A Guide for Hospitals and Health Care Providers

Virginia Legal Requirements and Health Care Practice Implications

Perinatal Substance Use:Promoting HealthyOutcomes

Perinatal CareTo promote healthy maternal and infant outcomes, theCode of Virginia sets forth screening and reportingrequirements for health care providers and hospitals. Thisbrochure discusses Virginia’s legal requirements and theimplications for practice.

As a health care provider, you have an important role inreducing substance use during pregnancy andpostpartum. You can improve maternal and infantoutcomes by providing regular prenatal education on:

• Regular prenatal care

• Nutrition

• Prevention of sexually transmitted infections (STI) andhuman immunodeficiency viruses (HIV)

• Effects of substance use on fetal development

and provide:

• Substance use screening

• Brief intervention

• Referral for substance abuse evaluation/treatment.

SubstanceAbuse

Screeningin

PrenatalCarePregnant women who use alcohol, tobacco, or illicitdrugs risk their infant’s health and development. Abuseof prescription or over-the-counter medications can alsocreate health risks. As a health care provider, you havean important role in reducing substance use duringpregnancy and postpartum.

LEGAL REQUIREMENTS §54.1-2403.1 of the Code of Virginia• Licensed practitioners shall, as a routine component

of prenatal care, establish and implement a medicalhistory protocol to screen all pregnant patients forsubstance use to determine the need for furtherevaluation.

• Practitioners shall counsel all pregnant women withpositive medical history screens and/or substanceevaluations on the potential for poor birth outcomesand appropriateness of treatment.

• The results of the medical history screen and/orsubstance use evaluation shall not be admissible inany criminal proceeding.

HEALTHCARE PRACTICE IMPLICATIONS Substance use by pregnant women occurs in all ethnic,geographic, and socioeconomic groups. Researchindicates that among those who use drugs,polysubstance use is the norm. In addition, manywomen use drugs in combination with alcohol andtobacco. Research has also shown that many womenwho abuse substances have co-occurring mental healthproblems and/or histories of trauma. Most substanceusers exhibit no signs on physical examination.

Substance Use History During pregnancy, women are often motivated tochange risky behaviors. Routine gynecologic andobstetric visits provide excellent opportunities for patienteducation and substance use screening.

Substance use screening can be easily incorporatedinto a routine medical history and supplemented bydrug toxicology when maternal risk indicators arepresent. Screening should occur at least once pertrimester since patterns of use may change over time.

Explaining the

significance of a

healthy environment

to a mother is critical

in helping her

build one.

Substance use discussion needs to occur within a healthcontext to lessen the stigma associated with the topicand convey concern for the health of the mother andbaby. A supportive, non-confrontational discussion shouldinclude:

• The health care benefits of not using drugs, alcohol ortobacco.

• Other related risky behaviors that may impact thehealth and well-being of the infant.

• Maternal health, obstetrical, and neonatalcomplications that may result from continued use.

• Evaluation and treatment options.

• Encouragement to accept a substance use assessmentreferral.

Habitual alcohol and other drug use may suppressappetite, impair metabolism, and alter nutrient absorption,thus affecting both maternal and fetal nutrition. Thechaotic lifestyle and other risky behaviors of somesubstance abusing woman may lead to self-neglect,including poor diet. Though abstinence is the goal, anysteps towards reducing use and/or related risk factors,e.g., poor nutrition, exposure to STI, etc. should beencouraged to improve birth outcomes. Someapproaches to reduce the harmful effects of substanceuse include decreasing use, interspersing use withperiods of abstinence, and avoiding drug-using friends.

Substance Abuse Services Public substance abuse services are provided byVirginia’s Community Services Boards (CSB). Pregnant,substance-using women receive treatment priority atCSBs and are offered services within 48 hours of theirrequest. Check with the CSB in your community to learnmore about substance abuse and available services.

A substance use history screening should includequestions concerning

• the frequency and amount of alcohol consumption priorto and during pregnancy;

• and the frequency and amounts of over-the-counter,prescription, and “street” drugs used prior to and duringpregnancy.

Patterns of use prior to conception are risk indicators forprenatal and postpartum use. A substance use historyscreening should include questions concerning:

• Effects of substance use on life areas such asrelationships, employment, legal, etc.

• Parent and partner substance use.

