1. 1 Primary Midwifery Care Midwifery Clinical Skills Primary Care Workshop 2012 Adpated from Judy Rogers’ Presentations 2011

2. Outline of workshop Part 1: Primary care -10 min Part 2: Regulatory framework – 30-40 min Part 3: Care Planning – 20 min Part 4: Primary Care Pitfalls 2

3. PART ONE: PRIMARY CARE Autonomous Provides care fully within scope Legally Responsible/ Accountable One Named Primary Care Giver (MRP) First Contact Hospital Admitting and Discharge privileges Broad Scope, Standards and Education = decision making and clinical judgment Woman as Primary Decision Maker + Midwife as Primary Caregiver = Shared Decision Making and Shared Responsibility

4. 4 Getting the “Big Picture” of Primary Care Communication with Clients Informed Choice Teaching Support Labour support Emotional Physical Documentation Paper Computer Home/hospital Collaboration With woman and family With second midwife With other health professionals EMS Monitoring Fetal Wellbeing Maternal Wellbeing Progress Care Management Decision Making Care Planning Evaluating Reformulating Environment Woman Centred Safety Equipment/Drugs Clean Up

5. 5 Primary Care Role CMO Registration Regulation : “primary caregiver” means a health care practitioner... Who acts as the first point of access to care for women seeking care during pregnancy and who functions without the supervision of a member or a member of another health care profession, making autonomous decisions with full responsibility for the care provided”

6. 6 Primary Care Role: Effective Interprofessional Collaboration Guided by principles of mutual respect and safe “woman-centred” care Clear formal communication With consultant With client Requests for consultation can be written or verbal Consultation involves an in-person assessment of the client by the consultant

7. 7 Primary Care Role: Effective Interprofessional Collaboration A midwife as primary care provider determines the indication, who to consult with and when Midwife takes responsibility for standards, policies and protocols Clear statement of reason, relevant Hx, expected outcome, client preference Clarity about who is in charge Well documented

8. PART TWO: REGULATORY FRAMEWORK Objective: To review the relevant legislation, CMO regulations and standards relevant to midwives in their role as primary caregivers

9. Primary Care: Regulatory Framework The Midwifery Act 1991 An Act Respecting the Regulation of the Profession of Midwifery Midwifery Act was previously bill 56 After it was passed the regulations were worked out; proclaimed December 31 1993 – (in effect since 1994)

10. Primary Care: Regulatory Framework ABORIGINAL EXEMPTION CLAUSE 8. (1) No person other than a member shall use the title “midwife”, a variation or abbreviation or an equivalent in another language. (2) No person other than a member shall hold himself or herself out as a person who is qualified to practise in Ontario as a midwife or in a specialty of midwifery. (3) An aboriginal person who provides tradtitional midwifery services may, (a) use the title “aboriginal midwife”, a variation or abbreviation or an equivalent in another language; and (b) hold himself or herself out as a person who is qualified to practise in Ontario as an aboriginal midwife. (MIDWIFERY ACT 1991) RESTRICTED TITLES

11. Primary Care: Regulatory Framework The practice of midwifery is the assessment and monitoring of women during pregnancy, labour and the post-partum 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.

12. Primary Care: Regulatory Framework The College of Midwives of Ontario (CMO) was established with the proclamation of the Regulated Health Professions Act and the Midwifery Act on December 31, 1993 to govern midwifery in the interest of public safety by: The CMO regulates the practice of the profession and governs members according to legislation, regulations, and by-laws The CMO sets standards of qualification for persons to be issued certificates of registration Responds to complaints from the public regarding midwifery practice Develops, establishes and maintains standards of professional ethics for the members; ensures members provide competent and ethical care to the clients they serve.

