AR - State Statutes and Regs

REGULATIONS GOVERNING LAY MIDWIFE PRACTICE

(Pursuant to ACT 481 of 1987)

100. GENERAL PROVISIONS Page

101. PURPOSE AND AUTHORITY..................... 5.....................

102. ADMINISTRATION OF PROGRAM 5

200. DEFINITIONS

201. "LAY MIDWIFE".................... .........………………................ 6

202. "PHYSICIAN"................................……… …………............ 6

203. "CERTIFIED NURSE MIDWIFE"..……....... ........................ 6

204. "REFERRAL PHYSICIAN/CERTIFIED NURSE MIDWIFE"..... ............. 6

205. "EMERGENCY PLAN" ............................……………........... 6

206. "LAY MIDWIFE PROTOCOL".. .................………................. 6

207. "LICENSED LAY MIDWIFE” 7

208. "APPRENTICE LAY MIDWIFE"................... ................ 7

209. "DEPARTMENT............. 7

210. "PRACTICE UNDER THE DIRECTION OF A PHYSICIAN"................... 7

211. "PRESCRIPTION DRUGS OR DEVICES".................. 7

212. "REFERRAL" 7

213. "CONSULTATION"........ 7

214. "IMMEDIATE TRANSPORT".................. 7

215. "CLINICIAN"................... 7

300. LICENSING

301. TEMPORARY PERMITS.. 7

301.01 "Eligibility Requirements" 8

301.02 "Application Procedure". 8

301.03 "Revocation" 8

302. REGULAR LICENSES 9

302.01 Eligibility Requirements 9

302.02 Renewal... 10

302.03 Reciprocity 11

302.04 Revocation 12

302.05 Application Procedure. 12

303. APPRENTICE PERMIT.. 12

303.01 Eligibility... 12

303.02 Renewal... 13

400. SCOPE OF PRACTICE

401. REQUIREMENTS FOR LAY MIDWIFERY PRACTICE 13

402. PROTOCOL FOR REQUIRED ANTEPARTUM CARE.. 15

402.01 Frequency of Visits........ 15

402.02 Routine Services..... 16

402.03 Routine Antepartum Services.... 17

402.04 Rh Follow-up Protocol... 17

402.05 Pre-delivery Home Visit 17

403. PROTOCOL FOR REQUIRED INTRAPARTUM CARE 18

403.01 Initial Clinical Assessment 18

403.02 Management of Labor....... 18

404. PROTOCOL FOR REQUIRED POSTPARTUM CARE.. 18

404.01 Immediate Care......... 18

405. PROTOCOL FOR REQUIRED NEWBORN CARE...... 19

405.01 Immediate Care.......... 19

405.02 Feeding..... 20

405.03 Care of Eyes.. 20

405.04 Vitamin K. 20

405.05 Newborn Screening.. 21

405.06 Cord Care 21

406. PROTOCOLS FOR ANTEPARTUM CONDITIONS REQUIRING

PHYSICIAN INTERVENTION.......... 21

406.01 Initial Risk Assessment 22

406.02 Antepartum Monitoring 23

406.03 Ongoing Antepartum Monitoring. 24

406.04 Ongoing Antepartum Monitoring After Referral................. 24

406.05 Antepartum Conditions Requiring Immediate

Transfer of Care to a Physician... 25

407. PROTOCOLS FOR INTRAPARTUM CONDITIONS REQUIRING

PHYSICIAN INVERVENTION.......... 25

407.01 Referral or Transport.. 25

407.02 Physician Consultation 26

407.03 Immediate Transport.. 27

408. PROTOCOLS FOR POSTPARTUM CONDITIONS REQUIRING

PHYSICIAN INVERVENTION.......... 27

408.01 Immediate Transport.. 27

408.02 Physician Consultation 27

409. PROTOCOLS FOR NEWBORN CONDITIONS REQUIRING

PHYSICIAN INTERVENTION.......... 28

409.01 Immediate Transport.. 28

409.02 Physician Referral or Transport... 28

409.03 Physician Consultation 28

500. REFERRAL PHYSICIAN................. 29

600. EMERGENCY MEASURES................. 29

700. RECORDKEEPING AND REPORTING REQUIREMENTS.......... 29

800. DEPARTMENT RESPONSIBILITIES..... 30

801. GRANTING PERMITS & LICENSES 30

802. REGISTRATION LISTING 30

803. MONITORING OUTCOMES 31

900. CERTIFICATION ....... 31

100. GENERAL PROVISIONS

101. PURPOSE AND AUTHORITY

It was determined by the General Assembly that adequate maternal care is not readily available in some parts of the state resulting in undue hardships to poor expectant mothers. Act 838 of 1983 provided for the lawful practice of lay midwifery in counties having 32.5% or more of this population below the poverty level. Act 481 of 1987 supercedes Act 838 of 1983, and expands the Lay Midwife licensure statewide.

The following Rules and Regulations are promulgated pursuant to the authority conferred by A.C.A. 17-85-101 et.seq. and A.C.A. 20-7-109 et.seq.

Specifically, Act 481 directs the Arkansas State Board of Health to administer the provisions of Act 481 and authorizes and directs the Board to adopt regulations governing the qualifications for licensure of lay midwives and the practice of lay midwifery. The broad authority vested in the Board of Health (Act 96 of 1913) to regulate and to ultimately protect the health of the public is the same authority the Board will utilize in enforcing the regulations, determining sanctions, revoking licenses, etc.

