Delivery and Postpartum Care
Considerations for Delivery
Birthing outcomes for pregnant people with a known opioid use disorder diagnosis can be improved through enhanced communication, comprehensive care coordination, advocacy, and follow-up during the postpartum period. It is important to continue to provide quality health care to the pregnant person and the baby during delivery.
- Those receiving medication assisted treatment for opioid use disorder during pregnancy should be maintained on their dose of methadone or buprenorphine while in labor and should receive additional pain relief. It is typical for those taking methadone or buprenorphine to require higher doses of opioids to relieve labor pains.
- Epidural and spinal analgesia should be offered as appropriate or desired.
- Opioid agonist-antagonist drugs should be avoided since they can precipitate acute withdrawal in patients taking an opioid agonist. Examples of such medications are butorphanol, nalbuphine, and pentazocine. Buprenorphine should not be offered to a patient who takes methadone for the same reason.
- Buprenorphine should not be offered to a patient who takes methadone for the same reason. Pediatric staff should be notified of all substance exposed infants—whether prescribed opioids or those used illicitly.
Treatment recommendations and anticipated non-opioid and opioid use varies between vaginal or cesarean delivery. Post-cesarean pain control options include scheduled administration of nonsteroidal anti-inflammatory drugs and/or acetaminophen, higher doses of oral or parental opioids or continuous postpartum epidural analgesia for 24-48 hours postpartum.
Consultation with an anesthesiologist upon admission to the labor unit and again in the postpartum period can help to optimize pain management. Collaboration with all individuals involved in prenatal, delivery and postpartum care is strongly encouraged to ensure quality health care is provided and allows each woman to have an individualized approach to treating her opioid use disorder while safely bringing life into the world.
Postpartum care is crucial to maintain a healthy, happy family. This period of time is associated with a high rate of relapse as there can be a variety of new triggers including: postpartum mood changes, newborns with NOWS, management of postpartum pain, sleep deprivation, changes in insurance status and access to treatment, breastfeeding and possible issues regarding infant custody and Child Protective Services (CPS) that may trigger mood disorders, as well as histories of complex trauma.
Postpartum care planning begins early during pregnancy and continues throughout prenatal care and in conjunction with the individualized substance abuse treatment plan.
Things to consider for postpartum care:
- Increase access and highly effective contraception immediately when postpartum begins, this should include a shared decision-making discussion between provider and patient
- Continue agonist medication-assisted treatment postpartum while offering a well-supported transition for ongoing care opioid use disorder
- Encourage breastfeeding, skin-to-skin contact, and decreased stimulation
- Appropriate postpartum planning is important
People and their families may be concerned that using substances while pregnant may result in referral to child protection services or punishing action. Pregnant people who receive routine prenatal care, are on MAT without ongoing substance use, are in treatment for substance use disorder, and are not generating concerns for child abuse or neglect, may have a deferment from a referral to CPS. Mandatory reporting laws and practices differ between states and tribes. It is important to speak with your prenatal provider about any concerns.
- For additional clinical guidance on delivery, access the ACOG Best Practice Recommendation Report [PDF - 1.1 MB] - ACOG Committee on AI/AN Women’s Health
- For additional clinical guidance on postpartum care, access the ACOG Safety Bundle
- Postpartum Pain Management - ACOG
- CAPTA Plans of Safe Care - The National Center on Substance Abuse and Child Welfare
- The National Maternal Mental Health Hotline provides 24/7, free, confidential support, resources and referrals to any pregnant and postpartum mothers facing mental health challenges and their loved ones. The service is available via phone and text in English or Spanish.
- Planning Guide for Creating Plans of Safe Care [PDF - 820 KB]
- Serving Native Families Affected by Substance Use Disorder: Active Efforts and Plans of Safe Care — Children and Family Futures organization