Implementing Midwifery Services in British Columbia

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1 Implementing Midwifery Services in British Columbia A Manual for Hospitals and Health Regions Revised and Updated March 2006 v. June 2014

2 ACKNOWLEDGEMENTS The 1997 version of this manual was created by the Midwifery Implementation Working Group, chaired by Luba Lyons Richardson, then president of the College of Midwives of BC, in collaboration with the BC Health Association (BCHA), and in particular BCHA senior staff person Lisa Kalstrom. The manual s development was supported and assisted by BC Children s and Women s Health Centre and came into being with the editorial assistance of Sandra Morris. The current manual has been revised and updated by the College of Midwives of BC (CMBC) and the Midwives Association of BC (MABC) as part of our ongoing commitment to support the integration of midwifery into BC hospitals. It builds on what has been learned over more than eight years of integrating midwifery services into hospitals and health regions throughout the province and incorporates feedback from: BC Children s and Women s Health Centre and St. Paul s Hospital Dept. of Midwifery; Victoria General Hospital and Lady Minto Hospital Dept. of Midwifery; BC Ministry of Health; and Individual midwives, physicians, nurses and administrators working in hospitals around British Columbia. v. August 2013

3 Table of Contents 1.0 Introduction 1.1 Purpose 2.0 What is Midwifery? 2.1 Definition of a Midwife 2.2 Midwifery Scope of Practice 2.3 Model of Midwifery Practice 2.4 Classes of Registration 3.0 Implementation of Midwifery in BC Hospitals 3.1 Issues and Tasks 3.2 Midwifery Integration Committee Mandate Membership Objectives Background Information Communication Plan Orientation Program for New Midwives 4.0 Hospital Risk Management and Midwifery Services 4.1 Goals of Risk Management for Midwifery Services 4.2 Midwives Liability Insurance Coverage 4.3 Hospital Liability Reasons Cited for Past Hospital Obstetrical Claims Minimizing Risks for Hospitals 5.0 Credentialing and Governance of Midwives 5.1 Credentialing Process Appeal Process Discipline Categories of Medical Staff Appointments 5.2 Staff Organization for Midwives Departmental Organization Medical Advisory Committee Participation on Committees 6.0 Working Together - Midwife, Nurse and Physician Roles and Responsibilities 6.1 Planned Hospital Births No Transfer of Care Required General Protocols Antenatal Labour Delivery Postpartum and Discharge Implementing Midwifery Services in BC Hospitals 1

4 6.2 Planned Hospital Birth Consultation and/or Transfer of Care Required General Protocols Antenatal Labour Delivery Postpartum and Discharge 7.0 Out-of-Hospital Birth 7.1 The Home Birth Demonstration Project Results and Recommendations 7.2 Standards for Planned Home Birth in BC 7.3 Working together - Roles and Responsibilities of Midwives, Nurses and Physicians 7.4 Planned Home Births No Transfer of Care Required General Protocols Antenatal Labour Delivery Postpartum 7.5 Planned Home Births Transport to Hospital for Consultation and/or Transfer of Care Required General Protocols Antenatal Labour Delivery Postpartum and Discharge 8.0 Midwives in Rural and Remote Communities 8.1 Smaller Practices 8.2 GP Staffed Hospitals 8.3 Specialized Practice Certifications 8.4 Hospitals Without Cesarean Capabilities 8.5 Creative Solutions that Support Rural and Remote Midwifery Practice 9.0 Questions and Answers 10.0 Evaluation of Midwifery Services in Hospitals Table 1 Committees and Organizations Working for Midwifery in BC Table 2 History of Midwifery in British Columbia 2 Implementing Midwifery Services in BC Hospitals

5 LIST OF APPENDICES Appendix 1: Appendix 1a: Appendix 1b: Appendix 1c: Appendix 2: Appendix 2a Appendix 2b Appendix 2c Appendix 2d Appendix 2e Appendix 2f Appendix 3: Appendix 4: Appendix 5: Appendix 6: Appendix 7: Appendix 8: Appendix 9: Appendix 10 Midwives Regulation & Schedules under the Health Profession Act Standards, Limits and Conditions for Prescribing, Ordering and Administering Drugs Standards, Limits and Conditions for Ordering and Interpreting Diagnostic and Screening Tests Standards, Limits and Conditions for Prescribing, Ordering and Administering Controlled Substances Excerpts from the Home Birth Demonstration Project Report CMBC policies on Home Birth: Required Equipment and Supplies for Home Birth Setting Policy on Second Birth Attendants Policy for Home Birth Transport Plan Transport Plan Home Birth Informed Consent Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia. CMAJ 2002 Bylaws for the College of Midwives Amendments to Hospital Act and Regulation Midwifery Model of Practice Sample Terms of Reference for a Midwifery Integration Committee Indications for Discussion, Consultation and Transfer of Care Indications for Planned Place of Birth Shared Primary Care Policy Competencies of Registered Midwives Recommendations for Midwife Certification for Care of Women Receiving Epidural Pain Relief in Labour All of these documents may be periodically updated. To ensure that you have the most recent versions subscribe to the CMBC s Registrants Handbook or consult the College s website at Implementing Midwifery Services in BC Hospitals 3