102. ADMINISTRATION OF PROGRAM

The State Board of Health has delegated the authority to administer the program, including the regulating and licensing of lay midwives, to the Arkansas Department of Health, Division of Perinatal Health, 4815 W. Markham, Little Rock, Arkansas 72205-3867.

The Board of Health shall establish an advisory board to oversee the practice of lay midwives. The composition of the advisory board will be as follows:

3-Physicians (preferably 1 OB/GYN, 1 Pediatrician and

1-Family Practice Physician)

1-Certified Nurse Midwife

3-Licensed Lay Midwives

2-Public Members

The purpose of the Advisory Board shall be to advise the Department and Board of Health in matters pertaining to the regulation of midwifery practice.

The minimum required activities of the Advisory Board include:

1. meet at least annually and as needed at discretion of Advisory Board chairperson

2. serve as community liaison regarding midwifery practice, and

3. periodically review rules and regulations and propose changes as needed.

The Advisory Board members will be appointed by the Board of Health for terms of at least 3 years.

200. DEFINITIONS

As used in these regulations, the terms below will be defined as follows, except where the context clearly requires otherwise:

201. "LAY MIDWIFE": Any person other than a physician or certified nurse midwife who shall manage care during the pregnancy of any woman or of her newborn during the antepartum, intrapartum, or postpartum periods; or who shall advertise as a midwife by signs, printed cards or otherwise. This definition shall not be construed to include unplanned services provided under emergency, unplanned circumstances.

202. "PHYSICIAN": Any 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 these regulations, physician refers only to those physicians currently practicing obstetrics.

203. "CERTIFIED NURSE MIDWIFE": Any person who is certified by the American College of Nurse Midwifery and is also currently licensed by the Arkansas Nursing Board or the appropriate licensing authority of a bordering state to practice nurse midwifery.

204. "REFERRAL PHYSICIAN/CERTIFIED NURSE MIDWIFE": A physician/certified nurse midwife who has obstetrical privileges in a hospital within 50 miles of the delivery site, and who accepts referrals from the licensed lay midwife and consults in the management of the lay midwife's patients.

205. "EMERGENCY PLAN": The emergency plan is developed by the Lay Midwife for each patient, and outlines a plan for transport to the nearest hospital licensed to provide maternity services. This hospital must be located within 50 miles of the planned delivery site.

206. "LAY MIDWIFE PROTOCOL": Describes those procedures which may be performed by the Lay Midwife outside the presence of a physician, but under conditions where the physician can be reached by the Lay Midwife by communication facilities. Section 400 of these Regulations comprise the Lay Midwife Protocol.

207. "LICENSED LAY MIDWIFE": Any person who is granted a regular or temporary license by the Arkansas Department of Health to practice lay midwifery.

208. ”APPRENTICE LAY MIDWIFE": Any person who is granted a permit to obtain the practical experience required to apply for a regular license.

209. "DEPARTMENT": The Arkansas Department of Health, Perinatal Health Division.

210. "PRACTICE UNDER THE DIRECTION OF A PHYSICIAN": The licensed lay midwife may perform only those medical acts and procedures which have been specifically authorized in the lay midwife protocol. If actions/procedures deviating from the official protocol are desired, an agreement signed by the Referral Physician describing these deviations/exceptions must be approved by the Department. (See Section 600.)

211. "PRESCRIPTION DRUGS OR DEVICES": A drug or device limited by A.C.A. 20-64-503 to dispensing by or upon a medical practitioner's prescription because the drug is (a) habit-forming, (b) toxic or having a potential for harm, or (c) permitted for use only under the practitioner's supervision. This includes any drug or device whose label contains the statement: "Caution- federal law prohibits dispensing without prescription".

212. "REFERRAL": Pertains to the referral of a patient to a physician or clinician, for a visit for evaluation and determination of future care.

213. "CONSULTATION": Refers to a phone consultation by the lay midwife to a physician or certified nurse midwife to determine the status and future care of a patient. The physician or certified nurse midwife may require the patient to come into his office for evaluation.

214. "IMMEDIATE TRANSPORT": The patient should be taken to a medical facility by the most expedient method of transportation available, to obtain treatment/evaluation for an emergency condition.

215. "CLINICIAN"; Refers to a Physician or Nurse Practitioner employed or contracted by the Department of Health to work in maternity clinics.

300. LICENSING

301. A Temporary Permit can be issued by the Board of Health to lay midwives from other states applying for licensure in Arkansas. These permits allow the lay midwife to legally practice in Arkansas while completing the licensure process. The Lay Midwife Advisory Board will review the applications and credentials of these lay midwives and make their recommendations to the Department concerning each applicant.

Temporary Permits are valid from date of issuance for one year or until applicant passes licensing exam and receives regular licensure or until applicant receives notification of failure to pass examination. The Temporary Permit is not renewable.

301.01 Eligibility Requirements for Temporary Permit.

1. Basic Education

A copy of a high school diploma or equivalent is required.

2. Communicable Disease Protection

Applicant must provide documentation of a negative TB skin test, negative chest x-ray or must submit a health card (documentation of negative TB skin test) issued by the Arkansas Department of Health at local health units.

Applicant must provide date of rubella immunization or documentation of a positive rubella blood titer (greater than or equal to 1:10). Such documentation is required only with the first application for any midwife permit.

3. Basic Cardio-Pulmonary Resuscitation (CPR) Training

Applicant must be currently certified by the American Heart Association or American Red Cross to provide cardio-pulmonary resuscitation to adults and infants.

