Current through Register Vol. 49, No. 9, September, 2024
100. GENERAL
PROVISIONS
101. PURPOSE AND AUTHORITY
It was determined by the General Assembly that adequate
maternal care is not readily available in some parts of the state resulting in
undue hardships to poor expectant mothers. Act 838 of 1983 provided for the
lawful practice of Lay Midwifery in counties having 32.5% or more of this
population below the poverty level. Act 481 of 1987 supercedes Act 838 of 1983,
and expands the Lay Midwife licensure statewide.
The following Rules and Regulations are promulgated pursuant to
the authority conferred by A.C.A.
17-85-101 et.seq. and A.C.A.
20-7-109 et.seq.
Specifically, Act 481 directs the Arkansas State Board of
Health to administer the provisions of Act 481, authorizes and directs the
Board to adopt regulations governing the qualifications for licensure of Lay
Midwives and the practice of Lay Midwifery. The broad authority vested in the
Board of Health (Act 96 of 1913) to regulate and to ultimately protect the
health of the public is the same authority the Board will utilize in enforcing
the regulations, determining sanctions, revoking licenses, etc.
102. ADMINISTRATION OF PROGRAM
The State Board of Health has delegated the authority to
administer the program, including the regulating and licensing of Lay Midwives,
to the Arkansas Department of Health and Human Services, Division of Health,
4815 W. Markham, Little Rock, Arkansas 72205-3867.
The Board of Health shall establish an advisory board to
oversee the practice of Licensed Lay Midwives. The composition of the advisory
board will be as follows:
1. Four
Licensed Lay Midwives.
2. One
Certified Nurse Midwife.
3. One
Physician who is currently practicing obstetrics.
4. Three consumers of midwifery service. (A
consumer of midwifery service is a woman or her spouse who has had a midwife
attended birth or someone who promotes midwifery or home birth in
Arkansas).
The purpose of the Advisory Board shall be to advise the
Division of Health and Board of Health on matters pertaining to the regulation
of Lay Midwifery practice.
The terms and conditions of membership are as follows:
1. The Board of Health will appoint Midwifery
Advisory Board (M.A.B.) members for terms of at least 3 years.
2. Members may serve 2 consecutive
terms.
3. Members will serve their
terms on a volunteer basis.
4. The
activities of the MAB include, but are not limited to, advising the Division of
Health and Board of Health by:
a. Meeting at
least annually and as needed at the discretion of the Midwifery Advisory Board
Chairperson.
b. Reviewing the rules
and regulations and proposing changes to them as needed.
c. Reviewing and approving continuing
education offerings.
d. Serving as
a community liaison regarding the practice of midwifery.
200.
DEFINITIONS
As used in these regulations, the terms below will be defined
as follows, except where the context clearly requires otherwise:
201. "APPRENTICE LAY MIDWIFE": A person who
is granted a permit by the Division of Health to obtain the practical
experience required to apply for a regular license.
202. "CERTIFIED NURSE MIDWIFE" (CNM): A
person who is certified by the
American College of Nurse Midwives and is also currently
licensed by the Arkansas Nursing Board or the appropriate licensing authority
of a bordering state to practice nurse midwifery. The CNM must be currently
practicing obstetrics.
203.
"CLINICIAN": A Physician, Certified Nurse Midwife, or Nurse Practitioner
employed or contracted by the Division of Health to work in maternity
clinics.
204. "CONSULTATION": A
phone consultation by the Licensed Lay Midwife to a Physician or Certified
Nurse Midwife to discuss the status and future care of a client. The Physician
or Certified Nurse Midwife may require the client to come into his/her office
for evaluation.
205. "DIVISION":
The Arkansas Department of Health and Human Services, Division of Health,
Perinatal Health Services, and Women's Health.
206. "EMERGENCY PLAN": The emergency plan is
developed by the
Lay Midwife for each patient, and outlines a plan for transport
to the nearest hospital with an active obstetrical service. This hospital must
be located within 50 miles of the planned delivery site.
207. "IMMEDIATE TRANSPORT": The client should
be taken to a medical facility by the most expedient method of transportation
available, to obtain treatment/evaluation for an emergency condition.
208. "LICENSED LAY MIDWIFE": A Lay Midwife
who is licensed by the Arkansas Department of Health & Human Services,
Division of Health to practice lay midwifery.
209. " LICENSED LAY MIDWIFE PROTOCOL":
Describes those procedures that may be performed by the Licensed Lay Midwife
outside the presence of a Physician, but under conditions where the Physician
can be reached by the Licensed Lay Midwife by communication facilities.
Section 400 of these Regulations comprise the Licensed Lay
Midwife Protocol.
210. "LAY
MIDWIFE": Any person other than a Physician or Certified Nurse Midwife who
shall manage care during the pregnancy of any woman or of her newborn during
the antepartum, intrapartum, or postpartum periods; or who shall advertise as a
midwife by signs, printed cards or otherwise. This definition shall not be
construed to include unplanned services provided under emergency, unplanned
circumstances.
