A window of opportunity? For pregnant women this effect is amplified - - PowerPoint PPT Presentation

A window of opportunity?

For pregnant women this effect is amplified as the risk extends to the care and well being of the unborn baby There is often conflicted and complex responses to this “heightened level of risk” by professionals involved in the care, family, partners and indeed the woman herself.

Alcohol & Drug use in pregnancy

 Caring for substance dependent women in pregnancy

can be extremely challenging and sometimes personally confronting

 Important to keep in mind that even the most complex

client wants to have a healthy baby and want to be able to love and care for their baby in a suitable home environment with love and support around them…….

But!! There is more than just the unborn baby to consider

 While a new pregnancy brings concerns about the

unborn baby the is also the very real and ongoing concern around parenting the baby and any other children in the woman’s care.

 This is a time to consider the risks to all concerned and

address the risks as they become evident

Issues surrounding parenting and drug use

Substa stanc nce e Abuse e does s not t always ys equal l poor r parenting. nting. co concerns ncerns exist t when:

Issues surrounding parenting and drug use

 Parental resources are tied up with seeking, using and

recovering from drugs

 Diversion of finances away from the family – this can in lead to

criminal activity

 Lack of routine within the family  Inconsistent & neglectful parenting  Poorly developed social networks & healthy social interactions

may be denied to children

 Mental health issues and fluctuating moods

Issues surrounding parenting and drug use

 Poor parental role modelling i.e. failure to model

clear boundaries & appropriate behaviour

 Exposed to hazardous drug use equipment  Dangers of overdose  Child parentification  Increase risk of child abuse-parents reduced ability

to cope with even minor stresses

Emotions surrounding drug use in pregnancy

Health Professionals



Anger



Blame



Annoyance



Anxiety



conflicted

Pregnant Woman

 Guilt  Shame  Fear  Anxiety

Walk a mile in my shoes…….

Perceptions of women regarding antenatal care

 Fear of being treated differently  Fear of child protection becoming involved-

particularly if there are already children in care

 Previous bad experiences (frequently history of abuse

is noted)- this may result in fear of examinations

 Uncomfortable around doctors and other health

professionals

Often late to book in and poor attendance

 Not wanting to disclose pregnancy  Fear of Child Protection Services  Fear of Judgement  Unhappy about pregnancy, often unplanned  Afraid something wrong with pregnancy  In Crisis - Housing issues/homelessness

Barriers to Care

Barriers to Care

 Partner problems/Family violence  Financial difficulties  Difficulty with transport/distance from clinic  Childcare issues  Clinic hours did not suit  Too tired to come to hospital

It is commonly believed that pregnancy and motherhood are periods of high motivation for women to enter drug treatment or seek support of some kind to address their substance use

Engagement

Antenatal care can provide a point of contact for women who may otherwise not present to other medical or treatment services It can potentially offer contact for 7 months This is very much dependent on engagement!!

Engagement

 Engagement may be lost at the first visit if the first

point of contact is with professionals inadequately skilled in working with substance using women.

 Care must be delivered in a non- judgemental manner

that supports women to care for themselves and their baby in partnership.

 Developing care pathways that are achievable and

considering the women’s strengths as well as their challenges in life.

Non judgemental, flexible,

multidisciplinary treatment approach ”optimises the women’s treatment experience within the medical system”….. Tobin (2005)

Assessment

 Assessment is ongoing  Many barriers to care  Respect for women’s strengths  Non judgemental approach & establishment of a

rapport is essential

 Disclosing drug & alcohol use in pregnancy is difficult

and is often under reported

Assessment

 Often difficult to engage and maintain in

pregnancy care.

 Essential to establish readiness for change

( Prochaska & DiClemente)

 Aim to establish a professional, trusting and

empathetic relationship so as the woman will feel encouraged to continue care.

 Failure of engagement may result in loss of that

woman to follow up with less than optimal

• utcomes for the woman and her baby.

Antenatal care

 High risk pregnancy  Increased incidence of

• spontaneous

abortion

• Premature labour and delivery
• IUGR
• Fetal distress (especially with acute

withdrawal)

 Fetal anomalies depending on type of substance

Drug & Alcohol Pregnancy Service

DAAPS

Multidisciplinary care

 Midwife Coordinator  Obstetrician  Social worker  Parenting educator  NPICU Discharge Coordinator  Drug & Alcohol liaison Service  Psychiatry Liaison Services  Psychologist  NNICU consultant  CPLO  CHAPS

Role of the Complex Care midwife

 Co-ordination of care for pregnant women with complex

needs associated with substance use.

