Multi-agency Guidelines for Women
on Substance Misuse in Maternity
Services.
Version:
2
Author:
Lynn Lynch
Date Approved:
July 2005
Status:
Final
Approved by:
Women and Children’s Clinical
Governance Group
Review Date:
May 2008
Responsible Director:
Mr. K.A. Asaad
Consultation:
Obstetricians, Risk Manager,
Supervisors of Midwives,
Senior Midwifery Staff,
Paediatricians, Neonatal Unit,
Community Drug and Alcohol
Teams.
Can this document be
included in the Trust’s
Yes
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No
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Multi –Agency Guidelines for Women on Substance Misuse in
Maternity Services.
If No please provide the reason on a separate sheet with as much detail
as possible. If you require any further information please contact the
information Governance Manager on ext 8259.
CONTENTS
1.
Introduction .................................................................... 3
2.
Objectives ....................................................................... 3
3.
Client Group .................................................................... 3
4.
Referrals ......................................................................... 4
5.
Liaison Meeting ................................................................ 4
6.
Management of Antenatal Care .......................................... 6
7.
Maternal Health Problems ................................................. 7
8.
In-patient management of pregnant women mis-using
substances .............................................................................. 7
9.
Continuing Opioid maintenance as an inpatient .................... 8
10. Urgent Buprenorphine (Subutex ) Stabilisation .................. 9
11. Procedure for Buprenorphine Stabilisation ........................... 9
12. Urgent Alcohol Detoxification ........................................... 10
13. Procedure for Diazepam loading dose therapy.................... 10
14. Stimulants .................................................................... 11
15. Management of labour .................................................... 12
16. Reasons for admission to SCBU........................................ 13
17. Effects of substance misuse on new born babies ................ 13
18. Neonatal management .................................................... 15
19. Postnatal Management.................................................... 16
20. Documentation .............................................................. 17
References ............................................................................ 19
Acknowledgements ................................................................. 21
Appendices ............................................................................ 22
Appendix 1 ............................................................................ 23
Appendix 2 ............................................................................ 26
Appendix 3 ............................................................................ 27
Appendix 4 ............................................................................ 28
Appendix 5 ............................................................................ 29
Appendix 6 ............................................................................ 30
Appendix 7 ............................................................................ 32
Appendix 8 ............................................................................ 33
Appendix 9 ............................................................................ 34
Appendix 10 .......................................................................... 35
Appendix 11 .......................................................................... 37
Appendix 12 .......................................................................... 38
Appendix 13 .......................................................................... 39
Appendix 14 .......................................................................... 40
Appendix 15 .......................................................................... 41
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Multi –Agency Guidelines for Women on Substance Misuse in
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1. Introduction

To create an environment where pregnant women with substance
misuse will have knowledge of, and confidence in a team who can
manage them sympathetically in pregnancy and help minimise harm to
the mother and baby.

To have a healthy mother and baby at the end of the pregnancy
2. Objectives

To develop and establish a common team approach to co-ordinate the
care and management of the mothers and babies throughout
pregnancy and afterwards.

To create women-centred care by involving women as early as
possible, and discuss with them their care using a planned, cooperative and non-judgemental approach.

To develop knowledge and expertise in the area of pregnancy and
substance misuse and act as a resource for other professionals.

To offer support, information and advice to women’s partners and
families where this is appropriate.

To provide the majority of antenatal care in the community in
partnership with the community drug and alcohol team (CDAT).

To provide information that will be available outlining the service and its
use for GP’s, drugs services, other relevant professionals and potential
clients/parents.
3. Client Group

Women with drug or alcohol misuse.

Women who are undergoing a detox programme with the CDAT.
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Multi –Agency Guidelines for Women on Substance Misuse in
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4. Referrals
Initial referrals are likely to made by Midwives and Obstetricians in particular,
as well as General Practitioners, the Maternity Services, Drugs Agencies,
Health Visitors or self-referrals.
Where possible a written referral should be submitted so that it can be
discussed at the monthly clinic meeting ( referral form appendix 1).
To make easy access possible, direct self-referrals can be made to the
antenatal clinic.
All new referrals are discussed at the monthly meeting.
5. Liaison Meeting
The standard conference on drug abuse (SCODA) and The Local
Government Drug Forum (LGDF) have recently revised good practice
guidelines for working with pregnant users, with a strong emphasis on
collaborative case management. They suggest four stages at which it might
be important to hold multi-agency meetings:
Booking Meeting – when pregnancy is confirmed.
Purpose: To identify pre-birth workers and individual responsibilities. Also to
discuss HIV / Hepatitis B and C Status.
Planning Meeting – should be held around the twenty eighth week of the
pregnancy.
Purpose: To discuss short and long term plans involving clients own Health
Visitor, midwife, Obstetrician and Paediatrician.
Pre-Transfer Home Meeting – soon after the birth.
Purpose: Formal feedback, liaison and evaluation of services delivered.
Identification of future input required, if appropriate.
Involving Paediatrician, named Midwife, Consultant Midwife, letter to GP and
Health Visitor.
The above model is to be adopted and implemented in each case. Meetings
would consist of key professionals involved i.e. named midwife, midwife
consultant, drug/alcohol worker, health visitor, social worker (if current case)
SCBU staff member and pregnant woman
(see appendix 2).
In order to improve communication in hospital and community and to develop
clear routes for referral – the following link people have been identified:
Midwife Consultant
Lynn Lynch
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Multi –Agency Guidelines for Women on Substance Misuse in
Maternity Services.
Midwife Consultant for Vulnerable Women
Women and Children Services
Prince Charles Hospital
Tel: 01685 721721 ext:8987/8541
Mobile: 07789504764
CDAT
Community Drug & Alcohol Team
Llwyn yr Eos Clinic
Church Village
Nr. Pontypridd
CF38 1RN
Tel: 01443 217026
CHILDREN & YOUNG PEOPLES DIVISION
Community Clinics
Tuesday 2.00 pm – Mountain Ash Hospital
Wednesday 2.00 pm – MIDAS, Merthyr Tydfil
MERTHYR
Post Office Lane
Merthyr Tydfil
CYNON
Llewellyn Street
Trecynon
Aberdare
CF44 8HU
Tel: 01685 724546
Tel: 01685 875481
DRUG AID - Tel: 01685 721991
FAMILY INTERVENTION SERVICE – Tel: 01685 375237
FAMILIES FIRST – Tel: 01443 208899
:
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Multi –Agency Guidelines for Women on Substance Misuse in
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6. Management of Antenatal Care
All pregnant women with substance misuse referred should be directed to Mr
S Vine, Consultant Obstetrician/Lynn Lynch Midwife Consultant. Referrals will
be discussed at the monthly team meeting.
Antenatal care should be undertaken monthly throughout pregnancy at any
site by an appropriately trained doctor/midwife. Information leaflet should be
given. Routine blood tests are offered and Hepatitis C screening should be
offered for women who have a past or current history of intravenous
substance misuse. Information about HIV testing should be given.
Obstetric booking – aim at 12 weeks. A full medical, social and drug history
to be taken. The usual antenatal blood screening (which will include
counselling for Hepatitis B and HIV) will be offered, including Liver Function
Tests and Hepatitis C.
Where a woman is not already in contact with CDAT she will be offered
referral (appendix 1 – referral).
Women are offered a routine anomaly scan at 18 – 20 weeks and further
scans if clinically indicated at 28–34 weeks to monitor growth. Fetal growth at
other visits will be monitored by measuring and plotting the symphysis fundal
height (Appendix 3) – if growth is difficult to assess clinically, another scan will
be offered.
Social Services, Children’s Division need to be informed if the client gives
written consent for a needs assessment. (An assessment will be made and a
care plan decided with the patient).Where substance misuse treatment is
necessary, this will be managed by CDAT. Care reviews will be presented
at the monthly meeting.
Where there are child protection concerns consent is not required.
Women should be encouraged to stabilise their substance misuse with a view
to reducing their overall drug consumption during pregnancy, including
methadone if prescribed.
Correspondence to GP’s about clinical care should be sent routinely at
booking and at 32 weeks when the action form has been developed. Any
child concerns will automatically be shared with social services.
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Multi –Agency Guidelines for Women on Substance Misuse in
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7. Maternal Health Problems
Associated problems need to be discussed with the client and reviewed
throughout the pregnancy, these include:







Harm reduction
General nutrition/health
Risks of anaemia
Dental hygiene
Infection, respiratory or injection sites.
Constipation
Psychological issues, such as fears and expectations
8. In-patient management of pregnant women misusing substances
Close liaison between the drug service and in-patient service is very helpful to
patient management. As a general rule, women being admitted to hospital in
receipt of a prescription should have that prescription in hospital. To avoid
“double prescribing” the patient’s usual prescriber should be contacted as
soon as possible so that community prescribing and dispensing can be
suspended.
BENZODIAZEPHINES
Women who are definitely (check with community prescriber) in receipt of
prescribed benzodiazepines outside hospital, should have their prescription
continued whilst in hospital. Where possible of the dose should be reduced
with specialist advice from the CDAT due to the risks of congenital deformities
associated with benzodiazepines. Women who are not in receipt of
prescribed benzodiazepines should not be prescribed them during admission
unless under specialist advice from the CDAT. Temazepam should not be
prescribed.
OPIATES
A person using opiates on a daily basis will start to have opiate withdrawal
symptoms when their intake ceases.
For Heroin - symptoms start at about 6 hours and peak at about 48 hours.
For Methadone - the symptoms may not start for at least 24 hours and will
not peak until 72 – 96 hours. Features of withdrawal include craving,
irritability, restlessness and later vomiting and diarrhoea.
Substitute prescribing can occur at any time during pregnancy following
specialist assessment by the CDAT and will usually consist of a daily
prescription for methadone or Buprenorphine (Subutex ).
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Multi –Agency Guidelines for Women on Substance Misuse in
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9. Continuing Opioid maintenance as an inpatient
Do not start methadone maintenance regimes without prior arrangement with
the CDAT. In the community all patients starting opioid maintenance require
a full CDAT assessment and three positive opioid samples (usually urine)
before commencing methadone. Patients on opioid maintenance will usually
be prescribed methadone, though some may be on sublingual Buprenorphine
(Subutex ). The prescribing of maintenance dihydrocodeine is discouraged.
(A protocol for stabilising opioid withdrawing pregnant women on
Buprenorphine when an inpatient under the care of maternity is described
below).
The following is intended for staff admitting women who are already on
community prescriptions of opioids:
N.B.
You may be told by the woman that she is on a maintenance methadone
(or other opioid) script.
DO NOT prescribe the maintenance methadone (or other opioid) before
phoning their usual community pharmacy to check:
1. That the individual concerned is currently being prescribed methadone
(or other opioid)
2. The quantity being prescribed
3. Whether she is actually picking up the medication prescribed.
Please:

Ask the community pharmacist to suspend the community script until
notified of discharge from the hospital

Notify the prescriber of the admission
Patients admitted to the ward for longer than 24 hours will have Methadone
administered to them by nursing staff from ward controlled drug stock. If
clients bring any community prescribed opiate in with them, they are to be
locked in the controlled drug cupboard and entered in the register as patients
own.
The community prescriber (usually CDAT) should be notified as soon as
possible regarding a discharge date so that a prescription can be arranged in
the community.
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Multi –Agency Guidelines for Women on Substance Misuse in
Maternity Services.
If the patient has to be discharged at the weekend and arrangements with
CDAT are not in place, the hospital pharmacy should be informed so that daily
doses of the methadone can be dispensed each day over the weekend
Pharmacy is open 9.00 a.m. – 12.00 p.m. on Saturday 11.00 a.m – 1.00 p.m
on Sunday and every bank holiday 9.00 am – 12.00 p.m. (except Christmas
Day).
N.B Any drug other than those prescribed by the hospital is not
permitted to be taken on the Trust premises.
10. Urgent Buprenorphine (Subutex ) Stabilisation
Buprenorphine is licensed for use in opioid dependency in the UK.
Buprenorphine is a partial opiate agonist, is taken sub-lingually and is suitable
for once daily regimes. It is less likely to produce severe respiratory
depression than full opiate agonist effect of Methadone
Buprenorphine offers a potentially safer alternative to methadone for urgent
opioid stabilisation, in the general hospital environment.
Buprenorphine stabilisation should only be considered for women who
are:




Not currently receiving opioid prescriptions from other sources
Not currently in labour
Actively withdrawing from opioids (see below)
An inpatient under the care of the maternity services
Before starting Buprenorphine stabilisation




Take history of substance use (check with an informant if possible)
Undertake Short Opiate Withdrawal Scale (SOWS – see appendix 13)
Confirm opioid use:
o Send a urine sample for urgent drug screen
o Dipstick urine for opiates
Discuss issues of opioid prescribing in pregnancy, give specific
Subutex info, and obtain consent for stabilisation and referral to CDAT.
11. Procedure for Buprenorphine Stabilisation
(Appendix 14)
N.B. Emphasis that the patient must take Buprenorphine sub-lingually (or
between the gums and cheeks).