13. Primary Care: Regulatory Framework The CMO establishes standards that ensure its members are responsive to individual and community needs. The CMO promotes a model of care for the profession that encourages informed choice for the client and participation of women by providing standards and guidelines for the midwives that ensure quality of care and protection of the public. The CMO accomplishes these goals in an atmosphere that is responsive to the public and its members

14. Primary Care: Regulatory Framework From the Midwifery Act 1991: “In the course of engaging in the practice of midwifery, a member is authorized, subject to the terms, conditions and limitation imposed on his or her certificate of registration, to perform the following: 1. Managing labour and conducting spontaneous normal vaginal deliveries 2. Performing episiotomies and amniotomies and repairing episiotomies and lacerations, not involving the anus, anal sphincter, rectum urethra and periurethral area. 3. Administering, by injection or inhalation, a substance designated in the regulations 4. Putting an instrument, hand or finger beyond the labia majora during pregnancy, labour and the post-partum period. 5. Taking blood samples from newborns by skin pricking or from women from veins or by skin pricking. 6. Inserting urinary catheters into women. 7. Prescribing drugs designated in the regulations.”

15. Primary Care: Regulatory Framework Law/Statute – Section E RHPA – Authorized Acts Midwifery Act – Scope of Practice and Authorized Acts Regulations – Section F Designated Drugs Records Standards – Section G Indications for Mandatory Discussion, Consultation and Transfer of Care (IMDCTC) Indications for Planned Place of Birth Standard on Records Content Standard on Shared Primary Care Policies – Section H Statement on Home birth Policy on Primary Care Guidelines – Section I Management of Labour as a Controlled Act for Midwives Laboratory Testing Diagnostic Imaging Shared Care with a Consulting Health Professional

16. Primary Care: Regulatory Framework – Responsibilities Management of labour is defined as professional responsibility and accountability accepted by a primary caregiver for decision making and the independent carrying out of controlled acts within the scope of midwifery practice. The responsibility to consult with a family physician/general practitioner, obstetrician and/or specialist physician lies with the midwife It is also the midwife’s responsibility to initiate a consultation within an appropriate time after detection of an indication for consultation. The severity of the condition and the availability of a physician(s) will influence these decisions.

17. Primary Care: Regulatory Framework – Responsibilities substances that a member may administer by injection on the member’s own responsibility: substances that a member may administer by inhalation on the member’s own responsibility: Designated drugs which members may prescribe: ALSO: a member may use a drug on the order of a member of the College of Physicians and Surgeons of Ontario; a member may administer any substance by injection or inhalation on the order of a member of the college of Physicians and Surgeons of Ontario (O. Reg. 13/10, s.3) And, a member may administer, prescribe or order any drug or substance that may be lawfully purchased or aquired without a prescription (O. Reg. 884/93, s.5.)

18. Primary Care: Regulatory Framework – IMDCTC The informed choice agreement between the midwife and the client should outline the extent of midwifery care, in order to make clients aware of the scope and limitations of midwifery care. The midwife should review the Indications for Mandatory Discussion, Consultation and Transfer of Care with the client

19. Primary Care: Regulatory Framework – IMDCTC Applies to all aspects of midwifery care Initial History and Physical Examination Prenatal Care During Labour and Birth Post Partum (Maternal) Post Partum (Infant)

20. Primary Care: Regulatory Framework – IMDCTC Category 1: Discussion Discuss with another midwife (midwives) or with a physician, with whom the care is shared, in order to plan care appropriately: Examples from the IMDCTC document adverse socio-economic conditions history of infant over 4500g presentation other than cephalic at 36 completed weeks no prenatal care failure to pass urine or meconium within 24 hrs of birth

21. Primary Care: Regulatory Framework – IMDCTC Category 2: Consultation ( with a physician) The need for consultation is identified by the midwife; the request for consultation is initiated and clearly communicated by the midwife The consultation process includes an in-person assessment of the client, prompt communication of findings & recommendations by the consultant to the midwife; DOCUMENTATION Primary care either stays with midwife or transferred to physician – clearly communicated to client Examples from the IMDCTC document: Significant use of drugs or alcohol Hyperemesis Prolonged active phase of labour Infant less than 2500g

22. Primary Care: Regulatory Framework – IMDCTC A Midwife must: 1. Initiate consultation 2. Clearly indicate that she is seeking a consultation 3. Request the opinion of a physician who is competent to give advise in the relevant field 4. Document consult 5. Discuss recommendations with client (including who will continue with primary care)