 Point of contact for women and their families- continuity

• f care.

 Resource person for other staff.  Provide education to women and other members of the

health care team.

 Liaise between all services in the hospital & in the

community.

 Work within the multidisciplinary team to identify needs &

provide management plans for the antenatal, intrapartum & postnatal period and to commence discharge planning as early as possible.

First appointment

 Engagement  Psycho-social history  Medical/Surgical History  Obstetric history  Drug & Alcohol history-

this is revisited frequently over the pregnancy

 Appropriate Referrals  Appropriate Clinic  Patient’s educational

requirements

 Harm minimisation

strategies

 Short term and long

term goals (priorities)

Referrals

All referral options and the reasons they are recommended are discussed with the woman first.

• Social work
• Psyche liaison/community mental health
• Parenting educator
• NPICU discharge coordinator
• Paediatrician
• Drug and Alcohol service
• Lactation consultant
• Dietician
• Dentist
• CHAPS
• Child protection/CPLO

Community referrals

 GP

 Alcohol and Drug Service  Detox unit  Bridge – Rehabilitation programs  Anglicare- GIDS  Holyoake  TasChard  Mental Health Service/Counselling services  Gateway referral - Good Beginnings, ESP, Mission, Baptcare,

Disability services

 Housing Tas/ Colony 47/Access  Legal services  Advocacy  Guardianship and administration board

Education

 Encourage all women to undertake some form of education  The objective is to allow all women to make informed choices, by providing

accurate information in an easily understood manner

 Keep in mind previous experience and prior learning  Include harm minimization e.g.. poly drug use, BBI, safe injecting information  Recommendation of methadone stabilization for

• piate users

 Drug education / potential risks associated for mother and baby  NAS  Birth planning /labour and delivery  Breastfeeding/feeding options  Postnatal information  Emotional health and wellbeing/PND/ help lines etc  Discharge planning  Safe sleeping  Support services  Family support network/establishing a circle of security

Assessing Harm

 Alcohol, tobacco and other substance use during

pregnancy have been linked to a number of adverse pregnancy and neonatal outcomes

 It is difficult to evaluate the exact harm contributed by

specific drugs independent of the risks associated with drug using lifestyles

• Poor nutrition
• Poverty
• Poly drug use
• Patterns of use
• Poor antenatal care
• Medical complications
• Social and environmental risks
• Co existing mental health issues

Systemic factors

 Ethical & logistical considerations make it difficult to

carry out high quality studies

 Inadequate or inflexible polices  Inadequate resources for early intervention and

prevention

 Lack of appropriate service availability  Service Gaps across all services  Fragmented approach to care management  Inexperienced or Judgemental practitioners

Labour and birth

 Admission in early labour may reduce the need to self

medicate for those at risk

 Methadone should preferably be given prior to

induction or in early labour but should not be withheld

 Pain relief may need special attention as receptors can

become opiate saturated, opiate analgesia, however, should not be withheld but effects should be carefully monitored

 Regional anaesthesia should be considered  All natural pain management methods should be

encouraged

Neonatal Abstinence Syndrome (NAS)

 Mothers must have a full explanation of NAS antenatally  They must be included in the observation process  Explanation needs to include

• ↑ length of stay
• ↑ chance of NPICU admission
• signs and symptoms of NAS
• morphine may be required for opiate withdrawal

 “Sub acute withdrawal” ( irritability, sleep and feeding

problems, restless behaviour and hypertonia may last for 4 to 6 months)

 NAS Guidelines available on the intranet

Breastfeeding

Factors affecting breastfeeding:

 Low self esteem  Fear of drug effects  Lifestyle  Support for her decision  Inaccurate information

Breastfeeding

 Opiates are present in breast milk  Breastfeeding is recommended for women who are

maintained on methadone

 It is not recommended if methadone is being used with

• ther drugs, unknown substances

 Periods of acute intoxication if using other drugs may

mean mother not capable of feeding and or caring safely for her baby

 Women with hepatitis c should be encouraged to feed their

babies unless there is blood from cracked nipples present

 HIV –breastfeeding not recommended  Weaning should be done slowly

Methadone in pregnancy

 Methadone maintenance program is recommended for

women using opiates regularly and who will experience withdrawal if she stops.

• NB. Acute withdrawal in pregnancy increases risk of

spontaneous abortion, FDIU, premature labour and delivery and fetal distress.

Advantages



Once a woman is stable on methadone she is then sourcing the drug in a routine and controlled manner. It is a known dose and purity.



