Association of Ontario Midwives Summer 2012

Association of Ontario Midwives Summer 2012
03
Protesting federal
cuts to refugee
health
04
Midwives advocate
for pay equity
06
Conference focuses
on growth
08
Meet three future
midwives
11
New hypertensive
guidelines
Association of Ontario Midwives
Minister of Health and Long-Term Care Deb Matthews
makes a surprise visit to the closing ceremonies of the
Association’s 28 th Annual Conference.

AOM News & Updates
New practice in Attawapiskat will
return birth to the community
There’s only one word to describe midwife Christine Roy’s reaction when provincial
Minister of Health and Long-Term Care Deb Matthews called her personally to let her
know Ontario would be funding a midwifery practice in Attawapiskat: “Stunned,” Roy
says with a laugh. “I was very thrilled.”
Roy says the minister
thanked her for the
work she was doing.
“She was happy to
know we were going
to do great things
for women and
their families in this
community.”
The road Roy and
fellow midwife Carol
Couchie traveled to
get to this moment
was a long one. The
two have known each
other for more than 20
years and got the idea
to build a midwifery
practice in Attawapiskat
several years
Attawapiskat
Fort Albany
Moosonee/
Moose Factory
Communities in WAHA
catchment area
Former routine
evacuation sites
Timmins
Returning Birth
to the North
Kingston
ago when they were working on the Quebec side of James Bay planning midwifery
services for a Cree community in the region.
The new practice, Neepeeshowan Midwives, will provide care and services in the
Weeneebayko Area Health Authority (WAHA), which includes the communities of
Moose Factory, Moosonee, Fort Albany and Attawapiskat. The midwives will provide
midwifery care to women in the catchment area, aiming to return birth to the
community while improving health outcomes.
As part of midwifery care services, Roy and Couchie will also provide breastfeeding
education and support and liaise with existing local health programs to reduce
smoking rates, improve nutrition and provide sexual health education.
Recent media reports have shone a light on how underserved the WAHA area
is, particularly with regard to housing, sewage and waste disposal. The need
for maternal care in the area is essential: the closest midwifery practices are in
Hearst and Timmins, both more than 350 km away and the nearest physicians
in the area are located in Moose Factory, more than 200 km away. Women are
typically evacuated from Attawapiskat around 37 weeks to either Moose Factory
(low-risk women), or Timmins or Kingston (high-risk women). Neepeeshowan
Midwives wants to reduce evacuations by allowing low-risk women to remain in
the community to birth because, according to Roy, “women should not have to hide
their pregnancy because they are afraid of being sent out.”
Roy says she and Couchie are planning on going to Moose Factory this fall for several
months to work with health professionals in the local hospital and to look at what
changes need to be made to policies and guidelines for processes such as emergency
medical transfers prior to starting to practice in Attawapiskat.
The new practice marks an important step in expanding midwifery services to remote
areas as well as Aboriginal communities.
AOM welcomes new
registrants into the
profession
This list includes new registrant
members from December 10, 2011
to May 31, 2012:
Erin Bleasdale
Cambridge Midwives
Khadija Boulaftali
Midwifery Collective of Ottawa
Courtney Dini
Midwives of Sudbury / Sagesfemmes
de Sudbury
Suzan Lorenz
Midwife Alliance
Susannah Merritt
Diversity Midwives
Jyothy Nair
Talbot Creek Midwives
Karen Ross
Thames Valley Midwives
Shezeen Suleman
The Midwives’ Clinic of East
York-Don Mills
Ontario Midwife is published three
times a year by the Association of
Ontario Midwives. This publication is
available online at www.aom.on.ca,
or you may request a printed copy. All
websites listed are “hotlinked” in the
digital copy. Scroll over the website
address and click to launch the site.
We welcome all feedback. Please
contact commsmanager@aom.on.ca,
or by phone: 416-425-9974 x2261 or
866-418-3773 x2261.
Association of Ontario Midwives
365 Bloor St. E., Suite 301
Toronto, ON M4W 3L4
www.OntarioMidwives.ca
2
ontario midwife • Summer 2012

Advocacy
Midwives protest planned cuts
to refugee health care
Midwives across Ontario joined other care providers and
concerned citizens on June 18 to protest cuts to the Interim
Federal Health Program, which provides temporary health
coverage to refugees and refugee claimants.
