Practice Advice: Supporting Clients in Early Labour

Complaint Trends: Early Labour and Assessments

The College, and particularly the Inquires, Complaints and Reports Committee (ICRC), has observed a trend in complaints related to early labour assessments. These complaints range from situations where clients reported that they felt dismissed, confused, or unsupported during early labour to labours progressing more quickly than anticipated resulting in births occurring at home before a midwife arrived.

These kinds of complaints show why clear communication from midwives to their clients and family members is important. They also stress the importance of timely assessments and of effective information sharing that ensures safety, fosters trust, and reflects person-centred care.

Recurring comments made by clients in these types of complaints include:

• Feeling vulnerable and hesitant to page again after an early labour phone assessment, particularly overnight. Expressing worry that the page may bother the midwife or feeling unsure if their instincts about their symptoms are correct.
• Being advised not to go to the hospital because it was “too early” and that the hospital would likely send them home. Feeling unsupported by this guidance.
• Making a choice to go to the hospital on their own initiative and independently and against the midwife’s recommendation.
• A client’s perception of being in active labour and feeling not believed by the midwife and/or that their reports are being dismissed, minimized or attributed to client anxiety and not clinical concern.
• That the midwife never offered or discussed an in-person assessment when conducting early labour phone assessments.

Many of these complaints appear to relate less to clinical judgement and more to how clients experienced communication and person-centred care. The College has heard from clients who have felt dismissed by well-intended guidance, and interpreted advice to remain at home as a midwife being reluctant to provide support. When clients feel unsure or unheard, they may hesitate to ask questions, leading to misunderstandings about their care and next steps.

The ICRC acts as a screening body for discipline matters. It conducts a document review of each complaint after an investigation to determine if it is serious enough to be referred to a formal discipline hearing. If it is, the ICRC then considers whether there is enough evidence to support specified allegations of professional misconduct. The College has historically referred few cases.

If the ICRC has concerns about a midwife’s practice but decides a discipline hearing isn’t required, it can make recommendations or take other action. For example, they can decide to recommend or order the midwife to complete specific education or mentoring, or it can issue an oral caution. All decisions are made in the public interest to ensure safe future practice.

The ICRC meets in panels that include both members of the public and midwives appointed by the College’s Board. While all panels review the case from a public interest perspective, midwives contribute professional expertise in determining whether concerns exist.

For more information on the complaints process, you can review the College’s website. The Resource for Midwives – Complaints and Investigations and the ICRC Risk Assessment Framework are useful documents to help you better understand the complaints processes and outcomes, and what the ICRC considers when making a decision on a complaint.

Each complaint is unique and considered on a case-by case basis, and it is not possible to determine what future outcomes of cases may be. However, in many past cases where the concerns about timely assessments were raised:

• No action was taken on the complaint, especially when:
  • The ICRC did not have concerns with the midwife’s conduct. For example, the ICRC believed that the midwife met the standard of practice of the profession based on the available information, including documentation.
  • There was insufficient evidence to support a regulatory response.
  • The midwife had reflected on the situation and demonstrated insight into how similar situations might be approached in the future.
  • The midwife had taken proactive steps to strengthen their practice to prevent the issue from occurring again. For example, taking a course in communication or record keeping.
    

• Advice and recommendations were provided to the midwife. These include recommendations that the midwife:
  • Offer or remind the client about their option of an in-person assessment, even in early labour.
  • Ensure that clients clearly understand any guidance or recommendations provided to avoid misinterpretation. Be clear that the guidance is intended to support their decision rather than discourage any choice.
  • Follow the Professional Standards for Midwives, with particular attention to standards related to person-centred care and particularly:
    • Listen to clients and provide information in ways they can understand.
    • Recognize clients as the primary decision-makers and provide informed choice in all aspects of care by making efforts to understand and appreciate what is motivating clients’ choices

• Issues related to timely assessments formed part of the record associated with two discipline matters.

The College is sharing this trend in complaints to support learning and awareness across the profession. The College recognizes that client expectations are high and that midwives work diligently to meet them. This trend in complaints demonstrates the significant influence that communication and assessment processes have on clients’ experiences in early labour, their vulnerability, as well as on their broader trust in midwifery care.

FAQs

Below are some examples of the types of inquiries from both clients and midwives that we receive and our answers:

Client Question: I paged my midwife, but she called me back and only talked to me on the phone. Is that the standard of care?

College Answer: Phone assessment is an important part of midwifery care, and sometimes an in-person assessment is either unnecessary or a secondary step to an initial phone discussion. The Professional Standards for Midwives require that midwives provide information so clients may make informed decisions about their care. Sometimes, this information is provided by phone following an assessment of your concerns or condition, as midwives are trained to respond to pages from their clients which may not require physically seeing you.

Practice Advice to Midwives: Clients sometimes tell us they didn’t feel heard or were afraid to call again, particularly when pages were made overnight. Clients benefit when they make a plan with their midwives for next steps (should the issue progress or change). This means that reassurance alone may not meet the client’s needs if a complete assessment cannot be achieved by phone. While a phone assessment might be clinically appropriate, it also matters how it is received. Offering an in-person assessment, along with your recommendations for why this may (or may not) be clinically appropriate, is part of an informed choice discussion, as is making a plan with clients for when they should contact their midwife again.

Relevant standards 14, 15, and 16.

Midwife Question: My practice partners think I should have offered an in-person visit, but the client didn’t ask for one. Isn’t it the client’s choice?

College Answer: How you provide care is based on your own style, available resources, and community standards. Though we do not provide individualized advice on what you should or shouldn’t have done, you must work within your scope and meet the Professional Standards at all times when providing midwifery care.

Practice Advice to Midwives: Midwifery is grounded in informed choice, but clients don’t always know what they can ask for, especially when they’re feeling unsure or anxious. Midwives listen to clients and are expected to provide information in ways clients can understand. Clients should understand that through your communications as part of informed choice discussions that they can request to be seen in person. A reminder to your client that an in-person assessment is an option is clearer than not broaching the subject at all.

Relevant standards 15 and 16.

Client Question: Was it appropriate for my midwife to discourage me from going to the hospital? I was sure I was in active labour, but she said I would “just be sent home.” I think she just didn’t want to come overnight.

College Answer: While the College’s Practice Advisor cannot tell you whether your midwife was right or wrong in this instance, we can share the standards that midwives are expected to meet in this situation. Midwives are expected to base their recommendations on clinical assessment and evidence, not convenience. They must provide care that is person-centred and supports informed choice.

Research shows that going to the hospital too early in labour often leads to unnecessary tests or interventions, and that waiting until active labour usually results in better outcomes. For this reason, a midwife may recommend staying home if everything appears safe.

Practice Advice to Midwives: Clients remain the primary decision-makers in their care. The midwife’s role is to provide information in a way that supports the client’s choices and ensures they feel safe and informed. To meet this standard, midwives should:

• Explain the reasons for any recommendation
• Answer questions and ensuring the client understands their options
• Make a clear plan for what to do next, including when to call back or request an in-person assessment or hospital attendance
• Provide or arrange 24-hour access to midwifery care throughout pregnancy, birth, and postpartum

Relevant standards 14, 15, 16, and 17.