Substance Misuse in Pregnancy, Labour and Post Delivery Clinical Guideline V3.0 Page 1 of 13

Substance Misuse in Pregnancy, Labour and Post Delivery Clinical Guideline

V3.0

April 2020

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Summary Illicit drug and alcohol use (including cocaine, amphetamines, opioids and marijuana) during pregnancy has been associated with a wide range of adverse neonatal outcomes, including fetal growth restriction; preterm birth; lower birth weight; neonatal abstinence syndrome; fetal distress; neurocognitive delays and impairment, and drug and alcohol misuse later in adolescence. 1, 2, 3 During the postpartum period, illicit drug and alcohol use is also associated with an increased risk of child neglect, violence exposure, physical abuse, and maternal mental health issues. 1

All of the commonly used opiates, including heroin and methadone, can produce neonatal abstinence syndrome in infants born to opiate dependent mothers. Neonatal abstinence syndrome includes all of the symptoms of adult withdrawal syndrome in addition to irritability, poorly coordinated sucking and in the most severe cases, seizures and death.4 Furthermore, women who are injecting drugs are also at risk of infection including hepatitis C and HIV, with the potential for vertical transmission* to the infant. 3

Mother–infant attachment and responsiveness is also compromised through drug and alcohol misuse, with postnatal depression and domestic abuse further complicating the mother–infant relationship. Mothers subsequently tend to be reluctant to attend health facilities for education, medical treatment or social support. 3 (New 2020)

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1. Aim/Purpose of this Guideline

1.1. This guideline aims to create an environment where women with problematic drug or alcohol use will have the knowledge of and confidence in a team who manage them sympathetically in pregnancy and help to minimise harm to the woman and baby.¹

1.2. This version supersedes any previous versions of this document. 1.3. Data Protection Act 2018 (General Data Protection Regulation – GDPR)

Legislation

The Trust has a duty under the DPA18 to ensure that there is a valid legal basis to process personal and sensitive data. The legal basis for processing must be identified and documented before the processing begins. In many cases we may need consent; this must be explicit, informed and documented. We can’t rely on Opt out, it must be Opt in.

DPA18 is applicable to all staff; this includes those working as contractors and providers of services.

For more information about your obligations under the DPA18 please see the ‘information use framework policy’, or contact the Information Governance Team rch-tr.infogov@nhs.net

1.4. This guideline makes recommendations for women and people who are pregnant. For simplicity of language the guideline uses the term women throughout, but this should be taken to also include people who do not identify as women but who are pregnant, in labour and in the postnatal period. When discussing with a person who does not identify as a woman please ask them their preferred pronouns and then ensure this is clearly documented in their notes to inform all health care professionals

2. The Guidance

All women must be asked at booking if they have historically or currently misuse drugs and/or alcohol. Midwives are to inform women that the safest approach is not to drink alcohol or use illicit substances during pregnancy due to the increased risks to the unborn. For those women who disclose misuse of substances and/or alcohol, midwives are to follow the Substance Misuse Pathway (Appendix 3) If a woman discloses that her partner or a household member is using illicit substances or misusing alcohol, to encourage woman to get them to engage with ‘We are with you’ service or GP. Document concerns on E3, initial safeguarding paperwork, discuss with team leader and consider referral to MARU. (New 2020)

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2.1. Ante natal care

Upon identifying that the woman is misusing alcohol or substances the Midwife will, with consent, refer to “We are with you” substance misuse service. This is sent electronically via E3. The referral form can also be found on TR11, Midwives Pathways & Templates (2020)

Midwives should calculate the amount of alcohol units consumed prior to pregnancy and current use at booking, using the World Health Organisation Audit C calculator WHO Audit C Calculator(new 2020)

If the score is over 5 at booking, this indicates a positive screen. The full Audit screening then should be undertaken as per the WHO guidance.