Rallies across Canada including Hamilton, Ottawa and Toronto
drew thousands who oppose the cuts that will come into
effect June 30 and leave already vulnerable populations
without access to medications to treat conditions such as
gestational diabetes, hypertension and nausea and vomiting.
A group of approximately 40 midwives attended the Toronto
rally, where midwife Manavi Handa
addressed the crowd to highlight how the
cuts will affect pregnant women.
“The proposed IFHP cuts will result in a
drastic number of women with no access to
prenatal care. Prenatal care is well-known to
be one of the most cost-effective interventions
in health care and inadequate prenatal
care will result in much sicker mothers and
babies,” Handa said.
Take action now
Midwives and supporters who wish to speak
out against the cuts can send Prime Minister
Stephen Harper and Minister of Citizenship
and Immigration Jason Kenney an e-postcard
from the OntarioMidwives.ca website.
National campaign
calls for equal access to
midwifery care
On May 5, the Canadian Association
of Midwives (CAM) kicked off their
national campaign “Choice. Access.
Midwives.” seeking midwifery care for
all Canadian women and babies.
Despite the fact that midwives
are primary care providers in
many provincial health systems,
regulated midwifery care is
currently unavailable to women
living in the Yukon, New Brunswick,
Newfoundland and Labrador and
Prince Edward Island.
Many women living in rural and
remote areas are being sent away
from their families, their support
systems and their communities weeks
before giving birth because they lack
access to obstetrical care.
And, although midwifery care has
been shown to greatly improve health
outcomes in Aboriginal communities,
the federal government is currently
unable to employ midwives on
reserves because the Treasury Board
lacks a job description for midwives.
CAM is urging all midwives and
midwifery supporters to sign an e-letter
addressed to Prime Minister Stephen
Harper, the Federal Minister of Health
and other government officials pushing
for equal access to safe, quality care for
all Canadian women.
CAM is pushing the federal
government to:
• work with and require all
provinces and territories to
legislate and fund midwifery as
part of their health care systems;
• support midwives in rural and
remote regions of Canada, to
ensure that women can stay in
their communities during the
normal and healthy process of
pregnancy and birth;
• include a job description for
midwife in the federal Treasury
Board, thereby allowing
midwifery care to become part
of direct services offered to
Aboriginal communities under
federal jurisdiction.
Though regulated in Ontario, midwifery
care is still out of reach for nearly 40% of
women who seek it here. Midwives know
the value of keeping birth close to home
and keeping birth within the community.
As the largest group of regulated
midwives in Canada, Ontario midwives
can prove valuable in voicing the need for
access to midwifery care for all.
Midwives can access the letter
campaign on the main page of the
CAM website, www.canadianmidwives.org.
Supporters are also urged to
copy the letter and send it to their MP.
www.aom.on.ca 3

AOM News and Updates
Midwives bring pay equity message to Queen’s Park
The AOM’s second annual lobby day at
Queen’s Park on May 2,held just three
days before the International Day
of the Midwife, was an opportunity
for midwives and clients to educate
MPPs about the key issues facing
the profession. It was also a time to
discuss strategies for giving Ontarians
even greater access to midwifery
care. During formal presentations and
casual conversations, politicians from
all three parties learned more about
hospital integration challenges, infrastructure
deficits and the wage parity
gap between midwives and comparable
professions. MPPs also shared
their perspectives on maternal and
newborn care in their communities.
Highlights of the day included:
• A press conference with Katrina
Kilroy, then president of the AOM,
and midwife Vicki Van Wagner,
member of the Provincial Council
for Maternal and Child Health,
that focused on issues including
pay equity. Kilroy explained
that due to a long history of
poor, inconsistent negotiations
between the profession and the
government, midwives’ salaries
have not only fallen behind
comparable health care providers,
but they have fallen behind both
the average public sector worker
and the rate of inflation.
