Current through Register Vol. 49, No. 2, February
2024
100.
GENERAL
PROVISIONS
101.
PURPOSE AND
AUTHORITY
Act 838 of 1983 provided for the lawful practice of Licensed
Lay Midwifery in counties having 32.5% or more of their population below the
poverty level.Act 481 of 1987 superseded Act 838 of 1983, and expanded the lay
midwifery licensure statewide. These Rules govern the practice of Licensed Lay
Midwives (LLMs) in Arkansas.
The following Rules are promulgated pursuant to the authority
conferred by the Licensed Lay Midwife Act A.C.A. §
17-85-101
et seq. And A.C.A. §
20-7-109.
Specifically, the LLM Act directs the Arkansas State Board of
Health to administer the provisions of the Act and authorizes and directs the
Board to adopt rules governing the qualifications for licensure of lay midwives
and the practice of Licensed Lay Midwifery. The broad authority vested in the
Board of Health, pursuant to ACA §
20-7-109,
to regulate and to ultimately protect the health of the public is the same
authority the Board utilizes in enforcing the Rules, determining sanctions,
revoking licenses, etc.
102.
ADMINISTRATION OF PROGRAM
The State Board of Health (BOH) has delegated the authority to
the Arkansas Department of Health (ADH).
103.
DEFINITIONS
As used in these Rules, the terms below will be defined as
follows, except where the context clearly requires otherwise:
1. ADVERTISEMENT AND ADVERTISING
Any statements, oral or written, disseminated to or before the
public, with the intent of selling professional services, or offering to
perform professional services. Advertising includes - but is not limited to -
promotional literature, websites, and social media sites used for the purpose
of selling services.
2.
APPRENTICE
A person who is training to become an LLM in Arkansas working
under the direct supervision of a preceptor.
3. ARKANSAS DEPARTMENT OF HEALTH CLINICIAN
An ADH physician, Certified Nurse Midwife (CNM) or nurse
practitioner providing ADH maternity services at a local health unit.
4. ARKANSAS RULES EXAMINATION
The exam that tests knowledge of the Rules Governing the
Practice of Licensed Lay Midwifery in Arkansas.
5. AUTOMATIC LICENSURE
Granting the occupational licensure without an individual
having met occupational licensure requirements provided under the Arkansas Code
or by other provisions in these Rules.
6. BIRTHING/BIRTH CENTER
Any facility licensed by ADH which is organized to provide
family-centered maternity care in which births are planned to occur in a
home-like atmosphere away from the mother's usual residence following a
low-risk pregnancy.
7.
CERTIFIED MIDWIFE (CM)
Individuals who have or receive a background in a
health-related field other than nursing, and graduate from a midwifery
education program accredited by the Accreditation Commission for Midwifery
Education (ACME). Graduates of an ACME accredited midwifery education program
take the same national certification examination as CNMs but receive the
professional designation of certified midwife.
8. CERTIFIED NURSE MIDWIFE (CNM)
A person who is certified by the American College of Nurse
Midwives and is also currently licensed by the Arkansas State Board of Nursing
or the appropriate licensing authority of a bordering state to perform nursing
skills relevant to the management of women's health care for compensation,
focusing on pregnancy, childbirth, the postpartum period, care of the newborn,
family planning, and the gynecological needs of women. The CNM must be
currently practicing midwifery unless stated otherwise in these Rules.
9. CERTIFIED PROFESSIONAL MIDWIFE
(CPM)
A professional midwifery practitioner who has met the standards
for certification set by the North American Registry of Midwives (NARM).
10. CLIENT
A pregnant woman, a postpartum woman for a minimum of thirty
(30) days, or her healthy newborn for the first fourteen (14) days of life who
is the recipient of LLM services.
11. CONSULTATION
The process by which an LLM who maintains primary
responsibility for the client's care, seeks the advice of a physician, CNM, or
ADH clinician. This may be by phone, in person or by written request. The
physician, CNM, or ADH clinician may require the client to come into their
office for evaluation.
12.
CONTACT HOUR
A unit of measure to describe 50-60 minutes of an approved,
organized learning experience that is designed to meet professional educational
objectives. It is a measurement for continuing education. One contact hour is
equal to 0.1 CEU. Ten contact hours are equal to one (1) CEU.
13. LABOR SUPPORT ATTENDANT
An individual who is present at the request of the client to
provide emotional or physical support for the client and her family.
14. LLM ASSISTANT
An individual who is present at the request of the LLM at any
point during the course of midwifery care of the client to provide services
under LLM supervision.
15.
LICENSED LAY MIDWIFE (LLM)
Any person who is licensed by ADH to practice midwifery and who
performs for compensation those skills relevant to the management of care of
women in the antepartum, intrapartum, and postpartum periods of the maternity
cycle.Also manages care of the healthy newborn for the first fourteen (14) days
of life.
16. LOCAL HEALTH
UNIT
A community-based ADH clinic site that provides medical and
environmental services.
17.
MIDWIFERY BRIDGE CERTIFICATE
A certification administered by NARM awarded to CPMs following
the completion of accredited approved continuing education contact hours based
upon identified areas to address emergency skills and the International
Confederation of Midwives (ICM) competencies.
18. NORTH AMERICAN REGISTRY OF MIDWIVES
(NARM)
The international certification agency that established, and
continues to administer, certification for the credential "Certified
Professional Midwife" (CPM) and the Midwifery Bridge Certificate (MBC).
19. PHYSICIAN
A person who is currently licensed by the Arkansas State
Medical Board - or the appropriate licensing authority of a bordering state -
to practice medicine or surgery. For the purposes of any sections of these
Rules governing the care of pregnant and postpartum women, "physician" refers
to those currently practicing obstetrics. For the purposes of any sections of
these Rules governing the care of newborn infants, "physician" refers to those
physicians who currently include care of newborns in their practices.
20. PRECEPTOR
A legally practicing obstetric or midwifery practitioner who
participates in the teaching and training of apprentice midwifery students and
meets NARM preceptor standards including credentials, years of experience, and
birth attendance requirements. A preceptor assumes responsibility for
supervising the practical (clinical obstetric) experience of an apprentice and
for the midwifery services they render during their apprenticeship. In the case
of transitional apprentices, the definition of preceptor in Appendix B
applies.
21. REFERRAL
The process by which the client is directed to a physician, CNM
or ADH clinician for management of a particular problem or aspect of the
client's care, after informing the client of the risks to the health of the
client or newborn.
22.
SUPERVISION
The direct observation and evaluation by the preceptor of the
clinical experiences and technical skills of the apprentice while present in
the same room.
23. TRANSFER
OF CARE
The process by which the LLM relinquishes care of her client
for pregnancy, labor, delivery, or postpartum care to a physician, CNM or ADH
clinician, after informing the client of the risks to the health or life of the
client.
24. UNIFORMED
SERVICE MEMBER
An active or reserve component member of the United States Air
Force, United States Army, United States Coast Guard, United States Marine
Corps, United States Navy, United States Space Force, or National Guard; an
active component member of the National Oceanic and Atmospheric Administration
Commissioned Officer Corps; or an active or reserve component member of the
United States Commissioned Corps of the Public Health Service.
25. UNIFORMED SERVICE VETERAN
A former member of the United States uniformed services
discharged under conditions other than dishonorable
104.
SCOPE OF PRACTICE
1. The LLM may provide midwifery care
according to the protocols in these Rules only to healthy women, determined
through a physical assessment and review of the woman's health and obstetric
history, who are at low risk for the development of medical or obstetric
complications of pregnancy or childbirth and whose expected outcome is the
delivery of a healthy newborn and an intact placenta. The LLM shall be
responsible for care of the healthy newborn immediately following delivery and
for the first fourteen (14) days of life (unless care is transferred to a
physician or APRN specializing in the care of infants and children before
that). After fourteen (14) days the LLM is no longer responsible and the client
should seek further care from a physician or an APRN specializing in the care
of infants and children. If any abnormality is suspected, including - but not
limited to - a report of an abnormal genetic/metabolic screen or positive
antibody screen, the newborn must be sent for medical evaluation as soon as
possible but no later than 72 hours. This does not preclude the LLM from
continuing to provide counseling regarding routine newborn care and
breastfeeding.
2. Although the ADH
Licensed Lay Midwifery program is supervised by ADH physicians, each LLM is
encouraged to develop a close working relationship with one or more specific
physicians in obstetric and pediatric practice, or CNMs in obstetric practice
who agree to serve as a referral/consultation source for the LLM. This
relationship is optional. The referral physician and LLM relationship, or the
CNM and LLM relationship, can be terminated by either party at any
time.
3. Apprentice midwives and
LLM assistants may only work under the on-site supervision of their
preceptor.
4. At various points
during the course of midwifery care, the LLM must inform the client of the
requirement for tests, procedures, treatments, medications, or referrals
specified in Section 300 (Protocols) of these Rules which are for the optimal
health and safety of the mother and baby, and refusal is strongly discouraged.
However, continuing care of a client who refuses some of these requirements is
permitted if the LLM meets certain requirements as outlined in paragraphs 5
through 8.
5. LLMs that have a
current Certified Professional Midwife (CPM) credential but do not have a
Midwifery Bridge Certificate (MBC) may continue care of clients that:
a. Refuse the following tests listed in
Section 302.02 Prenatal Testing:
i. Pap
test/HPV test.
ii. Test for
Gonorrhea and Chlamydia.
iii. Test
for Syphilis.
iv. Hepatitis B
test.
v. HIV counseling and
test.
b. Refuse
recommended Rh immunoglobulin as outlined in 302.05.
c. Refuse a referral or to follow advice
against home birth as a result of the identification of these pre-existing
conditions listed in 303.02:
i. History of
seven (7) or more deliveries.
ii.
Maternal age greater than or equal to forty (40) at estimated date of
delivery.
iii. Previous infant
weighing less than five (5) pounds or more than ten (10) pounds.
iv. Pregnancy termination or loss >= three
(3).
d. Refuse the
newborn procedures listed in 308.03 and 308.04:
i. Administration of eye medication if
indicated.
ii. Administration of
Vitamin K.
6.
LLMs that have both a current CPM and the MBC, or LLMs that have a CNM or CM,
may continue care of clients that refuse any test, procedure, treatment,
referral, or medication, except for:
a. The
precluded conditions listed in Section 303.01;
b. The requirement of having the Risk
Assessments listed in Section 302.01; or
c. Conditions requiring immediate transport
as listed in Sections 305.01, 307.01, and 309.01.
7. LLMs that do not have a current CPM
credential are not permitted to continue care for clients who refuse any of the
required tests, procedures, treatments, medications or referrals specified in
these Rules except for recommended Rh immunoglobulin as outlined in 302.05.
Should a client refuse Rh Immunoglobulin the LLM must follow
104.#8.b-f.
8. Should a client of
the LLM with a CPM, CM, CNM, or CPM/MBC refuse any of the tests or procedures
pursuant to paragraphs 5 and 6:
a. The LLM
must inform the client that the LLM is only permitted to continue to provide
care to the client if the LLM's certification meets the required standard as
outlined in 5 and 6.
b. The LLM
must inform the client of the potential risks to herself or her baby. It is the
responsibility of the LLM to provide current evidence and adequate information,
both written and verbal, to the client regarding the risks of declining the
test, procedure, treatment, medication or referral, including the risks and
benefits of no action at all. This must include the review of any available and
relevant ADH-approved sources on each test, procedure, treatment, medication or
referral being refused.
c. The LLM
must document the client's refusal using the ADH Informed Refusal Form and
include:
i. The information shared with the
client as outlined in 8.b. and the ADH-approved sources used.
ii. The client's written assertion refusing
the test, procedure, treatment, medication or referral.
iii. The client's affirmation of her
understanding and acceptance of the risks.
iv. A plan of care for the condition,
including a plan for transfer of care if indicated.
d. The ADH Informed Refusal form must be
signed and dated by both the LLM and the client, and a copy kept by the LLM in
the client's file. Signing the form shows they have discussed the risks and
benefits of continuing under the care of the LLM.
e. Each signed refusal form must be
documented by completing an Incident Report form and noting the Informed
Refusal on the next LLM Caseload and Birth Report Log.
f. Documentation of refusal must be included
in the client's record in the event a client changes her mind concerning an
informed refusal.
