007-13-20 Ark. Code R. § 1
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 Act 481 of 1987 superseded Act 838 of 1983, and expanded the lay midwifery licensure statewide.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.
The State Board of Health (BOH) has delegated the authority to the Arkansas Department of Health (ADH).
As used in these Rules, the terms below will be defined as follows, except where the context clearly requires otherwise:
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.
A person who is training to become an LLM in Arkansas working under the direct supervision of a preceptor.
An ADH physician, Certified Nurse Midwife (CNM) or nurse practitioner providing ADH maternity services at a local health unit.
The exam that tests knowledge of the Rules Governing the Practice of Licensed Lay Midwifery in Arkansas.
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.
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.
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.
A professional midwifery practitioner who has met the standards for certification set by the North American Registry of Midwives (NARM).
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.
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.
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.
An individual who is present at the request of the client to provide emotional or physical support for the client and her family.
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.
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.
A community-based ADH clinic site that provides medical and environmental services.
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.
The international certification agency that established, and continues to administer, certification for the credential "Certified Professional Midwife" (CPM) and the Midwifery Bridge Certificate (MBC).
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.
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.
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.
The direct observation and evaluation by the preceptor of the clinical experiences and technical skills of the apprentice while present in the same room.
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.
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.
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.
The composition of the MAB will be as follows:
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:
For the purpose of these Rules, the MAB will process the review of continuing education credits by the following criteria:
Applicants for initial licensure must meet the following requirements, except for those noted in Section 200. #3:
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
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
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:
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:
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.
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:
After three (3) years, a license in inactive status automatically expires. To become re-licensed the applicant must successfully fulfill all of the requirements for initial licensure as outlined in Section 201.
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).
As used in this subsection "automatic licensure" means granting the occupational licensure without an individual's having met occupational licensure requirements provided under this title or by the rules of the occupational licensing entity.
As used in this subsection, "returning military veteran" means a former member of the United States Armed Forces who was discharged from active duty under circumstances other than dishonorable.
Pursuant to Act 820 of 2019, automatic 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.
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.
Applicants from another U.S. jurisdiction where substantially equivalent licensure is not available, refer to Section 201 for licensure requirements.
The LLM must adhere to the LLM protocols as outlined in these Rules.
The following requirements must be met before a LLM can legally accept a client.
An LLM shall terminate care of a client only in accordance with this section unless a transfer of care results from an emergency situation.
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.
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:
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.
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.
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.
At each visit the LLM will perform and record the following services:
Screening for Group B Strep according to ADH approved guidelines available on the ADH website.
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.
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.
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:
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.
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.
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.
The LLM shall advise the mother of the necessity for newborn evaluation by a physician within 24 hours of birth when:
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.
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.
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.
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.
As soon as possible but within one (1) hour following the onset of active labor (5-6 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:
All services should be provided in a supportive manner and in accordance with these Rules.
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:
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.
The LLM must remain in attendance for at least two (2) hours after the delivery and shall assess and record the following:
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:
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).
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.
The following services must be provided by the LLM as part of immediate newborn care:
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.
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.
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.
The LLM must instruct the mother in routine cord care.
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).
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.
status.
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.
Caseload and Birth Log in the following month of care, regardless of whether or not the LLM attended the birth.
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.
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.
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.
The LLM shall follow all applicable laws pertaining to vital records.
ADH shall review applications for licensure and issue licenses or permits.
ADH shall maintain a list of all LLMs and Apprentice Midwives in the State of Arkansas, and make this list available to the public.
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.
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.
ADH shall administer the Arkansas Rules Examination at least three (3) times per year.
If any provision of these Rules, or the application thereof to any person or circumstances, is held invalid, such invalidity shall not affect other provisions or applications of these Rules which can give effect without the invalid provisions or applications; and to this end the provisions hereto are declared to be severable.
All Rules and parts of the Rules in conflict herewith are hereby repealed.
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 24 day of October. 2019.
Dated at Little Rock, Arkansas this 23rd day of November, 2020.
APPENDIX A:FORMS
1. LLM Disclosure Form
2. LLM Informed Refusal Form
3. LLM Initial License and Reactivation of License Application
4. LLM License Renewal Application
5. Instructions for Completing LLM Reports
6. LLM Caseload and Birth Log
7. LLM Monthly Worksheet
8. LLM Incident Report
9. Preceptor-Apprentice Agreement for NARM PEP Apprentices
10. LLM Pre-Licensure Criminal Background Check Petition
11. Hospital Reporting Form - Lay Midwife Patient Transfer (For Hospital/Healthcare Facility Use only)
ARKANSAS DEPARTMENT OF HEALTH LLM DISCLOSURE FORM
Client's Printed Name: ______________________________________________________________
Client's Address: ______________________________________________________________
Street
______________________________________________________________
City State Zip Code
Phone Number: _________________________________
In compliance with the Rules Governing the Practice of Licensed Lay Midwifery in Arkansas, at the time of acceptance into care, a Licensed Lay Midwife (LLM) must provide the following disclosures in oral and written form:
A. Licensed Lay Midwife Scope of Practice
B. Informed Consent for Licensed Lay Midwifery Care
C. Requirements for Licensed Lay Midwifery Care
D. Risks and Benefits of Home and Hospital Births
E. Emergency Arrangements
F. Plan for Well-Baby Care
A. Licensed Lay Midwife Scope of Practice |
The Rules Governing the Practice of Licensed Lay Midwifery in Arkansas require each LLM to provide information on the scope of licensed midwifery practice under these rules to clients seeking midwifery care. The LLM may provide approved midwifery care only to healthy women, determined to be at low risk for the development of complications of pregnancy or childbirth; and whose outcome of pregnancy is most likely to be the delivery of a healthy newborn and intact placenta. Apprentice midwives and LLM Assistants work under the on-site supervision of the LLM. A person may not practice or offer to act as an LLM in Arkansas unless he/she is licensed by the Arkansas State Board of Health. The responsibilities of the LLM are specified by the Rules in regards to:
1. Required prenatal care.
2. Attendance during labor and delivery.
3. Care of the healthy newborn for the first fourteen (14) days of life unless care is transferred to a physician or APRN whose practice includes pediatrics. After fourteen (14) days, the LLM is no longer responsible to provide care except for routine counseling on newborn care and breastfeeding as indicated. The client should seek further care from a physician or an APRN whose practice includes pediatrics. If any abnormality is identified or 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.
4. Postpartum care for a minimum of 30 days after delivery.
These would also apply to any arrangements the LLM has in regard to apprentices she is supervising, or arrangements made with other LLMs to attend the birth, if she/he is unavailable.
The LLM is responsible to ensure the client is informed of and understands the need to receive clinical assessments, including laboratory testing; evaluations by a physician, certified nurse midwife (CNM) or public health maternity clinician; and required visits with the midwife that are mandated by the Rules. The LLM is also responsible for informing the client of the necessary supplies the client will need to acquire for the birth and the newborn (including eye prophylaxis and vitamin K).
