Designated Drugs and Substances Regulation

Prescribing a medication includes giving written instructions for dispensing a medication by a pharmacist, and self-administration of that medication by a client. As well, the act of prescribing can include prescribing for the purpose of administering a medication. Drugs that may be prescribed by a midwife fall under Schedule 1 and Schedule 4 of the regulation.

In addition, midwives may prescribe any drug that may lawfully be purchased or acquired without a prescription, as set out in Section 6.

Administering medication is giving a medication through the correct route to a client. The regulation specifies which drugs can be administered by inhalation and which drugs can be administered by injection as these procedures are controlled acts authorized to midwives. Midwives can administer any medication that they are authorized to prescribe. Drugs that may be administered by inhalation by a midwife fall under Schedule 2. Drugs that may be administered by injection by a midwife fall under Schedule 3 and Schedule 4. Midwives can also administer by injection any drug on the order of a physician or nurse practitioner.

In addition, midwives may administer any substance that may lawfully be purchased or acquired without a prescription, as set out in Section 6.

Ordering a medication is the way that midwives prescribe a medication to be administered by a nurse in the hospital. This can be a verbal or written order; or may be part of a set of medications that midwives order in a group based on hospital protocols. In addition, midwives can receive orders from physicians or nurse practitioners to administer medications by inhalation or injection that are not included in the regulation.

In addition, midwives may order any drug or substance that may lawfully be purchased or acquired without a prescription, as set out in Section 6.

Using a medication means administration of a medication by any means other than inhalation or injection. This includes oral, vaginal, topical, or rectal routes of administration. Midwives can administer any medication that they are authorized to prescribe. Midwives can receive orders from physicians and nurse practitioners to use medications that are not included in the regulation.

In order to prescribe and administer opioids on their own authority, midwives must complete specified education and training as outlined in the Registrar’s Policy on Controlled Drugs and Substances Education and Training or Course Requirement or complete the College’s Safe Prescribing and Administration of Controlled Drugs and Substances course. The free course is available now, on this page.

A midwife who previously administered opioids on the order of a physician is able to continue working in this manner without any additional training. Please note if one midwife has not completed the specified training to be able to administer on their own authority, they are not able to carry out an order from another midwife to administer a controlled substance.

Midwives will be required to declare, in the College’s Registrant Portal during the 2024 Registration Renewal period, that they understand and are in compliance with the requirements that must be met in order to prescribe and administer by injection a controlled drug or substance set out in Schedule 4 of the Designated Drugs and Substances Regulation.

Midwives must be competent in all areas of their practice including prescribing and administering drugs and substances.

As such, prior to initiating any drug therapy, midwives must have sufficient knowledge, skill, and judgment to use the drug or substance safely and effectively.  Anything less may constitute professional misconduct. Midwives are expected to seek out the resources, courses, and training they need to be competent at prescribing or administering drugs and substances.

No. The laboratory tests that midwives may order are listed in Schedule 2 of the General Regulation under the Laboratory and Specimen Collection Centre Licensing Act, 1990.

The Ministry of Health held a public consultation on proposed changes to General Regulation under the Laboratory and Specimen Collection Centre Licensing Act, 1990 that closed on May 25, 2024.

There are many new additions to the list of laboratory tests that midwives will be able to order, including point of care tests like the Group B Strep rapid screen, and genetic screening tests like Non-invasive Prenatal Testing (NIPT). To see the proposed changes, click here.

The proposed expansion encompasses most of the tests that midwives might order in the scope of midwifery practice and includes tests that can facilitate timely consultations with other care providers when required. The College believes the proposed changes will:

1. Ensure clients have access to routine tests during pregnancy, birth, and postpartum directly through their midwife.
2. Decrease the number of unnecessary consultations with physicians for routine tests.
3. Facilitate timely consultations with physicians by providing a more complete clinical picture.
4. Ensure healthy, pregnant people can receive the care they need without unnecessary additional primary care or hospital visits.

Unlike previous versions, the new Designated Drugs and Substances Regulation does not specify indications for use, or limitations of use of particular medications or substances. The important exception to this is the medication Mifegymiso (or Misoprostol-Mifepristone), and other oxytocic and prostaglandins, which do have specified indications for use in the regulation.

All medications require that a midwife have the knowledge, skills, and judgement to prescribe and/or administer it, medications must be used to treat a condition that is within the midwifery scope of practice, and the medication’s use must be clinically indicated.

The College of Midwives does not provide funding. Midwives who require additional education to develop knowledge, skills, and judgment related to any aspect of their practice, or who are looking for information about funding agreements for midwives should contact the Association of Ontario Midwives.

Midwives who hold leadership roles within the hospital, such as lead midwives or head midwives, are primarily responsible for notifying hospital administration of changes to the Designated Drugs and Substances Regulation under the Midwifery Act, 1991. Lead midwives should be open to collaboration with hospital leaders such as the Chief of Medicine, the Medical Advisory Committee, and the Chief of Obstetrics to adapt any current processes that would need to change in light of the new regulation. The College of Midwives of Ontario has prepared a letter notifying hospitals to the changes contained within the Designated Drugs and Substances Regulation, which can be provided to midwives in order for them to communicate with their hospitals about these updates.

The College of Midwives of Ontario has also sent a letter to other health regulatory colleges, including the College of Physicians and Surgeons of Ontario, the College of Nurses of Ontario, and the Ontario College of Pharmacists, advising these regulators of changes to the Designated Drugs and Substances Regulation, with a request for them to share this information with their registrants.

The College’s Policy on Controlled Drugs and Substances Education and Training or Course Requirement refers specifically to Schedule 4, controlled drugs and substances, i.e. opioid analgesics. Each midwife will have unique education requirements dependent on their route of entry into midwifery practice and their background education. Midwives can consult the Policy on Controlled Drugs and Substances Education and Training or Course Requirement to understand exactly which education requirements apply to them.

For all other drugs and substances listed in the new regulation, it is the midwife’s responsibility to ensure that they have the knowledge, skills, and judgment to prescribe and administer medications contained within the list. Midwives will find a variety of clinical resources through the Association of Ontario Midwives and through other education centres to renew, refresh, or review their understanding of each drug or substance and their use.

The Designated Drugs and Substances Regulation, section 4(1) reads:

Section 4 (1) For the purposes of paragraph 5 of section 4 of the Act, a member may, in a public hospital, on the member’s own responsibility, administer by injection a substance set out in Schedule 4 to this Regulation…

Schedule 4 lists controlled drugs and substances fentanyl citrate, meperidine, morphine sulfate, and nalbuphine, which are all opioid analgesics.

All medications in the regulation must be used to treat a condition that is within the midwifery scope of practice, and the medication’s use must be clinically indicated. As such, the only use for the opioid analgesics listed above is for intrapartum pain management in a hospital setting.