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public can do it. But diagnosing someone with a disease or disorder based on thereading of that blood pressure (e.g., diagnosing a pregnant client with gestationalhypertension based on their blood pressure) is a controlled act. This is becausethere is not a great risk of harm in taking the blood pressure, but there may be arisk of harm when making a diagnosis based on that blood pressure.3LEGISLATIVE SCOPE OF MIDWIFERY PRACTICEThe legislative scope of midwifery practice consists of the scope of practicewives can order, and all other activities that202are in the public domain. This is commonly1statement, the controlled acts authorized to midwives, laboratory tests mid-referred to as the midwifery scope of practice. Inessence, the midwifery scope of practice is the ac-1,tivities, decisions, and tasks that a midwife is per-mitted to do by law. The midwifery scope is a legalneboundary; it is not flexible and cannot be expandedby practitioners, regulators, or institutions. ScopeThe midwifery scope is alegal boundary; it is notflexible and cannot beexpanded by practitioners,regulators, or institutions.Juchanges can only be achieved through a legislativechange.eScope of Practice Statement – Key Concepts and Definitionsiv3.1ctThe midwifery scope of practice statement is set out in the Midwifery Act:feThe practice of midwifery is the assessment and monitoring of women duringEfpregnancy, labour, and the post-partum period and of their newborn babies, theprovision of care during normal pregnancy, labour, and post-partum period andthe conducting of spontaneous normal vaginal deliveries.14The scope of practice statement uses several terms including postpartum,newborn, spontaneous, and normal that have no universal definition. In order to understand the scope, these terms need to be defined. The following aredefinitions of these terms for the purpose of interpreting the scope of practicestatement in the Midwifery Act, 1991. 14Newborn means a baby from the moment of birth up to eight weeks afterMidwifery Act at s. 3.COLLEGE OF MIDWIVES OF ONTARIO MIDWIFERY SCOPE OF PRACTICE 20216

birth. Note: Midwives are authorized to perform the controlled act of communicating a diagnosis only up to six weeks after birth. More on the controlled act ofcommunicating a diagnosis is described in Table 1. Normal means a clinical picture that is considered healthy or uncomplicated.Normal applies to the overall health status of the individual and does not necessarily rule out the presence of a specific condition or indicate the completeabsence of abnormal. Normal can include infections, conditions, or clinicalpresentations requiring monitoring or treatment when the overall healthstatus of the client or newborn is considered healthy or uncomplicated. Determining if a clinical situation is normal requires clinical judgment and mayPostpartum means the period of time beginning202 1also require diagnostic tests or consultations with other care providers.with the birth of a baby and ending eight weeksafter the birth when the effects of pregnancyon many systems have largely returned to the1,unpregnant state. Note: Midwives are authorizedto perform the controlled act of communicating anediagnosis only up to six weeks after birth. More ondescribed in Table 1. Juthe controlled act of communicating a diagnosis isSpontaneous means a birth that occurs withematernal effort only and is not assisted by anyNormal means an overallclinical picture that isconsidered low-risk oruncomplicated. Normalapplies to the overall healthstatus of the individualand determining if a clinicalsituation is normal requiresclinical judgment.ivmeans. A birth requiring forceps or vacuum isctnot spontaneous. Spontaneous refers only tofethe birth of the newborn and does not refer to the onset of labour and can Eftherefore include induction and augmentation.Woman means an individual who is pregnant, labouring, giving birth, orpostpartum. In this document, the terms “client” and “individual” will beused in place of woman unless woman exists in the language of the legislation.Using the definitions provided above, the midwifery scope of practice involvesproviding care to individuals during normal pregnancy, labour, spontaneous vaginal birth, and for up to eight weeks postpartum for both clients and newborns.Any person who falls outside of this time frame is not considered in the scope ofpractice, and midwives cannot provide care to them on their own authority. Thismeans midwives are not permitted to provide midwifery care to anyone who isnot pregnant or postpartum or who are not in labour or having a spontaneousCOLLEGE OF MIDWIVES OF ONTARIO MIDWIFERY SCOPE OF PRACTICE 20217