• Statements on the floor of
the legislature by Minister of
Health and Long-Term Care Deb
Matthews, Progressive Conservative
MPP Bill Walker, and NDP
critic for Health and Long-Term
Care France Gélinas honouring
the work that Ontario midwives
perform and celebrating International
Day of the Midwife (May
5). MPP Gélinas also specifically
mentioned pay equity.
• A luncheon that was attended
by more than 60 MPPs and their
staff. At the event, Minister
Matthews, MPP Bill Walker (PC),
and Deputy House Leader Cindy
Forster (NDP) expressed their
support for midwifery. Katrina
Kilroy and Vicki Van Wagner gave
a presentation on growing and
MPP Bill Walker, Minister of Health and Long-Term Care Deb Matthews, MPP Michael Gravelle and MPP Cindy
Forster pose with midwifery client babies at the lobby day lunch reception
strengthening
midwifery care
including pay equity.
For midwife and
former AOM board
member Kelly
Gascoigne, the lobby
day was an “opportunity
to catch the ear
of elected officials.”
At lunch she had an
opportunity to speak
with a number of
MPPs about issues
such as pay equity.
“It’s so important for
politicians to hear
from frontline workers
and their clients,”
says Gascoigne. “It’s
more meaningful in that
context.”
Gascoigne attended the AOM’s first
lobby day last year, which kicked
off the Ontario Needs Birth Centres
provincial election campaign. The
successful campaign culminated in
a March 20, 2012 announcement
by Premier McGuinty and Minister
Matthews to develop two
freestanding, midwifery-led birth
centres.
Midwifery client Kat Tannock and her baby Madi travelled from Peterborough
to be part of the day. Photo with MPP Christine Elliott.
“It’s astonishing the impact that you
can have when you make yourself
heard,” says Gascoigne.
Kelly Gascoigne attended this year’s
lobby day with a client, Michelle
Cruz. Cruz said she wanted to attend
because she feels strongly about
midwifery, having been in care with
both her children. She says she found
the lobby day informative and was
surprised to learn how many women
are unable to access midwifery care
4
ontario midwife • Summer 2012

Above: Attorney General John Gerretsen speaks with AOM President Lisa Weston, AOM Executive Director
Kelly Stadelbauer and then-President Katrina Kilroy
Right top to bottom: The AOM produced an information booklet for MPPs regarding the challenges and
opportunities apparent with the growth of midwifery; Over 60 MPPs and political staff attended the lunch
and learn session; A client finds a quiet moment during the busy day.
and how much midwifery is growing
in the province. She hopes politicians
came away from the event with
an increased
understanding
of the value of
midwifery care.
“I hope they see
how important
midwifery
Michelle Cruz
is,” says Cruz.
“Women need Midwifery client
the care and
they believe in
it. It’s so important and it needs to be
supported.”
Cruz and Gascoigne plan to schedule a
personal meeting with their local MPP
in the fall to discuss midwifery issues.
A statement made by Minister
Matthews in the legislature on May 2
underlined government support for the
midwifery model.
“Our government recognizes the
enormous
contribution
that midwives
make to our
health care
system and to
the well-being
of thousands
of women and
their newborn
babies,”
Matthews said. “The number of
midwives practising is expected
to grow at about 15 per cent per
year. I want to assure them that our
government is fully committed to
supporting this growth in midwives.”
“I hope they see how important midwifery is.
Women need the care and they believe in it.
It’s so important and it needs to be supported.”
To learn more about the lobby day, visit www.OntarioMidwives.ca
www.aom.on.ca 5

AOM Conference and Annual General Meeting
Strength in numbers: supporting the growth of midwifery
When Minister of Health and Long-Term
Care Deb Matthews stopped by
the Annual General Meeting and
Conference closing ceremonies to
announce funding for a practice in
Attawapiskat, the crowd responded
with a standing ovation. Funding
a practice for a remote Aboriginal
community in great need garnered an
emotional reaction from members.
This continued
support for the
growth of midwifery
is key as the
first class of the
expanded Midwifery
Education Program
(MEP) graduates
this spring. The
MEP now enrolls 90 Elizabeth Brandeis, RM
new students each
AOM vice-president
year at the three
sites combined,
compared with 60
prior to 2008. There are more than 600
midwives currently practicing in Ontario
and by 2015 it is anticipated there will
be more than 1,000.
