Guidelines for Supporting Midwives in Caring for Women Who Are Involved in Substance Use

Powys Teaching Local Health Board Title: Guidelines to support midwives when caring Directorate: Women’s and Children’s for women who are involved in substance use. Author: Lewis, Owen, Revell Code: PtHB/MAT 003

GUIDELINES FOR SUPPORTING MIDWIVES IN CARING FOR WOMEN WHO ARE INVOLVED IN SUBSTANCE USE

Policy Code Date Version Number Planned Review Date PTHB/MAT June 2009 1st Issue August 2012 003

Feb 2012 2nd Issue: Reviewed Feb 2015 and updated with RCOG Guidelines (2010)

Document Owner Approved By Date Women and Children’s Women’s and 29/03/12 Directorate Children’s Directorate Clinical Effectiveness Committee 16/04/12

Document Type Guidelines

Bwrdd Iechyd Addysgu Powys yw enw gweithredol Bwrdd Iechyd Lleol Addysgu Powys Powys Teaching Health Board id the operational name of Powys Teaching Local Health Board

Issue Date: 2009 Page 1 of 22 Review Date: 2015

Status: Final Approved by: Clinical Effectiveness Committee 16/04/12 Powys Teaching Local Health Board Title: Guidelines to support midwives when caring Directorate: Women’s and Children’s for women who are involved in substance use. Author: Lewis, Owen, Revell Code: PtHB/MAT 003

GUIDELINES FOR SUPPORTING MIDWIVES IN CARING FOR WOMEN WHO ARE INVOLVED IN SUBSTANCE USE

Contents Page

Validation Form 3

Equality Assessment 4

Relevant to 5

Purpose 5

Definitions 5

Responsibilities 5

Process 5

References 5

Appendices

For Reviewed / Updated Policies Only:

Relevant Changes – Date

2nd Issue: Reviewed and updated with RCOG Guidelines 29/03/12 (2010)

VALIDATION & RATIFICATION

Title: GUIDELINES FOR SUPPORTING MIDWIVE IN CARING FOR WOMEN WHO ARE INVOLVED IN SUBSTANCE USE Authors: Marie Lewis Practice Development Midwife, Donna Owen – Lead Midwife North Powys, Denise Revell Integrated Midwife Directorate: Women and Children’s Reviewed/Updated by: Marie Lewis Practice Development Midwife, Donna Owen – Lead Midwife North Powys, Denise Revell Integrated Midwife Approved for submission by: Cate Langley Date: 14/03/12

Evidence Base

Are there national guidelines, policies, legislation or standards relating to this subject area?

If yes, please include below:

British Medical Association Board of Science (2007): Fetal Alcohol Spectrum Disorders – A guide for healthcare professionals. BMA, London.

Centre for Maternal and Child Enquiries (2011): Saving Mothers’ Lives – Reviewing maternal deaths to make motherhood safer: 2006-2008. CMACE, London.

Day E, George S (2005): Management of Drug Misuse In Pregnancy. Advances In Psychiatric Treatment (2005) 11: 253-261. Article available at http://apt.rcpsych.org/content/11/4/253.full

Department of Health (England) and the Devolved Administrations (2007): Drug Misuse and Dependence – UK guidelines on clinical management. DoH (England), Scottish Government, Welsh Assembly Government and Northern Ireland Executive

Helpwithsmoking.com: The effects of smoking on the unborn child and complications of pregnancy and birth available at www.helpwithsmoking.com (accessed 20/2/12)

CONSULTATION

Please list the groups, specialists or individuals involved in the development &

Status: Final Approved by: Clinical Effectiveness Committee 16/04/12 Powys Teaching Local Health Board Title: Guidelines to support midwives when caring Directorate: Women’s and Children’s for women who are involved in substance use. Author: Lewis, Owen, Revell Code: PtHB/MAT 003 consultation process:

Name Date

Powys Midwives 26.2.2012

Supervisor of Midwives 26.2.2012

Practice Development Midwife 26.2.2012

Agreed by Women’s and Children’s Directorate 26.2.2012

Agreed by Head of Midwifery 26.2.2012

Please insert the name of the Directorate/ Departmental/Discipline Committee or Group that has approved this policy/procedure/guidelines/protocol