LLM providing care___________________________________________________________
Licensed in Arkansas since ____________________________________________________
Arkansas LLM License Number__________________________Expiration Date___________
Certified Professional Midwife (CPM)
Yes or No (Circle correct response)
Midwifery Bridge Certificate (MBC)
Yes or No (Circle correct response)
If CPM, Certification Number___________________________Expiration Date___________
Each statement below is to be read and initialed by the client.
B. Informed Consent |
________I understand that I am retaining the services of___________________________ who is an LLM, not a CNM or a physician.
________I understand the LLM does or does not (circle correct response) have liability coverage for services provided to someone having a planned home birth.
________I understand that the LLM practices in home settings and does not have hospital privileges.
________I understand the LLM does or does not (circle correct response) have a working relationship with a physician or CNM. If she/he does, they are:
Physician's Name:_____________________________________________________
CNM's Name:_________________________________________________________
________I understand that if my LLM relies on a hospital emergency room for backup coverage, the physician on duty may not be trained in obstetrics.
________I understand the LLM is trained and certified in Cardiopulmonary Resuscitation
(CPR) and neonatal resuscitation.
________I understand there are conditions that are outside the scope of practice of an
LLM that will prevent me from beginning midwifery care. These conditions include, but are not limited to: previous cesarean delivery, multiple gestation, and insulin-dependent diabetes.
_________ I understand that there are conditions that are outside the scope of practice of an LLM that will require physician consultation, referral or transfer of care to a physician, CNM or health department clinician, or transport to a hospital. If during the course of my care my LLM informs me that I have a condition indicating the need for a mandatory transfer, I am no longer eligible for a home birth by an LLM. These conditions include but are not limited to: placenta previa in the third trimester, baby's position not vertex at onset of labor, labor prior to thirty-seven (37) weeks gestation, or active herpes lesions at onset of labor.
_________ The LLM is responsible to inform and educate me (the client) on these and other potential conditions that preclude care by an LLM.
_________ I understand emergency medical services for myself and my baby may be necessary and a plan for emergency care must be in place for the prenatal, labor, birth and immediate postpartum and immediate newborn periods, as outlined in Section E of this form.
__________ I understand my laboratory test results must be reviewed and interpreted by a physician, CNM or ADH clinician.
_________ I understand that the LLM must work in accordance with all applicable laws. The Rules Governing the Practice of Midwifery in Arkansas are available online at the Arkansas Department of Health website or by contacting the Arkansas Department of Health.
C. Requirements for Licensed Lay Midwifery Care |
I understand the LLM has protocols as specified in the Rules Governing the Practice of Licensed Lay Midwifery in Arkansas that must be followed concerning care for normal pregnancy, labor, home birth and the postpartum period, and for specific potentially serious medical conditions. The following requirements are my responsibility, as a midwife client, to fulfill:
______ I must have an initial, and 36 week visit with a private physician or CNM or go to an
Arkansas Department of Health Local Health Unit which provides maternity services for a risk assessment, which includes a physical exam and lab work.
______ If my pregnancy continues beyond 41 weeks, I must have a visit before 42 weeks with a private physician or CNM or go to an Arkansas Department of Health Local Health Unit which provides maternity services for a risk assessment.
_______ I must ensure that all my healthcare providers have access to all my medical records at the time of each visit and at the time of delivery. It is unsafe for any of these practitioners to evaluate or deliver a client without knowledge of all lab results and current risk status.
_______ I must have Vitamin K on hand for the birth. This may be ordered in advance of delivery from the Local Health Unit or may be obtained at a pharmacy by prescription.
_______ I must have ophthalmic erythromycin on hand for the birth, if indicated. This may be ordered in advance of delivery from the Local Health Unit or may be obtained at a pharmacy by prescription.
D. Risks and Benefits of Home and Hospital Births |
Before becoming a client with the intent of delivery at home, I understand I need to be familiar with some of the advantages and disadvantages of having either a home birth or a hospital birth.
RISKS AND BENEFITS OF HOME AND HOSPITAL BIRTHS | |
BENEFITS | |
Home | Hospital |
* Planned home birth with skilled, trained, midwifery care | * Skilled, specialized obstetric staff |
* Natural progression of labor | * Medications to induce or maintain labor, if needed |
* Non-invasive monitoring of labor progression and fetal well-being | * Early detection of fetal distress through advanced monitoring techniques |
* Privacy and familiar home surroundings | * Equipment available for high risk situations: intensive care, resuscitative equipment, surgical suites |
* Decreased obstetric interventions - midwives are trained to handle some unexpected emergencies on site for low risk women | * Immediate medical intervention including medications and blood products if needed, by OB/GYN, pediatrician, and medical personnel trained to deal with life threatening emergencies on site |
* Preserves family togetherness; provides personalized care; honors client's choices for birthing position, movement, and food and fluids during labor; labor takes place in familiar surroundings | * Some hospitals provide family-centered birthing and some provide birthing suites that create a home-like atmosphere and incorporate client's choices into their birth plan |
* Use of natural, non-invasive pain relief techniques | * Availability of pain medications upon request |
* The absolute risk of a planned home birth may be low | * The American College of Obstetrics and Gynecology and the American Academy of Pediatrics state that hospitals and birthing centers are the safest settings for birth in the United States |
RISKS | |
Home | Hospital |
* A planned home birth is associated with a twofold increased risk of newborn death compared to a hospital birth for low risk mother/infant pairs, and greater increases for those at higher risk. | * Hospital births are associated with increased maternal interventions including the possibilities of: epidural analgesia, electronic contraction and fetal heart rate monitoring, IVs, vacuum extraction, episiotomy, and cesarean delivery. |
* Certain emergency conditions may occur without warning, which cannot be handled in a timely manner at home; and the home may lack needed emergency equipment for advanced resuscitation. In emergency situations greater risk of adverse outcomes exists, including death, for both mother and child. | * Not all hospitals have immediate availability of specialty consultation and care in cases of certain medical emergencies and in these situations there is the risk for adverse outcomes including death for the mother and child. |
* Transport time to a hospital in case of an emergency can seriously impact the outcome on health of mother and newborn. Travel time of more than 20 minutes has been associated with increased adverse newborn outcomes, including mortality. | * Hospitals that provide delivery services may not be available in some geographic areas requiring the mother to travel longer distances for urgent care of sudden risks. |
______I have reviewed the above table and have discussed with my midwife the risks and benefits of both home and hospital births.
E. Emergency Arrangements | |
An emergency plan must be developed between the client and the LLM detailing the arrangements for transport of the client to the nearest hospital licensed to provide maternity services or to the hospital where the back-up physician has privileges. The hospital must be within fifty (50) miles of the home birth site.
1. The licensed physician or CNM that will be consulted when there are deviations from normal in either the mother or infant is:
a. Name of Clinic/Physician/ADH Clinician/CNM for the mother:
________________________________________Phone Number____________
City/State______________________________
b. Name of Physician/ADH Clinician/CNM for the infant if known:
________________________________________Phone Number____________
City/State_________________________________
2. Transport Arrangements: In an emergency, transport to a hospital will be by: Ambulance:
Name:__________________________________________
Phone: __________________________________________
Miles from home birth site:___________
Estimated time to home birth site_______
Has the option of using a private vehicle for backup been discussed? [] Yes [] No
3. In the event of maternal emergency in a home birth, transport will be to the following:
Hospital:______________________________________________________
City/State:_______________________________________________________
Phone:___________________________________________
Miles from home birth site___________Estimated Time from home birth site_______
I understand that the physician on duty in this hospital emergency room may not be trained in obstetrics.
