Maternal care deserts are counties where no obstetric services are available, whether from hospitals, birth centers, or obstetric providers like certified nurse midwives.

The growth of these maternal care deserts is resulting in Emergency Medical Services (EMS) providers assuming the critical role of managing out-of-hospital births. This includes responding to unplanned roadside deliveries as well as supporting an increase of more community births at home. Due to this shift, competency in managing obstetric scenarios is more crucial than ever.

We sat down with two experts in EMS and simulation for a webinar to discuss this topic: Beyond the Hospital Walls: Advancing EMS Practice in Maternal Care. 

In this article, we provide highlights and key takeaways from the webinar. Read on to hear the experts’ insights on how simulation can effectively prepare medics to make an impact on maternal outcomes and build confidence and competency to welcome new lives in their communities. 

The Growing Role of EMS in Today’s Maternal Care Environment

“There’s a shift within healthcare right now, where we’re losing labor and delivery departments,” explained Elizabeth Travis, DHSc, NRP. “Mothers may not be as comfortable relying on the healthcare system for their children’s care as they once were, or they encounter challenges that make access difficult.”

“There’s just a large gap in availability of care,” she continues. “And who is called to meet that gap if you don’t have a midwife there? They call us. The medics, the EMTs.” She adds, “You’re about to get a lot more calls – because we’re looking at bigger and bigger gaps in actual availability of care.”

“You’re that middle ground,” she said. “Whether you’re a volunteer or a career medic, you’re now the care.” 

“We are able and ready to do more”

Historically, there has been limited, non-contextualized training to help EMS providers prepare for maternal cases. “It’s a high acuity, low [frequency] event – but that means it’s even more important to train it,” Dr. Travis points out.

The lack of effective training has left many providers fearful. “I know from my own research that that’s part of the missing link,” Dr. Travis shared. “All these medics were telling me, ‘We’d love to do it, but we’re terrified going in because we haven’t been trained to do it.’”

Current training falls short of the reality EMS providers are managing in the field. For example, many medics only observe C-sections in a hospital during their initial certification training. But this controlled environment doesn’t prepare them for the uncontrolled environment of managing a physiological or emergent birth in the field.  

“I think it’s a disservice to EMS to train us that way – because we’re ready to do more. We’ve seen it with cardiac arrests. We’ve seen it with trauma. We are able and ready to do more. [But] we must be trained to that.” 

– Elizabeth Travis, DHSc, NRP

Laerdal Medical

Building Competence Through Realistic Simulation Training

Both experts agreed that contextualized simulation training is crucial for building provider competence.  

“Not with a PowerPoint … they need hands-on. They need simulation.  They need to hear and experience what a mother is saying and the commotion that goes on. … When we can provide that level of evidence-based practice using hands-on simulation, having all five senses involved, we gain a much more competent, confident provider.” 

– Melissa Lawlor, CNM, FNP, EMT

Midwives Untethered

Simulation can help build competence by allowing medics to train in areas like:

• Managing complex delivery scenarios. Medics must be competent in handling complications that hospitals can bypass through surgery, such as a breech birth. “We don’t have that luxury in EMS,” Dr. Travis pointed out. “If the baby’s breech, the baby’s coming – and you need to learn how to manage that effectively.”
  
  
• Variable birth positions. Competency requires moving beyond the traditional supine (on the back) position, which is known to be difficult for the mom. Medics can train to manage births when the mom is standing up or on all fours, working with gravity for a smoother delivery.
  
  
• Equipment familiarity. Melissa shared that for community births, many midwives are using a T-Piece for resuscitation. “It’s much easier to resuscitate a baby with the T-Piece because it’s a softer inflation of the lungs,” she explained. “We’re teaching it to EMS because we want them to be familiar with it when they walk in on the scene.” 

Strategies for Simulation Success

Some of the key strategies the experts discussed include: 

Contextualize your training. Training must move away from the hospital setting and recreate the realities of the field. “Stop training like you were taught, which is the hospital setting. Start training in the bathroom, out in the cars, things like that. Small shifts,” Dr. Travis advised. 

Strive for real-life chaos. “We’re giving them the tub births [in our training],” Melissa said. “We’re giving them the closet births. The full monty of a hemorrhage or a shoulder dystocia with a baby who’s not breathing right – and they’re working through all of this with the commotion in the background. [This] is how we should be training.”

Train frequently. “It’s drills. It’s practice,” advised Melissa. “It’s like CPR. When you drill it down and you’re practicing it, it becomes rote memory in a way.”  

3 Small Practice Changes That Can Make a Big Difference

Dr. Travis and Melissa provided some meaningful suggestions that agencies can implement. Including these in your simulation scenarios will ensure that providers receive the low-dose, high-frequency training they need to feel confident. 

• ✓Skin-to-skin. Place baby directly on mom’s bare skin immediately after birth. “Baby belongs on mom,” Melissa said. This naturally regulates both mom and baby’s temperature, heart rate, breathing, and nervous system. Cover both with warm blankets on top. This addresses the problem of EMS frequently bringing in hypothermic babies. 
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• ✓Delayed cord clamping. Wait until the umbilical cord stops pulsating (feels limp like spaghetti) or turns completely white before clamping. One-third of the baby’s blood volume remains in the placenta, and waiting allows complete transfer, which benefits the infant. 
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• ✓Variable birth positions. Support mothers in positions other than supine (on their back). Positions like all-fours or standing work with gravity, reduce tearing, make labor easier, and decrease pain. EMS providers need training to catch babies safely in these positions. 
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