Keywords

Nursing care, Pregnancy, Substance use disorder

 

Authors

  1. Mahoney, Kathleen PhD, MSN, RNC-OB, EFM, CBC, APN-C
  2. Reich, Wendy MSN-Ed, RNC-OB, EFM, CBC
  3. Urbanek, Susan MSN, RNC-OB

Abstract

Abstract: The growing opioid crisis in the United States affects childbearing women and their infants at an alarming rate. Substance use disorders in pregnancy have transitioned from a topic barely addressed to one that has become mainstream in the issue of pregnancy management. Opioid use can include appropriate use of a prescribed medication, the misuse of street drugs, and maintenance on an opioid agonist treatment such as methadone. Identifying this population of childbearing women is critical to be able to organize the appropriate resources and to provide a comprehensive multidisciplinary evidence-based plan of care. All clinicians need to be educated in identifying and caring for the growing population of women with substance use disorders. Each component of the continuum from prenatal care, labor and birth, and postpartum has challenges and issues that can have a positive or negative impact on the outcome of the pregnancy and the mother-infant relationship. Risk assessment, medication-assisted treatment, pain management, and fostering maternal-infant bonding are important considerations in the care of the woman with substance use disorder. Unbiased empathetic nurses are well positioned to strongly advocate and intervene on behalf of women with substance use disorder, which in turn will help to create positive outcomes for the mother and her baby.

 

Article Content

Substance use disorder is a growing issue that affects the family throughout the prenatal, intrapartum, and postpartum periods (Substance Abuse and Mental Health Services Administration, 2018). Substance use has a negative impact on maternal health and on the newborn with neonatal abstinence syndrome. The rate of women in the United States presenting in pregnancy with substance use disorder increased 333% from a rate of 1.5 per 1,000 birth hospitalizations in 1999 to 2014 to a rate of 6.5 (Haight, Ko, Tong, Bohm, & Callaghan, 2018), with alarming increases found in the northeast (Hand, Short, & Abatemarco, 2017). Recognition and care management throughout the pregnancy, birth, and postpartum periods are crucial to optimizing positive outcomes. Nurses must be fluent in the evidence-based strategies available to treat and support women with substance use disorder throughout the childbearing timeframe.

  
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Prenatal Screening and Care

In 2018, the National Institute on Drug Abuse (NIDA) defined addiction as "... a chronic, relapsing brain disease that is characterized by compulsive drug seeking and continued use despite harmful consequences" (para. 1). As with any chronic disease, drug addiction causes physiologic changes. The initial choice to experiment with drugs is usually voluntary. Individuals start taking drugs for diverse reasons. These might include a need to feel better or more relaxed, to improve perception of their life, or plain curiosity (NIDA, 2018). This choice rapidly transforms to physical dependence and a loss of self-control, leading to addiction. Risk factors for addiction include biologic (genetics, stage of development, and family history of addiction or mental illness), psychosocial (low self-esteem, peer pressure, unresolved anger or grief, and conflicts with others), and environmental (chaotic home, abusive or neglectful family, living with others who abuse drugs, poor school environment, and feelings of isolation) (Maguire, 2014). With repeated drug use, a person no longer can make free choices about continued drug use. It is not a moral failure; it is a physiologic need. Addiction does not discriminate; it affects all cultures, ethnicities, and socioeconomic backgrounds.

 

Importance of Prenatal Care

Negative stereotypes from healthcare providers can hinder the success of the woman obtaining and/or continuing prenatal care. Stigmatization must be avoided, and all should have the shared goal of a healthy mother and baby. Regular prenatal care and encouraging use of the healthcare system as a means of support assist in keeping the mother engaged in her care (American College of Obstetricians and Gynecologists [ACOG], 2017a). The pregnant woman fears judgment from family, friends, child protective services, and the healthcare team. Effective therapeutic communication can help to alleviate this fear. Nurses are at the forefront of assuring a safe and nonthreatening environment that supports the continuation of prenatal care (Association of Women's Health, Obstetric and Neonatal Nurses [AWHONN], 2015a).

 

Management and treatment of substance use disorder involves a multidisciplinary approach. Coordinated care team members include but may not be limited to the obstetrician, addiction specialist, midwife, maternal-fetal medicine specialist, behavioral health specialist, and social worker. Screening for substance use is universal and not based on risk factors alone. It must be a part of comprehensive obstetric care and initiated at the first prenatal visit in collaboration with the pregnant woman and at several other times throughout the prenatal course (ACOG, 2017a).

