General considerations and resource management

Out-of-hospital deliveries not attended by physicians or midwives are a rare occurrence, comprising less than 2% of all births in the US [1]. The majority of out-of-hospital deliveries encountered by EMS personnel are uncomplicated vertex presentations and require only routine supportive care of both mother and neonate [1–3]. Maternal risk factors for unattended out-of hospital delivery include younger maternal age, multiparity, and poor prenatal care [3]. These same risk factors are associated with not only prematurity but higher incidence of fetal morbidity and mortality [3]. Literature over the last two decades shows a trend towards increasing numbers of unattended out-of-hospital deliveries and an increasing medicolegal burden of such cases [1]. It is imperative that medical directors provide robust training, protocol, and direct medical oversight support to crews managing out-of-hospital births.

Due to the low frequency and high-risk nature of unattended out-of-hospital births, along with the significant emotional component of these situations for both patient and provider, catastrophic outcomes are possible and do occur. It is important for EMS personnel to realize that the same risk factors that contribute to unattended out-of-hospital birth also contribute to prematurity (often extreme) and neonatal morbidity. Some complications are not amenable to successful resolution within the scope of practice of prehospital providers and will necessitate temporizing measures and rapid transport. The most practical approach is to focus training on the methodical application of interventions within the scope of care and whenever possible to expedite transport to an appropriate receiving facility.

Resource management at the scene of an unattended out-of-hospital childbirth also presents challenges as there will be at minimum two patients for the prehospital personnel to manage. As the proportion of overall pregnancies involving multiple gestations continues to rise, it is reasonable to expect EMS personnel to encounter increasing numbers of multiple birth situations, further complicating resource management. The request for additional resources, if available, should be made as soon as a multiple gestation birth, an abnormal presentation, or other childbirth emergency is identified. In some systems mother and neonate may also require transport to separate receiving facilities. Finally, given the emotionally charged nature of an out-of-hospital childbirth, attention must be paid to caring for other family members or loved ones on scene to ensure not only their support but also that they do not interfere with the provision of appropriate care.