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Patient Care

EMS and Midwives: Navigating the Out-of-Hospital Transfer

While the medical model of care views pregnancy and birth as a condition that requires management, the midwifery model views it as a normal function of a woman’s reproductive life.

Since the beginning of time, there have been references to women helping women give birth, the Old English definition of midwifery. Midwifery continues today and in fact is increasing in the U.S.: Out-of-hospital births now account for approximately 6% of American births, up from 1% in the 1960s. There were almost 60,000 out-of-hospital births in the U.S. in 2014. While most occurred in home settings, 18,000 were in birth centers, which are freestanding, homelike facilities designed for the midwifery model of pregnancy and birth. 

As more and more women seek alternative ways to normalize birth due to the ever-rising rate of interventions like c-sections (now at an astounding national average of 34%), midwifery care will continue to grow. This article discusses what a midwife is and how EMS and midwives can work together. 

Types of Midwives

While the medical model of care views pregnancy and birth as a condition that requires management, the midwifery model views it as a normal function of a woman’s reproductive life. A midwife’s goal is to keep birth as low-risk as possible. This doesn’t mean midwives are opposed to intervention should the need develop, especially if the mother and baby require advanced medical care. The mother’s desire for a vaginal or out-of-hospital birth never overrides the safety of her or her child. 

There are three types of midwives in the U.S.: the certified nurse midwife (CNM), certified midwife (CM), and certified professional midwife (CPM). Each has its own governing body that awards national certification, much like the National Registry of Emergency Medical Technicians. As with other licensed medical professionals in the U.S., states regulate the scope of practice within each classification of midwife, usually with boards to oversee licensure. 

certified nurse midwife is an RN who has gone back to a graduate school program, traditional or distance learning, to obtain a master’s degree in midwifery. Their nursing background and advanced degree enable them to provide a broad range of women’s healthcare services from puberty to grave. These midwives primarily practice in hospitals, but some practice in out-of-hospital settings. Subject to state law, CNMs can typically conduct Pap smears, write prescriptions, and attend to pregnant and birthing women, including scrubbing for c-sections. 

Nurse midwives are certified by the American Midwifery Certification Board (AMCB) and exist in all 50 states. States can adjust the CNM scope of practice to their unique needs.

The American College of Nurse-Midwives recognizes that being a nurse may not be feasible for all possible midwives and created the certified midwife path as an alternative. CMs take the same AMCB test as CNMs but have a bachelor’s degree in a healthcare-related field other than nursing and have graduated from an accredited program with a master’s degree in midwifery. These midwives will have the exact same scope of practice and ability to work in hospitals, birth centers, and homes as certified nurse midwives. 

This certification is still in its infancy and, though a national certification, is currently only recognized in six states: Delaware, Maine, Missouri, New Jersey, New York, and Rhode Island. 

Certified professional midwives may or may not have a medical education in something other than nursing. These midwives obtain either a master’s degree (by attending a university) or certificate (through distance learning) that allows them to take a board exam established by the North American Registry of Midwives. CPMs are recognized in most but not all states, and their scope of practice can vary dramatically. 

For the most part, CPMs practice in out-of-hospital settings—either homes or birth centers. These midwives focus on care for the pregnant female during pregnancy, labor, and birth, as well as for both mom and baby up to approximately six weeks postpartum. 

Midwives and Emergencies

All midwives are educated in neonatal resuscitation, CPR, and birth complications (e.g., nuchal cord, breech birth, postpartum hemorrhage, vaginal birth after c-section). For a woman to be a good candidate for out-of-hospital birth, both she and the baby must be low-risk. 

There are protocols all midwives use at every prenatal appointment to evaluate the patient’s status. Should some aspect of it be outside of normal, depending on the issue, either referral for more testing with an OB-GYN or a complete transfer of care would be in order. For example, if a patient’s glucose screening was outside normal limits, then retesting would be scheduled, and their diet would be evaluated. If a second test still returned abnormal results, then further testing would be needed, and the patient would be referred to an OB-GYN. Another example would be a mom who’s healthy, with all tests and evaluations within normal limits, but a sonogram of the baby reveals heart defects. The proper course of action would be a referral to a neonatologist and OB-GYN care. 

The reasons for an out-of-hospital midwife to call 9-1-1 can vary based on protocols and state laws. While midwives are educated and skilled in difficult births and emergencies that can arise during pregnancy and delivery, there will be a time in every midwife’s career when help will be needed. While 9-1-1 can be called for almost any emergency that arises, four common reasons are seizures of any kind (eclampsia), a prolapsed cord, postpartum hemorrhage, and newborn respiratory distress. 