9. It
is the responsibility of the LLM to engage in a process of continuous
evaluation, beginning with the initial consultation and continuing throughout
the provision of care. This includes continuously assessing safety
considerations and risks to the client and informing her of the same. The LLM
is expected to use their judgment in assessing when the client's condition or
health needs exceed the LLM's knowledge, experience or comfort level. The LLM
has the right and responsibility to terminate care under these
circumstances.
10. If any
medications that are provided by ADH or prescribed by a physician or CNM in
accordance with these Rules are administered at the home birth site, the LLM
shall document this in the client health record and include the following:
a. The name of the medication;
b. The lot number and date of
expiration;
c. The strength and
amount or dose of the medication;
d. The date and time the medication is
administered;
e. The name of the
prescriber; and
f. Document:
i. The name and the credentials of the nurse
administering the medication, or
ii. That the client, or LLM as agent to the
client, administered medication to the newborn.
11. The LLM is required to comply with all
provisions of HIPAA (Health Insurance Portability and Accountability
Act).
12. The LLM is required to
comply with all provisions of CLIA (Clinical Laboratory Improvement Amendments)
when tests are performed for the purpose of providing information for the
healthcare of midwife clients.
105.
TITLE PROTECTION
1. A person may not practice or offer to act
as a lay midwife in Arkansas unless licensed by the State Board of Health. It
is unlawful for any person not licensed as a lay midwife by the State Board of
Health to receive compensation for attending births as an LLM, or to indicate
that they are licensed to practice lay midwifery in Arkansas, excluding
licensed CNMs and licensed physicians.
2. Anyone unlawfully practicing lay midwifery
without a license shall be deemed guilty of a misdemeanor and upon conviction
thereof, shall be punished by a fine of not less than one hundred dollars
($100) nor more than five hundred dollars ($500), or by imprisonment in the
county jail for a period of not less than one (1) week nor more than six (6)
months, or by fine and imprisonment.
3. The courts of this state having general
equity jurisdiction are vested with jurisdiction and power to enjoin the
unlawful practice of midwifery in a proceeding by the State Board of Health or
any member thereof, or by any citizen of this state in the county in which the
alleged unlawful practice occurred or in which the defendant resides, or in
Pulaski County.
4. The issuance of
an injunction shall not relieve a person from criminal prosecution for
violation of the provisions of this chapter, but remedy of the injunction shall
be in addition to liability to criminal prosecution.
5. An LLM must use the title "Licensed Lay
Midwife" or the initials "LLM" on all materials related to their practice,
including all promotional materials.
106.
DELEGATION OF LICENSED LAY
MIDWIFERY FUNCTIONS1. An LLM assistant
may be engaged by the LLM to complement their work, but shall not be used as a
substitute for the LLM.
a. Tasks that may be
delegated to the LLM assistant before an assessment of the client's care needs
is completed by the LLM include:
i.
Noninvasive and non-sterile tasks if, in the judgment of the LLM, the LLM
assistant has the appropriate knowledge and skills to perform the
task.
ii. The collecting,
reporting, and documentation of temperature, weight, intake, output, and
contractions, indicating their frequency and duration.
iii. Reporting changes from baseline data
established by the LLM.
iv.
Assisting the client with ambulation, positioning or turning.
v. Assisting the client with personal
hygiene.
vi. Reinforcing health
teaching planned or provided by the LLM.
b. Tasks that must never be delegated to an
LLM assistant include, but are not exclusive to, the following:
i. The performance of a physical assessment
or evaluation.
ii. Physical
examination which includes - but is not limited to - fetal heart rate
auscultation, cervical exams, and blood pressure measurements.
iii. The provision of sterile invasive
treatments.
iv. The administration
of any prescription drugs.
v. The
use of any medical devices.
2. The LLM shall monitor and document the
care and procedures performed by any LLM assistant or labor support attendant
in the client's medical record.
3.
An LLM who has agreed to provide care to a client is held accountable to act
according to the standards of care set out in these Rules, until such a time as
that care is terminated by the client or the LLM in accordance with these
Rules.
4. An LLM may request a
registered nurse to perform selected acts, tasks or procedures that are outside
the scope of the LLM's practice but which do not exceed the scope of practice
of the nurse's license. It is the nurse's responsibility to be informed and act
in accordance with both the Arkansas Nurse Practice Act and the Arkansas State
Board of Nursing Rules.
5. An LLM
who also holds an Arkansas nursing license is required to act in accordance
with the following: the Rules Governing the Practice of Licensed Lay Midwifery
in Arkansas; the Arkansas Nurse Practice Act - as codified in Ark.Code Ann. §
17-87-101
- and the Arkansas State Board of Nursing Rules as promulgated by the Arkansas
State Board of Nursing. An LLM practicing under the scope of her nursing
license while acting as an LLM may be referred to the Arkansas State Board of
Nursing if any improper conduct is suspected.
107.
ADVERTISING
1. ADH permits advertising by LLMs regarding
the practice of Licensed Lay Midwifery in accordance with these
Rules.
2. No LLM shall disseminate
or cause the dissemination of any advertisement or advertising that is in any
way false, deceptive, or misleading. Any advertisement or advertising shall be
deemed to be false, deceptive or misleading if it:
a. Contains a misrepresentation of facts;
or
b. Makes only a partial
disclosure of relevant facts; or
c.
Contains any representation or claims as to services that the LLM cannot
legally perform; or
d. Contains any
representation, statement, or claim which misleads or deceives; or
e. Could lead a reasonably prudent person to
believe that the LLM is licensed to practice nursing or medicine when not so
licensed in the state of Arkansas.
3. Advertising that crosses into other states
must clearly state if any of the services offered are legal only in certain
states in which the LLM practices.
108.
IMMUNIZATIONS
All LLMs and their apprentices are strongly encouraged to have
routine vaccinations to the fullest extent unless contraindicated, and not to
rely on the immunization status of others or 'herd immunity' to protect them,
their clients, and their families.
109.
MIDWIFERY ADVISORY BOARD
The BOH shall establish and appoint the Midwifery Advisory
Board (MAB) to advise ADH and the BOH on matters pertaining to the regulation
of midwifery.
1. PURPOSE, DUTIES, AND
RESPONSIBILITIES:
a. Reviewing and advising
ADH and the BOH regarding the Rules.
b. Reviewing and advising ADH regarding
approval of continuing education units (CEUs).
c. Reviewing and advising ADH regarding
quality improvement data and information.
d. Serving as community liaisons to educate
the public and other providers regarding the practice of midwifery.
e. Promoting the safe practice of midwifery
by addressing issues and concerns regarding the practice of midwifery of ADH,
BOH, public consumers of midwifery services, and LLMs.
f. Reviewing Reports:
i. Statistical Reports
A. A draft of the annual LLM statistical
report will be available to MAB members for comment prior to the presentation
to the BOH.
B. Up to two (2) MAB
members may consult with ADH program staff in determining the plan for the
collection of data.
ii.
Disciplinary Case Reports
A. ADH will notify
the MAB of all disciplinary hearings taken before the BOH.A copy of the final
order will be made available to the MAB.
2. COMPOSITION OF THE MAB
The composition of the MAB will be as follows:
a. Four (4) Arkansas LLMs
b. One (1) CNM, currently licensed as a CNM
in Arkansas, preferably practicing.
c. One (1) member at large.
d. Three (3) public consumers who have either
had a midwife-attended birth, are the spouse of someone who has had a
midwife-attended birth, or are persons who have been involved in promoting
midwifery or home birth in the state of Arkansas.
3. NOMINATION OF MEMBERS
Members of the MAB are appointed by the BOH. The BOH requests
nominations from the MAB through ADH. The process for applying to serve on the
MAB is as follows:
a. Individuals
interested in either proposing a nomination or serving on the MAB must obtain
an "Application for Midwifery Advisory Board Appointment" from the
MAB.
b. The applicant will complete
the application form and submit it to the MAB according to the
instructions.
4. TERMS OF
MIDWIFERY ADVISORY BOARD MEMBERS
a. Midwifery
Advisory Board (MAB) members shall serve terms of up to four (4)
years.
b. No member may serve more
than two (2) consecutive full terms.
c. Members may be eligible for reappointment
two (2) years after the date of the expiration of the second full
term.
5. ORGANIZATIONAL
STRUCTURE OF THE MIDWIFERY ADVISORY BOARD
a.
MAB members shall establish and annually review the By-Laws of the Midwifery
Advisory Board.
b. Additionally, an
organizational chart with delegation of duties of MAB members and officers
shall be developed.
c. MAB members
shall elect a chair, vice-chair and secretary at its first meeting each year
that will serve until their successors are elected.
d. The MAB will schedule and conduct meetings
at least two (2) times a year and at other times, as necessary.
110.
CONTINUING
EDUCATION ACTIVITIES OF THE MIDWIFERY ADVISORY BOARD
For the purpose of these Rules, the MAB will process the review
of continuing education credits by the following criteria:
1. The application for review must be
received by the MAB at least sixty (60) days prior to the scheduled course
date, and shall be submitted simultaneously to ADH.
2. The MAB will review and evaluate the
application for the continuing education course and make a recommendation to
ADH.
3. The documentation will be
reviewed for appropriate content applicable to the protocols and clinical
practice of the Licensed Lay Midwifery program of Arkansas. Each application
shall be evaluated on the following criteria:
4. Completeness of application;
5. Agenda;
6. Intended audience;
7. Method of delivery (lecture, video,
correspondence, online, other);
8.
Course description and objectives; and
9. Biographical data for each speaker
including pertinent education and experience.
10. The recommendation of the MAB shall be
submitted in writing for ADH approval, no less than thirty (30) days prior to
the scheduled course date.ADH will make the final decision for approval of
continuing education courses, after consideration of timely received MAB
recommendations. All final decisions by ADH denying approval for continuing
education courses may be appealed to the Arkansas State BOH within thirty (30)
days of receiving the denial.
200.
LICENSING
1. An LLM license, valid for up to three (3)
years, is issued upon application and favorable review.Application materials
and instructions are available from the ADH website or by contacting the ADH
Women's Health Section for assistance.
2. Unless otherwise specified by these Rules,
individuals who wish to become licensed as an LLM in Arkansas are required to
have either current NARM CPM certification, current certification by the
American Midwifery Certification Board as a CNM or CM, or current certification
deemed equivalent and approved by ADH.
3. LLMs seeking renewal of their license must
have current CPM, CNM or CM certification unless they were licensed
continuously prior to these Rules and have never been certified as a CPM. Those
LLMs may renew their license by showing documentation of CEUs as required in
Section 202 #2d and completing the renewal application process.
4. It is the responsibility of the LLM to
ensure their credentials and certifications are current at all times. These
include - but are not limited to - CPM, CPR, and neonatal resuscitation. The
licensee must provide documentation upon request.
5. LLMs who receive a CPM or MBC must provide
verification with initial application and for license renewal, or within thirty
(30) days of initial certification.A notarized copy of the certificate or a
verification letter sent directly from NARM must be submitted to ADH.
6. In the event of a lapse or revocation of
any licensure or certification held the LLM must notify ADH within thirty (30)
days of revocation.
7. If the name
used on the application is not the same as that on any of the supporting
documentation, the applicant must submit proof of name change with
application.