4. In the event of a neonatal emergency requiring immediate transport, transport will be to the nearest hospital:
Hospital:_________________________________________________________
City/State:________________________________________________________
Phone:___________________________________________________________
Miles from home birth site___________Estimated Time from home birth site________
I understand that the physician on duty in this hospital emergency room may not be trained in obstetrics or pediatrics.
__________I agree to these arrangements should an emergency or medical complication arise.
F. Plan for Routine Well-baby Care |
A plan of care should be developed between the client and a physician or an APRN whose practice includes pediatrics to follow up with routine well-baby visits after birth. The LLM is responsible for newborn care immediately following delivery and for the first fourteen (14) days of life, unless care is transferred before that time. After fourteen (14) days, the LLM is no longer responsible to provide care except for routine counseling on newborn care and breastfeeding as indicated. The client should seek further care from a physician or an APRN whose practice includes pediatrics. If any abnormality is identified or 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.
Name of Physician/APRN for the infant:
___________________________________________________Unknown: []
Phone Number_____________________
City/State________________________________________
G. Consent Signatures |
The consent signatures page will be kept in the client's chart as proof that all above Disclosure Form items have been initialed.
I have discussed and provided in writing the information included in this disclosure form with my client. I have discussed with her how this impacts her pregnancy and its outcome.
LLM Signature:___________________________________________Date Signed______________
The above information has been discussed with me and also provided in writing. I understand its implications to my pregnancy and its outcome.
_____________________________________________
Client printed name
_____________________________________________________________________________
Client signature Date signed
ARKANSAS DEPARTMENT OF HEALTH LLM INFORMED REFUSAL FORM
Version Match 8, 2017
The Arkansas Lay Midwife Act gives authority to the Board of Health (BOH) to oversee Licensed Lay Midwives (LLMs) in Arkansas. As part of this authority, the BOH sets the rules for LLMs. These rules require that LLMs follow specific protocols for risk assessment, consultation, referral, and transfer of care to ensure the safety of the mother and baby. The BOH has delegated the authority to enforce these Rules Governing the Practice of Licensed Lay Midwifery in Arkansas to the Arkansas Department of Health (ADH).
LLMs are trained experts in the care of low-risk pregnancy for women who want to give birth outside of a hospital. Low-risk means that a woman is healthy and should have a normal birth of a healthy baby with no problems. Some women have health issues that give them a greater chance of problems for the mother or baby. The LLM's training may not prepare her/him to handle these health issues. The health issue may call for testing or treatment that the LLM cannot give. Careful thought and discussion about the safety of an out-of-hospital birth may be needed. A team of health care providers may be better able to handle some health issues. This team may involve LLMs, obstetricians, pediatricians, Certified Nurse Midwifes (CNMs), specialists, family doctors, and others.
The mother and her health practitioners should talk about her health issues. Together they can decide on the best plan for her care and for the birth of a healthy baby. Talking about the risks is important and required by the Rules Governing the Practice of Licensed Lay Midwifery in Arkansas, and, as stated by NARM (North American Registry of Midwives) requires that:
If a midwife supports a client's choices that are outside her Plan of Care, she must be prepared to give evidence of informed consent. The midwife must also be able to document the process that led to the decision and show that the client was fully informed of the potential risk and benefits of proceeding with the new care plan. It is the responsibility of the midwife to provide evidence-based information, clinical expertise, and when appropriate, consultation or referral to other providers to aid the client in the decision making process.
Both the mother and the LLM must sign this form. Signing the form shows that the LLM and the mother have discussed the risks to both mother and baby of refusing the required test, procedure, treatment, medication, or referral. That discussion must include reviewing material from an ADH-approved source for each requirement being refused by the client. The LLM and the mother must decide on a plan of care for the health issue and that plan must be written on the form.
LLM INFORMATION | |
Name: | Arkansas License Number: |
CPM # | CPM Expiration Date: |
MBC # | |
Telephone Number: | Email Address: |
CLIENT INFORMATION | |
Name: | Date of Birth: |
Address: | |
Telephone Number: | CLIENT FILE # |
The client must initial each of the following statements:
_____ I have been told by my LLM that my baby or I should have the following test,
procedure, treatment, medication, or referral required by the Rules Governing the Practice of Licensed Lay Midwifery in Arkansas:
____________________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
____I have been told of the following risks and benefits of the test, procedure, treatment,
medication, or referral:
____________________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
____ I have had an opportunity to review with my LLM the materials from the following ADH-approved sources:
____________________________________________________________________________________________
____________________________________________________________________________________________
____ I have had an opportunity to ask questions and have them answered to my satisfaction.
_____ I understand that my condition may require treatment that my LLM cannot provide.
_____ My LLM and I have developed a plan of care as follows:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Having considered all of my options and understanding the risks of refusing the test, procedure, treatment, medication, or referral, I have decided to go against the advice of my LLM and the Rules Governing the Practice of Licensed Lay Midwifery in Arkansas.
This is to certify that I, _________________________________________________________ ,
am refusing at my own insistence the test, procedure, treatment, medication, or referral listed above.
Client Signature: _____________________________________________ Date: ___________
LLM Signature: ______________________________________________ Date: ____________
Witness Signature: ___________________________________________ Date: ____________
ARKANSAS DEPARTMENT OF HEALTH LLM INITIAL LICENSE AND REACTIVATION OF LICENSE APPLICATION
ARKANSAS DEPARTMENT OF HEALTH LLM INITIAL LICENSE AND REACTIVATION OF LICENSE APPLICATION
Current Health-Related Other Licenses Name of Trade or Profession | State | License Number | Expiration Date |
Have you ever had a license revoked in any health-related field? [] Yes [] No If yes, specify: _____________________________________________________________________ | |||
Have you ever been convicted of a crime? [] Yes [] No If yes, a detailed statement, a summary of the charges, the final order, any probation or parole documentation, and any other relevant information must be attached and received before your application will be processed. | |||
Please list any other states ©or territories where you have held a Midwife license and indicate whether or not the license is current: ____________________________________________________________________________________________________________ | |||
(Verification of licensure sent from the state where the license is held may be requested.) | |||
Has your application for any professional license, certificate, registration been denied by any state licensing board or federal authority? [] Yes [] No If yes, specify _______________________________________________________________________________ | |||
I certify that all information given on this application is true and accurate. That in consideration of the issuance to me of a license to practice in Arkansas, I swear that I shall observe, abide by and uphold the laws of the State of Arkansas governing my practice and that I shall abstain from unethical, deceptive and fraudulent methods of practice and from unprofessional and unethical conduct, and that I shall not associate professionally with nor become a partner or employee of any person who resorts to such practices. I hereby agree that the violation of this oath shall constitute cause sufficient for the revocation of said license and surrender of the rights and privileges accorded me there under.