4. Practical Experience

The applicant must submit notarized evidence that the following practical experience requirements have been performed by the applicant under direct supervision:

Antepartum visits (at least 30 women) 75 visits

Management of Labor 30 patients

Delivery of newborn and placenta 30 patients

Newborn evaluation 30 patients

Postpartum evaluation (0-5 hours) 30 patients

Postpartum evaluation (24-72 hours) 30 patients

301.02 Application Procedure: Application materials and instructions are available from the Department's Division of Perinatal Health.

301.03 Revocation: Same as for Regular Licenses (See Section 302.04).

302. REGULAR LICENSES

Upon application and favorable review, a license is issued. The license is valid for two years.

302.01 Eligibility Requirements

The following requirements must be met before the Department will issue a lay midwife license.

1. Basic Education

A copy of a high school diploma or equivalent is required.

2. Communicable Disease

Applicant must provide documentation of a negative TB skin test, a negative chest x-ray or a health card (documentation of a negative TB skin test) issued by the Arkansas Department of Health at local health units.

Applicant must provide a date of rubella immunization or documentation of a positive rubella titer (greater than or equal to 1:10). Such documentation is required only with the first application for any midwife permit or license.

3. Cardio-pulmonary Resuscitation Training

Applicant must be certified by the American Heart Association or American Red Cross to perform adult and infant cardiopulmonary resuscitation (CPR). Certification shall be current at the time of application and be valid throughout the licensed period.

4. Practical Experience

The applicant must submit a notarized statement that the following minimal practical experience requirements have been performed under the supervision of a physician, certified nurse midwife, or licensed lay midwife. The name and a current postal address of the supervisor must be provided to allow possible verification by the Department.

Applicants for licensure must demonstrate competency in performing clinical skills during the antepartum, intra partum, post partum and the immediate newborn periods. Each applicant must successfully complete an evaluation of clinical skills. The "Clinical Evaluation of Apprentices" form must be completed by the preceptor and presented with the application for licensure.

This form should be submitted only after the applicant has a "pass" on each item except for certain emergencies that may not occur during a preceptorship.

When practical experience has been obtained outside of Arkansas, the Lay Midwife Advisory Board will review the preceptorship and make a recommendation to the Department concerning its adequacy.

Performs Under Direct Supervision:

Antepartum visits (at least 30 women) 75 visits

Management of labor 30 patients

Delivery of newborn and placenta 30 patients

Newborn evaluation 30 patients

Postpartum evaluations 0-5 hours

postpartum 30 patients

Postpartum evaluations 24-72 hours

postpartum 30 patients

5. Licensing Examination

After items 1 through 4 are satisfactorily completed, the applicant is eligible to sit for the licensing exam.

A passing score of 75 or higher on the licensing examination administered by the Department, is required for licensure.

If necessary to obtain a passing score, the examination may be taken up to three times. After the third failure to pass the exam, the lay midwife must repeat an apprenticeship before being allowed to re-test.

302.02 Renewal

The license must be renewed every 2 years and will be re-issued upon application and upon favorable review of required activity reports by the Department. This review will assure that:

1. Infant and adult CPR certification will not expire within the next three months.

2. The lay midwife acts in accordance with the lay midwife rules and regulations.

3. Any deviations from the lay midwife protocol must be renewed and signed by a referral physician prior to license renewal.

4. The midwife is not providing care for patients who have risk factors which preclude midwife care.

5. Documented negative TB skin test, negative chest x-ray or valid health card.

6. Twelve hours continuing education approved by Lay Midwife Advisory Board within past two years.

302.03 Reciprocity

All applicants for licensure in Arkansas must follow procedures for either a Temporary Permit and/or a Regular License. No licensure by endorsement or reciprocity is permitted.

302.04 Revocation

The Department may refuse to issue, may suspend or may revoke a permit for violation of State law or these Regulations including any of the following reasons:

1. Delinquency in submission of application and supporting documents for permit renewal of 30 days or more.

2. Dereliction of any duty imposed by law.

3. Falsifying information on the application.

4. Conviction of a felony.

5. Practicing while suffering from a contagious or infectious disease of public health importance.

6. Violation of any of the provisions of regulations contained herein.

7. Obtaining any fee by fraud or misrepresentation.

8. Knowingly employing, supervising, or permitting (directly or indirectly) any person who is not an apprentice or licensed lay midwife to perform any work covered by these regulations.

9. Using, causing, or promoting the use of any advertising matter, promotional literature, testimonial, or any other representation however disseminated or published, which is misleading or untruthful.

10. Representing that the service or device of a person licensed to practice medicine will be used or made available when that is not true, or using the words "doctor", or similar words, abbreviations or symbols implying involvement by the medical profession when such is not the case.

11. Permitting another person to use the license or permit.

12. Violation of the Prescription Drug or Devices Law, A.C.A. 20-64-503.

13. Gross Negligence.

14. Practicing while under the influence of any intoxicant or illegal drug.

Any lay midwife who is denied a license or whose license is suspended or revoked will be notified in writing by the Department. The lay midwife will be afforded opportunity of a hearing conducted pursuant to the Board's Administrative Procedures to appeal the Department's decision.

302.05 Application Procedure

Application materials and instructions are available from the Department.

303. APPRENTICE PERMIT

303.01 Eligibility

An apprentice permit authorizes the applicant to obtain under supervision, the practical experience required for licensure. The supervisor may be a licensed lay midwife, a certified nurse midwife, or a physician. The applicant must provide verification of apprentice-supervisor relationship(s). The initial permit, valid for two years, will be issued to persons who provide documentation of:

- A copy of a high school diploma or equivalent

- Documentation of negative TB skin test, negative chest x-ray or valid health card.