8. Apprentices who
hold a valid permit prior to the effective date of these Rules will follow the
requirements for licensure found in Appendix B: Transitional Provisions and
Forms.
9. If an application for
licensure or renewal is denied, the applicant may appeal that denial to the
Arkansas State BOH with thirty (30) days of receipt of the denial.
201.
ELIGIBILITY REQUIREMENTS FOR
INITIAL LICENSURE
Applicants for initial licensure must meet the following
requirements, except for those noted in Section 200. #3:
1. An applicant for an initial license to
practice midwifery shall submit:
a. A
completed application, provided by ADH.
b. A passport style and size photo of the
applicant, head and shoulders, taken within sixty (60) days prior to the
submission date of the application and attached to the application.
c. A copy of one of the following documents
that demonstrates the applicant is twenty-one (21) years of age or older:
i. The applicant's birth
certificate.
ii. The applicant's
U.S. passport, U.S. Driver's License, or other state-issued identification
document.
iii. Any document issued
by federal, state or provincial registrar of vital statistics showing
age.
d. Documentation of
a high school diploma or its equivalent, and documentation of the highest
degree attained after high school. This documentation should include the name
of the issuing school or institution and the date issued.
e. Documentation that applicant is certified
by NARM as a CPM or by the American Midwifery Certification Board (AMCB) as a
CNM or a CM, or holds a certification deemed equivalent and approved by ADH.
Documentation may be received in the form of a verification letter directly
from the credentialing body or a notarized copy of the applicant's
credential.ADH may request additional documentation to support applicants'
qualifications or certifications. It is the responsibility of the licensee to
ensure relevant credentials are current at all times and documentation must be
provided upon request.
f. If
applicable, documentation that applicant holds an MBC issued by NARM.
Documentation may be received in the form of a verification letter directly
from the certifying body or a notarized copy of the applicant's
certificate.
g. A list on the
application form of all current professional health-related licensure including
those from other jurisdictions.ADH may request verification.
2. Upon satisfactory review of the
application by ADH, the applicant:
a. Shall
take the Arkansas Rules Examination, which will be administered at ADH, three
(3) times each year on dates chosen and publicized by ADH.
b. Shall provide proof of identity upon
request in the form of a government-issued photographic identification card at
the time of testing.
c. Shall
receive a written notice of examination results. If the applicant scores 80% or
higher on the Arkansas Rules Examination, a license will be issued.
d. Shall be permitted to re-test if their
score is below 80%.
3.
All final decisions by ADH denying issuance of license may be appealed to the
Arkansas State BOH pursuant to the Arkansas Administrative Procedures
Act.
4. Prohibiting Criminal
Offenses
a. An individual is not eligible to
receive or hold a license issued by the ADH if that individual has pleaded
guilty or nolo contendere to or been found guilty of any of the offenses
detailed in Ark.Code Ann. § 17-3-102 et. seq. By any court in the State of
Arkansas or of any similar offense by a court in another state or of any
similar offense by a federal court, unless the conviction was lawfully sealed
under the Comprehensive Criminal Record Sealing Act of 2013 §
16-90-1401 et.
seq. or otherwise sealed pardoned or expunged under prior law.
b. ADH may grant a waiver as authorized by
Ark.Code Ann. § 17-3-102 in certain circumstances.
c. For the purpose of issuing a lay midwife
license, ADH is not authorized to conduct criminal background checks, but may
inquire about criminal convictions upon application or renewal of a license.
Any applicant or licensee which provides false information to ADH regarding a
criminal conviction may be subject to suspension, revocation or denial of a
license.
5. Pre-Licensure
Prohibiting Offense Determination
a. Pursuant
to Act 990 of 2019, an individual may petition for a pre-licensure
determination of whether the individual's criminal record will disqualify the
individual from licensure and whether a waiver may be obtained.
b. The individual must obtain the
pre-licensure criminal background check petition form from Appendix A of these
Rules.
c. ADH will respond with a
decision in writing to a completed petition within a reasonable time.
d. ADH response will state the reason(s) for
the decision.
e. All decisions of
ADH in response to the petition will be determined by the information provided
by the individual.
f. Any decision
made by ADH in response to a pre-licensure criminal background check petition
is not subject to appeal.
g. ADH
will retain a copy of the petition and response and it will be reviewed during
the formal application process.
202.
RENEWAL
1. Licenses expire on August 31 of the
renewal year, and applications and documentation must be submitted by July 2 of
the renewal year to be timely. Renewal will only occur upon receipt of
application and favorable review of required activity reports by ADH. This
review will ensure that the LLM has acted in accordance with these
Rules.
2. Applications for renewal
for LLMs who have been continuously licensed in the State of Arkansas prior to
the effective date of these Rules, and who have never received certification as
a CPM, must include:
a. A completed
application for renewal provided by ADH.
b. A copy of both sides of current
certification in adult and infant cardiopulmonary resuscitation (CPR).Approved
CPR courses include the American Heart Association and the American Red Cross.
Note: Only certification from courses which include a hands-on
skills component are accepted. Online-only courses are not accepted. It is the
responsibility of the licensee to ensure this certification is current at all
times and documentation must be provided upon request
c. A copy of both sides of current
certification in neonatal resuscitation through a course approved by NARM.
Note: Only certification from courses which include a hands-on skills component
are accepted. Online-only courses are not accepted. It is the responsibility of
the licensee to ensure this certification is current at all times and
documentation must be provided upon request
d. Documentation of thirty (30) hours of
continuing clinical education within the past three (3) years. Continuing
Education Units (CEUs) and contact hours will be approved according to the
following guidelines:
i. A maximum of five (5)
hours may be granted for documented peer review.
ii. CPR or neonatal resuscitation courses may
not be used as part of your CEU totals.
iii. Workshops or conferences relevant to the
clinical practice of midwifery in Arkansas that are sponsored by the following
organizations are pre-approved by the Licensed Lay Midwifery Advisory Board for
CEUs:
A. American College of Nurse
Midwives
B. American College of
Obstetrics and Gynecology
C.
Arkansas Department of Health
D.
International Childbirth Education Association
E. La Leche League International
F. University of Arkansas for Medical
Sciences
G. Midwifery Education
Accreditation Council (MEAC)
H. Any
state Nurses Association
I.
Arkansas Osteopathic Medical Schools
3. Applications for renewal for the LLM
licensed by ADH and certified as a CPM, CNM or CM or having a certification
previously approved by ADH (Section 201.#1.e.) must include:
a. A completed application for renewal in a
format provided by ADH.
b. Proof
that the relevant credential is current. Documentation may be received in the
form of:
i. Verification letter sent directly
from the certifying agency, or
ii.
Notarized copy of the certificate.
c. A list of all professional health-related
licensure in other jurisdictions on the renewal application. ADH may request
verification.
d. ADH may request
additional documentation to support applicants' qualifications or
certifications. It is the responsibility of the licensee to ensure relevant
credentials are current at all times and documentation must be provided upon
request.
4. The state
Arkansas Rules Examination must be taken for each licensing period within one
hundred and eighty (180) days prior to the expiration of the midwifery license.
A score of eighty percent (80%) or higher must be achieved. The test for
renewal of licenses will be available on the ADH website or by contacting the
ADH Women's Health section for information. The applicant must submit a copy of
the certificate of completion with the application for license
renewal.
5. All final decisions by
ADH denying renewal of license may be appealed to the Arkansas State BOH
pursuant to the Arkansas Administrative Procedures Act.
203.
GROUNDS FOR DENIAL OF APPLICATION,
DISCIPLINE, SUSPENSION, OR REVOCATION OF LICENSE
ADH may refuse to issue, suspend or revoke a license for
violation of the Licensed Lay Midwife Act or any provision of these Rules,
including - but not limited to - any of the following reasons:
1. Securing a license or permit through
deceit, fraud, or intentional misrepresentation.
2. Submitting false or misleading information
to ADH, the BOH, or the MAB.
3.
Practicing midwifery on expired credentials.
4. Knowingly making or filing a false report
or record, intentionally or negligently failing to file a report or record
required by these Rules, or willfully impeding or obstructing such
filing.
5. Failure to submit
requested midwifery records in connection with an investigation.
6. Engaging in unprofessional conduct or
dereliction of any duty imposed by law, which includes - but is not limited to
- any departure from, or failure to conform to, the standards of the practice
of midwifery as established by these Rules.
7. Revocation of CPM certification by
NARM.
8. Permitting another person
to use the licensee's license or permit.
9. Knowingly or negligently employing,
supervising, or permitting (directly or indirectly) any person to perform any
work not allowed by these Rules.
10. Obtaining any fee by fraud or
misrepresentation.
11. Knowingly or
negligently allowing an LLM apprentice to practice midwifery without a
supervising preceptor present, except in an emergency.
12. Using, causing, or promoting the use of
any advertising material, promotional literature, or any other representation -
however disseminated or published -which is misleading or untruthful.
13. Representing that the service or device
of a person licensed to practice medicine will be used or made available when
that is not true, or using the words "doctor", "registered nurse", "Certified
Nurse Midwife" or similar words, abbreviations, acronyms or symbols including
MD (Medical Doctor), DO (Doctor of Osteopathic Medicine), RN (Registered
Nurse), CNM, CM, APRN (Advanced Practice Registered Nurse), RNP (Registered
Nurse Practitioner), EMT (Emergency Medical Technician) or paramedic, falsely
implying involvement by such a medical professional.
14. Use of the designation "birth center" or
"birthing center" in reference to the LLM's home or office, or charging
facility fees for delivery in a "birth center" or "birthing center", unless
that center is licensed as such in compliance with the requirements set forth
by the Rules for Free-Standing Birthing Centers.
15. Violation of the Arkansas Legend Drugs
and Controlled Substances Law, A.C.A. §§
20-64-501 et seq.,
or the Federal Food, Drug and Cosmetic Act,
21
U.S.C. §§ 301 et seq.
16. Displaying the inability to practice
midwifery with reasonable skill and safety because of illness, disability, or
psychological impairment.
17.
Practicing while knowingly suffering from a contagious or infectious disease
that may be transmitted through the practice of midwifery.
18. Practicing midwifery while under the
influence of any intoxicant or illegal drug.
19. Judgment by a court of competent
jurisdiction that the individual is mentally impaired.
20. Disciplinary action taken by another
jurisdiction affecting the applicant's legal authority to practice midwifery in
that jurisdiction.
21. Disciplinary
action taken by another licensing or credentialing body due to negligence,
willful disregard for patient safety, or other inability to provide safe
patient care.
22. Gross
Negligence.
23. Conviction of a
felony.
24. Failure to comply with
an order issued by the Arkansas State BOH or a court of competent
jurisdiction.
25. Practicing
outside the scope of practice and protocols as outlined in these
Rules.
204.
DISCIPLINARY ACTIONS
Suspected cases involving violation of the Licensed Lay
Midwifery Act or these Rules may be referred by ADH to the BOH for a hearing,
according to the Arkansas Administrative Procedures Act. If the BOH finds that
a person holding a license or permit has violated the Licensed Lay Midwifery
Act or these Rules' sanctions, which include -but are not limited to - the
following, may be imposed:
1.
Revocation of license or permit.
2.
Suspension of a license or permit for a determinate period of time.
3. Written or verbal reprimand of a licensee
or permit holder.
4. Probation of
license or permit.
5. Limitations
or conditions on the practice of a person holding a license or
permit.
6. Continuing education
requirements to address known deficiencies.
7. Fines as imposed by the BOH under their
general authority to regulate.
ADH will notify licensee of any actions to be imposed.
Decisions may be appealed to the Circuit Court pursuant to the Arkansas
Administrative Procedures Act.
Any applicable certification or licensing agencies will be
notified of final actions on licenses including - but not limited to - NARM and
any states where the midwife holds a license.
