Substance Abuse in Pregnancy Nursing Care Plans

The pregnant patient with a substance use disorder often shows up late, if she shows up at all. She is afraid that disclosing her use will get her reported and her baby taken, so she avoids prenatal care and the problems compound. Your job is to keep her coming back. That starts with care that is nonjudgmental, consistent, and grounded in the fact that addiction is a chronic illness, not a moral failing.

As many as 375,000 infants may be affected by maternal substance use each year, and 10% to 20% of pregnant women admit to using illicit substances during pregnancy. Adolescents carry an increased rate of inhalant abuse and binge drinking. The drugs most commonly abused are nicotine, alcohol, marijuana, heroin, phencyclidine (PCP), opiates, cocaine, and methamphetamine. The fetal and maternal toll includes poor nutrition and weight gain, anemia, infection, pregnancy-induced hypertension, low birth weight, intrauterine growth restriction, and fetal alcohol syndrome (FAS).

Nursing Care Plans and Management

Management centers on physiological stability for mother and fetus, helping the client accept the reality of her situation, building coping skills, connecting her to a supportive recovery community, involving the family in treatment, and educating her about the condition, prognosis, and treatment options.

Nursing Problem Priorities

1. Ensure maternal and fetal safety.
2. Provide nonjudgmental, supportive care.
3. Assess and manage withdrawal symptoms.
4. Ensure access to appropriate prenatal care.
5. Promote healthy lifestyle choices.
6. Facilitate substance abuse treatment referrals.
7. Advocate for the rights and best interests of the mother and baby.

Nursing Assessment

Assess for the following subjective and objective data:

• Changes in appetite or sudden weight loss or gain
• Poor personal hygiene and neglect of physical appearance
• Bloodshot or glassy eyes, dilated or constricted pupils
• Slurred speech or impaired coordination
• Frequent mood swings or noticeable behavior changes
• Social withdrawal or isolation from friends and family
• Financial difficulties or unexplained borrowing of money
• Neglected responsibilities, such as missing work or school
• Secretive behavior or lying about activities and whereabouts
• Increased tolerance or needing larger amounts of the substance
• Withdrawal symptoms when attempting to stop or cut back
• Risky behaviors, such as driving under the influence
• Legal problems related to substance use
• Relationship conflicts with loved ones
• Neglected prenatal care or missed appointments

Nursing Diagnosis

Formulate the nursing diagnosis from your assessment findings and clinical judgment, prioritizing the patient's specific health concerns. Clinical expertise, not the diagnostic label itself, shapes the plan.

Nursing Goals

Goals and expected outcomes may include:

The client will verbalize how substance dependence and poor dietary intake affect nutrition and pregnancy, and will demonstrate behaviors and lifestyle changes that move her toward an appropriate weight, normalized lab values, and no signs of malnutrition. She will acknowledge the link between substance use and her current situation, identify ineffective coping behaviors and their consequences, and use effective coping and problem-solving skills. She will attend a support group such as Cocaine, Narcotics, or Alcoholics Anonymous regularly, verbalize acceptance of herself and an increased sense of worth, and set realistic goals for living without drugs while carrying the pregnancy to a healthy outcome.

She will admit she cannot control her drug use, surrender to powerlessness over the addiction, and recognize that willpower alone cannot maintain abstinence. She will participate actively in treatment, understand codependence, and take action to change self-destructive behaviors. She will remain abstinent during and after pregnancy, avoid complications of substance abuse, and show no untoward effects of withdrawal. The fetus will develop with no or minimal complications, be delivered at full term, and display no withdrawal symptoms at birth.

Nursing Interventions and Actions

1. Maintaining Adequate Nutrition

Many of these women come in late for prenatal care, worried their use will be discovered and reported. When money is short and the choice is drugs or food, drugs often win, which means no money for supplemental vitamins or iron either. Nutrition is one of the few protective factors you can build against the teratogenic effects of alcohol and drugs.

Assess the oral cavity. Note age, height, weight, body build, strength, and activity-rest pattern. This guides the dietary plan. Mucous membranes and teeth reflect intake. Methamphetamine users often describe their teeth as blackened, stained, rotting, or crumbling, driven by poor oral hygiene, high refined-carbohydrate intake, and increased oral acidity from the drug, regurgitation, or vomiting.

Determine anthropometric measurements: BMI, waist-to-hip ratio, skin-fold test, bioelectrical impedance. These measure subcutaneous fat and muscle mass to plan dietary needs. Most clients who abuse drugs present with below-normal BMI and biochemical values from poor-quality, nutrient-deficient food. Pregnant women addicted to methamphetamine show smaller biceps skinfold thickness and significantly lower BMI than non-addicted pregnant women.