• Previous referrals for substance useevaluation/treatment.

• Previous substance use treatment or efforts to seektreatment.

Screening tools such as the CAGE or 4P’s can be easilyintegrated into a medical history and quicklyadministered. If a urine or blood toxicology screen ismedically indicated during the perinatal period, informedconsent should be obtained.

Patient Discussion Most women want what is best for their newborns.Continued use of substances during pregnancy may bedue to habituation or addiction rather than a lack ofinformation or concern regarding the effects of substanceuse. A woman who continues to use during pregnancy,despite your interventions, should be referred for asubstance abuse treatment assessment.

HIVScreening

inPrenatalCare

LEGAL REQUIREMENTS§54.1-2403.01 of the Code of Virginia• Licensed practitioners, as a routine component of

prenatal care, shall advise all pregnant patients ofthe value of testing for HIV and that she will receivea HIV test.

• Practitioners shall counsel pregnant women with HIVpositive test results on the dangers to the fetus andthe advisability of receiving treatment in accordancewith current Centers for Disease Control andPrevention recommendations.

HEALTHCARE PRACTICE IMPLICATIONS An infant can contract HIV from the mother in utero,during childbirth, or through breast feeding.

Women have the right to refuse consent for testing andtreatment. Women diagnosed with HIV should seekhelp from experts specializing in HIV and perinataltransmission.

Zidovudine (ZDV) in combination with otherantiretroviral medications has been shown tosignificantly reduce the risk of prenatal HIVtransmission by 70%.

A baby can contract

HIV from the mother

while in utero, during

childbirth, or through

breast-feeding.

ReferralofSubstanceExposed

Newborns

forChildProtective

ServicesLEGAL REQUIREMENTS§63.2-1509 of the Code of Virginia • Attending physicians or other medical providers are

required to report suspected abuse or neglect to localdepartments of social services or the Child Abuseand Neglect Hotline. Newborns diagnosed byattending physicians as exposed to alcohol orcontrolled drugs not prescribed during pregnancy arealso required to be reported.

HEALTHCARE PRACTICE IMPLICATIONS In utero substance exposure can cause or contribute topremature birth, low birth weight, increased risk ofinfant mortality, neurobehavioral, and developmentalcomplications. Post-natal environmental factorsassociated with maternal substance use such aspoverty, neglect, unstable, or stressful homeenvironments present additional risks for these children.

Interventions to reduce adverse outcomes and promotehealthy home environments are critical to the well beingof substance-exposed children.

Identification of Substance-exposed NewbornsIdentification of substance-exposed newborns isdetermined by clinical indicators that include maternaland infant presentation at birth, substance use andmedical histories, and/or toxicology results.

Attending physicians are required to immediately makea report to Child Protective Services (CPS) if any one ofthe following occurs:

• Urine or blood toxicology conducted on the mother orinfant, within 48 hours of birth, is positive.

• A medical finding is made, within 48 hours of birth, ofnewborn dependency or withdrawal symptoms.

• An illness, disease, or condition attributable to inutero substance exposure is diagnosed within seven(7) days of birth.

• Fetal Alcohol Syndrome (FAS) is diagnosed withinseven (7) days of birth.

Records Release When reporting substance exposed newborns, healthcare providers are required by the Code of Virginia torelease, upon request, medical records that documentthe basis of the report of suspected child abuse orneglect.

Disclosure of child abuse/neglect information and recordsto CPS agencies is also permitted by the HealthInsurance Portability and Accountability Act of 1996(HIPAA), and federal Confidentiality of Alcohol and DrugAbuse Patient Information Regulations. (CFR 42 Part 2)

Reporting Liability Health care providers reporting in good faith are immunefrom civil and criminal liability pursuant to Section 63.2-1512 of the Virginia Code. Mandated reporter failure toreport could result in criminal liability punishable as amisdemeanor with an imposed fine.

Drug Testing While drug testing is useful for diagnostic and treatmentpurposes, it is not legally required to make a report toCPS. Drug testing may include maternal blood or urinetesting or hair analysis, or newborn urine or meconiumtesting. Laboratories routinely do a gas chromatographywith mass spectrometry or other confirmatory testwhenever they obtain a positive finding on a urine,meconium, or hair sample. Drug testing is only accuratefor recent use i.e., within 24-72 hours.

