Epidemiology of unplanned out-of-hospital births attended by paramedics.

BACKGROUND: Over the previous two decades the incidence and number of unplanned out of hospital births Victoria has increased. As the only out of hospital emergency care providers in Victoria, paramedics would provide care for women having birth emergencies in the community. However, there is a lack of research about the involvement of paramedics provide for these women and their newborns. This research reports the clinical profile of a 1-year sample caseload of births attended by a state-wide ambulance service in Australia. METHODS: Retrospective data previously collected via Victorian Ambulance Clinical Information System (VACIS ®) an in-field electronic patient care record was provided by Ambulance Victoria. Cases were identified via a comprehensive filter, and analysed using SPSS version 19. RESULTS: Over a 12-month period paramedics attended 324 out-of-hospital births including 190 before paramedics' arrival. Most (88.3%) were uncomplicated precipitous term births. However, paramedics documented various obstetric complications including postpartum haemorrhage, breech, cord prolapse, prematurity and neonatal death. Furthermore, nearly one fifth (16.7%) of the women had medical histories that had potential to complicate their clinical management, including taking illicit or prescription drugs. Mothers were more likely to be multiparas. Births were more likely to occur between 2200 and 0600 h. Paramedics performed a range of interventions for both mothers and babies. CONCLUSIONS: Paramedics provided emergency care for prehospital out-of-hospital births. Although most were precipitous uneventful births at term, paramedics used complex obstetric assessment and clinical skills. These findings have implications for paramedic clinical practice and education around management of unplanned out of hospital births.

Embedding assessment in a simulation skills training program for medical and midwifery students: A pre- and post-intervention evaluation.

BACKGROUND: Simulation-based programs are increasingly being used to teach obstetrics and gynaecology examinations, but it is difficult to establish student learning acquired through them. Assessment may test student learning but its role in learning itself is rarely recognised. We undertook this study to assess medical and midwifery student learning through a simulation program using a pre-test and post-test design and also to evaluate use of assessment as a method of learning. METHODS: The interprofessional simulation education program consisted of a brief pre-reading document, a lecture, a video demonstration and a hands-on workshop. Over a 24-month period, 405 medical and 104 midwifery students participated in the study and were assessed before and after the program. Numerical data were analysed using paired t-test and one-way analysis of variance. Students' perceptions of the role of assessment in learning were qualitatively analysed. RESULTS: The post-test scores were significantly higher than the pre-test (P < 0.001) with improvements in scores in both medical and midwifery groups. Students described the benefit of assessment on learning in preparation of the assessment, reinforcement of learning occurring during assessment and reflection on performance cementing previous learning as a post-assessment effect. CONCLUSION: Both medical and midwifery students demonstrated a significant improvement in their test scores and for most students the examination process itself was a positive learning experience.

Interprofessional education and practice guide No. 9: Sustaining interprofessional simulation using change management principles.

Collaboration between teams is an essential component of patient safety in the complex ever-changing environment of healthcare. Collaborative practice requires training, which needs to start prior to registration for it to be established in the clinical workforce by graduation. Despite the perceived value and motivation of course coordinators, interprofessional training programs often struggle to sustain, due to various reasons related to logistics of timetabling, staff availability and/or absence of institutional support. We present a guide, outlining the lessons learned from implementing a sustainable change from our 6-year experience of the Women's Health Interprofessional Learning through Simulation (WHIPLS) program. The WHIPLS program was initially piloted to teach clinical skills in an interprofessional environment for pre-registration medical and midwifery students and has become a core component of the clinical curriculum. We describe the steps that were required to attain this outcome using the Kotter's 8-step plan for management change. The key lessons learned were identifying overlaps in course curriculum, planning for leadership and implementation, creating institutional "buy-in", aligning with national goals, focusing on the learner, translating into routine clinical practice, keeping the program simple, accepting innovation and considering a strategic evaluation.

Antenatal Emergency Care Provided by Paramedics: A One-Year Clinical Profile.

