1. (a) Risk assessment or assessments.

   1. (1) Risk assessments shall be performed by a physician, a CNM, or a Department of Health clinician.
   2. (2) The purpose of these visits is to ensure that the client has no potentially serious medical conditions and has no medical contraindications to home birth.
   3. (3) Each risk assessment must be filed in the client’s medical record.
   4. (4) The risk assessments must be comprehensive enough for the LLM to identify potentially dangerous conditions that may preclude midwifery care or that require physician or CNM consultation.

   5. (5) Each client must be evaluated by a physician, a CNM, or a department clinician at the following times:

      1. (A) At or near the time care is initiated with the LLM and the evaluation must include the Required Antepartum Services listed in subsection (b) of this section;
      2. (B) At or near the thirty sixth week of gestation and must include:

2. (i) Review of the client’s complete prenatal record;

   1. (ii) Review of the results of all prenatal testing;

      1. (iii) Interval medical and obstetric history;

         1. (iv) Review of systems;
         2. (v) Pertinent physical examination, including:
3. (a) (a) Measurements of blood pressure, weight;

4. (b) (b) Fundal height;

   1. (c) (c) Estimated gestational age;

      1. (d) (d) Fetal presentation/position; and

         1. (vi) Group B strep testing, according to department-approved guidelines;

      2. (C)

         1. (i) Between forty-one (41) weeks, zero out of seven (0/7) days and forty-two (42) weeks, zero out of seven (0/7) days of gestation, the requirements for the thirty-sixth week assessment shall be repeated and may include additional tests or procedures.
         2. (ii) A documented plan for care beyond forty-two (42) weeks, zero out of seven (0/7) days gestational age must be submitted to the department as an additional required incident report.
         3. (iii) If a referral or this risk assessment is not made, or if the clinician advises against home delivery, the client must be transferred; and

      3. (D)

         1. (i) The LLM is responsible for reviewing the risk assessment data and ensuring that her or his client is low risk for home delivery.
         2. (ii) The LLM must base her or his decision on all information, results, and recommendations received from the clinician performing the risk assessment, including any statement in the client’s record by a physician, CNM, or department clinician indicating that the client is not suitable for home birth.

5. (b) Required antepartum services at or near the initiation of care.

   1. (1)

      1. (A) The LLM must ensure each client receives the following services at or near the initiation of care from a physician, CNM, or department clinician.
      2. (B) Exceptions to these required services are at the discretion of the physician, CNM, or department clinician who performs the risk assessment and must be documented in the client’s medical record.

   2. (2) The services are:

      1. (A)

         1. (i) Medical, obstetric, and nutritional history.
         2. (ii) The history must be comprehensive enough to identify potentially dangerous conditions that:
6. (a) (a) May preclude midwifery care; or

7. (b) (b) Require physician or CNM consultation;

   1. (B) A physical examination comprehensive enough to identify potentially dangerous conditions that may preclude midwifery care;

      1. (C) Estimation of gestational age;
      2. (D) Measurements of blood pressure, height, and weight; and

      3. (E) Prenatal testing:

         1. (i) Pap test/HPV test;
         2. (ii) Test for gonorrhea and chlamydia;
         3. (iii) Blood sample for blood group and Rh determination and antibody screen;
         4. (iv) CBC with platelets or hematocrit or hemoglobin;
         5. (v) Test for syphilis;
         6. (vi) Urine culture;
         7. (vii)
8. (a) (a) Blood sugar.

9. (b) (b) Test according to national standards as approved by the department and available on the department website;

   1. (viii) Hepatitis B test;

      1. (ix) Counsel client concerning maternal serum genetic testing, if before twenty (20) weeks gestation;

         1. (x) Rubella test if previous immunity not documented; and
         2. (xi) HIV counseling and test.
         3. (c) Collection of laboratory specimens.

   2. (1)

      1. (A) For LLMs who are trained in the collection of laboratory specimens and collect the specimens themselves, the specimens must be submitted to a standard lab.