______________________________________________________________
Signature of Applicant Date
ARKANSAS DEPARTMENT OF HEALTH LLM INITIAL LICENSE AND REACTIVATION OF LICENSE APPLICATION PROCEDURES FOR APPLYING FOR LAY MIDWIFERY LICENSE
Type or print the application and check thoroughly before submitting. An incomplete application will delay processing. All items must be on file before your application will be considered. If any of your application documentation requires additional information the review process may take longer. Apply far enough in advance to allow for processing time.
All applicants must submit the following items:
[] 1. Complete application form, including passport style and size photograph, head and shoulders, taken within 60 days of application date.
[] *2. Notarized copy of the applicant's high school diploma, GED Certificate or documentation of highest degree attained after high school. Must include the name of the issuing school or institution and the issue date.
[] * 3. Notarized copy of one of the following documents that demonstrates the applicant is 21 years of age or older:
[] A. Birth Certificate
[] B. U.S. Passport, current or expired
[] C. U.S. Driver's License or other state-issued identification document
[] D. Document issued by federal, state or provincial registrar of vital statistics
[] 4. Documentation, if applicable, in the form of a verification letter directly from the certifying body or a notarized copy of the applicant's certificate that applicant is currently certified:
[] i. By NARM as a Certified Professional Midwife (CPM).
[] ii. By the American Midwifery Certification Board (AMCB) as a certified nurse midwife (CNM).
[] iii. By the American Midwifery Certification Board (AMCB) as a certified midwife (CM).
[] iv. By certification deemed equivalent and approved by ADH.
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.
[] 5. Documentation, if applicable, 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.
Applicants with a current Apprentice permit issued prior to the effective date of these Rules must additionally submit the following notarized forms:
[] 1. Clinical Experience Documentation for Births as a Primary Midwife form
[] 2. Preceptor Verification Form
[] 3. Documentation of Acquisition of Clinical Knowledge and Skills (completed by each Preceptor)
[] 4. Copy of both sides of current certification in adult and infant cardiopulmonary resuscitation. Only certifications from courses which include a hands-on component are accepted. Online-only courses are not accepted. Approved CPR courses include the American Heart Association and the American Red Cross. It is the responsibility of the licensee to ensure this certification is current at all times and documentation must be provided upon request.
[] 5. Copy of both sides of current certification in neonatal resuscitation through a course recognized by NARM. It is the responsibility of the licensee to ensure this certification is current at all times and documentation must be provided upon request.
NOTE:
* Applicant's name must be the same on all documents or the applicant must submit proof of name change with application.
* ADH has the option to request of verification of current required certifications and of other licensure held.
* * Arkansas Apprentices that have provided this information to the Health Department with apprentice application will not be required to resubmit these items.
Mail all forms and attachments to:
ARKANSAS DEPARTMENT OF HEALTH
WOMEN'S HEALTH SECTION, SLOT 16
4815 W. MARKHAM ST.
LITTLE ROCK, AR 72205
ARKANSAS DEPARTMENT OF HEALTH LLM LICENSE RENEWAL APPLICATION
PROCEDURES FOR APPLYING FOR RENEWAL OF LAY MIDWIFERY LICENSE
Lay midwifery licenses are valid for up to three (3) years and are renewed on August 31 of the third year of licensure. Applications are due 60 days prior to that date.
In order to be reviewed an application for renewal must be complete and accompanied by all supporting documentation.
Type or print the application and review thoroughly before submitting. An incomplete application will delay processing.
All applicants must submit the following items before your application will be considered:
[] 1. Complete application form.
[] 2. Copy of certificate documenting completion of ADH exam on the Arkansas Rules with a score of
80% or higher. Instructions for taking the exam are available from ADH.
[] 3. Documentation, if applicable, in the form of a verification letter directly from the certifying body or a notarized copy of the applicant's certificate that applicant is currently certified:
[] By NARM as a certified professional midwife (CPM).
[] b. By the American Midwifery Certification Board (AMCP) as a certified nurse-midwife (CNM).
[] c. By the AMCP as a certified midwife (CM).
[] d. By certification deemed equivalent and approved by ADH. ADH may request additional documentation to support applicant's qualifications or certifications.
[] 4. Verification of Midwifery Bridge Certificate (MBC), if held and not previously submitted. Documentation may be received in the form of a verification letter directly from NARM or a notarized copy of the applicant's certificate.
For applicants who are 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 from NARM as a CPM, the following requirements must be met:
[] 1. Complete application form.
[] 2. Documentation of hours of continuing education obtained (LLM Rules, Section 202.#2.d.) Documentation must include a copy of the diploma or certificate and the following:
a. Type of training: College, Vocational Training, Continuing Education
b. Name of institution
c. Name of course
d. Dates attended (from-to)
e. Total number of credits/clock hours/contact hours f Date of diploma or certificate
[] 3. Notarized copy of both sides of current certification adult and infant cardiopulmonary resuscitation. Only certifications from courses which include a hands-on component are accepted. Online-only courses are not accepted. Approved CPR courses include the American Heart Association and the American Red Cross.
[] 4. Notarized copy of both sides of current certification in neonatal resuscitation through a course recognized by NARM.
NOTE:
* Applicant's name must be the same on all documents or the applicant must submit proof of name change with application.
* It is the responsibility of the licensee to ensure relevant credentials are current at all times and documentation must be provided upon request.
* ADH has the option to request verification of current required certifications and of other licensure held.
Mail all forms and attachments to:
ARKANSAS DEPARTMENT OF HEALTH WOMEN'S HEALTH SECTION, SLOT 16
4815 W. MARKHAM ST.
LITTLE ROCK, AR 72205
ARKANSAS DEPARTMENT OF HEALTH INSTRUCTIONS FOR COMPLETING LLM REQUIRED REPORTS
Caseload and Birth Log
The Licensed Lay Midwife Caseload and Birth Report Log is required under Section 500 of the Rules Governing the Practice of Licensed Lay Midwifery in Arkansas (Jun1 1, 2018). The form is available from the Arkansas Department of Health (ADH).
The Licensed Lay Midwife Caseload and Birth Report Log is designed to be a perpetual report, so that the same form may be copied and re-submitted on a monthly basis until the pages are full and new pages started. A new Caseload and Birth Report Log is opened each January 1. The current undelivered caseload will be carried over to a new birth log for the January 1 report. The report must be dated, completed and submitted monthly even if there is no new activity that month and must be postmarked no later than the 10th of the month.
The report consists of 2 pages:
* Coversheet: A continuous record of the year's activity. Each column represents one month. A new coversheet is initiated each January.
* Caseload List: Each page provides room for listing clients. Please copy and add additional sheets as needed. Each January, a caseload list of undelivered clients is submitted as the initial caseload for the calendar year.
The Caseload and Birth Report Log is used to report the following:
1. Women who receive prenatal care from the LLM for more than one month of the gestation period regardless of whether or not the LLM attended the birth.
a. Enter the name and estimated due date on the Log at the time the client enters into care of the LLM.
b. Enter the date the Disclosure Form is signed by client and LLM.
c. ADH requires that all clients receiving care be listed on the Log in order to establish statistically reliable data for annual reports.