- Documented positive rubella titer (greater than or equal to 1:10) or rubella immunization.

- Current certification by the American Red Cross or the American Heart Association to provide cardio-pulmonary resuscitation to adults and infants.

303.02 Apprentice Permit Renewal

The apprentice permit must be renewed every two years. To renew the permit, the apprentice shall submit evidence of:

- Progress made toward licensure that year, i.e. number of AP visits conducted, labor managements and deliveries, newborn evaluations and post-partum exams conducted under supervision.

- Verification of apprentice-supervisor relationship

- Current adult and infant CPR

- Negative TB skin test, negative chest x-ray, or valid health card

400. SCOPE OF PRACTICE AND PROTOCOLS

The lay midwife may provide complete obstetrical care to women who are determined to be at low risk for the development of medical or obstetrical complications of pregnancy or childbirth.

401. REQUIREMENTS FOR LAY MIDWIFERY PRACTICE

The following requirements must be met before a lay midwife can legally accept a patient.

1. Licensing - The lay midwife must possess a current Arkansas Lay Midwife License, Temporary Permit or Apprentice Permit. See Section 300.

2. Protocol - The lay midwife must adhere to the lay midwife protocol as specified in the conditions of practice as outlined in Sections 402-408 of these regulations.

3. Consent - At the time a request is made for care, the lay midwife must discuss certain information concerning lay midwife assisted home deliveries with the patient. This discussion must be documented by use of a disclosure form by the second visit. samples of acceptable disclosure forms are available from the Department. It must be signed by the patient and filed in her chart.

The disclosure form will include, but is not limited to the following:

a. The midwife has a protocol specified by the Department that she must follow regarding care for potentially serious medical conditions.

b. When a patient chooses midwifery care, she must accept the requirements laid out in the Regulations or seek another source of care. Patients may be discharged from care.

c. Risks and benefits of home birth.

d. Risks and benefits of hospital delivery.

e. Medical conditions which preclude home birth.

f. Medical conditions which may occur during labor or birth which would require physician consultation or transport to a hospital and referral to a physician.

g. Responsibilities of the midwife for prenatal care, attendance at the delivery, and postpartum care, and additional information regarding birth attendance by apprentices and/or possible birth attendance by another licensed midwife if the midwife is unavailable at the time of labor.

h. Required medical evaluation, laboratory testing, evaluation by physician or public health maternity clinic, required visits with midwife, obtaining of birth supplies and infant supplies.

i. Should an emergency transport become necessary there must be arrangements by the patient, in cooperation with the midwife, for transportation to the nearest hospital licensed to provide maternity services. The hospital must be located within 50 miles of the planned delivery site.

j. The lay midwife does, or does not have a referral physician with whom she consults concerning the patient's pregnancy.

k. The lay midwife is or is not covered by a malpractice insurance policy.

l. If the lay midwife relies on the hospital emergency room for backup coverage, the patient must be informed that the physician on duty may not be trained in obstetrics.

4. Emergency Plan - An individual emergency plan must be established by the lay midwife and client for each midwife patient. A copy of this plan, signed by the midwife, must be submitted to the Department for review within 30 days of acceptance of the patient by the lay midwife, and no later than the 34th week. The plan must include provisions for transport to the nearest hospital licensed to provide maternity services. This hospital must be located within 50 miles of the planned delivery site.

402. PROTOCOL FOR REQUIRED ANTEPARTUM CARE

The licensed lay midwife must provide antepartum care in cooperation with either a physician or the Department, through those local health units where maternity services are provided.

Joint care by a physician and licensed lay midwife. Each patient must be evaluated by a physician practicing obstetrics at or near the time that care is initiated and again at or near the 36th week. The purpose of these visits is to assure that the patient has no potentially serious medical conditions and has no medical contraindications for home birth by a licensed lay midwife. All required antepartum services must be done by the licensed lay midwife, the physician or a local health unit which provides prenatal care.

Joint care by the Department and the licensed lay midwife. In many local health units, routine antepartum services are provided by Department staff and contract physicians in maternity clinics. The Department, through these clinics, will provide care for women planning delivery by licensed lay midwives. Women choosing this option for antepartum care will receive all required services at the local health unit. The local health unit will provide a copy of the patient's record to the patient when requested. The licensed lay midwife may continue joint prenatal care.

Risk Assessment

At the time of the initial and 36th week visits, the physician or Department clinician, must complete a risk assessment of the patient (preferably utilizing a Hollister Record). A copy of the complete risk assessment must be forwarded to the Department with the Birth Report.

402.01 Frequency of Visits

Routine antepartum visits must be made at least every four (4) weeks during the first 28 weeks of gestation, every two (2) weeks from the 28th to 36th weeks, and weekly thereafter until delivery.

402.02 Routine Services

The lay midwife must ensure each patient receives from a physician or Department clinician, the following services at or near the initiation of care:

1. Medical, obstetrical and nutritional history. The history must be comprehensive enough to identify potentially dangerous conditions that may preclude midwife care, or that require physician consultation. Hollister forms are available at no cost from the Division of Perinatal Health.

2. A physical examination comprehensive enough to identify potentially dangerous conditions that may preclude midwife care.