Hospital policies should establish patient assessmentprocedures to determine the care needed by eachpatient. These assessments should identify each patient’smedical needs and complicating conditions, includingsubstance abuse, dependence and other addictivebehaviors. Assessment and screening procedures shouldinclude:

• Specific, evidence-based criteria for testing the motherand/or her newborn.

• Expectations regarding the timing of tests, test typesand consent.

Some hospitals request consent for testing while othersassume it within the patient’s general consent for care. Tolearn your hospital’s policy, check with its riskmanagement office.

LocalDepartmentofSocialServices

ResponseLocal departments of social services, which aresupervised by the Virginia Department of SocialServices, have legal responsibility, under the Code ofVirginia, to respond to reports of suspected child abuseor neglect.

Local departments of social services are required bythe Code of Virginia to:

• Respond to valid reports of suspected childmaltreatment.

• Evaluate child’s immediate safety.

• Complete a Family Assessment or Investigation by:

• Observing the child

• Interviewing family, siblings, other professionals

• Observing the child’s home, and

• Checking for prior reports on the family.

CPS services are provided to abused and neglectedchildren and their families regardless of income. Theprimary goal of CPS is to strengthen and supportfamilies in preventing the (re)occurrence of childmaltreatment through community-based services. If thechild cannot be safely maintained at home, a temporaryplacement is sought.

HospitalDischargePlanning

forSubstance-UsingPostpartum

Wom

enLEGAL REQUIREMENTS§32.1-127 of the Code of VirginiaHospitals shall implement protocols requiring writtendischarge plans for substance abusing, postpartumwomen and their infants.

• The discharge plan must be discussed with thepatient and appropriate referrals made anddocumented.

• The discharge plan shall involve, to the extentpossible, the child’s father and members of theextended family who may participate in follow-up care.

• Hospitals shall immediately notify the localCommunity Services Board (CSB) on behalf of thesubstance abusing, postpartum woman to appoint adischarge plan manager.

HEALTHCARE PRACTICE IMPLICATIONS Postpartum, substance-using women and theirnewborns have multiple health care, treatment, safety,and environmental needs. Their hospital discharge plansshould include:

• Information and medical directives regarding potentialpostpartum complications and, as appropriate,indicators of substance use withdrawal.

• A referral to CPS if the newborn has been bornsubstance-exposed or there are other abuse orneglect concerns identified by the attending physicianor other hospital staff.

• A follow-up appointment for pediatric care within 2-4weeks.

• A referral to early intervention Part C services fordevelopmental assessment and early interventionservices for the infant.

• A referral of the mother to the local CommunityServices Board (CSB) for substance use assessment.

• A follow-up appointment for the mother for postpartumgynecologic care and family planning.

Patient follow-through on substance use and health carereferrals is voluntary. Timely, coordinated outreach servicesprovided by the health care provider, the CSB, and CPScan provide incentives and the necessary leverage tomotivate the mother to follow through with dischargeplanning recommendations. A woman is more likely tofollow through with the CSB referral if she has contact withthe provider prior to her discharge from the hospital.Interagency protocols are recommended to facilitateservice coordination.

Confidentiality of Substance Abuse PatientInformation (CFR 42, Part 2) Federal regulations protect the confidentiality ofindividuals who seek treatment for substance usedisorders. Information that reveals a person isreceiving, has received, or has applied for services fora substance use disorder cannot be released ordisclosed without a valid written release from thepatient.

A general consent form or medical release form is notacceptable. To be valid, a written consent form for therelease of confidential information must specify:

• Patient’s name.

• Purpose of the disclosure.

• Name of the person/organization receiving theinformation.

• Information to be released.

• Patient’s right to revoke consent at any time, exceptto the extent that action taken is irrevocable.

• Patient’s right to revoke consent verbally or inwriting.

• Date or condition when consent expires.

• Date signed.

• Patient’s signature.

The information disclosed must contain a writtenstatement prohibiting redisclosure and may not beused in a criminal investigation or prosecution.

Information sharing can be facilitated by developingpolicies and procedures that can be incorporated intointeragency protocols. HIPAA does permit sharinginformation with CPS and should be included in theprocedures.

LEGAL REQUIREMENTS§32.1-134.01 of the Code of VirginiaEvery licensed nurse midwife, licensed midwife, orhospital providing maternity care shall, prior to releasingeach maternity patient, make information available to thepatient about:

• The incidence of postpartum blues and perinataldepression.