Note total daily calorie intake. Have the client keep a journal of intake, frequency, and eating patterns. This reveals nutritional strengths and gaps. Heroin, cocaine, and ecstasy are linked to metabolic problems; heroin users typically eat fewer vegetables, fruits, and grains than recommended and more sweets.

Assess energy expenditure relative to pregnancy needs and activity level. Both affect nutritional requirements. Chronic methamphetamine abuse alters brain dopamine activity and reduces motor function, which can produce significant social, occupational, and medical impairment.

Weigh the client weekly and record it. This tracks the effectiveness of the dietary plan. Cocaine acts as an appetite suppressant and tends to reduce body weight.

Review prenatal nutritional needs and build a dietary plan. Illicit drugs suppress appetite and push clients toward empty-energy, nutrient-poor foods that cause micronutrient deficiency. Increasing protein and reducing simple carbohydrates, with more vegetables and whole grains, can reverse much of the carbohydrate-metabolism damage.

Help develop a grocery budget and let the client select foods that meet the plan. This builds involvement and resolves deficiencies. Some experimental work suggests supplementing minerals and antioxidants such as vitamin E or C to replace the deficits seen in substance-dependent mothers and to protect the fetus.

Set an individualized exercise program. Exercise improves muscle tone, may promote appetite, and raises well-being. Moderate-to-vigorous exercise improves abstinence rates and anxiety or depressive symptoms across multiple substance use disorders and is an effective adjunct in withdrawal.

Promote essential micronutrients and multivitamins. Supplementation partly reverses the toxic effects of alcohol and drugs on fetal neurological development. Choline, vitamin E, betaine, folic acid, methionine, and zinc can attenuate alcohol-induced epigenetic changes and oxidative damage.

Collaborate with a dietitian. This establishes individual dietary needs and adds a learning resource for nutrition in both pregnant and nonpregnant states. Dietary support, weight monitoring, and fetal assessment together promote better outcomes.

Review labs as indicated, including glucose, serum albumin, and electrolytes. These reveal electrolyte imbalance, anemia, and other abnormalities needing specific therapy. Opiate addiction is associated with deficiencies of key proteins, fats, and minerals such as zinc, iron, calcium, chromium, magnesium, and potassium. Heroin use is implicated in blood-sugar disorders; fasting insulin levels run about 4 times higher in heroin users than in controls, and opioid-related insulin resistance may pair with beta-cell dysfunction.

Educate the client about outreach and food assistance programs. Poorly nourished, homeless, or incarcerated pregnant clients may need referrals to food assistance and shelters, plus transportation vouchers and prenatal multivitamins.

Refer to a dentist as needed. Healthy teeth support good intake, and dental hygiene is routinely overlooked in this population. Dental management is challenging and warrants professional referral.

2. Promoting Effective Coping

Substance use clouds judgment, erodes self-esteem, and strains family trust and communication. The patient needs new ways to handle stress, decision-making, and relationships that do not run through drug use. Confrontation backfires here; a steady, nonjudgmental presence is what keeps her engaged.

Assess her understanding of the pregnancy, the current situation, and how she has coped before. This shows the degree of denial and surfaces coping skills you can build on. Some clients plan a pregnancy and moderate their use beforehand, mitigated by their perception of how use affects their ability to conceive.

Identify triggers for relapse. Employment and financial stress, isolation, unhealthy relationships, being around using friends or partners, certain songs, premenstrual syndrome: triggers are individual. Naming them lets her plan how to avoid or handle them.

Give positive feedback when she recognizes denial in herself and others. Denial is the major defense in addiction and blocks therapy until she accepts the problem. Recognition for her effort enhances self-esteem and reinforces insight; women in recovery consistently value praise from their support network.

Hold firm expectations that she attend recovery support and therapy groups regularly. Attendance means admitting the need for help and working through denial, both tied to a better pregnancy outcome and long-term abstinence. Network members who keep clients in treatment and at appointments are the backbone of consistent recovery support.

Approach her without judgment. Watch for restlessness and rising tension. Confrontation can escalate agitation and compromise safety. Provider stigma is especially strong during pregnancy and keeps women from seeking care.

Teach the difference between experimental, occasional, and addictive use, and explain the biochemical and genetic basis of addiction. Use moves along a continuum from experimental to addictive, and understanding that progression helps combat denial and lifelong guilt and blame. Outreach workers educating and supporting women through pregnancy has worked in other settings.