Offer ‘Brief Advice’ leaflet NHS Brief Advice Leaflet (New 2020)

The named midwife should plan the scheduled midwifery antenatal care according to the current guidelines²

Following full antenatal history routine screening bloods will be taken with consent. Bloods may need to be taken by an anaesthetist or phlebotomist if there is a long history of injecting.

Women who have a history of IV drug use should be screened for Hepatitis C in addition to routine sceening (New 2020)

Complete initial safeguarding paper work and consider if an Early Help Hub (EHH) or Multi Agency Referral Unit (MARU) is necessary at this stage according to the maternity safeguarding children guidelines3

Inform named Obstetrician, Paediatrician, GP and Consultant Anaesthetist of drug/alcohol usage and any proposed plan of support and management throughout her pregnancy.

Arrange serial growth scans with consultant agreement and further scans if clinically indicated.

Referral made to appropriate professionals if screening results are positive e.g. HIV, Hep B or C for discussion around plan of care Keep in close contact with the woman for support and advice.

All attendances and non attendances should be documented on E3. Ensure Did Not Attend (DNA) or Booked Late for Antenatal Care Clinical Guideline is followed (2020)

Any changes to the management plan will be documented in the woman’s notes and on E3

If a woman regularly does not attend for ante natal care, whose drug use is chaotic, or there are other concerns identified, then a referral to Multi Agency Referral Unit should be made in consultation with other professionals involved with her ongoing care.

If referral to social care is made CMW will attend all safeguarding conferences and ensure all agreed outcomes and action plans are documented.

Where initial safeguarding paperwork has been commenced, these women will be discussed at the monthly vulnerable women’s meeting. (New 2020)

Advise the woman to deliver her baby in the obstetric unit and to stay a minimum of 72 hours post-delivery for Neonatal Abstinence Syndrome (NAS) obeservations. (New 2020)

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Even if the woman states that she no longer uses alcohol or drugs, the midwife should ask about usage at every contact. (New 2020)

2.2. Antenatal admissions

Inform the Safeguarding Midwives of any admission during office hours or leave a message.

Inform the woman that there should be no use of illicit drugs, or alcohol, on the hospital premises. RCHT Managment of Alcohol and Drug Use on RCHT Premises (New 2020)

If the woman has an alcohol dependency and is expected to be an inpatient for more than 24hrs she should be referred to RCHT Alcohol Liaison Team - 07557 215449 / 07557215450 for detox advice. (New 2020)

When on Methadone or Subutex, the woman will require her medication to be prescribed. Dosage to be checked with either her named substance misuse worker, GP or the substance misuse hospital outreach team at RCHT, 01872 254551. (New 2020)

Where a discharge happens over a weekend, or a bank holiday, a TTO should be given only until their own script can be reinstated in the community, to prevent withdrawal.

2.3. Intra-partum Care

Inform the Safeguarding Midwives of any admission during office hours or leave a message.

Check the safeguarding shared drive for any social care involvement and neonatal plan of care.

All screening blood results should be accessed and known as soon as possible and the labour managed according to relevant guidelines.

Ascertain from the woman if her birth partner/relatives are aware of her history and current use of a script to maintain the woman’s confidentiality.

Methadone/Subutex prescribing must continue in parallel to any other analgesia in labour. Sudden opiate withdrawal has been shown to possibly cause fetal distress.4

Routine continuous electronic fetal monitoring in an otherwise low risk woman is not required.

If there is any suspicion that the woman has misused a substance or alcohol just prior to or during labour a continuous CTG should be performed

Discussions regarding pain relief in labour should involve the woman, midwife caring for her and in some cases the anaesthetist. Women on a Subutex prescription should not be offered an opiate based analgesia, epidural is the preferred alternative.

If the woman is on a Methadone script do not offer Cyclizine as an antiemetic 5

Following the birth of the baby a neonatal observation chart should be commenced for a minimum of 72 hours, any subsequent monitoring will be based on an individual basis at the request of the paediatrician. See Neonatal Abstinence Syndrome (NAS) guideline.

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Neonatal team attendance at delivery is not a routine requirement, but the neonatal team should be informed of the birth of the baby and monitoring for NAS commenced.

