Midwifery Scope of Practice, Midwifery Act, 1991
"The practice of Midwifery is the assessment and monitoring of women during pregnancy, labour and the postpartum 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."
STATISTICS
Data from births from 1997 onward has been collected without any identifying information such as name or address. If you wish that your care not be included, please inform us. We hope to provide statistics relevant to our practice in the near future.
Currently available information from a few, randomly assigned midwifery practices in Ontario show that the caesarian rate is 6% (compared to 20% for physicians), an 8% episiotomy rate (50% for physicians), a 95% rate of successful breastfeeding at 6 weeks, and a 5% rate of epidural for pain relief (30% for physicians and 90-95% for most downtown hospitals, 70-75% for southern Ontario). Ontario midwives attend 40% of their births in the home setting (just less than 1,500 births in 1996).
SERVICES
Prenatal Care
Regular prenatal care is required for all clients. These visits are not only a safeguard for your health, but give you the opportunity to learn more about your body and your baby as your pregnancy progresses. Care includes monitoring maternal and fetal well-being, as well as establishing a relationship based on trust. Copies of records of care previously provided in pregnancy facilitate the care we provide.
Midwives, like physicians, can order lab tests and ultrasounds and can write prescriptions for certain products (currently not antibiotics or pain medication). We proved Informed Choice counseling for prenatal testing and refer to genetic specialists as needed.
Obstetric Ultrasound
OHIP will pay the cost of two (2) ultrasounds for low risk pregnant women. Additional ultrasounds are covered by OHIP only for clinical indications. There is good research to support not performing routine ultrasound in pregnancy. As midwives, we are comfortable following a normal, healthy pregnancy without the routine use of ultrasound.
Appointments
It is your responsibility to attend prenatal appointments. Women are seen once a month until 28 weeks of pregnancy, every two weeks from 28-36 weeks, and once a week thereafter until delivery. Appointments are booked to be 30-40 minutes; the booking (or first) and discharge (or final) visits are usually 90 minutes. If you require additional time with your midwife, please discuss this with her.
Prenatal appointments are conducted in the clinic. Women planning a home-birth will receive a visit at home at about 36 weeks of pregnancy to facilitate the midwife's knowledge of the environment and parking.
Street meters are available along Roncesvalles Avenue. The building is considered wheelchair accessible from Roncesvalles Avenue. It has an elevator and wheelchair washroom. If you or your partner is in a wheelchair and cannot access to our office, please speak with your midwife about alternate arrangements.
Partner Involvement
Your family, as you define it, is encouraged and welcome to attend appointments with you as often as you wish. We especially wish to meet with your partner by 36-37 weeks of pregnancy to discuss birth plans and care after the birth.
Sibling at Clinic and Births
If you are planning sibling participation at your birth, we suggest that you do bring your children with you occasionally to your appointment. We provide some toys and books to amuse your children, but we do expect you to provide supervision.
Children at Births
If you are planning sibling participation at your home or hospital birth we require that you have someone other that your partner or primary labour support person to be responsible for the child/children. This caretaker should be comfortable with your birth plans and be aware that she or he may have to leave the birth with the older child as needed.
Clients with a first Language other than English
Due to extensive costs of hiring translators we request that clients who do not speak English well have a trusted translator attend all the visits with the midwife, the birth and postpartum visits. We can provide telephone numbers for translation services.
Natural Childbirth
Midwives are specialists in aiding women through labour without the use of pain medication. The vast majority of clients in our practice deliver "naturally". The most commonly used pain medication for labour in Southern Ontario hospitals is the epidural (anesthetic administered by a specialist in the spine). Women requesting an epidural in labour may be transferred to an obstetrician for the birth.
Labour and Delivery
Initial labour contact with your midwife is by pager. The midwife generally attends in person once your active labour is established. Clients planning a hospital birth often labour at home with the midwife and move to the hospital in well-established active labour. Your second midwife arrives closer to the time of the birth.
We expect that clients will have labour support, and usually this person is her partner. If her partner is unable or unwilling to be at the labour and birth, someone else (a friend or relative) should be with the woman because midwives attend in active labour only. Each midwife and all second attendants in Midwife Alliance are certified in NEO, natal resuscitation, CPR and obstetrical emergency skills.
Postpartum Care
We remain with you in the immediate postpartum period for two to four hours and continue the 24-hour on call care until the discharge visit, at approximately six weeks. We urge parents to contact their midwife at any point if there are concerns or urgent questions. A midwife will visit the woman and her new baby within 24 hours and on at least 3 other occasions in the 2 weeks after the birth at either your home or in the hospital.