Reinforce disease-specific teaching. Teaching the client what addiction does to her and how to live without drugs supports recovery and gives her tools to use day to day.

Encourage her to take responsibility for her own recovery. When she accepts that responsibility, denial gives way to action. Encouragement, both general and treatment-specific, leaves clients feeling inspired and assured.

Encourage her to express feelings, and listen actively. Talking through problems with a support network is a predominant form of emotional support. She needs people who listen and offer honest moral support.

Set limits. Do not grant special privileges, accept excuses, or tolerate continued use. She has learned manipulative behavior over a lifetime and needs a new way to get needs met. Following through on consequences helps her change ineffective patterns, and many women value talk that is direct, honest, and holds them accountable.

Recognize enabling behaviors in family, partners, and staff. Without understanding enabling and codependence, no approach will be therapeutic. Intimate partners often mediate use for better or worse; some women started using in pursuit of intimacy or a perceived ideal relationship.

Teach relaxation, guided imagery, and visualization, and encourage their use. These build new ways to manage stress and solve problems. Doing enjoyable things together, including with supportive people, reinforces recovery through emotional connection.

Teach coping skills. The client can learn to identify, sit with, and express the emotions, thoughts, and behaviors that surround recovery, and to recognize the behaviors tied to difficult emotions.

Encourage involvement with self-help groups such as Alcoholics or Narcotics Anonymous. These give direct access to the support and peer accountability needed to maintain a drug-free life. Parenting classes and community awareness activities also inform women about the risks of use during pregnancy.

Assess for changes in mentation and other psychiatric disorders. Some clients use substances to relieve depression or anxiety. Screen with a tool such as the Patient Health Questionnaire; undiagnosed depression in pregnancy can lead to inadequate weight gain, preterm birth, and low infant birth weight.

Assess family dynamics and the effectiveness of support. Substance abuse is a family disease, and how members react shapes its course and how the client sees herself. Many unconsciously become enablers. Both peer support inside treatment and social support outside it are significant to outcome.

Monitor for psychosocial issues: lack of support, loneliness, depression, low confidence, powerlessness, domestic violence, socioeconomic problems. Providers who assess psychosocial factors are more likely to identify these concerns. Women report they do not want to feel alone, judged, or misunderstood, and they want a greater sense of their own worth.

Reinforce positive actions and encourage her to accept the input. Failure and low self-esteem have been recurring problems; she needs to learn to see herself as a person with positive attributes.

Discuss her behavior and use without judgment. Mothers with substance use disorder perceive stigma from providers, the public, loved ones, and themselves. A nonjudgmental presence conveys acceptance and opens insight into the problems use has created.

Help her acknowledge that substance use is the problem and that problems can be handled without drugs. Confront denial, projection, and rationalization. When drugs can no longer be blamed, she can begin to live without them. Warm, supportive providers let women be honest about their use, which opens access to counseling and treatment.

Use role rehearsal. This lets her practice the skills of living as a person who no longer needs drugs. Self-efficacy is the foundation for changing substance use behavior.

Administer antipsychotic medications as prescribed, noting precautions in pregnancy. See Pharmacological Management.

Involve her in group therapy. Sharing personal experience with addiction builds new skills, hope, and belonging. Connecting her with education and job opportunities adds structure and motivation to stay in recovery.

Build a plan to treat co-occurring mental illness. Clients who self-medicate other mental health problems will keep using unless both are treated together. Tailor coping-strategy interventions to whether anxiety, depression, or both are present.

Assess the dynamics with her significant other. Note domination by a partner or unwillingness to respond in his presence. Drug dependence and societal rejection can drive self-imposed or forced isolation, and some women's use is prompted by a using partner who is the father of the children.

Use crisis intervention techniques. She is more open to treatment in the crisis that pregnancy presents. The 5 A's Intervention, developed by the U.S. Public Health Service and supported by ACOG and the National Cancer Institute, takes about 5 to 15 minutes and should be used with every client who smokes or recently quit.

Help her acknowledge the problem exists. It is easier to accept once she recognizes that use is harming her fetus. Nonjudgmental, supportive relationships are what women credit with their ability to stop.

Help her plan to leave an abusive situation. A volatile situation requires careful attention to safety. Some women do not perceive their experiences as abuse, so disclosure and higher reported rates of abuse often come later in treatment as they grow more comfortable.

Identify goals for change. This directs care and reinforces that change is possible. Confidence in her ability to reach her goals matters.

Review alternative options. Brainstorming surfaces possibilities and gives a sense of control. Women have recommended comprehensive, wraparound inpatient programs spanning detoxification to aftercare, with skills classes and parenting groups.