6 Implementing Midwifery Services in BC Hospitals 1.0 INTRODUCTION Midwives in British Columbia offer primary care to healthy pregnant women and their normal newborns from early pregnancy through labour and birth and up to three months postpartum. The practice of midwifery in BC has been regulated by the College of Midwives since January Midwifery care from early pregnancy through to six weeks post-partum is funded through BC s Medical Services Plan (MSP). Since January 1998 the midwifery profession has grown from 29 registrants to over 100 registered midwives serving families in more than 25 BC communities in A fouryear degree program in midwifery at UBC is now graduating ten newly qualified midwives annually. They are joined in registration each year by an equal number of internationally-educated midwives assessed for equivalent qualifications and competencies by the College. 1.1 PURPOSE The purpose of this manual is: To assist hospitals and health regions in incorporating the health profession of midwifery into their clinical services. Midwives can be a valuable addition to the maternity care team in both urban and rural communities. As the profession grows, and with the support of hospitals and health regions, midwifery care can be made more widely available to women and their families across British Columbia. This document identifies issues that hospitals are encouraged to address early in the process of introducing midwifery services. As hospitals vary in size, services, geographic location, and climatic conditions, a range of issues are addressed in the manual. Not all will be applicable to all hospitals. Hospitals must consider their own unique characteristics in planning for the introduction and integration of midwifery care as part of their maternal and newborn services. The manual may also be of assistance to hospitals where midwives already have admitting privileges to better integrate and use the services of those midwives. Out-of-hospital birth While it is not the primary purpose of this manual to address issues related to out-of-hospital birth, choice of birth place is central to the philosophy of midwifery care in British Columbia and is an important part of any comprehensive midwifery service. Between January 1, 1998 and December 31, 2000, the Ministry of Health studied the delivery of planned home birth services by registered midwives in BC in order to determine how to best organize and administer those services to ensure the safest possible care. 4 Implementing Midwifery Services in BC Hospitals

7 An independent evaluation team conducted an analysis and evaluation of these two years of data, and recommended that home birth services continue to be delivered to well-screened, low-risk women in BC by registered midwives with emergency management skills, the necessary equipment and supplies, and access to ambulance and hospital back-up services. The Home Birth Demonstration Project outcomes were published the in the Canadian Medical Association Journal in (see Appendix 2f) Hospitals in communities where midwives practice have an important role to play in keeping planned home birth as safe as possible. More information on out-of-hospital birth and the hospital s role in both emergency and non-emergency situations can be found in Section 7 of this manual. 2.0 WHAT IS A MIDWIFE? 2.1 DEFINITION OF A MIDWIFE A midwife, as defined by the International Confederation of Midwives, is a person who: has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery. The midwife is recognized as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice to women during pregnancy, labour and the postpartum period, to conduct births on the midwife s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures. The midwife has an important task in health counseling and education, not only for the woman, but also within the family and community. This work should involve antenatal education and preparation for parenthood, and may extend to women s health, sexual or reproductive health and child care. A midwife may practice in any setting including the home, community, hospitals, clinics or health units. 1 1 Revised and updated at International Confederation of Midwives Council meeting, July, 2005, Brisbane, Australia. Supersedes ICM Definition of a Midwife 1972 and its amendments of Implementing Midwifery Services in BC Hospitals 5

8 2.2 MIDWIFERY SCOPE OF PRACTICE The Midwives Regulation under the Health Professions Act outlines the scope of midwifery practice in BC as follows: (see Appendix 1). assess, monitor, and care for women during normal pregnancy, labour, delivery, and the postpartum period; counsel, support, and advise women during pregnancy, labour, delivery, and the postpartum period; manage normal vaginal deliveries; care for, assess, and monitor the healthy newborn; and provide advice and information on care for newborns and infants, as well as on contraception and family planning. 2.3 MODEL OF MIDWIFERY PRACTICE The midwifery model of practice as developed in British Columbia and all across Canada defines midwifery practice as autonomous, community-based primary care. The midwifery model of practice incorporates the principles of continuity of care (and carer), informed choice, collaborative care, accountability, and evidence-supported practice, as briefly outlined below: (also see Appendix 5) Primary Care: A midwife, in her role as primary caregiver, is the first point of entry to health services for women seeking pregnancy-related health care. As a primary caregiver, the midwife functions under her own responsibility. For each client, the midwife, or a small team of midwives, provides a continuum of midwifery services throughout pregnancy, labour, birth and the postpartum period. Community-Based: Midwives work in autonomous practice within their communities. Midwives often practice within small group practices enabling them to share call while providing 24- hour availability to their clients. Midwifery care may be provided in midwifery clinics or offices, a woman s home, or in the hospital. In some rural and remote communities, or when working with special needs populations, a midwife may work in an on-call team with family physicians, nurses or nurse practitioners to provide community-based care. Continuity of Care: Continuity of care requires a time commitment from the midwife or team of midwives that enables them to provide safe, individualized care, including advocacy, emotional support, counseling, and education throughout the entire pregnancy, labour, birth and up to six weeks postpartum. This includes: developing a relationship with the woman during prenatal care; having a member of the team known to the woman available to her on an oncall basis; supporting the woman during labour and birth; and providing comprehensive care to the mother and newborn throughout the postpartum period, including advice and information on family planning services. 6 Implementing Midwifery Services in BC Hospitals