2. Clients who are referred for care, transferred to another provider, transported, lost to follow-up (or leave LLM care), or for other reasons are not attended by the LLM at birth.
3. Consultations between the LLM and a physician, CNM or an ADH clinician to discuss the status and future care of the client.
4. Labors/births attended by the LLM.
5. Apprentice name when apprentice participates in the client's birth.
On the Caseload List, the boxes for reporting Consults/Referrals and Transport or Hospitalization of Mother and/or Newborn shall be completed as follows:
* In the box write in the appropriate letter to indicate if it is a consult (C), referral (R) or transport for the mother (M), newborn (N) or both (B) and the date of the event.
Example: For a Consult : For a Maternal Transport:
M 2/17/2017 C 2/17/2017
ARKANSAS DEPARTMENT OF HEALTH INSTRUCTIONS FOR COMPLETING LLM REQUIRED REPORTS
Incident Report
The Incident Report form is used to document incidents or complications and must be submitted to ADH, postmarked by the 10th of the month. Please note that there is a different reporting time-frame for some complications. Refer to section 8 below or Rules section 400 for details. When a second page is needed to provide a comprehensive report, attach and number the second page. Do not write or record anything on the back of any pages.
The following events must be documented:
1. Consultations and Referrals. Refer to Rules definitions 103.10 and 103.22. Consultation is the process by which an LLM who maintains primary management 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. Referral is 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.
A consultation or referral must be documented in the client record and Incident Report whether or not a Transfer or Transport becomes necessary. Consultation and/or Referral is required for:
a. Pre-existing conditions listed in the Rules section 303.02
b. Prenatal conditions listed in 303.03
c. Intrapartum conditions listed in 305.02
d. Postpartum conditions listed in 307.02
e. Newborn conditions listed in 309.02
f. Other problems not specified in the protocol in which there are significant deviations from normal
2. Transfers. Refer to Rules definition 103.22: 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. A transfer may result from a consultation and/or referral for a complication, or may occur for social reasons (relocation, preference for another provider, preference for a hospital birth, financial reasons, et al). The delivery date for transfers is recorded when known by the LLM.Transfers resulting from complications include:
a. Conditions that preclude LLM care listed in 303.01
b. Recommendation of the consultant (physician, CNM, ADH clinician) following a risk assessment, consultation or referral c. Other conditions as determined by the LLM
ARKANSAS DEPARTMENT OF HEALTH INSTRUCTIONS FOR COMPLETING LLM REQUIRED REPORTS
3. Immediate Transport. Occurs when the client must be taken to a medical facility by the most expedient method of transportation available, to obtain treatment or evaluation for an emergency condition and includes:
a. Intrapartum conditions, Rules section 305.01
b. Postpartum conditions, Rules section 307.01
c. Newborn conditions, Rules section 309.01
d. Other conditions as determined by the LLM
4. LLM Terminated Care. Refer to Rules section 301.01.
5. Informed Refusals. LLMs who have a current CPM or MBC credential must utilize the ADH Informed Refusal Form in specific situations outlined in the Rules section 104, #4-8. The Informed Refusal Form must be completed according to Rules section 104, #8.c - #8.f. which includes the requirement for the LLM to document the Informed Refusal by completing an Incident Report form and noting the Informed Refusal on the next Caseload and Birth Report Log to be submitted to ADH. The form is maintained in the client record and a copy does not have to be submitted with the required monthly reports.
6. Third Risk Assessment (Post Dates). Refer to Rules section 302.01 (3) and 303.01 (5). Between 41 weeks and 0/7 days and 42 weeks and 0/7 days of gestation, a third risk assessment is required. A documented plan for care beyond 42 weeks 0/7 days gestational age must be submitted to the ADH as a required incident report.
7. Emergency Measures. Refer to Rules section 400. Refers to emergency measures taken by the LLM when the attendance of a physician or CNM cannot be speedily secured. Unauthorized emergency measures must be reported by the LLM. Physician- or CNM-authorized emergency measures must be reported with documentation of the physician or CNM signed orders.
8. Perinatal Hospitalization or Death. Refer to Rules section 400.
a. Complications resulting in intrauterine fetal death, or maternal or newborn death within 48 hours of delivery must be reported to ADH within two (2) business days.
b. Maternal or newborn deaths that occur between two (2) through thirty (30) days of birth will be reported to ADH within 5 business days.
c. Maternal or newborn hospitalizations that occur within thirty (30) days of delivery must be reported to ADH within five (5) business days.
The above reports must be mailed monthly to ADH and postmarked no later than the 10th of each month to the following address:
Arkansas Department of Health
Women's Health Section, Slot 16
4815 W. Markham Little Rock, AR 72205
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 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 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 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.
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
The apprentice must submit a signed Preceptor-Apprentice Agreement for each preceptor under whom they train. The preceptor is responsible for the training of the apprentice and for supervision of the apprentice's performance as an assistant or primary midwife in the attainment of the required clinical experiences and demonstration of skills. The preceptor shall provide instruction prior to the performance of clinical skills, and shall sign off on the required clinical experiences and skills.
Should any 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 preceptors unless a signed Preceptor-Apprentice Agreement is on file with 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).
Apprentice Information (PRINT):
Name___________________________________________________________________________________
Address_________________________________________________________________________________
City________________________________
State___________
Zip________________________________
Phones: (h)____________________ (c)______________________
email:___________________________
Preceptor Information (PRINT):
Name____________________________________________________________________________
Address__________________________________________________________________________
City________________________________ State___________ Zip_________________________
Phones: (h)_______________________(c)________________________
email:___________________
Licensed by (state)_____________ Date of expiration_____________________________________
CPM number_______________________Date of expiration________________MBC: [] Yes [] No
If preceptor is not licensed in Arkansas, a notarized copy of state license or CPM certificate must be submitted or a verification letter sent by NARM directly to ADH.
I agree to provide training in all of the required clinical knowledge and skills, and to supervise by direct, on-site, supervision, all clinical experiences that will have my signature on the clinical documentation experience forms for:
Apprentice's signature_________________________________________Date___________________
Signature of Preceptor________________________________________ Date___________________
ARKANSAS DEPARTMENT OF HEALTH APPRENTICE PERMIT RENEWAL
Renewed permits will be valid until three (3) years from the effective date of the Rules Governing the Practice of Licensed Lay Midwifery in Arkansas.
PROCEDURES FOR APPLYING FOR RENEWAL OF LAY MIDWIFERY APPRENTICE PERMIT __________________________For Transitional Apprentices__________________________
Transitional Apprentices will have three (3) years from the effective date of the Rules Governing the Practice of Licensed Lay Midwifery in Arkansas to successfully complete their apprenticeship and submit an application for lay midwifery licensure to ADH. If necessary, the apprentice permit may be renewed during this period and will be valid until three (3) years from the effective date of the Rules. The permit must be renewed by the permit's expiration date. All renewal requirements must be received by ADH at least 60 days before the permit's expiration date.
In order to be reviewed an application for renewal must be complete and accompanied by all supporting documentation.
Type or print the application and review thoroughly before submitting. An incomplete application will delay processing.
All applicants must submit the following items before your application will be considered:
[] 1. Complete application form.