Midwives monitor both the mother and baby's progress, ensure that breast-feeding is well established and provide valuable emotional support for new parents. Care with your midwives offici8ally ends at the six-week postpartum visit, at which time care is transferred to your family physician.
Prolonged Hospital Stay
In the event your midwife suggests you stay longer than about 3 hours after birth, you and your baby are transferred to a room in the postpartum section of the hospital. Healthy babies are expected to "room in" with the mother (i.e., the mother and baby are continuously together). Women who have had a caesarian section for the birth usually remain in the hospital for 2-4 days postpartum. Babies who are admitted to the Special Care Nursery are under the care of a pediatrician.
Early Discharge from Hospital
We promote early discharge from the hospital; our clients are discharge from the birthing room to home at about three hours after the birth. This discharge time is not restricted to a 9-5 period and can take place at anytime - day or night. With midwifery support and 24 on call coverage, early discharge is considered reasonable, for healthy women and babies.
Shared Care
Each woman is considered to be a client of the entire practice and we work in partnership to provide shared care. This means we share all aspects of your care. Your primary team (#1) will see you most frequently, your backup team (#2) sees you less frequently and the third on-call team (#3) sees you once in late pregnancy. In the circumstance of simultaneous births, you may have another midwife from the practice at your birth.
One midwife from your primary team (#1) attends to you throughout your labour, remains postpartum and conducts the majority of the postpartum care. One midwife from your backup team (#2) is called by the first midwife closer to the actual time of the birth so that there are two midwives at each birth for both home and hospital deliveries.
If there are issues that you wish to address, discuss them with your primary midwife. If this is unsatisfactory, or if there is a conflict, please contact your backup midwife. All client concerns are ultimately dealt with by the practice at large and we endeavor to meet the needs of clients as best as we are able.
On-Call/Off-Call
Midwives carry pagers and when on call, can be reached 24 hours a day for urgent concerns and labour calls. Generally midwives in this practice take one-month off-call for every five months of continuos work. We do not book due dates two weeks prior to and following the month off-call. This on-call/off-call schedule helps ensure the provision of Continuity of Care.
Alternative Care
As per the standards of the College of Midwives of Ontario (CMO), two midwives attend every delivery. The CMO has approved our practice the use of a second attendant. While the midwife is entirely responsible for primary care throughout the course of care, a Second Attendant is an assistant to the midwife during the birth and the immediate postpartum period. The Second Attendant is not a midwife and does not provide care in the absence of a Registered Midwife. Your midwife may request backup from emergency services (911) at a planned home birth in the absence of the backup midwife or Second Attendant, and/or in the event of complications.
In rare circumstances a non-midwife who has been assessed and accepted by the College of Midwives as a Second Attendant may act as a back-up at a birth. A Second Attendant is certified in neonatal resuscitation and obstetrical emergency skills. She is not a primary health care provider. The labour and delivery nurses at St. Joseph's Health Center are available in the role of a Second Attendant for planned hospital births that occur prior to the backup midwife arriving.
Transfer of Care
Midwives are specialists in normal and low risk birth. When care extends beyond the midwife's Scope of Practice, she is expected to ensure that adequate care with the proper professional is obtained. We do not accept women into care who are deemed to be high risk from the outset. In labour, in the event of a complication or emergency, at home or in the hospital, the midwife consults with the obstetrician or pediatrician on-call at St. Joseph's Health Centre. The on-call schedule of the obstetric department at St. Joseph's department cannot provide a female obstetrician upon request. You will be provided with a copy of the CMO Indications for Mandatory Discussion, Consultation and Transfer of Care at your booking visit. When care is transferred to an obstetrician in labour, the midwife will remain with the woman and her family to provide support. For example, in the event of a caesarian section, the obstetrician would take over primary care of the woman. In instances where all is well with the baby, the midwife remains as the baby's care provider.
Additional CMO guidelines (such as Guidelines to Ante-partum Consultations for Clients of Midwives to Anesthesia) are available in the lending library.
St. Joseph's Health Centre
St. Joseph's Health Centre (SJHC) is a level II hospital capable of caring for obstetrical emergencies. SJHC provides continuos 24 hour obstetric, anesthetic and pediatric coverage. The labour and delivery unit has private birthing rooms where the woman labours, delivers and remains for about 3 hours postpartum. Tours of the hospital are available (416-530-6367). SJHC has a level II nursery for those infants requiring close medical supervision under pediatric care.
