17 CAR pt. 47, Appendix A
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)
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
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.
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.
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.
| 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 |
| 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.
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
Version March 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 Midwives (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:
LLM Informed Refusal Form Version 3.8.2017 Page 2 of 3
☐ I have had an opportunity to review with my LLM the materials from the following ADH-approved sources:
☐ 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.
Client Signature: ____ Date: _
LLM Signature:
Witness Signature:
LLM Informed Refusal Form Version 3.8.2017 Page 3 of 3
LLM INITIAL LICENSE AND REACTIVATION OF LICENSE APPLICATION
| Last Name | First | Middle | Social Security Number | ||
|---|---|---|---|---|---|
| Date | |||||
| Street | City | State | Zip | ||
| Mailing Address, if different | |||||
| Home Phone ( ) | Business Phone ( ) | Other Phone (cellular, pager, etc.) ( ) | |||
| Date of Birth | Have you attended school, been licensed, or certified under a different name? ☐ Yes If yes, what name(s)______ ☐ No | ||||
| Did you graduate High School? ☐ Yes ☐ No | |||||
| If No, do you have a GED or High School Equivalency? ☐ Yes ☐ No | |||||
| From Where? | Date Obtained: | ||||
| Highest Grade Completed | Date Completed | Name of High School Zip | Address | State | |
| CPM Certificate # | Expiration Date | MBC Certificate # | |||
| CM (AMCB) Certificate # | Expiration Date | ||||
| CNM (AMCB) Certificate # | Expiration Date | CNM License # | Expiration Date | ||
| College or Vocational Training Name and Address of School | Dates Attended | Total Credit/ Clock Hours | Date of Diploma Or Certificate | ||
| From To | |||||
| From To | |||||
| From To |
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: _____ | |||
| Has your application for any professional license, certificate, registration been denied by any state licensing board or federal authority? ☐ Yes ☐ No If yes, specify _____ |
ATTACH RECENT PHOTOGRAPH HERE
Passport style taken within 60 days prior to submission of application
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
LLM INITIAL LICENSE AND REACTIVATION OF LICENSE APPLICATION
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
LLM LICENSE RENEWAL APPLICATION
| Last Name | First | Middle | Date of Birth | Date |
|---|---|---|---|---|
| It is your responsibility to notify us of any change in name or address | Midwife License Number | Social Security Number | ||
| Address (include Street, City, State, Zip) | Home Phone ( ) | |||
| Business Phone ( ) | ||||
| Mailing Address, if different from above | Other Phone (pager, etc.) ( ) | |||
| Email Address: | ||||
| CPM License # | Expiration Date | Midwifery Bridge Certificate # | ||
| CM Certificate # | Expiration Date | |||
| CNM Certificate # | Expiration Date | CNM License # | Expiration Date | |
| Current Midwifery Licenses other than Arkansas (Verification of licensure may be requested) | State | License Number | Expiration Date | |
| Current Health Related Licenses | State | License Number | Expiration Date | |
| Have you ever had a license revoked in any health-related field since last application? ☐ Yes ☐ No If yes, specify ___ ___ | Have you ever been convicted of a felony since last application? ☐ Yes ☐ No If yes, specify ______ | |||
| Has your application for any professional license, certificate, registration been denied by any state licensing board or federal authority? ☐ Yes ☐ No If yes, specify ______ | ||||
| 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 ___ |
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
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 (10^{\text{th}}) 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:
C 2/17/2017
M 2/17/2017
INSTRUCTIONS FOR COMPLETING LLM REQUIRED REPORTS
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
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
LLM CASELOAD AND BIRTH LOG
Midwife Name __ Apprentice(s), Back-up LLM Name(s) __
| FOR ADH USE ONLY | |
|---|---|
| Date Received | |
| By Mail | By Fax |
| # of Caseload Pages | |
| # of IR Pages |
Year ___ Report Dates ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
| Client Name | Estimated Due Date | Disclosure Form Signed | Left LLM Care for Non-Medical Reason | Lost Contact | Incident Report Required | Incident Report | Home Delivery | Hospital Delivery | Apprentice/s or other LLM Providing Care @ Birth | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Transfer Of Care Due to Medical Reason | Consult (C) Or Referral (R) | Consult (C) Or Referral (R) | Consult (C) Or Referral (R) | Consult (C) Or Referral (R) | Transport of Mother (M) Newborn (N) Both (B) | Hospitalization of Mother (M) Or Newborn (N) Within 30 days of Delivery | Informed Refusal Signed | |||||||||
| Date | Date | Date | Date | Date | Date | Date | Date | Date | Date | Date | Date | Date | Date | Date | Initials | |
FOR ADH USE ONLY
DATE RECEIVED
BY FAX BY MAIL
NO. CASELOAD PAGES
NO. INCIDENT REPORTS
LLM Name _ Monthly Totals for Year _
Enter the total number of events for each category for each month of the year. Enter 0 (zero) when there are no events in the month reporting. Attach this report form as a cover sheet to the Caseload and Birth Log and all related Incident Reports for the reporting month.