Day 1: Commence Buprenorphine 4mg 24 hours after the last dose of
methadone (maximum 30mg/day). Or 4-5 hours after the last use of
heroin (or other short acting opioid) and/or when mild to moderate
signs of opioid withdrawal are observed. (Any sooner may precipitate
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Multi –Agency Guidelines for Women on Substance Misuse in
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withdrawal symptoms).
hours.
Assess response to medication after two

Day 2: The dose will usually need to be increased by 4mg, to 8mg. If
there are signs of intoxication or side effects the dose can be
decreased by 2-4mg. Assess response to medication after two hours.

Day 3: The dose will usually need to be increased by 4mg, to 12mg.
Assess response to medication after two hours. Further increases may
be needed, but should be discussed with CDAT.
Refer to CDAT as soon as practically possible after starting a Buprenorphine
stabilisation. A referral will then be seen and assessed with five working
days, (including an assessment of the need for further opioid prescribing).
12. Urgent Alcohol Detoxification
Alcohol is associated with a multitude of congenital abnormalities, and
maternal ill health. Unmanaged alcohol withdrawal is hazardous and
potentially life threatening. Patients should be detoxified using diazepam
‘symptom triggered therapy’ (S-TT) based on the revised Clinical Institute
Withdrawal Assessment for Alcohol scale (CIWA –AR appendix 15). ST-T
titrates diazepam administered against withdrawal symptoms and signs.
Before starting detoxification




Take history of alcohol use (check with an informant if possible).
Take blood for U + Es, LFTs inc. Gamma GT, and FBC
Send a urine sample for drug screen
Discuss issues around alcohol use in pregnancy, and obtain consent
for alcohol detoxification and referral to CDAT.
13. Procedure for Diazepam loading dose therapy
The admitting doctor should prescribe: ‘diazepam liquid 20 mg to be given for
CIWA –Ar scores of 11 or more, up to a daily maximum of 200 mg’ in the ‘as
required and depot’ section of the prescription sheet. All other sedative
hypnotics already prescribed for the patient should continue to be prescribed
at the same doses and times, on a regular basis in the “regular medication”
section of the prescription sheet.
Within thirty minutes of presentation to the ward the patient should be
assessed using the CIWA-Ar. The patient should be given 20mg diazepam if
the score is 11 or more.
The CIWA-Ar should be re-administered at 90 minute intervals and the patient
given 20 mg diazepam each time the score is 11 or more, irrespective of
alcometer readings.
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Multi –Agency Guidelines for Women on Substance Misuse in
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When the CIWA –Ar score falls to 10 or less, no more diazepam should be
given but supportive therapy should be continued as described below.
The CIWA-Ar should be repeated once more, 90 minutes after the score has
fallen to 10 or less.
If the patient is asleep at night at the time of their scheduled CIWA-Ar then the
CIWA-Ar should be suspended and their respiratory rate should be checked
and noted. The patient should be returned to every 90 minutes and their
respiratory rate rechecked and noted. On waking the CIWA-Ar should
resume until tow consecutive CIWA-Ar scores have fallen to 10 or below.
Continue to measure temperature, pulse and blood pressure, six hourly for 24
hours to allow the early detection of concurrent illness.
14. Stimulants
There is no safe treatment for pregnant women who are using stimulants such
as amphetamines and cocaine.
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Multi –Agency Guidelines for Women on Substance Misuse in
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15. Management of labour
“For opiate dependent women receiving antenatal care, the management and
duration of labour and the incidence of caesarean section are no different
from those of a matched population”. (Fraser, 1983)

Most women will have been given information regarding the possibility
that their baby may suffer withdrawal symptoms and the possibility of
the baby being observed on the SCBU.
Pain relief needs special attention. Additional opiates may not be very
effective if the receptors are already saturated. Therefore, there should be a
low threshold for considering the use of an epidural.

If the woman is maintained on methadone it should be continued
during labour. Standard analgesia is indicated during labour as the
daily dose of methadone will not provide pain relief. There is little
evidence to suggest that pain relieving opiates are harmful to the fetus
already sensitised to opiates during pregnancy. (Fraser, 1983).

Withdrawal from opiates in labour may be shown by fetal distress on
the CTG monitor e.g. tachycardia, bradycardia, increased fetal
movements, meconium stained liquor.

It is helpful to ensure that a woman has adequate amount of opiate
throughout labour, so that the opiate withdrawal induced fetal distress
can be excluded from other obstetric emergencies.
Maternal withdrawal signs include restlessness, tremors, sweating,
abdominal pain, cramps, anxiety and vomiting.

Drug misuse is not a contraindication to having a PCA pump following
caesarean section and post-delivery pain relief/control should be
available as for every woman.

Routine care in labour should be carried out with the careful
observation of the mother and fetus for withdrawal.

The woman’s drug addiction may be recognised for the first time during
labour. Any Substance Misuser who goes into opiate withdrawal
during labour should be treated by a small dose of opiate.

Inform the Paediatrician of mother’s Substance Misuse when the
mother is in established labour. The Paediatrician is not required to be
present at delivery unless the clinical situation indicates otherwise.

Refer to the action which has been written in the ante-natal period.
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Multi –Agency Guidelines for Women on Substance Misuse in
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
If the baby requires resuscitation at birth DO NOT give Neonatal
Narcan unless prescribed by a Paediatrician as this could lead to rapid
withdrawal associated with increased Perinatal morbidity and death
(Gibbs 1989).

Care of the baby should be the same as any other baby, including the
encouragement of skin to skin contact.

Breast feeding should be encouraged, even if the mother continues to
use drugs. With the exceptions of those women who have a HIV
positive status due to the risk of HIV transfer when breastfeeding. The
following are also contraindications
o Hepatitis C
o Users of high does of benzodiazepines.
o Cocaine.
Methadone treatment alone is not contraindicated in breast feeding.

Early feeding of the neonate where condition allows is imperative in the
prevention of hypoglycaemia.

Normal infection control procedures around bodily fluids is all that is
necessary. Disposal of clinical waste and contaminated linen is as
normal.