      2. (B) The reports and test results must be sent for review and interpretation by a:

         1. (i) Physician;
         2. (ii) CNM; or
         3. (iii) Department clinician.
      3. (C) All reports and test results, including reviews and interpretations, must be recorded in the client record.

   3. (2)

      1. (A) If blood sugar testing is performed by the LLM, they shall:

         1. (i) Use only a United States Food and Drug Administration-approved device for the Clinical Laboratory Improvement Amendments of 1988, Pub.L. No. 100-578 (e.g., HemoCue Blood Glucose Analyzer); and
         2. (ii) Follow the department-approved standards for diabetes testing.

      2. (B) The results of all testing must be interpreted by a physician, CNM, or department clinician within ten (10) days.

         1. (d) Routine antepartum LLM care.
   4. (1) Frequency of visits. Routine antepartum visits must be made approximately every four (4) weeks during the first twenty-eight (28) weeks of gestation, approximately every two (2) weeks from the twenty-eighth to thirty-sixth weeks, and weekly thereafter until delivery.

   5. (2) Routine visit services. At each visit the LLM will perform and record the following services:

      1. (A) Weight;
      2. (B) Blood pressure;
      3. (C) Fundal height;
      4. (D) Determination of fetal position;

      5. (E) Urine testing for:

         1. (i) Glucose;
         2. (ii) Protein; and
         3. (iii) Nitrites;
      6. (F) Fetal heart rate;
      7. (G) Medical and nutritional history since last visit; and

      8. (H) Check for edema of:

         1. (i) Legs;
         2. (ii) Face; or
         3. (iii) Hands.

10. (e) Required antepartum services at twenty-four (24) to twenty-eight (28) weeks gestation.

    1. (1) Except for women with known gestational diabetes all women must be screened for gestational diabetes between twenty-four (24) to twenty-eight (28) weeks according to national standards approved by the department.

    2. (2) All women with negative Rh factor must be treated as follows:

       1. (A)

          1. (i) Repeat antibody screening at twenty-eight (28) weeks.
          2. (ii) If it is negative, advise client that an Rh immunoglobulin injection is recommended.
          3. (iii) If the client is enrolled in a local health unit maternity clinic, Rh immunoglobulin can be administered at the clinic, otherwise she must be referred to a physician or CNM to obtain the Rh immunoglobulin;
       2. (B) If antibody screen is positive, refer the client or consult a physician or CNM as soon as possible.

       3. (C)

          1. (i) If client declines Rh immunoglobulin, repeat antibody screening must be performed at twenty-eight (28) weeks and the LLM is responsible for providing the client with written information provided by the department outlining the risks of isoimmunization and the benefits of Rh immunoglobulin.
          2. (ii) A copy of the signed refusal form needs to be documented and filed in the client’s record.
    3. (3) Testing for CBC with platelets.
11. (f) Required antepartum service at thirty-five (35) to thirty-seven (37) weeks gestation. Screening for group B strep according to department-approved guidelines available on the department website.

12. (g) Antepartum preparation for home birth.

    1. (1) Pre-delivery home visit.

       1. (A) The LLM is required to make, prior to delivery, at least one (1) visit to the home where the birth will take place.

       2. (B)

          1. (i) The LLM should inform the client of the equipment and supplies that must be available at the time of delivery.
          2. (ii) She or he should instruct the client and family of requirements for an aseptic delivery site.

    2. (2) Obtaining department newborn care package.

       1. (A) The newborn care package provided by the department:

          1. (i) Contains the required newborn medications and other necessary items; and
          2. (ii) Is available to all LLM clients.
       2. (B) If the mother chooses to obtain the newborn care package from the department, she must notify the local health unit in sufficient time to allow the local health unit one (1) month to obtain the care package.

    3. (3) Obtaining medications for newborn.

       1. (A)

          1. (i) The LLM must advise the client that the newborn may need either Erythromycin one-half of one percent (0.5%) Ophthalmic or Tetracycline one percent (1.0%) Ophthalmic in individual dose packaging for newborn eye care.
          2. (ii) The mother may obtain one (1) of these medications before thirty-seven (37) weeks, zero out of seven (0/7) days of the pregnancy either by:
13. (a) (a) Prescription from a private physician;

14. (b) (b) CNM;

    1. (c) (c) Other licensed prescriber; or

       1. (d) (d) Prior arrangement with a local health unit.