Name Date

Women’s and Children’s Directorate 26/02/12

Clinical Effectiveness 16/04/12

Implications Please state any training implications as a result of implementing the policy / procedure. . None Please state any resource implications associated with the implementation. No Additional Resources required Please state any other implications which may arise from the implementation of this policy/procedure. none

For Completion by Quality & Safety Unit

Checked by: Date:

Submitted to CEC: Date:

Equality Assessment Statement

Please complete the following table to state whether the following groups will be adversely, positively, differentially affected by the policy or that the policy will have no affect at all.

Risk Assessment Equality statement Are there any new or additional risks arising from the implementation l t e e a c s i v

of this policy? None i a t r t p i e n s v e m r o d Do you believe thati they are adequately controlled? N/A.

e P A f o f i N

D Comments

Disability X

Gender X Woman focused midwifery policy

Race X

Religion/ x Belief

Sexual X Orientation

Welsh X Language

Human X Rights

Relevant to:

Local guideline for all midwives working in Powys.

Purpose:

The overall aim must be to provide safe and effective care to a woman in pregnancy, whilst allowing her to make an informed choice from the care options available to her. All agencies are responsible for identifying 5

Status: Final Approved by: Clinical Effectiveness Committee 16/04/12 Powys Teaching Local Health Board Title: Guidelines to support midwives when caring Directorate: Women’s and Children’s for women who are involved in substance use. Author: Lewis, Owen, Revell Code: PtHB/MAT 003 pregnant women with substance/alcohol misuse problems who may be in need of additional services and support.

Responsibilities

All midwives working within Powys hold a recognised midwifery qualification. No additional qualifications are required to carry out this policy. Midwives will be required to attend yearly obstetric emergency drills as part of their midwifery updates.

Monitoring

This policy will be monitored through clinical midwifery supervision, issues raised through training days and the Datix reporting system.

Purpose: GUIDELINES FOR SUPPORTING MIDWIVES IN CARING FOR WOMEN WHO ARE INVOLVED IN SUBSTANCE USE

Introduction

International comparisons of the prevalence of drug misuse are difficult due to the differences in data collection and analysis. However, studies consistently show that the UK has among the highest rates of recorded illegal drug misuse in the Western world (DoH 2007). It is assumed that 3% (n=20490) of maternities are to substance misusers (NICE 2010). Drug misuse can place an enormous strain on the families of drug misusers, including the children of drug misusing parents. It can also have a serious negative impact on the long-term health and wellbeing of family members. Effective support and treatment can have a positive impact on improving the quality of life for families and carers, as well as having major benefits for the fetus and child.

Accessibility is an essential component in the provision of maternity care. Many women who use substances often feel guilty and worried about the effect their use will have on the unborn baby. Due to this they can appear reluctant to disclose or seek advice from health professionals (Klee et al 2002). There is evidence that concern over disclosure of personal circumstances, such as substance misuse, migrant status and domestic 6

Status: Final Approved by: Clinical Effectiveness Committee 16/04/12 Powys Teaching Local Health Board Title: Guidelines to support midwives when caring Directorate: Women’s and Children’s for women who are involved in substance use. Author: Lewis, Owen, Revell Code: PtHB/MAT 003 abuse, is a barrier to women accessing antenatal care. For this reason it is vital that healthcare professionals explain the reasons why such details are needed, with whom they will be shared, and why this sharing of information is important (NICE 2010). It is imperative that midwives adopt a non-judgmental manner when caring for women to ensure that informed decisions are made in relevance to ongoing care and ensure partnership working (DoH 2007)

Saving Mothers’ Lives (2007 and 2011) drew attention to the fact that socially excluded women are at higher risk of death during or after pregnancy than other women. During the triennium 2006-2008, 26% of the mothers who died were poor or non-attenders for antenatal care (CMACE 2011). It was also identified that substance misuse, including occasional drug use and alcoholism, was a characteristic in 48 women who died (44%)

Fortunately the majority of pregnant substance users will experience a normal pregnancy, labour and delivery, and most babies will be of a normal term birth weight. However, there are also identified risks to the neonate, depending on the substance used, which are detailed below.