3. Blood sample for blood type and Rh determination and coombs titer if found to be Rh negative.

4. Hematocrit or hemoglobin.

5. Blood pressure, height and weight.

6. Pap smear.

7. VDRL - initially and repeat at 32-36 weeks.

8. Gonorrhea culture - recommend initially and require at 34-36 weeks.

9. Urine testing for glucose and protein.

10. Blood Sugar - initially and at 28 weeks gestation. Abnormal or borderline random or fasting blood sugars should be followed by a 1 hour glucose challenge test (GCT). If GCT is abnormal or borderline, follow with a 3 hour glucose tolerance test.

11. Estimation of gestational age by menstrual history, uterine size (measured by fundal height or by bimanual examination).

12. Hepatitis B test at initial visit.

13. Counsel patient concerning maternal serum alpha-fetoprotein testing, if before 20 weeks gestation.

402.03 Routine Antepartum Care

At each visit the licensed lay midwife will perform and record the following services:

1. Weight

2. Blood pressure

3. Fundal height

4. Determination of fetal position

5. Urine testing for glucose and protein

6. Fetal heart tones

7. Medical and nutritional history since last visit

8. Check for edema of legs, face and/or hands

9. Hematocrit or hemoglobin must be repeated at or near 32 weeks.

The lay midwife will refer patient immediately to a physician if any conditions precluding lay midwife care are noted.

402.04 Rh Follow-up Protocol. All women with negative Rh factor must be treated as follows:

1. Coombs test as soon as negative Rh is reported.

2. Repeat Coombs test at 28 weeks. If it is negative, advise patient that an immunoglobulin injection is recommended. If the patient is enrolled in a local health unit maternity clinic, immunoglobulin can be obtained at the clinic. If Coombs is positive, refer her to a physician immediately.

3. Obtain a cord blood sample for Coombs test at the time of delivery and send to a physician or a private laboratory. If the infant is Rh positive then the patient is to receive immunoglobulin again. This should be obtained within 72 hours of delivery from a private physician, or from the local health unit if the mother was enrolled in a health department maternity clinic. If the infant is Rh negative then nothing further need be done.

402.05 Pre-Delivery Home Visit

The licensed lay midwife is required to make, prior to delivery, at least one visit to the home where the birth will take place.

The midwife should inform the patient of the equipment and supplies which must be available at the time of delivery. She should instruct the patient and family of requirements for an aseptic delivery site.

403. PROTOCOL FOR REQUIRED INTRAPARTUM CARE

403.01 Initial Clinical Assessment

The licensed midwife must assess and record:

1. Physical conditions including temperature, pulse, respiration, blood pressure and urinalysis for glucose and protein.

2. Labor status (assessment of contractions, status of membranes, cervical dilitation and effacement).

3. Fetal position, station, size and presenting part, heart rate.

4. Condition of cervix, vaginal walls and pelvic floor.

403.02 Management of Labor

1. First stage. The licensed lay midwife must assess and record:

- Fetal heart rate and rhythm immediately following a contraction, at least every hour until 5 centimeters, then every 15 minutes until cervix is completely dilated, and after rupture of membranes.

- Duration, interval and intensity of uterine contraction and maternal blood pressure at least every 2 hours.

2. Second stage and third stage. The licensed lay midwife's duties include but are not limited to: ascertaining that labor is progressing; assessing and monitoring maternal and fetal well being; and delivering the newborn and placenta. All services should be provided in a supportive manner and in accordance with these regulations.

404. PROTOCOL FOR REQUIRED POSTPARTUM CARE

404.01 Immediate Care

The licensed midwife must remain in attendance for at least two (2) hours after the delivery and shall assess and record the following:

1. Immediately following the delivery of the placenta, the midwife shall determine that the uterus is firmly contracted without excessive bleeding, ascertain that the placenta has been delivered completely, and determine the number of cord vessels.

2. Midwives may repair lst and 2nd degree perineal lacerations.

3. During the two hour postpartum period, the midwife shall assess as needed: uterine firmness, vaginal bleeding, vaginal swelling and/or tearing, maternal blood pressure and pulse. The midwife shall remain in attendance until these signs are well within normal limits or until a physician is in attendance if they are found to be abnormal.

4. The midwife shall leave instructions for follow-up care that include signs and symptoms of conditions that require medical evaluation such as: excessive bleeding, increasing pain, severe headaches or dizziness and inability to void. Postpartum follow-up should include family planning, and the mother is given an appointment for postpartum evaluation from 2 to 6 weeks following delivery.

405. PROTOCOL FOR REQUIRED NEWBORN CARE

The licensed lay midwife shall be responsible for care immediately following the delivery only. Subsequent infant care should be managed by a physician, or a physician/registered nurse team. This does not preclude the midwife from providing counseling regarding routine newborn care and breastfeeding. If any abnormality is suspected, the newborn must be sent for medical evaluation as soon as possible.

405.01 Immediate Care

1. Suction nose and mouth well, as soon as possible, preferably prior to delivery of shoulders.

2. Immediately after delivering entire body, suction mouth, then nose again (suction toward cheeks, do not go down throat).

3. Clamp cord, then cut.

4. Dry infant in a warm towel, with special attention to the head.

5. Wrap infant in a warm blanket and place on side or next to mother.

6. Determine Apgar scores at one and five minutes after delivery.

7. Observe and Record:

a. Skin color and tone

b. Heart rate (120-180/minute)

c. Respiration rate and character (40-60/minute by one hour of age)

d. Estimated gestational age and plot on chart. Indicate average, small or large for gestational age.

e. Temperature (rectal initially, then axillary thereafter).

f. Weight, length, head circumference

8. Obtain cord blood for Coombs and Rh if mother is Rh negative.

405.02 Feeding: Infant should be placed at the breast as soon as stable after delivery. The bottle fed infant should be offered commercially prepared oral pediatric electrolyte solution within the first two to three hours after birth. If there are no problems with these feedings then progress to the chosen formula, every three to four hours. Instruct the mother to not let the infant go longer than six hours between feedings during the first 48 hours of life.

