- Downloadable PDF of the bundle
- Complete resource listing
- Supporting Commentary
- Safety Action Series presentation
- Provide education to promote understanding of opioid use disorder (OUD) as a chronic disease.
- Emphasize that substance use disorders (SUDs) are chronic medical conditions, treatment is available, family and peer support is necessary and recovery is possible.
- Emphasize that opioid pharmacotherapy (i.e. methadone, buprenorphine) and behavioral therapy are effective treatments for OUD.
- Provide education regarding neonatal abstinence syndrome (NAS) and newborn care.
- Awareness of the signs and symptoms of NAS
- Interventions to decrease NAS severity (e.g. breastfeeding, smoking cessation)
- Engage appropriate partners (i.e. social workers, case managers) to assist patients and families in the development of a “plan of safe care” for mom and baby.
Every clinical setting/health system
- Provide staff-wide (clinical and non-clinical staff) education on SUDs.
- Emphasize that SUDs are chronic medical conditions that can be treated.
- Emphasize that stigma, bias and discrimination negatively impact pregnant women with OUD and their ability to receive high quality care.
- Provide training regarding trauma-informed care.
- Establish specific prenatal, intrapartum and postpartum clinical pathways for women with OUD that incorporate care coordination among multiple providers.
- Develop pain control protocols that account for increased pain sensitivity and avoidance of mixed agonist-antagonist opioid analgesics.
- Know state reporting guidelines regarding the use of opioid pharmacotherapy and identification of illicit substance use during pregnancy.
- Know federal (Child Abuse Prevention Treatment Act – CAPTA), state and county reporting guidelines for substance-exposed infants.
- Understand “Plan of Safe Care” requirements.
- Know state, legal and regulatory requirements for SUD care.
- Identify local SUD treatment facilities that provide women-centered care.
- Ensure that OUD treatment programs meet patient and family resource needs (i.e. wrap-around services such as housing, child care, transportation and home visitation).
- Ensure that drug and alcohol counseling and/or behavioral health services are provided.
- Investigate partnerships with other providers (i.e. social work, addiction treatment, behavioral health) and state public health agencies to assist in bundle implementation.
Opioid use disorder (OUD)
- American College of Obstetricians and Gynecologists. Tobacco, Alcohol, Drugs, and Pregnancy
- Alcohol abuse and other substance use disorders: ethical issues in obstetric and gynecologic practice. Committee Opinion No. 633. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2015; 125:1529-37.
- Opioid use and opioid use disorder in pregnancy. Committee Opinion No. 711. American College of Obstetricians and Gynecologists. Obstet Gynecol. August 2017; 130(2):e81-e94.
- McLellan AT, Lewis DC, O’Brien CP, Kleber HD. Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA 2000; 284(13):1689-1695.
Neonatal abstinence syndrome (NAS)
- Hudak ML, Tan RC, Committee on Drugs and Committee on Fetus and Newborn. Neonatal drug withdrawal. Pediatrics 2012;129(2):e540-560.
- Kocherlakota P. Neonatal Abstinence Syndrome. August 2014; 134(2):e547-61.
Clinical pathways for prenatal, intrapartum and postpartum care
- Association of Women’s Health, Obstetric and Neonatal Nurses. POST-BIRTH Education Program
- Community Care of North Carolina. PMH Care Pathways: Postpartum Care and the Transition to Well Woman Care.
- Jones HE, Deppen K, Hudak ML, Leffert L, McClelland C, Sahin L, Starer J, Terplan M, Thorp JM Jr., Walsh J., Creanga AA. Clinical care for opioid-using pregnant and postpartum women: the role of obstetric providers. Am J Obstet Gynecol
- Prescribing Guidelines for Pennsylvania. Obstetrics and Gynecology Pain Treatment.
- Optimizing postpartum care. Committee Opinion No. 736. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;31(5):e140-e150.
- Meyer, M., G. Paranya, A. Keefer Norris and D. Howard. Intrapartum and postpartum analgesia for women maintained on buprenorphine during pregnancy. Eur J Pain 2010; 14(9): 939-943.
- Meyer, M., K. Wagner, A. Benvenuto, D. Plante and D. Howard. Intrapartum and postpartum analgesia for women maintained on methadone during pregnancy. Obstet Gynecol 2007; 110(2 Pt 1): 261-266.
Substance use reporting
- Kremer ME, Arora KS. Clinical, ethical, and legal considerations in pregnant women with opioid abuse. Obstet Gynecol 2015; 126(3):474-478.
- Substance abuse reporting and pregnancy: the role of the obstetrician-gynecologists. Committee Opinion No. 473. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011; 117:200-1.
CAPTA reporting and “Plan of safe care” guidelines
- Substance Abuse and Mental Health Services Administration. A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use Disorders. HHS Publication No. (SMA) 16-4978. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2016.
