need for complete documentation of these cases. Identified gaps in paramedic documentation suggest an inadequate understanding of birthing issues, and highlight the need for further and ongoing education in this area.6 17 19 As key health providers for the initial care of mother and neonate in BBAs, ambulance services should have been actively engaged in the recent Australian maternity services reform,18 but were not. A collaborative multidisciplinary approach between maternity and ambulance services to develop specific birthing clinical practice guidelines (CPGs) to support paramedics in the field20 should be undertaken. Not only will CPGs provide a concise guide to clinical management of prehospital birthing events, but also transport and destination decisionmaking tools.19 While development of protocols and CPGs is

important, ultimately, educating paramedics about the care of mothers and babies during childbirth is a cornerstone to improving maternal and neonatal outcomes.1 3 5–7 9 10 15–17 Traditionally, undergraduate paramedic education devotes a small portion of the curriculum11 29 to management of mother and neonate following birth. Little is known about graduates’ confidence and preparedness to manage this situation. In a study of paramedics in the USA, Dawson et al11 reported that after graduating, a majority of paramedics felt underprepared to manage BBAs, and so, lacked confidence in their clinical skills of caring for mother and neonate. The relatively infrequent occurrence of BBAs for paramedics highlights the importance providing good foundational education, as well as consistent updates of management of childbirth after graduation.2 9 15 19

CONCLUSION Considering the risk of poor maternal and neonatal outcomes compared with in-hospital births, BBAs are potentially high-risk events for mothers, babies and paramedics. While the higher incidences of neonatal susceptibility, such as prematurity, contribute to these poor outcomes, a contributing factor could be poor immediate care following birth. As well as substantial basic care around childbirth, undergraduate paramedic education should provide some skill development for managing obstetric emergencies. Due to limited exposure with childbirth, impacting on skill and knowledge retention, qualified paramedics require continuing educational programmes. Protocols and practice guidelines will support, and assist with, clinical management as well as transport and destination decisions. Whenever possible, ambulance services should evaluate whether paramedics can access appropriate resources to manage maternal and neonatal emergencies. Further research is required to explore the epidemiology and management of BBAs to identify future educational and service delivery needs. Contributors All authors contributed to the conception and design of the article. GM performed the majority of the analysis and interpretation of the data with some assistance from AM and LM. GM wrote the initial draft and all authors contributed to revising it critically for content. All authors provided approval for the final version. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.

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Involvement of emergency medical services at unplanned births before arrival to hospital: a structured review Gayle E McLelland, Amee E Morgans and Lisa G McKenna Emerg Med J 2014 31: 345-350 originally published online February 16, 2013

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