Substance Misuse in Pregnancy - NHS Lothian

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Antenatal Liaison Form (Substance Misuse) SM103 Mother’s name: …………..……………………………………………………………….............................................................................. Date of birth: ………………………………………………… Address: ……………………………………………………………………….............................................................................................. Tele. ……………………….................……………………… �------------------------------------------------------------------------� Postcode: EH _ _ / _ (only 1 st number of 2 nd part) Hospital Unit No .......................................... Mother’s age:……………………………………………………… Mother’s Chi No. ……………………………………… E.D.D: …………………………………………………………………… Parity: ............................................................... Tele. No. GP: ................................................................................................................................. ........................................ Midwife: ...................................................................................................................... ........................................ Health Visitor: ........................................................................................................... ........................................ CDPS / APS worker: ................................................................................................. ........................................ Other drug / alcohol worker: ................................................................................. ........................................ Social Worker: ........................................................................................................... ........................................ Maternity Unit: .......................................................................................................... ........................................ Consultant Obstetrician: ......................................................................................... ........................................ Smoker?... Yes/No If yes, number per day? ...................................... Prescribed medication at booking (drugs & dosage) .......................................................................................................................................................................................... .......................................................................................................................................................................................... Dispensing Arrangements?........................................................................................................................................ Pharmacy? ........................................................................................................ Tele: .............................................. Name of Prescriber? ..................................................................................... Tele: .............................................. Injecting drug use during pregnancy?… Yes/No If yes, please detail frequency ...............................…. If no, ever injected drugs in the past?… Yes/No Illicit (street) drug use since conception? (all drugs used, excluding those prescribed, enter average daily amounts taken in 1 st trimester) Heroin ...............................................................…... Diazepam/Temazepam ......................................................... Dihydrocodeine .................................................... Other tranquillizers? ........................................................... Methadone .....................................................….... Amphetamines (‘speed’) ...................................................…. Other opiates?...............................................….... Cocaine / Crack ...................................................…............…. Cannabis ….......................................................….... Ecstasy .......................................................…………………......…. Solvents / Volatile substances ................................................................................................................................ Other drug use? .......................................................................................................................................................... Referred to Community Drug Problem Service (CDPS)? … Yes/No Attended?… Yes/No Outcome? ..............................................................................................................…………………………………………………….. Substance Misuse in Pregnancy: Appendix 9 / November 2003 / PILOT
Alcohol use (tick average weekly consumption in 1st trimester)? 0-14 units � 15-21 units � 22-28 units � 29-35 units � 36-42 units � over 42 units � Pattern of alcohol use? (daily use?, weekend use? binge drinking? etc) ...................................................... ......................................................................................................................................................................................... Referred to Alcohol Problems Service (APS)? ... Yes/No Attended? ... Yes/No Outcome? ..............................................................................................................…………………………………………………….. History of drug/alcohol misuse in any previous pregnancies?… Yes/No If yes, outcome of previous pregnancies?………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………. Additional concerns? (e.g. not registered with GP, homeless, mental health problems, debts, legal problems, literacy problems, relationship difficulties, domestic abuse, sex industry worker etc) .......................................................................................................................................................................................... .......................................................................................................................................................................................... .......................................................................................................................................................................................... .......................................................................................................................................................................................... Child care concerns?... Yes/No Pre-birth child protection case conference held?... Yes/No Antenatal testing for Blood Borne Viruses? HIV – test accepted/declined Hepatitis B – test accepted/declined HBV immunised? ... Yes/No Hepatitis C – test offered?… Yes/No If yes, accepted/declined? Referred to high risk clinic?… Yes/No If yes, attended?… Yes/No Date of antenatal case discussion (around 28 th week): .................................................................................... Professionals involved?………………………………………………………………………………………………………………………………………….. Drug / alcohol use of partner? (please detail illicit & prescribed drugs taken / alcohol units per wk) .......................................................................................................................................................................................... .......................................................................................................................................................................................... Partner’s HIV / hepatitis B / hepatitis C status (if known) ............................................................................ .......................................................................................................................................................................................... Date form completed: ................................................................................................................................................ Signature of key midwife: ........................................................................................................................................ Later changes to prescribed drugs? (record any medication/dose changes and date of change) .......................................................................................................................................................................................... .......................................................................................................................................................................................... .......................................................................................................................................................................................... Completed by: .............................................................................................................................................................. *Form SM103. Photocopy and send to Link Midwife (Substance Misuse). Substance Misuse in Pregnancy: Appendix 9 / November 2003 / PILOT
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Substance Substance misuse misuse i
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This pack has been approved by Loth
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Page Drugs and their effects on the
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Appendices ........................