This year’s conference theme, Strength
in Numbers, Supporting the Growth
of Midwifery, addressed the need
for careful thought about shaping a
growing profession and addressing the
challenges inherent to that growth.
Conference presenter and assistant
dean of midwifery at McMaster
University Eileen Hutton says the
larger number of students has created
a challenge with regard to physical
space for clinical placements.
“When we were starting out, practices
were new, underutilized, there was lots of
space,” Hutton says. “Now practices have
more midwives but they haven’t changed
space . . . so even if the birth capacity is
there, the space availability isn’t.”
Finding non-midwifery clinical placements
is also proving to be difficult as
other health education programs are
also looking to grow their professions.
“We have more students, but the
medical programs have also grown
quite a lot . . . so there is direct competition
for spots,” Hutton says.
Fundamental changes both within
the profession and beyond will
have to be explored to help address
the changing needs of a growing
profession, Hutton says.
“Having our own standards allow us to
advocate on behalf of our clients who
may choose care that may not be reflected
in other professional guidelines yet is
evidence-based, reasonable and safe.”
Universities may need to work with
hospitals to change how placements
work; Hutton suggested a “package
deal” where hospitals who want
medical residents
also get midwifery
students, nursing
students and
physiotherapy
students, among
others.
As the profession
grows, some
hospitals are
capping the
number of
midwives
practicing there.
Hospitals and
health care providers need to work
together to find solutions to support
the growth of midwifery. For example,
having OBs on salary would enable
midwives to attend increasing
numbers of low-risk births, Hutton
suggested.
Association of Ontario Midwives
vice-president Elizabeth Brandeis’s
conference panel presentation focused
on how a greater understanding is
needed of both the similarities and
differences between the midwifery
model and care provided by obstetricians
and other providers.
“It’s important to establish where
common ground exists,” she says.
“Working in interprofessional groups
like MoreOB and labour and delivery
committees allows midwives to
interact on a more personal level
with leaders in the hospital and
set the tone for understanding the
foundation on which differences may
exist and when common standards
are appropriate.”
She noted that advocating for midwifery
community standards is an essential
part of growing a strong profession.
“If we don’t have our own midwifery
community standards, we are forced
to conform to other established
standards,” she says. “Having our own
standards allows us to advocate on
behalf of our clients who may choose
care that may not be reflected in other
professional guidelines yet is evidencebased,
reasonable and safe.”
Advocating for midwifery standards
in a hospital setting and educating
other professionals about midwifery is
critical. Brandeis says midwives should
initiate conversation via planning a
rounds or presenting to a committee.
Using tools such as clinical practice
guidelines (CPG) can depersonalize
conflict and show hospital colleagues
that midwives are part of a wellinformed
professional community.
“Our clients come to us with the
expectation that their choices will be
respected and supported. CPGs provide
a framework for us to inform and
support our clients in a range of diverse
choices,” she says. “When the conversation
is about the client and supporting
her autonomy and choice, the issues can
move away from ‘us vs. them’ and focus
on client-centred, evidence-based care
that supports normal birth.”
Providing support toward the kind of
research that informs tools such as the
CPGs is an important next step in moving
midwifery forward, Hutton says. Though
other professions can tap into dedicated
pockets of funding, such as hospital
competitions, midwives have few
funding streams to support research.
“In the last 20 years we’ve focused
on building a very strong education
program and strong practices . . . and
we are getting to a size where we can
put money into (research),” Hutton
says. “Practice didn’t evolve without
lots of support, and I think research is
no different.”
One of the benefits of expanding
the MEP and growing the number
of midwives is that strength really
does come in numbers. Now more
than ever, midwives can capitalize
on opportunities for creating new
practices, improving hospital
relations, and advocating for
dedicated research funds.
