Substance abuse is a mental illness that refers to the unsafe or misuse use of psychoactive substances, including alcohol and illicit drugs (World Health Organization [WHO], 2018). Psychoactive substance use can lead to dependence syndrome. Dependence syndrome includes behavioural, cognitive, and physiological sensations that develop following frequent use. Such syndromes include the urge to consume, difficulties with regulating substance use, continual use despite consequences, increased tolerance, and states of withdrawal (WHO, 2018). Furthermore, substance abuse during pregnancy is more prevailing than conceptualized, with up to 25% of child bearing women using illicit drugs. Substance abuse is significantly more common among women of reproductive ages than women in other populations. That being said, the average pregnant woman will take approximately four to five drugs during the duration of their pregnancy whereas 82% of those women take prescribed substances and 65% use nonprescription substances, including illicit drugs and alcohol (Wilson & Thorp, 2018). This paper will discuss substance abuse in pregnancy in relation to perinatal nursing. The incidence, physiology, morbidity and mortality with respect to the effects on the newborn and plan for labour and delivery, emotion and psychological support, discharge and follow up plans, in addition to nursing interventions, roles, and special considerations will be discussed.
Maternal substance abuse has reached levels of critical concern in North America over the past years. Wendell (2013), depicted that women currently represent 30% of the user population, with a majority of child bearing aged women. Substance abuse among the pregnant population varies significantly and is reflective of social status and income, race, age, cultural beliefs and norms, education and methods of screening for substance abuse (Cook et al., 2017). In addition, multiple risk factors for substance abuse include previous addictions, history of psychotic illness, history of physical or sexual abuse and environmental pressures (Wendell, 2013). According to Wendell (2013), the 2010 National Survey of Drug Use and Health reported an increase in the use of illicit drugs and alcohol among pregnant women. Trends suggest that tobacco, followed by alcohol, cannabis, cocaine, are by far the most commonly abused by this population (Cook et al., 2017). In Canada, new mothers reported that during their pregnancy 10.5% smoked cigarettes, 10.5% drank alcohol, and 1% used street drugs. However, one year later, the Perinatal Health Report revealed data depicting an overall increase in alcohol consumption and signifiant increases in smoking and drug use (Cook et al., 2017). These not so shocking trends are consistent with those observed in the United States, North America, and worldwide (Cook et al., 2017).
Alcohol and illicit drugs have a significant impact on the human body. A significant number of health concerns arise from substance abuse. Liver problems as a result of alcohol consumption, respiratory impairment and lung cancers related to smoking, HIV/AIDS and hepatitis from injecting drugs, are a few examples supporting the impact that such substances have on the body (Center for Substance Abuse Treatment [CSAT], 2009). According to CSAT (2009), women who partake in substance abuse may have physiological problems related to gynecology. Impairments may be seen in women’s menstrual cycles, with cramping and changes with the duration and volume of menstruation. On the other hand, women who use illicit drugs can experience amenorrhea, misleading them regarding the signs of pregnancy or withdrawal (CSAT, 2009). Women’s substance use also poses risks to the unborn fetus, although the total damage that substance abuse has on a fetus is not fully studied and known. Fetal brain development is the most studied and the greatest life-threatening effect of substance abuse during pregnancy (Wang, 2014). A constant misuse of alcohol and illicit drugs during the first half of the pregnancy is likely to harm the wiring and connections of the brain which allows for the optimal brain development, maturity, and ability to learn (Wang, 2014).
Morbidity and Mortality: The Effects on newborn & plan of care for Labour and delivery
Substance abuse, both drugs and alcohol, during pregnancy is associated with mother and fetus mortality and morbidity. There is a strong correlation between substance use and a high-risk pregnancy and delivery. Substances such as opioids, smoking, and alcohol have proven increased risks of preterm labour, early onset delivery, poor or lack of fetal growth and development, and stillbirths (Whiteman et al., 2014). Increased hospital stays postpartum, exceeding five days, is common for mothers of substance abuse. In addition, during their extended stay, mothers of substance abuse are more likely to experience the complications, as significant as death (Whiteman et al., 2014).
Maternal complications vary from one mother of substance abuse to another. Some complications may include respiratory, cardiovascular, neurological, psychoses, human immunodeficiency virus and/or metabolic. Bacterial infections, hypertension, seizures, vitamin deficiencies and malnutrition are the most common complications from the list above (Wilson & Thorp, 2008).
