Bridging the divide between Midwifery and EMS
By: Rocco L. Laudenslager
Tags: Birth

Credit to St Louis FD Foundation

Laws and licensure requirements vary from state to state, so it is paramount to research and understand your own state’s regulations regarding the legality of midwifery practices, but there are typically different types of midwifes such as Certified Registered Nurse Midwifes (CNM). These people are advanced practice Registered Nurses qualified in prenatal and maternal care, and of course child birth. You will most commonly find these professionals in a clinical setting, but it is possible to be dispatched to a home birth in which a CNM is the highest credentialed provider prior to your arrival. There also exists Certified Midwives (CM) and Certified Professional Midwives (CPM). These are direct entry midwives, and typically do not have the nursing license a CNM may have. Much like our own National Registry of Emergency Medical Technicians there exists a national certification for Certified Professional Midwives, (NARM, North American Registry of Midwives) but like our NREMT, does not grant a license to practice in itself. In a state that requires licensure, a prospective midwife will still need to apply for a state license. NARM certification testing can only be taken by a candidate who completed multiple “steps” of education including numerous prenatal and postnatal exams to be completed in addition to attending childbirths in various capacities.

A midwife may have an assistant with them, perhaps under this process themselves and there also may be a doula present at the birth.

A doula is an individual usually not employed by the midwife in question, and selected by the mother to offer emotional and physical support and reassurance, and not specifically medical care or supervision. Doulas can be found both inside, and outside the hospital.

However, due to the lack of regulation and laws nationally, if your state does not require a midwife or birth attendant to hold a level of certification or does not regulate what that certification requires in terms of competency standards and education; it is entirely possible to have an undertrained midwife assisting the mother in labor prior to your arrival.

The personal philosophies of midwives may vary, however it is safe to assume that their approach to childbirth will most likely be from a “stepped back” and “natural” approach than how a hospital Obstetrical team would manage a childbirth, which is a reason many mothers opt for home birth with a midwife rather than deliver in the hospital. In other words, because the mother wants a less invasive approach with less providers around, less interventions made, and to feel more comfortable in the process as the midwife assists the mother in delivering the child. Remember, providers do not birth a child. Rather, we assist the mother in their own natural process.

A midwife will often hold a closely personal rapport with the mother, with numerous exams and visits being made not only prior to the birth itself, but with a history and perhaps exam being taken before the midwife will even take the future mother on as a client. A competent midwife will not take a homebirth patient they deem high risk. This is important to keep in mind, because a midwife can offer EMS crews invaluable information on the history of the mother obtained through this many months long process. Has the mother had a birth before and if so were there any complications? Is the patient on any prenatal vitamins or other medications? Does the patient have any sort of other medical history relevant to the situation? Did your homebirth team take a set of vitals for you to document and trend? Did they make any interventions prior to your arrival? These are all important bits of information for you to know, and to inform the Hospital of. Often, a midwife will have a higher level of obstetrical knowledge than the average EMT due to their increased specialization. A competent midwife is an invaluable asset for acquiring a history of present illness.

credit to the UK NHS

But what does this mean for EMS?

It means you cannot know for sure how many people will be on scene prior to arrival and what level they are trained to. There could easily be a birth team of three people, in addition to possibly the presence of frantic family members. Keep your state laws in mind, and who you might have on scene.

Secondly, keep in mind that if you are being called to the scene of a home birth, it means that the midwife felt it necessary to at least have you there as a precaution for an unplanned interruption to this normally natural process. It could be a situation with the neonatal patient, the mother, or both. It could be a postpartum hemorrhage from a problem with the passing of the placenta, a pulseless and apneic neonatal patient right after birth, or anything inbetween. Ensure you consider the request for additional resources based off dispatch information early on, because the complication could be time sensitively critical.

When on scene, determine the number of patients. It could be that the baby is fine and the mother is in duress, or the other way around. Don’t get tunnel vision, focus on the big picture. Many EMTs or Paramedics may feel nervous and scared walking into a childbirth gone wrong, and feeling nervous is okay. Let your fright make you careful, and thoughtful. But don’t let it distract you from seeing the big picture and thinking critically. Do you see any obvious signs of the nature of illness right away, such as large amounts of blood on the floor or on blankets? Does the mother appear pallor? Do you see the neonate, and how do they appear?

Talk to the midwife, and ask why you were called. Get the most concise (but quick!) transfer of care report you can, including any interventions the midwife has made, what made them feel the need to call, and specific questions regarding the N.O.I. such as how long the mother has been bleeding, how long the baby has been experiencing bradycardia etc. And if the situation allows, have the midwife or a family member get a medication or medical history list together for you to inform the hospital of.

It is important for both professions of EMS and Midwifery to realize that the moment EMS is called, the midwife is no longer in charge. The EMT or Paramedic becomes the primary care provider for the patient, or patients. Get a report, show respect and compassion, employ birth team assistance in CPR or other forms of patient management if possible (Always follow state, local, and agency protocols in addition to your standing orders) but keep in that these are YOUR patients now and your responsibility.

A midwife may have made an intervention outside of your scope of practice prior to your arrival such as the starting of an IV, or placing an airway adjunct not in your protocol. Inform medical command, and properly document in detail any and all interventions made by the birth team prior to your arrival.

Transporting a midwife to the hospital with you and your patient may allow the midwife to also pass a detailed history to an obstetrical team including details you might have missed, in addition to making the mother more comfortable, but be clear with what your boundaries are. They are not there to continue care (Unless you have an offline or online medical command order for such) but to support the mother emotionally, and to assist in the deliverance of a report.

Remember that the job of an EMT or Paramedic is not only medical care, but emotional support as well. If a mother opted for a home birth, the chances are she wanted to avoid people like us. That is, non natural based providers. It’s important to remain compassionate, respectful, and to build a good rapport with the mother and to show an acknowledgement of an intimate moment such as childbirth. The mother’s privacy and emotional well being should be on your list of priorities whenever practical. The mother may benefit from being transported with the midwife, or doula. These are things to keep in mind for EMS providers in this new age of medicine.