9 Collaborative Care: Midwives collaborate with other health professionals to ensure their clients receive the best possible care. Collaborative care involves cooperation and consultation with other health care professionals in the provision of care. The College of Midwives has detailed Indications for Discussion, Consultation & Transfer of Care which set out those situations when a midwife must consult with or transfer care to a licensed physician (see Appendix 7). Informed Choice: Midwives respect the rights of women to make informed decisions about their care, including their choice of primary caregiver, their choice of services, and their choice of birth setting, whether home or hospital, within the scope of midwifery care. Midwives facilitate this process by: providing complete, relevant, objective information in a non-authoritarian, supportive manner; promoting shared responsibility among the woman, her family, and her caregivers, and recognizing and supporting the woman as the primary decision-maker regarding the services she will receive and the manner and setting in which her care is provided. Adequate time for discussion in the prenatal period is considered essential to the successful facilitation of informed choice. Second Attendant at Birth: The Canadian standard of care requires two qualified attendants attend every birth, each skilled in CPR, neonatal resuscitation, and the management of maternal and neonatal emergencies. Midwives attend hospital births with assistance from registered nurses, just as family physicians and obstetricians do. However, because the midwife is present to monitor and provide continuous primary care and support to the woman during labour, the nurse may not be as involved in the woman s ongoing care prior to the second stage of labour as she would be with a physician s patient. A midwife generally attends a homebirth with another registered midwife present to assist her from second stage through the immediate postpartum period. Where another midwife is not available, a qualified second birth attendant may be a registered nurse, physician, or other health care practitioner who has the knowledge and skills required to assist the midwife with the birth, in accordance with the midwifery model of care. Working with a second birth attendant who is not a registered midwife must be approved by the College. (see Appendix 2b Policy on Second Birth Attendants) Accountability: Midwives first accountability is to the women in their care. They are also accountable to their peers, their regulatory body, the health institutions in which they practice, and to the public for safe, competent, ethical practice. Midwives are required by their Implementing Midwifery Services in BC Hospitals 7

10 regulatory college to participate in quality assurances processes that incorporate peer review, feedback and evaluation. As a part of the hospital staff they also participate in morbidity and mortality rounds and other hospital review processes in the same way that physicians and other health care providers do. Evidence-Supported Practice: As a part of this accountability, midwives must stay current, share research evidence relevant to maternity care with their clients and incorporate it into their practices. They do this by: keeping up-to-date on the research literature, using critical thinking to assess its relevance to the women in their care and sharing information on the current evidence supporting different care modalities with those women; participating in peer review, multidisciplinary rounds and morbidity and mortality reviews; promoting and participating in research regarding midwifery outcomes and learning from and sharing the results of that research; participating in discussions on research, policy, education, and practice related to maternity care. 2.4 CLASSES OF MIDWIFERY REGISTRATION The College of Midwives of BC has a number of different classes of registration. The majority of BC midwives are general registrants. General registration allows a midwife to practice independently in the full scope of midwifery care in British Columbia. Some applicants for registration are granted Conditional registration prior to becoming general registrants. Conditional registration allows an individual to practice as a midwife under the supervision of an experienced general registrant who reports to the College. Many internationally-educated midwives are granted conditional registration for anywhere from a few months up to one year in order to address any discrete gaps in competencies or experience identified by the College s Prior Learning and Experience Assessment process. A conditional registrant may be a new graduate or may be a very experienced midwife who only requires supervision in order to orient her to the Canadian health care system. Supervision is a progressive process which starts with direct in-person supervision and moves toward the conditional registrant taking on more autonomous responsibility as competence is assessed, with supervision taking place by weekly chart review. Temporary registration is available to midwives who qualify for general registration but wish to practice in British Columbia for a short period, usually as a locum. The College also registers students from approved education programs (currently either UBC or the Ontario Midwifery Education Programme) to allow them to participate in clinical placements. Midwifery students do clinical placement with community midwives and with physicians and receive clinical instruction from these clinical preceptors both in the community and in the hospitals where they hold their privileges. 8 Implementing Midwifery Services in BC Hospitals