205.
INACTIVE STATUS
Inactive status is automatic on the day after the license
expires. LLMs who do not maintain a current license will be considered
inactive. Inactive status may be maintained for up to three (3) years. An LLM
with inactive status may not practice midwifery until the license is
reactivated. To reactivate a license with inactive status, the applicant
must:
1. Submit a copy of their
current CPM, CNM, or CM credential or, if the applicant was licensed prior to
the effective date of these Rules, document additional continuing education
credits totaling ten (10) hours for each year of inactive status,
2. Submit current CPR
certification,
3. Submit current
NARM-approved neonatal resuscitation certification, and
4. Take the Arkansas Rules Examination and
achieve a score of eighty percent (80%) or higher.
206.
REACTIVATION OF EXPIRED
LICENSE
After three (3) years, a license in inactive status
automatically expires. To become relicensed the applicant must successfully
fulfill all of the requirements for initial licensure as outlined in Section
201.
207.
APPRENTICESHIPS
Apprentices who hold a valid permit prior to the effective date
of these Rules will follow the requirements found in Appendix B; Transitional
Provisions and Forms.
An LLM will be responsible for notifying ADH of any apprentices
accepted under their supervision within thirty (30) days of signing, but prior
to the apprentice providing any services. The ADH Preceptor-Apprentice
Agreement form (found in Appendix A or available on the ADH website) shall be
used for this notification. Preceptors must meet all NARM preceptor
requirements. Any changes in the apprentice's contact information must be
provided to ADH by the LLM within thirty (30) days of the status change. If the
apprentice is still under the LLM's supervision after three (3) years, the LLM
must complete a new form indicating this status.
Should the Preceptor-Apprentice Agreement be terminated by
either party, it is the responsibility of both parties to notify ADH
immediately. An apprentice must not continue to perform under any preceptor(s)
unless a new signed Preceptor-Apprentice Agreement is on file with ADH.A signed
Preceptor-Apprentice Agreement for every preceptor under whom an apprentice
trains must be signed and sent to ADH.
Apprentices shall follow all applicable Arkansas laws and these
Rules.
Apprentices are required to comply with all provisions of HIPAA
(Health Insurance Portability and Accountability Act).
208.
LICENSURE OF UNIFORMED SERVICE
MEMBERS, UNIFORMED SERVICE VETERANS, AND THEIR SPOUSES
1. Applicability
This Rule applies to a:
a. Uniformed service member stationed in the
State of Arkansas;
b. Uniformed
service veteran who resides in or establishes residency in the State of
Arkansas;
c. The spouse of (a) or
(b) including a:
i. Uniformed service member
who is assigned a tour of duty that excludes the spouse from accompanying the
uniformed service member and the spouse relocates to Arkansas; or,
ii. Uniformed service member who is killed or
succumbed to his or her injuries or illness in the line of duty if the spouse
establishes residency in Arkansas.
2. Automatic Licensure
Automatic Licensure shall be granted to persons listed in
section 1 (a) if:
The person is a holder in good standing of occupational
licensure with similar scope of practice issued by another state, territory, or
district of the United States
3. Credit Toward Initial Licensure
Relevant and applicable uniformed service education, training,
or service-issued credential shall be accepted toward initial licensure for a
uniformed service member or a uniformed service veteran who makes an
application within one (1) year of his or her discharge from uniformed
service.
4. Expiration Dates
and Continuing Education
(a) A license
expiration date shall be extended for a deployed uniformed service member or
spouse for one hundred eighty (180) days following the date of the uniformed
service member's return from deployment.
(b) A uniformed service member or spouse
shall be exempt from continuing education requirements in Rule 202.02d for one
hundred eighty (180) days following the date of the uniformed service member's
return from deployment.
(c) Any
uniformed service member or spouse exercising the exemption shall provide
evidence of completion of continuing education before renewal or grant of a
subsequent license.
5.
ADH shall grant such automatic licensure upon receipt of all of the below:
a. Evidence that the individual holds a
substantially equivalent license in another state; and
b. Evidence that the applicant is a qualified
applicant under Section 208.1 a., b., or c.; and
c. The applicant shall hold his or her
occupational licensure in good standing;
2.
The applicant shall not have had a license revoked for:
a. An act of bad faith; or
b. A violation of law, rule, or
ethics;
3. The applicant
shall not hold a suspended or probationary license in a United States
jurisdiction.
b. A
completed application, provided by ADH.
c. A passport style and size photo of the
applicant, head and shoulders, taken within sixty (60) prior to the submission
date of the application and attached to the application.
d. If applicable, documentation that
applicant holds an MBC issued by NARM. Documentation may be received in the
form of a verification letter directly from the certifying body or a notarized
copy of the applicant's certificate.
e. A list on the application form of all
current professional health-related licensure, including those from other
jurisdictions. ADH may request verification.
6. All applicants who are licensed pursuant
to Section 208 must adhere to all LLM protocols as outlined in these
Rules.
209.
RECIPROCAL LICENSURE
Pursuant to Act 1011 of 2019, reciprocal licensure will be
granted based on substantially equivalent licensure in another U.S.
jurisdiction. Refer to Section 201.1.e of these Rules for all certifications
deemed substantially equivalent.
1.
Reciprocity
a. Required Qualifications. An applicant
applying for reciprocal licensure shall meet the following requirements:
i. The applicant shall hold a substantially
similar license in another United States jurisdiction.
1. Refer to Section 201.1.e of these Rules
for all certifications deemed substantially equivalent.
2. The applicant shall hold his or her
occupational licensure in good standing;
3. The applicant shall not have had a license
revoked for:
a. An act of bad faith;
or
b. A violation of law, rule, or
ethics;
4. The applicant
shall not hold a suspended or probationary license in a United States
jurisdiction;
ii. The
applicant shall be sufficiently competent in the lay midwifery; and
iii. The applicant will provide documentation
to ADH verifying current certification is held as required by Section
201.1.e.
b. Required
documentation. An applicant shall submit the documentation described below:
i. A completed application, provided by
ADH.
ii. A passport style and size
photo of the applicant, head and shoulders, taken within sixty (60) prior to
the submission date of the application and attached to the
application.
iii. A list on the
application form of all current professional health-related licensure,
including those from other jurisdictions. ADH may request
verification.
iv. As evidence that
the applicant's license from another jurisdiction is substantially similar to
Arkansas', the applicant shall submit the following information:
1. Evidence of current and active licensure
in that state.ADH may verify this information online if the jurisdiction at
issue provides primary source verification on its website or by telephone to
the other's state's licensing board; and
2. Evidence that the other state's licensure
requirements match those listed in Section 201.1.e.ADH may verify this
information online or by telephone to the other's state's licensing
board.
v. To demonstrate
that the applicant meets the requirements in Section 209.2.a.i.2-4, the
applicant shall provide ADH with:
1. The names
of all states in which the applicant is currently licensed or has been
previously licensed;
2. Letters of
good standing or other information from each state in which the applicant is
currently or has ever been licensed showing that the applicant has not had his
license revoked for the reasons listed in Section 209.2.a.i.3 and does not hold
a license on suspended or probationary status as described in Section
209.2.a.i.4.ADH may verify this information online if the jurisdiction at issue
provides primary source verification on its website or by telephone to the
other's state's licensing board.
vi. As evidence that the applicant is
sufficiently competent in the field of lay midwifery, an applicant shall:
1. Provide documentation to ADH verifying
current certification is held as required by Section 201.1.e.
2. If applicable, documentation that
applicant holds an MBC issued by NARM. Documentation may be received in the
form of a verification letter directly from the certifying body or a notarized
copy of the applicant's certificate.
2.
Temporary
Licensea. ADH shall issue
a temporary license immediately upon receipt and satisfactory review of the
application and the documentation required under Section 209.1.b.
b. The temporary license shall be effective
for ninety (90) days or until ADH makes a decision on the application, unless
ADH determines that the applicant does not meet the requirements in Section
209.2.a-b, in which case the temporary license shall be immediately
revoked.
c. An applicant may
provide the rest of the documentation required in Section 201 in order to
receive a license, or the applicant may only provide the information necessary
for the issuance of a temporary license.
d. Upon issuance of a temporary license, the
applicant will have up to ninety (90) days to successfully complete the
Arkansas Rules Examination as specified in Section 201.2.
e. Upon successful completion of the Arkansas
Rules Examination, the applicant will be issued a standard Arkansas Lay Midwife
License valid for up to three (3) years.
f. All standard license holders will follow
the renewal process outlined in Section 202 of these Rules.
g. If the applicant does not successfully
complete the Arkansas Rules Examination within ninety (90) days of issuance of
a temporary and provisional license, the temporary license will be considered
invalid.
h. If the applicant scores
less than 80% on the Arkansas Rules Examination, the temporary license will be
considered invalid.
i. A temporary
license cannot be reissued or extended.
j. The applicant must successfully complete
the Arkansas Rules Examination as specified in Section 201.2 in order to obtain
a standard Arkansas Lay Midwife License.
3.
License for person from
a state that doesn't license profession.
Applicants from another U.S. jurisdiction where substantially
equivalent licensure is not available, refer to Section 201 for licensure
requirements.
4. All
applicants who are licensed pursuant to Section 209 must adhere to all LLM
protocols as outlined in these Rules.
300.
PROTOCOLS
The LLM must adhere to the LLM protocols as outlined in these
Rules.
301.
REQUIREMENTS FOR
LICENSED LAY MIDWIFERY PRACTICE
The following requirements must be met before a LLM can legally
accept a client.
1. Licensing - The
LLM must possess a current Arkansas Lay Midwife License,. See Section
200.
2. Disclosure Form - At the
time a request is made for care, the LLM must discuss certain information
concerning LLM assisted home deliveries with the client. This discussion must
be documented by use of the disclosure form (found in Appendix A or available
on the ADH website). It must be signed and dated by the client at the same time
the LLM and client enter into an agreement for services and sign a contract.
This form must be filed in the client's medical record and noted on the next
caseload and birth report log sent to ADH by the LLM.
3. Emergency Plan - As part of the disclosure
form, an individual emergency plan must be established by the LLM and client.
The plan must include:
a. The name and contact
information of the physicians that will be consulted for the mother and the
newborn;
b. The arrangements for
transport from the delivery site to a hospital, if needed;
c. The hospital with obstetric services, or
the hospital where the physician or CNM has obstetric privileges, that will be
used for transport, which must be located within fifty (50) miles of the
delivery site; and
d. The nearest
hospital to the delivery site.
301.01 TERMINATION OF CARE
An LLM shall terminate care of a client only in accordance with
this section unless a transfer of care results from an emergency
situation.
1. Once the LLM has
accepted a client, the relationship is ongoing and the LLM cannot refuse to
continue to provide midwifery care to the client unless:
a. The client has no need of further
care;
b. The client terminates the
relationship; or
c. The LLM
formally terminates the relationship due to a provision of these Rules or for
any other reason.
2. The
LLM may terminate care for any reason by:
a.
Providing a minimum of thirty (30) days' written notice, during which time the
LLM shall continue to provide midwifery care until the client is able to select
another health care provider. If continuing care would cause the LLM to violate
these Rules, care can be terminated by the LLM without giving thirty (30) days'
notice. Justification for this action must be documented in the client's
record;
b. Attempting to tell the
client in person and in the presence of a witness of the LLM's wish to
terminate care. If the client will not meet with the LLM, the LLM must document
that the attempt was made and how it was made;
c. Providing the client with referrals to
other healthcare providers; and
d.
Documenting the termination of care in the client medical record and submission
of an ADH incident report.
301.02 TRANSFER OF CARE
If a transfer of care recommendation occurs during labor,
delivery, or the immediate postpartum period, and the client refuses transfer
the midwife shall call 911 and provide further care as indicated by the
situation. If the midwife is unable to transfer to a health care professional,
the client will be transferred to the nearest appropriate health care facility.