The baby should be transferred to the postnatal ward with its mother
unless there is a medical reason for admission to SCBU.
16. Reasons for admission to SCBU
1.
2.
3.
4.
5.
When incubator observation is necessary.
Withdrawal symptoms requiring treatment.
Hypoglycaemia.
Hypothermia.
All other reasons for admission that applies to all neonates.
17. Effects of substance misuse on new born babies
(Source: Standing Conference on Drug Abuse 1997 Drug Using Parents).
HEROIN, OTHER OPIATES AND OPIOIDS
The following signs and symptoms may be experienced:



High pitched cry
Increased respirations and heart rate
Hungry, but difficulty with feeding
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Multi –Agency Guidelines for Women on Substance Misuse in
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





Inability to establish sleep patterns
Sweating
Fever
Vomiting
Diarrhoea
Seizures
Withdrawal symptoms may start within 24 – 48 hours post delivery but can be
up to 2 weeks depending on drug use. There is no conclusive evidence that
there is physical or brain development impairment to the baby.
COCAINE



Impaired growth
Brain growth is also impaired
Cocaine constricts foetal blood vessels during pregnancy which may
result in reduced oxygen to the brain.
BENZODIAZEPINES (Diazepam, Nitrazepam)





Use in pregnancy may result in withdrawal symptoms including:
Floppiness, due to poor muscle tone
Reduced temperature
Feeding difficulties, due to poor sucking
Breathing difficulties
There is some evidence that benzodiazepine use is associated with increased
incidence of cleft palate.
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Multi –Agency Guidelines for Women on Substance Misuse in
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ALCOHOL
 Impaired growth
Heavy use in pregnancy carries the risk of fetal alcohol syndrome (FAS).
AMPHETAMINES

Low birth weight
CANNABIS

Low birth weight
18. Neonatal management
Care in the Special Care Baby Unit
1. Antenatal visit to the Special Care Baby Unit will be offered and
encouraged to all pregnant users and their partners as part of the birth
plan.
2. The parents should be kept informed of the neonates condition and
where condition allows be encouraged to participate in the routine care.
It is important at this time to assess the parents knowledge and
understanding of drug withdrawal symptoms.
3. Nurse in an environment with reduced stimuli i.e. quiet, no bright lights
with minimal handling.
Initially nurse in an incubator for easy
observation then into a cot when conditions is stabilised.
4. Observe baby for signs of drug withdrawal – chart to be completed and
kept in the mothers notes (see appendix 5).
5. Monitor vital signs 4 hourly and report any deviations from normal.
6. Administration of drugs as prescribed.
7. Feeding, to be commenced as soon as possible, where conditions
allows to maintain blood glucose level within normal limits. Observe
feeding technique and document findings clearly. Where external
feeding is not tolerated then fluid replacement and calories must be
given intravenously.
8. Paediatric Liaison Health Visitor to be informed of baby’s admission to
SCBU and of discharge.
9. On discharge GP and Generic Health Visitor to be informed by letter of
discharge and any relevant medication.
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Multi –Agency Guidelines for Women on Substance Misuse in
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10. Social Services informed if involved.
19. Postnatal Management

As previously stated mother and baby should be nursed together in the
postnatal ward.

Neonatal withdrawal symptoms from methadone, which has a longer
half-life than heroin, generally occurs, if at all, after 24 hours and within
72 hours. The mother should therefore be encouraged to stay in
hospital for a minimum of 72 hours so that any major symptoms of
opiate withdrawal in her baby can be monitored and treated.

Babies requiring treatment for drug and alcohol withdrawal will be
transferred to SCBU but returned to the ward as soon as possible.

Babies are often fractious even if they do not require treatment and the
mother will often require extra support in feeding and comforting her
baby – use of dummies, swaddling etc, may be helpful. However
dummies may not be appropriate if babies are being breastfed. Each
mother should be given a leaflet about neonatal withdrawal, care of the
newborn, breastfeeding etc.

Breastfeeding should be positively encouraged. Most drugs of misuse
do not pass into breast milk in quantities which are sufficient to have a
major effect on the newborn baby. Methadone and Buprenorphine
maintenance do not preclude breast feeding. Research suggests that
breastfeeding should not be discouraged in those who are either
Hepatitis B or Hepatitis C positive (Carey, 1995) (Lin et al, 1995),
however mothers need to be informed of the risks to their baby if they
are HIV positive and the risk of Hepatitis B and C transmission during
breastfeeding needs to be discussed at length.
The important point is that women should be given all the information
they need to make an informed choice about breastfeeding. Having
made that decision, they should be fully supported by all the
professionals involved (ISDD 1995)
Whilst on the ward there is a prime opportunity for midwives to educate the
mother regarding contraception and other areas of sexual health. Referral to
Domiciliary Family Planning Service (DFPS) can be made with clients consent
in antenatal period and post natal period for contraception and sexual health
advice. The only consistent advice usually given to substance misuser is
about the effects of drugs on their pregnancy, not about the effects of drugs
on menstruation, fertility or the appropriateness of different types of
contraception. Providing information and education empowers substance
misuser to take responsibility and make informed choices. Midwives need to
emphasise the important role of the GP, as well as the roles of GUM and
DFPS in encouraging women to address their sexual health. The importance
of cervical screening must be stressed (Miller, 1996). Ideally discussion
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Multi –Agency Guidelines for Women on Substance Misuse in
Maternity Services.
should be instigated in the antenatal period and referral made to DFPS rather
than when the woman is about to be transferred home post-delivery.
Substance Misuser can pose specific problems with regard to using
contraception.
If appropriate, contraception can be started prior to transfer home, it may help
to prevent an unwanted pregnancy.
TO MAINTAIN CONFIDENTIALITY THE WOMANS SUBSTANCE MIS-USE
SHOULD NOT BE DISCUSSED ON THE WARD ROUND.
POSTNATAL PLANNING MEETING
Soon after delivery, a meeting should be held to decide on the appropriate
support for the mother and input from midwife, Social worker, Health visitor,
GP and extra supervision if necessary. Continuing support is needed and
should include parenting advice and skills training , and involve services such
as Family Intervention Service (Merthyr) and Families First (Cynon).
20. Documentation
Documentation on the plan of care for all clients and babies should be,
wherever possible, held together so that communication is as efficient as
possible – particularly the
paediatric notes.
Action plan to be sent to health Visitor and GP.
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Multi –Agency Guidelines for Women on Substance Misuse in
Maternity Services.
TRANSFER HOME

Transfer needs to be arranged carefully in the planning meeting so that
the lines of communication are clear and individuals responsibilities
can be clearly defined.

Notice is required of discharge so that link drug workers can arrange
continuation of methadone prescription if needed in the community.

If discharge over weekend arrangements need to be made with
pharmacy for daily collection of Methadone dose, unless otherwise
agreed by CDAT team. Normally in community the methadone is given
and taken on the premises everyday to avoid 3 days dosage being
taken in one.
Pharmacy is open 9.00 a.m. – 12.00 p.m. on Saturday, 9.00
a.m. –11.00 am on Sunday and every bank holiday 9.00 am –
12.00 p.m. (except Christmas Day).

