Purpose of the Project and Stakeholders
The purpose of the instant project is to prepare a clinical pathway for the obstetric care of women with Opioid Use Disorder (OUD). Opioid use disorder is an ailment caused by the abuse or overuse of opioids, leading to addiction and dependency (Krans et al., 2015). Women with OUD require specialized attention and care in order to limit the vagaries of the condition on the process of motherhood. In this context, the process of care relating to motherhood begins with Antepartum Care, which relates to the necessary preparation before birth. It then extends to Intrapartum Care, which begins at the advent of care and proceeds through the process of delivery. Finally, there is the Postpartum Care that covers the first six weeks after birth. For the purposes of this research project, the care process also includes Discharge Planning, where caregivers work with new mothers as they prepare to leave the hospital with the babe. Among the essential components of the clinical pathway are guidelines of how to establish if a mother has OUD, aiding the mother to mitigate the adverse effects of OUD during the process of birth, and patient education in preparation for discharge and the obligations associated with caring for an infant (Krans et al., 2019). The clinical pathway developed in this project is for the Maternal-Child Health Department (MCH) of Englewood Health Hospital in Englewood, New Jersey. The research project was carried out in collaboration with the staff and leadership of this institution. Project stakeholders include the MCH department of Englewood Hospital, the New Jersey Department of health, and maternal health interest groups such as Partnership for Maternal Child Health of Northern New Jersey.
Project Process
The project process had three main components. The first relates to the Englewood Hospital, while the second relates to establishing the best procedures for providing OB care for patients with OUD; the final component was preparing the clinical pathway itself. In the first component, the research team interviewed some of the senior staff at Englewood involved in OB care. The interviewees included the Valerie French, Director of Maternal-Child Health, and Dr. Nancy Bohnarczyk. The team also followed up OB clinicians in their medical rounds and interviewed some of the OB nurses and patients. In the second component, the team undertook a comprehensive literature review on the subject of providing OB care for OUD patients. The team then synthesized the data from the literature review to come up with knowledge on how Englewood can provide the best care and outcomes for mothers with OUD. The final component was preparing the clinical pathway and submitting it to the leadership of Englewood for approval and ratification.
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Project Outcomes
The project's outcomes were a clinical pathway with four main components of providing optimum OB care for mothers with OUD as outlined herein below.
Antepartum Care: "Before child-birth"
In the context of the research project, antepartum care involves the process where Labor and delivery (L&D) nurses take over care from the nurses who had been handling prenatal care. This segment is sensitive from the perspective of OB care for OUD patients, as the L&D nurses need to establish if the patient has OUD. On the one hand, the nurses need to undertake an intensive investigation regarding the patient. On the other hand, the nurses need to earn the trust and confidence of the patient, which is essential for the delivery process. The clinical pathway provides for a consent-based investigation. The L&D nurses should check the patient physically for telltale signs of opioid abuse, such as puncture marks. The patient may also have physiological signs of opioid abuse. Secondly, the nurses should undertake an extensive review of patient records to investigate the susceptibility of opioid overuse or abuse, which may cause OUD. To ensure patient trust, and the nurses should seek patient consent before accessing any documents or records that the patient does not submit willfully. When the nurses have established that the patient has OUD, they should work together with the patient to reduce the impact of the condition on the process of delivery. For a start, the patient would need to stop using opioids, which will require the administration of Methadone (Krans et al., 2019). Nurses should investigate if the patient has any side effects and interactions with Methadone. Secondly, pain management is necessary during delivery, and the nurses should work with the patient to create alternative pain management protocols. Finally, patient education is crucial to enable the OB patient to play a positive role in the mitigation of OUD on the delivery process.
