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

Labor and Delivery Guidelines

1 Obtain a detailed history, including recent alcohol and other drug use, and conduct a comprehensive physical examination. The end of pregnancy is a period when women may relapse into previous substance- using behavior. Therefore, on admission to the labor room, a complete history and physical examination are needed. Information about alcohol and other drug use is important, as follows:

• Substance-using women often confuse the early signs of labor with signs of withdrawal, and they may medicate themselves during the early hours of labor.
• Substance-using women should be urged to admit all alcohol and other drugs taken recently. Once known, the effects of these drugs on the woman and her in- fant, and possible interactions with any medications used in labor, can be ascertained and the appropriate staff alerted.
• The use of alcohol or other drugs prior to arrival at the hospital can determine the type and amount of analgesic, if any, to be used during labor and delivery.

2 Repeat hepatitis B surface antigen and HIV screens, unless previously known to be positive, and repeat serological test for syphilis (titer if previously positive). Repeat these tests, with appropriate consents, to determine if there is any change from the previous tests, and to establish the present status of the woman and the fetus or neonate.

3 Obtain complete urine and/or blood toxicology screen. Substance-using women often arrive at the hospital with a high level of drugs in the blood due to recent use (see Guideline 15 -- Urine Toxicology Considerations).

4 Notify pediatric and nursing staff providing primary care. Advise staff of the patient's history of alcohol and other drug use, positive drug screening, and other pertinent medical conditions (e.g., results of hepatitis screen, serological test, and HIV test).

5 Notify social services. Advise staff of the patient's history of alcohol and other drug use and of any pertinent psychosocial concerns, such as unsafe living conditions.

6 Monitor the fetus as indicated. The greater likelihood of relapse at the time of labor increases the possibility of fetal stress and distress.

7 Provide pain management as appropriate. Analgesia and anesthesia administered during labor may include the same range of options available to all patients. Pain medication and attempts at adequate pain relief should never be withheld simply because the patient has a history of alcohol and other drug use. Regional anesthesia may be the procedure of choice. Analgesia and anesthesia administered during delivery may include

• Regional: Epidural or spinal
• Pudendal or local

The following statements also pertain:

• Due to tolerance, patients may require higher than usual doses of short-acting intramuscular/injection narcotics.
• Avoid use of combination narcotic agonist/ antagonists and pure narcotic antagonists because they may precipitate acute drug withdrawal.
• Methadone provides minimal analgesia for those women using opioids.

8 Select the delivery method dependent only on obstetrical indications.

9 Insert a central line if necessary. Because of the presence of sclerotic veins, many injection drug users require the insertion of a central line.

10 Follow universal precautions for blood and body fluids and OSHA standards that include

• Gowns, masks, eye protection, and double gloves for deliveries
• Gloves for invasive procedures, changing soiled linens or dressings, handling the placenta and cord, and handling the neonate prior to the first bath
• Mechanical or bulb aspiration of the newborn: Avoid mouth-operated aspiration traps.