11 3.0 IMPLEMENTATION OF MIDWIFERY IN BC HOSPITALS The Health authority, working with the hospital, is responsible for determining the overall mission and goals of the hospital. Health authorities and hospitals should seek broad input when evaluating the potential role of midwifery in a region s or hospital s maternity and newborn services. The evaluation should be based on a determination of the community s needs and desires for midwifery services. In order to ascertain these needs and desires the board may choose to undertake: an assessment of the demand for midwifery care or, more generally, an assessment of the demand for more locally available maternity care providers; an inventory of the existing services for meeting the maternity care needs in the community Are current services adequate? Do available services match the range of choices families in the community are seeking? What stresses are the current providers under? Is the current level of service sustainable? What is the likelihood of current practitioners retiring or otherwise ceasing to provide the current level of service over the next five to ten years? What is the current plan for the future of maternity services and how will midwives be integrated into this plan?; and an analysis of the fit between the need/ demand for maternity service, the existing services and what a midwifery service could offer, including how such a service could potentially enhance existing services. 3.1 ISSUES AND TASKS Hospitals and health regions will need to address a number of issues and undertake several tasks to facilitate the successful integration of midwifery care into their clinical services if they are to take the best advantage of what midwives can offer. Some of these tasks are listed below and detailed in Sections 4.0 through 7.0. They include: Review and adapt the hospital s quality assurance and risk management processes to include midwifery (see Section 4.0); Develop a credentialing and privileging process for midwives if one does not already exist (see Section 5.0); Determine an appropriate hospital organizational structure/governance for midwives (e.g. Of what department are midwives members? To whom do midwives report? Which hospital committees require midwife participation?) (see Section 5.0); Define the roles and responsibilities of midwives, nurses and physicians in providing maternal and newborn care (see Sections 6.0, 7.0 and 8.0); and Develop and carry out an ongoing evaluation of local maternity services and participate in any provincial evaluations of midwifery services or maternity services in general. (see Section 10.0) Implementing Midwifery Services in BC Hospitals 9

12 3.2 MIDWIFERY INTEGRATION COMMITTEE One effective way for hospitals to address the above issues is to form an internal multidisciplinary Midwifery Integration Committee or establish a Perinatal Advisory Committee for the region that is tasked to oversee and support the integration of midwifery. Many hospitals with existing midwifery services began by forming an internal Midwifery Integration Committee (see Appendix 6 for Sample Terms of Reference) Mandate The mandate of the Midwifery Integration Committee would be: To facilitate the integration and implementation of midwifery practice within the hospital Membership The Midwifery Integration Committee (MIC) may include: midwife(s) intending to apply for privileges at a hospital or a midwife from a nearby hospital (If there is no midwife near-by, a midwife from an existing hospital midwifery department can participate in meetings by teleconference); hospital registered nurses (management and staff); physicians (obstetrician, pediatrician, family practitioner, anesthetist); parent(s) /consumer(s) with an interest in or exposure to midwifery care; administrators(s); other department representatives as needed (e.g. admitting, pharmacy, laboratory, social work, imaging, etc.); and community-based professionals (e.g. public health nurse) Objectives The MIC will agree on objectives which include: to develop a plan for the implementation of midwifery services within the hospital that is consistent with the model of midwifery practice as required by law in BC. This plan should address the issues and tasks outlined in Section 3.1 above, and include a timeline for establishing a range of processes that promote effective inter-professional relationships and safe, collaborative care; to create an internal communication plan to familiarize staff with BC midwifery practice, the scope of midwifery care, and roles and responsibilities for various hospital practitioners as a part of this implementation plan (See Section 3.2.5); to create an external communication plan that includes liaison with the College of Midwives and the Midwives Association of BC. Staff from these organizations are happy to provide information and support; to develop an orientation program for midwives who receive hospital privileges and will be practicing in the hospital (See Section 3.2.6); and to develop a plan to incorporate midwifery students within the regional/hospital framework so that students in the University of British Columbia s Midwifery Education Program can participate in preceptorships at the hospital. 10 Implementing Midwifery Services in BC Hospitals

13 3.2.4 Background Information Members of the Midwifery Integration Committee will need to familiarize themselves with: relevant legislation Midwives Regulation (see Appendix 1) Schedule 1: Drugs and Substances (Appendix 1a) Schedule 2: Screening and Diagnostics Tests (Appendix 1b) Health Professions Act Hospital Act and Regulation (see Appendix 4); documents of the College of Midwives CMBC Bylaws, specifically: (see Appendix 3) Part VIII: Standards of Practice Appendix B: Code of Ethics Model of Midwifery Practice (see Appendix 5) Indications for Discussion, Consultation and Transfer of Care and Indications for Planned Place of Birth (see Appendix 7) Competencies of Registered Midwives (see Appendix 9) Policy documents related to out-of-hospital birth, especially as they relate to the interface between home and hospital (see Appendix 2); regional context information Hospital mission / role statement Regional Health Plan, Regional Management Plan Inventory of existing maternal and child health services in the community; and the hospital s Medical Staff Bylaws. If midwifery has not been incorporated in these, model Regional Medical Staff bylaws are available from the Ministry of Health Communication Plan One of the tasks of the Midwifery Integration Committee may be to develop an internal communication plan. The purpose of the communication plan will be to provide hospital staff with an introduction to midwifery in BC to familiarize them with the model of midwifery practice, the scope of midwifery care, and the roles and responsibilities for midwives, nurses, and physicians, as well as to provide updates on the progress of the integration of midwifery care into the hospital s services. Three mechanisms can be effective: Written Communication o provide articles for the hospital newsletter and the physician newsletter o distribute special Midwifery Bulletins to physicians with privileges, nursing units, and department heads o post the Midwifery Bulletins and relevant articles Presentations at Hospital Committee meetings o invite representatives of the College of Midwives and/or the Midwives Association to come and provide an introduction to midwifery in BC (e.g. to discuss regulation, standards, scope of practice, education requirements) and answer questions. These types of sessions have been helpful to hospitals in the past. Implementing Midwifery Services in BC Hospitals 11