[] 2. Copy of both sides of current certification in adult and infant cardiopulmonary resuscitation. Only certifications from courses which include a hands-on component are accepted. Online-only courses are not accepted. Approved CPR courses include the American Heart Association and the American Red Cross. It is the responsibility of the apprentice to ensure this certification is current at all times and documentation must be provided upon request.
[] 3. Copy of both sides of current certification in neonatal resuscitation through a course approved by NARM. Only certifications from courses which include a hands-on 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.
[] 5. Verification of all current Preceptor-Apprentice relationships documented by Preceptor-Apprentice Agreement forms for each preceptor signed within 90 days of application submission.
[] 6. Notarized documentation of clinical experience for the time period covered for this licensing period. This includes progress made toward licensure that year, i.e. number of AP visits conducted, labor managements and deliveries, newborn evaluations and post-partum examinations conducted under supervision.
NOTE:
* Applicant's name must be the same on all documents or the applicant must submit proof of name change with application.
* A Preceptor-Apprentice Agreement form must be signed by each preceptor under which the apprentice trains during the course of the apprenticeship and sent to ADH by the apprentice within 30 days of signing. An apprentice shall submit written notice to ADH within 30 days after any change to the relationship with a preceptor.
Mail all forms and attachments to:
ARKANSAS DEPARTMENT OF HEALTH
WOMEN'S HEALTH SECTION, SLOT 16
4815 W. MARKHAM ST.
LITTLE ROCK, AR 72205
DOCUMENTATION OF ACQUISITION OF CLINICAL KNOWLEDGE AND SKILLS FOR TRANSITIONAL APPRENTICES ONLY:
Instructions for the Documentation of Clinical Experiences
All apprentices must have a Preceptor-Apprentice agreement on file with ADH for each preceptor under whom the apprentice trains. These preceptors are responsible for the training of the apprentice and for the required clinical experiences. Other midwives licensed in the state of Arkansas may sign for some of the clinical experiences.
The dates from the first assist to the final primary birth should encompass at least one year.
Preceptors are expected to sign the documentation forms at the time the skill is performed competently. Determination of "adequate performance" of the skill is at the discretion of the preceptor, and multiple demonstrations of each skill may be necessary. Documentation of attendance and performance at births, prenatals, postpartums, etc., should be signed only if mutually agreed that expectations have been met. Any misunderstanding regarding expectations for satisfactory completion of experience or skills should be discussed and resolved as soon as possible.
The preceptor is expected to provide adequate opportunities for the apprentice to observe clinical skills, to discuss clinical situations away from the clients, to practice clinical skills, and to perform the clinical skills in the capacity of a primary midwife, all while under the direct supervision of the preceptor. This means that the preceptor should be physically present when the apprentice performs the primary midwife skills. The preceptor holds final responsibility for the safety of the client or baby, and should become involved, whenever warranted, in the spirit of positive education and role modeling.
Twenty (20) of the 75 prenatal exams are required to be initial exams and include the midwife's prenatal exam, initial interview and history (Appendix B, #9.c.).
Births as an Active Participant are births where the apprentice is being taught to perform the skills of a midwife. Charting, other skills, providing labor support, and participating in management discussions may all be done in Active Participant births in increasing degrees of responsibility. Catching the baby should be a skill that is taught towards the end of the active participant period, but not counted as a supervised primary. The apprentice does not have to perform all skills at every birth in this category, but should be present throughout labor and birth and should perform at least some skills at every birth. The apprentice should complete most of the active participant births before functioning as Primary Midwife under supervision.
Births as Primary Midwife under supervision means that the apprentice demonstrates the ability to perform all aspects of midwifery care to the satisfaction of the preceptor, who is physically present and supervising the apprentice's performance of skills and decision making. Some skills at these births may be performed by the preceptor or other midwives/apprentices, but the catching of the baby, most skills, and labor management should be performed by the apprentice who is claiming the birth as a primary birth under supervision.
**It is recommended that the apprentice make blank copies of all forms in the Application in the event that more space is needed for documentation of clinical experience, or when more preceptors are involved.
Documentation of Acquisition of Clinical Knowledge and Skills Clinical Experience Documentation for Births as an Active Participant
*see Preceptor-Apprentice Documentation Information prior to signing this form
Name of Apprentice ______________________________________________________________
Client Initials | Assist at Initial Midwife Exam | Number of Additional Prenatals | Assist at Birth | Date of birth | Place of birth | Assist Newborn Exam | Number of Postpartum Exams | Supervising Midwife's Signature |
Example | Yes | 4 | Yes | 1/3/06 | home | Yes | 2 | |
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There are no minimum numbers for any clinicals except assisting at birth, however, it is expected that the supervising midwife will provide training both outside of and during the performance of these other clinicals. The apprentice should provide the number of clinical experiences at which she assisted for each client listed. More than twenty spaces are provided in case some clinicals are performed on clients for which the apprentice does not attend the birth. Put a "yes" or "no" in columns unless a number, date, or other information is required. Do not leave spaces blank. Place of birth: indicate home, birth center, or hospital. Transports may count as an assist if the apprentice assisted during labor at home or birth center prior to transport.
There may be a period of training where the apprentice observes but does not perform assistant activities at clinical experiences. Observations should not be documented as assists.
Clinical Experience Documentation for Births as Primary Midwife
*see Preceptor-Apprentice Documentation Information prior to signing this form
Name of Apprentice _____________________________________________________________
Client Initials | Perform Initial Midwife Exam | Number of Additional Prenatals | Manage Labor and Birth | Date of birth | Place of birth | Perform Newborn Exam | Number of Postpartum Exams | Supervising Midwife's Signature |
Example | Yes | 8 | Yes | 1/3/06 | home | Yes | 2 | |
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Minimum required | 20 | 55 | 20 | 20 | 40 | |||
Your numbers |
The apprentice should provide the number of clinical experiences at which she assisted for each client listed. More than twenty spaces are provided in case some clinicals are performed on clients for which the apprentice does not attend the birth. Put a "yes" or "no" in columns unless a number, date, or other information is required. Do not leave spaces blank. For at least three clients, the apprentice should have provided a minimum of 4 prenatals, birth, newborn, and 2 postpartum exams. Place of birth code: please indicate home, birth center, or hospital. Transports to the hospital may not count toward required primary births, but may be documented for prenatal exams, etc.
Apprentice's name __________________________________________________________
The following skills must be documented by a qualified preceptor as being competently performed by the apprentice.
Performance of the skills includes a demonstration and/or verbal discussion of the knowledge implied by the performance of the skill. Please indicate "by discussion" if skill is not performed.
The preceptor should date and initial each line of any skill she is verifying. More than one preceptor may sign in order to complete the form. All preceptors who sign should also be listed on the Preceptor Verification Form.