6
ontario midwife • Summer 2012

Top left to right: National Aboriginal Council of Midwives (NACM) Vice-President Kerry Bebee with Aboriginal midwife
Dorothy Green; AOM members Natalie Kirby and Melissa Bevan check out the exhibitor booths
Centre left to right: Suzanne McGurn, Assistant Deputy Minister, Ministry of Health and Long-Term Care and AOM board
member Esther Willms; Members Mary Sharpe and Elana Johnson visit with Opening Ceremonies speaker and Toronto Star
columnist Catherine Porter; Members Jasmine Chatelain and Aimée Carbonneau share a conference hug
Bottom left to right: Canadian Association of Midwives (CAM) President Anne Wilson and AOM President Lisa Weston;
HIROC CEO Peter Flattery, AOM Director of Insurance and Risk Management Bobbi Soderstrom and Rogers Partners LLB
Sr. Partner Don Rogers ; Registered Nurses Association of Ontario (RNAO) President Rhonda Seidman-Carlson, RNAO CEO
Doris Grinspun and AOM Executive Director Kelly Stadelbauer

Student Profiles
Recent graduates bring new energy
and perspectives to midwifery
In an attempt to address a shortage of obstetrical care in Ontario, the provincial
government announced an expansion in 2007 of the Midwifery Education
Program (MEP) that would eventually see an additional 30 students per year
enrolling in the MEP, bringing each class to 90.
This spring, the first class of the expanded MEP graduated, helping to bump the
number of practicing midwives in Ontario to more than 600.
Meet three newly graduated midwives who are coming into the profession as part of
this first expanded class.
Stephanie Biswell
(McMaster)
Witnessing the prevailing racism in
her community while growing up,
Stephanie Biswell didn’t identify closely
with her Aboriginal heritage.
“It’s hard in Winnipeg to be outwardly
Aboriginal, so I ‘whited’ myself as much
as possible,” Biswell says.
All of that changed over the course
of completing the MEP at McMaster
University, which Biswell graduated
from in May.
“A large part of my growing and selfawareness
came from my classmates,”
she says. “I realized that being Aboriginal
is a key part of who I am and I really
embrace it.”
Thanks to her husband’s work in
Mozambique, Biswell had visions of
traveling to remote communities in
Africa to provide maternity care when
she first joined the program. But over
time and thanks to a placement at a
clinic in downtown Winnipeg, Biswell
shifted her view of how she’d like to practice midwifery.
“I still have visions of doing oversees work and seeing
midwifery from a global perspective, but I’ve also seen how I
have a lot of work to do here, in part with Aboriginal women.
These are my people who need help, and I am in this position
and I should help.”
Biswell is this year’s winner of the Murray and Eleanor
Enkin Midwifery Award at McMaster – which is awarded
to a graduating student who exemplifies superior
achievement in the humanitarian, professional and
academic domains of midwifery practice.
Biswell says that beyond her clinical learning, midwifery
education has also helped expand her perspective and develop
a broader sense of cultural understanding.
“I was young when I joined the program . . . and I felt maybe
I had come into it with all of these ideas of what people were
like or the world was like. (But) you realize the world isn’t so
narrow and you can’t make decisions about how people are.
It’s a life-long journey to never really close off how I think
about something or put people in a box.”
Biswell has accepted a position with Burlington and Area
Midwives and expects to start providing clinical care this
summer.
8
ontario midwife • Summer 2012

Heather Heinrichs (Laurentian)
Though Heather Heinrichs faced many of the common challenges
inherent to the MEP – such as juggling class work while being on
call – the toughest by far was having her apartment burn down
during her Normal Childbearing placement.
“I had to take a week off and sort out my life . . . it was definitely
a struggle trying to adapt to not having any of my notes or text
books,” she says. “But I persevered and got through it.”
That kind of determination will serve her well as she moves
forward with the career she long dreamed about. Growing up,
Heinrichs gained an interest in midwifery when she read The
Midwife’s Apprentice, a book geared toward young women.
“I thought being a midwife was really cool, but the book takes
place in the Middle Ages and I thought, doctors deliver babies
now, I can’t do that.”
Heinrichs not only learned that she could in fact be a midwife,
but now also has long-term aspirations of eventually returning to
her hometown of Winnipeg and setting up an Aboriginal-focused
midwifery practice.
Herself Métis, Heinrichs says she has found a great fit with
Seventh Generation Midwives Toronto, where she completed
her senior-year placement and will also be completing her new
registrant year.
“I feel really well supported by Seventh Generation Midwives,
in learning to be a midwife and in setting up my own
midwifery practice.”