In the event of baby needing resuscitation at birth Naloxone should be avoided due to the risk of sudden onset withdrawal/seizures.

If involved with Children’s services, inform the named social worker once baby is born, if out of hours inform the duty social worker on ext.1300 (New 2020)

2.4. Postnatal Care

Continue monitoring baby on ward for signs of NAS for 48-72 hours

Ensure prescribed medication is correct and has been stocked in the CD cupboard.

Postnatally the woman may not require all her prescription – discuss with We Are With You substance misuse worker.

When dispensing the medication ensure that the woman’s confidentiality is maintained.

Use caution when woman requesting frequent opiate analgesia, especially those that are on opiate replacement therapy (ie. methadone) (New 2020)

Ensure that the neonatal team are aware of information relating to the history and discharge planning of the baby.

Ensure that the mode of feeding is documented in hand held notes.

2.5. Breastfeeding

Breastfeeding is always encouraged unless there are contraindications. (see NAS Guidelines)

Prescribed medication must continue to avoid maternal withdrawal.

Maternal medication is best administered post breastfeeding rather than before.

To date, there are no reported cases of transmission of Hep C and Hep B in breast milk, therefore, breastfeeding should be encouraged in this client group

2.6. Prior to Discharge Home

Ensure a paediatrician has performed the NIPE check and reviewed the baby prior to discharge.

Ensure that the woman has enough prescribed medication to cover her at home only until her prescription can be reinstated in the community. This can be as a TTO.

Babies of Hep B positive women, refer to Hep B guidance

Babies of Hep B negative women, who are injecting users, offer baby neonatal vaccine.

The community midwife will provide the post natal care once discharged

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home.

On discharge and when there are safeguarding issues, discharging midwife must contact Safeguarding Midwife, Health Visitor, Social Worker

Also inform substance misuse worker of discharge for the women on Methadone /Subutex 24 hours before so that the script can be reinstated.

3. Monitoring compliance and effectiveness

Element to be monitored

1. All women to be asked alcohol and substance misuse at booking 2. Women who answer positively to alcohol to have Audit C

screening for units. 3. Joint pathway (Appendix 3) followed

Lead Named Midwives for Safeguarding

Tool Compliance of guidelines, documented on database

Frequency Annually

Reporting arrangements

Safeguarding Operational Children’s Group (SCOG) Maternity Forum

Acting on recommendations and Lead(s)

Named Midwives for Safeguarding Consultant Midwife for Vulnerable Women

Change in practice and lessons to be shared

SCOG & Women’s and Children’s Division

4. Equality and Diversity

4.1. This document complies with the Royal Cornwall Hospitals NHS Trust

service Equality and Diversity statement which can be found in the 'Equality, Inclusion & Human Rights Policy' or the Equality and Diversity website.

4.2. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2.

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Appendix 1. Governance Information

Document Title Substance Misuse in Pregnancy, Labour and Post Delivery Clinical Guideline V3.0

Date Issued/Approved: 4th April 2020

Date Valid From: April 2020

Date Valid To: April 2023

Directorate / Department responsible (author/owner):

Suzie Williams & Bernie Dolan

Named Midwives for Safeguarding

Contact details: 01872 254551/4549

Brief summary of contents To inform and support midwives in caring for women who present with substances misuse and to safeguard women and their children

Suggested Keywords: Substance Misuse

Target Audience RCHT CFT KCCG

Executive Director responsible for Policy:

Medical Director

Date revised: 4th April 2020

This document replaces (exact title of previous version):

The Management Of Substance Misuse In Pregnancy, Labour And Post Delivery V2

Approval route (names of committees)/consultation:

Maternity Guidelines Group. Ratification through Directorate meeting Safeguarding Children Operational Group (SCOG)

Care Group General Manager confirming approval processes

Debra Shields

Name and Post Title of additional signatories

Not required

Name and Signature of Care Group/Directorate Governance Lead confirming approval by specialty and care group management meetings

