Is unplanned out-of-hospital birth managed by paramedics ‘infrequent’, ‘normal’ and ‘uncomplicated’?

Abstract

BackgroundUnplanned out-of-hospital birth is often perceived as precipitate in nature, ‘infrequent’, ‘normal’ and ‘uncomplicated’. However, international studies report unplanned out-of-hospital birth is associated with increased rates of maternal and neonatal morbidity and mortality. This research describes intrapartum, immediate postpartum and neonatal care provided by paramedics in Queensland, Australia. The objectives were to (1) determine the number of cases where the paramedic documented birth or imminent birth during the study period (2) to describe the incidence of births prior to or during paramedic care (3) to detail any risk factors and/or complications recorded by paramedics during these cases, (4) identify paramedic pain management practices for intrapartum care, and (5) to examine the maternal and neonatal outcomes as documented by paramedics.MethodA retrospective analysis of Queensland Ambulance Service (QAS) de-identified patient care records, generated from clinical case data between the 1st of Jan 2010 and 31st of Dec 2011, was undertaken. Descriptive analysis and x 2 tests were used to test associations between categorical variables, and the Wilcoxon rank-sum for associates between continuous variables which were not normally distributed. Content analysis was utilised to code free text fields.ResultsSix thousand one hundred thirty-five records were identified as intrapartum cases. This represented approximately 0.5% of the annual QAS caseload; 5722 were classified as maternal records and 413 were neonatal records. Paramedics recorded antenatal and/or intrapartum complications in 27.3% (n = 1563) of cases. Abnormal maternal vital signs were recorded in 30.1% (n = 1725) of cases. Of the 5722 women attended by paramedics during their labour, a birth occured in 10.8% (n = 618) of cases. Parity was documented in 41.4% (n = 256) of mothers who birthed. Neonatal records were available for 66.8% (n = 413) of actual births, 60.0% (n = 248) recorded a full set of neonatal vital signs and an Apgar score. When an Apgar score was recorded, 21.8% (n = 91) scored ≤7 out of 10.ConclusionsThe research described intrapartum, immediate postpartum and neonatal care provided by paramedics and identified factors that may complicate paramedic clinical management of labouring and birthing women. Further research is required to determine if there are opportunities to improve the paramedic management of such cases.

Unplanned out-of-hospital birth and risk factors of adverse perinatal outcome: findings from a prospective cohort

“…As described by us and McLelland et al [23], most of the births (79%) occurred between the hours of 20.00 and 08.00 [24]. Moreover, Flanagan et al reported in a retrospective analysis of 192 unplanned out-of-hospital births, that 21% of the newborns had an Apgar score scored ≤7 out of 10, whereas in our cohort, it represented only 14% of the newborns [25]. Contrary to previous reports, a considerable proportions of mothers in our cohort (23.6%) had a midwife consultation in the 24 previous hours.…”

“…Contrary to previous reports, a considerable proportions of mothers in our cohort (23.6%) had a midwife consultation in the 24 previous hours. For instance, Flanagan et al reported that only 2.4% ( n = 15) of women who birthed before arrival stated that they had been sent home from hospital within the 12 previous hours [25].…”

Emergency medical technicians' experiences with unplanned births outside institutions: A qualitative interview study

“…One Swedish study supports the low frequency of debrief sessions after stressful events in out‐of‐hospital care (Bohström et al, ), as well as describes how collegial support and discussions with colleagues can be a positive strategy for stress reducing after stressful events such as childbirth. The increased risk of infant morbidity and mortality, compared with births in obstetric institutions, is well documented (Engjom et al, ; Flanagan et al, ; Jones et al, ; Nguyen et al, ), even though one study from Finland reports no major perinatal or maternal cases in their sample (Pirneskoski, Peräjoki, Nuutila, & Kuisma, ). Maternal outcomes, such as postpartum haemorrhage and severe perineal tears, are however not fully understood (Ford & Pett, ; Unterscheider et al, ).…”

“…Unplanned out‐of‐hospital births are associated with an increased risk of infant mortality compared with births in obstetric institutions (Engjom et al, ; Jones et al, ; Nguyen, Lefevre, & Dreyfus, ). One Australian study reported that 11% of women attended by EMTs during labour gave birth before arriving at hospital; of these, 27% were recorded with antenatal and/or intrapartum complications, while 22% of the babies were recorded with an Apgar score lower than 7 (Flanagan, Lord, & Barnes, ). Risk factors associated with both maternal and neonatal outcomes in unplanned out‐of‐hospital births include maternal characteristics (young maternal age, low socio‐economic status, immigrant background, smoking), pregnancy‐related factors (multiparity, placental conditions, low birthweight, prematurity, infections, concealed pregnancy) and poor antenatal care (Boland et al, ; Engjom, Morken, Høydahl, Norheim, & Klungsøyr, ; Gunnarsson, Fasting, Skogvoll, Smárason, & Salvesen, ; Jones et al, ; Nguyen et al, ; Unterscheider et al, ).…”

Factors associated with home births in Peru 2015–2017: A cross-sectional population-based study

“…Although childbirth care in health facilities or accompanied by skilled health personnel is encouraged, in various regions of the world, especially in low-income countries, home births represent more than 50% of the total number of births [ 9 , 10 ]. Higher rates of maternal and perinatal complications and deaths have been described in home births, as well as difficulties in managing complications due to the need for transfer to a health facility [ 11 , 12 , 13 ].…”