Pregnant, Substance-Using Women
Treatment Improvement Protocol (TIP) Series 2

Guideline 2 -- Medical Stabilization and Withdrawal

The initial stabilization as well as the medical withdrawal of pregnant women from their drug(s) of abuse are recognized means of reducing the acute illness associated with the use of alcohol and other drugs. The initial stabilization of the patient should be accomplished within 10 days of first contact or earlier if medically necessary. The goals listed on next two pages may be attained by one agency or a collaboration of agencies within the community. The latter option requires appropriate cross-training between agencies.

During the period of stabilization, caregivers need to monitor the mother and fetus for adverse signs of drug withdrawal, establish a basis for ongoing alcohol and other drug treatment and recovery, and initiate a relationship between the mother and available supportive services within the community. The lead agency is generally responsible for assigning an appropriate staff person to undertake case management functions. The role of the case manager is to monitor and promote completion of this initial phase.

The procedures to be completed for the initial stabilization of pregnant, substance-using women are presented on the following two pages. They also apply to all of the specific medical withdrawal guidelines that follow.

Medical and Obstetrical Assessment

1 Follow universal precautions for blood and body fluids and Occupational Safety and Health Administration (OSHA) standards. Staff in health care facilities, especially those working with patients with histories of alcohol and other drug use, should be well versed in the appropriate application of the precautions and standards. 2 Obtain a detailed history and comprehensive physical examination that includes an obstetrical evaluation. 3 Conduct a laboratory evaluation, including but not limited to, complete blood count (CBC), sequential multichannel autoanalyzer (SMA) 18, serological test for syphilis, and urine analy-sis. Obtain results from the prenatal panel if they are available. If the woman is admitted before an initial prenatal examination has been performed, all prenatal laboratory tests should be done (see Guideline 8-Prenatal Intake). 4 Discuss HIV and document the discussion on the chart. 5 Obtain urine toxicologies or blood alcohol level tests as necessary (see Guideline 15-Urine Toxicology Considerations). 6 Perform fetal assessment, including a baseline sonogram, Non-Stress Tests (NSTs), or biophysical profiles appropriate for gestational age, as necessary. 7 Make other referrals as necessary.

Alcohol and Other Drug Use Assessment

1 Obtain a history of alcohol and other drug use, covering legal and illegal drugs (prescription drugs, over-the-counter drugs, alcohol, cigarettes), that includes Duration of use, including age of first use Frequency, type, amount, and periods of abstinence Routes of administration Social context of use (when, where, and with whom the patient uses) Past treatment history Support group involvement 2 Determine the consequences of alcohol and other drug use for the patient (self-perceived and objective). 3 Identify relapse factors for the patient. 4 Obtain a family history of alcohol and other drug use. 5 Assess the patient's motivation for treatment, including self-perceived and objective difficulties in entering treatment. 6 Assess the patient's motivation for continued use of alcohol and other drugs. 7 Obtain urine and/or blood toxicologies as needed (see Guideline 15-Urine Toxicology Considerations).

Psychosocial Assessment

1 Assess the patient's support systems, including her role in family and neighborhood support systems, and the stresses created by these systems. 2 Assess the patient's perception of her pregnancy and pregnancy options. 3 Assess the patient's educational level. 4 Assess the patient's employment skills. 5 Assess abuse and neglect experienced by the patient as an adult and as a child, including Sexual abuse Physical abuse and neglect Emotional abuse 6 Assess legal considerations and problems. 7 Assess current crises. 8 Assess the patient's current life and environmental situation, including Housing Transportation Child care Monetary support and assistance 9 Assess the patient's relationship to her other children.

Mental Health Assessment
1 Conduct a mental health evaluation that includes Mental status examination Psychiatric symptomatology Past psychiatric history and treatment Suicide risk Family psychiatric history DSM-III-R diagnosis Treatment recommendations 2 Use standardized psychiatric evaluation tools in diagnosis and followup. 3 Maintain liaison and ongoing contact with other members of the assessment and treatment team.

Alcohol and Other Drug Treatment Planning

1 Prepare a treatment plan with input from the patient and representatives from all participating health care and service agencies, that includes Appropriate alcohol and other drug treatment Medical and obstetrical care Followup services 2 Facilitate the introduction of the patient into alcohol and other drug treatment by contacting the patient at any point of entry for service or place of evaluation.