Rachel Dennis (Ryerson)
Long before she even thought of entering
the profession, Rachel Dennis was having
an effect on midwifery clients.
In an effort to spend more time
together, Dennis’s
mom, midwife
Carol Couchie,
would bring
Dennis along to
postpartum visits.
One such visit was
to a new mom
having trouble
breastfeeding.
Rachel Dennis, RM
“My mom said,
‘Rachel was such a
good breastfeeder,
I brought her along as a good luck
charm,’” Dennis recalls. And her luck
proved true – the baby latched that day.
Years later at a goodbye party for
Couchie, who was moving out of
Toronto, a woman and her daughter
approached Dennis. It was the mother
from that day.
“She said, ‘this is the girl who helped
you breastfeed.’ It shocked me that she
remembered me and linked me to that
amazing moment,” Dennis says. “Even
though I didn’t think of it as a career,
midwifery was having an impact on
me for a very
long time.”
Despite
growing
up around
midwifery and
attending her
first birth at
age 12, Dennis
says she
never really
considered
it as a viable
career for herself until she was in her
twenties.
“It just kind of dawned on me one
day in terms of thinking what I could
do as a career where I could benefit
other people and work with babies
and women,” Dennis says. “I thought
about all the times I came across my
“I thought about all the times I came across
my mom with clients and all the things they
said about how she made their experience so
wonderful and life changing and I thought,
okay, maybe I can do that.”
Recent midwifery graduate
mom with clients and all the things
they said about how she made their
experience so wonderful and life
changing and I thought, okay, maybe I
can do that.”
Without previous experience in a
university setting, Dennis credits
Ryerson’s Aboriginal Student Services
for providing a support system that
helped her succeed.
“Without them, I would have felt
isolated,” Dennis says, noting she
valued the academic counselling
services the centre provided, as well
as socialization opportunities and
the ability for her to give back while
working as a peer support worker .
Dennis graduated in June as part
of Ryerson’s MEP and plans to start
working at Seventh Generation
Midwives Toronto later this year, after
taking some time off following the
birth of her second child this summer.
www.aom.on.ca 9

Rural and Remote Practice
Locum Program fosters sustainability and growth of rural and remote practice
In many rural, remote and northern
communities, midwifery care is
provided by a solo midwife or by
a small practice. Rural and remote
midwives accept the challenges of
working in smaller and sometimes
isolated communities, and the
additional strain of being completely
tied to their work. Unlike midwives in
larger midwifery practice groups, they
can’t rely on their colleagues to access
time off-call. The Locum Program
provides much needed vacation and
emergency relief for rural and remote
midwives, allowing them to recharge
and relax or to tend to pressing
personal matters. This in turn helps
midwifery to remain strong in small
communities.
In 2009, the AOM introduced a
program to respond to the needs
of rural and remote midwives with
funding from the Ministry of Health
and Long-Term Care. The AOM Rural
and Remote Locum Program provides
relief for midwives for holidays,
illness, emergencies, continuing
education or parental leave. It
enables midwives to turn off their
pagers with the confidence that their
clients are in the experienced hands
of another midwife.
For Natalie Kirby, who usually
works at Midwives Nottawasaga in
Collingwood, a locum placement
allowed her to support a solo midwife
in Powassan, near Kirby’s hometown
of North Bay. While on locum, Kirby
gained insight into the life of a solo
midwife when she was on call for 28
days in a row. During her second week
she attended four births, three in
hospital and one at home.
“Being a solo midwife is an incredible
responsibility,” says Kirby. She says
being able to provide relief to the
local midwife and provide care to her
clients was very rewarding. “Balance
is essential in our career. You need
time to be pager-free so you can sleep,
travel or do whatever you need to do.”
She was also happy to ensure that
clients had the birth experiences
they were seeking. “If a locum didn’t
come, the women might have been
transferred out of midwifery care
and wouldn’t have
had home visits,”
says Kirby.
Susan Wilts, a
solo midwife at
Huron Community
Midwifery Services
in Auburn, uses her
time off to volunteer
with a medical team
in Haiti. For the past
four years, the Locum
Program has enabled
midwife Maggie
Fioravanti to care
for Susan’s clients
while she is away.