Obstetric and fetal complications include placenta previa, abruption of the placentae, and even rupture of membranes (Wilson & Thorp, 2008). In other cases, poor growth of the fetus may occur due to the lack of maternal nutrition adequate oxygen supply. Most mothers dealing with substance abuse often deliver prematurely and pose long term developmental effects on the baby (Wilson & Thorp, 2008).
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Effects of substance abuse on the fetus and baby depend on the substance being smoked, snorted, inhaled, injected, swallowed or absorbed through the mucus membrane (Thorpe, 2008). Substances include congenital abnormalities, neonatal medical complication, and neurobehavioral alterations. Wilson and Thorp (2008), suggests that specific neonatal medical complications include sudden infant death syndrome (SIDS), neonatal abstinence syndrome (NAS), and respiratory distress syndrome.
The plan for labour and delivery includes a comprehensive approach that is inclusive of communication, education, compassion, respect, and holism free of judgement. It is imperative that a full support of staff, resources, and tools are present during all phases of labour to support mother, baby, and the family overcoming upcoming challenges and barriers leading to a healthy delivery, post-partum period, and discharge (Whiteman et al., 2014).
Emotional and Psychological Support
They most vital component to caring for a mother with substance abuse is directing treatment and control during prenatal, intrapartum, and postpartum periods towards counselling. Counselling is to be provided by those who have acquired extensive learning and training in the treatment of substance misuse and abuse in addition to pregnancy and determinants of health (Brady, McCauley, & Back, 2015). Counsellors and substance abuse treatment programs use a variety of techniques and modifications that include motivational interviewing, identification of triggers, stress reduction, medication, cognitive behavioural therapy, positive reinforcement of abstinence and contingency management of support groups (Gopman, 2014). Furthermore, Gopman (2014) articulates the importance of alternative therapies such as massage, acupuncture, yoga, which were studied and found to be effective in grounding and stabilizing the mind. Women who are child bearing and suffer from substance abuse are encouraged to develop and participate in social networks that are separate and beyond their bad acquaintances with respect to drug use, thus redirecting them from the pressures that come with their personal relationships (Cook et al., 2017).
Discharge and follow up plan
There are many considerations and learning topics that need to be identified prior to a discharge after birth. Significantly, there are a far greater number of considerations that need to be identified and discussed for a woman who is dealing with the issue of substance abuse. Pain management, preventing relapse, breast feeding guidance, newborn development and assessment as well as transition to primary care are specific areas of discharge and follow up planning that need to be addressed (Gopman, 2014).
Pain Management Postpartum
Both vaginal and caesarian births are accompanied by significant pain and discomfort postpartum. Keeping the history of a substance abuser in mind, pain medications are to be selected and used with severe caution. Non-Steroidal Anti-inflammatory Drugs, such as acetaminophen, is the most commonly prescribed medication in effort to relieve pain related to vaginal births (Gopman, 2014). Opioids may be the drug of choice when a significant increase in pain is felt in association with caesarian deliveries. Patients with a tolerance for opioids may have more difficulty controlling pain. It is suggested to allow for a higher or more frequent dosing of an opioid early on post-op, however quickly decreasing the need for opioid use to prevent relapse (Gopman, 2014). A discussion is critical to allow for the appropriate medications to be prescribed and so patient can understand the expectations and use of the prescription upon discharge. A follow up shortly after discharge is crucial to observe and track pain management related to drug use (Gopman, 2014).
After a delivery of a baby, substance abuse mothers may quickly have the urge to use. These mothers have a high risk for relapse as there is no longer a concern that exposure to drugs and alcohol will impact maternal and fetus health (Gopman, 2014). This population also has significant relapse rate due to the increased amounts of stress derived from postpartum depression, lack of sleep, hormone imbalances, and demands of parenting (Gopman, 2014). For the substance abuse mothers, close follow ups and early postpartum visits are crucial in preventing chances of relapse.