 

Screening and Follow-Up

Use of a validated screening tool to detect substance use is recommended. The 4P's screening tool includes questions regarding Parents, Partners, Past, and Present use of alcohol or drugs. Any "yes" sparks further assessment (Ewing, 1990). The CRAFFT tool is a substance use screening tool for women 26 years of age or younger. It encompasses six questions regarding; riding in a Car with someone, including self who was high or used drugs or alcohol, using drugs or alcohol to Relax or fit in, using drugs or alcohol when Alone, Forgetting things while using alcohol or drugs, Family or friends tell you that you should cut down, and getting into Trouble while using drugs or alcohol. If two or more questions are "yes," further discussion is needed (ACOG, 2017b; Center for Adolescent Substance Abuse Research, Children's Hospital Boston, 2009). Questioning should be done in private and encompass past and current alcohol, tobacco, and illicit illegal drug use. Misuse of prescription drugs and use of multiple prescription drugs for chronic pain relief is also explored, as polysubstance use is not uncommon.

 

Routine urine drug screening is controversial for many reasons. Urine testing reflects current or recent substance use; it does not rule out intermittent use, and may not detect all substances (ACOG, 2017a). The test only provides objective drug use at one point in time; it does not determine the frequency or degree of use. Consent should be obtained prior to urine drug screening. In addition, laboratory screening panels may differ from institution to institution and criteria to determine specific drug levels may vary.

 

A detailed history of substance use is obtained once the disorder is identified. The types of substances used, route (inhalation or injection), frequency, and length of use are recorded (Krans, Cochran, & Bogen, 2015). An inquiry regarding the partner and family history of substance use is done to determine the safety of the living environment. Maternal and neonatal risks associated with substance use are discussed. Routine testing for sexually transmitted infections and other infectious conditions is performed. Additional ultrasounds may be necessary to monitor appropriate fetal growth and placental function. Screening for psychosocial risk factors, mental health disorders, and intimate partner violence along with any referrals to medical and/or addiction specialists and counselors are part of the plan of care for the woman with substance use disorder. Smoking cessation information and nutritional counseling are both provided at each visit to underline the importance of healthy behaviors.

 

Medication-Assisted Treatment

Medication-assisted treatment (MAT) is prescribed to treat substance use disorder. Methadone and buprenorphine are opioid agonists and provide safe effective treatment options for the pregnant woman (ACOG, 2017a). These medications help reduce cravings and withdrawal and allow the brain to heal while working toward recovery. Women must be counseled that their infant may still experience neonatal abstinence syndrome as a result of this treatment (NIDA, 2018). A steady concentration of opioids prevents the fetus from experiencing cycles of withdrawal and toxicity.

 

Methadone is dispensed daily at state-licensed opioid treatment centers and is used to treat all levels of dependence. A specially trained certified physician can give a prescription for buprenorphine, which is used best to treat mild-moderate dependence. Split and increased doses may be needed as pregnancy progresses due to increased circulatory volume and changing metabolism. Therapeutic levels are individualized and will fluctuate by patient (Zedler et al., 2016).

 

Using MAT improves compliance with prenatal care. Several of the negative associated health risks with prenatal substance use could be avoided by establishing regular prenatal care and appropriate interventions. Incorporation of risk avoidance and treatment of the addiction as a chronic disease is critical especially during the prenatal period (Maguire, 2014). Developing a positive patient and provider rapport will facilitate the ability to deliver the required prenatal care needed for improved maternal and neonatal outcomes.

 

Intrapartum

Supportive Care

Care of the woman with substance abuse disorder during labor and birth who is managed on MAT is the same standard of obstetric care as that of the woman who is not being treated for or suffering from substance abuse disorder. Vital sign parameters, fetal monitoring standards, and oxytocin administration should be according to parameters put forth by AWHONN (2015b). All laboring women, regardless of substance abuse history, should be offered the same level of care.