vaginal birth. Midwives also cannot provide midwifery care to babies over eightweeks of age.3.2Controlled Acts Authorized to MidwivesMidwives are authorized to perform a number of controlled acts. Controlledacts are only authorized to midwives while engaging in the practice of midwifery. All of the controlled acts authorized to midwives are authorized only partially, which means midwives do not have the authority to perform any of thecontrolled acts in their entirety. The details of the controlled acts are describedbelow in Table 1. Column 1 sets out the controlled acts authorized to midwivesas set out in the Midwifery Act and the Controlled Acts Regulation. Column 2to the authorized act.TABLE 12021interprets what midwives are permitted to do and not permitted to do, related Controlled acts authorized to midwives and their interpretationINTERPRETATION1,CONTROLLED ACTPERMITTED1. Communicating a diagnosis May communicate a diagnosis to a client identifying diseasesJuidentifying, as the cause of aand disorders, based on tests or investigations that a midwifewoman’s or newborn’s symp-is authorized to perform, for clients and newborns up to sixweeks postpartum.etoms, a disease or disorder thatmay be identified from the re-neAuthorized to midwives under the Midwifery Act, 1991:ivsults of a laboratory or other testNOT PERMITTED ctor investigation that a memberfeis authorized to order or performon a woman or a newborn duringEfnormal pregnancy, labour, anddelivery and for up to six weekspostpartum.Must not communicate a diagnosis identifying diseases anddisorders for individuals after six weeks postpartum or fornewborns who are older than six weeks. Must not communicate a diagnosis to a client identifyingdiseases and disorders, based on tests or investigations thata midwife is not authorized to order or perform.Note: Not every interaction with a client, in relation to their health or condition, constitutes communicating adiagnosis. It is generally accepted that communicating a diagnosis includes the following three components:1. It must identify the existence of a disease or disorder based on tests and investigations2. It must include direct communication with a client or their representative regarding the identified diseaseor disorder based on tests or investigations3. It must be reasonably foreseeable that a client or their representative will rely on this diagnosis to makechoices about treatment15.15Richard Steinecke, Complete Guide to the Regulated Health Professions Act, (Aurora, Ont: Canada Law Book, 1995).COLLEGE OF MIDWIVES OF ONTARIO MIDWIFERY SCOPE OF PRACTICE 20218

CONTROLLED ACTINTERPRETATIONThis means that communicating a diagnosis to another healthcare provider, communicating the results ofan assessment to a client or forming a hypothesis of what could be causing the symptoms do not fall withinthe controlled act of communicating a diagnosis and so can be performed for individuals up to eight weekspostpartum or for newborns who are up to eight weeks old.PERMITTED2. Managing labour and conducting spontaneousMay manage labours and only conduct deliveries that arespontaneous, normal and vaginal.normal vaginal deliveries.NOT PERMITTED Must not conduct deliveries that are not spontaneous, normal1and vaginal. into women.202PERMITTED3. Inserting urinary cathetersMay go beyond the opening of the urethra only for insertingcatheters into clients.NOT PERMITTEDPERMITTED episiotomies and lacerations,not involving the anus, analsphincter, rectum, urethra andlacerations and episiotomies that involve the skin and muscleof the perineum and labia.NOT PERMITTEDeperiurethral area.May perform episiotomies and amniotomies. May repairJuamniotomies and repairingne4. Performing episiotomies andMust not insert urinary catheters into newborns.1, Must not perform any other procedures below the dermis asiv Effectthey fall under the broader controlled act not authorized to5. Administering, by injectionor inhalation, a substancemidwives. This includes repairing tissues of the anus, analsphincter, rectum, urethral or periurethral area andperforming procedures such as acupuncture or newbornfrenectomies.PERMITTED May administer, by injection or inhalation, any substancethat is included in the Designated Drugs regulation underdesignated in the regulations.the Midwifery Act, 1991 such as nitrous oxide for inhalation,Hepatitis B vaccine by injection, or fluids throughintravenous catheters.NOT PERMITTED Must not administer by injection or inhalation a substancethat is not designated in the Designated Drugs regulation.COLLEGE OF MIDWIVES OF ONTARIO MIDWIFERY SCOPE OF PRACTICE 20219

