Obstetric Neonatal Gynecologic Care

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What We Did About Prenatal Substance Abuse September 18, 2006 : 

What We Did About Prenatal Substance Abuse September 18, 2006 Judy Whitecrane MSN, CNM Director, Nurse-midwifery Service Phoenix Indian Medical Center

Key Components-Prenatal Substance Program: 

Key Components-Prenatal Substance Program Obstetric provider (CNM, OB, FP) Behavioral Health Provider (SW, SAC, MHNP) Clinical setting for both providers together Gifts and Incentives (Nominal cost) Works well in a large or small setting

Phoenix Indian Medical Center Obstetrics Department: 

Phoenix Indian Medical Center Obstetrics Department 850 deliveries per year 8 CNM’s & 8 MD’s Approx. 150 + UDS at birth Level II Nursery Active Caseload-600 prenatal clients 30 (5%) in “Special Care Clinic” Since 2003 Over 300 women enrolled in “Special Care Clinic”

How We Began: 

How We Began Aware of increased meth use in pregnancy Variation in treating & referring Lack of knowledge of what works Strong desire to protect the unborn Feeling helpless, angry, frustrated…myriad of emotional responses

What Drugs?: 

What Drugs? Methamphetamines Marijuana Cocaine/crack Alcohol- assume concurrent use? Heroin Other Narcotics- opioids

The Most Dangerous Drug: 

The Most Dangerous Drug Alcohol!!!

What Stimulant Drugs Do: 

What Stimulant Drugs Do Maternal Effects Fetal Effects Neonatal Effects

Maternal Effects: 

Maternal Effects Tachycardia, Hypertension Heart Attack, Stroke Cramping, Contractions- First trimester- SAB Second & Third trimester Preterm to term labor- often with tetanic contractions Abruption- separation of placenta from uterus shortly after receiving amphetamines/cocaine/crack Usually preceded by vaginal bleeding!!!! Potential death of mother and baby!!

Maternal Behavioral Effects…: 

Maternal Behavioral Effects… Compulsive sexual behaviors Multiple partners Selling sex for drugs High rate of STD’s Chlamydia, AIDS, Gonorrhea, Syphilis Criminal behaviors Stealing money to buy drugs Unintended Pregnancy!!!!

Fetal Effects: 

Fetal Effects Intrauterine growth restriction (IUGR) Caused by placental insufficiency Occurs in 30% of cocaine exposed fetuses (ACOG) Cardiovascular events Fetal tachycardia Fetal hypertension/stroke Increase in birth defects Neonatal asphyxia Cardiac, spina bifida, skeletal abnormalities, gastroschesis (hole in the abdominal wall) (Cocaine 4x’s, and Meth 6x’s)

Neonatal Effects: 

Neonatal Effects Preterm delivery STAT C/Section for fetal distress common Transport to NICU Small for Gestational Age (SGA) Small head circumference Learning disabilities,ADHD Developmental delays Neonatal Nursery Lethargic, poor feeder, later irritability Neurobehavioral delays Methadone- neonatal withdrawal may take 2-3 months (hospitalized)

Newborns and beyond NIDA study : 

Newborns and beyond NIDA study Howard, J., Tyler, R., Espinosa, M., & Beckwith, L. (1996). Birth outcomes 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 larger head circumferences

Meth Baby “Myth”: 

Meth Baby “Myth” No identified syndrome attributable to meth LD, ADHD, Conduct disorders may also have other environmental, medical, genetic causes Labels follow the individual Lower expectations may result

Pregnancy: 

Pregnancy “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)

PIMC Contingency (Reward) System: 

PIMC Contingency (Reward) System Stimulant users often respond well (TIP 33) (800)-729-6686 Maternal instinct not to harm developing baby Rewards for drug abstinence Healthy baby Gifts Avoidance of CPS at birth Vouchers for retail outlets Sense of accomplishment Human warmth, bonds with staff

Slide16: 

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..

