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									What We Did About Prenatal
     Substance Abuse

      Judy Whitecrane MSN, CNM
    Director, Nurse-midwifery Service
        Kimberly A. Couch, CNM
     Phoenix Indian Medical Center
    Phoenix Indian Medical Center
       Obstetrics Department
   900 deliveries per year
    – 8 CNM’s & 8 MD’s
    – Approx. 150 + UDS at birth
   Level II Nursery
   Active Caseload-700 prenatal clients
    – 625 CNM patients
    – 75 MD (Hi risk)
    – 30 (5%) in “Special Care Clinic”
         Projected Deliveries 2007
   Projected 168
    positive Urine Drug
    Screens on admission.                          PIMC Total Deliveries

   168 babies potentially   1000                                             950
    to be taken from their   800     742     782       772     784

    moms.                    600
   168 families, already    200
    struggling, to be          0
                                    2001   2002      2003    2004    2005    2006
    fragmented and
   3 years of operation
   Over 400 participants
   70% substance abuse
   30% “other diagnoses”
    – Depression/Anxiety/Grief
    – Domestic Violence
    – Bipolar
    – Schizophrenia
    – Developmental delays
       • FAS, FAE
    – Homelessness
             What Drugs?
 Methamphetamines
 Marijuana

 Cocaine/crack

 Alcohol- assume concurrent use?

 Narcotics- opioids
                Maternal Effects
   Tachycardia, Hypertension, Muscular excitability
   Abruption- separation of placenta from uterus
    shortly after receiving amphetamines/cocaine
    – Early in pregnancy- SAB
    – Mid-late pregnancy-massive hemorrhage
       • Potential death of mother and baby
   This is usually preceded by vaginal bleeding!!!!
                   Fetal Effects
   Intrauterine growth restriction (IUGR)
    – 30% of cocaine exposed fetuses (ACOG)
    – Placental insufficiency
    – Fetal tachycardia, (?hypertension), fetal stroke
   Increase birth defects-
    – Cardiac, spina bifida, skeletal abnormalities,
      gastroschesis (hole in the abdominal wall)
          – (Cocaine 4x’s, and Meth 6x’s)
                 Neonatal Effects
Preterm labor and delivery
    –   Small for Gestational Age (SGA)
    –   Small head circumference
    –   Learning disabilities
    –   ADHD
    –   Developmental delays, etc
   Neonatal Nursery
    – Lethargic, poor feeder, later irritability
    – Neurobehavioral delays
            How We Began
 Staff concern
 Variation in treating patients

 Variation in referral practices

 Lack of knowledge of what or if anything
 Strong desire to try to protect unborn

 Feeling helpless
       Identifying pregnant SAW
 ER
 OB triage

 Women’s clinic
    – Prenatal questionnaire, history, previous
      prenatal substance abuse
   Family/friends/staff refer
    Why do they seek health care?
   Trauma
    – Fell down, DV, Assault, Altercation
   Pelvic pain- STD’s- Chlamydia
   Vaginal bleeding
   Preterm contractions/labor
   No prenatal care + in labor
   Brought by concerned friend, family member
   Vague complaints, wants to “check my baby”
       Began Meeting May 2003
   Formed “Substance Abuse Workgroup”
   Nurses from OB ward
   Nurses from the Women’s Clinic
   Nurse-Midwives
   Social Workers
   Substance Abuse Counselors
   Public Health Nurse
   Case Management
   Pediatricians
    Goals of our substance abuse
 To protect the unborn from toxic drug
 To assist mother in successfully abstaining
  from drugs and alcohol
 To prevent repeat pregnancies with drug
  affected newborns
         Clinic Development
 Evidence based care
 Treatment Improvement protocols

 Idea of incentives emerged

 Idea of designated clinic emerged

 Written Guidelines developed
 “Pregnancy is a powerful motivator….when
  you find people receptive to treatment”
 “If you are able to get away from it during
  your pregnancy, that can carry over to a
  time when you’re not pregnant”

   (Randy Stevens, MD,-addiction researcher)
         Behavioral Risks
•   Compulsive sexual behaviors
•   Multiple partners
•   Selling sex for drugs
•   High rate of STD’s
     – Chlamydia, HIV, AIDS, Gonorrhea, Syphilis, Hepatitis C
       and B
• Criminal behaviors
     – Stealing for money to buy drugs
• Unintended Pregnancy!!!!
People with co-occurring MH and
 Addictive Disorders often seen in
 emergency rooms, jails, homeless
 shelters, on the streets, and in the
          Support Network
 Substance abusing women who are pregnant
  are viewed as the lowest, even less than
 They are cast aside by their families and
 Often their only support is the men who
  supply them with drugs because of the
  promiscuous sexual behavior they display.
    Maternal Coexisting conditions
   Methamphetamine Treatment Project
    (1999-2001) AJ of Addictions 2004
    – Large multisite study (1016 meth users)
    – High levels of psychiatric disease
       •   Depression/anxiety
       •   Attempted suicide
       •   Schizophrenia (10-65% use meth)
       •   Anger/assaultive behavior
               Urine Drug Screens
                 Written policy
   No prenatal care
   Limited or late entry to care
   Weight loss, emaciation
   History of substance abuse (per records)
   Self-reported history (Clinic posters)
   +Prenatal questionnaire for drugs within last year
   Vaginal bleeding
   Preterm contractions
   Other children removed from home
   Obvious intoxication
           October 2003
    “Special Care Clinic” begins
   One afternoon per week

