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Patient Care

Training EMS for Emergency Deliveries in the Field

First responders get very little training or hands-on experience with one of the most stressful, emotional, and eventful calls they experience: emergency birth in the field. While unplanned births outside the hospital are uncommon and usually uncomplicated, they represent a vulnerable situation for both women and neonates. Field deliveries are most commonly complicated by maternal hemorrhage or neonatal hypothermia, demanding rapid assessment and cautious action from responders.1   

Every spring first responders from San Antonio and the surrounding areas come together for the Southwest Texas Regional Advisory Council (STRAC) conference. At this conference first responders receive training in a wide variety of topics, discuss new research that applies to their field, and undergo hands-on refresher courses. One such refresher is “EMS to Hospital: Managing Delivery Emergencies in the Field,” run by the OB/GYN department from the UT Health San Antonio Long School of Medicine.2  

UT Health San Antonio and STRAC have combined for this training for several years. However, during the 2019 session students posed some interesting questions: 1) What percentage of first responders in San Antonio and the surrounding area actually attend the STRAC conference? And 2) do the first responders feel they are adequately trained in emergency birth in the field? 

To answer these questions students sat down with STRAC attendees and asked them if they felt adequately trained for emergency birth in the field, and if they felt their coworkers who did not attend the show felt so as well. Unanimously respondents conveyed they were grateful for the one-hour training during the STRAC conference but felt it was simply not enough. They reported they didn’t get enough hands-on experience due to the high number of attendees and because their entire team was not able to attend. Responders said their goal was to take their skills back to their station and teach others, yet they quickly found this was not practical, as they had no access to birthing manikins for practice and did not feel they were adequately trained to teach others. 

After understanding that conference attendance was a major barrier to learning, we calculated that fewer than 10% of the emergency first responders in the San Antonio area actually attended the STRAC conference. Therefore, medical students at UT Health San Antonio led an initiative to partner with first responders and take the “EMS to Hospital” course to individual fire stations. In this manner EMTs and paramedics could be trained in small group sessions, free of charge, with the goal of improving knowledge and confidence regarding obstetrical management in the field.

Materials and Methods

The project was conducted by three fourth-year medical students as an elective course, with the help of two faculty advisers. They contacted 25 fire stations in the San Antonio area to announce the course and explain its objectives. They completed a total of 10 training sessions between October and December. A session consisted of a 30-minute presentation of the “EMS to Hospital” course, which covered topics including normal vaginal delivery, breech delivery, umbilical cord prolapse, shoulder dystocia, and maternal hemorrhage with uterine massage. After the presentation they conducted a hands-on practice session wherein first responders had the opportunity to practice bimanual uterine massage, normal vaginal delivery, and breech delivery using obstetric manikins. To assess the educational success of this course, each first responder took precourse and postcourse surveys. Finally, the training concluded with practice questions revolving around clinical scenarios to solidify overall understanding. 

Results

In total 59 surveys were completed. The mean percentage of correct responses improved from 45% to 99% (see graphs). The most-missed question, “What is the next best step after identifying an umbilical cord prolapse?” scored 45% on the precourse survey and 99% on the postcourse survey. The question, “What is the most common cause of postpartum hemorrhage?” improved from 34% to 99%. The mean percentage of correct responses improved from 45% to 99%. On the precourse survey, 55% of responders agreed or strongly agreed with the statement “I feel very confident about my ability to adequately perform an emergency field delivery.” After the workshop 100% of responders indicated agreement or strong agreement with that statement.

Discussion

This unique educational opportunity was well-received by local first responders and had a positive impact on their relationship with obstetrical emergencies. The data clearly showed participants had educational improvements within all areas of the course. Overall, participants increased their percentage of correct answers by 55%. In addition, 81% of first responders felt more confident about performing an emergency delivery in the field than before the class. Meanwhile 45% of responders who were not confident prior to the session expressed confidence afterward.  

In the survey question No. 2 was the most missed in both pre- and post-assessments; however, there was a remarkable decrease in incorrect answers (from 73% to 3% of participants). This further demonstrates the effectiveness of the presentation’s emphasis on key concepts. 

General feedback indicated the hands-on simulation and practice questions were the most instrumental to students' success following the course. Overall, the course was successful in its goals of improving first responders’ knowledge and confidence regarding emergency obstetrical situations. Data obtained from the surveys can be used to tailor future courses for maximum educational impact; however, even in its current form the presentation has proven a useful tool in exposing emergency care providers to vital obstetrical concepts.

Conclusion

The session yielded evidence of multifaceted improvement for participants. First responders improved in their responses to survey questions regarding obstetrical management and self-reported increased confidence in their ability to perform in emergency field delivery scenarios. General feedback indicated the hands-on simulation and practice questions were the most instrumental to post-course success. 

The future direction of this project will be to develop a formal curriculum that can be widely distributed free of charge to first responders and medical schools. This will allow educational partnerships to develop so this training can reach as many first responders as possible in years to come. Currently at UTHSA, fourth-year medical students are working with third-year medical students to train them as teachers so the formal education and partnership with San Antonio first responders can continue. 

Although this project was created to establish a refresher course on obstetrical emergencies in the field, future efforts should be directed toward evaluating long-term retention of participants’ knowledge and tracking patient outcomes from responders receiving this supplemental training.  