211. "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. Where these regulations govern the care of pregnant and postpartum
women, "Physician " refers only to those currently practicing obstetrics. Where
these regulations govern the care of newborn infants, "Physician" refers only
to those who currently include hospital care of newborns in their
practices.
212. "PRACTICE UNDER THE
DIRECTION OF A PHYSICIAN": The Licensed Lay Midwife may perform only those
medical acts and procedures that have been specifically authorized in the Lay
Midwife protocol. If actions/procedures deviating from the official protocol
are desired, an agreement signed by the Referral Physician describing these
deviations/exceptions must be approved by the Division. (See Section 600
Emergency Measures.)
213.
"PRESCRIPTION DRUGS OR DEVICES": A drug or device limited by A.C.A.
20-64-503 to dispensing by or upon
a medical practitioner's prescription because the drug is (a) habit-forming,
(b) toxic or having a potential for harm, or (c) permitted for use only under
the practitioner's supervision. This includes any drug or device whose label
contains the statement: "Caution-federal law prohibits dispensing without
prescription".
214. "REFERRAL":
Pertains to the referral of a client to a Physician, Certified Nurse Midwife,
or Division clinician for an office visit for evaluation and determination of
future care.
215 "REFERRAL
PHYSICIAN/CERTIFIED NURSE MIDWIFE": A
Physician/Certified Nurse Midwife who has obstetrical
privileges in a hospital within 50 miles of the delivery site, and who accepts
referrals from the Licensed Lay Midwife and consults in the management of the
Lay Midwife's clients.
216.
"TRANSFER OF CARE": Client's care is transferred to a Physician or Certified
Nurse Midwife when complications arise beyond the scope of midwifery practice
as defined in these regulations.
300. LICENSING
A Lay Midwife license, valid for two years, is issued upon
application and favorable review. Application materials and instructions are
available from the Division.
301.01
Eligibility Requirements
The following requirements must be met before the Division will
issue a Lay Midwife license.
1. Basic
Education
A copy of a high school diploma, GED certificate, or highest
degree attained is required.
2. Communicable Disease
Applicant must provide documentation of a negative TB skin
test, a negative chest x-ray or a health card (documentation of a negative TB
skin test) issued by the Division of Health at local health units.
Applicant must provide a date of rubella immunization or
documentation of immune status. Such documentation is required only with the
first application for any Lay Midwife permit or license.
3. Cardio-pulmonary Resuscitation Training
Applicant must be certified by the American Heart Association
or American Red Cross to perform adult and infant cardiopulmonary resuscitation
(CPR). Certification shall be current at the time of application and be valid
throughout the licensed period.
4. Practical Experience
The applicant must submit a notarized statement that the
following minimal practical experience requirements have been performed under
the supervision of a Physician, Certified Nurse Midwife, or Licensed Lay
Midwife. The applicant must also provide the name and a current postal address
of the supervisor to allow verification by the Division.
Applicants for licensure must demonstrate competency in
performing clinical skills during the antepartum, intrapartum, postpartum, and
the immediate newborn period. Each applicant must successfully complete an
evaluation of clinical skills. The " Clinical Evaluation of Apprentices" form
must be completed by the preceptor and presented with the application for
licensure.
This form should be submitted only after the applicant has a
"pass" on each item except for certain emergencies that may not occur during a
preceptorship.
When practical experience has been obtained outside of
Arkansas, the Lay Midwife Advisory Board will review the preceptorship and make
a recommendation to the Division concerning its adequacy.
a. The applicant must attend a minimum of 20
births as an active participant.
b.
Functioning in the role of primary Lay Midwife 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
5. Licensing Examination
After provisions 1-4, listed in Section 301.01, are
satisfactorily completed, the applicant is eligible to sit for the licensing
exam.
1. Pass the North American
Registry of Midwives (NARM) written examination. The exam may be administered
by the Arkansas Department of Health and Human Services, Division of Health, or
at a regularly scheduled test site arranged through NARM.
2. Pass the Arkansas Midwife Regulations exam
with a score of 75% or higher. This exam is administered by the
Division.
3. If necessary to obtain
a passing score, the examinations may be taken up to three times. If the
Midwife fails either the NARM exam or the Arkansas Midwife Regulations exam
three times, she must repeat an apprenticeship before being allowed to
re-test.
301.02 Renewal
The license must be renewed every 2 years and will be re-issued
upon application and favorable review of required activity reports by the
Division. This review will assure that:
1. The application is completed.
2. Infant and adult CPR certification will
not expire within the next three months.
3. The Lay Midwife acts in accordance with
the Lay Midwife rules and regulations.
4. Any deviations from the Lay Midwife
protocol must be renewed and signed by a referral Physician prior to license
renewal.
5. The Lay Midwife is not
providing care for clients who have risk factors which preclude Lay Midwife
care.