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Introduction Welcome to the ‘Subs
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Please note: 1. The terminology use
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Introduction Key points Setting the
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Pre-conceptual care � Agencies in
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Substance Misuse in Pregnancy 14
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Setting the scene The extent of the
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Organisational difficulties Profess
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• Financial problems (including d
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The important role of partners need
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ecognises that a woman’s needs ar
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Guidelines on good practice This se
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An assessment of the partner’s dr
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Care management Some women with sub
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Introduction Information and guidel
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anxiety related problems and can in
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Drugs and their effects on the deve
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Effects of tobacco The significant
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Effects of drugs (illicit and presc
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• fetal death in-utero (miscarria
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Introduction Key points Setting Neo
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• poor feeding ability (hungry bu
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monitored. Any drug treatment admin
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� Swaddling of the baby will help
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Babies with severe symptoms usually
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Management of substance use in preg
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Scottish Executive advice recommend
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If a ‘hazardous’ drinking score
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Assessing drug related problems It
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Substitute prescribing Lothian has
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drug use should be the first goal t
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A final word: Over the years, much
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Amenorrhoea does not necessarily me
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Pre-conceptual advice on drug use c
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Antenatal care Receiving good quali
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the antenatal ward, labour ward, an
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usually possible to be quite reassu
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can be more serious in women with s
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Introduction Key Risk points assess
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for the women and can make attendan
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These documents contain important i
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Intrapartum care (labour and childb
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There may be placental insufficienc
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states she is taking the baby home
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Women who are Hepatitis B positive
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Postnatal care The care of a pregna
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Relapse prevention support work can
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Introduction Assessing and managing
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A number of childcare problems have
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� Report your concerns to the Chi
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Finally, it is important to remembe
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Services List Services providing ma
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with a drug dependency who are on s
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Drug services in Lothian Most speci
Page 125 and 126: Local drug services � Locality Cl
Page 127 and 128: Alcohol services in Lothian Most sp
Page 129 and 130: Other services in Lothian A variety
Page 131 and 132: Introduction Key points Setting Fur
Page 133 and 134: � Royal College of Obstetricians
Page 135 and 136: General � Scottish Executive webs
Page 137 and 138: References Abel EL, (1998) ‘Fetal
Page 139 and 140: NICE (National Institute for Clinic
Page 141 and 142: Introduction Key points Setting the
Page 143 and 144: Drug/Alcohol related problem: refer
Page 145 and 146: Substance Misuse in Pregnancy 124
Page 147 and 148: INDEX Alcohol, 37-38, 52-56, 84 scr
Page 149 and 150: Introduction Key Appendices points
Page 151 and 152: Substance Misuse in Pregnancy 128
Page 153 and 154: Blood Borne Viruses and Pregnancy H
Page 155 and 156: Management of HIV positive pregnant
Page 157 and 158: east fed after these are given. The
Page 159 and 160: It is good practice therefore to of
Page 165 and 166: Introduction Appendix 4: Model Care
Page 167 and 168: Introduction Appendix 5: Key Consen
Page 169 and 170: Introduction Key points Setting App
Page 175: Appendix 9: Introduction Midwifery
Page 179 and 180: Community Baby developed NAS sympto
Page 181 and 182: Neonatal Abstinence Syndrome Assess
Page 183 and 184: Drug Drug use use in in pregnancy p
Page 185 and 186: aby. If you want to come off, it is
Page 187 and 188: Labour Labour and and childbirth ch
Page 189 and 190: Midwifery Midwifery care care staff
Page 191 and 192: Helpful Helpful numbers numbers My
Page 193 and 194: Produced by NHS Lothian © 2003
Page 195 and 196: This leaflet provides you with info
Page 197 and 198: Parents are encouraged to keep a cl
Page 199: Breastfeeding Breastfeeding and and
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Substance Misuse in Pregnancy - NHS Lothian

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