Warning Signs and Symptoms of Possible Substance Use:

 Sedation

 Inebriation

 Euphoria

 Agitation

 Aggressiveness

 Paranoia

 Increased physical activity

 Anxiety and nervousness

 Disorientation

 Depression

 Irritability

 Suicidal ideations or attempts

 Dilated or constricted pupils

 Rapid eye movements

 Tremors

 Track marks, abscesses or injection sites

 Inflamed or eroded nasal mucosa

 Nose bleeds

 Tachycardia

 Hypertension

 Increased body temperature

 Hair loss

 Hallucinations

 Nystagmus

 Gum or periodontal disease

 Skin conditions

 Weight loss/low BMI

 Anaemia

 Frequent hospitalisations

 Chronic mental illness

Women who are pregnant (which is often unplanned) and misuse substances often face other issues including:

 Family history of substance abuse

 Physical or sexual abuse as a child

 Domestic violence

 Sexually transmitted infections

 HIV

 Poor nutrition

 Psychological disorders including depression, anxiety, eating disorders and severe mental illness

 Medical problems such as hepatitis, liver disease and pancreatitis

 Tobacco use

 Dental disease

 Breastfeeding challenges and barriers

Actions:

 Full booking history (preferably before 10 weeks gestation), to include discussion around lifestyle, family and social issues. Midwives need to be mindful that a woman’s lifestyle choices should be respected providing an informed choice has been made

 Excellent communication and multi-agency working to ensure appropriate care to meet woman/family needs whilst respecting the woman’s confidentiality and personal wishes

 Involvement of woman and family/carers in planning care. Encourage women to engage with services, and inform health professionals of any change of circumstances e.g. address

 Consider child protection/child in need concerns – referral as appropriate

 Early referral to obstetrician to plan care for pregnancy/labour and postnatal period

 Ensure continuing support from other agencies e.g. Kaleidoscope (formerly PDAC), CAIS [if under 18], IFSS team involvement and refer as appropriate

 Advise delivery in Consultant Led Unit due to increased risks to neonate

 NICE recommend women have at least one opportunity to attend a one to one consultation with a health professional with no other person available (unless an interpreter is required in which case it should not be a family member)

Alcohol

Studies report that there is little standardisation in definitions of low, moderate and heavy drinking. The Office for National Statistics defines heavy drinking as six or more units on at least one day in the week. Binge drinking can be considered to refer to heavy drinking during the space of an evening or similar time-span (BMA 2007). Data on rates of drinking in pregnancy are based on self-reporting, and therefore are often unreliable. Alcohol is teratogenic (crosses the placenta), and the damage caused on the developing fetus is dependent on the level of maternal alcohol consumption, and at what stage of the pregnancy it is consumed. Women who binge drink are more likely to have children with facial dysmorphology, cardiac anomalies or cognitive impairment than women who drink the same amount of alcohol over an extended period of time.

Risks To Mother:

 Infertility

 Miscarriage

 Preterm labour

 Stillbirth 10

Risks To Fetus/Baby

 Reduced fetal movements

 Intra-uterine growth retardation/low birth weight

 Fetal Alcohol Syndrome

 Facial anomalies

 Abnormal neurodevelopment including decreased cranial size, structural brain abnormalities, impaired fine motor skills, hearing loss, poor co-ordination

 Failure to thrive

 Behavioural and cognitive abnormalities

 Cardiac anomalies (atrial and ventricular septal defects)

 Hypoplastic kidneys

 Hydronephrosis

At present there is no clear evidence to identify what level of drinking is harmful to a pregnant woman and her baby. NICE advises the following recommendations for alcohol consumption in pregnancy:

 Pregnant women and women planning a pregnancy should be advised to avoid drinking alcohol in the first 3 months of pregnancy if possible because it may be associated with an increased risk of miscarriage.

 If women choose to drink alcohol during pregnancy they should be advised to drink no more than 1 to 2 UK units once or twice a week (1 unit equals half a pint of ordinary strength lager or beer, or one shot [25 ml] of spirits. One small [125 ml] glass of wine is equal to 1.5 UK units). Although there is uncertainty regarding a safe level of alcohol consumption in pregnancy, at this low level there is no evidence of harm to the unborn baby.