405.03 Care of Eyes: The midwife must see that either Erythromycin 0.5% Opthalmic or Tetracyline 1.0% Opthalmic in individual dose packaging for eye prophylaxis is available at the time of delivery. A suitable medication should be obtained by the mother before week 36 of the pregnancy either by prescription from a private physician or by prior arrangement with a local health unit. If the mother chooses to obtain medication from the local health unit, she must notify the local health unit in sufficient time to allow them one month to obtain the drug. The local health unit will not routinely have the medication on hand.

The midwife must assure that the infant receives the drug within 1 hour of birth. If the infant does not receive the drug for any reason, the midwife must document the incident on the birth report.

405.04 Vitamin K: The lay midwife must advise parents that the infant should receive Vitamin K as soon as possible after birth. The medication should be obtained by prescription before week 36 of pregnancy from a private physician or by prior arrangements with a local health unit. If the mother chooses to obtain free medication from the local health unit, she must notify the unit in sufficient time to allow them one month to obtain the drug. The local health unit will not routinely have the drug on hand. The lay midwife must assure that the infant receives Vitamin K within 2 hours of birth. If Vitamin K is not administered, the lay midwife must document the incident on the birth report.

405.05 Newborn Screening: All infants must have a capillary blood sample (from heel prick) for the newborn screening mandated by law and specified on the Department collection form. The lay midwife is responsible for advising the parents of this law and the procedure for conducting newborn screening and documenting that a blood sample is obtained after 24 hours and no later than 7 days after birth. The sample is submitted to the Department no later than 72 hours after collection. Required forms are available from local health department offices. If the blood sample is not obtained for any reason, the midwife must document the incident on the birth report.

405.06 Cord Care: The umbilical cord stump must be swabbed with a providone iodine antiseptic. The midwife must instruct the mother in routine cord care.

406. PROTOCOLS FOR ANTEPARTUM CONDITIONS REQUIRING PHYSICIAN INTERVENTION

Each patient must have a risk assessment documented by a physician or ADH clinician at the initial visit and again around the 36th week.

The following sections detail the actions which should be followed by the lay midwife if the patient exhibits/develops the specified conditions. Those conditions requiring immediate transport are specified. In regards to all other conditions requiring physician referral, the lay midwife must refer those women and newborns for medical care as soon as possible.

In the event of an immediate transport, the lay Midwife must notify the emergency room of the designated hospital of their imminent arrival and provide a copy of the medical record to the receiving physician.

The lay midwife is expected to use his/her judgment regarding the need for referral and/or emergency transport when problems arise that are not specified in this protocol. Such care must be documented in the birth report.

406.01 Initial Risk Assessment:

The risk assessment documents that the client does not have one of the following conditions precluding midwife care.

1. Heart disease

2. Epilepsy

3. Diabetes, Type I, Type II or gestational diabetes

4. Neurological disease

5. Sickle cell disease and other hemoglobinopathies

6. Cancer

7. Psychiatric disorder

8. Active tuberculosis

9. Chronic pulmonary disease

10. Thrombophlebitis

11. Endocrinopathy

12. Collagen vascular disease or other severe collagen disease

13. Renal disease

14. Hypertension

15. Known drug or alcohol addiction

16. Significant congenital or chromosomal anomalies

17. Seven or more previous deliveries

18. Previous postpartum hemorrhage without intervening normal delivery. Previous hemorrhage caused by placenta previa or placenta abruptio is not considered a hemorrhage for this purpose.

19. Rh negative isoimmunization-positive coombs

20. Malformed pelvis (fractures, rickets, etc.)

21. Confirmed multiple gestation

22. Previous operative procedure on the uterus including cesarean sections, but excluding dilatation and curettage (D&C) or biopsy)

23. Placenta previa (diagnosed by ultrasound)

24. Confirmed fetal death

25. Lack of documented prenatal care prior to 34 weeks.

26. Previous preterm infant without intervening term delivery.

27. Access to telephone or 2-way radio is more than five minutes away.

406.02 Antepartum Monitoring

The physician or Department clinician must document that the mother is free from the following conditions, or that the condition does not pose a risk in this pregnancy and may be managed by the midwife. The physician may choose to co-manage the client with the midwife until time for the delivery.

1. Structural abnormalities of the reproductive tract

2. History of stillbirths

3. Two or more spontaneous or induced abortions

4. Sexually transmitted disease

5. Age 40 or greater

6. Treated infertility

7. Previous infants 4500 grams or greater (10 lbs)

8. Previous small for gestational age infant

9. Suspected inadequate pelvis

10. Suspected fetal death

11. Positive Coombs

12. Postterm pregnancy greater than 41 weeks. Biweekly nonstress testing must begin by day one of 42 weeks by LMP.

13. Previous premature with intervening term delivery.

14. Previous obstetrical hemorrhage with intervening normal delivery.

15. Decreased fetal movements of less than 10 within a three hour period.

406.03 Ongoing Antepartum Monitoring

The following conditions will be monitored by the midwife. If the condition persists, a physician must be consulted by phone or in person. The midwife is expected to act in accordance with the physician's recommendation and record them in the patient's record.

