Case Scenario: You receive a late-to-care client who is booked for their initial intake appointment at 28 weeks gestational age. As you conduct the appointment, you review their prior medical records, which indicate a history of preeclampsia in a previous pregnancy.
You assess the client in your office, and their blood pressure (BP) on your clinic’s automatic sphygmomanometer is 152/88. You retake their BP and again, it’s high, with a reading of 158/92. Their urine tests negative for protein. You ask your client if they’ve experienced swelling, epigastric pain, or any feelings of being unwell, and they say no, but tell you over the past few weeks, they have had a few BP readings on their “old monitor left over from the last pregnancy,” of over 150/90.
You know that this could be serious, but you aren’t yet sure if it’s actually a hypertensive disorder of pregnancy (HDP), as your client seems well, has no other symptoms, and really doesn’t fit the profile of previous clients you’ve had with HDP.
You consider your options: sending this client into emergency will probably result in a long wait for your client, and they have their four- and eight-year-old children with them. Deep down, you’re worried about over-reacting. The last time you had an assessment like this in the hospital, you had an uncomfortable interaction with the on-call doctor who seemed frustrated with you for “wasting time and resources.” You’re also nervous, and ask yourself, “what if this really is preeclampsia?” You are undecided about next steps, and feel under pressure to take the correct course of action.
The College has noted an increase in the number of complaints received and professional practice advice inquiries this past year related to the identification and management of hypertensive disorder of pregnancy (HDP). The highest risk areas include over-normalization of hypertension symptoms, incomplete assessment in the presence of hypertension symptoms or history, delays in consultation, and communication errors at time of transfer of care.
Hypertensive disorders of pregnancy are a significant cause of maternal and neonatal mortality in Canada. Hypertensive disorders of pregnancy can pose a source of unique challenges related to quality of care. Management of this complex range of disorders is not always straight forward and represents an excellent case study in the interplay between midwifery scope of practice, communication, and collaboration with physician specialists.
Midwives are able to conduct a variety of assessments and order a range of laboratory investigations which allow for appropriate identification and arrange for proper management of HDP. For example, it is within a midwife’s scope of practice to assess blood pressure, conduct urinalysis to determine the presence of protein, and assess client reports of symptoms consistent with hypertensive disorders. Additionally, it is within the midwife’s scope of practice to arrange urgent assessment in hospital, and emergent consultation with physician specialists to minimize the risk of harm presented by the progression of untreated HDP. Identification of hypertension and appropriate consultation and transfer of care are essential skills for midwives.
Communication within the client’s circle of care is an important consideration for midwives managing HDP. Midwives must meet standards of Leadership and Collaboration in order to safely consult, complete a transfer of care, and follow up on laboratory investigations and health surveillance for clients with HDP. Equally important is accurately documenting communication with clients, and their responses to your advice, as well as following up with clients to ensure they understand the information correctly.
Taking proactive steps toward establishing clinical confidence in this area will help midwives feel confident about planning next steps and appropriately manage care when faced with abnormal assessment or test results. Ensuring that you have high quality systems in place for the identification of HDP, and pathways to ensure timely consultation and transfer of care are critically important in managing potentially life-threatening conditions.
Midwives should remember that they are responsible for recognizing developing medical conditions and if their clinical judgment is to escalate the level of care, they must act accordingly in the best interest of their client. Any resulting negative repercussions with health care providers should be dealt with at the system level when possible.
The College continues to regulate midwifery in Ontario in the public interest. The following relevant Professional Standards for Midwives exist to ensure that midwives meet the minimum threshold of safe and ethical practice:
Professional Knowledge and Practice:
1. Work within the boundaries of the Midwifery Act related to scope of practice and the controlled acts authorized to midwives.
2. Be competent in all areas of your practice.
3. Know, understand, and adhere to the standards of the profession and other relevant standards that affect your practice.
5. Maintain contemporaneous, accurate, objective, and legible records of the care that was provided during client care.
- Offer treatments based on the current and accepted evidence, and the resources.
7. Order tests or prescribe medications only when you have adequate knowledge of clients’ health and are satisfied that tests and medications are clinically indicated.
Leadership and Collaboration:
23. Be accountable and responsible for clients in your care and for your professional decisions and actions.
25. Establish and work within systems that are clear to clients whether you are a sole practitioner, part of a primary care team of midwives, or a member of an interprofessional care team by:
25.1. developing and following a consistent plan of care
25.2. practising with clearly defined roles and responsibilities based on scopes of practice
25.3. assuming responsibility for all the care you provide
25.4. ensuring that the results from all tests, treatments, consultations, and referrals are followed-up and acted upon in a timely manner
25.5. providing complete and accurate client information to other midwives or care providers at the time care is transferred over to them
25.6. taking reasonable steps to ensure that a midwife or another care provider known to the client is available to attend the birth.
27. Collaborate with the most responsible provider (MRP), after a transfer of care, to provide care that is in the best interest of the client.
Adhering to the Professional Standards for midwives also means staying up to date with evidence-based practice. For example, midwives should review the updated Association of Ontario Midwives Clinical Practice Guideline 15, entitled Hypertensive Disorders of Pregnancy, 2023. Other resources include the ALARM course from the Society of Obstetricians and Gynaecologists (SOGC), which is now available online, and other current clinical guidance, such as the SOGC Guideline No. 426: Hypertensive Disorders of Pregnancy: Diagnosis, Prediction, Prevention, and Management.
It is the responsibility of midwives to establish a consistent approach to:
- identifying symptoms of HDP
- recommending preventative treatments for clients at risk for hypertension
- establishing monitoring and assessment protocols for their practice
- acting in the presence of concerning symptoms reported by clients, and
- referring clients to specialists in a timely fashion when hypertension is suspected or confirmed.
As primary-care providers, midwives use their knowledge, skills, and judgement in all areas of their work. If a midwife has identified gaps in their knowledge with regard to the identification, prevention, treatment, and management of hypertensive disorders of pregnancy, they are responsible for addressing these competencies. The College partners with registrants to ensure Ontarians who choose midwifery care can expect skilled, safe, and ethical care.