Download Pregnancy Protocol - Child Protection Partnership

'Getting Our Priorities Right'
&
'Hidden Harm'
Pregnancy Protocol
ABERDEEN CITY JOINT ALCOHOL AND DRUG ACTION TEAM
ABERDEENSHIRE ALCOHOL AND DRUG ACTION TEAM
MORAY DRUG AND ALCOHOL ACTION TEAM
NORTH EAST OF SCOTLAND CHILD PROTECTION COMMITTEE
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“Getting Our Priorities Right” and “Hidden Harm” Inter-Agency Guidelines
Pregnancy Protocol (to be read as part of the above pack).
This protocol applies to all those working or involved with:
 Pregnant women who have problematic substance use.
 The children of pregnant problematic substance users and their partners.
 Men whose partners are pregnant and where there are concerns in relation to
problematic substance use.
Overview
There is growing public and professional awareness of the profound effects of
parental drug and alcohol misuse on the wellbeing of children. Problematic
substance use and good parenting are incompatible and increases the risks of harm
to children. However, with the right kind of treatment and support problematic
substance using parents are capable of caring for their children. A key factor in
providing treatment and support thus preventing the detrimental effects of parental
problematic substance use is early intervention, which focuses on the period of
pregnancy and immediate postnatal period. Interventions need to start before a
baby’s birth to enable parents to provide safe and appropriate parenting therefore
reducing the physical and emotional harm caused by problematic substance use and
lifestyle choices. (“Getting Our Priorities Right”, (2003)).
Some pregnant women with problematic substance misuse issues do not seek
antenatal services until late in pregnancy or when in labour. They may not realise
they are pregnant because of the effects of some substances on the menstrual
cycle. Their problematic substance use and associated life-style may make other
more urgent demands on their time. They may fear their drug use or drinking will be
detected through routine urine or blood tests, or that if they tell staff they will be
treated differently or that child protection agencies will be contacted automatically.
They may feel guilty about their drug or alcohol use and want, or feel they ought to
stop but are worried that they will not succeed. They may be worried that their baby
will be damaged or display withdrawal symptoms after birth. Many of these problems
can be overcome by provision of accessible antenatal services that tackle these
worries honestly and sympathetically. (“Getting it Right for Every Child: Proposals for
Action”, (2005)).
“Getting Our Priorities Right” (2003) established a baseline and the later document
“A Framework for Maternity Services in Scotland” (2003) went on to set out broad
principles for underpinning good practice in maternity care, recommending that;
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The woman should be the focus of maternity care, should be empowered and
able to make informed decisions about her care.
Staff should recognise and support the role of fathers and/or partners
throughout the pregnancy and childbirth.
Maternity services must be readily and easily accessible to all, sensitive to the
needs of the local population and primarily community-based, with good
continuity of care.
Women should be involved in the planning of maternity services.
A multi-disciplinary approach is essential in the management of pregnant
alcohol or drug-using women.
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Consideration must be given to the impact and harm continued problematic
substance use has on an unborn child.
Research shows that the immediate withdrawal of drugs or alcohol could
result in premature birth or miscarriage, thus advice must be sought from
midwifery or substance misuse services before giving any advice on
cessation, or reduction of drug or alcohol misuse to a pregnant woman.
Effects of Maternal Problematic Substance Use on the Pregnancy and the
Unborn Baby
“Parental problem drug use can and does cause serious harm to children at every
age from conception to adulthood.” (Hidden Harm, (2003)).
Pregnant women who use drugs or alcohol experience a range of medical problems,
some specifically due to their drug or alcohol use, but many are due to their
background of multiple social problems which are frequently exacerbated by
problematic substance use.
Many women attending maternity services are undernourished, have poor dental
health and suffer from recurrent infections as a result of problematic substance use,
particularly poor injecting practices. The unborn child of problematic substance using
parents needs to be protected as soon as the mother’s pregnancy is confirmed.
Maternal drug or alcohol use carries significant risk, which can affect foetal
development. Drug injecting during pregnancy may also result in the transmission of
HIV and viral hepatitis to the baby. (Siney, (2002)).
