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Best practice №36

Educate pregnant women about opioid use disorder in pregnancy and the hospital experience

by Lorena Watson, Martha Tesfalul

Last updated September 3rd, 2020

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Overview

Thoughts about labor and delivery, for most pregnant women, are riddled with questions and anxiety about the unknown.  For the pregnant woman with opioid use disorder (OUD), there is an additional layer of stress, emotions, and anxiety related to childbirth and motherhood associated with her path to wellness and recovery.  After having built relationships and trust with her prenatal care team, the thought of transitioning care to a new team of providers in the L&D unit can cause additional stress for the mother with OUD.  She may or may not have already met or had an opportunity to build trust and relationships with this staff and may question their motives, feel judged, and begin to worry that her newborn will be taken from her or that her pain will not be managed due to her OUD status.

Providing education about expected health care services and processes is associated with social and psychological benefits including reduced fears and anxiety, and provides patients with an opportunity to ask questions, thus increasing a patient’s overall knowledge related to the anticipated experience. Providing education on what to expect in the hospital during a prenatal care appointment can reinforce previously received childbirth education and/or facilitate education for those who were unable or chose not to attend.  

The “what to expect in the hospital” conversation during a prenatal care appointment is an opportunity to introduce the new L&D team and to discuss goals and options for pain management and institutional screening and drug testing. It is also an opportunity to address and debunk any myths or untruths about the upcoming experience, especially regarding social and child welfare referrals and support. Transparency in the provision of information shows that providers care and facilitates continued engagement by the mother with OUD in the development of a Plan of Safe Care and self-management.  Ultimately these efforts increase coping skills and support the increased likelihood of a positive labor experience.

Why we are recommending this best practice

Education and social support are the best ways to facilitate continued engagement with the Plan of Safe Care, recovery & wellness, positive progression through the continuum of care, and optimal patient experience.

Strategies for implementation

  • Include “what to expect in the hospital” in the prenatal checklist.  The discussion should be scheduled for the third trimester.

  • Present the topic of postpartum care coordination. The postpartum period represents a time of increased vulnerabilities, and women with OUD relapse and even overdose far more often in the postpartum period than during pregnancy. Relapse is a common part of addiction, and often someone with OUD will relapse several times before successfully quitting. Forty-nine percent of women with OUD treated with medication assisted treatment (MAT) in an initial pregnancy were not in treatment at the start of a subsequent pregnancy, even with specific transition plans for MAT continuation (including warm handoffs).  Of those on MAT, only 37% of women had the same MAT provider for both pregnancies. Education for the family and the patient around this is very important. Patients often have “all or none” thinking, but slips and relapses commonly occur, and it doesn’t mean failure. Stressful events are triggers for relapse, including loss of insurance and access to treatment, demands of caring for a new baby, sleep deprivation, and fear of losing child custody.
    • Discuss postpartum information, such as contraception and access to psychosocial support.
    • Emphasize that the first obstetrical follow-up visit is between weeks one and two.

  • Engage hospital L&D staff and prenatal providers. 
    • Recruit from both environments (clinic/provider office and hospital) to champion the collaboration.
    • Discuss important workflows and policies and ensure that prenatal care providers are sharing accurate information.   
    • Discuss offering an opportunity to schedule a “meet and greet” that supports a warm handoff.
    • Understand the hospital’s intrapartum pain management policies in order to educate the patient on pain control options and encourage transparency regarding OUD for optimal management of pain and symptoms.

  • Design an educational “what to expect in the hospital” curriculum unique to your hospital.

Resources

References

  • Substance Abuse and Mental Health Services Administration. Clinical guidance for treating pregnant and parenting women with opioid use disorder. https://store.samhsa.gov/product/Clinical- Guidance-for-Treating-Pregnant-and-Parenting-Women-With-Opioid-Use- Disorder-and-Their-Infants/SMA18-5054. Accessed December 19, 2019.

Lorena Watson

FNP

Lorena Watson is a Family Nurse Practioner. Her focus is rural health and providing compassionate patient-centered care in Lake County, CA. She coordinates and provides care for mothers with OUD through pregnancy and postpartum. Before becoming an FNP, Lorena was a labor and delivery nurse for 16 years.

Martha Tesfalul

MD

Dr. Martha Tesfalul is currently a Maternal-Fetal Medicine Fellow at at the University of California, San Francisco. Having served as the Quality Improvement (QI) Chief in her final year of residency, she has a professional interest in health systems strengthening and health equity. She has received local, regional and national recognition for her efforts in clinical care, education, and research including awards from the Pacific Coast Obstetrical and Gynecological Society and the Foundation for the Society for Maternal-Fetal Medicine. In addition to her commitment to improving the care of pregnant patients in California, Dr. Tesfalul engages in QI-focused research in in the East African country Eritrea.