1. Inappropriate weight gain (as defined below).

- Less than 14 pounds by 30 weeks gestation

- Less than 1/2 pound per week during third trimester

- More than 8 pounds weight gain in 2 weeks.

2. Abnormal routine urinalysis, glucose or protein 1+ or greater

3. Vaginal itching, burning, abnormal discharge, bleeding

4. Stinging, burning, painful, or blood-tinged urine

5. Hematocrit less than 30 or hemoglobin less than 10

6. Oral temperature greater than 100.5 degrees

7. Active herpetic lesions

8. Hyperemesis (persistent vomiting) with any weight loss

9. Persistent urinary tract infections refractory to treatment

10. Decrease or cessation of fetal movement or kick counts below 8 per hour

11. Rupture of membranes without onset of labor within 12 hours.

406.04 Ongoing Antepartum Monitoring after Referral

The following conditions can be monitored by the midwife after examination and evaluation by a physician.

1. Cervical effacement or dilation prior to 36 weeks

2. Polyhydramnios or oligohydramnios

3. Suspected incompetent cervix

4. Blood pressure greater than 140/90 or increase greater than 30 mm systolic or 15 mm diastolic

5. Edema of face and hands that is persistent or occurs with elevated blood pressure or protein.

6. Size/date discrepancy of 3 weeks or more

7. Prior fetal or neonatal death

8. Vaginal bleeding which is heavier than that associated with normal menstrual period

9. Abnormal pap smear

10. Structural abnormalities of reproductive tract

11. Positive hepatitis B test

12. Abnormal maternal serum alpha feta-protein

406.05 Antepartum Conditions Requiring IMMEDIATE TRANSFER OF CARE to a Physician.

1. Third trimester bleeding heavier than period

2. Rupture of membranes without onset of labor within 18 hours

3. Severe preeclampsia

4. Severe headaches, epigastric pain, or visual disturbances

5. Fetal heart rate below 120 or above 160 or irregular while lying on left side

6. Suspected or confirmed fetal death

7. Spontaneous rupture of membranes prior to 36 weeks

407. PROTOCOLS FOR INTRAPARTUM CONDITIONS REQUIRING PHYSICIAN INTERVENTION

407.01 Referral or Transport

The following conditions require examination by a physician or transport to a hospital

1. Vaginal bleeding heavier than a period

2. Suspected or confirmed fetal death

407.02 Physician Consultation

The following intrapartum conditions require a phone consultation with the physician. The midwife must document the physician's instructions and act accordingly.

1. Prolonged labor in a primigravida defined as:

- More than 20 hours from onset of contractions to 4 cm.

- No more than 8 hours from 4cm to 9cm. Mean duration of active phase is about 5 hours.

- More than 3 hours from 9cm to complete dilitation. (average deceleration phase 54 min)

- Cessation of progressive descent for one hour after descent process has been documented.

- more than 2 hours pushing

2. Prolonged labor in a multipara defined as:

- More than 14 hours from onset of contractions to 4cm.

- No more than 4 hours from 4cm to 9cm. Mean duration of the active phase is 2.2 hours.

- More than 1 hour from 9cm to complete dilitation (average deceleration phase 14 min).

- Cessation of progressive descent for one hour after the descent process has been documented.

- More than one hour pushing.

3. Blood pressure greater than 140/90, or increase greater than 30 systolic or 15 diastolic

4. Abnormal routine urinalysis:

glucose 1+ or greater, and/or

protein 1+ or greater with associated symptoms

of preemclampsia or urinary tract infection

5. Hematocrit less than 30% or hemoglobin less than 10 gm.

407.03 Immediate Transport

The following conditions require immediate transport to the designated emergency hospital.

1. Persistent or recurrent FHT below 100 or above 160 when lying on left side

2. 1000 cc or more (4 cups) blood loss with or without delivery of placenta

3. Active vaginal, cervical or vulvar herpetic lesions at onset of labor

4. Presentation other than vertex at onset of labor or when lay midwife arrives at delivery

5. Retained placental fragments or partially separated placenta

6. Active labor before 36 weeks gestation

7. No delivery of placenta within one hour. If there is bleeding and the fundus fails to contract, then transport immediately, do not wait one hour.

408. PROTOCOLS FOR POSTPARTUM CONDITIONS REQUIRING PHYSICIAN INTERVENTION

408.01 Immediate Transport

The following conditions require immediate transport to a hospital.

1. Bleeding in amounts greater than normal lochia

2. Third or fourth degree lacerations

3. Blood pressure below 100/50 if pulse exceeds 100; pallor, cold clammy skin, weak pulse

408.02 Physician Consultation

These conditions require physician consultation, and if requested, referral or transport to a hospital.

1. Uterine size to 16-20 weeks after delivery of placenta

2. First or second degree lacerations not repaired by midwife.

3. Maternal temperature greater than 100.6 degrees

4. Foul smelling lochia

409. PROTOCOLS FOR NEWBORN CONDITIONS REQUIRING PHYSICIAN INTERVENTION

409.01 Immediate Transport

These conditions require immediate transport to a hospital

1. Grunting respirations or retractions of chest lasting longer than one hour

2. Cyanosis

3. Seizures (unusual eye movements, tongue thrusting, jerking that cannot be stopped by holding extremity)

4. fever greater than or equal to 101 degree F.