CONTROLLED ACTINTERPRETATION6. Prescribing drugs designatedPERMITTED in the regulations.May prescribe drugs included in the Designated Drugsregulation and drugs that can be lawfully purchased oracquired without a prescription.NOT PERMITTED Must not dispense, sell, or compound a drug. Must not prescribe a drug that is not included in the regulation.PERMITTED7. Putting an instrument, hand or finger beyond the labia majoraMay perform procedures that involve hands, fingers orinstruments placed beyond the labia majora or anal verge.labour and the postpartumThis means midwives may perform numerous proceduresperiod.on clients including inserting a speculum into the vagina,2021or anal verge during pregnancy,inserting fingers, catheters or intrauterine devices into thevagina and cervix, inserting a finger into the rectum, andNOT PERMITTEDMust not perform a procedure on a newborn that goes beyondne 1,inserting a fetal scalp electrode.their labia majora or the anal verge.pregnancy, labour and themedications that are included in the Designated Drugsregulation under the Midwifery Act, 1991.NOT PERMITTEDctpostpartum period.May go beyond the anal verge for the purpose of administeringivbeyond the anal verge during edesignated in the regulationsPERMITTEDJu8. Administering suppository drugsEffe 9. Taking blood samples from Must not administer any medication beyond the anal vergethat are not included in the Designated Drugs regulation.Must not administer suppository drugs to newborns.PERMITTEDnewborns by skin pricking or May take blood samples from newborns by skin pricking only.from persons from veins or by May take blood samples from a client’s veins by venipunctureor by skin pricking.skin pricking. May take blood samples from a non-client if the test isrelated to the delivery of midwifery care to the client.NOT PERMITTED Must not perform venipuncture on newborns. Must not take blood samples from a non-client if the test isunrelated to the delivery of care to the client.COLLEGE OF MIDWIVES OF ONTARIO MIDWIFERY SCOPE OF PRACTICE 202110

CONTROLLED ACTINTERPRETATION10. Intubation beyond the larynxPERMITTED of a newborn .16May insert an instrument beyond the larynx of a newbornfor the purpose of intubation only.NOT PERMITTED Must not insert an instrument beyond the larynx of a newbornfor anything other than intubation. Must not insert anything beyond the larynx of an adult.PERMITTED by injection or inhalation ifMay administer by injection or inhalation any substancethat has been ordered by a physician.the procedure is ordered by amember of the College of202111. Administering a substanceNOT PERMITTEDPhysicians and Surgeons of Ontario.Must not administer by injection or inhalation a substancethat is not designated in the Designated Drugs regulation oris not ordered by a physician.nePERMITTED12. Applying and ordering the application of soundwaves1,Authorized to midwives under the Controlled Acts Regulation:May order and perform pregnancy diagnostic ultrasounds andpelvic diagnostic ultrasounds during the postpartum period.Jufor pregnancy diagnosticExamples include routine fetal assessment, confirmation ofultrasound or pelvic diagnosticplacental location and retained products of conception.eultrasound17.Must not order or perform diagnostic ultrasounds for conditions that are not related to pregnancy, birth or postpartum,3.3Effe ctivNOT PERMITTEDor on parts of the body that do not include the fetus or pelvicorgans. Must not order or perform ultrasounds on newborns.Practising to the Full Legislative ScopePractising to the full legislative scope, also known as full scope midwifery, meansproviding all aspects of midwifery care scope including labour, birth, postpartum16Under the Midwifery Act, a midwife is only authorized to perform this procedure when performed inaccordance with the Intubation of a Newborn requirements set out in the General Regulation O. Reg.335/12, 1991 c. 31. S. 15.1.17This controlled act is authorized to midwives by way of an exemption under s. 4 of the ControlledActs Regulation under the RHPA. The exemption means midwives are permitted to apply and performpregnancy and pelvic diagnostic ultrasounds but the authorization to do so is not found in the MidwiferyAct, 1991 with the other authorized acts.COLLEGE OF MIDWIVES OF ONTARIO MIDWIFERY SCOPE OF PRACTICE 202111