OBJECTIVE: To report on clinical and socio-demographic factors of a one-year caseload of women attended by a statewide ambulance service in Australia, who presented during pregnancy, prior to the commencement of labor. METHODS: Retrospective clinical data collected via in-field electronic patient care record (VACIS®) by paramedics during clinical management was provided by Ambulance Victoria. Cases were electronically extracted from the Ambulance Victoria Clinical Data Warehouse via comprehensive filtering followed by case review. RESULTS: Over a 12-month period, paramedics were called to 2,098 women with pregnancy as a primary or non-primary clinical consideration. Women's ages ranged from 14 to 48 years. The majority were multigravidas (86%). There was a greater chance that ambulance services would be required during business hours than any other time of the day. Paramedics noted pregnant women required ambulance services for a range of primary presenting symptoms both obstetric (n = 1137) and non-obstetric (n = 961). Some women had pre-existing conditions including asthma, hypertension, and diabetes potentially complicating their pregnancies. Paramedics administered analgesia to one third of the women. Paired t-tests revealed significant improvement in the pain relief and overall vital signs of the women encountered. Less than half the women (n = 986, 47%) required interventions. CONCLUSIONS: This is a unique population wide analysis of ambulance service resource use exploring the clinical profile of pregnant women requiring ambulance services in one calendar year. To manage obstetric and non-obstetric complications in this population safely and effectively, paramedics require an understanding of the unique physiological adaptions during pregnancy. This study therefore has both educational and practice implications.

Victorian paramedics' encounters and management of women in labour: an epidemiological study.

BACKGROUND: Although it is generally accepted that paramedics attend unexpected births, there is a paucity of literature about their management of women in labour. This study aimed to investigate the caseload of women in labour attended by a statewide ambulance service in Australia during one year and the management provided by paramedics. METHODS: Retrospective clinical data collected on-scene by paramedics via in-field electronic patient care records were provided by Ambulance Victoria. Patient case reports were electronically extracted from the Ambulance Victoria's Clinical Data Warehouse via comprehensive filtering followed by manual sorting. Descriptive statistics were analysed using Statistical Package for Social Sciences (SPSS v.19). RESULTS: Over a 12-month period, paramedics were called to 1517 labouring women. Two thirds of women were at full-term gestation, and 40% of pre-term pregnancies were less than 32 weeks gestation. Paramedics documented 630 case reports of women in early labour and a further 767 in established labour. There were 204 women thought to be second stage labour, including 134 who progressed to childbirth under paramedic care. When paramedics assisted with births, the on-scene time was significantly greater than those patients transported in labour. Pain relief was provided significantly more often to women in established labour than in early labour. Oxygen was given to significantly more women in preterm labour. While paramedics performed a range of procedures including intravenous cannulation, administration of analgesia and oxygen, most women required minimal intervention. Paramedics needed to manage numerous obstetric and medical complications during their management. CONCLUSIONS: Paramedics provide emergency care and transportation for women in labour. Most of the women were documented to be at term gestation with minimal complications. To enable appropriate decision making about management and transportation, paramedics require a range of clinical assessment skills comprising essential knowledge about antenatal and intrapartum care.

Investigation of the self-reported health and health-related behaviours of Victorian mothers of school-aged children.

Lifestyle may influence many health-related issues currently facing Australian women. The extent to which women with school-aged children attend to their own health is unknown and the associations between health behaviours and health status requires investigation. This study aimed to investigate the prevalence of health behaviours (alcohol consumption, health-promoting activities) and their impact on self-reported health (weight, sleep quality, mental health) among mothers of school-aged children in Victoria. Mail-out survey design (n=263) including the Depression Anxiety Stress Scale (DASS) and Health Promoting Activities Scale was used to explore issues. The results indicated that substantial numbers of mothers reported moderate to extreme DASS scores: depression (n=45, 17%); anxiety (n=41, 15.6%); stress (n=57, 21.7%). The majority participated in physical activity less often than daily. High rates of daily alcohol use (20%) and poor sleep quality were reported. Nearly one-half (n=114, 46%) of the sample were overweight or obese and also reported poorer mental health than other women in the sample (P<0.001). Significant associations were detected between maternal weight, mental health and participation in health-promoting activities. The findings indicate that there is a need for increased health education and services for women with school-aged children. Direct services and population-based health promotion strategies may be required to address healthy lifestyle issues and educate mothers about the possible health legacy of poor health behaviours.