Concerns regarding the mothers ability to cope with the newborn
should be dealt with in the normal manner, in keeping with the Child
Protection Procedures, assessment framework.
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Multi –Agency Guidelines for Women on Substance Misuse in
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References
Department of Health (1999)
Framework for the Assessment of Children
in Need and Their Families . D.O.H.
Department
for
Education
and
Employment, Home Office
Department of Health (1999)
Drug Misuse and Dependence Guidelines
on Clinical Management. The Scottish
Office, Welsh Office, Department of Health
and Social Services, Northern Ireland
Drug Using Parents
Policy Guidelines for Inter-agency Working
SCODA 1997
Drug
Pregnancy
Childcare (1991)
and A Guide For Professionals.
Publication. London.
ISDD
Klee H., Lewis S. and Jackson Illicit Substance Misuse in Pregnancy and
Early Motherhood: an analysis of
M. (1995)
impediments to effective service delivery.
A report prepared for D.O.H. 1995
Macrory F. (1997)
Substance Misuse, Pregnancy and Care
of the Newborn. Manchester St Mary’s
Hospital and Manchester Drug Service
The National Assembly for Working Together to Safeguard
Wales (2000)
Children. A guide to inter-agency
working to safeguard and promote
the welfare of Children, CARDIFF
Fraser, AC. (1983)
The Pregnant Drug Addict. The Journal of
Maternal and Child Health. Nov. pp. 461 –
463
The Institute for the Study of Drugs, pregnancy and childcare: A Guide
Drug Dependence (ISDD) for Professionals.
(1995)
London
Lind, HH., Kao, JH., Hsu., Absence of infection in breastfed infants
born to Hepatitis C virus – infected
HY.,Ni., YH et al (1995)
mothers. The Journal of Paediatrics.
Vol.126, No.4
Miller, J. (1996)
Addressing the Issues of Contraception in
Substance Misuse Services: is it a
concern? Psychiatric Care: ANSA. Vol. 3
supplement 1. 1996
19
Multi –Agency Guidelines for Women on Substance Misuse in
Maternity Services.
Siney, C. (1999)
Pregnancy and Drug Misuse: Books for
Midwives Press
20
Multi –Agency Guidelines for Women on Substance Misuse in
Maternity Services.
Acknowledgements
To all the members of the working party and their contributions to the writing
of these guidelines, CDAT, Obstetricians, Paediatrician, Dr Cassidy
(Research & Development), Professor Richards (G.P) Midwifery, SCBU,
Antenatal Clinic, Pharmacy (PCH), Health Visiting, Families First, Chris
Parsons (Senior Nurse Child Protection), Alison Minett (Social Services), Joy
James (University of Glamorgan) and South Wales Police.
Many thanks to hospitals that have shared their guidelines and
advise, North Wales, Liverpool, Manchester and Faye Macrory,
Consultant Midwife in Drug & Alcohol Dependence, Manchester.
21
Multi –Agency Guidelines for Women on Substance Misuse in
Maternity Services.
Appendices
1.
Referral form to Consultant Midwife
CDAT and Families First
Appendix 1
2.
Information Sharing model
Appendix 2
3.
Symphysis – fundal height chart
Appendix 3
4.
Special Care Baby Unit
5.
Neonatal drug withdrawal chart
6.
Neonatal Management
Appendix 6
7.
Role of Midwife
Appendix 7
8.
Role of the Health Visitor
Appendix 8
9.
Role of the Community Drug & Alcohol Team
Appendix 9
10.
Role of the social workers
Appendix 10
11.
Role of the Obstetricians/Paediatricians
12.
Child Protection and Risk Assessment
Appendix 12
13.
Short opiate withdrawal scale
Appendix 13
14.
Buprenorphine Patient Information
Appendix 14
15.
Institute withdrawal clinical assessment
for alcohol
Appendix 4
Appendix 5
Appendix 11
Appendix 15
22
Multi –Agency Guidelines for Women on Substance Misuse in
Maternity Services.
Appendix 1
Referral form to Consultant midwife
Maternity Substance Misuse Team
NAME:
…………………………………………………………………………………………
………
ADDRESS:
………………………………………………………………………………………….
.
…………………………………………………………………………………………
…………………..
……………………………………………..
………………………………………
POSTCODE:
CONTACT
NUMBER:
……………………………………………………………………………
NAME OF PERSON RESPONSIBLE FOR REFERRAL:
…………………………………………………………………………………………
……………………
REASON FOR REFERRAL:
PREGNANT
YES / NO
ADVICE ONLY
YES / NO
I CONSENT FOR REFERRAL TO MIDWIFE CONSULTANT AND WHEN AN
INPATIENT FOR DETAILS OF MEDICATION / PERSCRIBTION AND
DOSAGE TO BE FORWARDED TO THE HOSPITAL PHARMACY, PRINCE
CHARLES HOSPITAL.
23
Multi –Agency Guidelines for Women on Substance Misuse in
Maternity Services.
COMMUNITY DRUG & ALCOHOL REFERRAL FORM
This form is not available on computer
24
Multi –Agency Guidelines for Women on Substance Misuse in
Maternity Services.
FAMILIES FIRST REFERRAL FORM
This form is not available on computer
25
Multi –Agency Guidelines for Women on Substance Misuse in
Maternity Services.
Appendix 2
INFORMATION SHARING
Woman
Midwife
Community Drug
and Alcohol Team
other Agencies.
Named Obstetrician / Paediatrician
Obstetric and Paediatric Liaison,
Health Visitor and CDAT
Development of Care pathways
Head of Midwifery
Senior Nurse Child Protection.
Hospital Link
Social Worker
Relevant G.P & Paediatric
Liaison Health Visitor
Social Services/Children &
Young Peoples Division
As appropriate
Discharge of mother and baby
 Letter to GP and Health Visitor
 Inform appropriate agencies
CONFIDENTIALITY
 Never an absolute “RIGHT”
 Child Protection always overrides
 Be upfront about your concerns
 Put concerns into context
 Discuss concerns with Senior member of staff responsible for Child
Protection if in doubt
N.B All professionals have a duty of care towards the baby.
26
Multi –Agency Guidelines for Women on Substance Misuse in
Maternity Services.
Appendix 3
SYMPHYSIS – FUNDUS MEASUREMENTS
This form is not available on computer
27
Multi –Agency Guidelines for Women on Substance Misuse in
Maternity Services.
Appendix 4
THE ROLE OF THE SPECIAL CARE BABY UNIT
Some babies born to patients of the maternity substance misuse may spend
time on the Special Care Baby Unit, which is the responsibility of the neonatal
paediatrician.
It is useful for there to be liaison between SCBU and the maternity substance
misuse in order for the SCBU to gain some familiarity with the women whose
babies may end up in their care. Involvement with the maternity substance
misuse will also help ensure clear and open communication about the patient
and the baby between the SCBU and other parts of the maternity drug clinic.
SCBU need to be aware of the special needs of the mother separated from
her baby. Information needs to be available to the mother about the condition
of her baby.
It will remain the responsibility of the staff on SCBU to notify the Paediatric
Liaison Health Visitor.
Where possible, mother and baby should remain together on the postnatal
ward.
28
Multi –Agency Guidelines for Women on Substance Misuse in
Maternity Services.
Appendix 5
NORTH GLAMORGAN NHS TRUST
The sick newborn baby
Assessment Chart for Neonatal Drug Withdrawal
Name:
DOB:
ADDRESS:
Score baby 6 hourly
Score according to the following scale
0
1
2
= Absent
= Mild to moderate
= Severe
DATE & TIME
(6 HOURLY)
SYMPTOMS
Tremor
Irritability
Hypertonicity/
Hyperactivity
Vomiting
High pitched
cry
Sneezing
Respiratory
distress
Fever
Diarrhoea
Sweating
Convulsions
Total score
SIGNATURE
29
Multi –Agency Guidelines for Women on Substance Misuse in
Maternity Services.
Appendix 6
Guidance for Management of the Neonatal