- Center for Substance Abuse Treatment. Substance Abuse Treatment: Addressing the Specific Needs of Women. Treatment Improvement Protocol (TIP) Series 51. HHS Publication No. (SMA) 09-4426. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009.
- Cultural sensitivity and awareness in the delivery of health care. Committee Opinion No. 493. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;117:1258–61.
- Effective patient–physician communication. Committee Opinion No. 587. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:389–93.
- Health literacy to promote quality of care. Committee Opinion No. 676. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;128:e183–6.
- Informed Medical Decisions Foundation.
- Suplee PD et al. Focusing on maternal health beyond breastfeeding and depression during the first year postpartum. J Obstet Gynecol Neonatal Nursing. Nov-Dec 2014; 43 (6):782-91.
- Suplee, P.D., Gardner, M. & Borucki, L. (2014). Low income, urban women’s perceptions of self and infant care during the postpartum period. JOGNN, 43, 803-812.
- Terplan, M., N. Longinaker and L. Appel. Women-Centered Drug Treatment Services and Need in the United States, 2002-2009. Am J Public Health. 2015; 105(11): e50-54.
Every provider/clinical setting
- Assess all pregnant women for SUDs.
- Utilize validated screening tools to identify drug and alcohol use.
- Incorporate a screening, brief intervention and referral to treatment (SBIRT) approach in the maternity care setting.
- Ensure screening for polysubstance use among women with OUD.
- Screen and evaluate all pregnant women with OUD for commonly occurring co-morbidities.
- Ensure the ability to screen for infectious disease (e.g. HIV, Hepatitis and sexually transmitted infections (STIs)).
- Ensure the ability to screen for psychiatric disorders, physical and sexual violence.
- Provide resources and interventions for smoking cessation.
- Match treatment response to each woman’s stage of recovery and/or readiness to change.
SUD screening tools
- National Institute on Drug Abuse. Clinician’s Screening Tool for Drug Use in General Medical Settings.
- Sample Screening Tools
Screening, brief intervention and referral to treatment (SBIRT)
- Substance Abuse and Mental Health Services Administration (SAMHSA). Screening, Brief Intervention, and Referral to Treatment (SBIRT).
- Washington State Department of Health. Substance Use Disorders During Pregnancy: Guidelines for Screening and Management. Last modified 2017-05-04 08:57. DOH Publication Number: 950-135.
- Wright, T. E., M. Terplan, S. J. Ondersma, C. Boyce, K. Yonkers, G. Chang and A. A. Creanga. The role of screening, brief intervention, and referral to treatment in the perinatal period. Am J Obstet Gynecol 2016.
Co-morbidity screening; Infectious disease
- Krans EE, Zickmund SL, Rustgi VK, Park SY, Dunn SL, Schwarz EB. Screening and Evaluation of Hepatitis C Virus Infection in Pregnant Women on Opioid Maintenance Therapy: A Retrospective Cohort Study. Subst Abus. 2016;37(1):88-95.
- Holbrook, A. M., J. K. Baxter, H. E. Jones, S. H. Heil, M. G. Coyle, P. R. Martin, S. M. Stine and K. Kaltenbach. Infections and obstetric outcomes in opioid-dependent pregnant women maintained on methadone or buprenorphine. Addiction 2012; 107 Suppl 1: 83-90.
- American Academy of Pediatrics. Maternal Depression Screening.
- Chapman, S. L. and L. T. Wu. Postpartum substance use and depressive symptoms: a review. Women Health. 2013; 53(5): 479-503.
- MCPAP for Moms.
- Postpartum Support International.
- Sample Screening Tools
Violence and abuse
- Reproductive and sexual coercion. Committee Opinion No. 554. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:411–5.
- Health Cares About Intimate Partner Violence.
- National Health Resource Center on Domestic Violence.
Every provider/clinical setting/health system
- Ensure that all patients with OUD are enrolled in a woman-centered OUD treatment program.
- Establish communication with OUD treatment providers and obtain consents for sharing patient information.
- Assist in linking to local resources (e.g. peer navigator programs, narcotics anonymous (NA), support groups) that support recovery.
- Incorporate family planning, breastfeeding, pain management and infant care counseling, education and resources into prenatal, intrapartum and postpartum clinical pathways.
- Provide breastfeeding and lactation support for all postpartum women on pharmacotherapy.
- Provide immediate postpartum contraceptive options (e.g. long acting reversible contraception (LARC)) prior to hospital discharge.
- Ensure coordination among providers during pregnancy, postpartum and the inter-conception period.
- Provide referrals to providers (e.g. social workers, psychiatry, and infectious disease) for identified co-morbid conditions.
- Identify a lead provider responsible for care coordination, specify the duration of coordination and assure a “warm handoff” with any change in the lead provider.
