The College provides advisory services for midwives and members of the public who have questions about College standards, and the legislation and regulations that govern midwifery practice in Ontario.
The inquiries 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’ve included answers to many of these common requests for clarification or information below.
You can also learn more about the scope of practice and professional standards in those sections of our website.
If you have a question that you don’t see addressed on this page, please contact our professional practice advisor at 416.640.2252 or by email at email@example.com.
When a client declines aspects of care
Case scenario: A midwife is caring for a client planning a home birth. At 35 weeks gestation the client tells their midwife they want to labour and birth on their own, without any interventions, and they will not call a midwife to attend. The midwife explains to the client the research on the safety of home birth with a trained care provider and recommends the client plan their home birth with a midwife in attendance. The client reaffirms her desire to birth without midwives in attendance and to have midwifery care during the postpartum.
What should midwives consider when managing caseloads during staffing shortages?
Case scenario: A midwifery practice group has recently lost two midwives to unexpected leaves of absence. The midwives were both part of separate shared care pods where midwives were on call one week, off call but doing clinic one week and on vacation the third week. Since the midwives went on leave one week ago, there are 60 clients who no longer have a midwife assigned to them and two pods that are short one midwife.
When must a midwife stop providing care to a client?
Case scenario: Midwife B discharged her client once the full course of midwifery care had been provided. Care was then transferred to the client’s family physician. Midwife B received a phone call from the former client a few days later, stating that her baby’s skin appeared to be yellow and asking if Midwife B could come over to look. Midwife B asked the former client to text a picture of her baby. She also asked the former client if the baby had a fever, which the former client confirmed. After looking at the baby’s picture on her phone, Midwife B told the former client that her baby had jaundice, and to contact her family physician for further care.
When can midwifery students be involved in a client’s care?
Case scenario: Midwife M told her client at their first appointment that a student would be involved in the client’s care. When the client was in active labour at the hospital, the student attended to the client and checked the fetal heart rate without Midwife M present in the room. The client was surprised that Midwife M wasn’t present for this. The student advised the client that Midwife M was outside the door of the room completing charting and could be called in to attend to the client if the client wished for her to be present.
Common Practice Advice Questions
Scope of Practice
According to the Midwifery Act, 1991, the scope of midwifery practice includes:
- assessment and monitoring of pregnant people during pregnancy, labour, and the post-partum period and of their newborn babies,
provision of care during normal pregnancy, labour, and the post-partum period, and
- conducting of spontaneous normal vaginal deliveries.
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.
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, they should transfer the client’s care to a midwife or physician who is competent to provide it.
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 to resume primary care if it returns to the scope of practice or to assume responsibility for the newborn.
A decision tree on the midwifery scope of practice can be found in the College’s Midwifery Scope of Practice document.
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.
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.
Midwives are not authorized to perform newborn tongue-tie release unless under delegation.
Midwives are authorized to provide care to a newborn when the newborn’s mother is not in midwifery client if the care provided is within the scope of midwifery practice.
Prescribing Drugs and Ordering and Performing Tests
Midwives are authorized, under the Midwifery Act, to perform the controlled act of prescribing drugs designated in the regulations. This means that a midwife prescribing drugs is limited to:
- those drugs that are listed in the Designated Drugs Regulation
- any drug that can lawfully be purchased without a prescription. To determine if a drug can be purchased without a prescription, consult Health Canada’s drug database.
Midwives are permitted to use any drug on the order of a physician and may prescribe under delegation.
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 for midwives.
The controlled act of dispensing only applies to prescription drugs and does not apply to drugs that can be purchased without a prescription.
Midwives are authorized to order all laboratory tests listed in Schedule 2: Tests — Requisition By Midwife, Section 18 of General Regulation 45/22 under the Laboratory and Specimen Collection Centre Licensing Act R.R.O. 1990.
Some tests in Schedule 2 are specific to diagnosing only one condition. For example, test #2, Bilirubin-conjugated, is a test that can be ordered for diagnosing only one condition (i.e., hyperbilirubinemia).
Other tests in Schedule 2 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.
Midwives do not have the authority to perform point-of-care tests for diagnosis and treatment of their clients. Healthcare professions that are permitted to perform point-of-care tests must have an exemption in the General Regulation (O. Reg. 45/22) under the Laboratories and Specimen Collection Centre Licensing Act, 1990, and midwifery is not one of the exempt professions.