Can we teach core clinical obstetrics and gynaecology skills using low fidelity simulation in an interprofessional setting?

Core clinical skills acquisition is an essential component of undergraduate medical and midwifery education. Although interprofessional education is an increasingly common format for learning efficient teamwork in clinical medicine, its value in undergraduate education is less clear. We present a collaborative effort from the medical and midwifery schools of Monash University, Melbourne, towards the development of an educational package centred around a core skills-based workshop using low fidelity simulation models in an interprofessional setting. Detailed feedback on the package was positive with respect to the relevance of the teaching content, whether the topic was well taught by task trainers and simulation models used, pitch of level of teaching and perception of confidence gained in performing the skill on a real patient after attending the workshop. Overall, interprofessional core skills training using low fidelity simulation models introduced at an undergraduate level in medicine and midwifery had a good acceptance.

Involvement of emergency medical services at unplanned births before arrival to hospital: a structured review.

OBJECTIVE: While infrequent, unplanned births before arrival (BBAs) are clinically significant events at which, conceivably, paramedics will be the first health professionals in attendance. This review aims to demonstrate that paramedics not only attend and transfer birthing women, but also use critical clinical and decision-making skills. It further proposes strategies that will support paramedics manage out-of-hospital obstetric emergencies. DESIGN: The bibliographic databases EMBASE, MEDLINE, CINAHL and Maternity and Infant Care were searched from 1991 to 2012 for relevant English language publications using key words and Medical Subject Heading (MeSH) terms. Data were extracted with respect to study design, incidence of BBAs, attendance of paramedics, complications and recommendations. RESULTS: Fourteen studies were selected for inclusion arising from the US, UK and Europe. While all studies acknowledged paramedics attend BBAs, seven reported the incidence of BBAs attended by paramedics, and two discuss issues specifically encountered by paramedics. Paramedics attended between 28.2% and 91.5% of all BBAs. While the articles reviewed noted that most of the births encountered by paramedics were uncomplicated, they all reported maternal or neonatal complications. Eight articles reported the most common maternal complication was excessive bleeding after birth, and nine reported the most frequent neonatal complication was hypothermia regardless of gestation. CONCLUSIONS: Paramedics need to be adequately educated and equipped to manage BBAs at both undergraduate and graduate levels. Protocols should be developed between health and ambulance services to minimise risks associated with BBAs. A dearth of information surrounds the incidence of BBAs attended and the management performed by paramedics highlighting the need for further research.

Incidence, mortality, and factors associated with primary postpartum haemorrhage following in-hospital births in northwest Ethiopia.

BACKGROUND: Of the 1010 reported maternal deaths in 2018, just over 65% occurred in hospitals in Ethiopia. However, there is a lack of standardised data about the contributing factors. This study aimed to investigate the incidence, mortality, and factors associated with primary postpartum haemorrhage following in-hospital births in northwest Ethiopia. METHODS: A retrospective cohort design was used; an audit of 1060 maternity care logbooks of adult women post-partum at Felege Hiwot Referral Hospital and University of Gondar Comprehensive Specialized Hospital. The data were abstracted between December 2018 and May 2019 using a systematic random sampling technique. We used the Facility Based Maternal Death Abstraction Form containing sociodemographic characteristics, women's medical history, and partographs. Primary postpartum haemorrhage was defined as the estimated blood loss recorded by the staff greater or equal to 500 ml for vaginal births and 1000 ml for caesarean section births, or the medical doctor diagnosis and recording of the woman as having primary postpartum haemorrhage. The data analysis was undertaken using Stata version 15. Variables with P ≤ 0.10 for significance were selected to run multivariable logistic analyses. Variables that had associations with primary postpartum haemorrhage were identified based on the odds ratio, with 95% confidence interval (CI) and P-value less than 0.05. RESULTS: The incidence of primary postpartum haemorrhage in the hospitals was 8.8% (95% CI: 7.2, 10.6). Of these, there were 7.4% (95% CI: 2.1, 13.3) maternal deaths. Eight predictor variables were found to be independently associated with primary postpartum haemorrhage, including age ≥35 years (AOR: 2.20; 95% CI: 1.08, 4.46; P = 0.03), longer than 24 hours duration of labour (AOR: 7.18; 95% CI: 2.73, 18.90; P = 0.01), vaginal or cervical lacerations (AOR: 4.95; 95% CI: 2.49, 9.86; P = 0.01), instrumental (forceps or vacuum)-assisted birth (AOR: 2.92; 95% CI: 1.25, 6.81; P = 0.01), retained placenta (AOR: 21.83; 95% CI: 6.33, 75.20; P = 0.01), antepartum haemorrhage in recent pregnancy (AOR: 6.90; 95% CI: 3.43, 13. 84; p = 0.01), women in labour referred from primary health centres (AOR: 2.48; 95% CI: 1.39, 4.42; P = 0.02), and births managed by medical interns (AOR: 2.90; 95% CI: 1.55, 5.37; P = 0.01). CONCLUSION: We found that while the incidence of primary postpartum haemorrhage appeared to be lower than in other studies in Africa the associated maternal mortality was higher. Although most factors associated with primary postpartum haemorrhage were consistent with those identified in the literature, two additional specific factors, were found to be prevalent among women in Ethiopia; the factors were referred women in labour from primary health facilities and births managed by medical interns. Maternal healthcare providers in these hospitals require training on the management of a birthing emergency.