6. Documented negative TB
skin test, negative chest x-ray or valid health card.
7. Documentation of twenty hours of
continuing clinical education within the past two years. Continuing Education
Units (CEU's) will be approved according to the following guidelines:
a. A maximum of five hours may be granted for
documented peer review.
b.
Educational content that is required for licensure (i.e. CPR) or is generally
considered core content of an apprenticeship will not be considered continuing
education.
c. Any workshops or
conferences relevant to the clinical practice of midwifery that are sponsored
by the following organizations are pre-approved by the Lay Midwifery Advisory
Board for CEU'S:
American College of Nurse Midwives American College of
Obstetrics and Gynecology Arkansas Department of Health & Human
Services,
Division of Health International Childbirth Education
Association La Leche League International University of Arkansas Medical School
Midwifery Education Accreditation Council (MEAC) Any state Nurses
Association
301.03 Practical Experience Equivalency
All applicants for licensure in Arkansas must follow procedures
for Regular License. Midwives holding a Certified Professional Midwife
certificate through the North American Registry of Midwives may apply for a Lay
Midwife license. The CPM credential will be considered equivalent to the
practical experience and NARM testing requirement. The Lay Midwife must
complete an application, meet all the requirements for education, TB, rubella,
and CPR and pass the state regulations test.
301.04 Revocation
The Division may refuse to issue, may suspend or may revoke a
license for violation of State law or these Regulations including any of the
following reasons:
1. Dereliction of
any duty imposed by law.
2.
Falsifying information on the application.
3. Conviction of a felony.
4. Practicing while knowingly suffering from
a contagious or infectious disease of public health importance.
5. Violation of any of the provisions of
regulations contained herein.
6.
Obtaining any fee by fraud or misrepresentation.
7. Knowingly employing, supervising, or
permitting (directly or indirectly) any person who is not an Apprentice or
Licensed Lay Midwife to perform any work covered by these
regulations.
8. Using, causing, or
promoting the use of any advertising matter, promotional literature,
testimonial, or any other representation however disseminated or published,
which is misleading or untruthful.
9. 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", or similar words, abbreviations or
symbols implying involvement by the medical profession when such is not the
case.
10. Permitting another person
to use the license or permit.
11.
Violation of the Prescription Drug or Devices Law, A.C.A.
20-64-503.
12. Gross Negligence.
13. Practicing while under the influence of
any intoxicant or illegal drug.
Any Licensed Lay Midwife who is denied a license or whose
license is suspended or revoked will be notified in writing by the Division.
The Lay Midwife will be afforded opportunity of a hearing conducted pursuant to
the Board's Administrative Procedures to appeal the Division's decision.
301.05 Inactive status
Inactive status is automatic on the day after the license
expires. Licensed Lay Midwives who do not maintain a current license will be
considered inactive. Inactive status may be maintained for four years. To
reactivate an inactive license the Lay Midwife must document continuing
education credits totaling 10 hours for each year of inactive status. Other
requirements for licensure must be met including current CPR certification and
proof of absence of TB. A Lay Midwife with inactive status may not practice
midwifery until reactivating the license.
301.06 Reactivation of expired license
After four years the inactive license automatically expires. To
become re-licensed the Lay Midwife must successfully retake the licensure
exams, document 20 hours of continuing education within the last two years,
document current CPR certification and present proof of the absence of
TB.
302. APPRENTICE PERMIT
302.01 Eligibility
An Apprentice Permit authorizes the applicant to obtain under
supervision, the practical experience required for licensure. The supervisor
may be a Licensed Lay Midwife, a Certified Nurse Midwife, or a Physician. The
applicant must provide verification of Apprentice-Supervisor relationship(s).
Apprentice Midwives work under direct supervision of their supervisor(s). The
initial permit, valid for two years, will be issued to persons who provide
documentation of:
1. A copy of high
school diploma, GED certificate, or highest degree attained.
2. Negative TB skin test, negative chest
x-ray or valid health card.
3. Date
of rubella immunization or proof of immune status. This documentation is
required only with the first application for the permit.
4. Current certification by the American Red
Cross or the American Heart Association to provide cardio-pulmonary
resuscitation to adults and infants.
302.02 Apprentice Permit Renewal
The Apprentice Permit must be renewed every two years. To renew
the permit, the Apprentice shall submit evidence of:
1. Progress made toward licensure that year,
i.e. number of AP visits conducted, labor managements and deliveries, newborn
evaluations and post-partum exams conducted under supervision.
2. Verification of Apprentice-Supervisor
relationship
3. Current adult and
infant CPR
4. Negative TB skin
test, negative chest x-ray, or valid health card
400. SCOPE OF
PRACTICE AND PROTOCOLS
Section 400 of these Regulations comprise the Licensed Lay
Midwife Protocol.
The Licensed Lay Midwife may provide complete obstetrical care
to women who are determined to be at low risk for the development of medical or
obstetrical complications of pregnancy or childbirth.