       2. (B)

          1. (i) The LLM must advise the client that the newborn should receive vitamin K within two (2) hours of birth.
          2. (ii) The medication should be obtained by prescription before thirty-seven (37) weeks, zero out of seven (0/7) days of pregnancy:
15. (a) (a) From a private physician, CNM, or other licensed prescriber; or

16. (b) (b) By prior arrangements with a local health unit.

    1. (C) The LLM must advise the client that:

       1. (i) All medications must be administered to the newborn by a person licensed by the State of Arkansas to administer medications (nurse, physician), and that prior arrangements should be made in order to ensure the licensed person will be available to administer the medications soon after birth;

          1. (ii) The client has the option to administer the medications to her newborn with instructions from the licensed prescriber (physician, CNM, or department clinician); or
          2. (iii) The client has the option to allow the LLM to act as her agent to administer to her newborn the following medications:
17. (a) (a) Erythromycin one half of one percent (0.5%) Ophthalmic or Tetracycline one percent (1.0%) Ophthalmic; and

18. (b) (b) Vitamin K, only allowed to be administered orally by the LLM.

    1. (4) Obtaining intrapartum and postpartum medications for mothers. The LLM will discuss with her or his client the protocol for each of the following medications that require the client to make arrangements to obtain the prescriptions and establish a plan for the administration of medications prior to the onset of labor:

       1. (A) Rh immunoglobulin for Rh negative mothers with an Rh positive newborn;
       2. (B) GBS prophylaxis according to department-approved guidelines; and
       3. (C) Benzocaine fourteen percent (14%) available in gel form, solution, or spray that may be used for the repair of first and second degree lacerations by the LLM after birth.

    2. (5) Preparing bottle-feeding mothers.

       1. (A) For the client planning to bottle feed her newborn, commercially prepared, client-selected formula shall be available for an initial feeding within the first two (2) to three (3) hours after birth.
       2. (B) Client-selected formula must be available for newborn feedings.

    3. (6) Education of client for required genetic/metabolic screening.

       1. (A) The LLM is responsible for advising the client of the:

          1. (i) Law that requires newborn screening (Arkansas Code § 20-15-302); and
          2. (ii) Procedure for conducting newborn screening.
       2. (B) Information is available on the department website.

    4. (7) Completion of newborn hearing screening.

       1. (A) The LLM is responsible for advising the client of the:

          1. (i) Newborn infant hearing screening law (Arkansas Code § 20-15-1101 et seq.); and
          2. (ii) Available resources to obtain the newborn hearing screening.
       2. (B) Information is available on the department website.

    5. (8) Preparation for well-baby care.

       1. (A) The LLM is responsible for advising the mother that beyond the first fourteen (14) days of life, the LLM is no longer responsible and the mother should seek further care from a physician or an APRN specializing in the care of infants and children.
       2. (B) This does not preclude the LLM from providing counseling regarding routine newborn care and breastfeeding.

    6. (9) Preparation for secondary prevention of newborn early-onset group B strep. The LLM shall advise the mother of the necessity for newborn evaluation by a physician within twenty-four (24) hours of birth when:

       1. (A)

          1. (i) Maternal GBS status is unknown and membranes are ruptured in labor more than eighteen (18) hours before birth.
          2. (ii) Refer to 17 CAR § 17-310(b)(7)(H); and

       2. (B)

          1. (i) The mother has indications for GBS prophylaxis in labor, regardless of adequate antibiotic treatment prior to birth and regardless of the presence or absence of symptoms of illness.
          2. (ii) Refer to 17 CAR § 17-304(g)(3)(B).

Codification Notes: "APRN" means advanced practice registered nurse. "CBC" means complete blood count. "CNM" means certified nurse midwife. "GBS" means group B streptococcus. "HIV" means human immunodeficiency virus. "HPV" means human papillomavirus. "LLM" means licensed lay midwife.