- Develop a communication strategy to facilitate coordination among the obstetric provider, OUD treatment provider, health system clinical staff (i.e. inpatient maternity staff, social services) and child welfare services.
- Engage child welfare services in developing safe care protocols tailored to the patient and family’s OUD treatment and resource needs.
- Ensure priority access to quality home visiting services for families affected by SUDs.
OUD treatment services
- Substance Abuse and Mental Health Services Administration (SAMHSA). Substance abuse treatment facility locator.
- Buprenorphine licensure and training information.
- Substance Abuse and Mental Health Services Administration (SAMHSA). Medication-Assisted Treatment. Physician and Program Data.
- Substance Abuse and Mental Health Services Administration (SAMHSA). Directory of Single State Agencies (SSA) for Substance Abuse Services.
- Substance Abuse and Mental Health Services Administration (SAMHSA). Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Rockville, MD. 2004.
- Substance Abuse and Mental Health Services Administration (SAMHSA). Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Rockville, MD. 2005.
- Substance Abuse and Mental Health Services Administration (SAMHSA). A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use Disorders. Rockville, MD.
- Prescribing Guidelines for Pennsylvania. Use of Addiction Treatment Medications in the Treatment of Pregnant Patients with Opioid Use Disorder.
SUD recovery resources
- Narcotics Anonymous.
- Substance Abuse and Mental Health Services Administration (SAMHSA). Recovery Community Services Program. What Are Peer Recovery Support Services?
Breastfeeding and lactation
- Academy of Breastfeeding Medicine protocols.
- Academy of Breastfeeding Medicine Protocol C, Jansson LM. ABM clinical protocol #21: Guidelines for breastfeeding and the drug-dependent woman. Breastfeeding medicine: the official journal of the Academy of Breastfeeding Medicine. 2009; 4(4):225-228.
- American College of Obstetricians and Gynecologists. Optimizing support for breastfeeding as part of obstetric practice. Committee Opinion No. 658. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;127:e86–92.
Family planning and contraception
- Long-acting reversible contraception: Implants and intrauterine devices. Practice Bulletin No. 121. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118(1): 184-96.
- Increasing access to contraceptive implants and intrauterine devices to reduce unintended pregnancy. Committee Opinion No. 642. American College of Obstetricians and Gynecology. Obstet Gynecol 2015;126:e44–8.
- Immediate postpartum long-acting reversible contraception. Committee Opinion No. 670. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;128:e32–7.
- Centers for Disease Control and Prevention. US Medical Eligibility Criteria (US MEC) for Contraceptive Use.
- Hofler, L.G., et al., Implementing Immediate Postpartum Long-Acting Reversible Contraception Programs. Obstet Gynecol, 2017. 129(1): p. 3-9.
- Terplan, M., et al., Contraceptive use and method choice among women with opioid and other substance use disorders: A systematic review. Preventive Medicine, 2015. 80: p. 23-31.
Home visitation programs
- Health Resources & Services Administration. Maternal & Child Health. Home Visiting.
Every clinical setting/health system
- Develop mechanisms to collect data and monitor process and outcome metrics to ensure high quality healthcare delivery for women with SUDs.
- Develop a data dashboard to monitor process and outcome measures (i.e. number of pregnant women in OUD treatment at specified intervals).
- Create multidisciplinary case review teams to evaluate patient, provider and system-level issues.
- Develop continuing education and learning opportunities for providers and staff regarding SUDs.
- Identify ways to connect non-medical local and community stakeholders with clinical providers and health systems to share outcomes and identify ways to improve systems of care.
- Engage child welfare services, public health agencies, court systems and law enforcement to assist with data collection, identify existing problems and help drive initiatives.
Process and outcome monitoring
- National Committee for Quality Assurance. Prenatal and Postpartum Care Quality Measure.
- National Quality Forum. Clinical Performance Measures of Contraceptive Care.
- Dehlendorf C, Bellanca H, Policar M. Performance measures for contraceptive care: what are we actually trying to measure? ARHP Commentary – Thinking (Re)Productively. 2017. 433-437.
Connecting non-medical stakeholders with clinical providers
© 2017 American College of Obstetricians and Gynecologists. Permission is hereby granted for duplication and distribution of the bundle document, in its entirety and without modification, for solely non-commercial activities that are for educational, quality improvement, and patient safety purposes. All other uses require written permission from ACOG.
Standardization of health care processes and reduced variation has been shown to improve outcomes and quality of care. The Council on Patient Safety in Women’s Health Care disseminates patient safety bundles to help facilitate the standardization process. This bundle reflects emerging clinical, scientific, and patient safety advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Although the components of a particular bundle may be adapted to local resources, standardization within an institution is strongly encouraged.
The Council on Patient Safety in Women’s Health Care is a broad consortium of organizations across the spectrum of women’s health for the promotion of safe health care for every woman.