Oxford Handbook of Midwifery (41 page)

1
Barlow J, Birch L (2004). Midwifery practice and sexual abuse.
British Journal of Midwifery
12
(2), 72–5.

CHAPTER 8
The need for social support

150‌‌

Management of substance misuse

The use of illicit substances such as cocaine and heroin during pregnancy is associated with a number of unfavourable outcomes. Early referral to a specialist midwife will provide a more efficient coordination of care. This is particularly significant in view of the contribution of substance misuse to maternal mortality.
¹

Poor outcomes associated with substance misuse can range from:

• Prematurity
  
• Intrauterine growth restriction—reductions in birth weight are most marked in the infants of women who are multiple-drug users
  
• Premature rupture of the membranes
  
• Meconium stained amniotic fluid
  
• Fetal distress
  
• Opiates increase the likelihood of antepartum haemorrhage
  
• Cocaine has been associated with placental abruption particularly if taken around the time of delivery.
  ²
  

  Antenatal care is often inadequate because of late presentation, reluctance to have involvement with social services, and a chaotic lifestyle. In order to improve outcomes it is important to engage pregnant drug users early and some drug services have set up joint clinics with antenatal services and also liaise with labour wards.
  

  The overall aim of antenatal care is to minimise harm and stabalize the woman’s lifestyle. For women using opiates, substitution therapy with methadone is associated with greater success of antenatal care and better maternal and infant outcomes.
  

  Methadone prescriptions are arranged using strict and detailed guidelines. Oral methadone is dispensed in 1mg/mL solution and the usual
  

  dose is between 10 and 20mg daily to be taken as a single dose. The dose is adjusted according to the degree of dependence.
  

  It is recommended
  ²
  that the midwife should aim to:
  

• Encourage the woman to attend antenatal care regularly
  
• Normalize the care as much as possible taking into account the social and medical problems associated with substance misuse
  
• Give accurate and honest advice on the risks of substance misuse
  
• Provide good communication between professionals so advice is consistent
  
• Provide an individualized multi-agency plan for each client.
  

  Obtaining a history
  

  All information disclosed is confidential and should only be recorded in the hospital notes, not the client-held notes. The following information should be documented:
  

• What drugs are being used with any additional substances such as alcohol or diazepam?
  
• The amount used daily in either dosage or monetary terms
  
• The method of use and whether clean equipment is used
  
• Length of time of use and what was being used at the time of conception
  

MANAGEMENT OF SUBSTANCE MISUSE

151

Investigations

The following investigations may be performed having first asked for consent.

The woman may be referred to a specialist drug liaison midwife to coordi- nate her antenatal care if one is available in the area and also to a medical social worker. The woman’s health visitor may also be involved especially in follow-up care.

The notes need to have a paediatric alert documented for continuing care of the baby once delivered.

1. Lewis, G (ed.) (2007).
   The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives: Reviewing Maternal Deaths to Make Motherhood Safer
   —
   2003–2005
   . The 7th report on Confidential Enquires into Maternal Deaths in the United Kingdom. London: CEMACH.
   
2. Department of Health (England) and the devolved administrations (2007).
   Drug Misuse and Dependence: UK Guidelines on Clinical Management
   . London: Department of Health (England).
   

   CHAPTER 8
   The need for social support
   

   152‌‌
   

   Preparing the parents for birth
   

   ‘
   Antenatal education is a crucial component of antenatal care, yet practice and research demonstrate that women and men now seek far more than the traditional approach of a birth and parenting program attended in the final weeks of pregnancy
   ’.
   ¹
   

   Many women having their first baby find themselves isolated from a social support network, having moved away from where they were brought up and working full time, which isolates them from neighbours and the surrounding community. Through attendance at antenatal classes, parents may benefit from meeting new friends who will be going through the same experiences.
   

   Parent education classes can also provide an opportunity to discuss fears and worries and to exchange views with other parents-to-be, as well as providing information about aspects of pregnancy, labour, birth and the care of the baby. Special classes may be developed for instance for teenagers or women experiencing multiple pregnancies.
   

   Parents attending antenatal classes need to:
   

   • Obtain balanced, realistic information so they know what to expect
     
   • Learn skills that will help them to cope during labour
     
   • Know about the emotional and social aspects of birth and being a parent
     
   • Learn about life after birth and caring for their new baby.
     

     Antenatal class management
     

     Managing an antenatal class requires practice, and experience can be gained from working alongside an experienced class leader. The main
     

     points for the midwife who facilitates a class to consider are listed below.
     

   • It is important to have received good preparation in adult learning techniques and to have gained confidence in managing and leading small interactive learning groups.
     
   • Continuity of course leadership is essential to avoid duplication or omission of content and, more importantly, because the leader has to earn the trust of the group, in order to build relationships that enable the group to reflect on and discuss sensitive issues.
     
   • Lectures are of limited value; it is more important to give information in short sessions that allow the learning of practical skills and subsequent discussion.
     
   • Parents need to have the opportunity to learn about and to try out self-help strategies for dealing with labour.
     
   • Topics such as labour pain, crying babies, exhaustion, and postnatal mental health issues need to be given a realistic perspective.
     

1
Svensson J, Barclay L, Cooke M (2008). Effective antenatal education: strategies recommended by expectant and new parents.
Journal of Perinatal Education
17
, 33–42.

THE BIRTH PLAN

153‌‌

The birth plan

Discuss the birth plan with the woman and take opportunities to support her in her choices for the birth at any point during pregnancy. As the birth becomes imminent, record her wishes and give her the opportunity to discuss any concerns in the last few weeks of the pregnancy.

A birth plan should be flexible enough to take into account the unexpected. Enable the woman to appreciate that labour does not always go to plan. The following are some suggestions of things a woman may wish to discuss for inclusion in her plan.