Intrapartum Care – "Time from Onset of Labor through Delivery of Placenta"
Intrapartum care involves two distinct possibilities. The first involves patients that the L&D nurses have already worked with during antepartum care. For such patients, the nurses are already aware that they have OUD and a management plan as outlined above is developed for them. However, some patients will be wheeled in the hospital without having undertaken antepartum care at the institution. For such, the L&D nurses will need to undertake a precise evaluation to establish if they have a susceptibility to OUD. This evaluation includes carefully perusing hospital records and, where possible, checking with the physician who may have been handling the patient (Krans et al., 2019). If the evaluation confirms that the patient has OUD, the nurses should report to the supervisor/manager and the Department of Children Protection and Permanency (DCPP). The report is necessary to ensure that the child gets the best possible care after delivery. Since opioid use cannot continue, the nurses should ensure that there is a sufficient supply of Methadone and administer it consistently during and after delivery. The nurses should also inform the neonatal intensive care unit (NICU) team on whether they need to collect meconium for testing upon delivery (Mozurkewich et al., 2014). Finally, the nurses should liaise with the patient and the other clinicians involved in developing an alternative pain management strategy.
Postpartum Care – "First six weeks after delivery."
The patients will need continuous care during the postpartum period. In most cases, the discharge of the mother from the hospital will also take place during this period unless a significant complication arises. Continuous care includes regular administration of Methadone (Krans et al., 2015). OB nurses should seek to establish if there is a need to adjust the Methadone doses. Secondly, the patient will still need pain management during this period. Non-steroidal anti-inflammatory drugs (NSAIDs, such as Ketorolac) and Acetaminophen (Tylenol) are most suitable, but the nurses need to investigate for contraindications such as Liver Disease, GI conditions (Jones et al., 2009). Patient education is also crucial at this stage, more so as the patient prepares for discharge. The patient education will include modalities for reducing proclivity for future opioid abuse (American College of Obstetricians and Gynecologists, 2017). Patient education also includes lactation consult for breastfeeding support. The nurses should also provide training material for the patient to continue studying after being discharged.
Conclusion
For the safety of the baby, the OB nurses may need to take extra precautions. Precautions include contacting child welfare services in developing safe care protocols. Such a move may have ramifications for mother and child. Hence, nurses should first seek guidance from Englewood Hospital Social Services. As an alternative to involving children's services, the nurse can liaise with social workers and other interdisciplinary entities - Department of Children Protection and Permanency (DCPP) to develop modalities for ensuring that the OUD does not inordinately affect the child.
References
American College of Obstetricians and Gynecologists. (2017, August). Obstetric care for women with opioid use disorder . Council on Patient Safety in Women's Health Care . https://safehealthcareforeverywoman.org/patient-safety-bundles/obstetric-care-for-women-with-opioid-use-disorder/#link_acc-1-4-d
Jones, H. E., O'Grady, K., Dahne, J., Lemoine, L., Milio, L., Ordean, A., & Selby, P. (2009). Management of acute postpartum pain in patients maintained on methadone or buprenorphine during pregnancy. The American Journal of Drug and Alcohol Abuse (35:3), 151-156. doi:10.1080/00952990902825413
Krans, E. E., Campopiano, M., Cleveland, L. M., Goodman, D., Kilday, D., Kendig, S., ... & D'Oria, R. (2019). National partnership for maternal safety: consensus bundle on obstetric care for women with opioid use disorder. Obstetrics & Gynecology , 134 (2), 365-375.
Krans, E., Cochran, G., & Bogen, D. (2015, June). Caring for opioid-dependent pregnant women: prenatal and postpartum care considerations. Clinical Obstetrics and Gynecology (58(2)), 370-379. doi:10.1097/GRF.0000000000000098
Mozurkewich, MD, MS, E. L., & Rayburn, MD, MBA, W. F. (2014, June). Buprenorphine and methodone for opioid addiction during pregnancy. Obstetrics & Gynecology Clinics, 41 (2), 241-253. doi:10.1016/j.ogc.2014.02
State of New Jersey Department of Human Services. (2019, March 16). Division of Mental Health and Addiction Services . State of New Jersey Department of Human Services . https://www.state.nj.us/humanservices/dmhas/resources/services/treatment/sa_women.html