• Shaken baby syndrome or traumatic inflicted braininjury and the dangers of shaking infants.

The Code of Virginia requires health care providers toshare certain information with the maternity patient andothers. This information shall be discussed with thematernity patient and the father of the infant, otherrelevant family members, or caretakers who are presentat discharge.

HEALTHCARE PRACTICE IMPLICATIONS Research has shown that 6% to 15% of womenexperience depressive symptoms during a pregnancy orin the first year following birth. About 10% of thosewomen experience a major depressive episode. Womenwho abuse drugs or alcohol often have a co-occurringmental health disorder.

The most common condition is postpartum blues, whichis a normal period of hormonal readjustment followingdelivery. The woman with perinatal depression will havesymptoms that interfere with her ability to care for herself,her infant and/or conduct normal activities. Perinataldepression often goes unrecognized because womenmay be reluctant to report their symptoms to theirhealthcare provider.

Traumatic Inflicted Brain Injury also known as ShakenBaby Syndrome is the collection of signs and symptomsresulting from violent shaking of an infant or small child. Itis a form of child abuse. Every year there is an estimated1,200-1,400 children in America are shaken for whomtreatment is sought. Approximately one in three babiesdies as a result of injuries.

DischargeEducation

onPostpartum

Blues,PerinatalDepression,andTraum

aticInflicted

BrainInjury

(ShakenBaby

Syndrome)

Patient DiscussionEducation about postpartum blues, perinataldepression and Traumatic Inflicted Brain Injury isbest discussed within a healthcare context. A supportivediscussion includes:

Postpartum Blues and Perinatal Depression• Incidence of postpartum blues and perinatal

depression.

• Signs and symptoms of postpartum blues andperinatal depression.

• The need for the mother to share her symptoms andfeelings with family, friends, and her health careprovider.

Educational resources are available at www.mededppd.org

Traumatic Inflicted Brain Injury/Shaken BabySyndrome• Dangers of shaking a baby.

• Techniques to help parents and caregivers cope witha crying baby.

• Stress management techniques.

Educational resources for parents and caregivers ofnewborn infants are available on the National Center onShaken Baby Syndrome Web site: www.dontshake.com

EffectivePractices

Strategies to promote prevention and intervention withwomen who use drugs or alcohol during pregnancyinclude:

• Routinely screen all pregnant women regardingsubstance use, mental health, and risky behaviors.

• Conduct screenings in a private and confidentialmanner.

• Learn more about addiction and recovery.

• Know how and where to refer women for assessmentand treatment.

• Be supportive and nonjudgmental.

• Follow up; discuss concerns at subsequent visits.

Up-front case

management is

necessary to enhance

women’s treatment

motivation and

prolong treatment

retention.

The persons portrayed in this brochure are models.Photos are intended for illustrative purposes only.

Virginia Department of Social Services7 N. Eighth Street, 4th Floor

Richmond, Virginia 23219(804) 726-7555

www.dss.virginia.gov

B032-01-0037-01-eng (04/08)

State Resources

Child Abuse and Neglect Hotline 1-800-552-7096

Virginia Department of Health Division of Women’s and Infant’s Healthwww.vahealth.org/wih(804) 864-7772

Department of Mental Health, Mental Retardation andSubstance Abuse Services, Office of Child andFamily Serviceswww.dmhmrsas.virginia.gov/CFS(804) 371-7999

Early Intervention Part C ServicesInfant & Toddler Connection of Virginiawww.infantva.org(804) 786-3710

Internet Resources

American College ofObstetricians and Gynecologistswww.acog.com

American Academy of Pediatricswww.aap.org

National Organization on FetalAlcohol Syndrome (NOFAS) www.nofas.org

American Society of Addiction Medicine www.asam.org

National Clearinghouse for Alcohol and Drug Informationwww.health.org

Physicians & Lawyers for National Drug Policy www.plndp.org

National Institute on Drug Abuse www.nida.nih.gov

Substance Abuse and MentalHealth Services Administration www.samhsa.gov

Mid-Atlantic Technology Transfer Center www.mid-attc.org

Postpartum Blues and Perinatal Depressionwww.womanshealth.gov/healthpro