Midwifery Students
We are a teaching practice for the university midwifery program, which includes clinical teaching and supervision of midwifery students. Because of the importance of educating midwives, we encourage you to include students in your care. We also respect your need to meet and feel comfortable with any student who may be involved in your care. Students are involved in all aspects of midwifery care and are always under the supervision of the senior midwife. Their biographies will be provided to you at the point we receive them.
Confidentiality
We make every effort to maintain the confidentiality of your records. There may be times, however, when we must share with other midwives or physicians information, which may be significant to our care of you. Specific details of your case may also be required during a peer review. Names and identifying information are not released.
Due to the relationship, which often develops between clients and midwives, clients may reveal to the midwife details of past sexual abuse by previous health care providers. If the name of the alleged abuser is disclosed to us, we are required by law to report them to their College or professional association.
We do teach other parents by telling birth stories. While no names are mentioned, someone may recognize your birth in that story. Please tell us if you want no mention made by us of your experience.
Risks and Benefits of Place of Birth
Research indicates that the vast majority of births in North America are low risk. There are risks and benefits to both home and hospital deliveries and we encourage clients to carefully evaluate the choice of either settings. Minor complications are not frequent and midwives have extensive experience and training to detect and respond to each situation. True obstetric emergencies are rare. Midwives in this practice are certified in Neonatal Resuscitation, Emergency Obstetrical Skills and Adult CPR. We encourage our clients to speak with us regarding specific concerns that they might have.
In reviewing the risks and benefits of place of birth, be aware that no place is "risk free". Your choice of birthplace needs to reflect your process of informed decision making.
Home Birth
Research done in Canada and around the world includes that home birth is a safe option for healthy, low-risk women. Although we routinely carry emergency equipment (such as oxygen) and supplies (such as anti-hemorrhagic drugs) to home births, in some rare emergencies the technology available only in a hospital would be essential for the well being of baby, mother, or both. Most complications can be dealt with safely at home, or after transport to the hospital. Families choosing to birth at home cite the convenience, comfort, and reduced rates of intervention and infection in their decision making. "Birth is more than a physical or medical event" (CMO, 1994).
There are times when a midwife will recommend a change of plans from a planned home birth to a planned hospital birth. This may be for medical or social reasons.
Hospital Birth - St. Joseph's Health Centre
The College of Midwives of Ontario recommends a planned hospital birth in the following circumstances:
Multiple birth (i.e. twins)
Breech presentation
Pre-term labour prior to 37 weeks of pregnancy
Documented post-term pregnancy of more than 43 completed weeks
A transfer to St. Joseph's Health Centre would occur if a complication arises during a home birth. In the event of an emergency, we transport to the nearest hospital if there are time constraints. When we are in a hospital other than St. Joseph's Health Centre, we do not have privileges but continue to provide supportive care.
Responsibilities of Parents
Midwifery care is a relationship of trust and communication. The following suggestions indicate the level of involvement we encourage of our clients.
We encourage you to be as frank and honest with as possible with our midwives, discussing issues with us as they may arise. Developing a trusting relationship is considered an important part of your care with us. We strongly believe in a "harm reduction" approach to substance use. Please advise your midwives if at any time during your care that you have used prescription medications, over-the-counter drugs, street drugs, alcohol, tobacco, and herbal or homeopathic remedies.
Whether clients are planning a home or hospital delivery, we encourage you to visit the maternal and newborn centre at SJHC. Please arrange a tour of the labour and Delivery unit. These are offered twice monthly and book up quickly. Call 416-530-6367 to reserve a space.
To deliver at home or labour at home for a hospital birth, your home must have heat and running water. Your home need not be "sterile''; it should, however, be clean.
We provide home birth parents a kit of some medical supplies in addition to the list of required supplies. We require parking immediately near your home for the birth and postpartum visits because we carry quite a lot of heavy equipment. If you do not have parking, we ask that you let us know well in advance of your due date. We are proponents of breast-feeding and encourage you to make contact with La Leche League prior to your birth (416-483-3368) or attend the free breast-feeding class at St. Joseph's Health Centre (416-530-6367)
Urgent Midwifery Related Concerns
Clients are expected to page a midwife for urgent midwifery concerns.
Non-Urgent Midwifery Related Concerns
In non-emergencies leave a message with your full name, work number, and your home phone number on the midwife's voice mail at the office. We are attentive to your messages and we try to return them within two to three working days.
Non-Midwifery Concerns
We do not treat or diagnose non-midwifery medical problems. For asthma attacks, open wounds, broken arms, concussions, pneumonia, allergic reactions, etc., please contact your family practice physician or nearest emergency room. We cannot list every urgent maternal or infant problem. Please use your own judgement and page your midwife with immediate concerns regardless of the time.
