Develop a patient-centered approach to developing a peripartum plan of care for pregnant patients with opioid use disorder (OUD) to facilitate continuation of appropriate medication assisted treatment (MAT) dosing, pain management and related needs.
Why we are recommending this best practice
A clear, informed plan developed with patients and relevant providers for the management of OUD in the peripartum period will avoid physiologic instability, facilitate patient buy-in, and optimize transitions of care.
Strategies for implementation
- Develop a peripartum checklist for patients with OUD, ideally with multidisciplinary input, highlighting key patient health information, current MAT therapeutic regimen, contact information for providers, and recommended activities to prepare patients for the peripartum period in the hospital (please see the Resources section of this Best Practice: Sample Peripartum Checklist for Patients with OUD).
- Develop a protocol to utilize the peripartum checklist. Plan strategically for how to incorporate the designed checklist into prenatal care (ideally at the beginning of the third trimester, or at any time for late entrants into prenatal care) and how to share the checklist with the hospital at which a patient intends to deliver (e.g., faxing when checklist is completed, and/or at 36 weeks).
- Implement peripartum checklist. Ideally patients and providers would have updated copies of the checklist and it could be customized (e.g., more elaborated paper checklist for patients, abbreviated electronic text checklist for providers). Consider incorporating it into the electronic medical record.
Kayla is now 38 weeks pregnant and doing well on buprenorphine. She calls your office complaining of leaking fluid. You advise her to go to obstetrical triage for evaluation. She is found to have ruptured membranes and is admitted by the laborist for induction. Kayla is quite uncomfortable and neglects to inform her care team that she is on buprenorphine. The staff is unable to retrieve her prenatal records. Twelve hours into her stay, she begins having significant pain, sweats, nausea, and chills. The nurse also notes some irregularities and changes in the fetal heart rate. Kayla finally states she is experiencing opiate withdrawal and requests buprenorphine. Unfortunately, the hospital does not have buprenorphine immediately available in the medication dispensing machine. Two extremely uncomfortable hours later, Kayla receives her buprenorphine and is finally comfortable again. By this point her records, including the consultation with the anesthesiologist, have been retrieved and her pain is managed with an epidural.
Failed communication to inpatient providers leads to fragmented care once the patient is admitted for labor. There are various ways that a warm handoff can be undertaken at the time of labor to ensure that patient care is not compromised. These include, but are not limited to, a third trimester patient review with the hospital team and/or a pre-registration exchange of critical information (including buprenorphine duration and dosage) that allows confidential information sharing with the medical staff, a prenatal care summary or card specific to MAT that allows the patient to confidentially inform hospital staff of her medication and dosage upon admission, and having the prenatal care provider discuss with the patient the importance of disclosing her MAT needs with hospital staff at the time of admission.