Help her choose and commit to the best option, and support implementation. As options are discussed, the right one becomes clear, and supporting it helps her persevere. Trusting, collaborative relationships with providers keep clients in treatment.

Discuss the need for help in a caring, nonjudgmental way. A moralistic approach triggers defensiveness and blocks recovery. Treat substance abuse as the illness it is, with patience, kindness, consistency, and firmness when needed.

Teach assertive communication. This helps her refuse use, end relationships with users and dealers, build healthy relationships, and regain control. A positive relationship with a provider supplies objective advice and comfort she may not have elsewhere.

Support self-examination of spirituality and faith. Surrendering to a power greater than oneself can reduce the sense of powerlessness and is commonly used in substance use interventions, including spiritually modified cognitive behavioral therapy and 12-step approaches.

Help her find healthy ways to meet pregnancy needs and divert from drug use. Constructive empowerment supports recovery. Encourage a new social network away from the drug lifestyle and offer alternatives such as acupuncture to manage stress and restore biochemical balance.

Discuss how use has affected her life, work, and relationships. Many clients lack knowledge of how use affects them and their fetus and how quickly addiction takes hold, until the drug matters more than anything, including their children. Awareness undercuts the sense of powerlessness.

Help her make an appointment with a treatment program, such as partial hospitalization, Narcotics or Alcoholics Anonymous, or a shelter for abused women. Following through is often easier than the first contact, and continuing treatment is essential to both recovery and pregnancy. She may need more frequent appointments and miss more of them due to transportation and childcare barriers. Multidisciplinary care including counselors, social workers, case managers, psychiatrists, and opioid replacement providers is required.

Discuss private addiction counseling. This may be needed, especially when isolation makes a group setting feel unsafe at first. Counseling techniques include motivational interviewing, trigger identification, stress reduction, cognitive behavioral therapy, and contingency management.

Help her prepare for parenthood. Accessing prenatal care and disclosing use are the first steps toward investing in her health and her child's. Provide referrals to educational programs and teach her about neonatal abstinence syndrome (NAS), including its diagnosis, treatment, and the expected length of the infant's hospital stay.

The family carries the same illness. Substance abuse damages marital, financial, and emotional stability, parental competence, and the physical and mental health of every member. Treat the family alongside the client.

Assess family history. Explore each member's role, the circumstances of use, strengths, and growth areas. Note attitudes toward pregnancy and parenting. This sets the focus and surfaces the potential for change.

Assess each family member's current level of functioning. This shapes the ability to cope. Parents with substance use disorder may be absent or unable to provide the nurturing children need, and family roles shift during recovery.

Assess social and environmental stressors. Screen for intimate partner violence, homelessness, and food insecurity at the first visit, periodically through prenatal care, and whenever circumstances change. Women with substance use disorders are at higher risk for these problems.

Determine the extent of enabling by family members and explore it with them. Enabling is doing for the client what she must do for herself. People want to help, but they often cover up the user's inability to cope with daily responsibilities.

Explore how the family has coped with her use, including denial, repression, rationalization, hurt, loneliness, and projection. The codependent person carries the same anxiety, self-hatred, helplessness, low self-worth, and guilt and needs help building practical coping skills. Some members need professional treatment for depression or anxiety themselves.

Teach the family about enabling and the characteristics of codependence. Awareness opens the door to change. Some tangible supports double as enabling, such as childcare or shelter that protects continued use, and these are harmful to recovery.

Give the client and family factual information about how addiction affects the family, fetus, and pregnancy, and what to expect with abstinence. Many do not understand the nature of addiction or its family involvement, and families who use legally obtained drugs may not recognize the abuse. Families benefit from education on symptoms, causes, effects, treatment, relapse, and available support programs.

Encourage family members to examine their own feelings with perspective and objectivity. When they recognize the actions that perpetuate the problem, they can change themselves, and the client can then face the consequences of her own actions.

Involve the significant other in referral plans. Recovery rates nearly double when the family is treated alongside the client. Engage the family early, during assessment when possible.

Recognize staff enabling behaviors and feelings. Lack of understanding of enabling and codependence produces nontherapeutic care. Staff may feel angry toward a client who keeps using despite knowing the fetal risk. Women with opioid use disorder fear judgment from the nurses and providers caring for them, and the emotional support they need is not always given.

Facilitate or provide family treatment. Couple and family sessions address questions, change interaction patterns, and improve communication, while members work on the emotional burdens and behaviors that interfere with recovery.

Help the family support the client without enabling. Members can learn relapse warning signs and how to intervene early in the relapse process.