14 o request attendance of midwives and other hospital staff who will be affected by the introduction of midwifery services at meetings of relevant hospital committees (e.g. Medical Advisory Committee, General/Medical Staff meetings, Program Advisory Committees, Perinatal Committees, Nursing Professional Practice Committee, etc.) where the implementation of midwifery is being discussed. o undertake presentations and discussions with any group upon request. In-service Programs o as the implementation process progresses, more specific presentations on special topics may seem appropriate - e.g. consultation with and transfer of care to physicians, establishing protocols for receiving a transfer from an out-of hospital birth, midwives consulting with anesthetists and supporting women with epidural anesthesia, etc. (with a guest speaker from the College of Midwives); liability issues (with a guest speaker from the Midwives Protection Program); experiences integrating midwives in other hospitals (with guest speaker from a midwifery department in a BC Hospital with an established midwifery service) Orientation Program for New Midwives Hospitals are responsible for orienting midwives to hospital operations, protocols, policies and procedures. The College of Midwives has developed the following outline to assist hospitals in orienting midwives who are granted admitting privileges and who will be practicing in the hospital. Date Completed Orientation Provided by Administration and Organizational Structure introduction to the CEO, and heads of departments like Nursing, Family Practice, Obstetrics. Pediatrics, Anesthesia, Midwifery orientation to how midwifery fits in the structure of the hospital hospital committee structure and expectations for participation Admissions and Health Records admission and discharge procedures record keeping systems and protocols computer systems and dictation acceptable abbreviations chart completion requirements Hospital Staff Available for Consultation on call schedules for obstetrics and pediatrics role of family practice in call schedule anesthesia services availability and paging systems of physicians above time to travel to the hospital for any of the above first response for neonatal resuscitation assistance: peds, anesthesia, gp or protocols for consultation and transfer of care consultation regarding narcotic analgesia in labour midwife s role in normal newborn care at cesarean deliveries 12 Implementing Midwifery Services in BC Hospitals

15 Date Completed Orientation Provided by Laboratory, Diagnostic Imaging and Pharmacy procedures and forms for ordering tests availability of services and results including after-hours, holidays and weekends Blood bank availability including access to antenatal and postnatal anti- D fetal blood gas analysis availability procedures for ordering and prescribing drugs in hospital any limitations on the availability of medications that midwives normally prescribe Other Health Workers and Services hospital services offered by social work, nutrition, physiotherapy, etc. breastfeeding support services stillbirth and bereavement programs communicating with public health nursing and community-based services protocols for communicating with the medical officer of health Emergency Procedures emergency code procedures calling for help and locating all emergency equipment fire procedures Infection Control Protocols general infection control protocols disposal of hazardous objects and substances delivery room set up and sterile technique protocols for delivery and operating rooms Special Screening or Treatment Protocols for Obstetrics or Pediatrics induction and augmentation of labour pre-labour rupture of membranes screening and treatment of GBS meconium protocols for the management of specific obstetrical emergencies Educational Resources re-certification programs in neonatal resuscitation and CPR obstetric and pediatric rounds hospital in-service training or certification programs in specific skills frequency of course offered in hospital by BCRCP opportunities to practice clinical skills e.g. an NRP practice station Complaints Procedures process for dispute resolution among hospital staff and practitioners process for incident reporting The Midwifery Integration Committee may decide on additional topics to include in an orientation program. Implementing Midwifery Services in BC Hospitals 13

16 4.0 HOSPITAL RISK MANAGEMENT AND MIDWIFERY SERVICES Hospitals are responsible for assuring the standards and safety of obstetrical care delivered under their auspices. Consequently, any risks arising from midwifery services provided in the facility, as with physician services, will necessarily involve the quality assurance and risk management processes of the hospital. 4.1 GOALS OF RISK MANAGEMENT FOR MIDWIFERY Effective risk management for midwifery, as for other maternity care providers, facilitates: positive outcomes; high quality care; maximum choice for women in the context of evidence-supported practice; and minimum liability costs 4.2 MIDWIVES LIABILITY INSURANCE COVERAGE Like physicians, midwives are independent contractors with hospital privileges. They carry individual professional liability insurance obtained through registration and their membership in their professional association. The Midwives Association of BC manages the Midwives Protection Program with the support of the Risk Management Branch of the BC Ministry of Finance. The insurance program provides up to $7 million in coverage per occurrence. The College of Midwives obtains confirmation of liability insurance coverage before issuing a certificate of registration. Hospitals may also ask for proof of liability coverage before issuing midwives hospital privileges. All college approved second birth attendants are covered under the primary midwife s liability coverage with the Midwives Protection Program. 4.3 HOSPITAL LIABILITY Although the number of obstetrical liability claims in BC are a small percentage of total hospital claims (about 6% from ), they represent a disproportionate share of total hospital insurance costs (about 30% incurred or reserved in the same period). This is because negative outcomes from obstetrical care affect a relatively young population childbearing women and neonates. As a result, they would be expected to have many potential life years ahead of them, and they may require extensive health services and support for the remainder of their lives Reasons Cited for Past Hospital Obstetrical Claims Analysis of past hospital obstetrical claims in BC indicate that the most common reasons cited for claims are: poor communication among hospital staff and physicians; failure to identify non-reassuring fetal status; delays in diagnosis and treatment; failure of hospital personnel to take reasonable action when he/she observes potential obstetrical care problems; and inadequate documentation. 14 Implementing Midwifery Services in BC Hospitals