The midwife shall attempt to contact the facility and continue to provide care
as indicated by the situation.
302.
PROTOCOL FOR REQUIRED ANTEPARTUM
CARE302.01 RISK ASSESSMENT(S):
Risk assessments shall be performed by a physician, a CNM or an
ADH clinician. The purpose of these visits is to ensure that the client has no
potentially serious medical conditions and has no medical contraindications to
home birth. Each risk assessment must be filed in the client's medical
record.
The risk assessments must be comprehensive enough for the LLM
to identify potentially dangerous conditions that may preclude midwifery care,
or that require physician or CNM consultation.
Each client must be evaluated by a physician, a CNM, or an ADH
clinician at the following times:
1.
At or near the time care is initiated with the LLM, and the evaluation must
include the Required Antepartum Services listed in Section 302.02.
2. At or near the
36th week of gestation and must include:
a. Review of the client's complete prenatal
record;
b. Review of the results of
all prenatal testing;
c. Interval
medical and obstetric history;
d.
Review of systems;
e. Pertinent
physical examination, including:
i.
Measurements of blood pressure, weight
ii. Fundal height
iii. Estimated gestational age
iv. Fetal presentation/position;
and
f. Group B Strep
testing, according to ADH approved guidelines.
3. Between 41 weeks 0/7 days and 42 weeks 0/7
days of gestation, the requirements for the 36th
week assessment shall be repeated and may include additional tests or
procedures.A documented plan for care beyond 42 weeks 0/7 days gestational age
must be submitted to ADH as an additional required incident report. If a
referral or this risk assessment is not made, or if the clinician advises
against home delivery, the client must be transferred.
4. The LLM is responsible for reviewing the
risk assessment data and insuring that her client is low risk for home
delivery. The LLM must base her decision on all information, results and
recommendations received from the clinician performing the risk assessment,
including any statement in the client's record by a physician, CNM or ADH
clinician indicating that the client is NOT suitable for home birth.
302.02 REQUIRED ANTEPARTUM
SERVICES AT OR NEAR THE INITIATION OF CARE
The LLM must ensure each client receives the following services
at or near the initiation of care from a physician, CNM, or ADH clinician.
Exceptions to these required services are at the discretion of the physician,
CNM, or ADH clinician who performs the risk assessment and must be documented
in the client's medical record.
1.
Medical, obstetric and nutritional history. The history must be comprehensive
enough to identify potentially dangerous conditions that may preclude midwifery
care, or that require physician or CNM consultation.
2. A physical examination comprehensive
enough to identify potentially dangerous conditions that may preclude midwifery
care.
3. Estimation of gestational
age.
4. Measurements of blood
pressure, height and weight.
5.
Prenatal Testing:
a. Pap test/HPV
test.
b. Test for Gonorrhea and
Chlamydia.
c. Blood sample for
blood group and Rh determination and antibody screen.
d. CBC with platelets or hematocrit or
hemoglobin.
e. Test for
Syphilis.
f. Urine
culture.
g. Blood Sugar: test
according to national standards as approved by ADH and available on the ADH
website.
h. Hepatitis B
test.
i. Counsel client concerning
maternal serum genetic testing, if before 20 weeks gestation.
j. Rubella test if previous immunity not
documented.
k. HIV counseling and
test.
302.03
COLLECTION OF LABORATORY SPECIMENS
For LLMs who are trained in the collection of laboratory
specimens and collect the specimens themselves, the specimens must be submitted
to a standard lab. The reports and test results must be sent for review and
interpretation by a physician, CNM or ADH clinician. All reports and test
results, including reviews and interpretations, must be recorded in the client
record.
If blood sugar testing is performed by the LLM, they shall use
only an FDA approved device for CLIA (e.g. HemoCue Blood Glucose Analyzer), and
follow the ADH approved standards for diabetes testing. The results of all
testing must be interpreted by a physician, CNM, or ADH clinician within ten
(10) days.
302.04 ROUTINE
ANTEPARTUM LLM CARE
1. Frequency of Visits
Routine antepartum visits must be made approximately every four
(4) weeks during the first 28 weeks of gestation, approximately every two (2)
weeks from the 28th to 36th weeks, and weekly thereafter until delivery.
2. Routine Visit Services
At each visit the LLM will perform and record the following
services:
a. Weight.
b. Blood pressure.
c. Fundal height.
d. Determination of fetal position.
e. Urine testing for glucose, protein, and
nitrites.
f. Fetal heart
rate.
g. Medical and nutritional
history since last visit.
h. Check
for edema of legs, face or hands.
302.05 REQUIRED ANTEPARTUM SERVICES AT 24 TO
28 WEEKS GESTATION
1. Except for women with
known gestational diabetes all women must be screened for gestational diabetes
between 24-28 weeks according to national standards approved by ADH.
2. All women with negative Rh factor must be
treated as follows:
a. Repeat antibody
screening at 28 weeks. If it is negative, advise client that an Rh
immunoglobulin injection is recommended. If the client is enrolled in a local
health unit maternity clinic, Rh immunoglobulin can be administered at the
clinic, otherwise she must be referred to a physician or CNM to obtain the Rh
immunoglobulin.
b. If antibody
screen is positive, refer the client or consult a physician or CNM as soon as
possible.
c. If client declines Rh
immunoglobulin, repeat antibody screening must be performed at 28 weeks and the
LLM is responsible for providing the client with written information provided
by ADH outlining the risks of isoimmunization and the benefits of Rh
immunoglobulin. A copy of the signed refusal form needs to be documented and
filed in the client's record.
3. Testing for CBC with platelets.
302.06 REQUIRED ANTEPARTUM SERVICE
AT 35 TO 37 WEEKS GESTATION
Screening for Group B Strep according to ADH approved
guidelines available on the ADH website.
302.07 ANTEPARTUM PREPARATION FOR HOME BIRTH
1. Pre-Delivery Home Visit
The LLM is required to make, prior to delivery, at least one
visit to the home where the birth will take place.
The LLM should inform the client of the equipment and supplies
that must be available at the time of delivery. She should instruct the client
and family of requirements for an aseptic delivery site.
2. Obtaining ADH Newborn Care Package
The Newborn Care Package provided by ADH contains the required
newborn medications and other necessary items and is available to all LLM
clients. If the mother chooses to obtain the newborn care package from ADH, she
must notify the local health unit in sufficient time to allow the local health
unit one month to obtain the care package.
3. Obtaining Medications for Newborn
a. The LLM must advise the client that the
newborn may need either Erythromycin 0.5% Ophthalmic or Tetracycline 1.0%
Ophthalmic in individual dose packaging for newborn eye care. The mother may
obtain one of these medications before 37 weeks 0/7 days of the pregnancy
either by prescription from a private physician, CNM or other licensed
prescriber, or by prior arrangement with a local health unit.
b. The LLM must advise the client that the
newborn should receive Vitamin K within two (2) hours of birth. The medication
should be obtained by prescription before 37 weeks 0/7 days of pregnancy from a
private physician, CNM or other licensed prescriber or by prior arrangements
with a local health unit.
c. The
LLM must advise the client that:
i. All
medications must be administered to the newborn by a person licensed by the
state of Arkansas to administer medications (nurse, physician), and that prior
arrangements should be made in order to assure the licensed person will be
available to administer the medications soon after birth, or
ii. The client has the option to administer
the medications to her newborn with instructions from the licensed prescriber
(physician, CNM, or ADH clinician), or
iii. The client has the option to allow the
LLM to act as her agent to administer to her newborn the following medications:
A. Erythromycin 0.5% Ophthalmic or
Tetracycline 1.0% Ophthalmic.
B.
Vitamin K, only allowed to be administered orally by the LLM.
4. Obtaining
Intrapartum and Postpartum Medications for Mothers
The LLM will discuss with her client the protocol for each of
the following medications that require the client to make arrangements to
obtain the prescriptions and establish a plan for the administration of
medications prior to the onset of labor:
a. Rh immunoglobulin for Rh negative mothers
with an Rh positive newborn
b. GBS
prophylaxis according to ADH approved guidelines.
c. Benzocaine (14%) available in gel form,
solution or spray that may be used for the repair of 1st and 2nd degree
lacerations by the LLM after birth.
5. Preparing Bottle-feeding Mothers
a. For the client planning to bottle feed her
newborn, commercially prepared, client-selected formula shall be available for
an initial feeding within the first two to three hours after birth.
b. Client-selected formula must be available
for newborn feedings.
6.
Education of Client for Required Genetic/Metabolic Screening
The LLM is responsible for advising the client of the law that
requires newborn screening (A.C.A. §
20-15-302)
and the procedure for conducting newborn screening. Information is available on
the ADH website.
7.
Completion of Newborn Hearing Screening
The LLM is responsible for advising the client of the newborn
infant hearing screening law (A.C.A. §
20-15-1101 et
seq.) and the available resources to obtain the newborn hearing screen.
Information is available on the ADH website.
8. Preparation for Well-Baby Care
The LLM is responsible for advising the mother that beyond the
first fourteen (14) days of life, the LLM is no longer responsible and the
mother should seek further care from a physician or an APRN specializing in the
care of infants and children. This does not preclude the LLM from providing
counseling regarding routine newborn care and breastfeeding.
9. Preparation for Secondary Prevention of
Newborn Early-Onset Group B Strep Disease
The LLM shall advise the mother of the necessity for newborn
evaluation by a physician within 24 hours of birth when:
a. Maternal GBS status is unknown and
membranes are ruptured in labor >18 hours before birth. Refer to Section
309.02 (8).
b. The mother has
indications for GBS prophylaxis in labor, regardless of adequate antibiotic
treatment prior to birth and regardless of the presence or absence of symptoms
of illness. Refer to Section 303.03 (2).
303.
PROTOCOL FOR ANTEPARTUM
CONDITIONS REQUIRING INTERVENTION
Each client is to have a risk assessment (see Section 302.01)
documented by a physician, CNM, or ADH clinician at or near the initiation of
care and again around the 36th week. The following
sections detail the actions to be followed by the LLM if the client exhibits or
develops one of the specified conditions. The LLM will refer women for medical
evaluation as soon as possible after the condition is identified. The LLM is
expected to use /their judgment regarding the need for consultation, referral,
or transfer when problems arise that are not specified in these Rules. In
addition to the birth log, such care will be documented on an incident report
and submitted to ADH.
303.01
CONDITIONS PRECLUDING MIDWIFERY CARE
The following conditions preclude midwifery care and the client
must be transferred to a physician, CNM, or ADH clinician upon diagnosis. There
may be additional high-risk conditions judged by either a physician, CNM, ADH
clinician, or LLM that could also preclude midwifery care.
1. Previous cesarean delivery
2. Multiple gestation
3. Documented placenta previa in the third
trimester
4. Insulin-dependent
diabetes
5. Pregnancy that extends
beyond 42 weeks 0/7 days gestational age unless there is a third risk
assessment and a documented plan of care submitted to ADH. If the clinician
advises against home delivery, the client must be transferred.
303.02 PRE-EXISTING CONDITIONS
REQUIRING ANTEPARTUM CONSULTATION, REFERRAL, OR TRANSFER OF CARE
If any of the following pre-existing conditions are identified
the client must be examined by a physician, CNM, or ADH clinician. A plan of
care for the condition must be established, including a plan of for transfer of
care if indicated, and execution of the plan of care must be documented.
Midwives caring for these clients will be required to submit additional
incident reports to ADH. If a referral is not made or if the clinician advises
against home birth, the care must be transferred to a physician or CNM.
1. Heart disease
2. Epilepsy
3. Diabetes
4. Neurological disease
5. Sickle cell or other
hemoglobinopathies
6.