Keep the client focused on her children. Help the family understand how substance use disorder affects children, encourage open dialogue, and support normal routines, active interest in the child's life, and evaluation of any child with a psychiatric disorder or substance use disorder.

3. Accepting the Situation

Denial is the central obstacle. It is a conscious or unconscious process that keeps the patient from recognizing and addressing the problem, and it interferes directly with treatment. On top of denial, fear of legal consequences and child protective services keeps women from seeking care and from being honest once they do. Your task is to separate the person from the behavior and make honesty safe.

Identify her reason for starting abstinence and entering therapy. This shows her willingness to commit and whether she believes she can change. Deciding to quit is the key first step.

Assess her level of acceptance versus denial. Denial blocks participation in treatment. Many women fear seeking care because of legal ramifications and child protective services, which makes building trust harder.

Convey acceptance while separating the client from unacceptable behavior. This promotes dignity and self-worth. Treat each woman as an individual with individual needs; trust makes her more likely to reach for help.

Give honest, factual answers to her questions. Trust is the basis of the therapeutic relationship. Clients with opioid use disorder struggle to trust themselves and others, and they worry providers will contact police or CPS.

Teach her how addiction affects mood and personality. She may mistake these effects and use them to justify continued use. Underlying depression, anxiety, PTSD, bipolar disorder, schizophrenia, and personality disorders often go undiagnosed in this population.

Discuss the impact of use on her pregnancy. Seeing the link between use and her problems is the first step out of denial. Pregnancies complicated by substance abuse carry risk for miscarriage, preterm delivery, intrauterine growth restriction, placental abruption, fetal intraventricular hemorrhage, intrauterine fetal demise, NAS, and other developmental effects.

Stay nonjudgmental and watch for restlessness and rising tension. Clients addicted to opioids fear judgment from their care team, and the support they need is often withheld. The ANA Code of Ethics is clear that nurses practice with compassion and respect for the dignity and worth of every person.

Give positive feedback when she recognizes denial in herself and others. Praise for her effort reinforces insight, and women value the recognition they receive from their support network.

Encourage her to self-admit to a treatment program. Self-admission means denial has been addressed to some degree. Many clients enter treatment not yet ready to change, and low motivation can affect outcomes.

Assure her that substance abuse is a chronic, physiologic illness, not a moral failing. It is easier to accept treatment for an illness than for a perceived moral weakness.

Have her compile a list of the harmful consequences and situations driven by her use. This breaks through denial and helps identify past relapse triggers. Ask her to share the list with another nurse, a peer, or someone in her treatment program.

Encourage her to develop alternative behaviors to drug use and to own her recovery. Denial gives way to positive action when she accepts responsibility for herself.

Be aware of your own enabling behaviors. Caregiving can slide into taking care of clients in ways that backfire. Enablers minimize the addiction, make excuses, pay bills, or hide the damage, all of which help the patient avoid confronting the addiction itself.

Encourage involvement with self-help and family programs such as Alcoholics or Narcotics Anonymous, Al-Anon, Al-Ateen, and professional family therapy. These connect the client and family to the support needed for continued sobriety. Al-Anon and Nar-Anon help families learn from others and focus on the positive changes they can make.

4. Preventing Injuries and Promoting Safety

Chemical dependency is chronic, relapsing, and progressive, and without treatment it can end in disability or premature death. The fetus takes the same systemic hit as the mother, often worse, because it cannot metabolize drugs efficiently and keeps experiencing the effects long after the drug has cleared the mother's system. First-trimester exposure is especially damaging to fetal growth and development.

Identify the substance the client is or has been using. Screen every pregnant woman at the first prenatal visit for past and present use of tobacco, alcohol, and other drugs, including recreational use of prescription, over-the-counter, and herbal products. Start with over-the-counter and prescribed medications, move to legal drugs such as caffeine, nicotine, and alcohol, then ask about illicit drugs such as cocaine, heroin, and marijuana.

Use validated screening tools. Validated questionnaires plus assurance of confidentiality improve communication and truthfulness. The 4Ps Plus is designed to identify pregnant women who need in-depth assessment; it has 5 questions and takes under a minute.

Monitor vital signs regularly. Sniffed or smoked cocaine crosses the mucous membranes to the CNS and causes sudden vasoconstriction, driving up respiratory rate, cardiac rate, and blood pressure. Marijuana, sometimes used to counter early-pregnancy nausea but not advised, produces tachycardia and can lower blood pressure, causing orthostatic hypotension.

