Revised Good Practice Guidelines Women, Pregnancy and Substance Misuse Protocol Reference: 009/250810 Date of Issue: September 2010 Prepared by: Lorna MacAskill, Midwifery Date of Review: September 2012 Development Of!cer, Sandra Harrington, Consultant Midwife Lead Reviewer: Sandra Harrington, Version: 2 Consultant Midwife Rati!ed by: Nursing, Midwifery & AHP Date: 25th August 2010 Policies, Procedures and Guidelines Group EQIA undertaken: 6th July 2010 EQIA Completed: 25th August 2010 Distribution: • Board Nurse Director • Youth Justice Strategy Group • Lead Midwives/Midwives • Highland Alcohol and Drug • University of Stirling Partnership (HADP) - Highland Campus Midwifery Dept • Argyll and Bute Alcohol and Drug • University of Paisley - Midwifery Dept Partnership (ABADP) • Lead Nurses/Health Visitors • Area Medical Committee • Osprey House • Councils on Alcohol • CPN(A)s including dual Diagnosis Workers • Women’s Aid • GPs & GP Sub Group • Action for Children • Obstetricians • APEX • Directorate Managers/Clinical Services Managers • Northern & Strathclyde Police • Assistant General Managers/Locality Managers • Local Authority: • Homeless Day Centre • Team Managers for children and • Connecting Young Carers families • Beechwood • Integrated Services Of!cers • Caley House • Integrated Services Co-ordinators • Direct Health Services Management Team • Fostering Service • Nursing, Midwifery & AHP Leadership Committee • Youth Action Teams • Clinical Governance Department • Argyll & Bute Head of Children’s • Child Protection Action Group Services - Highland and Argyll & Bute • STRADA, Highland Method CD Rom Email ü Paper Intranet ü Warning - Document uncontrolled when printed Version: 2 Date of Issue: September 2010 Page 1 Date of Review: September 2012 Contents Women, Pregnancy & Substance Misuse Revised Good Practice Guidelines Page no Foreword 4 Summary of Guidelines 6 1. Background 7 2. The Principles of Addressing Health Behaviour Change 8 3. The Substances 3.1 Smoking 10 3.1.1 Smoking Cessation Pathway 13 3.1.2 Nicotine Replacement Therapy 14 3.1.3 Smoke-Free Homes Project 14 3.2 Alcohol 15 3.2.1 Alcohol Care Pathway 19 3.2.2 Alcohol Brief Interventions 20 3.2.3 T-ACE Alcohol Audit Tool 22 3.3 Drugs 3.3.1 Drugs and their effects in pregnancy 25 3.3.2 Referral Pathway when working with female 27 substance misusers 3.3.3 Methadone Use in Pregnancy 28 4. The Challenges 4.1 The Extent of the Problem 29 4.2 Multi-agency W orking and Information Sharing 30 4.3 Keeping Children Safe 32 4.4 Mental Health 34 4.5 Domestic Abuse 35 4.6 Equality and Diversity 36 4.7 Training and Development 37 Warning - Document uncontrolled when printed Version: 2 Date of Issue: September 2010 Page 2 Date of Review: September 2012 Page 5. The W oman’s Journey 5.1 Antenatal Care 38 5.2 Booking Appointment 39 5.3 Care Schedule: Substance Misuse in Pregnancy 40/41 5.4 Booking Bloods 42 5.5 Blood Borne Viruses 42 5.6 Role of Secondary Obstetric Services 44 5.7 Ongoing Antenatal Care 45 5.8 Neonatal Abstinence Syndrome 46 5.9 Missed Appointments 48 5.10 Ultrasound Scans 48 5.11 Pre-birth Planning Meeting 49 5.12 Admission 50 5.13 Con!dentiality W ithin the W ard 50 5.14 Labour and Pain Relief 50 5.15 Postnatal Care 51 5.16 Infant Feeding 52 5.17 Discharge Planning Meeting 53 5.18 Contraception 54 5.19 Prior to Discharge 54 5.20 Ongoing Postnatal Care 55 6. Conclusion 56 7 References 57 Appendices 1. Contacts 60 2. Useful websites 63 3. NRT Pregnancy Risk/bene!t Assessment 64 4. Smoking Cessation Referral form 65 5. Neonatal Abstinence Score Sheet 66 6. Caring For a Baby W ith Drug W ithdrawals 67 7. Contributors 68 8. Glossary 69 Warning - Document uncontrolled when printed Version: 2 Date of Issue: September 2010 Page 3 Date of Review: September 2012 Forew ord The foundations for health and wellbeing are established in the earliest moments of life (For Highland’s Children 3). Pregnancy offers an opportunity for integrated children’s services in Highland to provide effective intervention to ensure the best possible care is provided to promote the wellbeing of women and their infants pre-conceptually, throughout pregnancy and into parenthood. A signi!cant number of children are affected by substance misusing parents. (Hidden Harm- Next Steps 2006). Moreover there is growing evidence that there is a relatively narrow window of opportunity for intervention in a child’s early years: lack of adequate nurture is likely to have a long-term damaging effect, with children going on to live chaotic lives themselves. Research suggests that women who misuse substances, and their infants, have better outcomes if they take up antenatal care early and if they use services consistently throughout pregnancy (Scottish Executive 2003). Pregnancy may motivate many women to access support for substance misuse issues but some may feel inhibited due to feelings of guilt or fear that their children may be removed from them (Hidden Harm-Next Steps 2006). Services therefore need to be accessible, welcoming and empowering for those women affected by substance misuse, just