   Longer appointments

   Social workers/substance abuse counselor
    in clinic to see patients
      Prenatal care-First visit
 Discuss presenting problem
 Routine prenatal workup, STD testing

 If substance abuse, discuss thoroughly and
  review drug contract and ask for signature
 UDS at each visit

 Can be refused, but…refusal is considered a
  positive test
 Slips happens
     Stages in Methamphetamine
   1. Get started
    – agrees to participate in Special Care Clinic.
   2. Get clean
    – Counseling sessions, UDS, Gifts & Incentives
   3. Stay clean
    – Continue with above throughout pregnancy
   4. Stay Healthy (Long-term abstinence support
    plan) -We need a postpartum program!!!
                          adapted from CSAT, 1999
Special Care Clinic Agreement
Name _______________________
____ I would like to participate in the Special Care Clinic Program. I know I will receive gifts at
each visit for my baby and myself.

____I agree to see a social worker and work with her/him on a plan that will help me with this
pregnancy and beyond.

Drug and Alcohol program
_____I agree to urine drug testing whenever asked by my Nurse-Midwife or Physician.

____ I would like to participate in receiving gift certificates each time I have 3 negative drug
tests and have kept my counseling appointments.
Date_______Drug Screen _______ Date _______Drug Screen_________
Date_______Drug Screen _______ Date _______Drug Screen_________
Date_______Drug Screen _______ Date _______Drug Screen_________
Date _______Drug Screen_______ Date _______Drug Screen_________
Date _______Drug Screen_______ Date _______Drug Screen_________
Date _______Drug Screen_______ Date _______Drug Screen_________
Date _______Drug Screen_______ Date _______Drug Screen_________
Gift certificate-Date______
Gift certificate-Date______
Gift certificate-Date______
I agree to what is checked above:
_________________________ Date_______
           Frequency of visit
 Heavy meth use- consider residential
 If + for drugs, weekly visits with midwife,
  and 2 or more visits with social
 When several drugs screens are negative,
  consider weekly visits, etc…
   Elk, R., Schmitz, J., Spiga, R., Rhoades, H., Andres, R.,
    & Grabowski, J. (1995). Behavioral treatment
    of cocaine-dependent pregnant women and TB-
    exposed patients. Addictive Behaviors, 20, 533–542.
   This preliminary study examined the efficacy of a
    contingency management procedure (shaping) on
    decreasing cocaine use and increasing compliance with
    health regimens and pregnant substance abusers
    – Pregnant substance abusers received monetary incentives for each
      successive decrease in the level of cocaine metabolite, cocaine-free
      specimens, or having all three specimens collected each week meet
      incentive criteria.
    – All pregnant patients remained in treatment until delivery; mean
      treatment duration was 16 weeks.
    – Compliance with prenatal care was high, with a mean rate of
      72.5% of kept versus scheduled visits..
     PIMC Contingency (Reward)
   Stimulant users often respond well (TIP 33)
   Maternal instinct not to harm developing baby
   Rewards for drug abstinence
    –   Healthy baby
    –   Gifts
    –   Helps with CPS at birth
    –   Vouchers for retail outlets
    –   Sense of accomplishment
    –   Human warmth, bonds with staff
         Urine Drug Screens
 Every 3 negative drug screens-rewarded
  with $10 gift certificate for Wal-Mart,
  target, or Food City
 Positive drug screens- non-punitive, just
  seen more frequently (2-3X’s weekly if
  methamphetamines or cocaine)
             Gifts & Incentives
   Gift for self and gift for baby at each visit-
    – Make-up, hair care products, jewelry, watches,
      lotions etc…
    – Blankets, clothing, pacifiers, baby pictures
   “Fetus” models; 11-12 week mini baby
    Social Services/Substance abuse
   Makes it as accessible as possible!!!
    –   PIMC, next door the prenatal visit
    –   Don’t have to explain to clerk purpose of visit
    –   Same counselor each visit
    –   Female preferred
    Social Worker; Typical First
 Develop trust
 Encourage participation

 Discuss Special Care Clinic-

 “Why are you here?”