General Skills
Demonstrates use of universal health precautions relevant to midwifery care __________
Demonstrates appropriate application of aseptic and sterile technique _______________
Demonstrates thorough and accurate documentation of care ______________________
Pharmacology
Demonstrates knowledge of the benefits and risks of the following and refers for prescription and administration when indicated:
Rh Immune Globulin (RhoGam) for an Rh negative mother _______________________
Vitamin K & erythromycin for the newborn __________________________________
Pitocin ______________________________________________________________
Safe use, care, and transport of oxygen _____________________________________
Prophylaxis for Group B Strep ____________________________________________
Postpartum Rubella immunization when non-immune ___________________________
Antepartum
Assessment Skills:
Basic health history/OB and gynecological history/family history ____________________
Obtains diet history and provides nutritional education ___________________________
Obtains interval updates of medical history ____________________________________
Evaluates general appearance ________________________________________________
Obtains weight and height __________________________________________________
Assesses maternal weight gain ______________________________________________
Vital signs: temp, pulse, respirations, blood pressure ______________________________
Urine testing for glucose, protein and nitrites ___________________________________
Examination of the skin for color and appearance _________________________________
Examination of the pupils, whites and conjunctiva of the eyes _______________________
Examination of the thyroid gland for enlargement ________________________________
Examination of lymph glands of the neck and underarm for enlargement ______________
Auscultates heart for rate and rhythm __________________________________
Auscultates lungs for abnormal breath sounds ___________________________________
Percusses the costovertebral angle for pain _____________________________________
Speculum examination of the vagina for color, discharge, leakage of fluid _____________
Identifies position, presentation, lie of fetus (Leopold's maneuvers) __________________
Assessment of Fetal Heart Rate auscultated by fetascope or doppler __________________
Identifies pelvic landmarks, assesses pelvis ____________________________________
Measurement of fundal height _______________________________________________
Estimates fetal size ___________________________________________________
Lower extremities for varicosities ____________________________________________
Edema of face legs and hands _______________________________________________
Determines estimated due date _____________________________________________
Assesses well-being ______________________________________________________
Intervention Skills:
Evaluates knowledge of self- breast exam techniques _____________________________
Instruction of clean catch urine specimen _____________________________________
Recognizes the indications for genetic counseling and refers as appropriate ____________
Understands and applies knowledge of good eating practices _______________________________
Evaluates and makes recommendations for discomforts of pregnancy ______________
Demonstrates knowledge and application of ADA Clinical Practice Recommendations for gestational diabetic screening and diagnosis _____________________________________
Demonstrates knowledge of normal and abnormal of required prenatal screening tests
_______________________________________________________________________
Completes pre-delivery home visit ____________________________________________
Educates regarding home birth supplies ________________________________________
Identifies and takes appropriate action including consultation, referral, or immediate transport when indicated and according to LMW Protocols in the following Prenatal situations:
Suspected abnormality on physical examination __________________________________
Size/Date discrepancy ______________________________________________________
Elevated Blood Pressure Readings ____________________________________________
Abnormal Kick Count ______________________________________________________
Abnormal weight gain or loss ________________________________________________
Abnormal Prenatal screening tests ___________________________________________
Symptoms of urinary tract infections _________________________________________
Hyperemesis ____________________________________________________________
Abnormal Fetal Heart Rate Patterns ___________________________________________
Absence of Fetal Heart Rate _________________________________________________
Position other than vertex presentation ________________________________________
Preterm labor ____________________________________________________________
Symptoms of Ectopic (Tubal )pregnancy ______________________________________
Abnormal vaginal bleeding __________________________________________________
Prolonged or Premature rupture of membranes ___________________________________
Post term pregnancy _____________________________________________________
Labor and Birth
Assessment Skills:
Takes history relevant to labor _____________________________________________
Assesses effacement and dilation of cervix ___________________________________
Assesses station of presenting part _________________________________________
Assesses fetal lie, position, and descent ______________________________________
Assesses uterine contractions for frequency, duration, and intensity ________________
At required intervals, monitors and assesses fetal heart rate during and between contractions
_____________________________________________________________________
Assesses food and fluid intake and output _____________________________________
Assesses maternal well-being and responds appropriately:
Vital signs _____________________________________________________________
Emotional well being ___________________________________________________
Assesses labor progress ____________________________________________________
Intervention Skills:
Demonstrates basic labor support skills and comfort measures ______________________
Uses maternal position changes to facilitate labor ________________________________
Demonstrates perineal support and hand techniques for delivery ____________________
Demonstrates proficiency in assisting normal, spontaneous vaginal birth _____________
Supports father and other family members __________________________________
Organizes birth equipment _______________________________________________
Follows sterile technique ________________________________________________
Identifies and takes appropriate action including consultation, referral or immediate transport when indicated and according to LMW Protocols in the following Intrapartum situations:
Abnormal fetal heart rates/patterns ___________________________________________
Prolapsed cord ___________________________________________________________
Breech presentation and birth _______________________________________________
Face presentation and birth _________________________________________________
Multiple birth ____________________________________________________________
Shoulder dystocia _________________________________________________________
Abnormal bleeding ________________________________________________________
Nuchal hand, arm, or cord __________________________________________________
Edematous cervical lip _____________________________________________________
Rupture of membranes _____________________________________________________
Meconium stained fluids ___________________________________________________
Abnormal changes in vital signs (maternal) ____________________________________
Maternal dehydration and/or exhaustion _______________________________________
Prolonged labor in:
Primagravida ______________________________________________________
Multigravida ______________________________________________________
Abnormal progress of labor _________________________________________________
Symptoms of Pre-eclampsia _________________________________________________
Suspected fetal death ______________________________________________________
Postpartum Period
Assessment Skills
Determines signs of placental separation ______________________________________
Assesses placenta for size, structure, completeness, cord insertion, and number of vessels, and color ________________________________________________________________
Assesses uterus from birth throughout the immediate postpartum period for height, size, consistency, and retained clots _______________________________________________
Identifies bladder distention and consults or refers if indicated ______________________
Assesses and estimates blood loss ____________________________________________
Assesses lochia: amount, odor, consistency, color _______________________________
Recognizes postpartum hemorrhage ___________________________________________
Recognizes symptoms of shock ______________________________________________
Assesses perineum and cervix for lacerations ___________________________________
Identifies potential perineal infection or suture breakdown __________________________
Identifies abnormal uterine size after delivery of placenta ___________________________
Identifies signs of uterine infection ____________________________________________
Identifies need for Family Planning counseling and refers as indicated _________________
Intervention Skills:
Appropriately assists with placental delivery ___________________________________
Demonstrates competency in repair of 1st and 2nd degree perineal lacerations ____________
Demonstrates plan for referral for extensive lacerations ______________________________
Takes appropriate action for postpartum hemorrhage (fundal massage, bimanual compression, expression of clots, activating emergency transport plan) __________________
__________________________________________________________________________
Demonstrates correct maternal positioning for treatment of shock and activates emergency transport plan ______________________________________________________________
Instructs the mother on postpartum conditions requiring medical evaluation (i.e. excessive bleeding, increasing pain, severe headaches or dizziness or inability to void) ____________
__________________________________________________________________________
Develops guidelines for emergency transport of mother or baby _______________________
