A window of opportunity? For pregnant women this effect is amplified - PowerPoint PPT Presentation

A window of opportunity?

For pregnant women this effect is amplified as the risk extends to the care and well being of the unborn baby There is often conflicted and complex responses to this “heightened level of risk” by professionals involved in the care, family, partners and indeed the woman herself.

Alcohol & Drug use in pregnancy  Caring for substance dependent women in pregnancy can be extremely challenging and sometimes personally confronting  Important to keep in mind that even the most complex client wants to have a healthy baby and want to be able to love and care for their baby in a suitable home environment with love and support around them…….

But!! There is more than just the unborn baby to consider  While a new pregnancy brings concerns about the unborn baby the is also the very real and ongoing concern around parenting the baby and any other children in the woman’s care.  This is a time to consider the risks to all concerned and address the risks as they become evident

Issues surrounding parenting and drug use Substa stanc nce e Abuse e does s not t always ys equal l poor r parenting. nting. co concerns ncerns exist t when:

Issues surrounding parenting and drug use  Parental resources are tied up with seeking, using and recovering from drugs  Diversion of finances away from the family – this can in lead to criminal activity  Lack of routine within the family  Inconsistent & neglectful parenting  Poorly developed social networks & healthy social interactions may be denied to children  Mental health issues and fluctuating moods

Issues surrounding parenting and drug use  Poor parental role modelling i.e. failure to model clear boundaries & appropriate behaviour  Exposed to hazardous drug use equipment  Dangers of overdose  Child parentification  Increase risk of child abuse-parents reduced ability to cope with even minor stresses

Emotions surrounding drug use in pregnancy Health Professionals Pregnant Woman  Anger  Blame  Annoyance  Anxiety  Guilt  conflicted  Shame  Fear  Anxiety

Walk a mile in my shoes…….

Perceptions of women regarding antenatal care  Fear of being treated differently  Fear of child protection becoming involved- particularly if there are already children in care  Previous bad experiences (frequently history of abuse is noted)- this may result in fear of examinations  Uncomfortable around doctors and other health professionals

Barriers to Care Often late to book in and poor attendance  Not wanting to disclose pregnancy  Fear of Child Protection Services  Fear of Judgement  Unhappy about pregnancy, often unplanned  Afraid something wrong with pregnancy  In Crisis - Housing issues/homelessness

Barriers to Care  Partner problems/Family violence  Financial difficulties  Difficulty with transport/distance from clinic  Childcare issues  Clinic hours did not suit  Too tired to come to hospital

It is commonly believed that pregnancy and motherhood are periods of high motivation for women to enter drug treatment or seek support of some kind to address their substance use

Engagement Antenatal care can provide a point of contact for women who may otherwise not present to other medical or treatment services It can potentially offer contact for 7 months This is very much dependent on engagement!!

Engagement  Engagement may be lost at the first visit if the first point of contact is with professionals inadequately skilled in working with substance using women.  Care must be delivered in a non- judgemental manner that supports women to care for themselves and their baby in partnership.  Developing care pathways that are achievable and considering the women’s strengths as well as their challenges in life.

Non judgemental, flexible, multidisciplinary treatment approach ”optimises the women’s treatment experience within the medical system”….. Tobin (2005)

Assessment  Assessment is ongoing  Many barriers to care  Respect for women’s strengths  Non judgemental approach & establishment of a rapport is essential  Disclosing drug & alcohol use in pregnancy is difficult and is often under reported

Assessment  Often difficult to engage and maintain in pregnancy care.  Essential to establish readiness for change ( Prochaska & DiClemente)  Aim to establish a professional, trusting and empathetic relationship so as the woman will feel encouraged to continue care.  Failure of engagement may result in loss of that woman to follow up with less than optimal outcomes for the woman and her baby.

Antenatal care  High risk pregnancy  Increased incidence of - spontaneous abortion -Premature labour and delivery -IUGR -Fetal distress (especially with acute withdrawal)  Fetal anomalies depending on type of substance

Drug & Alcohol Pregnancy Service DAAPS Multidisciplinary care  Midwife Coordinator  Obstetrician  Social worker  Parenting educator  NPICU Discharge Coordinator  Drug & Alcohol liaison Service  Psychiatry Liaison Services  Psychologist  NNICU consultant  CPLO  CHAPS

Role of the Complex Care midwife  Co-ordination of care for pregnant women with complex needs associated with substance use.  Point of contact for women and their families- continuity of care.  Resource person for other staff.  Provide education to women and other members of the health care team.  Liaise between all services in the hospital & in the community.  Work within the multidisciplinary team to identify needs & provide management plans for the antenatal, intrapartum & postnatal period and to commence discharge planning as early as possible.

First appointment  Engagement  Appropriate Referrals  Psycho-social history  Appropriate Clinic  Medical/Surgical History  Patient’s educational requirements  Obstetric history  Harm minimisation  Drug & Alcohol history- strategies this is revisited  Short term and long frequently over the pregnancy term goals (priorities)

Referrals All referral options and the reasons they are recommended are discussed with the woman first. - Social work - Psyche liaison/community mental health - Parenting educator - NPICU discharge coordinator - Paediatrician - Drug and Alcohol service - Lactation consultant - Dietician - Dentist - CHAPS - Child protection/CPLO

Community referrals  GP  Alcohol and Drug Service  Detox unit  Bridge – Rehabilitation programs  Anglicare- GIDS  Holyoake  TasChard  Mental Health Service/Counselling services  Gateway referral - Good Beginnings, ESP, Mission, Baptcare, Disability services  Housing Tas/ Colony 47/Access  Legal services  Advocacy  Guardianship and administration board

Education  Encourage all women to undertake some form of education  The objective is to allow all women to make informed choices, by providing accurate information in an easily understood manner  Keep in mind previous experience and prior learning  Include harm minimization e.g.. poly drug use, BBI, safe injecting information  Recommendation of methadone stabilization for opiate users  Drug education / potential risks associated for mother and baby  NAS  Birth planning /labour and delivery  Breastfeeding/feeding options  Postnatal information  Emotional health and wellbeing/PND/ help lines etc  Discharge planning  Safe sleeping  Support services  Family support network/establishing a circle of security

Assessing Harm  Alcohol, tobacco and other substance use during pregnancy have been linked to a number of adverse pregnancy and neonatal outcomes  It is difficult to evaluate the exact harm contributed by specific drugs independent of the risks associated with drug using lifestyles

• Poor nutrition • Poverty • Poly drug use • Patterns of use • Poor antenatal care • Medical complications • Social and environmental risks • Co existing mental health issues

Systemic factors  Ethical & logistical considerations make it difficult to carry out high quality studies  Inadequate or inflexible polices  Inadequate resources for early intervention and prevention  Lack of appropriate service availability  Service Gaps across all services  Fragmented approach to care management  Inexperienced or Judgemental practitioners

Labour and birth  Admission in early labour may reduce the need to self medicate for those at risk  Methadone should preferably be given prior to induction or in early labour but should not be withheld  Pain relief may need special attention as receptors can become opiate saturated, opiate analgesia, however, should not be withheld but effects should be carefully monitored  Regional anaesthesia should be considered  All natural pain management methods should be encouraged