 

If the laboring woman is on MAT, she may be known to social services because they are an intricate member of the team during the prenatal period. Linking the woman on MAT with social and community resources can aid in access to support, which can assist in preemptive care planning and advocacy for the mother and the newborn. If the woman is not being managed with MAT and is actively using illicit drugs, withdrawal may begin 4 to 6 hours after the last use. This withdrawal can be dangerous for both the mother and the unborn fetus. Fetal seizures and placental abruption may be a result of acute maternal drug withdrawal (Jones et al., 2008; Volkow, 2016). Consultation with addiction specialists, mental health providers, and social workers remains critical as a continuum from the prenatal period or as initiation for the woman who presents with substance use disorder in labor.

 

Pain Management

Pain management for the opioid-tolerant or substance using laboring woman requires modifications for safe care. Medication-assisted treatment is not a substitute for labor pain management and must be continued during labor to avoid acute withdrawal. Intravenous methadone can be titrated and administered if oral medication is not possible (Jones et al., 2008). Small divided doses can also be used to maintain a therapeutic state for the woman if this is deemed more beneficial. The MAT strategy may affect pain management plans. Working closely with the woman and a pain management specialist prior to birth is the best course of treatment planning in order to avoid acute withdrawal (ACOG, 2017a).

 

Effective MAT is generally achieved with individualized daily dosages of methadone or buprenorphine maintenance (Zedler et al., 2016). The MAT medication should not be changed because the woman is in labor: the woman must be maintained on the same drug and dosage that has resulted in successful management of the addiction. Pain is assessed using the standard numeric or otherwise appropriate scale. Coordination is best done if the obstetrical team works in conjunction with the addiction specialist, pain management specialist (often the anesthesiologist), and social worker to achieve positive outcome.

 

Narcotic agonist-antagonist drugs such as butorphanol (Stadol(C)) or nalbuphine (Nubain(C)) should not be given to woman receiving MAT as they may precipitate acute opiate withdrawal (ACOG, 2017a; Jones et al., 2008). Nurses and other care providers should be aware that pain perception may be increased and usual doses of pain medication may not provide relief. If there are no medical contraindications, neuraxial analgesia/anesthesia can be offered. This option is appropriate for both laboring women and those anticipating a cesarean birth.

 

At the time of birth, a team who has the capability to perform neonatal resuscitation must be in attendance. A member of this team should be capable of performing an initial baseline behavioral assessment on the neonate to determine any signs of neonatal abstinence (Kocherlakota, 2014). Stable infants should be placed skin-to-skin with the mother.

 

Postpartum

Supportive Care

Although the care of every postpartum mother has similar components, special considerations should be in place for the mother with a substance use disorder. Goals should include stabilization in the immediate postpartum period, pain management, promotion of maternal-infant bonding, and initiation of breastfeeding if the patients so desire (Cleveland, 2016; McKeever, Spaeth-Brayton, & Sheerin, 2014). Establishing a trusting relationship with the mother is important as this will promote participation in her ongoing care (Leslie & Lonneman, 2016). The mother needs to know her providers are not judgmental and that she is respected and well cared for during her hospital stay. Patients who are engaged and active participants in their own care have much better outcomes. Helping mothers to identify better ways to care for themselves and their infants can instill the competence and confidence they need which may lead to them seeking treatment or to remain in treatment (Krans et al., 2015).

 

Pain Management

The woman experiencing pain postpartum does not have the ability or desire to care for herself or her infant, so this is a priority during the postpartum period. Dosing for MAT should be continued throughout the postpartum period. Pain tolerance and pain sensitivity in the substance use disorder patient may be altered (McKeever et al., 2014). Pain management for the mother who has given birth vaginally may be less of a challenge than for those who have had a cesarean. Nonopioid pain management may be enough along with their maintenance therapy for those patients giving birth vaginally. Pain management modalities other than medication can be effective when the care plan is specific to the needs or the patient. These include but are not limited to the use of witch hazel pads, sitz baths, and ice.

 

The ACOG (2018) has recognized the adaptability of the World Health Organization's three-tier system for pain management that was originally introduced for cancer pain management. Initially, the new mother's pain can be managed with nonopioid analgesics (tier 1) and if these drugs are not effective, adding milder opioids may prove beneficial (tier 2). If needed, stronger opioids are added to manage her pain (tier 3). If the woman who gives birth vaginally has experienced any type of birth trauma associated with an instrumental birth, shoulder dystocia and/or lacerations, leaving the epidural in place can be an additional option for pain management.

