Labor and delivery

When a patient presents to the hospital, the type and dose of maintenance medication must be verified and continued throughout labor. It is critical to remember that the maintenance dose will not provide adequate pain relief in labor and analgesic needs should be based on clinical evaluation.1 Acute pain during labor and postpartum should not be treated with additional doses of methadone.7 Optimally, laboring epidural or combined spinal/epidural analgesia works well. For acute pain prior to an epidural, a patient should never be treated with mixed agonist or antagonist opioid analgesics such as nalbuphine or butorphanol. These medications may accelerate acute withdrawal symptoms because they can expel the methadone from the mu receptor.7

Postpartum, the patient should be reminded to return to her maintenance therapy treatment center or her prescribing buprenorphine physician to resume her daily dosages. Coordination related to hospital release should be done avoid interruption in the patient receiving her daily medication.1 Women often have a desire to become drug free for herself and her newborn. The patient should be encouraged to postpone this endeavor until she establishes drug-free living arrangements, completes breastfeeding, her infant sleeps through the night, and until personal and social stability is achieved.1


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Neonatal abstinence syndrome

Even though methadone maintenance therapy improves pregnancy outcomes, it places the infant at risk for neonatal abstinence syndrome (NAS). This is usually characterized by hyperactivity of the central and autonomic nervous systems; infants may exhibit uncoordinated sucking reflexes that can lead to poor feeding, become irritable, and may have a high-pitched cry.3 Withdrawal symptoms usually appear within 72 hours after birth and can last several days to weeks. Collaboration with the pediatric team is needed for optimal management of the neonate.3

Patient education

Breast feeding should be encouraged during the postpartum period, as methadone is only minimally excreted in breast milk. Breastfeeding may also decrease some of the symptoms of NAS by encouraging mother-infant bonding and thereby increasing supportive care, which is a basic treatment of NAS.6 The patient should also be educated prior to pregnancy and during the postpartum period about contraception and prevention of sexually transmitted infections. Coordination with case management should assist the patient with psychosocial support services, including relapse prevention programs, chemical dependency treatment, and ensuring safe living arrangements for both mother and infant.3

Conclusion

As difficult as these situations may appear to providers, every effort should be encouraged to offer these patients the best care possible for themselves and their infants. The key is not abstinence for these patients, but maintenance therapy. Caring for the opioid-dependent pregnant woman should be viewed as an opportunity to make life-changing interventions for the sake of her health and the health of her unborn child.

Christy L. Brocato, MSN, CNM, RDMS, FNP-BC, is a certified nurse midwife at the University of Florida Health Jacksonville.

References

  1. Jones HE, Deppen K, Hudak ML, et al. Clinical care for opioid-using pregnant and postpartum women: the role of obstetric providers. Am J Obstet Gynecol. 2014;210:302-310.
  2. Percoraro A, Ma M, Woody GE. The science and practice of medication-assisted treatments for opioid dependence. Subst Use Misuse. 2012;47:1026-1040.
  3. ACOG Committee on Health Care for Underserved Women; American Society of Addiction Medicine. ACOG Committee Opinion No. 524: opioid abuse, dependence, and addiction in pregnancy. Obstet Gynecol. 2012;119:1070-1075.
  4. Park EM, Meltzer-Brody S, Suzuki J. Evaluation and management of opioid dependence in pregnancy. Psychosomatics. 2012;53:424-432.
  5. Management of substance abuse. Abuse (drug, alcohol, chemical, substance or psychoactive substance).  World Health Organization website. http://www.who.int/substance_abuse/terminology/abuse/en/
  6. Winkblaur B, Kopf N, Ebner N, et al. Treating pregnant women dependent on opioids is not the same as treating pregnancy and opioid dependence: a knowledge synthesis for better treatment for women and neonates. Addiction. 2008;103:1429-1440.
  7. Seligman NS, Berghella V. Methadone maintenance therapy during pregnancy. UpToDate website. http://www.uptodate.com/contents/methadone-maintenance-therapy-during-pregnancy?source=see_link. Updated October 14, 2014.
  8. Jones HE, Martin PR, Heil SH, et al. Treatment of opioid-dependent pregnant women: clinical and research issues. J Subst Abuse Treat. 2008;35:245-259.
  9. Alto WA, O’Connor AB. Management of women treated with buprenorphine during pregnancy. Am J Obstet Gynecol. 2011;205:302-306.
  10. Maguire D. Drug addiction in pregnancy: disease not moral failure. Neonatal Netw. 2014;53:11-18.
  11. National Institute on Drug Abuse (NIDA). National Institutes of Health, US Department of Health and Human Services[M4] . Commonly Abused Drugs and Prescription Drugs 2014. Available at: www.drugabuse.gov
  12. Center for Adolescent Substance Abuse Research (CeASAR) at Boston Children’s Hospital. The CRAFFT screening interview. Boston (MA): CeASAR; 2009. Available at: http://www.ceasar.org/CRAFFT/pdf/CRAFFT_English.pdf.
  13. Foo L, Frei M, Lubman DI. Managing opioid dependence in pregnancy: A general practice perspective. Australian Family Physician, 2013; 42(10):713-716.

All electronic documents accessed on September 1, 2015.