The Readiness of Australian Health Care Students to Encounter Patients Experiencing Partner Abuse.

Partner abuse is a significant contributor to mortality and morbidity worldwide, and has been identified as a priority health care issue. Most health care students rarely receive education on partner abuse and report not feeling ready to encounter patients experiencing partner abuse. Analysis of the current readiness of health care students and can inform educational needs to address this gap. The READIness to encounter partner abuse patients Scale was delivered to a convenience sample of Australian prequalification health care students. Participant demographics and estimated hours of education were also reported. Mean readiness scores were calculated by discipline. The relationship between hours of education and readiness scores was calculated using linear regression. A total of 926 participants were included in the analysis. Approximately half of the participants (47.5%) reported less than two hours of education. Mean readiness of students was 4.99 out of 7 (SD 0.73, range 4.39-5.95). Linear regression revealed a significant association between hours of education and readiness, r(925) = .497, p < .000. Australian health care students receive little education about partner abuse, and do not report feeling ready to encounter patients experiencing partner abuse. An individual's confidence and belief in their abilities appear to be the key factor influencing overall readiness. Participants indicated a strong belief that responding to partner abuse was part of their professional role, which is a positive change from previous research. Higher hours of education is associated with higher readiness, though which educational methodologies are most impactful remains unclear.

Exploring Diabetes Educators' Core Competencies in the Kingdom of Saudi Arabia.

BACKGROUND: Diabetes education provided by qualified and competent diabetes educators (DEs) is effective in reducing risks of diabetes complications. Globally, the DE workforce comprises a mixture of professions, with the majority being nurses. It is necessary to regularly assess DEs' competence and knowledge to ensure that quality diabetes education is being delivered. OBJECTIVE: This study explored the self-perceived competence and the diabetes knowledge of DEs in the Kingdom of Saudi Arabia (KSA). METHODS: This study explored the self-perceived competence and the diabetes knowledge of DEs in the Kingdom of Saudi Arabia (KSA), using a quantitative, cross-sectional survey, administered at 20 diabetes centres. A total of 368 DEs were invited to participate in the study. RESULTS: Surveys were completed by 324 DEs (response rate = 88%), 84% (n=271) were nurses. From a possible overall range between 63-252, the mean (M) was 168.59 and standard deviation (SD) was (35.6) hence perceived competence of the DEs was low, Of a maximum possible score of 45 for the diabetes knowledge test, response scores ranged from 9 to 40, with M = 26.2 (6.0). Perceived competence and diabetes knowledge varied depending on age, nationality, educational qualification, primary profession, and whether or not the DE held a specialised diabetes qualification. CONCLUSION: DEs in the KSA need to develop and enhance their competence and knowledge in order to provide quality diabetes care and education. The low perceived competence and scores in the knowledge test show that intervention measures are needed to regularly assess and improve the core competencies of DEs. Further research is required to identify DEs' barriers to having sufficient competencies and knowledge.

National Healthcare System Development of Ethiopia: A Systematic Narrative Review.