This will reduce risks of blood borne viruses

Methadone in Pregnancy

 Decreases need for crime – reduces financial problems  Generally less poly drug use and drug seeking

behaviour.

 There is improved fetal growth and survival  Less prematurity

Cannabis

Use in pregnancy and breastfeeding:

 Similar to smoking cigarettes eg. IUGR, low birth weight,

increased risk of miscarriage and premature labour

 Difficult to assess as users more likely to smoke cigarettes  NAS – not well described, restlessness, wakefulness and

feeding difficulties have been reported

 THC freely excreted in breastmilk  THC is fat soluble and may accumulate in brain and

adipose tissue

 Some hospitals don’t recommend breastfeeding for heavy

users as long term effects are largely unknown

Amphetamines in Pregnancy

 Little information about effects on fetus  Increase risk of cleft palate and lip  miscarriage  Increase risk of placental abruption  Premature labour  IUGR and low birth weight  Need to consider other variables such as poor

antenatal care, maternal nutrition and poly drug use in many cases

Amphetamines-Effects on the Neonate and breastfeeding

 If used close to birth baby may be directly affected

and be agitated and restless

 There may be increase in the startle response  Abnormal sleep patterns  Withdrawal symptoms may be evident in babies of

regular users in the first weeks after birth

 All babies should be observed for NAS

Benzodiazepines

 CNS Depressants  Can cause addiction and dependancy  Should never be stopped abruptly  Best avoided in pregnancy  Increased risk of cleft lip and palate  Withdrawal symptoms common in neonates- includes poor sucking,

poor temperature control, hypotonia, respiratory distress, irritability, excessive sucking, diarrhoea, tremors and seizures

 Symptoms may take from 1 to 7 days to appear and can last from 7 to 28

days

 Should not breast feed when taking larger than therapeutic doses  Those women on lower doses should only feed 1 to 2 hours after a dose

and should observe baby for excessive drowsiness.

Alcohol in pregnancy and breastfeeding



Alcohol is a teratogen



The NH&MRC recommends women who are pregnant should abstain from alcohol and they should never become intoxicated.



No study has demonstrated a specific threshold so there is no known safe level of alcohol consumption in pregnancy.



An average of 2 or more standard drinks a day has been linked to low birth weight, behavioural and learning difficulties and increased risk of spontaneous abortion (Dore 2002).



Impact on the fetus tends to have a dose dependant effect with unpredictable outcomes from mild decrease in cognitive functioning to fetal alcohol syndrome (FAS) in it’s severest form.



Blood levels of the fetus equal blood alcohol levels of the mother.



Binge drinking said to be potentially harmful due to the peak blood alcohol levels achieved being higher than regular consumption.



Women should not drink while breastfeeding as it passes into the milk. The alcohol level in breast milk is the same as the blood alcohol level of the mother.

Discharge planning

 Commenced from the first visit  There must be a clear plan established in

partnership with the woman

 Case conferences are held for all high risk women  Suitable, sustainable support systems should be

• rganised and clarity around everyone’s

responsibilities known

 A lead agency is determined as early as possible  At all stages throughout the pregnancy and during

admission risk factors are assessed and reassessed

Children at risk

 Research suggests that the 1st 6-12 months after birth is a

critical time for women using substances and their babies/children

 There is a high rate of relapse  Greater risk for Child Protection intervention  Disengaging with services that are often critical in

providing monitoring and support

 It is imperative that services work together and a lead

agency is identified before discharge

 A case manager should be appointed from the lead agency

to ensure ongoing coordination of services

 Children must remain visible and this must be a clear

message to women and their families

When the risk is too great…..

 Even when babies need to go into out of home care early in the post natal

period, communication with the woman and her partner is vital and a plan to continue appropriate treatment and to remain linked into services is strongly encouraged.

 Change is possible and giving people hope is imperative to emotional well

being and human spirit this can still be imparted even in the most difficult of circumstances, with the passage of time, intensive ongoing support and motivation things are possible.

 As long as women have a clear understanding of what is expected of them and

who needs to remain involved for ongoing support and services uphold their responsibility in providing adequate communication to the family they have something to work toward and of all things in life, our children appear to be

• ur best motivator even if the odds are stacked.

Vision for the future

 Public mother baby unit as a transition from hospital

to home for families at risk

 Drug and alcohol treatment service/liaison team

within the hospital- provision for initiating methadone maintenance

 Availability of long term case management for at risk

families to help keep families together with the ability to monitor and provide intensive support at the same time, there is a major gap from 0-5 years