However, midwives are permitted to collect specimens and perform point-of-care tests for COVID-19.
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.
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.
Learn more about the expectations of midwives regarding delegation on our Standards of Practice page.
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
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 in accordance with the Second Birth Attendant Standard.
A second birth attendant may be a registered nurse attending a home birth or a retired midwife for example. A second birth attendant cannot be a midwife registered in the inactive class.
A midwife working with a second birth attendant must practise according to the Second Birth Attendant Standard which 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 profession’s scope of practice or perform them under delegation from the midwife.
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 helpful resource for more information about documentation.
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.
There are two possible ways to ask this question.
- I am not comfortable providing care because I don’t agree with the client’s choices
Clients have the right to accept or refuse treatment based. 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.
- 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.
In all situations, a midwife must never abandon a client in labour.
More information on discontinuing client care can be found in the College’s Guide on Ending the Midwife Client Relationship.
The 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 its intake process. The intake process must be clear to clients prior to intake, and it must be defensible.
Members 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. Learn more in the College’s Inactive Class Information document.
COVID-19 FAQs for Midwives
When practising remotely, midwives should continue to document their findings in accordance with College standards and take every reasonable precaution to protect the confidentiality and privacy of their clients’ personal health information.
Health Quality Ontario has developed draft clinical guidance for health care professionals providing care remotely.
Midwives remain accountable and responsible for clients in their care and their professional decisions and actions must always be justifiable. The College recognizes that midwives may not be able to meet all College standards and that there may be a need to adjust their practice to be able to provide appropriate care to their clients and newborns.
It is therefore important that if midwives cannot meet a standard of the profession, they must ensure that their clients receive the best care possible in the current circumstances and document the rationale for any decisions they make.
In some cases, midwives will know in advance that they cannot meet a particular standard.
One example of this is when midwives cannot meet the Second Birth Attendant Standard because they plan to work with second-birth attendants who do not have a current certificate in Neonatal Resuscitation or an obstetrical emergency skills program.
In this example, midwives may apply for a waiver from these requirements of the Second Birth Attendant Standard because of extenuating circumstances (e.g., if courses in NRP or obstetrical emergency skills are not being offered).
More information on the waiver policy, including the Application for a Waiver of Standards, is available on the College’s website. Any questions about waivers can be directed to firstname.lastname@example.org.
Midwives should exercise professional judgment in every situation to provide care that is in their clients’ best interest within the limits of their competence and the midwifery scope of practice that is in line with any directive or current guidance available from Public Health, the Ministry of Health, and the hospitals where they hold privileges.
The College of Midwives of Ontario, as a health care regulator, does not have a policy regarding mask wearing for midwifery clients but does require midwives follow current best practice for infection prevention and control. There is no longer a Ministry directive requiring all individuals wear masks in healthcare settings however there remain recommendations regarding clients with suspected or confirmed COVID-19.
Midwives must work in accordance with the rules set by each of the locations where they practise, including their midwifery practice group policies, institutional policies (e.g., hospitals), and community standards. Some of these locations may have implemented their own rules regarding mask-wearing for clients that midwives and their clients will be required to follow.
COVID-19 vaccines are not included in the Designated Drugs Regulation so midwives are not authorized to administer them on their own authority. COVID-19 vaccines should only be administered by a midwife using an order or under delegation.
Yes. Midwives are authorized to order—for midwifery clients and their newborns—laboratory testing for COVID-19, as it is considered “virus isolation.”
Disclosing your immunization status for COVID-19 is a personal decision, as it is personal health information covered under the Personal Health Information Protection Act. However, certain situations may arise where a midwife has a professional obligation to make a disclosure in the interest of client and public safety.
If there is a realistic possibility of COVID-19 transmission to a client that would be mitigated if the midwife were vaccinated, there may be a duty for the midwife to proactively notify the client of their immunization status.
The College of Midwives is not currently requesting or expecting disclosure of a registered midwife’s COVID-19 status or immunization status to the College.
Yes. If a client wishes to have their care transferred either because a midwife declines to disclose their immunization status, or because they disclose that they have not received a vaccination for COVID, the midwife should refer the client to another midwife or physician in accordance with the Standards of Practice.