401. REQUIREMENTS FOR LICENSED LAY MIDWIFERY
PRACTICE
The following requirements must be met before a Lay Midwife can
legally accept a client.
1. Licensing
- The Lay Midwife must possess a current Arkansas Lay Midwife License, or
Apprentice Permit. See Section 300.
2. Protocol - The Licensed Lay Midwife must
adhere to the Lay Midwife protocol as specified in the conditions of practice
as outlined in these regulations.
3. Consent - At the time a request is made
for care, the Licensed Lay Midwife must discuss certain information concerning
Lay Midwife assisted home deliveries with the client. This discussion must be
documented by use of a disclosure form by the second visit. Samples of
acceptable disclosure forms are available from the Division. It must be signed
by the client and filed in her chart.
The disclosure form will include, but is not limited to the
following:
a. The Licensed Lay Midwife
has a protocol specified by the Division that she must follow regarding care
for potentially serious medical conditions.
b. When a patient client chooses midwifery
care, she must accept the requirements laid out in the Regulations or seek
another source of care. Clients may be discharged from care.
c. Risks and benefits of home
birth.
d. Risks and benefits of
hospital delivery.
e. Factors which
preclude a home birth.
f. Medical
conditions which may occur during labor or birth that would require Physician
consultation or transport to a hospital and referral to a Physician or
Certified Nurse Midwife.
g.
Responsibilities of the Licensed Lay Midwife for prenatal care, attendance at
the delivery, and postpartum care, and additional information regarding birth
attendance by Apprentices and/or possible birth attendance by another Licensed
Midwife if the Midwife is unavailable at the time of labor.
h. Required medical evaluation, laboratory
testing, evaluation by Physician, Certified Nurse Midwife, or public health
maternity clinic, required visits with Midwife, obtaining of birth supplies and
infant supplies.
i. Should an
emergency transport become necessary there must be arrangements by the client,
in cooperation with the Midwife, for transportation to the nearest hospital
with an active obstetrical service to provide maternity services or the
hospital where the back-up Physician has privileges. The hospital must be
located within 50 miles of the planned delivery site.
j. The Licensed Lay Midwife does, or does not
have a referral Physician or Certified Nurse Midwife with whom she consults
concerning the client's pregnancy.
k. If the Licensed Lay Midwife relies on the
hospital emergency room for backup coverage, the client must be informed that
the Physician on duty may not be trained in obstetrics.
4. Emergency Plan - An individual emergency
plan must be established by the Licensed Lay Midwife and client for each
Midwife client. A copy of this plan, signed by the Midwife, must be placed in
the client's chart. The plan must include provisions for transport to the
nearest hospital with an obstetrical service, or to the hospital where the
Physician or CNM has obstetrical privileges. This hospital must be located
within 50 miles of the planned delivery site.
402. PROTOCOL FOR REQUIRED ANTEPARTUM CARE
Risk Assessment:
Each client must be evaluated by a Physician, a CNM, or a
Division maternity clinician at or near the time care is initiated with the Lay
Midwife, and again at or near the 36th week of
gestation. The purpose of these visits is to assure that the client has no
potentially serious medical conditions and has no medical contraindications to
home birth. The evaluation must include a maternity risk assessment (see
Routine Services below) that will be filed in the client's chart.
402.01 Frequency of Visits
Routine antepartum visits must be made at least every four (4)
weeks during the first 28 weeks of gestation, every two (2) weeks from the 28th
to 36th weeks, and weekly thereafter until delivery.
402.02 Routine Services
The Licensed Lay Midwife must ensure each client receives from
a Physician, CNM, or Division clinician, the following services at or near the
initiation of care:
1. Medical,
obstetrical and nutritional history. The history must be comprehensive enough
to identify potentially dangerous conditions that may preclude midwife care, or
that require Physician or CNM consultation.
2. A physical examination comprehensive
enough to identify potentially dangerous conditions that may preclude Midwife
care.
3. Blood sample for blood
group and Rh determination and titer if found to be Rh negative.
4. Hematocrit or hemoglobin.
5. Blood pressure, height and
weight.
6. Pap smear, unless
negative result is documented within past six months.
7. VDRL.
8. Gonorrhea and Chlamydia.
9. Urine testing for glucose, protein, and
asymptomatic bacteriuria (nitrites).
10. Blood Sugar - Follow American Diabetes
Association (ADA) Clinical Practice recommendations for gestational diabetes
mellitus (GDM) screening and diagnosis. If performed by the Licensed Lay
Midwife, use only a CLIA-waived device approved by the FDA for diagnosis (e.g.
HemoCue Blood Glucose Analyzer), and follow the ADA recommendations for
screening and diagnosis. ADA standards are available through the
Division.
11. Estimation of
gestational age.
12. Hepatitis B
test.
13. Counsel client concerning
maternal serum genetic testing, if before 20 weeks gestation.
