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Substance Use and Addiction During Pregnancy: Identifying Unvoiced Needs

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Substance Use and Addiction During Pregnancy: Identifying Unvoiced Needs SUBSTANCE USE AND ADDICTION DURING PREGNANCY: IDENTIFYING UNVOICED NEEDS JASSIN M. JOURIA, MD DR. JASSIN M. JOURIA IS A MEDICAL DOCTOR, PROFESSOR OF ACADEMIC MEDICINE, AND MEDICAL AUTHOR. HE GRADUATED FROM ROSS UNIVERSITY SCHOOL OF MEDICINE AND HAS COMPLETED HIS CLINICAL CLERKSHIP TRAINING IN VARIOUS TEACHING HOSPITALS THROUGHOUT NEW YORK, INCLUDING KING’S COUNTY HOSPITAL CENTER AND BROOKDALE MEDICAL CENTER, AMONG OTHERS. DR. JOURIA HAS PASSED ALL USMLE MEDICAL BOARD EXAMS, AND HAS SERVED AS A TEST PREP TUTOR AND INSTRUCTOR FOR KAPLAN. HE HAS DEVELOPED SEVERAL MEDICAL COURSES AND CURRICULA FOR A VARIETY OF EDUCATIONAL INSTITUTIONS. DR. JOURIA HAS ALSO SERVED ON MULTIPLE LEVELS IN THE ACADEMIC FIELD INCLUDING FACULTY MEMBER AND DEPARTMENT CHAIR. DR. JOURIA CONTINUES TO SERVES AS A SUBJECT MATTER EXPERT FOR SEVERAL CONTINUING EDUCATION ORGANIZATIONS COVERING MULTIPLE BASIC MEDICAL SCIENCES. HE HAS ALSO DEVELOPED SEVERAL CONTINUING MEDICAL EDUCATION COURSES COVERING VARIOUS TOPICS IN CLINICAL MEDICINE. RECENTLY, DR. JOURIA HAS BEEN CONTRACTED BY THE UNIVERSITY OF MIAMI/JACKSON MEMORIAL HOSPITAL’S DEPARTMENT OF SURGERY TO DEVELOP AN E- MODULE TRAINING SERIES FOR TRAUMA PATIENT MANAGEMENT. DR. JOURIA IS CURRENTLY AUTHORING AN ACADEMIC TEXTBOOK ON HUMAN ANATOMY & PHYSIOLOGY. Abstract All healthcare professionals involved in the prenatal care of women should be observant to the unvoiced needs of the pregnant patient. This includes ongoing evaluation of the expectant mother’s knowledge of labor and delivery, emotional state and health risks. Screening for the risk and the diagnosis of a substance use disorder during pregnancy, as well as correlating socioeconomic and other environmental stressors; and, treatment and follow-up of the mother’s recovery and the child’s development in utero and after birth are discussed. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1 Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. Continuing Education Credit Designation This educational activity is credited for 3 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Statement of Learning Need Identifying existing risks during a woman’s prenatal appointment requires open communication between the clinician and patient regarding substance use, including tobacco use and alcohol consumption, and possibly domestic abuse. Health clinicians must recognize their role to identify the patient’s unvoiced needs. This includes discussing health risks of malnutrition, depression and domestic abuse, which are difficult subjects for women to discuss if not approached carefully by a clinician using compassionate therapeutic communication. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 2 Course Purpose To provide health clinicians with the fundamental knowledge and skills to promote healthy pregnancies, as well as basic concepts that should be well understood by healthcare professionals involved with the perinatal care of expectant mothers exposed to environmental stressors and possibly substance use. Target Audience Advanced Practice Registered Nurses and Registered Nurses (Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion) Course Author & Planning Team Conflict of Interest Disclosures Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures. Acknowledgement of Commercial Support There is no commercial support for this course. Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 3 1. During pregnancy, the issues associated with alcohol are best stated as follows: a. each trimester is affected the same by alcohol consumption. b. alcohol consumption is safest during the first trimester. c. consuming alcohol only causes mild behavioral changes. d. there is no safe amount of alcohol. 2. Signs and symptoms of fetal alcohol syndrome in the neonate include: a. heart defects. b. small and narrow eyes. c. smooth upper lip. d. All of the above. 