Question: I have a number of questions in regards to the management of obstetrical emergencies and the established standards outlined in the BLS. I know that out of hospital delivery in comparison to other call types is a rare occurrence for Paramedics. So it may be reasonable to deter pre-hospital management of certain situations for definitive care, just based on training, risk and benefit. However, I think it is important for Paramedics to know how to manage these situations when they arise.

For an example, In the BLS standards shoulder dystocia although rare is not specifically outlined. If one does some research or digs back to many college programs where the HELPER mnemonic is touched on we find that suprapubic pressure and the McRoberts maneuver can resolve many of these situations, preventing trauma and harm to the mother and newborn. Although not identified clearly in the BLS both of these interventions are touched on in other areas such as breech delivery and emergency delivery. I wondered the reason why these interventions are not applied specifically to the situation where the shoulders do not deliver and rather the Paramedic is to initiate transport immediately? Secondly, what would MAC's direction be to the Paramedic managing a possible shoulder dystocia? With the potential for fetal hypoxia and stress it seems reasonable to apply these same interventions in this setting.

If we go along the same question of course we aren't performing field episiotomy or controlled clavicle fractures but why can we not assist a shoulder or roll the pt on all fours in this setting? Sure we can and use our judgment but with the legalities of following the standards it may be deemed as a deviation. Can Paramedics really apply the appropriate measures from various parts of the standards to situations like dystocia and still remain legally within their scope?

The only other question this may bring up is how do we hold midwives, who have a higher level of training and knowledge to the BLS Standards?

Thank you for your question. You clearly are well versed with additional training in obstetrics. You raise excellent points.

As you know, the BLS Patient Care Standards do not form part of Base Hospital oversight. The delivery of a new born is not a controlled medical act for which Base Hospitals are tasked with medical directive creation and oversight. Currently the MOHLTC EHS branch responsible for the BLS Patient Care Standards and they are completing a new addition to these standards and we are anticipating an imminent release of the first draft.

The excellent content suggestions you describe would require additional training for all paramedics. The decision to embark upon this specific additional obstetrical training for Ontario paramedics rests with the MOHLTC and not Base Hospital Programs.

As for your question regarding midwives and how you "hold midwives" to the BLS Standards, we are not sure of how best to answer this. Midwives are not held to the BLS Patient Care Standards. Midwives are autonomous practitioners who are accountable to their own professional college for their practice. Midwifery practice is regulated under the Regulated Health Professions Act. Base Hospital recently completed a joint workshop and webinar with midwives this year focusing on inter-professional cooperation and scope of practice which may give you some more background into your question.

The link is here on our web site: www.lhsc.on.ca/About_Us/Base_Hospital_Program/Education/Paramedic_Rounds.htm

For more information governing the practice of midwives, please see the link below: www.cmo.on.ca/

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