14. Rubella screen if previous immunity not
documented.
15. HIV counseling and
test.
16. Group B Strep screening
at 35-37 weeks.
Licensed Lay Midwives who are trained in the collection of
laboratory specimens may do so. The specimens must be submitted to a standard
lab, and the reports must be reviewed and interpreted by the Physician, CNM or
Division Clinician.
402.03 Routine Antepartum Care
At each visit the Licensed Lay Midwife will perform and record
the following services:
1.
Weight.
2. Blood
pressure.
3. Fundal
height.
4. Determination of fetal
position.
5. Urine testing for
glucose, protein, and nitrites.
6.
Fetal heart tones.
7. Medical and
nutritional history since last visit.
8. Check for edema of legs, face and/or
hands.
9. Hematocrit or hemoglobin
must be repeated at or near 28 weeks.
The Lay Midwife will transfer care of the client immediately to
a Physician if any conditions precluding Lay Midwife care are noted.
402.04 Rh Follow-up
Protocol
All women with negative Rh factor must be treated as
follows:
1. Coombs test as soon as
negative Rh is reported if antibody screen was not performed with the initial
lab work.
2. Repeat Coombs test 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, an Rh immunoglobulin can be obtained at the clinic.
If Coombs is positive, refer her to a Physician
immediately.
3. Obtain a
cord blood sample at the time of delivery. Send to a standard laboratory for Rh
type. If the infant is Rh positive then the client is to receive immunoglobulin
again. This should be obtained within 72 hours of delivery from a private
Physician, or from the local health unit if the mother was enrolled in a
Division of Health maternity clinic. If the infant is Rh negative then nothing
further need be done.
402.05 Pre-Delivery Home Visit
The Licensed Lay Midwife is required to make, prior to
delivery, at least one visit to the home where the birth will take
place.
The Licensed Lay Midwife 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.
403.
PROTOCOL FOR REQUIRED INTRAPARTUM CARE
403.01
Initial Labor Assessment
The Licensed Lay Midwife 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. Condition of
cervix, vaginal walls and pelvic floor.
403.02 Management of Labor
1. First stage. The Licensed Lay Midwife must
assess and record:
a. Fetal heart rate and
rhythm immediately following a contraction, at least every hour until 5
centimeters, then at least every 30 minutes until cervix is completely dilated,
and after rupture of membranes, after any treatment, procedure or intervention,
when there is a change in contractions or labor pattern, and when there is any
indication that a medical or obstetrical complication is developing.
b. Rule out prolapsed cord by checking fetal
heart rate and rhythm immediately after rupture of membranes and during and
after the next two contractions.
c.
Duration, interval and intensity of uterine contraction and maternal blood
pressure at least every two hours.
d. Maternal blood pressure and temperature
every two hours.
2.
Second stage and third stage. The Licensed Lay Midwife's duties include but are
not limited to:
a. Ascertaining that labor is
progressing;
b. Assessing and
monitoring maternal and fetal well being including heart rate at least every 15
minutes and c. Delivering the newborn and placenta
All services should be provided in a supportive manner and in
accordance with these regulations.
404. PROTOCOL FOR
REQUIRED POSTPARTUM CARE
404.01 Immediate Care
The Licensed Lay Midwife 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 Midwife 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. Midwives may repair 1st and 2nd degree
perinatal lacerations.
3. During
the two-hour postpartum period, the Midwife shall assess as needed: uterine
firmness, vaginal bleeding, vaginal swelling and/or tearing, maternal blood
pressure and pulse. The Midwife 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 Midwife 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.
The mother is given an appointment with the Midwife for postpartum evaluation
from 2 to 6 weeks following delivery. Postpartum follow-up should include
family planning counseling and the need for rubella vaccine if
susceptible.
5. A follow-up home
visit is performed at 12 to 24 hours postpartum to evaluate for excessive
bleeding, infection, or other complications.
405. PROTOCOL FOR REQUIRED NEWBORN CARE
The Licensed Lay Midwife shall be responsible for care
immediately following the delivery only. Subsequent infant care should be
managed by a Physician, or a Physician/Registered Nurse team. This does not
preclude the Lay Midwife from providing counseling regarding routine newborn
care and breastfeeding. If any abnormality is suspected, the newborn must be
sent for medical evaluation as soon as possible.
405.01 Immediate Care
1. Suction nose and mouth prior to delivery
of shoulders if needed.
2.
Immediately after delivering entire body, suction mouth, then, nose again if
needed.
3. Clamp cord, then
cut.
4. Dry infant in a warm towel,
with special attention to the head.
5. Wrap infant in a warm blanket and place on
side or next to mother.
6.
Determine Apgar scores at one and five minutes after delivery.
7. Observe and Record:
a. Skin color and tone.
b. Heart rate (120-180/minute).
c. Respiration rate and character
(40-60/minute by one hour of age).
d. Estimated gestational age. Indicate
average, small or large for gestational age.
e. Temperature, note if rectal or
axillary.
f. Weight, length, head
circumference.