17 4.3.2 Minimizing Risk for Hospitals Given the reasons cited above, the hospital risk management programs for maternity care should emphasize: Multidisciplinary communication processes that are understood and acted upon; Careful monitoring, early recognition, and communication of signs of fetal or maternal distress; Timely action avoidance of unnecessary delay in diagnosis and treatment; Coordinated multidisciplinary team involvement to ensure an appropriate response to obstetrical care concerns involving any type of primary maternity care provider, whether midwife, family physician or obstetric or pediatric specialist; and Documentation of care provided by responsible personnel in labour and delivery area. Hospitals will need to include midwives in their risk management policies and procedures for the delivery of maternity and newborn care. The risk management requirements include but are not limited to: ensuring that only qualified midwives practice within the facility by obtaining a Certificate of Professional Conduct from the College of Midwives and monitoring communications received by the College updating midwives registration status; establishing policies and procedures to govern the credentialing process for granting of privileges to specific midwives, and ensuring the scope of midwifery practice within the facility is consistent with the midwife s legislated scope of practice; defining the ultimate channels of authority for determining the overall standard of obstetrical care in the hospital in general and in a particular case, if necessary. Ensuring that all practitioners involved in obstetrical care understand and act on these channels of authority; instigating appropriate mechanisms for conflict resolution, problem solving, and quality assurance to address operational, professional, and care issues which arise in the delivery of obstetrical care; defining roles, care expectations, and practice relationships between midwives and nurses, and having these arrangements documented, understood, and practiced by all parties; defining roles, care and transfer expectations, protocols for consultation, and practice relationships between midwives and physicians based on the CMBC s Indications for Discussion, Consultation and Transfer of Care (see Appendix 7), and having these arrangements documented, understood, and practiced by all parties; defining roles, responsibilities and reporting relationships between midwives and diagnostic and support services, and having these arrangements documented, understood, and practiced by all parties; promoting effective and timely care, communication, consultation, transfer of care, and provision of appropriate interventions / protocols; Implementing Midwifery Services in BC Hospitals 15

18 assuring that documentation systems are established for health records and other record keeping systems in the hospital; expanding existing processes for risk management, quality assurance, and discipline to include midwives; evaluating hospital admission and discharge planning protocols to ensure that midwifery clients can link up with appropriate community services, especially after 6 weeks postpartum, to ensure continuity of care for mother and infant; and expanding incident reporting to include both the hospital s and the midwife s insurers as necessary. 5.0 CREDENTIALLING AND ORGANIZATION OF MIDWIVES The Regional Medical Staff Bylaws in Appendix 9 define the credentialing, appeal, and disciplinary processes for appointments to hospital Medical Staff. For the purposes of these Bylaws, Medical Staff includes physicians, dentists and midwives. The Bylaws also define the organizational structure and lines of authority through which the medical staff is accountable to the Board for the quality of care, research, and education provided by the organization. 5.1 CREDENTIALING PROCESS The Board has the authority to appoint practitioners to its medical staff. With the 1997 amendments to the Hospital Act, the definition of a practitioner was expanded to include midwives, in addition to physicians and dentists. (see Appendix 4) All appointments to the medical staff must consider the needs of the hospital and the community it serves, and are contingent upon the ability of the hospital resources to accommodate the appointment. The criteria for the appointment of midwives to the medical staff are similar to those for physicians and dentists. These include: being a registered member in good standing with the College of Midwives. The College of Midwives registers midwives to practice within their defined Scope of Practice (see Appendix 3). While a hospital or regional governing board may limit this scope of practice within a given facility, as they may also do for physicians and dentists, it should be noted that midwives have a well-defined scope of practice in regulation, and care must be taken to ensure that any further limitations do not impair the midwife s ability to provide safe and effective care within the hospital. The board cannot expand the midwifery scope of practice beyond the definition specified by the College of Midwives; having a demonstrated ability to provide client care at an appropriate level of quality and efficiency; having adequate training and experience for the privileges requested; providing evidence of professional liability insurance satisfactory to the Board; being willing to participate in the discharge of staff obligations appropriate to membership groups; 16 Implementing Midwifery Services in BC Hospitals

