Victorian paramedics' encounters and management of women in labour: an epidemiological study

Maternal Transport, What Do We Know: A Narrative Review

Objective

This review examines the initial development of a transport system for neonates, followed by a subsequent evolution of a transportation system for the maternal/fetal unit, and then a maternal transport system (antepartum, intrapartum, and postpartum) to specifically address maternal morbidity/mortality.

Methods

A literature search was undertaken using the electronic databases PubMed, Embase, and CINAHL. The search terms used were "maternal transport" AND "perinatal care" OR "labor" "obstetrics" OR "delivery". The years searched were 1960-2023.

Results

There were 260 abstracts identified and 52 of those are the basis of this review. The utilization of a transportation system with the regionalization of levels of care has resulted in a significant reduction in neonatal, perinatal, and maternal morbidity and mortality. Although preterm delivery remains a concern in women transported, the number of deliveries that have occurred during transport is relatively small. Reimbursement for transportation continues to be a problem in several states.

Conclusion

A state-of-the-art transportation system has evolved that transfers neonates, maternal/fetal dyad, and pregnant women (antepartum, intrapartum, postpartum) to the appropriate level of care facility to ensure the best maternal/fetal/neonatal outcomes.

Simple Yet Effective-Sterile Water Injections to Treat Labor Pain in the Transport Environment

Sterile water injections (SWI) is a nonpharmacologic pain relief option to treat back pain in labor. This case report describes and discusses the use of SWI in the context of an obstetric retrieval of a 29-year-old woman who was transferred by the Royal Flying Doctor Service South Eastern Section. It provides an overview of SWI, discusses the relevance for medical transport, and offers suggestions for medical transport professionals.

Unplanned out-of-hospital birth apparatus benefits: A paramedic simulation trial

Unplanned births outside of hospitals have becoming an issue in cities. The majority of healthcare professionals are paramedics. When performed alone, this event frequently causes them strain and anxiety. Their primary worries were the safety of mothers and newborns, as well as insufficient obstetrical equipment. As a result, our team developed a portable birth bed equipped with newborn safety devices for this research. One hundred fourteen paramedics of local area participated in this study and were divided into intervention and conventional group. In simulation trials, the study found that this safety intervention outperformed the conventional setup. We determined that our technology aided in the delivery of unusual babies. However, it requires additional research in the actual situation.

The General Public Awareness of Emergency Conditions and the Services Provided by Emergency Medical Services

Objective

Considering the growing use of emergency medical services (EMS), we evaluated the level of public awareness of emergency situations in Iran.

Methods

This cross-sectional study was conducted from August 2021 to January 2023 on Iranian residents in Tehran, who were older than 18 years old. The participants were directed to a URL for an online survey link and asked to select their preferred options for the predetermined scenarios. We divided the participants into three groups: abuse, misuse, and non-use. At least 12 correct answers were required to qualify as acceptable knowledge and practice responses (KP score). Then, the relationship between participants' baseline characteristics and their level of awareness was investigated.

Results

Totally, 3864 people participated in the study, of whom 50.5% were men. The participants' ages ranged from 18 to 90 years old, with a mean age of 40.01±11.30 years. In general, the rate of abuse, misuse, and not-use in at least one scenario was 74.5%, 64%, and 70.4%, respectively. The results of the multivariable regression analysis indicated that female sex (OR=1.29), a higher education level (OR=3.36), a higher income level (OR=1.64), and Turkish ethnicity (OR=1.20) were significantly associated with the correct KP score.

Conclusion

The degree of inappropriate utilization of EMS services in Iran was significant. We found that the proper knowledge regarding the appropriate use of EMS was significantly associated with the participant's level of education, academic field, job, and income.

Research protocol for delivering on the front line: a qualitative exploration of paramedics' experiences of providing pre-hospital maternity care in the United Kingdom

Background and aim

Maternity patients form a small but significant portion of paramedical workload and this research aims to pragmatically explore East of England Ambulance Service paramedics' experiences of providing pre-hospital maternity care.

Methods

Through semi-structured individual interviews, participants' thoughts and feelings regarding obstetric confidence and competence will be explored. It will be investigated whether they think their training and equipment is adequate and what they would change about maternity patient management. Data will be thematically analysed and the findings used to improve paramedic training, with a view to improving their confidence and competence. In turn, this should improve patient experiences and outcomes.

