nCM 1028

8LCLS1A1lCnAL CCnul1lCnS
Su8S1AnCL A8uSL
SU8S1ANCL A8USL
kefers to the cont|nued use of substances desp|te re|ated prob|ems |n
phys|ca| soc|a| or |nterpersona| areas
kecurrent abuse resu|ts |n fa||ure to fu|f||| ma[or ro|e ob||gat|ons and
there may be substancere|ated |ega| prob|ems
1he safest pregnancy |s one |n wh|ch the mother |s tota||y drug and
a|coho| fee w|th once except|on
Ior pregnant women add|cted to hero|n methadone
ma|ntenance |s safer for the fetus than acute op|ate
detox|f|cat|on
A|coho| and other drugs eas||y pass from a mother to her baby through
the p|acenta
Ser|ous hea|th r|sk of smok|ng when pregnant
a 8|eed|ng comp||cat|ons
b M|scarr|age
c St|||b|rth
d rematur|ty
e |acenta rev|a
f |acenta| Abrupt|on
g Low 8|rth We|ght
h Sudden Infant Death Syndrome (SIDS)
| Congen|ta| Abnorma||t|es
8AkkILkS 1C 1kLA1MLN1
regnant women often do not seek he|p because of the fear of
|os|ng custody of the ch||d or of cr|m|na| prosecut|on
regnant women who abuse substances common|y have ||tt|e
understand|ng of the ways |n wh|ch these substances affect them
the|r pregnanc|es and the|r bab|es
St|gma shame and gu||t |ead to a h|gh den|a| of dr|nk|ng or drug
prob|ems both by the woman herse|f and by fam||y members and
fr|ends who concea| the abuse from outs|ders to protect the abuser
1hey often de|ay seek|ng prenata| care unt|| |abor beg|ns
1rad|t|ona||y substanceabuse treatment programs have not
addressed |ssues that affect pregnant women such as concurrent
need for obstetr|c care and ch||d care for other ch||dren
Long wa|t|ng ||st and |ack of hea|th |nsurance present further
barr|ers to treatment
LLGAL CCNSIDLkA1ICNS
8ecause of the r|sks to the unborn ch||dren pregnant women who
abuse substances may face cr|m|na| charges under expanded
|nterpretat|ons of ch||d abuse and drugtraff|ck|ng statutes
Some po||cymakers have proposed that pregnant women who
abuse substances shou|d be
a Ia||ed
b |aces under house arrest
d Comm|tted to psych|atr|c hosp|ta|s
for the rema|nder of the|r pregnanc|es
Nurses who screen for substance abuse |n pregnancy and
encourage prenata| care counse|||ng and treatment w||| be of
greater benef|t to the mother and ch||d than w||| prosecut|on
A pub||c hea|th approach to substance abuse can |nsp|re
macro|eve| po||cy that |s des|gned to strengthen commun|t|es as
we|| as spef|c|c treatment and prevent|on programs embedded |n
the commun|t|es
CAkL MANAGLMLN1
Care of the substancedependent pregnant woman |s based on
a n|stor|ca| data
b Symptoms
c hys|ca| f|nd|ngs
d |aboratory resu|ts
Screen|ng quest|ons for a|coho| and drug abuse shou|d be
|nc|uded |n the overa|| assessment of the f|rst prenata| v|s|t of a||
women
8ecouse women often deny or qreot/y underreport usoqe
when osked direct/y obout druq or o/coho/ consumption it
is crucio/ thot the nurse disp/oy o nonjudqmento/ ond
motteroffoct ottitude whi/e tokinq the history in order to
qoin the womons trust ond e/icit o reosonob/y occurote
estimote
nformotion obout druq use shou/d be obtoined by first
oskinq obout the womons intoke of overthecounter ond
prescribed medicotions
Next her usoqe of "/eqo/" druqs such os coffeine
nicotine ond o/coho/ shou/d be oscertoined
lino//y the womon shou/d be questioned obout the use
of i//icit druqs such os cocoine heroin ond morijuono
1he approx|mate frequency and amount shou|d be documented
for each drug used
SCkLLNING ULS1ICNNAIkLS
Genera||y ask about consequences of heavy dr|nk|ng a|coho|
|ntake or both
2 We|| known screens used
M|ch|gan A|coho||sm Screen|ng 1est (MAS1)
CAGL
SCkLLNING 1LS1 DLVLLCLD SLCIIICAL ICk ALCCnCL USL DUkING
kLGNANC
1 1ACL
2 1WLAk
1ACL 1est
now many dr|nks can you ho|d before gett|ng s|eepy or pass|ng
out? (1CLLkANCL)
nave peop|e ANNCLD you by cr|t|c|z|ng your dr|nk|ng?
