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Professional Practice Advice

The College of Midwives of Ontario provides advisory services for midwives and members of the public who have questions related to College standards, and the legislation and regulations that govern midwifery practice in Ontario. Please note that a Professional Practice Advisor cannot help you make a decision about a particular clinical situation but can help you understand how the standards, legislation and regulations relate to that situation.

The questions we receive the most are related to the midwifery scope of practice, including delegation, and access to the laboratory tests and medications required to optimize client care. We have included answers to some of the most frequently asked questions below. 

If you have questions that are not addressed or require further clarification, please contact us.

By phone at 416.640.2252 ext. 230 or toll free at 1.844.640.2252 ext 230.

By email practiceadvice@cmo.on.ca.

Frequently Asked Questions

Scope of Practice

What is the Midwifery Scope of Practice?

The midwifery scope of practice is outlined in the scope of practice statement in the Midwifery Act, 1991 and the controlled acts authorized to midwives. According to the Midwifery Act, the scope of practice of midwifery is the assessment and monitoring of women during pregnancy, labour and the post-partum period and of their newborn babies, the provision of care during normal pregnancy, labour and post-partum period and the conducting of spontaneous normal vaginal deliveries. Providing care that is not in the scope of practice, such as performing controlled acts on individuals who are not pregnant or postpartum, must only be performed under delegation.

Do I have to practise to the full scope of practice?

Midwives are not required to perform all procedures that are in the midwifery scope of practice and should only perform those procedures they are competent to perform. For example, vaginal breech birth is in the scope of practice for midwives but many midwives do not have the skills to confidently offer planned vaginal breech to their clients. If midwives do not have the skills to provide this care then they should transfer the client’s care to a midwife or physician who is competent to provide it.

What do I do when a client’s care is outside the midwifery scope of practice?

When the care a client requires is outside the midwifery scope of practice the midwife should transfer the client to a physician because midwives are not authorized to provide care that is outside the scope. When a transfer occurs for care that is outside the midwifery scope of practice, the midwife should maintain a care provider relationship in order to resume primary care if it returns to the scope of practice or to assume responsibility for the newborn.

What kind of training do I need to take before performing a new procedure?

The College does not specify the training programs that midwives are required to take prior to performing a new procedure (e.g. before performing pregnancy diagnostic ultrasounds or assisting at a caesarean section). Instead the College requires that midwives obtain the knowledge, skills and judgment to competently perform any new procedure that they include in their practice and to maintain competence in all procedures they perform throughout their careers. These expectations are set out in the Professional Standards for Midwives under Professional Knowledge and Practice.

Can midwives perform newborn tongue tie release (frenotomy)?

Midwives are not authorized to perform tongue tie release. Tongue tie release falls under the controlled act of performing a procedure on tissue below the dermis, below the surface of a mucous membrane, in or below the surface of the cornea, or in or below the surfaces of the teeth, including the scaling of teeth and midwives are not authorized to perform this controlled act. Midwives must only perform tongue-tie release under delegation.

Can I provide care to newborns when their mothers are not in midwifery care?

Midwives are authorized to provide care to a newborn when the newborn’s mother is not in midwifery client as long as the care provided is in the midwifery scope. 

Prescribing Drugs and Ordering and Performing Tests

What drugs can I prescribe?

Midwives are authorized, under the Midwifery Act, to perform the controlled act of prescribing drugs designated in the regulations. This means that midwifery prescribing is limited to:

Midwives are however, permitted to use any drug on the order of a physician and may prescribe under delegation.

Can I give free drug samples to clients?

No. Midwives are not permitted to give sample prescription drugs to clients. Providing prescription drugs to clients is considered dispensing which is a controlled act not authorized to midwives.

The controlled act of dispensing only applies to prescription drugs and does not apply to drugs that can be purchased without a prescription.

What tests can I order?