Non-Conveyance Due to Patient-Initiated Refusal in Emergency Medical Services: A Retrospective Population-Based Registry Analysis Study in Riyadh Province, Saudi Arabia

This research study aimed to investigate the association between demographic and operational factors and emergency medical services (EMS) missions ending in non-conveyance (NC) due to patient-initiated refusal (PIR). We conducted a retrospective population-based registry study by analyzing 67,620 EMS missions dispatched to the scene during 2018 in the Riyadh province. First, the number and percentages of conveyances statuses were calculated. Then, using crude and adjusted linear and logistic regression analysis, we determined which characteristics were predictors of NC due to PIR. We found that 23,991 (34.4%) of missions ended in NC due to PIR, and 5969 ended in EMS-initiated refusal (8.6%). NC rates due to PIR were higher for women, adults, for missions in Riyadh city, during nighttime, for medical emergencies, and for advanced life support (ALS) crews. We also found the following additional predictors significantly associated with the odds of NC due to PIR in crude regression analyses: age category, geographical location, EMS-shift, time of call, emergency type, and response time. We conclude that the NC rate represents half of all missions for patients requesting EMS, and the rate in Riyadh city has increased compared to previous studies. Most NC cases occur for the highest urgency level of medical emergency type in Riyadh city during the nighttime with ALS crews. NC due to PIR involves younger patients more than elderly, and females more than males. This study’s findings have provided empirical evidence that indicate that conducting further studies involving EMS providers, patients, and the public to identify precise and detailed reasons is required.

Do women's perspectives of quality of care during childbirth match with those of providers? A qualitative study in Uttar Pradesh, India

Background: Persistently high maternal mortality levels are a concern in developing countries. In India, monetary incentive schemes have increased institutional delivery rates appreciably, but have not been equally successful in reducing maternal mortality. Maternal outcomes are affected by quality of obstetric care and socio-cultural norms. In this light there is need to examine the quality of care provided to women delivering in institutions.

Objective: This study aimed to examine pregnant women’s expectations of high-quality care in public health facilities in Uttar Pradesh, India, and to contrast this with provider’s perceptions of the same, as well as the barriers that limit their ability to provide high-quality care.

Methods: A qualitative descriptive analysis was conducted on data from two studies – focus group discussions with rural women in their last trimester of pregnancy (conducted in 2014) to understand women’s experience and satisfaction with maternal care services, and in-depth interviews with care providers (conducted in 2016–17) to understand provision of person-centred care. Provider perspectives were matched with themes of women’s perspectives on quality of childbirth care in facilities.

Results: Major themes of care prioritised by women included availability of doctors at the facility; availability of medicines; food; ambulance services; maintenance of cleanliness and hygiene; privacy; good and safe delivery with no complications; client-provider interaction; financial cost of care. Many women also voiced no expectation of care, indicating disillusionment from the existing system. Providers concurred with women on all themes of care except availability of doctors, as they felt that trained nurses were proficient in conducting deliveries.

Conclusions: This study shows that women have clear expectations of quality care from facilities where they go to deliver. Understanding their expectations and matching them with providers’ perspectives of care is critical for efforts to improve the quality of care and thereby impact maternal outcomes.

Epidemiology of unplanned out-of-hospital births attended by paramedics

BACKGROUND

Over the previous two decades the incidence and number of unplanned out of hospital births Victoria has increased. As the only out of hospital emergency care providers in Victoria, paramedics would provide care for women having birth emergencies in the community. However, there is a lack of research about the involvement of paramedics provide for these women and their newborns. This research reports the clinical profile of a 1-year sample caseload of births attended by a state-wide ambulance service in Australia.

METHODS

Retrospective data previously collected via Victorian Ambulance Clinical Information System (VACIS ®) an in-field electronic patient care record was provided by Ambulance Victoria. Cases were identified via a comprehensive filter, and analysed using SPSS version 19.

RESULTS

Over a 12-month period paramedics attended 324 out-of-hospital births including 190 before paramedics' arrival. Most (88.3%) were uncomplicated precipitous term births. However, paramedics documented various obstetric complications including postpartum haemorrhage, breech, cord prolapse, prematurity and neonatal death. Furthermore, nearly one fifth (16.7%) of the women had medical histories that had potential to complicate their clinical management, including taking illicit or prescription drugs. Mothers were more likely to be multiparas. Births were more likely to occur between 2200 and 0600 h. Paramedics performed a range of interventions for both mothers and babies.

CONCLUSIONS

Paramedics provided emergency care for prehospital out-of-hospital births. Although most were precipitous uneventful births at term, paramedics used complex obstetric assessment and clinical skills. These findings have implications for paramedic clinical practice and education around management of unplanned out of hospital births.