nave you ever fe|t you ought to CU1 DCWN on your dr|nk|ng?
nave you ever had a dr|nk f|rst th|ng |n the morn|ng to steady your
nerves or get r|d of a hangover? (LLCLNLk)
SCCkING 1wo po|nts are g|ven for the 1CLLkANCL quest|on for the
ab|||ty to ho|d at |east a s|xpack of beer or a bott|e of
w|ne
A "yes" answer to any of the other quest|ons rece|ves one
po|nt
An overa|| score of 2 |nd|cates a h|gh probab|||ty that
the woman |s a r|sk dr|nker
1WLAk 1est
now many dr|nks can you ho|d before gett|ng s|eepy or pass|ng out?
(1CLLkANCL)
nave c|ose fr|ends or re|at|ves WCkkILD or comp|a|ned about your
dr|nk|ng dur|ng the past year?
Do you somet|mes take a dr|nk |n the morn|ng when you f|rst get up?
(LLCLNLk)
nas a fr|end or fam||y member ever to|d you about th|ngs you sa|d or
d|d wh||e you were dr|nk|ng that you cou|d not remember? (AMNLSIA)
Do you somet|mes fee| the need to kU1]CU1 down on your dr|nk|ng?
SCCkING 1wo po|nts are g|ven for the 1CLLkANCL quest|on for the
ab|||ty to ho|d more than f|ve dr|nks
A "yes" answer to the WCkk quest|on rece|ves two
po|nts
A "yes" answer to any of the other quest|ons rece|ves
one po|nt
An overa|| score of 2 |nd|cates that the woman |s ||ke|y to
be a r|sk dr|nker
Ur|ne screen|ng |s unre||ab|e because a|coho| |s undetectab|e w|th|n
a few hours fo||ow|ng |ngest|on
Abnorma| ||ver funct|on stud|es can prov|de d|agnost|c data about
the phys|ca| effects of a|coho| abuse
Ur|ne tox|co|ogy test|ng |s often performed to screen for ||||c|t drugs
use
Drugs may be found |n ur|ne days to weeks after |ngest|on
depend|ng on how qu|ck|y they are metabo||zed and
excreted from the body
Mecon|um (from the neonate) and ha|r can a|so be ana|yzed to
determ|ne past drug use over a |onger per|od of t|me
In add|t|on to screen|ng for a|coho| and drug abuse the nurse shou|d
a|so screen for phys|ca| and sexua| abuse and h|story of psych|atr|c
|||ness because these are r|sk factors |n women who abuse substances
Ser|a| u|trasound stud|es usua||y performed to determ|ne gestat|ona|
age because the woman may have amenorrhea as a resu|t of her drug
use or may not know when her |ast menstrua| per|od occurred
LANNING
An |nterd|sc|p||nary mode| |s essent|a| when p|ann|ng the care for
women who abuse substances
Ma[or |ssues that must be addressed |n treatment for women that
genera||y are not part of treatment for men are
a Low se|festeem
b St|gmat|zat|on
c n|gh probab|||ty of sexua| abuse and phys|ca| abuse
d Lack of soc|a| support
e Need for soc|a| serv|ces and ch||d care
f Need for women's hea|th serv|ces
g Need for support and educat|on |n the mother|ng
ro|e
Drugfree pub||c hous|ng or res|dent|a| commun|t|es may offer an
|dea| route to stab|||zat|on |n a safe env|ronment
1reatment must demonstrate cu|tura| sens|t|v|ty and
respons|veness to recogn|ze ethn|c|ty and cu|ture as an |mportant
part of her |dent|ty
Cther needs of many women |nc|ude
a ke|at|onsh|p counse|||ng
b Cop|ng sk|||s tra|n|ng
c vocat|ona| and |ega| ass|stance
IN1LkVLN1ICN
1 Lducat|on about spec|f|c effects on pregnancy the fetus and the
newborn for each drug used