Performs maternal exam at 12-24 hours __________________________________________
Performs Postpartum evaluation at 2-6 weeks ______________________________________
Identifies and takes appropriate action including consultation, referral or immediate transport when indicated and according to LMW Protocols in the following Postpartum situations:
Abnormal uterine involution __________________________________________________
Maternal fever _____________________________________________________________
Signs of uterine infection ____________________________________________________
Signs of breast infection _____________________________________________________
Hemorrhage ________________________________________________________________
Third and fourth degree lacerations _____________________________________________
Signs and symptoms of shock _________________________________________________
Activates emergency transport plan ____________________________________________
Newborn Care
Assessment Skills:
Recognizes signs and symptoms of respiratory distress, possible infection, seizures or jaundice in newborns ________________________________________________________________
Determines APGAR scores at one and five minutes ______________________________
Performs newborn assessment and evaluation to minimally include:
General appearance _______________________________________________________
Alertness _______________________________________________________________
Flexion of extremities and muscle tone ________________________________________
Sucking ________________________________________________________________
Palate: visualization and palpation ___________________________________________
Skin color, lesions, birthmarks, vernix, lanugo, and peeling _______________________
Measurements of length, head and chest circumference ___________________________
Weight _________________________________________________________________
Head: molding, fontanels, hematoma, caput, sutures ____________________________
Eyes: jaundice of whites, pupils, tracking, spacing ______________________________
Ears: positioning, responds to sound, appear patent _____________________________
Observe chest for symmetry ________________________________________________
Listen to and count heart rate and respirations _________________________________
Fingers and toes, normal structure and appearance, creases, prints __________________
Genitalia: normal appearance, testicle descent in males __________________________
Takes and records temperature ______________________________________________
Takes and records femoral pulse _____________________________________________
Assesses baby for jaundice _________________________________________________
Gestational age assessment and refers for less than 36 weeks gestation _______________
Performs newborn exam at 24-48 hours _______________________________________
Intervention Skills:
Assures that the baby's airway is clear, uses suction when indicated ________________
Promotes temperature regulation of newborn ___________________________________
Supports the establishment of emotional bonds among the baby, mother, and family __________________________________________________________________
Cuts, clamps, and cares for cord ______________________________________________
Collects cord blood when indicated _________________________________________
Documents administration of eye prophylaxis _________________________________
Performs or refers for the state required Newborn Screening test __________________
Completes Infant Hearing Loss Screening Form _________________________________
Educates mother/parents regarding cord care ___________________________________
Assists mother in establishing breastfeeding ___________________________________
Provides breastfeeding instruction information _________________________________
Instructs mother in normal and abnormal feeding patterns _________________________
Assists with breastfeeding positioning and milk expression _______________________
Identifies and takes appropriate action including consultation ,referral or immediate transport when indicated and according to LMW Protocols in the following Newborn situations:
Apgar score of less than 5 at one minute or 7 at 5 minutes ________________________
Jaundice at 0-24 hours ____________________________________________________
Meconium staining on the skin _____________________________________________
Abnormal heart rate ______________________________________________________
Birth weight less than 5 lbs or greater than 10 lbs _______________________________
Abnormal voiding or stool pattern ___________________________________________
Temperature over 100 or less than 97.7 ______________________________________
Abnormal cry ___________________________________________________________
Abnormal feeding patterns (vomiting, poor suck, lethargy) _______________________
Jaundice at 24-48 hours ____________________________________________________
Abnormal respiratory pattern (tachypnea or apnea) ______________________________
Signs of bleeding (i.e. petechia, bruises) _______________________________________
Rupture of membranes more than 24 hours before birth ___________________________
Education and Counseling Skills
Interaction, Support and Counseling Skills:
Understands and applies principles of informed choice ___________________________
Exhibits communication skills with women, peers, other health care providers _______________________________________________________________________
Functions as women's advocate during pregnancy, birth, and postpartum period __________________________________________________________________
Assesses maternal support system ___________________________________________
Consults with other health care professionals regarding problems ___________________
Basic Prenatal Education
Understands and can demonstrate knowledge of:
Emotional and physical changes during pregnancy and postpartum _________________
Signs of labor ___________________________________________________________
Fetal development ________________________________________________________
Preparing home and family members for birth, as is culturally relevant ______________
Preparation for breastfeeding _______________________________________________
Effects of smoking, drugs, and alcohol consumption _____________________________
Signs and symptoms that necessitate an immediate call to the midwife _______________
Preparation for the postpartum period _________________________________________
Exploration of fears, concerns, and psycho-social status with family, as appropriate ______________________________________________________________
Benefits of exercise _______________________________________________________
Sexuality education appropriate to pregnancy and postpartum ______________________
Information about required prenatal tests and lab work ____________________________
Circumcision information, as culturally appropriate ______________________________
Information regarding eye prophylaxis ________________________________________
Information regarding vitamin K _____________________________________________
Information regarding the LLM Newborn Care Kit provided by
ADH _____________________________________________________________
Information regarding the state required PKU for newborn screening ________________
Information regarding the Newborn Screening test _____________________________
Information regarding Screening for Infant Hearing Loss _________________________
Record Keeping and Forms
Demonstrates knowledge on completion of the Birth Certificate __________________
Demonstrate knowledge on completion of the Acknowledgement of Paternity
Affidavit _____________________________________________________________
Demonstrate knowledge of LLM Caseload and Birth Log and ADH submission requirements ________________________________________________________
Demonstrate knowledge of Incident Report and ADH submission requirements __________________________________________________________
Understand components of Emergency Back-up Plans ___________________________
Understand components of LLM Disclosure Form _______________________
Understand the LLM record keeping requirements _______________________
Understand the ADH record audit requirements _____________________________
Understand requirements for CLIA certification to perform laboratory tests _________
Documentation of Acquisition of Clinical Knowledge and Skills
By signing this form for the Documentation of Acquisition of Clinical Knowledge and Skills, I recognize that I have completed the orientation process for each of the skills listed. I have demonstrated knowledge, understanding and competency in the skills and procedures as verified thru demonstration or discussion by my supervising preceptor(s). I have demonstrated knowledge of and adherence to the Rules Governing the Practice of Licensed Lay Midwifery in Arkansas.
________________________________________ ________________________
Signature of Preceptor date
*Notarize here if you are an Apprentice applying for the Lay Midwife License
Notary seal for verification of preceptor's signature:
____________________________________________ ______________ _______________
Signature of Notary date signed date of expiration
Preceptor Verification Form for LLM Application
All apprentices must have a Preceptor-Apprentice agreement on file with the Department of Health for each preceptor under whom they train. Preceptors are responsible for the training of the apprentice and for the majority of the required clinical experiences. Other midwives licensed in the state of Arkansas may sign for some of the clinical experiences and skills. If any preceptor not licensed in the state of Arkansas is also a signer of any clinical experiences or skills, that preceptor must have a Preceptor-Apprentice Agreement on file with ADH. The following information must be filled out for any preceptor who signs any portion of the Application as documentation of clinical experiences or skills. Preceptors must be licensed in a state as a licensed midwife or CNM, or must have the credential Certified Professional Midwife (CPM). Number of births listed below means the number supervised for THIS APPRENTICE, not the total experience of the supervising midwife. Fill out all lines for documentation of clinical experiences, indicating zero if none supervised, before signing.
APPENDIX C: CEU CALCULATIONS
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 |
007.13.20 Ark. Code R. § 001