3. The chemical substance, cotinine, is detectable in patient’s urine for __________ following cigarette use. a. 3 to 5 days b. for a month c. for 24 hours d. up to ten days 4. The fetus of a smoking mother is more likely to develop a. congenital malformations. b. preeclampsia. c. diabetes. d. Chadwick’s sign. 5. True or False: According to the American College of Obstetrics and Gynecology, women should be screened for tobacco use at their initial prenatal appointment on a case-by-case basis. a. True b. False nursece4less.com nursece4less.com nursece4less.com nursece4less.com 4 Introduction Substance use during pregnancy is not uncommon. Pregnant women have been found to consume alcohol during the first trimester of pregnancy, and both illicit and prescription drug use have become a public health concern for women during pregnancy. Fetal exposure to substances affects normal fetal development and is associated with a high rate of low birth weight and childhood development and cognitive impairment. Health professionals must approach the subject of substance use during prenatal visits in a careful manner and from a position of being nonjudgmental and of providing unconditional support. The Prenatal Visits During prenatal visits the health clinician should identify unvoiced needs of the prenatal patient. Utilizing therapeutic communication to discuss these sensitive issues with women during pregnancy is essential when trying to understand their perspective and obstacles. Some commonly unvoiced needs are associated with lack of a support system, domestic abuse, depression, substance use and malnourishment. Malnourishment, may include weight loss, inability to gain weight, or reported consumption of processed foods low in nutritional value. Lack of a support system is linked to postpartum depression,1 a serious mental health issue that can affect recovery following birth and maternal-infant bonding. A lack of support during pregnancy also correlates with depression in pregnancy and difficulty with labor and breastfeeding in the postpartum phase.2 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 5 Depression can affect the developing fetus leading to low birth weight, pre-term delivery and even cognitive abnormalities. Many women feel ashamed of their depression and will not report their feelings of sadness, lethargy, or anhedonia to their health team. Clinicians should evaluate the prenatal clients’ emotional state during every follow-up. Substance use is fairly common during pregnancy. In fact, a national survey found that 18 % of pregnant women drank alcohol during their first trimester.3 The number of women using opioid medication reportedly was increased; nearly 25 % of women of childbearing age used opioid medications every year.4 Such statistics confirm the important need for clinicians to delicately approach the subject of substance use and addiction with pregnant women during prenatal visits, and from a position of total support. The risk of physical abuse is increased for pregnant women, an alarming fact that all health team members should be monitoring during prenatal visits. Unexplained bruising, depression and late initiation of prenatal care should be a warning sign that physical abuse may be occurring. In addition to these considerations, other needs may need to be identified later on during the prenatal visit. Education on normal and abnormal pregnancy symptoms, as well as what symptoms require a phone call to the physician or a trip to the emergency room should be discussed. Signs of labor and the process of labor should not be assumed knowledge and the clinician should review this with the patient before her delivery date. The pregnant woman and her spouse should also be encouraged to take a prenatal labor preparation course. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6 Lochia bleeding (bleeding in the postpartum phase) should be discussed. Lochia that stops completely and then restarts or lochia that is getting heavier rather than lighter may require urgent intervention. Breastfeeding is also a common concern for pregnant mothers nearing their delivery date. Health staff should ask perinatal patients if they have any questions and ask what they know about breastfeeding. Some women should be prompted to attend breastfeeding courses or schedule an appointment with a lactation consultant. Many mothers worry about returning to work after the birth of their child. Prenatal clients should be asked about their plans and given resources and support for ideas if they are unsure about daycare or the ability to cope with leaving their infant. Substance Use And Early Identification The main theme of this section is the early identification of substance use in pregnant women, which can often be a difficult topic to approach during a
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