Consequences of per|nata| drug use shou|d be
c|ear|y commun|cated and abst|nence
recommended as the safest course of act|on
Women are often more recept|ve to mak|ng
||festy|e changes dur|ng pregnancy than at any
other t|me |n the|r ||ves
1he casua| exper|menta| or recreat|ona| drug user
|s often ab|e to ach|eve and ma|nta|n sobr|ety when
she rece|ves
a Lducat|on
b Support
c Cont|nued mon|tor|ng throughout pregnancy
er|od|c screen|ng dur|ng pregnancy of women who have adm|tted
to drug use may he|p them to cont|nue abst|nence
regnancy presents a w|ndow of opportun|ty for mot|vat|ng women
to stop the|r abuse of substances
2 1reatment for substance abuse w||| be |nd|v|dua||zed for each
woman depend|ng on the type of drug used and the frequency
and amount of use
a Detox|f|cat|on shortterm |npat|ent or outpat|ent treatment
b Longterm res|dent|a| treatment
c Aftercare serv|ces
d Se|fhe|p support groups
neonata| outcomes are |mproved among |nfants whose
mothers rece|ved an |ntegrat|on of substance abuse treatment
w|th prenata| care
Women for Sobr|ety may be a more he|pfu| organ|zat|on for
women than A|coho||cs Anonymous or Narcot|cs Anonymous
wh|ch are based on the 12step program
1he emphas|s on power|essness over add|ct|on and
avo|dance of codependency found |n 12step programs
may d|sempower and |so|ate women part|cu|ar|y women
of co|or
1he confrontat|ona| techn|ques of the 12step program
deve|oped to break down den|a| |n men may be espec|a||y
threaten|ng to women who often fee| unworthy and fu|| of
shame and gu||t
In genera| |ongterm treatment of any sort |s becom|ng |ncreas|ng|y
more d|ff|cu|t to obta|n part|cu|ar|y for women who |ack |nsurance
coverage
A|though some programs a||ow a woman to keep her ch||d
w|th her at the treatment fac|||ty far too few are ava||ab|e
to meet the demand
Change of ||festy|e
Methadone treatment for pregnant women dependent on hero|n
or other narcot|cs |s controvers|a|
If women w|thdraw from hero|n dur|ng pregnancy
b|ood f|ow to the p|acenta |s |mpa|red
Metahdone however can cause detr|menta| feta|
effects and the newborn w||| have to w|thdraw from
|t after b|rth
A|coho| and drug treatment program |nd|v|dua| or group
counse||ng and part|c|pat|on |n se|fhe|p support groups
Coca|ne use dur|ng pregnancy has |ncreased dramat|ca||y |n
the |ast few years A number of materna| and feta|
comp||cat|ons accompany coca|ne use
a |acenta| abrupt|on
b rematur|ty
c SGA |nfants (Sma|| Gestat|ona| Age)
When |t |s determ|ned that a pregnant woman |s us|ng
coca|ne she shou|d be adv|sed to stop us|ng |mmed|ate|y
8ecause of the ||festy|e often assoc|ated w|th drug use substance
abus|ng women are at r|sk for S1Is |nc|ud|ng nIV
Laboratory assessments w||| ||ke|y |nc|ude screen|ng
for S1Is such as
a Gonorrhea and ch|amyd|a| |nfect|on
b Ant|body determ|nat|ons for nepat|t|s 8 and nIV
c Chest kray f||m may be taken to assess for
pu|monary prob|ems such as
h||ar |ymphadenopathy
pu|monary edema
bacter|a| pneumon|a
fore|gn body embo||
d Sk|n test to screen for tubercu|os|s may a|so be
ordered
A|though substance abusers may be d|ff|cu|t to care for at any