Undergraduate paramedic student psychomotor skills in an obstetric setting: An evaluation

The clinical education of paramedic students is an international concern. In Australia, student placements are commonly undertaken with local district ambulance services, however these placements are increasingly limited. Clinical placements within inter-professional settings represent an innovative yet underdeveloped area of investigation. This paper addresses that gap by reporting a pilot evaluation of paramedic student clinical placements in a specialised obstetrics setting. Using a case study approach, the evaluation aimed to identify paramedic psychomotor skills that could be practised in this setting, and understand the nature of key learning events. A purposive sample of paramedic students was recruited following completion of the obstetrics placement. A combination of student reflection and assessed psychomotor skills data were collected from clinical placement logs. Content analysis of all data was conducted inductively and deductively, as appropriate. Findings indicated a comprehensive range of psychomotor skills can be practised in this setting, with over thirty psychomotor skills identified directly related to the paramedic curriculum; and seven psychomotor skills indirectly related. The themes finding confidence in maternity care, watching the experts, and putting theory into practice provide narrative insight into the clinical learning experience of paramedic students in this setting. Further research is recommended to build upon this pilot.

Characteristics and outcomes of women using emergency medical services for third-trimester pregnancy-related problems in India: a prospective observational study

OBJECTIVES

Characterise the demographics, management and outcomes of obstetric patients transported by emergency medical services (EMS).

DESIGN

Prospective observational study.

SETTING

Five Indian states using a centralised EMS agency that transported 3.1 million pregnant women in 2014.

PARTICIPANTS

This study enrolled a convenience sample of 1684 women in third trimester of pregnancy calling with a 'pregnancy-related' problem for free-of-charge ambulance transport. Calls were deemed 'pregnancy related' if categorised by EMS dispatchers as 'pregnancy', 'childbirth', 'miscarriage' or 'labour pains'. Interfacility transfers, patients absent on ambulance arrival and patients refusing care were excluded.

MAIN OUTCOME MEASURES

Emergency medical technician (EMT) interventions, method of delivery and death.

RESULTS

The median age enrolled was 23 years (IQR 21-25). Women were primarily from rural or tribal areas (1550/1684 (92.0%)) and lower economic strata (1177/1684 (69.9%)). Time from initial call to hospital arrival was longer for rural/tribal compared with urban patients (66 min (IQR 51-84) vs 56 min (IQR 42-73), respectively, p<0.0001). EMTs assisted delivery in 44 women, delivering the placenta in 33/44 (75%), performing transabdominal uterine massage in 29/33 (87.9%) and administering oxytocin in none (0%). There were 1411 recorded deliveries. Most women delivered at a hospital (1212/1411 (85.9%)), however 126/1411 (8.9%) delivered at home following hospital discharge. Follow-up rates at 48 hours, 7 days and 42 days were 95.0%, 94.4% and 94.1%, respectively. Four women died, all within 48 hours. The caesarean section rate was 8.2% (116/1411). On multivariate regression analysis, women transported to private hospitals versus government primary health centres were less likely to deliver by caesarean section (OR 0.14 (0.05-0.43)) CONCLUSIONS: Pregnant women from vulnerable Indian populations use free-of-charge EMS for impending delivery, making it integral to the healthcare system. Future research and health system planning should focus on strengthening and expanding EMS as a component of emergency obstetric and newborn care (EmONC).

Antenatal Emergency Care Provided by Paramedics: A One-Year Clinical Profile

OBJECTIVE

To report on clinical and socio-demographic factors of a one-year caseload of women attended by a statewide ambulance service in Australia, who presented during pregnancy, prior to the commencement of labor.

METHODS

Retrospective clinical data collected via in-field electronic patient care record (VACIS®) by paramedics during clinical management was provided by Ambulance Victoria. Cases were electronically extracted from the Ambulance Victoria Clinical Data Warehouse via comprehensive filtering followed by case review.

RESULTS

Over a 12-month period, paramedics were called to 2,098 women with pregnancy as a primary or non-primary clinical consideration. Women's ages ranged from 14 to 48 years. The majority were multigravidas (86%). There was a greater chance that ambulance services would be required during business hours than any other time of the day. Paramedics noted pregnant women required ambulance services for a range of primary presenting symptoms both obstetric (n = 1137) and non-obstetric (n = 961). Some women had pre-existing conditions including asthma, hypertension, and diabetes potentially complicating their pregnancies. Paramedics administered analgesia to one third of the women. Paired t-tests revealed significant improvement in the pain relief and overall vital signs of the women encountered. Less than half the women (n = 986, 47%) required interventions.

CONCLUSIONS

This is a unique population wide analysis of ambulance service resource use exploring the clinical profile of pregnant women requiring ambulance services in one calendar year. To manage obstetric and non-obstetric complications in this population safely and effectively, paramedics require an understanding of the unique physiological adaptions during pregnancy. This study therefore has both educational and practice implications.