While screening is performed throughout pregnancy, undiagnosed eclampsia can occur in any birth setting and during pregnancy, birth, or postpartum. In this case EMS would be needed immediately. Magnesium sulfate is typically the first-line agent for acute treatment and prophylaxis of seizures in eclampsia and pre-eclampsia. 

Prolapsed cords are rare but can happen in any birth environment. Midwives should also possess the skills to deal with these. EMS assistance may be needed in moving and positioning the patient or possibly starting an IV. Based on state laws, some midwives carry terbutaline to slow labor. 

Hemorrhaging after delivery is not an uncommon hazard. Midwives are very good at managing the risk factors and bleeds should one arise. If the midwife has maxed out the protocol for Pitocin, Methergine, Cytotec, and fluid resuscitation, a call for help would be in order. If you have Pitocin in your med box, use it.

Newborn respiratory distress is another complication. Most babies in this category just need a few puffs of air to be good to go. However, when the baby is not responding, help will be needed. Skills like umbilical cord cauterization and initiating IOs for certain meds will not be a part of midwives’ protocols. 

Control the Chaos

Having worked both sides of a critical care mother/baby transfer, one thing seems constant in such situations: chaos. EMS can help avoid confusion on scene by following these steps. 

Step 1—Identify yourself, the lead midwife, and the patient(s). 

A great way to start would be, “Hello, my name is Jessica. I’m a paramedic with XYZ Ambulance Company. Who is the lead midwife, and who is the patient?” This eliminates any confusion right off the bat and sets the stage for professionalism and rapport—crucial when time is of the essence. By introducing yourself, you have eliminated any question about scope of practice in the midwife’s mind. Out-of-hospital midwives often work in a team environment, so identifying the lead midwife is important, as they will provide information about the patient and why EMS was called. 

Identifying the patient is also important, as it may not always be necessary to transport both mother and baby. Several years ago I attended a birth that went well, but as I tried to deliver the placenta, it would not come out. I attempted assisted delivery and administered Pitocin with the IV fluid, but mom continued to bleed. Other midwife staff called 9-1-1. A paramedic unit and the fire department arrived. Upon arrival the entire group looked at me with a “what do we do?” look. I identified myself and the rest of the team and proceeded to give the report: whom the patient was, what we needed, and where we would be going. The mother was the patient, not the baby. The baby stayed with the father and the rest of the midwife team for transitioning and stabilization, while I accompanied the mom and paramedic to the hospital. Once I established the lead and assigned roles, comanaging the patient was seamless. 

Step 2—Ask how you can help and assign roles. 

Picture this: A resuscitation of a newborn is in full swing. Ask if the midwife needs to switch out and where they are in the inverted pyramid of neonatal resuscitation. Maybe you need to establish a UVC (umbilical venous catheter) and push epinephrine, or possibly initiate deep tracheal suctioning or an advanced airway, as the midwife team continues resuscitation. This information will not be ascertained if EMS swoops in, scoops up the baby, and runs out the door. 

Step 3—The goal is comanagement. 

A midwife has been caring for this patient for most if not her entire pregnancy. The midwife knows the mother’s current and past medical history, blood type, last sonogram, and much more; midwives are also experienced in resuscitation and management of difficult deliveries. If we as EMS providers do not approach the patient from a perspective of comanagement, we will miss an opportunity to provide continuity of care. 

Step 4—Transport the team. 

In a true emergency the lead midwife should accompany you to the hospital in the back of the ambulance. Not only is this a way to reassure the patient, but it keeps the midwife accessible for care purposes. The midwife knows all about this patient medically, psychologically, and what led to the need for EMS. Leaving the midwife behind will interrupt continuity of care. 

Conclusion

Medicine is ever-changing. In EMS flexibility is one of many cornerstones that comprise a great provider. I urge you to learn more about these fellow caregivers. Find out who practices in your area and what your state laws governing scope of practice are; tour a birth center. Take this new camaraderie a step further and host a joint training. 

Jennifer Lee Worth, a famous midwife in the East End of London, said, “Love is the very stuff of life.” Let the love of your profession guide you to making it better than you found it.  

Resources

1. Doyle K. Out-of-hospital births on the rise in U.S. Scientific American, www.scientificamerican.com/article/out-of-hospital-births-on-the-rise-in-u-s/.

Jessica Arno, NRP, CPM, is a paramedic, midwife, instructor, and public speaker who has been training the U.S. military since 2004 in combat, flight, and critical care prehospital medicine. Visit her website at www.combatmidwife.com. 

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