8. Obtain
cord blood for Rh and antibody screen if mother is Rh negative.
405.02 Feeding
Infant should be placed at the breast as soon as stable after
delivery. The bottle fed infant should be offered commercially prepared oral
pediatric electrolyte solution within the first two to three hours after birth.
If there are no problems with these feedings then progress to the chosen
formula, every three to four hours. Instruct the mother in normal and abnormal
feeding patterns.
405.03
Care of Eyes
The Licensed Lay Midwife must see that either Erythromycin 0.5%
Ophthalmic or Tetracycline 1.0% Ophthalmic in individual dose packaging for eye
prophylaxis is available at the time of delivery. The mother must obtain a
suitable medication before week 36 of the pregnancy either by prescription from
a private Physician or by prior arrangement with a local health unit. If the
mother chooses to obtain medication from the local health unit, she must notify
the local health unit in sufficient time to allow them one month to obtain the
drug. The local health unit will not routinely have the medication on
hand.
The Lay Midwife must assure that the infant receives the drug
within 1 hour of birth. If the infant does not receive the drug for any reason,
the Midwife must document the incident in the client's chart.
405.04 Vitamin K
The Licensed Lay Midwife must advise parents that the infant
should receive Vitamin K as soon as possible after birth. The medication should
be obtained by prescription before week 36 of pregnancy from a private
Physician or by prior arrangements with a local health unit. If the mother
chooses to obtain free medication from the local health unit, she must notify
the unit in sufficient time to allow them one month to obtain the drug. The
local health unit will not routinely have the drug on hand. The Lay Midwife
must assure that the infant receives Vitamin K within 2 hours of birth. If
Vitamin K is not administered, the Lay Midwife must document the incident in
the client's chart.
405.05
Newborn Screening
All infants must have a capillary blood sample (from heel
prick) for the newborn screening as mandated by law and as specified on the
Division collection form. The Licensed Lay Midwife is responsible for advising
the parents of this law and the procedure for conducting newborn screening and
documenting that a blood sample is obtained after 24 hours and no later than 7
days after birth. The sample is submitted to the Division no later than 72
hours after collection. Required forms are available from local Division of
Health offices. If the blood sample is not obtained for any reason, the Midwife
must document the incident in the client's chart.
405.06 Cord Care
The Midwife must instruct the mother in routine cord
care.
406.
PROTOCOLS FOR ANTEPARTUM CONDITIONS REQUIRING PHYSICIAN INTERVENTION
Each client is to have a risk assessment (see Section 402, p
14) documented by a Physician, CNM, or Division of Health 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 Licensed
Lay Midwife if the client exhibits or develops the specified condition. The Lay
Midwife will refer women for medical evaluation as soon as possible after the
condition is identified. The Lay Midwife is expected to use his/her judgment
regarding the need for consultation, referral, and transport when problems
arise that are not specified in the protocol. In addition to the birth log,
such care will be documented on an additional report.
406.1 Initial risk Assessment
The following conditions preclude midwife care and care must be
transferred:
1. Previous cesarean
delivery
2. Multiple
gestation
3. Documented placenta
previa in the third trimester
4.
Position other than vertex at the onset of labor
5. Labor prior to 36 weeks gestation
If any of the following PREEXISTING conditions are identified
the client must be examined by a Physician or CNM, currently practicing
obstetrics. Division clinicians may accept the referral per Division of Health
protocol. A plan of care for the condition must be established, and execution
of the plan must be documented. Midwives caring for these clients will submit
additional required reports. If a referral is not made or if the clinician
advises against home birth, the care must be transferred immediately to a
Physician or Certified Nurse Midwife.
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. Known drug or alcohol addiction
16. Significant congenital or chromosomal
anomalies
17. History of post
partum hemorrhage not caused by placenta previa or abruption
18. Rh negative isoimmunization (positive
Coombs)
19. Structural
abnormalities of the reproductive tract including fibroids
20. Lack of documented prenatal care by a
Physician, CNM or Division Clinician prior to 34 weeks
21. HIV positive or AIDS
22. Previous infant with GBS
disease
23. History of unexplained
perinatal death
24. History of 7 or
more deliveries
25. Maternal age
greater than 40
26. Previous infant
weighing less than 5 pounds or more than 10 pounds
406.02 Antepartum Monitoring
If any of the following PRENATAL conditions are identified, the
client must be examined by a Physician or CNM currently practicing obstetrics.
Division clinicians may accept referrals per Division of Health protocol. A
plan of care for the condition must be established, and execution of the plan
must be documented. Midwives caring for these clients will submit additional
required reports. If a referral is not made or if the clinician advises against
home delivery the client must be transferred.