19 providing documentation of experience, competence, and reputation from any previous hospital appointment; and agreeing to be governed by the requirements set out in the Hospital Act and Regulation, Regional Medical Staff Bylaws and Rules, hospital policies, and affiliation agreements, if any. Appointments are generally for one year, but will vary from region to region and should be consistent with appointments made to medical staff within each facility. There will also be a process for reappointment which usually includes some minimum requirements for participation in departmental and/or quality assurance activities. Midterm requests for additional privileges are processed according to the requirements described in the Regional Medical Staff Bylaws Appeal Process Amendments to the Regulation under the Hospital Act expanded access to the Hospital Appeal Board. This means that a registered midwife may appeal a negative decision by a Board to that governing body or, within certain limitations, to the Hospital Appeal Board. A registered midwife now sits on the Appeal Board. (see Appendix 4) Discipline The Board has overall responsibility for ensuring effective disciplinary procedures in the hospital. The Board may at any time cancel, suspend, restrict, or refuse to renew any appointment of a member of the medical staff (including physicians, dentists, and midwives). Grounds for disciplinary action include unprofessional or unethical conduct, or violation of the requirements set out in legislation, bylaws, rules and policies of the Ministry of Health and the Board Categories of Medical Staff Appointments A specific sub-category for midwives is outlined in the Regional Medical Staff Bylaws. The categories for all Medical Staff (including physicians, dentists, and midwives) appointments are: Active; Provisional; Associate; Consulting; Locum Tenens; Scientific and Research; and Honorary The categories most relevant to midwives are outlined below: Active: Members of the active staff may admit, attend, investigate, diagnose, and treat patients in the hospital within the limits of their privileges. They may be required to attend a designated minimum number of the general medical staff meetings and the primary departmental/divisional meetings, as specified in the Regional Medical Staff Bylaws. (see Appendix 9) They may also be required to Implementing Midwifery Services in BC Hospitals 17

20 participate in the administrative and educational activities of the medical staff. In addition, they must have satisfactorily completed the required period on the provisional staff. (see below) Provisional: Midwives who meet the criteria for active staff membership are usually initially granted privileges to the provisional staff category for a minimum of six months. Provisional staff have the same privileges and responsibilities as active staff, except they are not entitled to vote and hold office. A midwife who has a conditional certificate of registration will usually hold provisional staff privileges until she is granted general registration by the College. Associate: Members of the associate staff generally participate in patient care under the direction of the most responsible care giver. They may not admit patients nor write orders for patients in hospital unless those privileges have been specifically granted to them. They may write orders for diagnostic and treatment services for out-patients. They may utilize diagnostic facilities and assist in the delivery room, but cannot perform patient investigational procedures or participate beyond the privileges granted to them. (In some hospitals this position is called clinical trainee rather than associate staff.) A conditional registrant may also be granted associate privileges. However, in order to meet her conditions, a conditional registrant is required to demonstrate that she can work more independently that this category sometimes allows. Provisions will need to be made for conditional registrants to admit patients and write orders if they are privileged in this category. Locum Tenens: Members of the locum tenens staff are appointed to replace a member of the active or provisional staff during an absence. Privileges for locum tenens do not exceed those of the staff member they are replacing. Renewal of locum tenens privileges may be considered upon review. Locum tenens are expected to attend educational activities. A midwife who has a temporary certificate of registration will usually apply for privileges in this category. 5.2 STAFF ORGANIZATION FOR MIDWIVES Departmental Organizations Depending on the number of midwives holding privileges at a given hospital, a midwife may be a member of a separate department of midwifery or may be assigned to an existing medical department such as obstetrics or family practice. Some regions are currently moving toward regional departments of midwifery. The Chief of the department (in smaller facilities, the Senior Medical Advisor/Chief of Staff) is responsible for the supervision and quality of midwifery care provided in the hospital. Where midwifery departments exist, they are expected to take leadership in establishing their own departmental programs while working within the hospital-wide quality improvement and utilization management programs. 18 Implementing Midwifery Services in BC Hospitals

21 5.2.2 Medical Advisory Committee Medical Advisory Committees (MACs) may include physicians appointed to clinical and administrative positions, department heads, general medical staff, and senior administrators. Where a hospital has a department of midwifery, the head of that department will sit on and report to the MAC. The functions of the MAC include but are not limited to: making recommendations to the Board on the staff appointments of all applicants; making recommendations to the Board and the CEO for the establishment, maintenance, and continuing improvement of medical, dental, and midwifery standards; reviewing and evaluating clinical practices within the hospital and reporting on the quality of care provided; investigating any alleged breach by staff members of the bylaws and rules of the hospital; and assisting in providing continuing education for members of the medical staff. The duties of the MAC with respect to midwives parallels those for physicians and dentists, and includes the supervision of midwifery care. The powers of the Senior Medical Administrator/Chief of Staff and the medical department heads extend to include midwives, as they do dentists. Specifically, where there are concerns about the quality of care and safety of the patient, they have the authority to remove care of a patient from any health practitioner. Where a hospital has a department of midwifery, the head of that department also carries this responsibility Participation on Committees Just as hospitals have traditionally provided opportunities for obstetricians, family practitioners, paediatricians, anaesthetists, and nurses to participate in establishing standards of maternal and newborn practice, peer review mechanisms, multidisciplinary teaching opportunities and evaluation programs to review outcomes of care, midwives are now included in these same opportunities and activities. All medical staff (including physicians, dentists and midwives) have obligations and responsibilities to participate on committees addressing quality improvement, risk management, utilization review, ethics, education and research. Implementing Midwifery Services in BC Hospitals 19