{Original Copy Signed}

Name: Caroline Amukusana

Signature of Executive Director giving approval

{Original Copy Signed}

Substance Misuse in Pregnancy, Labour and Post Delivery Clinical Guideline V3.0 Page 9 of 13

Publication Location (refer to Policy on Policies – Approvals and Ratification):

Internet & Intranet Intranet Only

Document Library Folder/Sub Folder Midwifery & Obstetrics

Links to key external standards None

Related Documents:

References 1. Farr SL, Hutchings YL, Ondersma SJ,

Creanga AA. Brief interventions for illicit drug use among peripartum women. American Journal of Obstetrics and Gynecology 2014, 211(4), 336–343. www.ncbi.nlm.nih.gov/pubmed/24721261

2. Terplan M, Ramanadhan S, Locke A et al. Psychosocial interventions for pregnant women in outpatient illicit drug treatment programs compared to other interventions. Cochrane Database of Systematic Reviews 2015. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006037.pub3/p df/standard

3. Turnbull C and Osborn DA. Home visits during pregnancy and after birth for women with an alcohol or drug problem. Cochrane Database of Systematic Reviews 2012. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004456.pub3/p df

4. Minozzi S, Amato L, Bellisario C et al. Maintenance agonist treatments for opiate-dependent pregnant women. Cochrane Database of Systematic Reviews 2013. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006318.pub3/p df (New 2020)

5. Advisory Council on the Misuse of Drugs (2003) Hidden Harm: Responding to the needs of children of problem drug users. London: Home Office.

6. Department of Health (2008) Ante Natal Care. Routine care for the Healthy Pregnant Woman. London

7. Royal Cornwall Hospital NHS Trust (2008) Safeguarding Children – Guidelines for Midwives.

8. Abdel-Latif, M.E, Pinner, J, Clews, S,

Substance Misuse in Pregnancy, Labour and Post Delivery Clinical Guideline V3.0 Page 10 of 13

Cooke, F, Lui, K, Oei, J (2006)Effects of Breast Milk on the Severity and Outcome of Neo Natal Abstinence Syndrome Among Infants of Drug Dependent Mothers. Pediatrics, 117: 1163-9

9. Ruben, S.M, McLean, P.C, Melville, J (1989) Cyclizine Abuse Among a Group of Opiate Dependents Receiving Methadone. British Journal of Addiction 84: 929-934

Training Need Identified? No

Version Control Table

Date Version

No Summary of Changes

Changes Made by (Name and Job Title)

July 2008 V1.0 Initial version Bernie Dolan Specialist Midwife

July 10 V1.1 Updated to include referral form

Bernie Dolan Specialist Midwife

July 12 V1.2 Updated to include compliance monitoring Bernie Dolan Specialist Midwife

April 2017 V2.0 Updated appendices to remove specialist midwife role

Safeguarding team

4th April 2020

V3.0 Updated. Change of name for Addaction service, removed referral from. Alcohol brief advice and screening tool added. Pathway updated

Suzie Williams & Bernie Dolan,

Named Midwives for Safeguarding

All or part of this document can be released under the Freedom of Information

Act 2000

This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing

Controlled Document

This document has been created following the Royal Cornwall Hospitals NHS Trust Policy for the Development and Management of Knowledge, Procedural and Web

Documents (The Policy on Policies). It should not be altered in any way without the express permission of the author or their Line Manager.

Substance Misuse in Pregnancy, Labour and Post Delivery Clinical Guideline V3.0 Page 11 of 13

Appendix 2. Initial Equality Impact Assessment Form

Are there concerns that the policy could have differential impact on:

Equality Strands: Yes No Unsure Rationale for Assessment / Existing Evidence

Age x

Name of the strategy / policy /proposal / service function to be assessed: Substance Misuse in Pregnancy, Labour and Post Delivery Clinical Guideline V3.0

Directorate and service area: Obstetrics & Gynaecology, Maternity Services

New or existing document: Existing

Name of individual completing assessment: Suzie Williams & Bernie Dolan

Telephone: 01872 254551/ 4549

1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at?