Document a thorough history. These women are at risk for a range of infections and medical conditions, so obtain a comprehensive history and complete physical. Accepting language encourages honest answers without fear of reproach.

Review laboratory results. Expect screening for syphilis, hepatitis B and C, and HIV, plus a complete blood count and a TB skin test. Test for other common sexually transmitted infections such as gonorrhea and chlamydia.

Assess for barriers to treatment. Stigma, labeling, and guilt are significant barriers, as are long waiting lists and lack of health insurance.

Use a nonjudgmental approach. Women who use psychoactive drugs often receive negative feedback from society and providers. She is more likely to trust and disclose her patterns if you do not judge her or her choices.

Develop a standardized, consistent plan of care. A consistent plan limits opportunities to play staff against one another. Substance abuse is an illness, and these clients deserve patience, kindness, consistency, and firmness when needed.

Educate her about the effects of prenatal exposure to illicit substances. If a drug screen is positive, use it to open a discussion about prenatal exposure, which may lead to a diagnostic assessment or a referral for counseling.

Explain the legal considerations. Women often avoid help for fear of losing custody or facing prosecution. Reassure her that sharing confidential information with providers does not make her liable to prosecution, but be honest that states vary: providers may be required to report positive drug results in a pregnant woman or newborn to the state child protection agency.

Educate her about the effects of illicit substances if she plans to breastfeed. All abused substances appear in breast milk, some in greater amounts. Breastfeeding is contraindicated for clients who use amphetamines, alcohol, cocaine, heroin, or marijuana. For some women, the wish to breastfeed is strong motivation to stay sober.

Assist a client in alcohol withdrawal with ambulation and self-care. This prevents falls. Alcohol withdrawal produces poor gait, motor incoordination, severe tremors, altered mental status, and a high seizure risk.

Educate her about the effects of smoking in pregnancy. Smoking raises the risk of spontaneous abortion, preterm labor and birth, maternal hypertension, placenta previa, and abruptio placenta. These outcomes can be avoided if she stops before becoming pregnant.

Counsel her on the maternal effects of illicit drugs. Perinatal cocaine use increases the risk of preterm labor, abortion, abruptio placenta, seizures, withdrawal, uterine rupture, and cerebral infarcts. Marijuana increases the risk of spontaneous abortion and preterm delivery. Narcotic dependence brings medical, nutritional, and social neglect, physical dependence, malnutrition, compromised immunity, hepatitis, fatal overdose, and increased risk of preterm labor and preeclampsia. Chronic methamphetamine use can cause psychosis, paranoia, hallucinations, memory loss, and aggression.

Implement contingency management. Participants receive incentives such as small cash amounts, privileges, or prizes for maintaining abstinence. These motivational approaches increase treatment retention and prolong abstinence in pregnant clients with cocaine, opiate, and nicotine dependence.

Administer medications for opioid dependence as prescribed. Methadone maintenance sustains opioid concentrations in mother and fetus, minimizes craving, and prevents fetal stress; it is the standard of care for pregnant women dependent on heroin or other narcotics. Buprenorphine, a synthetic opioid, is equally effective and safe and is used alone or combined with naloxone as a first-line treatment for heroin addiction and a replacement for methadone.

Administer medications for alcohol withdrawal syndrome. Antabuse (disulfiram) is a deterrent to impulsive drinking. Naltrexone, originally a heroin treatment, is approved for alcoholism and reduces cravings, working best with psychosocial treatment. Ondansetron, a serotonin receptor antagonist, reduces consumption and craving in early-onset alcohol use disorder.

Enroll her in a smoking cessation program. Women are more likely to attempt to quit during pregnancy than at any other time. Cessation programs are effective and should be offered to every pregnant smoker and continued postpartum, since many resume after birth. The 5 A's Intervention, supported by ACOG and the National Cancer Institute, takes about 5 to 15 minutes.

Offer information about rehabilitation options. Detoxification, short-term inpatient or outpatient treatment, long-term residential treatment, aftercare, and self-help groups are all options. Women for Sobriety may suit women better than Alcoholics or Narcotics Anonymous, which were originally developed for male substance abusers.

Assess fetal heart rate regularly. Ongoing use, especially of stimulants, raises the risk of intrauterine growth restriction and perinatal death. One approach is weekly fetal heart rate monitoring starting at 32 weeks gestation for women with ongoing stimulant use, with induction considered at 38 weeks, balancing the risks of induction against continued exposure.

Screen the mother for alcohol problems. Screening women of reproductive age helps prevent FAS, which appears in newborns of mothers with chronic alcoholism and sometimes in those of low-to-moderate drinkers.