Cancer
7. Psychiatric
disorders
8. Active
tuberculosis
9. Chronic pulmonary
disease
10.
Thrombophlebitis
11.
Endocrinopathy
12. Collagen
vascular diseases or other severe collagen disease
13. Renal disease
14. Hypertension
15. Drug or alcohol use during current
pregnancy
16. Significant
congenital or chromosomal anomalies
17. History of postpartum hemorrhage not
caused by placenta previa or abruption
18. Rh negative isoimmunization (positive
Coombs)
19. Structural
abnormalities of the reproductive tract including fibroids
20. HIV positive or AIDS
21. Previous infant with GBS
disease
22. History of unexplained
perinatal death
23. History of
seven (7) or more deliveries
24.
Maternal age greater than or equal to forty (40) at estimated date of
delivery
25. Previous infant
weighing less than five (5) pounds or more than ten (10) pounds
26. Previous surgery involving the uterus or
cervix.
27. Pregnancy termination
or loss >= three (3)
303.03 ANTEPARTUM CONDITIONS REQUIRING
CONSULTATION, REFERRAL OR TRANSFER OF CARE
If any of the following antepartum conditions are identified, a
physician/CNM consultation, referral or transfer is required and the client
must be examined by a physician or CNM currently practicing obstetrics. ADH
clinicians may accept referrals per ADH protocol. A plan of care for the
condition must be established, and execution of the plan must be documented.
Midwives caring for these clients shall submit additional required incident
reports to ADH. If a referral is not made or if the clinician advises against
home delivery the client must be transferred immediately to a physician or
CNM.
1. A sudden decrease in fetal
movement or kick count of less than 10 per hour after 27 weeks 6/7
days.
2. Group B Strep Prophylaxis
Indications. CDC approved Group B Strep intrapartum prophylaxis (per ADH
approved guidelines) must be obtained for the clients listed below
(A-D).Clients who refuse antibiotics will be transferred from midwifery care to
a physician for hospital care unless a physician agrees to supervise the LLM
care of the client. The plan of care agreed to by the physician and the LLM
must be documented and submitted as an incident report to ADH.
a. Clients who test positive for Group B
Strep in the urinary tract at any time in the current pregnancy (regardless of
repeated testing that is negative for Group B Strep). Vaginal/rectal testing
for Group B Strep is not indicated when the urine testing is positive for Group
B Strep in the current pregnancy.
b. Clients who test positive for Group B
Strep in the vagina or rectum at any time in the current pregnancy (regardless
of repeated testing that is negative for Group B Strep).
c. Clients with positive history of birth of
an infant with early-onset Group B Strep disease.
d. Clients with antepartum Group B Strep
culture status that is unknown at the time of labor onset and:
i. Temperature in labor ( > 100.4 degrees
F); or
ii. Rupture of membranes
> 16 hours (Refer to 305.01 Immediate Transport #12). Prophylactic
antibiotics are indicated by 18 hours of ruptured membranes; or
iii. Preterm labor (< 37 weeks 0/7 days of
gestation)
3.
Cervical effacement or dilatation prior to 37 weeks 0/7 days
4. Late term pregnancy greater than 41 weeks
0/7 days. The third risk assessment is required between 41 weeks 0/7 days and
42 weeks 0/7 days, and transfer of care may be required depending on results.
(Section 302.01. #3)
5. Genital
herpetic lesions
6. Clients with a
previous preterm delivery must be co-managed until 37 weeks 0/7 days
7. Suspected or confirmed fetal
death
8. Vaginal bleeding heavier
than a normal period
9. Persistent
or significant weight loss after the first trimester
10. Abnormal weight gain
11. Symptoms of vaginitis refractory to
treatment
12. Symptoms of UTI
refractory to treatment
13.
Hematocrit of < 30 or hemoglobin of < 10, or platelets <
100,000
14. Hyperemesis with weight
loss
15. Two blood pressure
readings at least one hour apart of systolic [GREATER THAN EQUAL TO] 140 or
diastolic [GREATER THAN EQUAL TO] 90
16. Size/date discrepancy of three (3) or
more weeks on two (2) successive exams
17. Positive antibody screen
18. Abnormal Pap test
19. Sexually transmitted infection
20. Ruptured membranes without onset of labor
within 24 hours and Group B Strep testing is negative. Refer to Section 303.03
(2) for mothers that are GBS positive or have unknown GBS status.
21. Signs and symptoms of
pre-eclampsia
22. Fetal heart rate
below 110 bpm or above 160 bpm
23.
Spontaneous rupture of membranes prior to 37 weeks 0/7 days
24. Gestational Diabetes, as defined by ADH
approved guidelines
25. Rh negative
mothers with abdominal trauma, with or without antepartum bleeding.
26. Position other than vertex any time after
35 weeks 6/7 days
304.
PROTOCOL FOR REQUIRED INTRAPARTUM
CARE304.01 INITIAL LABOR ASSESSMENT
As soon as possible but within one (1) hour following the onset
of active labor (56 cm with regular and painful contractions) or as soon as
possible but within one hour following the pre-labor rupture of membranes, the
LLM must assess and record:
1.
Physical conditions including temperature, pulse, respiration, blood pressure
and urinalysis for glucose and protein.
2. Labor status including assessment of
contractions, status of membranes, cervical dilatation and
effacement.
3. Fetal position,
station, size, presenting part and heart rate. Establish a fetal heart rate
baseline by checking rate and rhythm every 15 minutes for the first hour of
observation.
4. In case of
suspected pre-labor rupture of membranes, avoid digital exams unless the client
is in active labor or delivery is imminent. A sterile speculum examination is
advised to inspect for umbilical cord prolapse and to assess the
cervix.
304.02 MANAGEMENT
OF LABOR
1. First stage. The LLM must assess
and record:
a. Fetal heart rate and rhythm
(immediately following a contraction):
i. At
least every hour until five to six (5-6) centimeters, then at least every
thirty (30) minutes until cervix is completely dilated.
ii. Immediately after rupture of membranes
and during and after the next two contractions to rule out prolapsed
cord.
iii. After any treatment,
procedure or intervention.
iv. When
there is a change in contractions or labor pattern.
v. When there is any indication that a
medical or obstetric complication is developing.
b. Duration, interval and intensity of
uterine contractions at least every two (2) hours or more frequently if
indicated.
c. Maternal blood
pressure and heart rate in active labor:
i.
Every two (2) hours, or more frequently if indicated.
ii. Blood pressure every fifteen (15) minutes
when there is a systolic reading of [GREATER THAN EQUAL TO] 140 or a diastolic
of [GREATER THAN EQUAL TO] 90.
iii.
Heart rate every 15 minutes when maternal heart rate is < 70 or >
110.
d. Temperature:
i. Every two (2) hours in active
labor,
ii. Every two (2) hours
following rupture of membranes,
iii. Every thirty (30) minutes when oral
temperature is 99.5º F or higher.
2. Second stage and third stage. The LLM's
duties include but are not limited to:
a.
Assessing and documenting
i. That labor is
progressing.
ii. Maternal and fetal
well-being including fetal heart rate at least every 15 minutes or more
frequently if indicated.
b. Delivering the newborn and placenta.
All services should be provided in a supportive manner and in
accordance with these Rules.
305.
PROTOCOL FOR INTRAPARTUM
CONDITIONS REQUIRING PHYSICIAN OR CNM INTERVENTION
305.01 IMMEDIATE TRANSPORT
The following INTRAPARTUM conditions preclude midwifery care,
and when identified, the client must be transported to the planned hospital by
the most expedient method of transportation available to obtain
treatment/evaluation:
1. Position
other than vertex;
2. Active
genital herpes lesions;
3. Labor
prior to 37 weeks 0/7 days gestation;
4. Bleeding in labor that exceeds scant
amount with each cervical examination;
5. Thick meconium if birth is not
imminent;
6. Prolapsed
Cord;
7. Non-Reassuring fetal heart
rate (FHR) Patterns (Category II or Category III) that are repetitive and do
not promptly respond to maternal position changes, unless birth is imminent.
(Category I FHR patterns are reassuring and are not an indication to
transport.) Characteristics of Category II and III include:
a. Variable decelerations: Abrupt decreases
in the FHR by 15 bpm or more lasting 15 seconds or more
b. Late decelerations: Gradual decreases in
the FHR occurring in the latter portion of the contraction, returning to
baseline after the end of the contraction
c. Prolonged decelerations: A decrease in the
FHR baseline by 15 bpm or more lasting between two (2) minutes and ten (10)
minutes
d. Tachycardia: FHR baseline
> 160 bpm
e. Bradycardia: FHR
baseline < 110 bpm;
8.
Signs of maternal infection - any of the following:
a. Temperature of [GREATER THAN EQUAL
TO]100.4
b. Fetal tachycardia
(baseline heart rate > 160)
c.
Maternal tachycardia (heart rate > 110)
9. Signs of fetal infection: baseline FHR
> 160 or a baseline FHR that is continually increasing;
10. Suspected or confirmed fetal
death;
11. Two high blood pressure
readings, meaning a systolic of [GREATER THAN EQUAL TO] 140 or a diastolic of
[GREATER THAN EQUAL TO] 90, two (2) hours apart unless birth is imminent.;
or
12. Unknown GBS status prior to
sixteen (16) hours of ruptured membranes, when delivery is not imminent
(prophylactic antibiotics are indicated by eighteen (18) hours of ruptured
membranes).
305.02
PHYSICIAN CONSULTATION
The following INTRAPARTUM conditions require consultation with
a physician or CNM who has obstetric privileges in a hospital within fifty (50)
miles of the delivery site. A plan of care must be established and execution
documented.
Midwives caring for these clients will submit additional
required incident reports (found in Appendix A or available on the ADH website)
. If consultation is not available the client must be transported to the
hospital per the emergency plan. If the client's condition is not stable she
should be transported to the nearest hospital.
1. Prolonged labor in a primagravida defined
as:
a. more than 20 hours from onset of
contractions to 5 centimeters
b.
more than 17 hours from 5 centimeters to complete dilation
c. more than two and a half (2.5) hours
pushing
d. more than one (1) hour
from delivery of the infant to delivery of the placenta.
2. Prolonged labor in the multigravida
defined as:
a. more than 14 hours from onset
of contractions to 5 centimeters
b.
more than 16 hours from 5 centimeters to complete dilation
c. more than one (1) hour pushing
d. more than one (1) hour from delivery of
the infant to delivery of the placenta.
306.
PROTOCOL FOR REQUIRED
POSTPARTUM CARE306.01 IMMEDIATE CARE
The LLM must remain in attendance for at least two (2) hours
after the delivery and shall assess and record the following:
1. Immediately following the delivery of the
placenta, the LLM shall determine that the uterus is firmly contracted without
excessive bleeding, ascertain that the placenta has been delivered completely,
and determine the number of cord vessels.
2. LLMs may repair 1st and 2nd degree
perineal lacerations. LLMs may apply topical benzocaine (14%) available in gel
form, solution or spray) for repair of lacerations. Benzocaine requires a
prescription from a physician, CNM or ADH clinician for the client and the
prescription must be written in the client's name.
3. During the two (2)-hour postpartum period,
the LLM shall assess, as needed: uterine firmness, vaginal bleeding, vaginal
swelling or tearing, maternal blood pressure and pulse. The LLM shall remain in
attendance until these signs are well within normal limits or until a physician
or CNM is in attendance if they are found to be abnormal.
4. The LLM shall leave instructions for
follow-up care that include signs and symptoms of conditions that require
medical evaluation such as: excessive bleeding, increasing pain, severe
headaches or dizziness and inability to void.
306.02 FOLLOW-UP POSTPARTUM CARE
1. A follow-up home visit shall be performed
between 12 to 36 hours postpartum to evaluate for excessive bleeding,
infection, or other complications.