1. Decreased fetal movement or kick count of
less than 10 per hour
2. Positive
Group B Strep-CDC approved prophylaxis must be obtained
3. Cervical effacement or dilatation prior to
36 weeks
4. Post term pregnancy
greater than 42 weeks (document consult as third risk assessment and include
with report)
5. Primary herpetic
outbreak
6. Clients with a previous
preterm delivery must be co-managed until 36 weeks
7. Suspected or confirmed fetal
death
8. Vaginal bleeding heavier
than a normal period
9. 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 less
than 30 or hemoglobin of less than 10
14. Hyperemesis with weight loss
15. Two blood pressure readings of 140/90 or
more
16. Size/date discrepancy of 3
or more weeks on two successive exams
17. Positive Coombs
18. Abnormal PAP smear
19. Sexually transmitted disease
20. Ruptured membranes without onset of labor
within 18 hours
21. Signs and
symptoms of pre-eclampsia
22. Fetal
heart rate below 120 or above 160 or irregular while lying on left
side
23. Spontaneous rupture of
membranes prior to 36 weeks
24.
Gestational Diabetes
407. PROTOCOLS FOR INTRAPARTUM CONDITIONS
REQUIRING PHYSICIAN OR CNM INTERVENTION
407.01
Immediate Transport
The following INTRAPARTUM conditions preclude midwifery care,
and when identified, the client should be transported to the planned
hospital:
1. Position other than
vertex
2. Active genital herpes
lesions
3. Labor prior to 36 weeks
gestation
407.02
Physician Consultation
The following INTRAPARTUM conditions require consultation with
a Physician or CNM who has obstetrical privileges in a hospital within 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
reports. 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 4 cms b. more than 17 hours from 4 cm to delivery c. more than
2.5 hours pushing d. more than 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 4 cm b. more than 13 hours from 4 cm to delivery of the infant
c. more than 1 hour pushing d. more than 1 hour from delivery of the infant to
delivery of the placenta.
3. Two blood pressure of greater than 140/90
two to four hours apart, or a significant rise over baseline, with or without
proteinuria.
4. Abnormal urine
protein associated with signs and symptoms of pre-eclampsia.
5. Persistent Fetal heart rate above 160 or
below 120 while mother is on left side.
6. Maternal temperature of greater than 100.4
unresponsive to hydration.
7. Thick
meconium stained fluid if birth is not imminent.
8. Abnormal bleeding.
9. Suspected or confirmed fetal death.
408. PROTOCOLS
FOR POSTPARTUM CONDITIONS REQUIRING PHYSICIAN OR CNM INTERVENTION
408.01 Immediate Transport
The following POSTPARTUM conditions preclude midwifery care and
when identified, the client should be transported to the hospital:
1. Hemorrhage
2. Third and fourth degree
lacerations
3. Signs and symptoms
of shock
408.02 Physician
Consultation
The following IMMEDIATE POSTPARTUM conditions require
consultation with a Physician or a CNM who has obstetrical privileges in a
hospital within 50 mile of the delivery site. A plan of care must be
established and execution documented. Midwives caring for these clients will
submit additional required reports. If consultation is not available or if the
client's condition is not stable, the client must be transported to a
hospital:
1. Uterine size 16 to 20
weeks after delivery of placenta
2.
Two maternal temperatures of 100.4 or greater checked one hour apart
3. Signs of uterine infection.
409. PROTOCOLS FOR
NEWBORN CONDITIONS REQUIRING PHYSICIAN INTERVENTION
409.01 Immediate Transport
The following NEWBORN conditions, when identified, require
transport of the infant to the hospital:
1. Respiratory distress
2. Central cyanosis
3. Seizures
4. Temperature of 101 or more
5. Jaundice at 0 to 24 hours
409.02 Physician Consultation
The following NEWBORN conditions require consultation with a
Physician whose practice includes pediatrics. A plan of care must be
established and execution documented. Midwives caring for these infants will
submit additional required reports. If consultation is not available the infant
should be transported to the hospital.
1. Apgar of score of less than 5 at one
minute or 7 at five minutes
2.
Significant abnormalities
3.
Jaundice at 24 to 48 hour of life
4. Meconium staining on the skin
5. No urination at 12 hours of life
6. Lethargy or weak suck reflex
7. Heart rate greater than 180 or less than
90 at rest
8. Birth weight of less
than 5 1/2 pounds or more than 10 pounds
9. Infant temperature of greater than 100 or
less than 97.7
10. Gestational age
of less than 36 weeks
11. Abnormal
cry
12. No stool after 48
hours
13. Vomiting after
feedings
14. Apnea lasting longer
than 10 seconds
15. Signs of
bleeding (petechiae, bruises)
16.
Tachypnea of greater than 60 breaths per minute after 4 hours of life
17. Mother's membranes ruptured for more than
24 hours
500. REFERRAL PHYSICIAN
Each Licensed Lay Midwife is encouraged to develop a close
working relationship with one or more specific Physician in obstetrical
practice or CNM in obstetrical practice who agree to serve as a Referral source
for the Lay Midwife. This relationship is optional. The duty of a Referral
Physician or CNM is to provide support to the Licensed Lay Midwife when
potentially serious conditions, as listed in sections 406 - 409 occur.