Minor signs do not require treatment.
Withdrawal from opiates may occur < 24 hours (e.g. Heroin).
Withdrawal from opioids may occur 3 – 4 days after birth (e.g.
methadone).
Poly Substance Misuse may delay or skew withdrawal signs.


Aim of treatment: comfort not sedation.
Baby is reviewed daily by paediatric staff.
When a baby shows signs of withdrawal RE: Diarrhoea / vomiting,
convulsions or the inability to settle after feeding, treatment should be
considered. When the baby is not being treated on the Special Care Baby
Unit admission should be considered.
Treatment plan
When medication is necessary, it should be commenced at level
4 and the baby reviewed every 24 hours. If the baby is feeding
well and settling between feeds the level should be reduced and
the baby observed.
: Level 4
40 micrograms/kg morphine sulphate
oral preparation given 4 hourly
: Level 3
30 micrograms/kg morphine sulphate
oral preparation given 4 hourly
: Level 2
20 micrograms/kg morphine sulphate
oral preparation given 4 hourly
: Level 1
10 micrograms/kg morphine sulphate
oral preparation given 4 hourly
Continue to reduced every 24 hours if the baby is feeding well and settling
better between feeds.
If the feeding and settling does not improve or profuse watery stools and
profuse vomiting continue – discuss with senior paediatrician.
30
Multi –Agency Guidelines for Women on Substance Misuse in
Maternity Services.
Other medication may be required eg: diazepam for benzodiazepine use or
chloral hydrate for cocaine/crack use.
If pharmaceutical treatment not required – the mother will still require support
to help her comfort the baby – cuddling and swaddling is helpful. An infant
soother (“dummy”) may be necessary.
31
Multi –Agency Guidelines for Women on Substance Misuse in
Maternity Services.
Appendix 7
THE ROLE OF THE MIDWIFE
Technically the Clinic is managed by an Obstetrician, but demands on their
time are such that the midwife consultant will co-ordinate the maternity team.
At the patients first contact with a midwife a full medical, social and obstetric
history is taken. The midwife will then agree with the mother, the named
midwife who will be responsible for co-ordinating her care.
The midwife will promote breast-feeding and explore with patient’s issues
around Substance Misuse and breast-feeding. The midwife will liaise with the
Teams midwives, Health Visitors, CDAT, GPs and when appropriate to the
Obstetric Team.
The midwife is crucial in the time of confinement in hospital and will take a key
role in communication with different parts of the hospital, e.g. neonatal care,
special care baby unit, the delivery suite and wards.
The midwife will co-ordinate the planning meeting at 32 weeks gestation and
the development of the individual action plans. The midwife will be
responsible in contacting the GP and forwarding the Action Plan and any
other relevant, involved agency.
The action will be visible in the maternity notes.
If the midwife has a client who is misusing drugs – referral should be made to
CDAT and priority treatment will be given. This will also be a way to check
whether the women are already known to CDAT, with consent.
Referral will be made with clients consent (unless referral is for Child
Protection) to the Social Services, Children’s Division for an assessment of a
child in need.
The Midwife will have input into the care meetings held with Family
Intervention Service (Merthyr) and Families First (Cynon).
REMEMBER CHILD PROTECTION ISSUES ALWAYS OVERIDES.
32
Multi –Agency Guidelines for Women on Substance Misuse in
Maternity Services.
Appendix 8
THE ROLE OF THE HEALTH VISITOR
Identify
my
role
to
families,
established
relationships
with
clients/families/professionals and other agencies to aid effective
communication in the antenatal and postnatal period.
Develop relationships with the maternity Substance Misuse and understand
the role they have in helping and facilitating health gain for the client and
family.
Attending and planning meetings at 32 weeks gestation to discuss and have
input regarding action plan.
Provide a clear and on-going assessment of the client and family to the multidisciplinary team ensuring an effective and holistic approach to care.
Named Health Visitor clearly identified in the notes.
Identify the needs of the clients and how these can be managed, to maximise
a successful outcome.
Identify appropriate resources to meet needs, plan and initiate measures to
promote health and prevent disease.
Provide information and on-going support for the client and family in the postnatal period.
Monitoring the development and care of the child within the primary health
care setting.
Promoting and safeguarding the welfare of the child. Working within the
guidelines of Working Together to Safeguard Children Document (NAW
2000).
The Paediatric Liaison Health Visitor will be notified of all baby’s that have
been treated on SCBU.
33
Multi –Agency Guidelines for Women on Substance Misuse in
Maternity Services.
Appendix 9
THE ROLE OF THE COMMUNITY DRUG & ALCOHOL TEAM
Responsibility for any community prescribing is undertaken by the CDAT .
Priority will be given to pregnant women who visit or are referred, to be seen
by CDAT.
The CDAT will complete a full assessment of all referred women. The details
of that assessment and any proposed treatment plan will be fed back to the
maternity meeting. The nominated CDAT keyworker will keep the midwife
and other professionals informed of treatment progress and their relevant
information.
The CDAT can be contacted for advice on urgent treatment opiates during
office hours. Out of hours refer to the urgent Buprenorphine stabilisation
Responsibility for any community prescribing will rest with CDAT.
34
Multi –Agency Guidelines for Women on Substance Misuse in
Maternity Services.
Appendix 10
THE ROLE OF THE SOCIAL WORK TEAM MEMBER
Children & Young Peoples Division has the primary statutory responsibility to
prevent and investigate child abuse. All staff have a duty to recognise and refer child
abuse and neglect, even though investigations are carried out by specialist
staff.(section 3.1 page 29 ACFC, Child Protection Procedure).
Substance misusing pregnant women should not automatically initiate
child protection procedures, however there is an increased likelihood that
their babies may present with urgent needs and they should be offered
and able to access an initial assessment of need.
Referrals will be made to Children’s Services (with consent unless referral is for child
protection). An assessment of a child in need will be conducted.
Questions that need to be raised should include:



What support is there
Are other children involved
What is the pattern of drug abuse.
Assessment is the first stage in helping a vulnerable child and his or her family, its
purpose being ‘to contribute to the understanding necessary for appropriate planning’
(Compton and Galaway, 1989) and action. Assessment has several phases which
overlap and lead into planning, action and review:

Clarification of source of referral and reason;

Acquisition of information;

Exploring facts and feelings;

Giving meaning to the situation which distinguishes the child and family’s
understanding and feelings from those of the professionals;

Reaching an understanding of what is happening, problems, strengths and
difficulties, and the impact on the child (with the family wherever possible);

Drawing up an analysis of the needs of the child and parenting capacity within
their family and community context as a basis for formulating a plan.
Framework for the Assessment of Children in Need and their Families,
p29, Doh, 2000).
35
Multi –Agency Guidelines for Women on Substance Misuse in
Maternity Services.
THE ASSESSMENT FRAMEWORK.
(Source: Department of Health (2000) Framework for the Assessment of
Children in Need and Their Families. London. The Stationery Office).
36
Multi –Agency Guidelines for Women on Substance Misuse in
Maternity Services.
Appendix 11
THE ROLE OF THE PAEDIATRICIANS AND THE OBSTETRICIANS
A Paediatrician will see clients at the request of the midwife as and when
appropriate during the pregnancy. Important issues to discuss will be neonatal
withdrawal, breast feeding and postnatal care of the baby.
The Paediatrician will be notified and have input at the 32 week planning
meeting with the development of the action plan for delivery and post-natal
period.
The Obstetrician has obstetric responsibility for the mother.
37
Multi –Agency Guidelines for Women on Substance Misuse in
Maternity Services.
Appendix 12
CHILD PROTECTION AND RISK ASSESSMENT
Drug misuse may not impact on parenting capabilities however, an
assessment is required to determine whether the unborn child or other
children in the family are at risk of “Significant Harm” or when the child is born
may be assessed as a “Child in Need”. For child involved assessment written
consent is required.
This assessment would need to be multi-agency as required by “Working
Together To Safeguard Children” and the assessment completed within the
“Framework of Assessment for Children and their Families”.
All staff must adhere to the relevant Area Child Protection Committee Child
Protection Procedures, raising the concern in a clinic setting would require
further clarification. Section 3.1 page 29 of the Merthyr and Cynon ACPC
Child Protection Procedure require referral as soon as a professional is aware
of a concern.

Protection of the child as the paramount and overriding consideration.

Consideration of the position of any other children in the family,
including making certain that they are safe.

Accurate and factual observation of the situation found

Checking whether the child’s (or family’s) name is on the child
protection register, and if so contacting the social worker who is the key
worker immediately.

Consultation with other professional colleagues – the strategy
discussion.

Keeping parents, children and others important to the child fully
informed and consulted

A full medical assessment of the child, in light of any explanation given
as to their cause.

Prompt and careful recording of any action which was taken, including
written confirmation of contacts with other agencies (section 3.1 page
28 – 29 Merthyr and Cynon ACPC Child Protection Procedures).
38
Multi –Agency Guidelines for Women on Substance Misuse in
Maternity Services.
Appendix 13
SHORT OPIATE WITHDRAWAL SCALE
NAME:_________________CASE No:__________ SHEET No:________
Starting date: ___/___/___ = DAY 1
Severe =3
Moderate = 2
Mild = 1
Nil = 0
DAY
1
2
3
4
5
6
7
8
9
10
Feeling Sick
Stomach Cramps
Muscle Spasms
Feeling Cold/Gooseflesh
Sweating
Heart pounding
Muscular tension
Aches and pains
Weakness
Yawning
Runny eyes
Difficulty sleeping
TOTAL SCORE
39
Multi –Agency Guidelines for Women on Substance Misuse in
Maternity Services.
Appendix 14
Patient Information – BUPRENORPHINE (Subutex )
PLEASE READ THIS LEAFLET CAREFULLY
This leaflet will tell you about SUBUTEX, a medicine your doctor has
prescribed for you. It should give you all the information you need, but if
there is anything you do not understand, please ask your doctor,
pharmacist, or midwife.
WHAT IS SUBUTEX?
Each sublingual tablet contains Buprenorphine hydrochloride, equivalent
to either 0.4 mg, 2 mg or 8 mg Buprenorphine base as the active
ingredient, along with a number of inactive ingredients.
WHAT TYPE OF MEDICINE IS IT?
SUBUTEX sublingual tablets contain Buprenorphine hydrochloride, one of
a group of medicines called ‘opioids’, strong pain relievers.
However, when it is used for the treatment of patients addicted to opioid
drugs such as morphine and heroin, it acts as a substitute for these drugs
and therefore aids the patient in withdrawing from them over a period of
time. If treatment is stopped abruptly, withdrawal symptoms can occur.
These tablets are described as ‘sublingual’. This means that the tablets
should be placed under the tongue and kept there until fully dissolved,
which usually occurs within 5 to 10 minutes.
WHAT IS YOU MEDICINE FOR?
SUBUTEX sublingual tablets are used as part of a medical, social and
psychological treatment programme for patients addicted to opioid drugs.
BEFORE TAKING THE MEDICINE
SUBUTEX should not be used:
In children under the age of 16 years

If your allergic to Buprenorphine or to any of the other
ingredients in this medicine.

If you have serious breathing problems

If you have serious problems with your liver, or if your doctor
detects the development of such a problem during treatment.

If you are intoxicated due to alcohol or have delirium tremens
(the ‘shakes’ and hallucinations).

If you are breast feeding a baby (unless your doctor has
discussed the issues with you).

If you are pregnant (unless your doctor tells you to take it).
Tell your doctor if you have any of the following illnesses before treatment
or developing then during treatment, as your doctor may need to alter the
dose of this medicine:

Asthma or breathing problems

Kidney disease
SUBUTEX should be used exactly as prescribed by your doctors. Some
people have died form respiratory failure (inability to breathe) whilst using
benzodiazepines medicines used to treat anxiety or sleep disorders in
combination with SUBUTEX. Therefore whilst you are being treated with
this medicine, do not use benzodiazepines unless they have been
prescribed by your doctor.
Some cases of severe liver problems have occurred during treatment,
although they may not necessarily have been caused by SUBUTEX. If
you develop severe fatigue, have no appetite or if your skin or eyes look
yellow, tell your doctor immediately.
This medicine can cause withdrawal symptoms if you take it less than four
hours after an opioid (morphine, heroin or other related products).
This medicine can cause drowsiness, which may be made worse
if you also drink alcohol or take tranquillisers or anti-anxiety
drugs. If you are drowsy, do not drive or operate machinery.
SUBUTEX may cause your blood pressure to drop suddenly,
causing you to feel dizzy if you get up too suddenly form lying or
sitting down.
Drug dependence may occur as a result of taking this medicine.
Athletes should be aware that this medicine may cause a positive
reaction to ‘anti-doping’ tests.
ARE THERE ANY MEDICINES WHICH SHOULD NOT BE
TAKEN AT THE SAME TIME AS SUBUTEX?
You should not use benxodiaxepines (medicines used to treat
anxiety or sleep disorders) such as Temazepam and diazepam,
unless they are prescribed by your doctor. Strong painkillers
and cough medicines, containing opioid related substances,
certain antidepressants, including monoamine oxidase inhibitors,
dedating antihistamines, sedatives , antipsychotic drugs may
increase the effects of SUBUTEX. If you are taking any other
medicines, you should tell your doctor or midwife if you are
taking any other medicines. Let him or her know if you are
taking a blood-thinning drug called phenprocoumon.
Do not drink alcohol or take medicines that contain alcohol whilst
you are being treated with SUBUTEX. Alcohol and certain other
medicines (as listed above) increase the sedative effects of
buprenorphine, which can make driving and operating machinery
hazardous.
WHAT IS THE DOSE?
The tablets are administered sublingually. This means that you
must place the tablet under your tongue and allow it to dissolve,
which may take 5 to 10 minutes. This is the only way the tablets
should be taken. Do not chew or swallow them whole, as this
will make them ineffective. Your ’detox’ nurse will tell you how
much SUBUTEX to take and you should always follow their
advice.
For opioid (heroin and the like) addicts starting SUBUTEX:
Ensure at least 4 hour gap after other opioids (such as morphine,
heroin, dihydrocodeine) before taking the first SUBUTEX tablet.
For patients receiving methadone and switching to SUBUTEX:
before starting SUBUTEX treatment, your keyworker should have
reduced your methadone to a maximum of 30 mg per day.
Allow at least 24 hours between your last methadone dose and
starting SUBUTEX.
The initial dose is 0.8 mg to 4 mg,
administered once daily. During treatment, your ‘detox’ nurse
may increase your dose of SUBUTEX, to a maximum single daily
dose of 32 mg, depending on your response. After a period of
stabilisation your ‘detox’ nurse will gradually reduce your dose.
Depending on your progress, your dose may continue to be
reduced under careful medical supervision, until it is stopped
altogether. Do not suddenly stop taking the tablets, as this may
cause withdrawal symptoms.
ARE THERE ANY SIDE EFFECTS?
Like all drugs, SUBUTEX may cause side effects. After your first
dose, you may suffer some opioid withdrawal symptoms. Other
side effects that may occur are:
Constipation; headaches; difficulty in sleeping; lack of energy or
weakness; drowsiness; nausea and vomiting; fainting and
dizziness; drop in blood pressure on changing position from
sitting or lying down to standing; sweating. Rarely, the following
have occurred: severe difficulty in breathing, liver problems,
hallucinations.
If you think that you are suffering from these or any other side
effects, you should tell your ‘detox’ nurse or keyworker. Like all
opioid drugs SUBUTEX can cause dependence.
40
Multi –Agency Guidelines for Women on Substance Misuse in
Maternity Services.
Appendix 15
CLINICAL INSTITUTE WITHDRAWAL ASSESSMENT FOR ALCOHOL
(CIWA –Ar)
Patient __________________Date __________Time ___________
Pulse (taken for one minute)______
NAUSEA AND VOMITING – ask “do you
feel sick to your stomach? Have you
vomited?”
Observation
0 No nausea
1 Mild nausea with no vomiting
2
3
4 Intermittent nausea with dry heaves
5
6
7 Constant nausea, frequent dry heaves and
vomiting
TREMOR – arms extended and fingers spread
apart.
Observation
0 No tremor
1 Not visible, but can be felt fingertip to fingertip
2
3
4 Moderate, with patient’s arms extended
5
6
7 Severe, even with arms not extended
PAROXYSMAL SWEATS - |Observations
0 No sweat visible
1 Barely perceptible sweating, palms moist
2
3
4 Beads of sweat obvious on forehead
5
6
7 Equivalent to acute panic states as seen in
severe delirium or acute schizophrenic reactions
ANXIETY – Ask “ Do you feel nervous?”
Observation
TACTILE DISTURBANCES – Ask “Have you any
itching, pins and needles, any burning or numbness
or do you feel bugs crawling under your skin?”
0 None
1 Very mild itching, pins and needles, burning or
numbness
2 Mild itching, pins and needles, burning or
numbness
3 Moderate itching, pins and needles, burning or
numbness
4 Moderately severe hallucinations
5 Severe hallucinations
6 Extremely severe hallucinations
7 Continuous hallucinations
AUDITORY DISTURBANCES – Ask “Are you more
aware of sounds around you? Are they harsh? Do
they frighten you?
0 Not present
1 Very mild sensitivity
2 Mild harshness or ability to frighten
3 Moderate harshness or ability to frighten
4 Moderately severe hallucinations
5 Severe hallucinations
6 Extremely severe hallucinations
7 Continuous hallucinations
VISUAL DISTURBANCES – Ask “Does the light
appear to be too bright? Is its colour different? Does
it hurt your eyes? Are you seeing things that you
know are not there? Observation
0 Not present
1 Very mild sensitivity
2 Mild sensitivity
3 Moderate sensitivity
4 Moderately severe hallucinations
5 Severe hallucinations
6 Extremely severe hallucinations
7 Continuous hallucinations
HEADACHE,FULLNESS IN HEAD – Ask “does your
head feel different/Does it feel like there is a band
around
your head?” Do not rate for dizziness or lightheadedness. Otherwise rate severity
41
Multi –Agency Guidelines for Women on Substance Misuse in
Maternity Services.
0 No anxiety
1 Mildly anxious
2
3
4 Moderately fidgety and restless
5
6
7 Equivalent to acute panic states as seen in
severe delirium or acute schizophrenic reactions
AGITATION – Observation
0 Normal
1 Somewhat more than normal activity
2
3
4 Moderately fidgety and restless
5
6
7 Paces back and forth during most of the
interview, or constantly thrashes out.
0 Not present
1 very mild
2 mild
3 moderate
4 moderately severe
5 severe
6 very severe
7 extremely severe
ORIENTATION AND CLOUDING OF SENSORIUM
– Ask “What day is this/ Where are you? Who am I?”
0 Orientated and can do serial additions
1 Cannot do serial additions or is uncertain about
date
2 Disorientated for date by no more than tow
calendar days
3 Disorientated for date by more than tow calendar
days
4 Disorientated for place and /or person
5
6
7
Total CIWA –Ar Score (max. possible score 67)
______
Please add score to attached ST-T
Monitoring form
42