Determine her specific drug use and intake. The effect on the fetus depends on the drug, dose, route, maternal and fetal genotype, and timing of exposure. Polydrug use, reporting errors, and variable street-drug purity make specific effects hard to pin down.

Review ultrasound results for fetal growth and gestational age. Serial ultrasound is usually done because amenorrhea from drug use may obscure dates. The fetus is at high risk for intrauterine growth restriction from nicotine's vasoconstrictive effects on the placenta and umbilical vessels, which cause fetal hypoxia and undernourishment.

Assess for fetal exposure to illicit substances. Umbilical cord tissue and meconium can be analyzed for longer-term exposure to amphetamines, opiates, cocaine, cannabinoids, and alcohol.

Assess fetal growth perinatally and postnatally. Severe chronic alcoholism produces predictable abnormal patterns of fetal and neonatal growth, and the prenatal growth deficiency persists after birth in linear growth, weight gain, and head circumference.

Assess for signs of FAS. Diagnosis rests on minimal criteria in three categories: prenatal and postnatal growth restriction; CNS dysfunction including cognitive impairment; and craniofacial features such as microcephaly, small eyes, short palpebral fissures, thin upper lip, flat midface, and an indistinct philtrum.

Assess for symptoms of alcohol withdrawal in the neonate. Withdrawal can occur in neonates, particularly when maternal ingestion is near birth, with jitteriness, increased tone and reflexes, and irritability.

Assess the neonate for drug withdrawal. Newborns of mothers addicted to cocaine, heroin, methadone, or other drugs are born addicted and often withdraw early. Symptoms include tremors, restlessness, hyperactivity, disorganized or hyperactive reflexes, increased muscle tone, sneezing, tachypnea, vomiting, diarrhea, disturbed sleep, and a shrill, high-pitched cry. Ineffective sucking and swallowing cause feeding problems, with frequent regurgitation and vomiting after feeds.

Include the parents in planning care. Caring for the infant of a substance-abusing mother challenges the whole team, and parents are part of planning for the newborn and for support at home.

Increase the mother's awareness of alcohol's harms. There is no known safe threshold, so advise abstinence throughout pregnancy. Low-level consumption in early pregnancy is not an indication for termination, but a woman who has already consumed alcohol should stop to limit further risk.

Decrease environmental stimuli and plan care carefully. Care for a newborn with FAS is supportive and focused on preventing complications such as seizures. Keep the room dimly lit and plan activities to minimize stimulation.

Swaddle the infant snugly. For a cocaine-exposed infant, position to avoid eye contact and swaddle snugly with arms across the chest to reduce self-stimulation and protect the skin. Use vertical rocking and a pacifier to counter poor response to stimuli.

Provide adequate nutrition for weight gain. Feed frequent small amounts with the head elevated during and after feeding to reduce vomiting and aspiration. The suck reflex may be weak, so try different nipples to compensate.

Explain the effects of maternal drug use on the newborn and the withdrawal process, without judgment. A woman using cocaine should stop immediately and will need significant help, including a treatment program, counseling, and self-help support, to make this change.

Encourage open communication with the parents, especially the mother. Keep them informed of the condition, procedures, and treatments. Answer questions, correct misconceptions, and listen to their concerns to give them a sense of control.

Encourage the mother to interact with the newborn. Involve her in care routines to build connection. Show her how to provide care and avoid overstimulation to strengthen her confidence and sense of control.

Administer medications to a newborn with NAS. Observe newborns for 3 to 7 days for NAS; those needing pharmacologic treatment generally receive oral morphine or methadone. Once a dose controls withdrawal, wean it over several days, then observe after the last dose to confirm stability. Infants of mothers on buprenorphine may have less risk of needing treatment and shorter treatment when it is needed.

Administer opioid replacement therapy to the mother. See Pharmacological Management.

Instruct the mother to avoid breastfeeding if using street drugs. Breast milk is the optimal source of nutrition, but exposing the infant to additional drugs must be avoided. The AAP advises that mothers using street drugs should not breastfeed, while women in a supervised methadone program may breastfeed if they are adequately nourished and screen negative for illicit drugs.

Administer intravenous fluids as prescribed. Withdrawal can cause vomiting and diarrhea, so give oral and parenteral fluids as ordered to maintain fluid balance.

5. Initiating Patient Education and Health Teachings

A lack of pregnancy-related knowledge hurts both the patient and her child, and it is sharper in adolescents whose age and maturity affect how well they absorb teaching and recognize danger signs. Equip her with the knowledge to engage in good health practices and make informed choices.