| MONTH | NEW CLIENTS | LEFT CARE Non-Medical Reason | LOST CONTACT | TRANSFER CARE for Medical Reason | NUMBER OF CONSULTS | NUMBER OF REFERRALS | TRANSPORTS Mother(M) Newborn(N) Both(B) | Hospitalized within 30 days of Delivery Mother(M) Newborn(N) | Number of Home Births | Number of Hospital Delivery | Number of Incident Reports |
|---|---|---|---|---|---|---|---|---|---|---|---|
| JANUARY | |||||||||||
| FEBRUARY | |||||||||||
| MARCH | |||||||||||
| APRIL | |||||||||||
| MAY | |||||||||||
| JUNE | |||||||||||
| JULY | |||||||||||
| AUGUST | |||||||||||
| SEPTEMBER | |||||||||||
| OCTOBER | |||||||||||
| NOVEMBER | |||||||||||
| DECEMBER |
| FOR ADH USE ONLY | |||
|---|---|---|---|
| Date Received | |||
| By Mail | By Fax | ||
| # of Report Pages |
LLM Name: ____ Apprentice Name: ___ Date of Incident: ____ Date of Report: ___ Client Name: ____ EDD: ____ Delivery/Birth Date: _______ LLM Action: Informed Refusal ☐ Consult ☐ Referral ☐ Transfer ☐ Transport ☐ Third Risk Assessment (Post Dates) ☐ Authorized Emergency Measures ☐ Un-Authorized Emergency Measures ☐ Other Incident: Hospitalization of Mother/Newborn within 30 Days of Delivery ☐ Unattended Home Birth ☐ (Must report within 5 business days) Maternal/Newborn Death within 48 hours Delivery ☐ OR Within 2-30 days of Birth ☐ (Must report within 2 business days) (Must report within 5 business days)
Describe the Condition identified by the LLM and the Related History that led to the LLM's Action:
CPM/MBC Informed Refusal Form
Date Signed: ____ List the Refused Requirement(s): ____
Consultants Name (Physician, CNM, or ADH Clinician): _______
Hospital ____ Address ____
Phone Number _______
Findings of Consultant:
Recommendations and Actions of Consultant of the Consultant (for authorized emergency measures attach signed MD/CNM orders):
LLM Plan of Care:
Outcome of Care. With delivery of the newborn, include the Method of Birth, Birth Weight, Apgars, any Complications:
In accordance with the Rules Governing the Practice of Licensed Lay Midwifery in Arkansas the Incident Report must be mailed to ADH by the 10th of the month following the event; earlier reporting is required for certain events as noted in this form. Enclose the report with the corresponding Caseload and Birth Log for the month. Documentation of medical consults must be maintained in the client health record and made available upon request.
PRECEPTOR-APPRENTICE AGREEMENT FOR NARM PEP APPRENTICES
The preceptor must submit a signed Preceptor-Apprentice Agreement for each apprentice. 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).
Preceptors must meet all preceptor requirements of the North American Registry of Midwives (NARM).
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
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 ________
| Last Name | First | Middle | Date |
|---|---|---|---|
| Street Address | City | State | Zip |
| Mailing Address, if different | |||
| Home Phone ( ) | Business Phone ( ) | Other Phone (cellular, pager, etc.) ( ) |
Criminal Record Information (Attach additional paper if necessary):
By signing this petition:
I swear or affirm that the statements contained herein (and included on any attached documentation) are true and correct and that I do not misrepresent any information contained therein.
I acknowledge that, in addition to this petition, I may be required to undergo a state and federal criminal background check at my own expense.
I acknowledge that any decision made in response to this petition is subject to change if there has been a change to the provided information during the formal application process.
I acknowledge that any decision made in response to this petition only applies to the criminal records aspect of the licensing process and does not guarantee licensure.
I acknowledge that any decision made in response to this petition is not subject to appeal.
Signature: ____ Date: ___
Act 977 of the 2019 Regular Session of the Arkansas Legislature requires that "A hospital or licensed healthcare facility shall report to the Department of Health when a known transfer occurs of a patient from the care of a lay midwife during the labor and delivery process to the hospital or licensed healthcare facility." Transfer reports regarding a lay midwife patient during the labor and delivery process may be filed electronically through the Lay Midwife Patient Transfer Reporting Form below or via call, mail, fax or email directed to:
Women's Health Section Phone: (501) 661-2480 Arkansas Department of Health Fax: (501) 661-2464 4815 W. Markham, Slot 16 Email: adh.whgen@arkansas.gov
Little Rock, AR 72205
*required information TYPE OR PRINT LEGIBLY IN INK
| Name of Facility* | Telephone Number* | Date of Patient Transfer* | |
|---|---|---|---|
| Street Address* | City* | State* | Zip Code* |
| Name* | Title* | Phone Number* |
|---|---|---|
| Email Address |
| Patient's Last Name* | Patient's First Name* | Patient's Date of Birth* | |
|---|---|---|---|
| Street Address | City | State | Zip Code |
| INTRAPARTUM | POSTPARTUM | NEWBORN |
|---|---|---|
| ☐ Prolonged or Arrested Labor ☐ Fetal Position other than Vertex ☐ Active Genital Herpes Lesions ☐ Labor prior to 37 weeks 0 days ☐ Bleeding in Labor ☐ Meconium ☐ Prolapsed Cord ☐ Non-reassuring Fetal Heart Rate ☐ Maternal Infection ☐ Suspected or Confirmed Fetal Death ☐ Maternal Elevated Blood Pressure ☐ Unknown GBS Status ☐ Other (Please describe): Outcome of Delivery: ☐ Vaginal Birth ☐ Cesarean Birth ☐ Additional Complications: | ☐ Hemorrhage ☐ Symptoms of Shock ☐ Elevated Blood Pressure ☐ Tear or Laceration ☐ Maternal fever ☐ Inability to urinate ≥ 6 hours after delivery ☐ Other (Please describe): _____ | ☐ Respiratory Distress/Cyanosis ☐ Seizures ☐ Abnormal temperature ☐ Jaundice ☐ Abnormal heart rate ☐ Unable/Refuse to Feed ☐ Congenital anomaly ☐ Petechiae or bruising ☐ Other (Please describe): _____ |
| Midwife's Last Name* | Midwife's First Name* | |
|---|---|---|
| Street Address | City | State Zip Code |