Maternal problematic substance use during pregnancy is reportedly associated with
higher rates of perinatal mortality and morbidity, largely because of increased rates
of delivery of babies who are preterm or of low birthweight or small for gestational
age. There is also reported to be a higher incidence of sudden infant death
syndrome among such babies. Many babies born to problematic substance using
mothers will suffer from neonatal abstinence syndrome (NAS) otherwise called drug
withdrawal. (Lloyd and Myerscough, (2006)).
The Effects of Neonatal Abstinence Syndrome
Almost every substance misused passes from the mother’s blood stream through the
placenta to the unborn baby. Substances that cause dependence and addiction in
the mother also cause the baby to become addicted. At birth the baby’s need for
substance may continue. However, since the substance is no longer readily
available the baby will experience withdrawal to a greater or lesser degree. The
signs of drug withdrawal are collectively named neonatal abstinence syndrome
(NAS).
The following are the most common signs of NAS. However, each baby may
experience symptoms differently. The signs include, high-pitched cry, fever,
irritability, tremors, disruption of normal sleep pattern, sweating, diarrhoea, weight
loss, fast breathing and skin excoriation from constant movements. In severe cases
a baby may develop seizures. (Lloyd and Myerscough, (2006); Siney, (2002)).
Foetal Alcohol Syndrome and Foetal Alcohol Spectrum Disorders.
The importance of recognising women who are heavy alcohol consumers during
pregnancy and providing support to reduce or discontinue their habit is clear. There
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is an increasing body of evidence supporting the harmful effects to the unborn baby
from alcohol consumption during pregnancy. (SAADAT, (2006)). These effects
include pre and postnatal growth deficiency, central nervous system dysfunction and
distinctive facial features. Babies may have difficulty feeding, be irritable and have
difficulties establishing a regular sleeping pattern. Children exposed to alcohol in
utero may suffer from serious cognitive effects and behavioural problems, which may
present later in development. (Royal College of Obstetricians and Gynaecologists,
(2006)).
Many babies suffering from withdrawal will require admission to a neonatal unit for
special care. NAS resolves slowly and many babies suffer NAS following discharge
from hospital. These babies will require on-going care and may continue to require
medication.
Additionally babies may suffer from delayed onset NAS. These delayed signs are
important because irritability, feeding difficulties and failure to sleep place additional
burdens on parents or carers.
“Window of Opportunity” A Multi-Agency Approach
The impact of problematic substance use (particularly alcohol and illegal drugs) on
children has been well documented. (Barnard and McKeganey, (2004)). Children of
people with substance using problems will often be at risk from receiving poor and
neglectful parenting, having poor physical and psychological health and relationship
problems. (Harbin and Murphy, (2006)).
A woman’s motivation for getting help for her substance problems is often increased
because of pregnancy. This “window of opportunity” enables agencies to work
closely together in order to minimise the harm to both the mother and her unborn
baby’s health and to protect the welfare of any children in her or her partner’s care.
Importantly, a problematic substance misusing partner can be fast tracked into
treatment services.
The welfare of the child must be paramount and all agencies are responsible for
identifying pregnant women with substance misuse problems who may be in need of
additional services and support. All agencies need to share their concerns with the
appropriate agencies (social work.health, police).
Concerns may come from indirect knowledge, such as those working with the father,
partner, carer and any associated children, as well as from direct contact with the
pregnant woman.
When an agency identifies a pregnant woman experiencing substance misuse
problems, then the NESCPC Guidelines should be followed (link to Section 5, page
52 on Pregnant Women Who Also Misuse Substances)
An the Initial Referral Discussion Social Work, Health and Police will decide
whether further protective action is necessary in relation to the unborn child and any
other children in the family.(see page 26,NESCPC Guidelines).
The interests of the unborn child/children and the mother and her partner are
inextricably linked. All services i.e. Maternity, Primary Care Health services, Social
Work, Substance Misuse Services and other agencies must work closely together
with parents to assist in tackling their problematic substance use.
