Two main themes were identified from the analysis: 1) Navigating complexity and uncertainty in unplanned births; and 2) Practical challenges and unsuitable environments, with several lower-order themes under each (Table 2).
Table 2: Identified themes, subthemes, and impactful quotes from EMS
Theme one: Navigating complexity and uncertainty in unplanned births
Clinicians in this study attributed the challenges of unplanned birth events to a significant presence of unknown factors. Participants articulated a fragmented understanding of the situation as a challenge in making well-informed clinical decisions and responding to unforeseen complications in what were often complex situations. These challenges were heightened when caring for young pregnant mothers or attending to patients delivering in deprived or rural areas.
Ambiguous clinical impressions
EMS were frequently called under the impression of addressing abdominal or back pain for a female patient and found themselves unprepared for imminent birth. Many participants recounted similar scenarios in which the mother they attended was unaware of her pregnancy or denied being pregnant until she unexpectedly went into labor either en route to the hospital or within minutes of the ambulance crew's arrival on scene. These women often had not received any antenatal care; therefore, the gestation period and high-risk complications were unknown to EMS personnel. Furthermore, patients lacked a midwife to contact for assistance which tasked EMS with providing lead obstetric care.
Participants explained the lack of information about patients' pregnancies influenced their decisions regarding drug administration. In all cases, a cautious approach was taken when providing pain medication due to suspicion that contractions might be presenting as stomach and back pain. Furthermore, participants highlighted various factors that complicated their ability to assess obstetric situations and engage effectively with patients.
Caring for young mothers
EMS described challenging scenarios in which teenage patients were in denial or concealing their pregnancies, mainly out of fear of family reactions. Participants described feeling caught off guard by not having any prior information about the pregnancy and trying to transport the patient and parents safely to the closest hospital. In one serious case, a female paramedic with 10+ years of experience described attending to a young patient who had been impregnated under abusive circumstances and was in denial about her pregnancy. Many participants detailed the challenges of managing the mother’s emotional needs and protecting her dignity and privacy while discreetly trying to provide care for the neonate.
Remote and deprived communities
Another frequently cited factor that compounded concern among EMS in this study was responding to laboring women in high-deprivation or remote parts of the country. Participants working rurally reflected on the additional challenges of high-pressure birthing situations when they were aware that access to additional resources was limited, and hospital facilities were a significant distance away. Many also described low health literacy in some rural areas as a challenge in persuading patients to seek care or agree to be transported to a hospital. One EMT with less than three years of experience recounted the heightened emotions experienced when responding to an imminent birth in a rural part of the country, far from a birthing unit or hospital. It was their first experience with birth and was a highly confronting experience.
Theme two: Practical challenges and unsuitable environments
When asked about the challenges of providing intrapartum care during prehospital deliveries, many participants articulated that limited equipment and unsuitable environments introduced practical challenges that exacerbated the pre-existing difficulties in the situation.
Limited equipment
The most cited concern was the lack of equipment in the ambulance to treat complicated births and neonates, particularly in cases of breeched birth, a tangled umbilical cord, and a low heart rate. Clinicians expressed significant vulnerability and concern around having limited tools in the ambulance to respond effectively in these situations.
In high-risk obstetric situations, participants often had to improvise to meet the demands of the situation. Some focused on facilitating immediate skin-to-skin contact between the mother and newborn after birth. However, when the mother required urgent treatment, like in cases of post-partum hemorrhage, the limited equipment in the ambulance led participants to come up with creative solutions such as heating up the ambulance and using makeshift blankets to keep the neonate warm.
Participants also shared challenging experiences where the mother and neonate had to be driven to a birthing unit or hospital separately, necessitated by limited ambulance space. Many voiced concerns about the potential emotional impact this could have on the mother. Some working in rural settings described experiences where either the baby or mother were transported by helicopter due to the urgency of the complications they were presenting and the distance to the nearest hospital on road. This logistical challenge added an additional layer of complexity to the high-pressure situation.
Unsuitable environments
The second most cited obstacle was providing intrapartum care in physically challenging environments such as homes with no electricity, in public areas, or during cold seasons in a residence without heating. Participants described the added risks of delivering in an unplanned area such as navigating poorly lit homes for equipment they need and trying to keep the mother and neonate warm in cold winter conditions.
Other participants that assisted with delivery en route to the hospital voiced concerns about preserving the mother's dignity. Frequently, they found themselves needing to pull over on to the sides of busy roads, navigating the delicate balance between providing medical care while protecting the mother’s privacy from bystanders.