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

Labor and Delivery Guidelines

1 Obtain a detailed history and conduct a comprehensive physical examination, although circumstances may impede these activities prior to delivery, that includes

• A complete medical, surgical, reproductive, and alcohol and other drug use history
• An appropriate family history, with special emphasis on alcohol and other drug use and mental illness
• Information about the baby's father, including alcohol and other drug use and medical history

2 Obtain complete baseline laboratory data that include

• Blood group, Rh factor determination, and antibody screen
• Rubella immune status
• Serologic test for syphilis
• Hepatitis B surface antigen screen
• Liver function tests
• Renal function tests
• Complete blood count with indices and platelet count
• Complete urinalysis and urine screen for bacteriuria

HIV counseling should be provided in the postpartum period and testing should be encouraged.

If the patient is seen early in labor, it may be technically feasible to obtain a Pap smear, GC culture, and chlamydia screen. Do a PPD, preferably with an antigen panel unless previously positive, in which case a chest radiograph is needed.

3 Obtain a urine toxicology screen, with or without blood alcohol level, as indicated (see Guideline 15 -- Urine Toxicology Considerations).

4 Obtain a sonogram. In order to decide about optimal delivery management, it is helpful to obtain a sonogram on intake prior to delivery. This procedure will provide information about approximate gestational age, estimated fetal weight (EFW), and presentation, and can rule out multiple gestation and major con- genital anomalies.

5 Notify pediatric and nursery staff of the patient's history of alcohol and other drug use and other pertinent medical conditions.

6 Notify social services so that a psychosocial assessment is completed after delivery. Because of confusion and fear, some substance-using women abandon their infants at the hospital rather than discuss various options for the infant's care and legal custody. Assignment of a case manager is essential for the patient and her newborn to ensure followup medical care, initiate alcohol and other drug treatment, and provide access to social services.