 Women should be informed that getting drunk or binge drinking during pregnancy (defined as more than 5 standard drinks or 7.5 UK units on a single occasion) may be harmful to the unborn baby.

Antenatal Care

 Encourage honest disclosure regarding alcohol use at booking  Discuss NICE guidelines regarding alcohol and pregnancy  Discuss risks associated with heavy alcohol use  Encourage women to engage with antenatal care  Offer support and referral to appropriate agency (Kaleidoscope – formerly PDAC) if not already attending  Early referral to consultant obstetrician for plan of care for pregnancy/birth/postnatal period  Consider child protection/child in need issues and refer as necessary  Antenatal care to be planned in accordance to individual needs  Assess fetal well being/growth at each antenatal appointment, with appropriate referral if any concerns  Ensure excellent multi-agency communication and documentation to ensure appropriate plan of care and support is in place  Consider parenting support e.g. one to one, Action for Children groups, peer support groups  Plan of care to be documented in held notes and reviewed/updated at each antenatal contact  Discuss possibility of baby being admitted to neonatal unit following delivery for observation

Labour

 Recommend delivery at District General Hospital (DGH) in view of increased risks to neonate (see above)  Women choosing to remain in Powys for delivery should have a clinical alert completed following discussion with a Supervisor of Midwives (SoM). Also consider child protection issues  If Social Services involvement inform them of admission in labour and delivery (according to child protection plan)

Postnatal Care

 Plan postnatal care in accordance to woman’s/family needs  Monitor well being of mother and baby at each postnatal contact  Assess parenting skills/bonding at each contact  Continue multi-agency support regarding alcohol use  Continue to assess and address child protection issues  Plan of care to be documented in postnatal pathway  Ensure adequate handover of care to health visitor

Smoking (Tobacco)

It is estimated that up to 25% of women who smoke stop before their first antenatal appointment. However, 27% of women in the UK report that they are current smokers at the time of the birth of their baby (NICE 2008). The British Market Research Bureau (2007) found that mothers who had only been advised to give up smoking were much more likely to quit compared to mothers who had only been advised to cut down (36% and 8% respectively). In the triennium 2006-2008, 28% of the women who died were identified as current smokers (CMACE 2011).

Tobacco smoke contains more than four thousand harmful chemicals, a number of which are known to be carcinogenic to humans, whilst others are highly toxic and poisonous. The chemicals most likely to affect the development of the fetus include nicotine, tar and carbon monoxide.

Risks To The Mother:

 Ectopic pregnancy  Miscarriage  Placenta previa  Placental abruption  Thromboembolism  Tachycardia  Hypertension  Maternal respiratory problems  Thrush  Premature rupture of membranes

 Reduced absorption of vital vitamins and folic acid

Risks To The Fetus/Baby:

 Reduced oxygen supply in-utero  Reduced fetal movements  Intra-uterine growth retardation/low birth weight  Fetal tachycardia  Fetal distress  Reduced lung capacity  Premature birth  Stillbirth  Respiratory problems  Early neonatal death/cot death  Psychological and behavioural problems

Antenatal Care

 Assess smoking status at booking (current and past)

 Discuss risks associated with smoking (including passive smoking)

 Advise women to give up rather than cut down (NICE 2010)

 Offer referral to smoking cessation services and document as appropriate

 Discuss use of nicotine replacement therapy - advise to remove patches at bedtime (NICE 2010)

 Review smoking status throughout pregnancy and update management plan accordingly

 Continue to assess fetal growth/well being – refer if any concerns

Labour

 NICE do not have any specific guidelines for place of delivery for women who smoke

 Identify any other underlying risks which may require delivery in a consultant unit e.g. small for gestational age, concerns regarding fetal wellbeing, maternal hypertension, placental problems

Postnatal Care

 Support and encourage woman/family to cut down or stop smoking

 Discuss health risks to mother and baby including increased risks of respiratory problems, and cot death

 Plan of care to be documented in postnatal pathway

 Ensure adequate handover of care to health visitor

ILLICIT DRUGS

Whilst this list is useful it is not exclusive and other substances such as legal highs should also be considered.