 Participation is voluntary

 Identify their strengths

 Mini-psychosocial assessment
             Newborns and beyond
                 NIDA study
   Howard, J., Tyler, R., Espinosa, M., & Beckwith, L. (1996). Birth
    outcome in cocaine- abusing women following three months of
    drug treatment. In L. S. Harris (Ed.), Problems of drug
    dependence, 1995: Proceedings of the 57th Annual Scientific
    Meeting. National Institute on Drug Abuse.
   Polydrug-using (cocaine plus other drugs) pregnant women (N = 72)
    participated in a drug treatment program including regular urine
    toxicology testing.
   Women who decreased their drug use at least 50% from intake
    gave birth to infants with longer gestational periods, higher birth
    weights, and larger head circumferences.
           Meth Baby Myth
 No identified syndrome attributable to meth
 LD, ADHD, Conduct disorders may have
  environmental cause
 Labels follow the individual

 Lower expectations may result
          Breastfeeding and Meth
 Infant deaths reported after meth using
  mom breastfeeds
 Institutional policies often prohibit

 Benefits
    –   Fewer colds, flu, etc…
    –   Less obesity
    –   Less diabetes
    –   Bonding/attachment issues
         “Reasoned Approach”
   Explain and document risk.
    – Maintained abstinence during pregnancy after
      entering SCC
 Breastfeeding hotline info
 What to do if slip occurs- no breastfeeding
  for 3 days, call hotline & counselor, etc….
         Patient evaluations
 Some still lost to follow-up
 50% have four or more visits- some as
  many as ten visits
 Good rapport with patients

 Many are drug free- others with occasional
  usage. Often self-report lapses
        Comments from patients
   I can’t believe I have done this!!- (gone without
   “It helped me realize I’m gonna be a mother. Also
    how to take care of myself & child”
   “Helped me to quit and not use when pregnant”
   “It helped the most to be screened and drug
      Comments from patients
 “It helped by not judging me”
 “The social worker and the OB people &
  the Drs. They all helped me want to change
  my life for the better. Thank you for
  helping me want to stay clean”
 “Kept me clean by encouragement”
      Phase II –drop in deliveries
                + UDS
 Reported to CPS
 If baby is also +, increases level of concern

 Baby may be placed in foster care

 Extremely emotional event

 Mother may plunge deeper into drugs
           Phase II
Drop in deliveries with + drug
–   Set up database of these patients
–   Nurse-midwife as Case manager
–   Encourage contraception, treatment
–   Prevent another substance exposed infant next
              Patient #1
              Meth Death
 Multigravida
 Class B DM

 Two other children alive and well; received
  prenatal care with them
 Began using meth 2 years ago

 Unplanned pregnancy

 No prenatal care
              Meth Death
 Presents to ER

 Ketoacidosois

 Sepsis, Fever 103

 Dies in ER
                Patient #2
                Near Miss
 Limited prenatal care- no records
 Vaginal bleeding all night-

 FOB brings patients in- he is extremely
  agitated-worried about “her”
 Patient Reports bleeding, “not that bad”

 Can’t lay down in bed-has to sit up to get
  her breath
 Looks pale
           Near Miss Cont’d

 EFM- contractions with late decels
 Estimated at 34 weeks


 Baby survives

 Admission Maternal Hg- 3.0

 Transfused in OR

 Patient Survives
                      Patient #3
   No prenatal care, G8P6sab1, Two previous C/S, 4VBAC
   Estimated to be term, admits to Meth use that morning.
   “My water broke this morning, I’m in labor”
    No FHT’s, IUFD (pt. reports last fetal movement within
    the hour.)
   Delivers a few hours later with pitocin augmentation of
    labor. The infant is in an advanced state of decomposition.
    Death probably occurred days prior.
       Patient #3 Postpartum
 Profuse bleeding and retained placenta
 To the OR, 100 feet away from the delivery
  room, this patient lost 2500cc of blood. She
  lost another 2000cc during the procedure.
 Stat Hysterectomy and massive blood
               Patient #4
 30 week IUP
 No prenatal care

 Contracting

 3/-1/80%

 BP 160/99

 Maternal HR 130’s

 Vaginal bleeding off and on
            Patient #4 treatment
   Tocolysis-MgSO4-6 Gram bolus, 2 Grams per
    hour (Avoid terbutaline)
   CBC, Type and screen (cross)
   UDS
   Large bore IV (2)
   Prepare for transport
   Betamethasone 12 mg IM (24-34 weeks-ACOG)
    – 2 doses 12 hr apart
   Apresoline 5-10 mg IV- give in small doses
              Future plans
 On site GED program
 On site support group (substance using
 Native parenting program

 After care groups

 Graduate continue to be involved and
  mentor others
 Form a multidisciplinary team
 Use known treatment protocols

 Market your program to all departments,
  members of your organization
 Use non-punitive, non-judgmental
 Use pregnancy as a motivator

 Celebrate every success

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