22 6.0 WORKING TOGETHER Roles and Responsibilities of Midwives, Nurses and Physicians in Planned Hospital Births This section presents sample protocols, reflecting those currently in use in a number of BC hospitals, to govern the roles and responsibilities of midwives, nurses and physicians working together as a team to provide the best possible care to pregnant women and their newborns. These protocols suggest ways midwives, nurses and physicians can communicate with each other to ensure roles and responsibilities are understood throughout prenatal care, labour, and delivery, postpartum and newborn care. It is expected that these sample protocols will be modified to reflect particular circumstances within given regions and hospitals. In BC law and for the purposes of this document: midwife means a registered midwife with the College of Midwives of BC (CMBC); and nurse means a registered nurse with the College of Registered Nurses of BC (CRNBC). At the end of this manual there are Questions and Answers about specific situations which may not be addressed in the sample protocols. The sample protocols are divided into two scenarios: 1) Planned Hospital Births No Transfer of Care Required 2) Planned Hospital Births Consultation and/or Transfer of Care Required In the first scenario, where no transfer of care is required, physicians are not involved in the woman s or newborn s care in most cases. Midwives and nurses are actively involved in intrapartum and immediate postpartum care in both scenarios. 6.1 PLANNED HOSPITAL BIRTHS NO TRANSFER OF CARE REQUIRED For the majority of a midwife s low-risk clients no transfer of care to a physician will be required. Midwives and nurses will work together during labour, delivery, postpartum and newborn care, and sometimes for certain aspects of antenatal care. Roles and responsibilities during each of these stages for low risk birth are outlined here: General Protocols The midwife attends her client at the hospital throughout labour, delivery and the immediate postpartum. Usually the midwife will have begun her care in labour by assessing the woman at home and will accompany the woman to the hospital when active labour is established. The scope of midwifery includes primary responsibility for the care, monitoring and support of the pregnant woman and her healthy newborn. The continuous presence of the midwife during active labour often results in nurses having a more limited role in order to avoid duplication of services. The nurse works directly with the midwife and the woman during the second and third stages of 20 Implementing Midwifery Services in BC Hospitals

23 labour and until the mother and newborn are stable in the immediate postpartum. Situations where the nurse may be more involved with a midwifery client s care include: 1) if the midwife is a distance away (e.g. attending postpartum visits) when the woman goes into labour, or when the midwife s telephone assessment indicates that the woman s labour is progressing quickly, she will ask the woman to go directly to the hospital and the nurse will provide care until the midwife arrives; 2) when labour is prolonged the midwife may need relief from the nurse for a rest or meal break; 3) when the midwife has two women in labour at once she may need additional nursing support in caring for one or both of these women; or 4) when the woman s labour is being induced, the midwife will attend at the time of induction (e.g. the midwife may apply the cervical ripening agent) and then the nurse will notify the midwife to return at the onset of active labour. It is recommended that all charting in hospital, whether undertaken by the nurse, midwife or physician, be done on a single interdisciplinary record which includes the provincial perinatal forms provided by the BC Reproductive Care Program (BCRCP) to ensure continuity in documentation. Healthcare practitioners are responsible for documenting their own actions and initialing all documentation of the care they have provided. Drugs and Substances that a midwife may prescribe, order and administer on her own responsibility, or administer following a physician s order, are listed in Schedule 1 of the Midwives Regulation. (see Appendix 1a) The midwife writes orders for drugs in the usual manner employed by the hospital. Screening and Diagnostic Tests that a midwife may order, perform, collect samples for, and/or interpret the reports of on her own responsibility are listed in Schedule 2 of the Midwives Regulation. (see Appendix 1b) The midwife orders tests in the usual manner employed by the hospital Antenatal The midwife, or team of midwives, sees the woman for a regular course of antenatal care, usually beginning in early pregnancy. She performs a wellwoman physical and orders screening and diagnostic tests as appropriate. At the onset of care, the midwife informs her client about the scope and limitations of midwifery practice and reviews with her the Indications for Discussion, Consultation and Transfer of Care, a document of the College of Midwives which describes the boundaries of the midwife s scope of practice in specific clinical situations. (see Appendix 7) In the first trimester the midwife advises her client to see her family physician for a medical exam if she has not already done so. This ensures that the woman s family physician is aware of her pregnancy should a consultation during pregnancy be needed. It also lets the physician know that mother and baby will be returning for ongoing medical care when their course of midwifery care is complete. The midwife may refer the woman to her family physician or to a specialist during the prenatal period if health problems outside of her scope of practice arise. (see Midwives Regulation, Appendix 1) Implementing Midwifery Services in BC Hospitals 21

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