Midwives are authorized to order all laboratory tests listed in Appendix B: Tests That a Midwife May Request under Regulation 682 (Laboratories) of the  Laboratory and Specimen Collection Centre Licensing Act R.R.O. 1990. Some of the tests in Appendix B are specific to diagnosing only one condition. Test #2, Bilirubin-conjugated, is an example of a test that can be ordered for diagnosing only one condition (i.e. hyperbilirubinemia). Other tests in Appendix B can be ordered for diagnosing several conditions. Test #30, Virus isolation, is an example of a test that can be used to diagnose more than one possible condition. Virus isolation permits midwives to order tests to diagnose viruses such as SARS-CoV-2 and HSV 1.

Can midwives perform point-of-care tests?

Midwives do not have the authority to perform point-of-care tests for diagnosing and treating their clients. Health care professions that are permitted to perform point-of-care tests must have an exemption under Regulation 682 (Laboratories) under the Laboratory and Specimen Collection Centre Licensing Act (the “Act”) and midwifery is not one of the professions that is exempt. The Act and its regulations are administered and enforced by the Ministry of Health.

Point-of-care testing is defined in the regulation as testing performed outside a clinical laboratory at or near where a patient is receiving care. To be considered point-of-care testing, the specimen being tested must be taken from the human body such as blood, urine or amniotic fluid. Many tests performed at or near where the client is receiving care do not fall under the definition of a point-of-care test because they are not performed on specimens taken from the body. Tests such as bilirubin screening using transcutaneous bilirubinometers and bedside ultrasounds are not considered point-of-care tests.

Delegation

What does it mean to work under delegation?

Delegation provides midwives with the legal authority to perform a controlled act that is otherwise not authorized to the midwifery profession. This allows midwives to work outside the midwifery scope of practice when a regulated health professional, with the authority to perform the controlled act, grants this authority to the midwife. Delegation must occur, for example, for a midwife to provide care to someone who is not pregnant, intrapartum, postpartum or newborn.

Working under delegation takes place either through a direct order or a medical directive. 

A direct order authorizes the midwife to perform a controlled act from another healthcare provider or delegator, usually a physician, for a specific client. A direct order occurs after the client has been assessed by the delegator who provides the details required for the midwife to carry out the procedure. A direct order should be documented but can be verbal in emergencies or when documentation is not possible.

A medical directive authorizes the midwife to carry out a medical procedure or series of procedures for any client as long as the clinical conditions set out in the directive exist and are met. Medical directives are written in advance.

What do I need to have in place to work under delegation?

Delegation must only be done when:

  • the delegator is authorized and competent to perform and delegate the controlled act
  • it is in the best interest of the client
  • the client has consented to the performance of the controlled act being done under delegation
  • the midwife has the knowledge, skills and judgment to perform the delegated act.

The expectations for midwives regarding delegation can be found in the Professional Standards for Midwives under Leadership and Collaboration.

Can a midwife delegate a controlled act to another person?

A midwife can delegate all controlled acts authorized to the midwifery profession except for the controlled act of prescribing a drug designated in the regulation. The College’s standards do not allow midwives to delegate the controlled act of prescribing. Delegation requires that the midwife is assured of the competence of the individual they are delegating to and has determined that the individual is authorized to receive that delegation.  In all situations, the delegating midwife remains responsible for the performance of the delegated controlled act.

Second Birth Attendants

Who can I work with as a second birth attendant?

Midwives can work with a second birth attendant who is competent to provide care under the direction of the midwife managing the labour, birth and immediate postpartum and who holds current certification in neonatal resuscitation, cardiopulmonary resuscitation and an obstetrical emergency skills program in accordance with the Second Birth Attendant Standard. A second attendant can be a registered nurse or a paramedic for example. A second birth attendant cannot be a midwife registered in the Inactive class.

What can a second birth attendant do at a birth?