The Referral Physician and Lay Midwife relationship, or the CNM
and Lay Midwife relationship, can be terminated by either party at any
time.
600. EMERGENCY
MEASURES
The Licensed Lay Midwife must consult a licensed Physician or
CNM whenever there are significant deviations from normal in either the mother
or the infant, and must act in accordance with the instructions of the
Physician or CNM. In those situations requiring transport to a hospital, the
Lay Midwife must notify the emergency room of the designated hospital of an
imminent transport and provide a copy of the medical record to the receiving
Physician.
The Lay Midwife is expected to use his/her judgment regarding
the need for referral and/or emergency transport when problems arise that are
not specified in the protocol. Such care must be documented in additional
required reports.
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.
Any authorized or unauthorized emergency measures must be
reported to the Division on the Birth Log. In the case of actions/procedures
authorized by a Physician or CNM in the case of a specific emergency, the Lay
Midwife will document these orders with an order signed by the Physician or CNM
and submitted to the Division of Health on the 10th
of the following month.
700. RECORD KEEPING AND REPORTING
REQUIREMENTS
A monthly reporting log will be maintained and sent to the
Division postmarked no later than the 10th of each
month. Log forms will be provided by the Division. The log will include births
that month as well as report clients who were referred, transported, lost to
follow-up, or for other reasons not attended by the Licensed Lay Midwife at
birth.
When a consultation for a complication occurs (whether or not
the complication resulted in a referral or transport and whether or not the
Licensed Lay Midwife remained in attendance) the care must be documented in
greater detail using, forms provided by the Division. These forms will be sent
to the Division on the 10th of the month following
the event.
All client records must be maintained for 24 years.
The Division will audit selected records from each Licensed Lay
Midwife's practice each year. The purpose of the audit will be to confirm
compliance with these regulations.
The Licensed Lay Midwife will use the Birth Log to document
care of a woman receiving prenatal care from the Lay Midwife for more than one
month of the gestational period regardless of whether or not the Lay Midwife
attended the birth.
Midwives supervising an Apprentice should record the name of
the Apprentice on the Birth Log when the Apprentice provided care. Because the
Lay Midwife is responsible for the clinical work of her Apprentices, all
reports will be filled in the attending Midwife's name.
Complications resulting in the death of a mother, infant or
fetus, within 24 hours of delivery, must be reported to the Division within 2
working days.
The Licensed Lay Midwife is responsible for ensuring that all
required services are documented on client records maintained by the Midwife.
The records will remain confidential. They are subject to periodic review by
Division staff.
The Licensed Lay Midwife is responsible for completing and
submitting birth certificates according to instructions of the Division's
Office of Vital Statistics.
800. DIVISION RESPONSIBILITIES
801. GRANTING PERMITS AND LICENSES
Staff of the Women's Health Section shall review applications
for licensure and issue licenses or permits.
802. REGISTRATION LISTING
The Division shall maintain a list of all Licensed Lay Midwives
and Apprentice Midwives holding permits in the State of Arkansas.
803. MONITORING OUTCOMES
The Division shall monitor perinatal outcomes of home births
with Lay Midwife attendance and will publish these statistics annually.
The Division shall also review birth reports from Licensed Lay
Midwives to assure that such Midwives are practicing within regulatory
guidelines and standards of care. The Division will conduct investigations
regarding complaints or deviations from the Regulations.
804. ADMINISTRATION OF TESTS
The Division shall administer a licensing
examination.
900.
SEVERABILITY.
If any provision of these Rules and Regulations, or the
application thereof to any person or circumstances is held invalid, such
invalidity shall not affect other provisions or applications of these Rules and
Regulations which can give effect without the invalid provisions or
applications, and to this end the provisions hereto are declared to be
severable.
1000. REPEAL.
All Regulations and parts of Regulations in conflict herewith
are hereby repealed.
1100.
CERTIFICATION
This will certify that the Regulations Governing Lay Midwife
Practice was prepared pursuant to A.C.A.
20-7-109 et. seq. and A.C.A.
17-85-101 st.seq. A public hearing
was held on the 27th day of
June, 2006.
This will also certify that the foregoing Rules and Regulations
Governing Lay Midwife Practice in Arkansas were adopted by the Arkansas Board
of Health at a regular session of same held in Little Rock, Arkansas on the
25th day of January,
2007.
Dated at Little Rock, Arkansas this
13th day of March,
2007.
(Signed Paul Halverson) Director,
Division of Health Arkansas Department of Health & Human Services
The foregoing Regulations Governing Lay Midwife Practice, a
copy of which has been filed in my office, is hereby in compliance with the
Administrative Act, on the 16th day of
March, 2007.
(Signed) Mike Beebe
Governor State of Arkansas