Objective: To describe the evidence on the development of the National Healthcare System in Ethiopia. Method: The databases Embase, Ovid Emcare, Ovid MEDLINE, and Scopus were searched, together with the reference lists of the identified articles, relevant reports and books were searched. Articles were included if they described health services development in Ethiopia. Results: In Ethiopia, medical care has historically been performed by traditional healers who use magic and superstition. Over time, modern medicine continued to develop, and by 2014, 5% of Ethiopia's total Gross Domestic Product was spent on health. In 2017, nearly 1.26 healthcare workers per 1000 population provided services through 21,071 healthcare organizations, with the majority being rural health posts. There are shortages of healthcare workers and limited numbers of hospitals. However, the introduction of the Health Extension Program and Health Extension Workers has improved access to healthcare in the country and could be a model for other African nations. Conclusion: Although the health care strategies introduced by the Ethiopian government have improved some health issues, accessibility to healthcare institutions that provide curative services is limited.

Core competencies for diabetes educators: A scoping review.

AIMS: Diabetes educators (DEs) play a major role in diabetes education and management. The aims of this scoping review were to compile the currently identified core competencies for DEs and, to review the currently used criteria to assess DEs' core competencies. METHODS: A scoping review was conducted using the methodology of the Joanna Briggs Institute. Five databases (Ovid, CINAHL, Scopus, Web of Science and PubMed) were searched. Keywords as well as inclusion and exclusion criteria were identified as search strategies and study selection for this review. RESULTS: A total of (n = 22) publications comprising sixteen peer-reviewed studies and six professional-organisations (grey literature) were selected for review, as they listed the core competencies of DEs. The most common core competencies were related to knowledge and skills in diabetes self-management education, knowledge of pathophysiology and epidemiology, teaching skills, clinical skills and cultural competency. Evidently, an appropriate tool for assessing DEs' competencies is currently unavailable. CONCLUSIONS: Given the importance of diabetes education in the care of people living with diabetes, it is imperative that DEs possess competencies in diabetes education and management. The review also identified the need to develop a globally applicable core competency assessment tool for DEs.

A demographic snapshot of midwives in Victoria.

Midwifery in Victoria has experienced significant change over the last twenty years. Over more recent years, midwifery workforce issues have become prominent with studies highlighting an ageing midwifery population and a high proportion of part time employment. During a study conducted in 2005 that explored midwives' attitudes to online and computer based learning the demographic data proved to warrant more detailed analysis. This paper presents a discussion on that data. Participants for the study were drawn from the membership of the Australian College of Midwives (ACM) Victorian branch. However, while the sample was small (n=169), the findings presented in the paper add to the existing body of knowledge around the midwifery workforce in Victoria. They reinforce that the midwifery workforce remained an ageing one, predominantly female, and a significant percentage were employed on part time or casual bases. With graduates emerging from recently introduced undergraduate midwifery programs, it is argued that it is timely for larger studies of the midwifery workforce to be conducted. Studies should seek to explore a range of factors such as reasons why midwives are choosing not to work in full time employment.

Core competencies for diabetes educators: a scoping review protocol.

REVIEW QUESTION/OBJECTIVE: The purpose of the proposed review is, firstly, to map the core competencies for diabetes educators, as reported in the literature, and secondly, to review currently used criteria for core competencies in the assessment of diabetes educators.

New midwives' experiences of transition support during their first year of practice: a qualitative systematic review protocol.

REVIEW QUESTION/OBJECTIVE: The current review aims to investigate new midwives' experiences of transition support during their first year of practice as registered midwives. A further objective is to identify the social support experiences of new midwives during their first year of practice as registered midwives.Specifically, the review question is: How do new graduate midwives experience transition and social support during their first year of practice?

Interprofessional simulation of birth in a non-maternity setting for pre-professional students.