For women to be managed sympathetically in pregnancy and help to minimise harm to the woman and children

2. Policy Objectives*

To inform and support midwives in caring for women who present with substances misuse to safeguard women and their children

3. Policy – intended Outcomes*

To encourage women with substance misuse to engage with the maternity service

4. *How will you measure the outcome?

Compliance monitoring Audits

5. Who is intended to benefit from the policy?

Women, Children and Unborn babies

6a Who did you consult with b). Please identify the groups who have been consulted about this procedure.

Workforce Patients Local groups

External organisations

Other

X

Please record specific names of groups Maternity Guidelines Group. Ratification through Directorate meeting Safeguarding Children Operational Group (SCOG)

What was the outcome of the consultation?

Approved

7. The Impact Please complete the following table. If you are unsure/don’t know if there is a negative impact you need to repeat the consultation step.

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Sex (male, female, trans-gender / gender reassignment)

x Applicable to women only

Race / Ethnic communities /groups

x

Disability - Learning disability, physical impairment, sensory impairment, mental health conditions and some long term health conditions.

x

Religion / other beliefs

x

Marriage and Civil partnership

x

Pregnancy and maternity

x

Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian

x

You will need to continue to a full Equality Impact Assessment if the following have been highlighted:

You have ticked “Yes” in any column above and

No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or

Major this relates to service redesign or development

8. Please indicate if a full equality analysis is recommended. Yes No X

9. If you are not recommending a Full Impact assessment please explain why.

Not indicated.

Date of completion and submission

4th April 2020 Members approving screening assessment

Policy Review Group (PRG) Approved

This EIA will not be uploaded to the Trust website without the approval of the Policy Review Group. A summary of the results will be published on the Trust’s web site.

Substance Misuse in Pregnancy, Labour and Post Delivery Clinical Guideline V3.0 Page 13 of 13

Revised March 2017 BD & SW. Review 2020

Appendix 3 Substance Misuse Pathway for Midwives

All women are asked if they or anyone in their household misuse drugs and / or alcohol at Booking YES

No

Repeat the question at any time if their behaviours lead to

believe they may be utilising illicit drugs

and / or alcohol

Antenatal – Offer Referral to Substance Misuse Service ‘we are with you’ – refer via E3 Refer to Obstetric Consultant

Advised to deliver in Consultant Unit

Refer to Anaesthetist if difficult venous access and also screening for Hep C

Community Midwife to provide routine care

Commence Safeguarding Paperwork / Consider MARU Referral

If they respond ‘No’ but you still have concerns refer to

MARU and commence Safeguarding Paperwork.

Discuss concerns

with both your Team Leader and

Safeguarding Midwives.

Community Midwife Share with the woman, the baby will need up to 72 hours Neonatal Abstinence Syndrome (NAS) observations

Ensure serial growth USS or as per Consultant Plan

Discharge plan documented on TR11 Shared Drive

Utilise DNA guideline if needed

Discuss with substance misuse worker if they have one, if not follow referral process.

Labour Notify substance misuse worker & Social Worker (if known to children’s services)

Urine specimen for drug screening, with consent, if woman perceived to be under the influence of substances

Note that the woman may still require analgesia for labour

If using Subutex avoid opiates; epidural preferable

If on Methadone avoid Cyclizine

Notify neonatal team at delivery and ensure senior paediatrician review

Post Natal Timely prescription for woman if on opiate replacement therapy (methadone or subutex)

Neonate 72 hours Neonatal Abstinence Syndrome (NAS) observations depending on drug usage

A discharge planning meeting with professionals may be required when there are safeguarding concerns.

Inform Community Midwife, substance misuse worker & Social Worker (if involved) of discharge.

We Are With You

Will contact the woman within 10 days of receipt of the referral

Will feedback to the community midwife when contact with the woman has been made

Will make and share their plan for frequency of their visits. We Are With You

Will subsequently communicate with the named Community Midwife.