 

Pre- and Postcourse Surveys

1) Which of the following is a normal physiologic change of pregnancy? 

a. Increased blood pressure 

b. Increased heart rate 

c. Decreased body temperature 

d. Decreased blood volume 

2) What is the next best step after identifying an umbilical cord prolapse? 

a. Palpate the cord to check for a pulse 

b. Elevate the presenting fetal part 

c. Advise the mother to present to the hospital immediately 

d. Prepare for field delivery 

3) Which of the following is the best management for eclamptic seizure? 

a. Magnesium sulfate 

b. Valium 

c. Ativan 

d. Oxygen 

4) What is the most common cause of hemorrhage after delivery? 

a. Birth canal lacerations 

b. Retained tissue in the uterus 

c. Peripartum infection 

d. Uterine atony 

5) Please use the scale below to rate the following statement: I feel very confident about my ability to adequately perform an emergency field delivery. 

1. Strongly disagree 

2. Disagree     

3. Agree 

4. Strongly agree

 

Sidebar: When the Water Doesn't Break

It’s always a reliable marker of impending delivery—isn’t it?  

My wife and I sit quietly staring at each other in the OB unit of our small-town rural hospital. Today is the day she gets induced.

Just getting access to the OB unit included temp checks at the door, masks, and special instructions to come in a back door due to COVID-19. No visitors allowed, and restrictions on how many times I can leave hospital property—this is going to be interesting. 

The midwife comes in and does an initial check of the cervix. “Wow!” she exclaims. “You’re already like 5 cm dilated and 75% effaced.” My wife, however, does not appear to be in labor. Small contractions every few minutes, and she is still being nice to me. 

We wait for a few hours before the nurse comes back and checks her cervix again. Contractions are a little more consistent now, but she’s still calling me “babe.” We discuss starting Pitocin to speed things up, and the nurse begins the infusion. 

It’s about this time I get a notification on my iPhone that my new AirPod Pros have been delivered to my front porch. I start to reason with myself that now the time is to go grab them—I mean, I have to help with the baby later. I can’t tell my wife the real reason I need to run home, and I’m not even sure the hospital will let me leave unless I have a good reason. Then it clicked: I had actually left my omeprazole at home and could say I needed to run home and grab my “medication.” 

I asked the nurse, adding we live just 10 minutes away. She says, “Yeah, I believe you have plenty of time.” My wife’s water still hasn’t broken. 

I put on my hospital-issued mask and begin my journey. I can just smell the new Apple product packaging as I turn into my neighborhood. Then I see a text pop up from my wife.

Can you hurry? I’m anxious, and they [contractions] are super painful. 

I’m almost home—it’s too late to turn around now! I fly into the driveway, grab the box, and book it back toward the hospital. I call and ask if her water broke yet. She says no, but this time she isn’t saying “babe.” I can hear the nurse coaching her breathing. 

I barely make it back to her room than the midwife yells, “Guys, we’re about to have a baby!” I back out of the way as they assist her back to the bed.

I check for crowning and can see the top of the baby’s head. “Has her water broken yet?” I ask. The midwife tells me sometimes the water does not break. That information is new to me. 

“So the baby can literally come out in the amniotic sac?”

“Yes, but it’s very rare—maybe one in 80,000 births.” 

My mind won’t comprehend how a baby can come out of this opening and not break open the amniotic sac. This is like trying to fit a baby-size water balloon through a toilet paper roll. The midwife looks up and says, “You may want to get your camera rolling. This baby is coming out en-caul.”

I look down and see my son fully surrounded by an amniotic sac. The nurse lays the baby on my wife’s chest still in the ol’ birth bag. He screams as the midwife opens the sac to a burst of water. The entire delivery team is in awe. The nurse tells me some cultures believe babies born en-caul will have good luck for their whole lives.

My wife finally looks somewhat relieved. Her healthy baby boy is here with a near-perfect Apgar score. And it’s at this moment that I realize how much faith I put in the act of water breaking as a marker for imminent delivery. Whether you’re transporting a patient in labor or just running home to grab your AirPods, I learned you shouldn’t use the water breaking as an estimate for delivery. 

I also learned the noise-canceling feature of my AirPods works phenomenally.

—Tyler Christifulli, CCP, FP-C, NRP

 

References

1. McLelland GE, Morgans AE, McKenna LG. Involvement of emergency medical services at unplanned births before arrival to hospital: A structured review. Emerg Med J, 2014; 31: 345–50.

2. Page-Ramsey SM, Stansbury N, Pescador J, Riggs V. EMS to Hospital: Managing Delivery Emergencies in the Field. South Texas Regional Advisory Council, Regional Emergency Healthcare Systems Conference, San Antonio, Tex., May 2019.

Nicholas Stansbury is a fourth-year medical student at UT Health San Antonio’s Long School of Medicine. 

Jorge Pescador is a fourth-year medical student at UT Health San Antonio’s Long School of Medicine. 

Veronica Riggs is a fourth-year medical student at UT Health San Antonio’s Long School of Medicine. 

Sarah M. Page-Ramsey, MD, is a board-certified OB/GYN physician, clinical professor of OB/GYN, and program director for the OB/GYN residency training program at UT Health San Antonio.

Erin Mankus, MD, is a board-certified OB/GYN physician and clinical professor at UT Health San Antonio.
 

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