23. Primary Care: Regulatory Framework – IMDCTC Category 3: Transfer to a physician for primary care Physician takes over primary care role Midwife often takes on supportive care – see CMO standard on supportive care Examples from the IMDCTC document: Hx: any serious med condition (cardiac renal disease with failure or insulin dependent diabetes mellitus) Prenatal: insuline dependent diabetes, multipes (>twins) labour: active genital herpes, PTL (<34 wks) Pp maternal: hemorrhage unresponsive to therapy, uterine prolapse Pp infant: APGAR <7 @ 10 min, suspected seizures, major congenital condition requiring immediate intervention

24. PART THREE: Care Planning Care planning requires a systematic process of assessment and knowledge application in order to determine the kind of care that is appropriate & the necessary steps i.e. routine care, midwifery interventions, increased midwifery monitoring, more frequent reassessment, consultation, transfer of care, medical monitoring or intervention

25. Care Planning: Communication Communication about care plans is an integral part of informed choice Effective communication is an essential component of risk management a clear plan can help woman/partner to cope with challenging situations, such as: pregnancy problems, prelabour, early labour, active labour, breastfeeding problems Important to communicate with your preceptor: “What’s your plan?” Important to communicate with other care providers part of documentation part of consultation

26. Care Planning: How to make a plan When making a care plan it is important to be methodical but not mechanical. Each step is vital, but cannot necessarily be done in a set order eg. a “hunch” or preliminary assessment may precede and inform how you gather subjective and objective information. You may need to plan in order to get objective information or more subjective information. Once you have done all of the steps you may need to go back to the beginning. Be flexible and use common sense the bottom line: you need a plan that is informed by and consistent with the clinical picture.

27. Care Planning: How to make a plan What SUBJECTIVE information do you have? What is the woman reporting? Why is she calling? What is the story the woman/parents are telling you? What is the response to your questions?

28. Care Planning: How to make a plan What are your OBJECTIVE findings? Vital signs, abdominal palpation, physical assessment of woman or newborn. Remember to consider relevant health hx, lab and ultrasound, findings, pregnancy progress

29. Care Planning: How to make a plan What is/are your ASSESSMENT/s? What do you think is happening; Is it normal or abnormal? What is your differential Diagnosis? “…it is most likely a horse but it could be a pony, a zebra or even a unicorn..”

30. Care Planning: How to make a plan Based on your assessment, what needs to be done: further investigations, routine care, education, support, monitoring, consult/transfer, interventions? What is your plan? What will you do? Communication & Documentation

31. Care Planning: How to make a plan EVALUATE - is you plan working? What are the results of monitoring, consultation, intervention? REVISE - based on ongoing collection of S and O information

32. 32 PART FOUR: Dilemmas of Primary Care

33. 33 Dilemmas: Giving Over/Avoiding Responsibility too tired/ too busy role confusion lack of knowledge fear avoiding making own assessments/ decisions letting other caregivers opinions override your own judgments avoiding giving bad news normalizing/pathologizing psychologizing using informed choice to avoid taking responsibility

34. 34 Dilemmas: Taking On Too Much Responsibility too tired/too busy protecting clients protecting co-workers role confusion lack of knowledge Ego: “I can do this so I should” desire to be part of team/ “help” other care providers avoiding giving bad news normalizing/pathologizing psychologizing denial

35. 35 Avoiding Pitfalls & Exemplary Care Don’t ignore a situation that doesn’t make sense Communicate formally with clients and other caregivers Share the decision making process without avoiding responsibility Claim your fullest scope but know your limits Do your own assessments Phone assessment is not full assessment Hallway chats are not consults Avoid “cover yourself”/convenience use of other health services Role clarity avoids many problems

36. 36 Avoiding Pitfalls & Exemplary Care If you don’t like a policy/protocol regulation, change it Don’t blame others/avoid victim stance Take problems to the appropriate people and expect interprofessional respect and collaboration The gold standard is the CMO but local variations and interprofessional standards apply and evolve Know the difference and work for the broadest and most flexible midwifery system to meet women’s needs Good practice may lead regulatory/policy change