t|me they are often part|cu|ar|y cha||eng|ng dur|ng the |ntrapartum
and postpartum per|ods because of man|pu|at|ve and demand|ng
behav|or
1h|s women d|sp|ay poor contro| over the|r
behav|or and a |ow thresho|d for pa|n
Increased dependency needs and poor parrent|ng
sk|||s may a|so be apparent
&&& Nurses must understand that substance abuse |s an |||ness
and that these women deserve to be treated w|th
a at|ence
b k|ndness
c Cons|stency
d I|rmness
DLALING WI1n kLGNAN1 SU8S1ANCL A8USLkS
kea||ze that the dec|s|on to become and rema|n sober can on|y
be made by the substance abuser
Understand that nurses do not have the power to care anyone
We are on|y cheer|eaders and supporters
Lducate yourse|f about the effects of drug use |n genera| and |ts
effect on pregnancy and the newborn spec|f|ca||y
1reat substance abusers w|th the same respect and cons|derat|on
you show other peop|e
8ecome fam|||ar w|th your |oca| treatment centers Learn wh|ch of
them w||| accept pregnant women keep an uptodate ||st of groups
meet|ng |n your commun|ty
kemember that there are no "hope|ess cases" It |s never too |ate
to qu|t!
ract|ce pat|ence and pers|stence It may take months or years to
see the effects of your work
Lven women who are act|ve|y abus|ng drugs w||| exper|ence pa|n
dur|ng |abor and after g|v|ng b|rth
W|thho|d|ng ana|ges|a or anesthes|a |n an attempt to
"pun|sh" them for prenata| substance abuse |s not
he|pfu| and shou|d be avo|ded
It |s he|pfu| to deve|op a standard|zed p|an of care so
that pat|ents have ||m|ted opportun|t|es to p|ay staff
members aga|nst each other
Mother|nfant attachment shou|d be promoted by
|dent|fy|ng the woman's strengths and by re|nforc|ng
pos|t|ve materna| fee||ngs and behav|ors
Staff|ng shou|d be suff|c|ent to ensure str|ct
surve|||ance of v|s|tors and prevent unsuperv|sed
drug use
Adv|ce regard|ng breastfeed|ng must be |nd|v|dua||zed
A|though a|| abuse substances appear |n breast
m||k some |n greater amounts than others
breastfeed|ng |s def|n|te|y contra|nd|cated |n
women who cont|nue to use
a Amphetam|nes
b A|coho|
c Coca|ne
d nero|n
e Mar|[uana
1he baby's nutr|t|on and safety needs are or
pr|mary |mportance |n th|s cons|derat|on
Ior some women a des|re to breastfeed may
prov|de strong mot|vat|on to ach|eve and
ma|nta|n sobr|ety
DISCnAkGL CI A kNCWN SU8S1ANCL A8USLk WI1n nLk 8A8
1he home s|tuat|on must be assessed to determ|ne that the
env|ronment |s safe and that someone w||| be ava||ab|e to meet the
|nfant's needs |f the mother proves unab|e to do so
nosp|ta|'s soc|a| serv|ces department w||| be
|nvo|ved |n |nterv|ew|ng the mother before
d|scharge to ensure that the |nfant's needs w||| be
met
Iam||y members and fr|ends w||| be asked to
become act|ve|y |nvo|ved w|th the mother before
d|scharge
A home care or pub||c hea|th nurse may be asked to
make home v|s|ts to assess the mother's ab|||ty to
care for the baby and prov|de gu|dance and support
If ser|ous quest|ons about the |nfant's we||be|ng
ex|st the case w||| probab|y be referred to the
state's ch||d protect|ve serv|ces agency for further
act|on