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If there is reluctance to engage with services designed to minimise harm to the
unborn baby or children staff must consider whether the potential risk is significant
enough to override the need for consent. Agencies must address this fear and use
the opportunity afforded by pregnancy to develop best practice and provide effective
assessment and support. (link to section on Information sharing and consent in
NESCPC guidelines-pages 3-6 and information leaflet in GOPR pack)
Best practice means:
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Identifying as early as possible in pregnancy the possible spectrum of risk to,
and needs of both mother and baby, and alerting services before birth;
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Developing effective care plans and regular and realistic review of the plans;
offering a range of multi-agency/multi-professional approaches to care, that
are non-judgemental; and
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Ensuring that no pregnant woman with problematic substance usage arrives
at a maternity unit to give birth without her situation being known and without
support being available for her and her child. ("Hidden Harm – Next Steps,
(2006)).
The most effective assessment and support comes through good information
sharing, joint assessments of need, joint planning, professional trust within the interagency network and joint action in partnership with families.
Assessment of Risk
When a woman is pregnant and she, and/or her partner, has problems with drugs or
alcohol (or a newborn baby is found to be in this situation), then a multi-agency
assessment of risk and need must be made in respect of both the unborn child (or
baby), the parents or carers and any other children in the family.
This is especially important where service awareness of earlier births may need to
be clarified, for example, in the case of older or overseas children.
The assessment should cover both consideration of the provision of appropriate
services and whether or not to recommend a Pre-Birth Case Conference.
A Pre-Birth Case Conference should be held by or before 28 weeks gestation and
never later that 32 weeks, where assessment indicates risk of significant harm.
24 Weeks Gestation or Mid-Trimester Multi-Agency Review.(MTR).
Whether or not a Pre-birth Case Conference has been convened, a multi-agency
pre-birth case review must always take place at the 24 week stage.
The pre-birth case discussion must include all those involved with the parents
e.g., midwife, health visitor, GP, substance misuse service worker, social
worker, support worker, Drugs Action and obstetrician, and where possible,
parents should be invited. If parents are not present then their views must be
taken into consideration.
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The Review should;
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Consider all available information and make decisions about the level of
interventions and support to be offered for the remaining pregnancy and the
immediate postnatal period.
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Consider all actual or potential risk.
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Confirm and review the care plan for pregnancy.
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Identify / confirm the key worker.
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Decide whether to recommend a Pre-Birth Child Protection Case Conference, if
one has not already been convened..
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Formulate and agree a discharge plan and set out clearly in the mother’s and
baby’s notes. Agreement should be made as to who has the responsibility for
taking this task forward and involving the mother in the process.
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If no protection plan via a pre-birth case conference and no recommendation for
a case conference, agree and record an action plan with actions allocated to
relevant people.
Inform the mother, where possible, of the outcome / decisions made.
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Ongoing risk assessment by all agencies must continue.
There should be an Initial Referral Discussion between Social Work, Health and
Police in relation to any baby, who is born with neonatal abstinence syndrome (NAS)
and who has not been previously identified..
Local multi-disciplinary policies are recommended to improve communication and
reduce risks to the unborn baby or children of substance misusing parents.
Obstetric departments should develop good links with local substance misuse
specialists and Primary Care health services and the local social work, children and
families teams..
The key area of managing the care of pregnant problematic substance users, their
partners and children is the co-ordination between the relevant agencies to assess
risk, set goals and plan support networks.
Agencies must consider referral for a Pre-Birth Case Conference as early as
possible if there appears to be a risk of significant harm to the child when he
or she is born.
For further information on the Care Pathway and management of pregnant
substance users please see attached flowchart. Please note that this is a guide and
assessments must always be ongoing and decisions reviewed at all stages
throughout the pregnancy.
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References / Further Reading.
“A Matter of Substance? Alcohol or Drugs: Does it Make a Difference to the Child?”
(Scottish Association of Alcohol and Drug Action Teams (SAADAT), 2006)
“Alcohol Consumption and the Outcomes of Pregnancy” (Royal College of
Obstetricians and Gynaecologists. RCOG Statement 5, March 2006)
“Framework for Maternity Services in Scotland” (Scottish Executive, 2003).
“Getting It Right for Every Child: Proposals for Action” (Scottish Executive, 2005).
“Getting Our Priorities Right: Good Practice Guidance for Working with Children and
Families Affected by Substance Misuse” (Scottish Executive, 2003).
“Hidden Harm – Responding to the Needs of Children of Problem Drug Users.