Assess her knowledge of her own condition, including pregnancy, complications, and needed lifestyle changes. This guides planning for the long-range changes that maintain drug-free status. She may know the drug on the street but not the medical facts or its relationship to pregnancy. Pregnant women with opioid use disorder often have little social capital and face financial and residential instability, interpersonal violence, and psychiatric comorbidities that worsen severity.

Assess for signs of depression, including a history of substance abuse. Use a Patient Health Questionnaire (PHQ-9) for depression risk. Without comprehensive screening, significant information stays hidden, and undiagnosed depression can lead to inadequate weight gain, preterm birth, and low infant birth weight.

Assess anxiety in the client and significant others. Anxiety hinders processing information. The stigma women who use substances face is even greater in pregnancy, and shame, misconceptions about prescription opioids, and fear of CPS leave opioid use disorder undiagnosed and untreated.

Encourage regular physical examination, including vaginal culture for STIs. Cultures detect organisms dangerous to the fetus or newborn, such as group B streptococcus, chlamydia, syphilis, and gonorrhea. Injected drug use raises HIV and hepatitis risk, and money earned through prostitution adds further STI risk to the fetus.

Review sonogram results. Ultrasonography assesses growth and reveals possible intrauterine growth restriction or fetal alcohol effects. Alcohol crosses the placenta at the same concentration as in maternal blood, which may cause fetal alcohol exposure or fetal alcohol spectrum disorder (FASD), marked by prenatal and postnatal growth restriction, cognitive challenge, microcephaly, and cerebral palsy.

Provide information on the maternal and fetal effects of drugs. Review the client's and partner's use history. Recognizing the harms may motivate her to stop. For some, pregnancy is the impetus to quit; others can only reduce use. Identifying problems early helps plan for fetal needs.

Provide varied teaching materials, including articles, books, and videos, and encourage reading and discussion. These women commonly have little understanding of how substances affect them, their pregnancies, and their babies. Bibliotherapy can complement other approaches when materials match the client's educational and cognitive level.

Give the client and partner an active role in learning through discussion, group participation, and role-playing. Active participation enhances learning. Partner support is linked to higher self-efficacy in parenting, so connecting partners with treatment may improve motivation.

Discuss the relationship between use and the current pregnancy. Clients often have misperceptions or denial about the real reason for admission. Seeing the link between use and personal problems is the first step out of denial.

Schedule activities specific to individual needs. Information is assimilated better at an individual learning pace. Day-to-day structure supports recovery, and people in recovery draw meaning and pride from consistently holding a job.

Provide information on available organizations and referral programs. Long-term support maintains recovery and addresses pregnancy and psychosocial needs. The full range of services may include detoxification centers, treatment programs, shelters, food banks, pregnancy outreach, aftercare, parenting programs, and childcare.

Educate her about medications used as adjuncts in alcohol disorder treatment, such as disulfiram, naltrexone, and ondansetron. Teach the risks of drinking while taking disulfiram, which deters impulsive drinking; alcohol on disulfiram causes severe nausea, vomiting, hypotension, headache, palpitations, seizures, or death. Naltrexone reduces alcohol cravings and works best with psychosocial treatment, with side effects including insomnia, anxiety, headache, low energy, abdominal pain, and joint and muscle pain.

6. Administer Medications and Provide Pharmacologic Support

Methadone and buprenorphine treat opioid dependence and reduce withdrawal. Antipsychotics may be prescribed to manage psychosis, hallucinations, or severe mood disturbance, and phenobarbital is used in specific cases such as seizure disorders. The provider selects medications based on individual needs, risks, and benefits.

Antipsychotic Prolonged psychosis after LSD or PCP use can be treated with antipsychotics for the underlying functional psychosis that has emerged. Individuals who have taken large doses of LSD are at risk for residual psychotic symptoms and are managed with antipsychotics if symptoms persist.

Methadone Methadone is used for detoxification and maintenance. It weakens craving, decreases the effects of heroin, and assists in withdrawal and long-term maintenance, with fewer side effects than heroin, letting the client maintain daily activities and ultimately withdraw.

Phenobarbital Phenobarbital treats alcohol withdrawal and reduces the frequency and severity of seizures. It is a Schedule C-IV controlled substance. Evidence shows alcohol withdrawal has a better clinical outcome when treated with benzodiazepines.

Opioids Opioid replacement therapy is associated with longer gestation and higher infant birth weight. It avoids the intoxication-withdrawal cycles common with short-acting opioids such as heroin or oxycodone, sparing the fetus the effects of those cycles, including preterm delivery, IUGR, and intrauterine fetal demise.