Cannabis

Cannabis is the most widely used illegal drug in the western world. The direct effects of cannabis on the fetus are uncertain but may be harmful. Cannabis use is often associated with smoking tobacco which is known to be harmful. Because of this women should be discouraged from using cannabis during pregnancy (NICE 2008)

Risks To Mother

 Depression

 Lethargy

 Paranoia

 Memory loss

Risks To Fetus/Baby

 Effects of cannabis on the fetus are uncertain

 Risks associated with cigarettes

Cocaine

Cocaine is available as a powder that can be snorted or injected, or as ‘crack’ that is more suitable for smoking. Cocaine appears to have a low specific teratogenicity, however, maternal cocaine use during pregnancy has still been associated with numerous maternal, fetal and neonatal problems. Currently there are no safe drug substitutes for cocaine suitable in pregnancy, and treatment is often a combination of symptomatic and psychosocial interventions during the withdrawal phase.

Risks To Mother

 Risks associated with lifestyle e.g. poor nutrition

 Placental abruption

 Spontaneous abortion

 Pre-eclampsia

Risks To Fetus/Baby

 Intrauterine growth retardation

 Pulmonary oedema

 Seizures

 Cardiac arrhythmias

 Congenital anomalies affecting mostly ocular and urogenital systems

 Neonatal intoxication

 Irritability 16

 Hypertonia

 Sleep and appetite disturbances

Opiates

Heroin is a relatively short acting drug. The cycle of withdrawal and intoxication places stress on the fetus, and withdrawal in particular has been associated with fetal death. Often street heroin is adulterated with other substances to increase the bulk, causing other problems to the fetus.

Methadone can reduce the incidence of obstetric and fetal complications. A successful maintenance programme can stabilise a woman’s drug use and lifestyle, which may increase their uptake of antenatal care. Research evidence has consistently shown that women who receive methadone maintenance therapy during pregnancy have better outcomes than women who remain on heroin. Methadone should be continued throughout the whole pregnancy, and because of the metabolism of methadone is increased in pregnancy, previously stable women may experience withdrawal symptoms in the third trimester.

Risks To Mother

 Risks associated with lifestyle are increased (poverty, infection, poor nutrition, housing etc)

 Risks associated with cigarette smoking (see above)

 Risk of miscarriage in first trimester due to withdrawal

Risks To Fetus/Baby

 Intrauterine growth retardation/low birth weight

 Prematurity

 Neonatal Abstinence Syndrome (NAS)

 Fetal and neonatal death

Neonatal Abstinence Syndrome

Any opioid (including methadone) used by the mother during pregnancy can result in Neonatal Abstinence Syndrome (NAS). The clinical signs of NAS occur in 48-94% of infants exposed to opioids in utero, with signs of withdrawal from methadone being more common than from heroin (Day and George 2005). NAS occurs with notable variability, and its severity is not related to maternal methadone dose or cumulative methadone exposure in utero, i.e. babies of women on low doses of methadone are as equally likely to suffer NAS as babies whose mothers are taking higher doses. NAS frequently results in significant morbidity and prolonged hospital stays. Presenting symptoms of NAS generally occur within the first 24-72 hours, although some infants can present with significant symptoms up to four weeks of age.

Signs and Symptoms of NAS

 Excessive cry

 Restlessness

 Irritability

 Exaggerated Moro reflex

 Tremors

 Increased Muscle Tone

 Generalised seizure

 Hyperthermia

 Excoriation of skin

 Yawning

 Sweating

 Nasal stuffiness

 Sneezing

 Tachypnea (resps > 60/min)

 Poor feeding

 Vomiting

 Loose stools

 Failure to thrive

Remember Naloxone can precipitate acute withdrawal symptoms in babies of mothers who use opiates and should not be used in neonatal resuscitation

Supportive measures for a neonate with NAS include:

 Keeping the baby in a quiet dimly lit room

 Close gentle interaction with mother

 Small frequent feeds

 Close monitoring by nursing and medical staff

Antenatal Care

 Women are often poor attenders

 Detailed history about lifestyle as well as current and previous drug use (illicit and prescription). Remember to be non-judgemental