2. For all mothers with Rh negative blood and
a newborn that is Rh positive, the LLM must counsel the mother to obtain
postpartum Rh immunoglobulin within 72 hours of delivery.
3. The LLM is required to follow the mother
for a minimum of thirty (30) days from delivery.Care shall include family
planning counseling and education on the need for updated immunizations,
including the rubella vaccine if susceptible. The final postpartum evaluation
shall be performed between 4 to 6 weeks after delivery.
307.
PROTOCOL FOR POSTPARTUM
CONDITIONS REQUIRING PHYSICIAN OR CNM INTERVENTION
307.01 IMMEDIATE TRANSPORT
The following POSTPARTUM conditions preclude midwifery care and
when identified, the client must be transported to the hospital indicated in
the emergency plan by the fastest method of transportation available to obtain
treatment/evaluation:
1. Hemorrhage:
estimated blood loss of 500 milliliters or more
2. Exhibiting signs of shock:
a. Systolic BP < 90
b. Diastolic BP < 60
c. Heart rate < 50 or > 120
d. Respiratory rate < 10 or >
30
e. Maternal agitation, confusion
or unresponsiveness
3.
Elevated BP:
a. Systolic [GREATER THAN EQUAL
TO] 160
b. Diastolic [GREATER THAN
EQUAL TO] 100
4. Third
and fourth degree lacerations
5.
Maternal temperature > 100.4 on two (2) occasions one hour or more
apart
6. Inability to urinate by
six (6) hours after delivery
307.02 CONSULTATION OR REFERRAL
The following POSTPARTUM conditions require consultation with a
physician or a CNM.A plan of care must be established and execution documented.
Midwives caring for these clients will submit additional required incident
reports to ADH (found in Appendix A or available on the ADH website).
1. Signs and symptoms of postpartum
infection:
a. Endometritis
b. Mastitis
c. Urinary tract infection
2. Signs and symptoms of
sub-involution
3. Signs and
symptoms of postpartum pre-eclampsia
4. Signs and symptoms of postpartum
depression
308.
PROTOCOL FOR REQUIRED NEWBORN CARE
The LLM shall be responsible for newborn care immediately
following the delivery and care of the healthy newborn for the first fourteen
(14) days of life unless care is transferred to a physician or APRN
specializing in the care of infants and children before that. After fourteen
(14) days the LLM is no longer responsible and the mother should seek further
care from a physician or an APRN specializing in the care of infants and
children. If any abnormality is suspected, including - but not limited to - a
report of an abnormal genetic/metabolic screen or positive antibody screen, the
newborn must be sent for medical evaluation as soon as possible but no later
than 72 hours. This does not preclude the LLM from providing counseling
regarding routine newborn care and breastfeeding.
308.01 IMMEDIATE CARE
The following services must be provided by the LLM as part of
immediate newborn care:
1. Suction
nose and mouth prior to delivery of shoulders if needed.
2. Assess presence of meconium.
3. Assess baby's status at birth as vigorous
or non-vigorous.
4. Immediately
after delivering entire body, suction mouth, then nose again, if
needed.
5. Clamp and cut the
cord.
6. Directly place baby
skin-to-skin with mother, covering baby with a blanket. The baby should ideally
remain in direct skin-to-skin contact with their mother immediately after birth
until the first feeding is accomplished.
7. Determine Apgar scores at one (1) and five
(5) minutes after delivery while baby is with mother.
8. Routine care can be done with the baby and
mother in skin-to-skin contact to insure warmth. Observe and record:
a. Skin color and tone.
b. Heart rate.
c. Respiration rate and character.
d. Estimated gestational age. Indicate
average, small or large for gestational age.
e. Axillary temperature.
f. Weight, length, head
circumference.
9. Obtain
cord blood for Rh and antibody screen if mother is Rh negative.
308.02 FEEDING
Newborn should be placed at the breast as soon as stable after
delivery. The bottle fed newborn should be offered formula of choice within the
first two to three hours after birth. Instruct the mother in normal and
abnormal feeding patterns.
308.03 If indicated, the LLM must advise
parents that the newborn must receive either Erthromycin 0.5% Opthalmic or
Tetracycline 1.0% Opthalmic within one (1) hour of birth. The LLM must document
in the client's medical record whether or not medication was administered to
the newborn and by whom.
308.04 The
LLM must advise parents that the newborn must receive Vitamin K within two (2)
hours of birth. The LLM must document in the client's medical record whether or
not medication was administered to the newborn and by whom.
308.05 NEWBORN SCREENING
1. Genetic/Metabolic Screening:
All newborns must have a capillary blood sample within the
required time frame for the newborn screening as mandated by law and as
specified on the ADH collection form. Information can be obtained by contacting
the ADH Newborn Screening program.
2. Infant Hearing Screening:
The LLM must instruct the mother in available resources to
obtain the infant hearing screen. Assistance in completing and submitting the
required form can be obtained by contacting the ADH Infant Hearing
Program.
308.06
CORD CARE
The LLM must instruct the mother in routine cord care.
309.
PROTOCOL FOR
NEWBORN CONDITIONS REQUIRING PHYSICIAN INTERVENTION
309.01. IMMEDIATE TRANSPORT
The following NEWBORN conditions, when identified, require
immediate transport of the newborn to the hospital by the most expedient method
of transportation available to obtain treatment/evaluation. LLMs that
participate in the care of these newborns are required to submit additional
incident reports (found in Appendix A or available on the ADH website).
1. Respiratory distress
2. Central cyanosis
3. Seizures
4. If a temperature outside the normal range
of 97.7F (36.5C) - 99.3F (37.4C) per axilla is note, appropriate corrective
measures must be taken, and temperature taken hourly for the next two (2)
hours. Three (3) persistently out of range temperatures warrant
transfer.
5. Jaundice at 0 to 24
hours
6. Apgar score of < five
(5) at one minute or > seven (7) at five minutes
7. Apnea lasting > ten (10)
seconds
8. Heart rate > 160 bpm
or <100 bpm
9. Pallor and poor
capillary refill
10. Poor suck or
refusal to feed
11. High-pitched
cry
12. Any significant congenital
anomaly including ambiguous genitalia
13. Skin with petechiae or significant
bruises
14. Poor response to sound
or touch
15. Poor tone
(floppy)
309.02.
PHYSICIAN CONSULTATION
The newborn must be weighed weekly. During the first two (2)
weeks of life the newborn must be immediately referred to a pediatric or family
medicine provider for any illness or abnormal physical finding. The newborn
must also be referred if there are any concerns about weight gain, feeding,
elimination, development, or abnormal screening results.
The following NEWBORN conditions require immediate (unless
otherwise indicated) consultation with a physician whose practice includes
pediatrics. A plan of care must be established and execution documented.
Midwives caring for these newborns will be required to submit additional
required incident reports to ADH (found in Appendix A or available on the ADH
website). If consultation is not available the newborn must be transported to
the hospital listed in the plan of care.
The LLM is responsible for the coordination of the physician
consultation with the child's parents, and must follow-up on this consultation
and document the outcome in the client's record.
1. Jaundice at 24 to 48 hour of
life
2. No urination at 12 hours of
life
3. Birth weight of less than 5
1/2 pounds or more than 10 pounds
4. Abnormal cry
5. No stool after 48 hours
6. Vomiting after feedings7. Tachypnea of
greater than 60 breaths per minute after 4 hours of life
8. Mother's membranes ruptured for more than
18 hours and unknown GBS status.
9.
Infant born to mother with indications for GBS prophylaxis in labor that did
not receive antibiotics [GREATER THAN EQUAL TO] 4 hours prior to birth (per ADH
approved guidelines found on ADH website).
10. Jittery
11. Floppy
12. Eye rolling
400.
EMERGENCY
MEASURES
The LLM must consult a licensed physician or CNM whenever there
are significant deviations from normal in either the mother or the newborn, and
must act in accordance with the instructions of the physician or CNM. In those
situations requiring transport to a hospital, the LLM must notify the emergency
room or labor and delivery unit of the designated hospital of an imminent
transport and provide a copy of the complete medical record to the appropriate
staff at the receiving facility.
1.
The LLM is expected to use their judgment regarding the need for referral or
emergency transport when problems arise that are not specified in the
protocol.
2. No Licensed Lay
Midwife may assist labor by any forcible or mechanical means; attempt to remove
adherent placenta; administer, prescribe, advise or employ any prescription
drug or device; or attempt the treatment of a precluded condition, except in an
emergency when the attendance of a Physician or CNM cannot be speedily
secured.
3. Any authorized or
unauthorized emergency measures must be reported to ADH in an incident report
(found in Appendix A or available on the ADH website). In the case of
actions/procedures authorized by a physician or CNM in the case of a specific
emergency, the LLM will document these orders with an order signed by the
physician or CNM and submit it to ADH on the 10th of
the following month.
500.
RECORD KEEPING AND REPORTING REQUIREMENTS
501.
MONTHLY REPORTS
1. A monthly reporting log, referred to as
the Caseload and Birth Log (found in Appendix A or available on the ADH
website), will be maintained and sent to ADH postmarked no later than the
10th of each month regardless of any changes or
additions to the Log.
2. Each woman
receiving care for two (2) or more visits shall be listed on the Caseload and
Birth Log in the following month of care, regardless of whether or not the LLM
attended the birth.
502.
INCIDENT REPORTS1. When any
complication occurs (whether or not the LLM remained in attendance) the care
must be documented in greater detail using ADH forms (found in Appendix A or
available on the ADH website). The LLM shall send these forms to ADH by the
10th of the month following the event.
2. When an LLM's client delivers outside the
hospital without attendance by an LLM, the LLM must submit an incident report
(form found in Appendix A or available on the ADH website) describing the
circumstances and outcome of the unattended birth. The LLM shall send these
reports to ADH by the 10th of the month following
the event.
503.
RECORD AUDITS
ADH will audit selected records from each LLM's practice each
year. The purpose of the audit will be to confirm compliance with these Rules.
The LLM will be required to submit the records for each client selected by ADH
for auditing.
504.
DOCUMENTATION BY LLM APPRENTICES1.
LLMs supervising an apprentice midwife should record the name of the apprentice
on the Birth Log when the apprentice provided care during the intrapartum and
immediate postpartum period. Because the LLM is responsible for the clinical
work of their apprentices, all reports will be filed by the attending
LLM.
2. Clinical services provided
by apprentice midwives shall be documented by the apprentice in the client
record and co-signed by the LLM. Initials may be used providing the initials
clearly identify the person providing care.
505.
REPORTING MATERNAL, FETAL, OR
NEWBORN EVENTS
The LLM is required to track maternal and newborn events for
thirty (30) days unless care is terminated by the client. Maternal events,
pregnancy loss at any gestational age, or newborn events must be reported
according to the following schedule. In each of these instances, LLMs will
complete the required incident report (found in Appendix A or available on the
ADH website) and submit it, with a complete copy of the client record, to
ADH.
1. Complications resulting in
intrauterine fetal death, or death of a mother or newborn within 48 hours of
delivery must be reported to ADH within two (2) business days;
2. Maternal or newborn deaths that occur
between two (2) through thirty (30) days of birth must be reported to ADH
within five (5) business days;
3.
Maternal or newborn hospitalizations that occur within thirty (30) days of
delivery must be reported to ADH within five (5) business days.
506.
CLIENT HEALTH
RECORD
The LLM is responsible for ensuring that all required services
are documented on client records maintained by the LLM. Each page of the client
record must contain the client ID number. The records will remain confidential.
They are subject to periodic review by ADH staff. All client records must be
maintained for at least 25 years.
507.
VITAL RECORDS
The LLM shall follow all applicable laws pertaining to vital
records.
600.
ADH RESPONSIBILITIES
601.