“Substance Abuse Workgroup” Began Meeting May 2003: 

“Substance Abuse Workgroup” Began Meeting May 2003 Nurses from the Women’s Clinic Nurse-Midwives Social Workers Nurses from OB ward Substance Abuse Counselors Public Health Nurse Case Management Pediatricians

Clinic Development: 

Clinic Development Evidence Based Care (SAMHSA, CSAT) Treatment Improvement protocols (TIP’s) Designated clinic-Thursdays Written Guidelines developed

October 2003 “Special Care Clinic” begins: 

October 2003 “Special Care Clinic” begins One day per week Longer appointments Social workers/substance abuse counselor in clinic to see patients

Stages in Methamphetamine Treatment: 

Stages in Methamphetamine Treatment 1. Get started 2. Get clean 3. Stay clean 4. Stay Healthy (Long-term abstinence support plan)

How are pregnant substance abusing women identified ?: 

How are pregnant substance abusing women identified ? ER visits OB triage visits Women’s clinic, identified from Patient records Prenatal questionnaire Posters Family/friends/employees report

Presenting Diagnosis: 

Presenting Diagnosis 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”

Prenatal care-First visit: 

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

Slide24: 

Special Care Clinic Agreement Date_________ 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_______ Signature

Coexisting Conditions: 

Coexisting Conditions People with co-occurring MH and Addictive Disorders often seen in emergency rooms, jails, homeless shelters, on the streets, and in the obituaries.

Maternal Coexisting conditions: 

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

PIMC Special Care clients: 

PIMC Special Care clients 70% Substance abuse Often have coexisting conditions 30% Diagnosis of: Depression/Anxiety/Grief Domestic Violence Bipolar Schizophrenia Developmental delays- FAE, FAS

Gifts & Incentives : 

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 frames… Incentives- gift card for retail outlet for 3 negative UDS

Urine Drug Screens Written Policy: 

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 2-3 years Vaginal bleeding Preterm contractions Other children removed from home Obvious intoxication

Urine Drug Screens: 

Urine Drug Screens Every 3 negative drug screens-rewarded with $15 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)

Frequency of visits: 

Frequency of visits Heavy meth use- consider residential Rotted teeth Sustained weight loss Emaciated looking Sores Poor hygiene Resistant to treatment/denial Positive UDS, weekly visits with midwife, and 2 or more visits with social worker/week When several drugs screens are negative, consider weekly visits, etc…

Social Services/Substance abuse Counseling: 

Social Services/Substance abuse Counseling Makes it as accessible as possible!!! Next door to the prenatal visit Don’t have to explain to clerk purpose of visit Same counselor each visit Female preferred Native counselors preferred

Patient evaluations: 

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: 

Comments from patients I can’t believe I have done this!!- (gone without drugs) “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 tested”

Comments from patients: 

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”

“Drop in Deliveries” No prenatal care, + UDS: 

“Drop in Deliveries” No prenatal care, + UDS Reported to CPS If baby is also +, increases level of concern Baby often placed in foster care Extremely emotional event Mother may plunge deeper into drugs

Special Care Clinic Phase II : 

Special Care Clinic Phase II Set up database of these patients Current address & phone number Nurse-midwife as Case manager Encourage contraception, treatment Prevent another substance exposed infant next year

Patient #1 Meth Death: 

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: 

Meth Death Presents to ER IUFD Ketoacidosois Sepsis, Fever 103 Dies in ER

Patient #2 Near Miss: 

Patient #2 Near Miss No prenatal care 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 : 

Near Miss Cont’d EFM- contractions with late decels Estimated at 34 weeks STAT C/S Baby survives Admission Maternal Hg- 3.0!!! Transfused in OR Patient Survives 6 months later- pregnant again & still using

Patient #3- Common Scenario: 

Patient #3- Common Scenario No prenatal care Estimated to be term “I’m in labor” Many contractions with late decels STAT C/Section UDS + Meth Social Services, CPS, Level II nursery

Social Worker; Typical First Visit: 

Social Worker; Typical First Visit Develop trust Encourage participation Discuss Special Care Clinic- “Why are you here?” Identify their strengths Mini-psychosocial assessment

Summary: 

Summary Form a multidisciplinary team Use known treatment protocols Market your program to all departments, members of your organization Use non-punitive, non-judgmental approaches Use pregnancy as a motivator Celebrate every success

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