A midwife working with a second birth attendant must practise according to the Second Birth Attendant Standard that requires the midwife to be in attendance during the provision of care by the second birth attendant. A second birth attendant can perform controlled acts that are in their own professions’ scope of practice or perform them under delegation from the midwife. A second birth attendant must only provide care they are competent to provide and the ultimate responsibility lies with the attendant midwife who is responsible for the care provided by the second birth attendant.

Record Keeping

What does it mean to keep records that are contemporaneous, accurate, objective and legible as required by the Professional Standards for Midwives?

Midwifery records must clearly document all aspects of a client’s care so that the chart is an accurate picture of the care that was both offered and provided by everyone involved. Included in the client record are objective assessments of the client’s condition, the information provided to the client for decision-making (e.g. risks and benefits of treatment options), and the client’s decisions and management plans. Generally, narrative notes are required to accurately reflect client care for important clinical events such as initial visits and discharge visits, informed choice discussions, and consultations with and transfers of care to other health care providers. When charts are shared between more than one midwife, it should be clear from each entry which midwife provided care. The Health Insurance Reciprocal of Canada’s (HIROC)  Strategies for Improving Documentation: Lessons from Medical Legal Claims is a relevant resource for more information about documentation.

How long should a client’s midwifery records be kept?

The age of the client at discharge from midwifery care dictates how long the client record must be retained.

  • For clients over the age of 18 at discharge, their midwifery records must be retained for a minimum of 10 years after the date of discharge
  • For clients under the age of 18 at discharge, their midwifery records must be kept for a minimum of 10 years after the client turns 18 years old. This means that a newborn’s midwifery records must be retained for 28 years from their date of birth.

What do I do when a client requests or demands care I am not comfortable providing?

There are two possible ways to ask this question.

1. I am not comfortable providing care because I don’t agree with the client’s choices

The Health Care Consent Act, 1996 presides over all care and clients have the right to accept or refuse treatment based on the Health Care Consent Act. This is reiterated in the Professional Standards for Midwives under Person-Centred Care . It is the responsibility of midwives to provide the client with current, evidence-based information and allow clients to make their own informed decisions even if the decisions are not in keeping with current treatments and best practices.

2. I am not comfortable providing care because I do not have the required knowledge and skills to provide the care

If a midwife does not have the knowledge and skills to provide the care being requested, the client should be transferred to a care provider with the competencies to provide the care. If the client refuses the transfer then the midwife must use their judgment to determine the next steps. The next steps might involve gathering additional care providers to assist in the care or discontinuing client care. The Professional Misconduct Regulation (O. Reg. 388/09) states that discontinuing professional services respecting a client is an act of professional misconduct unless:

i. the client requests the discontinuation,

ii. alternative services acceptable to the client are arranged,

iii. there is no longer a relationship of trust and confidence between the midwife and the client and the client is given a reasonable opportunity to arrange alternative services, or

iv. the client requests services inconsistent with the standards of practice of the profession and the midwife has adhered to the standard of practice for discontinuing care in such circumstances.

In all situations, a midwife must never abandon a client in labour. This is a standard of the profession in the Professional Standards under Integrity.

More information on discontinuing client care can be found in the College’s Guide on Ending the Midwife Client Relationship.

Can our practice make a policy about who we take into care?

The Professional Standards for Midwives principle of Person-Centred Care requires that every practice develop a reasonable and transparent client intake process. It is up to each practice to determine how best to develop their intake process. The intake process must be clear to clients prior to intake and it must be defensible.

Members Registered in the Inactive Class

Can I provide labour support at my friend’s birth when I am registered in the Inactive class?

Midwives registered in the Inactive class are able to provide labour support at the birth of friends and relatives as their role at these births is not considered the practice of midwifery. However, applying midwifery knowledge and using midwifery skills to work as a labour support provider is considered practising midwifery and must not be done while registered in the Inactive class. For more information on what midwives can do while registered in the Inactive class, please refer to the College’s document on the inactive class.