BACKGROUND: Simulation-based learning is an approach recommended for teaching undergraduate health professionals. There is a scarcity of research around interprofessional simulation training for pre-professional students in obstetric emergencies that occur prior to arrival at the maternity ward. OBJECTIVES: The primary aims of the study were to examine whether an interprofessional team-based simulated birth scenario would improve undergraduate paramedic, nursing, and midwifery students' self-efficacy scores and clinical knowledge when managing birth in an unplanned location. The secondary aim was to assess students' satisfaction with the newly developed interprofessional simulation. DESIGN: Quasi-experimental descriptive study with repeated measures. SETTING: Simulated hospital emergency department. PARTICIPANTS: Final year undergraduate paramedic, nursing, and midwifery students. METHODS: Interprofessional teams of five students managed a simulated unplanned vaginal birth, followed by debriefing. Students completed a satisfaction with simulation survey. Serial surveys of clinical knowledge and self-efficacy were conducted at three time points. RESULTS: Twenty-four students participated in one of five simulation scenarios. Overall, students' self-efficacy and confidence in ability to achieve a successful birth outcome was significantly improved at one month (p<0.001) with a magnitude of increase (effect) of 40% (r=0.71) and remained so after a further three months. Clinical knowledge was significantly increased in only one of three student groups: nursing (p=0.04; r=0.311). Students' satisfaction with the simulation experience was high (M=4.65/5). CONCLUSIONS: Results from this study indicate that an interprofessional simulation of a birth in an unplanned setting can improve undergraduate paramedic, nursing and midwifery students' confidence working in an interprofessional team. There was a significant improvement in clinical knowledge of the nursing students (who had least content about managing birth in their program). All students were highly satisfied with the interprofessional simulation experience simulation.

Paramedics׳ involvement in planned home birth: A one-year case study.

OBJECTIVE: to report findings from a study performed prior to the introduction of publicly funded home birth programmes in Victoria, Australia, that investigated the incidence of planned home births attended by paramedics and explored the clinical support they provided as well as the implications for education and practice. METHODS: retrospective data previously collected via an in-field electronic patient care record (VACIS(®)) was provided by a state-wide ambulance service. Cases were identified via a comprehensive filter, manually screened and analysed using SPSS version 19. RESULTS: over a 12-month period paramedics attended 26 intended home births. Eight women were transported in labour, most for failure to progress. Three called the ambulance service and their pre-organised midwife simultaneously. Paramedics were required for a range of complications including post partum haemorrhage, perineal tears and neonatal resuscitation. Procedures performed for mothers included IV therapy and administering pain relief. For infants, paramedics performed intermittent positive pressure ventilation, endotracheal intubation and external cardiac compression. Of the 23 women transferred to hospital, 22 were transported to hospital within 32minutes. CONCLUSIONS: findings highlight that paramedics can provide clinical support, as well as efficient transportation, during perinatal emergencies at planned home births. Cooperative collaboration between ambulance services, privately practising midwives and maternity services to develop guidelines for emergency clinical support and transportation service may minimise risk associated with planned home births. This could also lead to opportunities for interprofessional education between midwives and paramedics.

Support needs of breast-feeding women: views of Australian midwives and health nurses.

OBJECTIVE: to explore the views of midwives and maternal-child health nurses regarding factors that influence breast feeding initiation and continuation, focusing on how support for women could be improved to increase breast feeding duration. DESIGN: a focus group study. SETTING: hospital or domiciliary (home-visiting) midwives and community-based maternal and child health (MCH) nurses in one region of Victoria, Australia. METHODS: twelve MCH nurses and five midwives who provided supportive services to women in the immediate postnatal period attended one of three audio-recorded focus groups. Thematic findings were identified. FINDINGS: four key themes were: 'Guiding women over breast-feeding hurdles', 'Timing, and time to care'; 'Continuity of women's care' and 'Imparting professional knowledge'. Given the a pattern of hospital discharge of mother and infant on day one or day two after birth, participants thought the timing of immediate postnatal breast-feeding support was critical to enable women to initiate and continue breast feeding. Community-based MCH nurses reported time gaps in uptake of new mother referrals and time-pressured face-to-face consultations. Both groups perceived barriers to continuity of women's care. CONCLUSIONS: health services subscribe to the Baby Friendly Health Initiative and government policies which support breast feeding, however providers described time pressures and a lack of continuity of women's care, including during transition from hospital to community services. IMPLICATIONS FOR PRACTICE: there is a need to examine administration of service delivery and how domiciliary and community nurses can collaborate to establish and maintain supportive relationships with breast feeding women.