  
Table Suggested Clin... - Click to enlarge in new windowTable Suggested Clinical Implications

Pain management can prove to be more challenging for women who had a cesarean birth. Using a multimodal approach can be beneficial along with adjusting the doses of the treatment therapy. Using divided doses of the MAT treatment in combination with short-acting opioids, nonnarcotic analgesics and anti-inflammatory medications are often successful. In the event the patient is not tolerating fluids or solids by mouth, methadone as the MAT mechanism can be given intravenously (ACOG, 2017a). The use of patient-controlled analgesia (PCA) is another option for the post-op patient. Using PCA pumps offers the opportunity for the patient to actively be involved in their own care.

 

Postpartum Follow-Up

It is also important to work closely with the facility where the patient is in treatment to ensure proper dosing is carried out and to share how her pain was managed during the hospital stay. The postpartum period is stressful for many new mothers. Relapse from treatment is higher in the postpartum period than at any other time in the childbearing cycle (ACOG, 2017). Patients on long-term maintenance therapy should be managed using a team approach for pain management to ensure a positive experience for the new mother during postpartum.

 

Many women with substance use disorder will be fearful of state or local regulatory involvement. Safety of the home environment and evaluation of her ability to care for the infant are of primary concern (Kocherlakota, 2014). A consequence of substance use disorder may include loss of custody of the child on a temporary or permanent basis. Nurses should be prepared to support the mother and family in communications with these agencies and to provide reinforcement of the importance of remaining in treatment and maintaining sobriety.

 

Breastfeeding

Lack of provider knowledge about the safety and benefits of breastfeeding for the substance use disorder mother and her infant presents a problem (Pritham, 2013). Both ACOG and AWHONN recognize the benefits of breastfeeding for infants born to women with substance use disorder. Specific conditions that mothers must commit to while breastfeeding their infants include enrollment in a supervised MAT program, avoidance or limiting tobacco and alcohol use, and cessation of illicit drug use (ACOG, 2017; Cleveland, 2016).

 

Many mother experience guilt knowing they have exposed their infants to opioids during the prenatal course. Taking an active role in the care and feeding of their baby can help with the maternal-infant bonding. Women should be educated that there will be passage of small amounts of the MAT into the breast milk (ACOG, 2017) but this may assist the infant who is being treated for neontal abstinence syndrome (NAS). Breastfeeding may decrease some of the symptoms of NAS by encouraging mother-infant bonding and thereby increasing supportive care, which is a basic treatment of NAS. Mothers will also need support from the lactation consultant because many of the NAS infants struggle to latch, have a poor suck swallow coordination, and demonstrate excessive sucking (Cleveland, 2016). When possible, rooming-in is encouraged which helps the mother-infant bonding and provides an opportunity for clinicians to assess the maternal-infant dyad and educate the mother as what to expect from her baby as they go through withdrawal and how she can better help them.

 

Clinical Implications

The prenatal setting should provide the woman with substance use disorder with a safe place to receive care. Continuous risk assessment must be conducted. Screenings for intimate partner violence, sexually transmitted infections, and use of alcohol or nicotine are critical as they present as high-risk comorbidities. Assessment for appropriate fetal growth and continued use of MAT must be done.

 

The intrapartum team provides consistent and nonjudgmental care. Along with supportive care, assessment of labor progress and the fetal response, a heightened attention to pain management is critical and MAT must be continued. Communication to the neonatal providers to prepare for an NAS-affected infant is essential. Providing the mother with the opportunity to experience skin-to-skin can be the start of a positive maternal-infant relationship.

 

The postpartum nurse must also be cognizant of the pain management challenges that mothers will face. Changes associated with birth may have an impact on the dosages of MAT. Breastfeeding consultation for mother-baby couplets is necessary. Nursing support for the family involvement with state and community agencies is necessary for honest and transparent communication.

 

As the population of substance use disorder mothers continues to grow, nurses must be aware of their physical and emotional needs of the course of care during the childbearing process. Nonjudgmental evidence-based care must be provided. Communication strategies that engage and involve the woman and her support system will make her feel well cared for and supported. The new mother must be able to appropriately care for herself and her baby as she returns to medical management of her addiction. Nurses are well positioned to coordinate the care and the education needed to keep the mother and her family engaged in healthy behaviors. The unbiased, nonjudgmental care given to these women can contribute positively to the successful maternal-infant relationship.

 

References

 

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