This question comes from a Queensland paramedic but is relevant nation wide as it relates to interactions between paramedics and midwives. As my correspondent says:
Some interesting points have come up about the paramedic interaction with a home birth midwife and/or a Doula at a scene and the obligations around standards of care.
What interests me, and if you don’t mind I would love your opinion are the new guidelines just published last week by the Australian College of Midwives concerning transfer of a mother from a home birth, see link below
I draw your attention to page 14 onwards and the sentence ‘If circumstances escalate, the midwife recommends transfer: if the woman continues to decline transfer, the midwife calls an ambulance, requests that the personnel wait outside if possible, continues to provide care and documents the decision-making process and care provided.’
I wonder about the ‘wait outside’ legally don’t paramedics have a duty of care to assess the patient if called?
They are indeed interesting points. The heading on p 14 is ‘Recommended Process in the Event a Woman Declines Transfer to Hospital for Herself’. The Recommended process says ‘In the event of an emergency or birth is imminent, the midwife: … calls an ambulance and requests that the personnel wait outside if possible’.
Later:
If circumstances escalate, the midwife recommends transfer: if the woman continues to decline transfer, the midwife calls an ambulance, requests that the personnel wait outside if possible, continues to provide care and documents the decision-making process and care provided.
These recommendations are repeated in Figure 3 which a flow chart for the same ‘process’.
One wonders why someone is going to call an ambulance and then ask them to wait outside, and also what does ‘if possible’ mean? Let us consider the issues from a legal point of view.
First health professionals need to work together. A registered mid-wife has professional obligations to the woman and child in her care and no doubt has a prior and long standing relationship with them. IT would be erroneous to think that is somehow secondary to the duty of the ambulance paramedics once called. It would be inappropriate for the paramedics to simply push the midwife aside and say ‘where here now’ just as it would be inappropriate for a midwife to push aside paramedics who were already assisting a woman in labour (see also Step aside – I’m a doctor (October 17, 2014).
Professional respect should mean that paramedics when called should engage with the midwife to determine what is the situation, how it is being handled and what does the midwife think they paramedics can offer. Working together is of course the best solution. Working together would also require the midwife to work with the paramedics, not leave them outside until she or he is ready to call them in. The critical issue is that all the health professionals communicate to act in the best interests of the woman and child and with due respect for the woman’s autonomy.
But, at the end of the day, the paramedics do have a duty to the person in need of care and having been called could not just ‘wait outside’ forever nor could or should they leave the scene without first talking to the woman involved, making an assessment of her condition and giving their recommendations as to whether transport to hospital is required. If the woman is competent and informed she may refuse treatment and/or transport but they are all things the paramedics would want to document in accordance with their own treatment or protocol. If the paramedics were to just wait outside and the patient’s condition deteriorated or she died, there would not doubt in my mind that both the paramedics and the midwife would be in breach of their professional obligations to both mother and child.
Whilst respect for patient autonomy does mean that the woman, if competent and informed, can refuse treatment and transport, the same is not so clear for the baby. Whilst a parent can give or refuse consent for the treatment of their child that decision must be informed and in the best interests of the child (see Secretary of the Department of Health and Community Services v JWB and SMB (1992) 175 CLR 218 or ‘Marion’s case’). A woman who is going through a critical labour and refuses treatment or transport of her infant may not be either competent or informed. Paramedics and the midwife owe a separate duty of care toward the child who, once born, is a separate legal entity and they would have to assess that child and make a separate decision as to whether transport to hospital is needed. The paramedics can’t do that if they are waiting outside.
The Recommended Procedure does not say how long the paramedics should be asked to wait and they may well, rightly, point out that there are other demands on their time.
Conclusion
It is my view that the recommendation that ‘the midwife calls an ambulance, requests that the personnel wait outside if possible’ is both silly and unprofessional.
It is silly as it doesn’t say how long they are expected to wait nor reflect the reality that ambulances are not available to stand by at a midwife’s convenience.
It is unprofessional as it does not recognise that the paramedics are also health professionals with their own treatment protocols, capacity to engage with their patients and their own duty of care. It treats paramedics as old fashioned ‘load n go’ ambulance drivers (and was, presumably, written without consultation with a body such as the Australian and New Zealand College of Paramedicine or some other body representing the professional concerns of paramedics). The ‘Recommended process’ does not encourage communication between the midwife and the paramedics to develop a plan of action to advance the interests of both mother and child. A better statement would be:
‘the midwife calls an ambulance and, upon their arrival, discusses with the paramedics the situation at hand, treatment provided so far, details of the midwife’s concerns and recommendations and then works with the paramedics to develop a treatment plan that is in the best interests of the woman and child and gives full affect to her autonomy to the extent that she is capable of making informed health care decisions’
Australian Emergency Law 
What an interesting and thoughtful perspective. I work in a different jurisdiction, being Canadian, but since I attend out of hospital births often address many of these same issues in my own practice. While the legal framework may be different, the points about blending the clinical roles and competencies of providers from different professions stand and are interesting to consider! We often interact with paramedics similarly when meconium is present in the fluid; if the birth is imminent and so transfer is inappropriate, they will often remain on scene to assist with intubation if needed but do often wait outside the room out of respect for the woman’s privacy. However, this is not an indefinite arrangement: the midwife will usually specifically request their attendance until the baby has been born vigorous and it is clear resuscitation and/or transport of the newborn will not be required.
As an aside, I would caution the author against the implications of suggesting that women experiencing “critical labours” may not be informed or competent (enough to refuse transfer, presumably). In most other cases, pain or physical distress are not assumed to impede competence or autonomy in decision-making in the absence of other indicators of impaired mental competence. As for women not being informed enough, this is more easily remedied with information than with overriding an adult’s autonomous decision. A demonstrated willingness to make the decision that a healthcare provider thinks is the most appropriate one is not and should not be a criterion for competence.
All in all, a thoroughly interesting article – thank you for writing! Always very interesting to see the similarities and differences in practice standards and relationships across settings.
I agree that nothin should be assumed to impede competence. As I did say ‘If the woman is competent and informed she may refuse treatment and/or transport but they are all things the paramedics would want to document in accordance with their own treatment or protocol’ that is competence is something that needs to be considered. The starting point is that any adult is competent to make informed decisions but that too should not be assumed without question where life or death is at stake. And as for being informed as to the consequences of a decision, including whether the decision really is about life or death, as one of the commentators on FaceBook said:
To reiterate I don’t mean to imply that ‘critical labour’ does or can be assumed to impede competence. The law does require however that a valid refusal is both competent and informed and paramedics would want to document what they did to test those issues as required by their service guidelines.
This is an interesting first: “The law does require however that a valid refusal is both competent and informed…” I’d be very interested to know which laws you are referring to?
The common law starting with In Re T [1992] EWCA Civ 18 through to PBU & NJE v Mental Health Tribunal [2018] VSC 564 and multiple cases in between.