as they do for others (Scottish Executive 2003). Services need to identify and address the social, physical and emotional needs of the whole family, mindful of the risks and measures that may be required to support vulnerable women, their partners and children. Getting It Right For Every Child - Girfec (Scottish Government 2008) supports this approach and aims to ensure that all children in Scotland are at the centre of care provision and that children and families get the help they need, when they need it. The pathway detailed in this guidance represents best practice for maternity staff across Highland. Hidden Harm-Next Steps identi!es best practice as: “...providing support and encouragement to parents who have sought help for their substance misuse during pregnancy so that they continue with their treatment after the birth of their child”. Other agencies involved with pregnant women who misuse substances have a critical role to play in supporting vulnerable women and will also !nd this guidance useful. The interests of the child and the mother are inextricably linked: maternity services and those who are helping the parent tackle their substance misuse must work closely together (Hidden Harm-Next Steps 2006). The Early Years Framework (Scottish Government 2008) recognises the impact our experiences pre-birth and during the early years have on our adult life and supports an early intervention and prevention approach. Girfec offers practitioners across all agencies the same practice models and tools to enable robust assessment and planning of care within a health and social context. Warning - Document uncontrolled when printed Version: 2 Date of Issue: September 2010 Page 4 Date of Review: September 2012 Much of Scottish Government policy is focused on tackling health inequalities and improving the nation’s health: • The Health Improvement HEAT Targets (Health Improvement, Ef!ciency, Access and Treatment) include national goals to reduce alcohol use and smoking rates. • Hidden Harm-Next Steps Supporting Children - W orking with Parents • Early Years Framework (antenatal to eight years). • Equally W ell: Implementation Plan • Better Health, Better Care: Scotland’s Action Plan for Health These policies and plans are available from the Scottish Government website: www.scotland.gov.uk/publications “Women, their partners and their families should always be treated with kindness, respect and dignity. The views, beliefs and values of the woman, her partner and her family in relation to her care and that of her baby should be sought and respected at all times.” (NICE 2008). Inequality and social exclusion have an impact on health and it is essential that appropriate information, support and referral are provided to all women based on need (NHS QIS 2009). This also applies to women who have problems with drug or alcohol misuse, who should have access to a full range of services within a multi-disciplinary assessment process. Good practice in maternity care can help to provide the necessary early links with families and ensure that resources are in place to enable everyone to work together to provide a coherent and responsive service. Warning - Document uncontrolled when printed Version: 2 Date of Issue: September 2010 Page 5 Date of Review: September 2012 Sum m ary of Guidelines n Pregnant women who misuse substances should be managed according to best practice as stated in ‘Getting Our Priorities Right: Good Practice Guidance for W orking with Children and Families affected by Substance Misuse’ (Scottish Executive Health Department, 2003). n Staff who are taking a booking history should always ask sensitively but routinely about all substance misuse. The Scottish W oman Held Maternity Record (SW HMR) contains sections relating to the use of tobacco, alcohol and prescribed or illicit drugs. n W hen appropriate, staff should deliver a ‘brief intervention’ regarding smoking or alcohol use. If required, women can be referred for specialist smoking cessation support or additional support from specialist alcohol/drug services. n Information on any social problems that could affect medical and social outcomes of pregnancy, including substance misuse, should be documented in the SW HMR and summary sheet. The Girfec approach should be used to enable robust assessment and planning of care for women and their babies. n There are challenges for service providers to engage with women whilst balancing the needs of their children. Obstetricians, midwives and addiction services need to be aware of the laws and issues that relate to child protection. If they have any concerns they must refer to the Highland Child Protection Guidelines or contact their designated Child Protection Advisor for advice. n All staff supporting pregnant women who have drug or alcohol problems, including obstetricians, GPs, midwives, health visitors, social and addiction services, require ongoing training so that they have the knowledge and skills required to identify problems, assess severity and refer women to other appropriate, specialist services.