and newborn care, including all of the authorized acts.The ability to work to the full midwifery scope is influenced by intrinsic and extrinsic factors. Intrinsic factors are personal factors, such as being a new midwifewho has not been exposed to all of the procedures required to work to full scopeor a midwife who has an injury that limits their ability to provide all aspects ofmidwifery care. Midwives cannot, however, limit their scope of practice in contravention of provincial or national laws. For example, a midwife cannot use discretion over their own scope of practice to exclude individuals from care based onone of the protected grounds in the Ontario Human Rights Code.Extrinsic factors are those such as practice setting or client needs. For example,1a midwife may be practising in a hospital that does not provide epidural anal-202gaesia so would not have access to this part of the scope. While extrinsic factorsshould be based on resources and the best interest of clients, there are situationswhere this is not the case. This occurs when midwifery practices choose not towork to the full scope even when their privileging hospital supports it. This also1,occurs when institutions, such as hospitals, limit midwives from providing fullscope midwifery care despite evidence showing that optimizing the midwiferynescope of practice is in the best interest of the public. The scope of practice of everyhealth professional should enable them to contribute optimally to providing highJuquality patient-centred care without compromising patient safety and that thehealth care system should enable them to practise to the fullest extent of thisescope18. When client care is not central to the decision-making about scope lim-ivitations then midwives, midwifery practices, and advocacy organizations shouldctwork with these institutions to develop policies andfeprotocols that reflect the legislative scope of mid-Efwifery practice.Practising to the full legislative scope requires thatmidwives have the necessary competencies to do so.As primary care providers and regulated healthcareproviders, midwives are responsible for determining the limits of their own competence. A midwife’scompetence can change throughout their career.As primary care providersand regulated healthcareproviders, midwives areresponsible for determiningthe limits of their owncompetence.Midwives can gain new competencies by engaging in professional development activities, such as18Canadian Medical Association, “Best Practices and Federal Barriers: Practice and Training Healthcare Professionals” (Submission to the House of Commons Standing Committee on Health: 2015) at 3.COLLEGE OF MIDWIVES OF ONTARIO MIDWIFERY SCOPE OF PRACTICE 202112

participating in trainings, taking courses, and providing elements of care theyhad not previously provided. At the same time, a midwife may lose competenciesif they have not provided certain elements of care for an extended period of time.In allsituations midwives must be competent in all aspects of care they are providing or they must consult with, or transfer the care of the client to, another careprovider.WHEN A CLIENT’S CONDITION IS OUTSIDETHE LEGISLATIVE SCOPE OF PRACTICE202When a client’s condition falls outside the legisla-14tive scope of practice, the midwife has two options:either they transfer responsibility and accountability (i.e., transfer care) for the client to another1,health care provider or provide care under delega-Transfer care to another care providerJu4.1netion in accordance with College standards.A transfer of care is the transfer of primary clinicalA transfer of care is thetransfer of primary clinicalresponsibility to anothercare provider and isrequired when a client’scondition is outside thelegislative scope of practice.responsibility to another care provider and i

The purpose of this document is to describe the midwifery scope of practice set out in the Midwifery Act, 19911, its regulations and other legislation that govern the midwifery profession in Ontario. In addition to providing information about scope, this document also provides regulatory guidance to midwives about work-