Breast Feeding Support
Breast feeding is a topic that raises many concerns and questions for the lay postpartum women. However, educating to a substance abuse mother is critical for the wellbeing of both mother and newborn (Gopman, 2014). Methadone and buprenorphine are acceptable forms of synthetic analgesic drugs that enable substance abuse mothers to breastfeed while controlling their addiction. It is proven that the amount of drug used is unlikely to negatively effect the baby and just as unlikely to prevent or treat neonatal abstinence syndrome (NAS). Breastfeeding and skin to skin contact may in fact diminish some symptoms of NAS (Gopman, 2014). Breastfeeding may also be a motivating for mothers, thus keeping clean of substance abuse (Demirci, Bogen, &Klionskyb, 2015). Patients in this predicament need education regarding opioid replacement and health conditions such as Hepatitis C that may influence a women’s decision/ability to breastfeed safely. Some users also need to be made aware of how to properly feed their newborn prior to discharge if abstinence is not of interest, thus breastfeeding is unsafe (Demirci, Bogen, &Klionskyb, 2015).
Newborn Development and Guidance
Recovery from substance abuse requires additional support to assure stability, health, and safety for both mother and newborn. Environmental resources that include parental and newborn care, substance abuse treatment, child development support that facilitate ongoing participation and trust are crucial in making sure that mother and baby are progressing and developing as they should be. Parenting classes and support groups provide opportunities for families to share knowledge and experiences with this matter (House, Coker, & Stowe, 2016).
Transition to Primary Care
Access to primary care services out of hospital is of utmost importance for women with substance abuse to attain. Encouraging women to seek visits with a current provider or a non-obstetric provider is an important message after delivery or potential loss of fetus (Gopman, 2014). The goal of this is to facilitate a smooth transition of care where the mother and fetus can have trust, respect, and compassion facilitated in an environment that can provide ongoing health care to a developing fetus and recovering or addicted mother.
Nursing interventions and roles and Special Considerations
Nursing has an imperative role in the prevention, treatment, and interventions for those who are dealing with substance use in pregnancy. As per Stone (2015), early recognition, intervention, and screening are the most effective tools and strategies that help an individual recognize the issue of substance abuse before the misuse of substances progresses.
Nurses have the role and duty to provide non-judgmental, compassionate, and ethical care that is client centered and holistic. In fact, pregnant women with substance abuse disorders often fear stigmatization, shame, and judgement, therefore decline prenatal and postnatal care (McKeever, Spaeth-Brayton, & Sheerin, 2015). Identifying pregnant women with substance abuse is an ongoing challenge for nurses as well as other members of the interdisciplinary team, as these women have distinct care and treatment needs (Stone, 2015). An important topic that needs to be addressed for nurses and health care members caring for women’s who display these issues is recognizing the need for multidisciplinary management to promote and ensure positive maternal and fetal health outcomes as well as compliance with substance abuse treatment (McKeever et al., 2015). Nurses must advocate for the education and resources that this population requires, so that they can become active partners in their care (McKeever et al., 2015). It is reported that pregnant women dealing with substance abuse were seeking nurses who showed the ability to listen, hear, and respond to their concerns, while keeping them safe and build a trusting relationship (Stone, 2015). It is vital that nurses initiate and influence patients to partake in education and support services regarding the latest on perinatal addiction and pregnancy. Therefore, special considerations like those listed above are required by nurses and interdisciplinary team members in order to provide safe, ethical and compassionate care from prenatal to postnatal for this population (McKeever et al., 2015).
In conclusion, it is evident that substance abuse in pregnancy is significant issue in North America today. To understand substance abuse in pregnancy, the incidence, physiology, morbidity and mortality with respect to the effects on the newborn, plan for labour and delivery, psychological support, discharge, nursing interventions, roles, and considerations are components that need to be understood. After a comprehensive review of scholarly literature, it is clear that further education, support groups, screening, and public health access and supports need to be introduced. Such interventions will greater enhance the provision and care for addicted women and women trending towards addiction during pregnancy. Due to the fact that substance abuse is a global issue, municipal, provincial and national leaders must work together to provide supports and resources to mothers who abuse substances prior to conception or during their pregnancy. They are both crucial and essential in helping control, support, and reduce the number of pregnant women with substance abuse issues. All in all, it is imperative that perinatal nurses fulfill their duty to provide treatment by initiating early recognition, screening, and treatment programs for such individuals. It is the goal of nurses and multidisciplinary teams to put a stop to the increasing trend of this epidemic.
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