Wilts says Fioravanti
(who retired from St.
Jacobs Midwives in 2008) is the ideal
person to relieve her because she has
extensive experience with Old Order
Amish and Mennonite women, who
make up 80 percent of Wilts’s practice.
According to Wilts, Fioravanti also
has the sense of adventure needed to
navigate southwest Bruce County in
the middle of winter. Many of Wilts’s
clients live on rural roads that don’t
appear on maps and aren’t plowed
between 9:30 p.m. and 4:30 a.m. –
even if there’s been a snowstorm. Her
clients don’t have telephones and
Top and above: Collingwood midwife Natalie Kirby provided off-call relief for
a solo midwife in northern Ontario during a locum placement in Powassan,
near Kirby’s hometown of North Bay. She was on call for 28 days straight and
attended four births in one week.
there is limited cell phone service in
the area. Babies are often delivered by
lantern light and using the bathroom
means a cold walk to the outhouse.
“A midwife (working in this area)
definitely has to have a good vehicle,
warm clothes and boots, and a GPS,”
says Wilts.
As midwifery in Ontario grows with
more practices in rural and remote
areas of the province, the AOM Locum
Program will continue to support
midwives and sustain midwifery care
in these communities.
To find out more about the Rural and Remote Locum Program,
please contact the AOM at 416-425-9974 or 1-866-418-3773 x2257.
10
ontario midwife • Summer 2012

Clinical Practice Guidelines Update
New CPG will facilitate evidence-based midwifery care
related to hypertensive disorders
The AOM’s newest Clinical Practice Guideline (CPG), Hypertensive
Disorders of Pregnancy, provides a critical review
of research questions relating to midwifery care and the
screening, diagnosis, assessment and monitoring of hypertensive
disorders of pregnancy (HDP).
The new HDP CPG replaces AOM
CPG No. 4: Guideline for Monitoring
Blood Pressure in Pregnancy. It is now
available at www.aom.on.ca under the
health care professionals tab.
For the first time ever, the AOM has
produced a summary document to
accompany the new CPG. Designed
for busy clinicians, the summary
contains key highlights as well as a
complete list of recommendations for
practice from the full HDP CPG. The
six-page summary provides midwives
Pictured to the right: the AOM’s latest CPG on
hypertensive disorder and the first ever CPG
summary on HDP.
with easy access to some of the most essential content of
the CPG. The document is intended to be used in conjunction
with the full HDP CPG, not instead of it. For a complete
analysis of the research relevant to HDP and midwifery
practice, along with all citations, midwives are strongly
encouraged to read the full CPG.
An AOM Clinical Practice Guideline Summary
Hypertensive DisorDers of pregnancy
Hypertensive disorders of pregnancy (HDP) are a major
cause of poor pregnancy outcome in Canada and internationally.
HDP encompasses a spectrum of conditions,
including pre-existing hypertension, gestational hypertension
and preeclampsia. These conditions range in severity
from a mild increase in blood pressure at term to multisystem
conditions with the potential for significant harm. For
many of the clinical manifestations of HDP, optimal strategies
for prevention and management have yet to be determined,
with delivery of the fetus being the only definitive
treatment. Despite extensive research, the onset of hypertension
during pregnancy has proven difficult to predict.
Definition and Classification of HDP
See Society of Obsetricians and Gynaecologists of Canada
(SOGC) Clinical Practice Guideline No. 206: Diagnosis,
Evaluation and Management of the Hypertensive Disorders
of Pregnancy.
• Hypertension in pregnancy is defined as a dBP ≥ 90
mmHg, based on the average of at least two measurements
taken using the same arm.
• Severe hypertension is defined as a sBP ≥ 160
mmHg or a dBP ≥ 110 mmHg.
• Proteinuria is defined as a urinary protein measurement
equal to or greater than 0.3g/day in a 24-hour
urine collection or ≥ 30 mg/mmol urinary creatinine
in a spot urine sample.
Hypertensive disorders of pregnancy should be classified
as pre-existing or gestational hypertension based on
gestational age (GA) at diagnosis.