Report of an Inquiry by the Advisory Council on the Misuse of Drugs” (ACMD, 2003)
“Hidden Harm Next Steps Supporting Children – Working with Parents” (Scottish
Executive, 2006)
“Neonatal Abstinence Syndrome. A New Intervention: A Community Based,
Structured Health Visitor Assessment” (Lloyd, DJ; Myerscough, EJ. Scottish
Executive Social Research Substance Misuse Research Programme, 2006)
North East of Scotland Child Protection (NESCPC) Guidelines (www.nescpc.org.uk)
“Pregnancy and Drug Misuse” (Siney, C. BfM. Books for Midwives. 2002 ed)
“Secret Lives: Growing with Substance. Working with Children and Young People
Affected by Familial Substance Misuse” (Harbin, F; Murphy, M. (Eds) Russell House
Publishing. Lyme Regis, Dorset, 2006)
“Sharing Information About Children At Risk: A Guide to Good Practice” (Scottish
Executive, 2003)
“Substance Misuse and Childcare” (Harbin, F; Murphy, M. (Eds) Russell House
Publishing, Lyme Regis, Dorset, 2000).
“The Impact of Parental Problem Drug Use on Children: What is the Problem and
What Can be Done to Help?” (Barnard, M; McKeganey, N. Addiction. 99-5, 552-9,
2004)
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MANAGEMENT OF PREGNANT SUBSTANCE USERS
Booking Visit - Pregnancy Confirmed
Woman declares herself to be pregnant
The midwife will inform parent/s that under NESCPC
guidelines the midwife must inform and share
information with;
 Specialist Service eg.
The Golden Square Pregnancy Team
 Social Work
 Substance Misuse Service
 Drugs Action
Point of Contact:
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Community Midwife
GP
Social Worker
Drug Worker
Health Visitor
CPNs (Substance Misuse Service)
Other eg. Relative
Service offered must be acceptable to the woman. May
be with local midwife or specialist.
Parent/s must be informed about the planned midtrimester review and reasons
High-risk pregnancies are always referred to
consultant clinic
There must be an Initial Referral Discussion
between Social Work, Police and Health. This
discussion should decide whether or not to
proceed to Pre-Birth Case Conference.
Ongoing midwifery care as per NHS Guidelines.
If unborn child to be placed on CP Register at birth,
then ongoing core group meetings to progress
Protection Plan.
(Community Midwife or Specialist Clinic)
24 Weeks Gestation or Mid-Trimester multi-agency Review (MTR)
The MTR must:
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Immediate Postnatal Period
Mother and baby will undergo a 5-10 day assessment
in a hospital setting. This time will be used to assess
parenting and withdrawal in the newborn.
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Generic/specialist midwife will liaise with:
Community Midwife
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Social Worker/key worker
Health Visitor
Share all available information and make decisions about the level of
interventions and support to be offered for the remaining pregnancy and
the immediate postnatal period
Consider all actual or potential risk if no Pre-Birth Case Conference has
taken place.
Confirm and review the care plan for pregnancy
Identify / confirm the key worker
Decide whether to recommend a Pre-Birth Child Protection Case
Conference if this has not taken place..
Formulate and agree a discharge plan with the mother and set out clearly
in the mother’s and baby’s notes. Agreement should be made as to who
has the responsibility for this task
If no Pre-Birth Case Conference has taken place and decision not to
recommend this, the Initial Referral Discussion process should enable
agencies to continually share, review and evaluate information as it
becomes known(NESCPC guidelines pg 26).
Inform the mother, where possible, of the outcome / decisions made
CPN/Substance Misuse Service
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Others where relevant to ensure ongoing
support and risk assessment
Ongoing care as per NHS Guidelines
Late Presentation to Maternity Services
An Initial Referral Discussion must take place if
concerns about risk to unborn child.
Baby identified as suffering from NAS (and not
previously identified as “at risk”)
Automatic Initial Referral Discussion between Social
Work Health and Police..
Care Plan as per entry point to care.
The child's needs are paramount. If at any point child protection concerns arise do
not delay in sharing concerns with Social Work or Police as per NESCPC Guidelines.
All professionals and services providers have a duty to take action to make sure that
a child whose safety or welfare may be at risk is protected from harm, even if the
child is not the client/patient.
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