 Encourage women to make lifestyle changes for the benefit of her health and the baby’s – pregnancy is often seen as ‘the window of opportunity’

 Effective multi-agency working, involving the woman and her family, to ensure the best outcome for pregnancy and birth

 Consider child protection issues with appropriate referrals as necessary. Information to be forwarded to DGH

 Early referral to DGH for obstetric opinion regarding care in pregnancy/labour and postnatal period

 Encourage women to continue support with agencies such as Kaleidoscope, CAIS and IFSS to ensure appropriate monitoring of drug use, methadone therapy and family support.

 Discuss recommendations to deliver in a DGH, and the possibility of baby being admitted to a neonatal unit for observation

 Management plan to be completed in hand held notes and reviewed/updated at each contact

Labour

 Delivery at a DGH should be recommended

 Women choosing to stay in Powys for delivery should have a clinical alert completed following discussion with a Supervisor of Midwives (also consider child protection issues)

 Inform Social Services (if involved) when admitted in labour and following delivery, according to child protection plan

 Pain relief will need special attention with a low threshold for considering the use of epidural

 Increase risk of fetal hypoxia, fetal distress and meconium due to placental insufficiency

 Naloxone is not suitable for neonatal resuscitation

Postnatal Care

 It is likely that a postnatal stay in a DGH will be required to observe for signs of NAS

 Ensure that parents have emergency contact numbers following discharge in case of any concerns

 Advise to continue monitoring the baby for signs of NAS and contact a health professional immediately if concerned

 Postnatal visiting to planned according to individual needs/child protection plan

 Breastfeeding to be encouraged except where the mother uses cocaine, crack cocaine or very high doses of benzodiazepines. Specialist advice should be sought where the mother is HIV or Hepatitis C positive

 Inform relevant agencies e.g. Social Services once mother and baby have been discharged home

 Assess parenting skills and offer support and guidance as necessary

 There is an increased risk of postnatal depression

 Multi-agency communication and documentation should be of a high standard, especially when discharging from maternity services to health visitors

Also Refer To The Following Policies:

All Wales Birth Centre Guidelines All Wales Child Protection Guidelines Antenatal Care Guidelines Children of Parents Who Misuse Alcohol or Substances Guideline Guideline for Assessing Fetal Growth Mental Health Guideline

References:

British Medical Association Board of Science (2007): Fetal Alcohol Spectrum Disorders – A guide for healthcare professionals. BMA, London.

Centre for Maternal and Child Enquiries (2011): Saving Mothers’ Lives – Reviewing maternal deaths to make motherhood safer: 2006-2008. CMACE, London.

Day E, George S (2005): Management of Drug Misuse In Pregnancy. Advances In Psychiatric Treatment (2005) 11: 253-261. Article available at http://apt.rcpsych.org/content/11/4/253.full

Department of Health (England) and the Devolved Administrations (2007): Drug Misuse and Dependence – UK guidelines on clinical management. DoH (England), Scottish Government, Welsh Assembly Government and Northern Ireland Executive

Helpwithsmoking.com: The effects of smoking on the unborn child and complications of pregnancy and birth available at www.helpwithsmoking.com (accessed 20/2/12)

Klee H, Jackson M, Lewis S (2002): Drug Misuse and motherhood. Routledge, London

National Institute for Health and Clinical Excellence (2007): Intrapartum Care – Care of healthy women and their babies during childbirth. NICE, London

National Institute for Health and Clinical Excellence (2008): Antenatal Care – Routine care for healthy pregnant women. NICE, London

National Institute for Health and Clinical Excellence (2010): How To Stop Smoking In Pregnancy And Following Childbirth – Public Health Guidance 26. NICE, London

Royal College of Obstetricians and Gynaecologists-Commissioned by NICE (2010): Pregnancy And Complex Social Factors – A model for service provision for pregnant women with complex social factors. NICE, London

Washington State Department of Health (2009): Substance Abuse During Pregnancy – Guidelines for Screening. Washington DoH, USA

Status: Final Approved by: Clinical Effectiveness Committee 16/04/12