409.02 Referral or Transport

The following conditions require examination by a physician or transport to a hospital

1. Jaundice noted 0-24 hours after birth

2. Mother's membranes ruptured 24 hours or more before delivery.

409.03 Physician Consultation

These conditions require physician consultation, and if requested by the physician, referral or transport to a hospital.

1. APGAR score of less than 5 at one minute and/or 7 at five minutes

2. Obvious significant abnormalities

3. Skin color that is markedly pale, blue, or gray

4. Jaundice within 24-48 hours of birth

5. Meconium staining on skin

6. No urination during first 12 hours after birth

7. Lethargy or weak sucking reflex

8. Heart rate greater 180 or less than 90 at rest

9. If infant is small for gestational age (less than 5 1/2 lbs.) or large for gestational age (greater than 10 lbs).

10. Infant temperature greater than 100 degrees

11. Gestational age less than 36 weeks

12. Poor cry

13. No stool after 48 hours

14. Vomiting (not spitting up) after feedings

15. Jitteriness

16. Vomiting blood

17. Apnea lasting longer than 10 seconds

18. Inability to keep infant warm

19. Signs of bleeding (petechia, bruises)

20. Lethargy

21. Tachypnea of greater than 60 breaths per minute after 4 hours of life.

500. REFERRAL PHYSICIAN

Each lay midwife is encouraged to develop a close working relationship with one or more specific physician in obstetrical practice who agree to serve as a Referral Physician for the lay midwife. This relationship is optional. The duty of a Referral Physician is to provide support to the licensed lay midwife when potentially serious conditions, as listed in sections 406 - 409 occur.

The Referral Physician-Lay Midwife relationship can be terminated by either party at any time.

600. EMERGENCY MEASURES

The licensed lay midwife must consult a licensed physician whenever there are significant deviations from normal in either the mother or the infant, and must act in accordance with the instructions of the physician. In those situations requiring transport to a hospital, the lay midwife must notify the emergency room of the designated hospital of an imminent transport and provide a copy of the medical record to the receiving physician.

The lay midwife is expected to use his/her judgment regarding the need for referral and/or emergency transport when problems arise that are not specified in the protocol. Such care must be documented in the birth report.

No lay midwife may assist labor by any forcible or mechanical means; attempt to remove adherent placenta; administer, prescribe, advise or employ any prescription drug or device; or attempt the treatment of a precluded condition, except in an emergency when the attendance of a physician cannot be speedily secured.

Any authorized or unauthorized emergency measures must be reported to the Department on the Birth Report. In the case of actions/procedures authorized by a physician in the case of a specific emergency, the lay midwife will document these orders with an order signed by the physician and submitted to the Department within 14 days.

700. RECORDKEEPING AND REPORTING REQUIREMENTS

Midwives must submit birth reports to the Department following each birth, no later than 30 days after the birth.

Midwives must submit reports on any woman in labor transported prior to delivery and any woman receiving prenatal care from the midwife for longer than one month of the gestational period regardless of whether or not the lay midwife attended the birth. The Birth Report will be used to document this care.

Midwives supervising an apprentice should record the name of the apprentice on the Birth Report when the apprentice provided care.

Complications resulting in the death of a mother, infant or fetus, within 24 hours of delivery, must be reported to the Department within 2 working days.

The lay midwife is responsible for ensuring that all required services are documented on patient records maintained by the midwife. The records will remain confidential. They are subject to periodic review by Department staff.

The midwife is responsible for completing and submitting birth certificates according to instructions of the Department's Division of Vital Statistics.

800. DEPARTMENT RESPONSIBILITIES

801. GRANTING PERMITS AND LICENSES

Staff of the Perinatal Health Division shall review applications for licensure and issue licenses or permits.

802. REGISTRATION LISTING

The Department shall maintain a list of all lay midwives and apprentice midwives holding permits in the State of Arkansas.

803. MONITORING OUTCOMES

The Department shall monitor perinatal outcomes of home births with lay midwife attendance and will publish these statistics annually.

The Department shall also review birth reports from licensed lay midwives to assure that such midwives are practicing within regulatory guidelines and standards of care. Investigations will be conducted by the Department on complaints or deviations from the Regulations.

804. ADMINISTRATION OF TESTS

The Department shall oversee the development and administration of a licensing examination.

900. CERTIFICATION

This will certify that the Regulations Governing Lay Midwife Practice was prepared pursuant to A.C.A. 20-7-109 et. seq. and A.C.A. 17-85-101 st.seq. A public hearing was held on the twenty-first day of January 1992.

This will also certify that the foregoing Rules and Regulations Governing Lay Midwife Practice in Arkansas were adopted by the Arkansas Board of Health at a regular session of same held in Little Rock, Arkansas on the day of , 1992.

Dated at Little Rock, Arkansas this day of , 1992.

Director

Arkansas Department of Health

The foregoing Regulations Governing Lay Midwife Practice, a copy of which has been filed in my office, is hereby in compliance with the Administrative Act, on the day of , 1992.

Governor

State of Arkansas

MEMORANDUM

TO: Board of Health Members

FROM: Donnie Smith, Administrative Director

Maternal & Child Health

SUBJ: Lay Midwife Regulations

DATE: April 6, 1992

Enclosed is a copy of the revised Regulations Governing the Practice of Lay Midwifery. In compliance with the Administrative Procedures Act, the Department has conducted a public hearing and submitted the proposed changes to Legislative review. Comments from each were basically favorable. A copy of the proposed changes were detailed in a mailing to Board members last fall.

The Department is asking for approval by the Board of Health, to complete the Administrative process.