• Pre-existing hypertension: diagnosis before pregnancy
or prior to 20 weeks’ GA. In women with
pre-existing hypertension, preeclampsia is defined
by the presence of one or more of the following at
or after 20 weeks’ GA:
» resistant hypertension
» new or worsening proteinuria
» one or more other adverse conditions*
• Gestational hypertension: Diagnosis at or after 20 weeks’
GA. In women with gestational hypertension, preeclampsia
is defined by the presence of one or both of:
» new-onset proteinuria
» one or more of the other adverse conditions*
For a full description of research questions
relating to midwifery and hypertensive disorders
of pregnancy (HDP), please refer to the
full HDP CPG at http://bit.ly/aomcpgs
• Severe preeclampsia is defined as preeclampsia
with onset before 34 weeks’ GA, with heavy proteinuria
or one or more other adverse conditions.*
• HELLP syndrome is charactherized by hemolysis, elevated
liver enzymes and low platelet count. It can
occur either with or without other typical symptoms
of preeclampsia.
*Adverse conditions associated with preeclampsia
• Maternal symptoms: persistent or new/unusual
headache, visual disturbances, persistent abdominal
or right upper quadrant pain, severe nausea or
vomiting, chest pain or shortness of breath.
• Maternal signs of end-organ dysfunction: seizures,
severe hypertension, pulmonary edema, or suspected
placental abruption.
• Fetal morbidity: oligohydramnios, intrauterine
growth restriction, absent or reversed end-diastolic
flow in the umbilical artery by Doppler velocimetry,
or intrauterine fetal death.
• Abnormal maternal laboratory testing:
» elevated serum creatinine (see below)
» elevated AST, ALT or LDH with symptoms
(see below)
» platelet count < 100 x 10 9 /L
» serum albumen < 20 g/L
NORMAL VALUES IN PREGNANCY
First
trimester
Second
trimester
Third
trimester
Creatinine (µmol/L) 35-62 35-71 35-80
AST (SGOT) (U/L) 3-23 3-33 4-32
A LT (SGPT) (U/L) 3-30 2-33 2-25
LDH (U/L) 78-433 80-447 82-524
Source: James D, Steer P, Weiner C et al. Pregnancy and laboratory
studies: a reference table for clinicians. Obstet Gynecol.
2010 Apr;115(4):868
Emergency Skills Workshops
The Association of Ontario Midwives
reminds members that all registered
midwives in Ontario are required to
recertify in emergency skills every two
years in order to maintain their registration
with the College of Midwives
of Ontario.
Register early because space is limited
and sessions sell out.
The AOM is pleased to offer the
following courses.
August 24, 2012 - Hamilton
Crowne Plaza Hamilton
Pavillion BC
150 King St. East
September 7, 2012 - Markham
Holiday Inn & Suites Markham
Ellesmere Room
7095 Woodbine Ave.
September 14, 2012 - Ottawa
Travelodge Ottawa Hotel &
Conference Centre
Greenery Room
1376 Carling Ave.
November 16, 2012 - Toronto
Association of Ontario Midwives
365 Bloor St. E. Suite 301
Fees:
AOM Member - $325.00
ESW Workbook (2009 version) -
$45.00
Session times:
AM: 08:30 - 12:30 or
PM: 13:30 - 17:00
To register for any of these sessions
visit the AOM member site to register
online, or print the registration form
on the website and mail or fax it back
to the address provided.
If you require any additional information
please do not hesitate to
contact ESW Co-ordinator Kristina
Mullen at events@aom.on.ca or by
calling (416) 425-9974 x 2255.
www.aom.on.ca 11

Choice.
Access.
Midwives.
Registration Now Open!
Accès.
Choix.
Sages-
Femmes.
Register before September 7, 2012 and save up to $75!
For more information including travel discounts and booking accommodations, visit:
www.canadianmidwives.org/conference
CAM’s 12 th AGM, Conference & Exhibit
October 17 to 19, 2012
Sheraton Hotel
St. John’s, Newfoundland & Labrador
12 ième AGA, congrès et exposition ACSF
du 17 au 19 octobre, 2012
Hôtel Sheraton
Saint-Jean de Terre-Neuve & Labrador