GRANTING PERMITS AND LICENSES
ADH shall review applications for licensure and issue licenses
or permits.
602.
REGISTRATION LISTING
ADH shall maintain a list of all LLMs and Apprentice Midwives
in the State of Arkansas, and make this list available to the public.
603.
MONITORING
OUTCOMES
ADH shall monitor perinatal outcomes of home births attended by
LLMs and publish these statistics annually.
ADH shall also review LLMs' records to assure that such LLMs
are practicing within regulatory guidelines and standards of care.
604.
INVESTIGATION
ADH will conduct investigations regarding complaints or
deviations from the Rules.
ADH will consider all available information that is relevant
and material to the investigations.
Where, in the opinion of the Director of ADH, the public's
health, safety or welfare imperatively requires emergency action, ADH may
temporarily suspend the license of an LLM pending proceedings for revocation or
other action. All proceedings initiated under this provision shall be promptly
instituted and determined. The licensee may request a hearing on a temporary
suspension with five (5) days of receiving notice.
605.
ADMINISTRATION OF TESTS
ADH shall administer the Arkansas Rules Examination at least
three (3) times per year.
900.
CERTIFICATION
This will certify that the Rules Governing the Practice of
Licensed Lay Midwifery in Arkansas were prepared pursuant to A.C.A.
20-7-109
and A.C.A.
17-85-101
et seq.
This will also certify that the foregoing Rules Governing the
Practice of Licensed Lay Midwifery in Arkansas were adopted by the Arkansas
Board of Health at a regular session of same held in Little Rock, Arkansas on
the 28th day of October, 2021
APPENDIX A: FORMS
ARKANSAS DEPARTMENT OF HEALTH LLM DISCLOSURE
FORM
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ARKANSAS DEPARTMENT OF HEALTH LLM INFORMED REFUSAL
FORM
Version Match 8, 2017
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ARKANSAS DEPARTMENT OF HEALTH
LLM INITIAL LICENSE AND REACTIVATION OF LICENSE
APPLICATION
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ARKANSAS DEPARTMENT OF HEALTH LLM LICENSE RENEWAL
APPLICATION
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ARKANSAS DEPARTMENT OF HEALTH
INSTRUCTIONS FOR COMPLETING LLM REQUIRED
REPORTS
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ARKANSAS DEPARTMENT OF HEALTH
PRECEPTOR-APPRENTICE AGREEMENT FOR NARM PEP
APPRENTICES
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ARKANSAS DEPARTMENT OF HEALTH
LLM PRE-LICENSURE CRIMINAL BACKGROUND CHECK
PETITION
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ARKANSAS DEPARTMENT OF HEALTH
HOSPITAL REPORTING FORM - LAY MIDWIFE PATIENT
TRANSFER
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APPENDIX B: TRANSITIONAL PROVISIONS AND
FORMS
TRANSITIONAL APPRENTICES
Apprentices with active permits issued prior to the effective
date of these Rules, henceforth referred to as "Transitional Apprentices", will
have three (3) years from the date these Rules take effect to successfully
complete their apprenticeship and submit an application for lay midwifery
licensure to ADH, and request approval to sit for the NARM written examination
under the requirements listed in this Appendix. If they have not done so by
that date, it will be necessary for the applicant to fulfill the requirements
listed in Section 201 (Initial Licensure).
1. The apprentice must submit a signed
Preceptor-Apprentice Agreement to ADH within thirty (30) days of signing for
each preceptor under which the apprentice trains during the course of their
apprenticeship. The ADH Preceptor-Apprentice Agreement form (found in this
Appendix) or available on the ADH website) shall be used for this
notification.
2. Should the
Preceptor-Apprentice Agreement be terminated by either party, it is the
responsibility of both parties to notify ADH immediately. An apprentice must
not continue to perform under any preceptor(s) unless a new signed
Preceptor-Apprentice Agreement is on file with ADH.
3. Preceptors must be an Arkansas-licensed
midwife or certified nurse-midwife, or if outside of Arkansas, preceptors must
be licensed by the state of residency as a direct-entry midwife or certified
nurse midwife, or have a Certified Professional Midwife credential from the
North American Registry of Midwives.
4. Any changes in the apprentice's contact
information must be provided to ADH by the apprentice within thirty (30) days
of the status change.
5.
Apprentices shall follow all applicable Arkansas laws and these
Rules.
6. Apprentices are required
to comply with all provisions of HIPAA (Health Insurance Portability and
Accountability Act).
7. Permit
Renewal
For those apprentices holding valid Apprentice Permits, on or
before the effective date of these Rules, the permit must be renewed by the
permit's expiration date if necessary. Renewal will only occur upon application
and favorable review by ADH. This review will assure that the lay midwife
apprentice is acting under the supervision of the preceptor and in accordance
with these Rules. The permit will be valid until three (3) years from the
effective date of these Rules. If an apprentice has not obtained Arkansas
licensure by that date, the applicant will no longer be considered a
transitional apprentice and must follow the guidelines for licensure found in
Section 201 (Initial Licensure).
To renew the permit, the Apprentice shall submit the following
evidence at least sixty (60) days before the expiration date of the
permit:
a. A completed application
(Appendix A).
b. A copy of both
sides of current certification in adult and infant cardiopulmonary
resuscitation (CPR). Approved CPR courses include courses that are approved by
NARM. Note: Only certification from courses which include a hands-on skills
component are accepted. Online-only courses are not accepted. It is the
responsibility of the apprentice to ensure this certification is current at all
times and documentation must be provided upon request.
c. A copy of both sides of current
certification in neonatal resuscitation through a course approved by NARM.
Note: Only certification from courses which include a hands-on skills component
are accepted Online-only courses are not accepted. It is the responsibility of
the apprentice to ensure this certification is current at all times and
documentation must be provided upon request.
d. Documentation of clinical experience for
the time period covered for the current permit period. This includes progress
made toward licensure for those years, i.e. number of antepartum (AP) visits
conducted, labor managements and deliveries, newborn evaluations and postpartum
examinations conducted under supervision.
e. Verification of all current
Preceptor-Apprentice relationships documented by a Preceptor Apprentice
Agreement form for each preceptor signed within 90 days of application
submission.
8. Initial
Licensure
Transitional apprentices who are approved by ADH to sit for,
and who pass, the NARM written examination will be issued a license upon
completion of all other requirements.
A transitional apprentice who receives licensure must go
through NARM and become certified as a CPM in order to be eligible to renew
their license at the end of their initial licensure period. License renewal
will follow the procedures outlined in Section 202.
Once the CPM certification is received, a notarized copy of the
certificate or a verification letter sent directly from NARM must be submitted
to ADH within thirty (30) days of certification.
Eligibility requirements for approval for transitional
apprentices to sit for the NARM written examination:
a. A completed application.
b. Additional documentation as follows:
i. A passport style and size photo of the
applicant, head and shoulders, taken within sixty (60) days of the submission
date of the application and attached to the application.
ii. A copy of one of the following documents
that demonstrates the applicant is 21 years of age or older:
A. The applicant's birth
certificate.
B. The applicant's
U.S. passport, U.S. Driver's License or other state-issued identification
document.
C. Any document issued by
federal, state or provincial registrar of vital statistics showing
age.
c. A copy
of both sides of current certification in adult and infant cardiopulmonary
resuscitation (CPR). Approved CPR courses include courses that are approved by
NARM. Note: Only certification from courses which include a hands-on skills
component are accepted. Online-only courses are not accepted. It is the
responsibility of the licensee to ensure this certification is current at all
times and documentation must be provided upon request.
d. A copy of both sides of current
certification in neonatal resuscitation through a course approved by NARM.
Note: Only certification from courses which include a hands-on skills component
are accepted. Online-only courses are not accepted. It is the responsibility of
the licensee to ensure this certification is current at all times and
documentation must be provided upon request.
e. Documentation of a high school diploma, or
its equivalent, and documentation of the highest degree attained after high
school. This documentation should include the name of the issuing school or
institution and the date issued. Applicant's name must be the same as on the
copy of the diploma or degree. If applicant's name is not the same, applicant
must submit proof of name change with application.
f. Verification of professional
health-related licensure in other jurisdictions may be requested by
ADH.
9. Documentation of
Practical Experience
Applicants for licensure must demonstrate competency in
performing clinical skills during the antepartum, intrapartum, postpartum, and
the immediate newborn periods. Each applicant must successfully complete an
evaluation of clinical skills. The applicant must submit a statement that the
following minimal practical experience requirements have been performed under
the supervision of a physician, CNM, or LLM.
These forms should be submitted only after the applicant has a
"pass" on each item, except for certain emergencies that may not occur during a
preceptorship. The following required forms must be submitted:
a. Clinical Experience Documentation for
Births as a Primary Midwife form
b.
Preceptor Verification Form for LLM Application
c. Documentation of Acquisition of Clinical
Knowledge and Skills (completed by each Preceptor Midwife)
i. The applicant must attend a minimum of 20
births as an active participant.
ii. Functioning in the role of primary LLM
under direct on-site supervision, the applicant must attend a minimum of an
additional 20 births, of these:
A. A minimum
of 10 must occur in an out-of-hospital setting and
B. A minimum of 3 must include at least 4
prenatal exams, birth attendance, the newborn exam, and 1 postpartum exam, each
conducted personally by the applicant with direct supervision.
C. 75 prenatal exams, including 20 initial
exams
D. 20 newborn exams
E. 40 postpartum exams
10. Licensing
Examination
a. After the provisions listed
above are satisfactorily completed, the applicant is eligible to take the NARM
licensing exam.
b. Upon receipt of
documentation that the applicant has passed the NARM examination the applicant
is eligible to take the Arkansas Rules Examination, administered at ADH at
least three (3) times each year.
c.
The applicant shall provide proof of identity by a government-issued
photographic identification card upon the request of the individual
administering the test.
d. If an
applicant scores eighty percent (80%) or higher correct answers on the Arkansas
Rules Examination, ADH shall provide to an applicant a written notice of
examination results and a license will be issued.
ARKANSAS DEPARTMENT OF HEALTH
PRECEPTOR-APPRENTICE AGREEMENT FOR TRANSITIONAL
APPRENTICES
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ARKANSAS DEPARTMENT OF HEALTH
APPRENTICE PERMIT RENEWAL
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DOCUMENTATION OF ACQUISITION OF CLINICAL KNOWLEDGE AND
SKILLS FOR TRANSITIONAL APPRENTICES ONLY:
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APPENDIX C: CEU CALCULATIONS
CALCULATIONS FOR NUMBER OF CEUS REQUIRED FOR LLM RENEWAL OF
LICENSE BASED ON ALL BEING RENEWED IN AUGUST EVERY 3 YEARS.
|
Months since license was issued |
Number of CEUs required |
|
36 |
30 hours |
|
35 |
29 hours |
|
34 |
28 hours |
|
33 |
27 hours |
|
32 |
27 hours |
|
31 |
26 hours |
|
30 |
25 hours |
|
29 |
24 hours |
|
28 |
23 hours |
|
27 |
23 hours |
|
26 |
22 hours |
|
25 |
21 hours |
|
24 |
20 hours |
|
23 |
19 hours |
|
22 |
18 hours |
|
21 |
17 hours |
|
20 |
17 hours |
|
19 |
16 hours |
|
18 |
15 hours |
|
17 |
14 hours |
|
16 |
13 hours |
|
15 |
12 hours |
|
14 |
11 hours |
|
13 |
10 hours |
|
12 |
10 hours |
|
11 |
9 hours |
|
10 |
8 hours |
|
9 |
7 hours |
|
8 |
6 hours |
|
7 |
5 hours |
|
6 |
4 hours |
|
5 |
3 hours |
|
4 |
3 hours |
|
3 |
2 hours |
|
2 |
1 hours |
|
1 |
0 hours |
