Fall 2008
[PDF format for easy printing]

                  Perinatal Illicit Drug Exposure
               Risk Assessment Tool

                                        Obstetrics clinic
                                        AND labor and delivery unit

Current pregnancy: Risk factors

¨ Yes

o No

No prenatal care or late prenatal care (> 16 weeks gestation)

¨ Yes

o No

Poor prenatal care with 4 or fewer prenatal visits (unexplained)

¨ Yes

o No

Different prenatal and delivery care providers (unexplained “hospital hopping”)

¨ Yes

o No

Acute hypertension of ≥140/90 mmHg (unexplained)

¨ Yes

o No

Seizures, stroke, or myocardial infarction (unexplained)

¨ Yes

o No

Premature delivery (unexplained)

¨ Yes

o No

Out-of-hospital delivery (unanticipated)

¨ Yes

o No

Presentation at hospital in second stage of labor  (unexplained)

¨ Yes

o No

Precipitous labor of less than 3 hours (unexplained)

¨ Yes

o No

Placental abruption (unexplained)

¨ Yes

o No

Stillbirth (unexplained)

¨ Yes

o No

Tobacco or alcohol use

¨ Yes

o No

Maternal report of illicit drug use

¨ Yes

o No

Physical signs of illicit drug use (IV tracks, visible tooth decay, sores on face, arms, or legs)

¨ Yes

o No

Altered mental status suggesting influence or withdrawal from drugs

¨ Yes

o No

Maternal urine drug screen positive

Maternal medical history: Risk factors

¨ Yes

o No

Hepatitis B or C, syphilis, or HIV within the last 3 years (unexplained)

¨ Yes

o No

Maternal depression or major psychiatric illness within the last 3 years that has not been treated

¨ Yes

o No

Illicit drug use during any pregnancy

Family history: Risk factors

¨ Yes

o No

Illicit drug use by mother or partner within the last 3 years

¨ Yes

o No

Illicit drug rehabilitation by mother or partner within the last 3 years

¨ Yes

o No

Domestic violence in home within the last 3 years

¨ Yes

o No

Child abuse, neglect, or court ordered placement of child outside of home

If YES to any of the questions above:

¨   Request informed consent from the mother to order urine screening for illicit
     drugs.

¨   Contact the unit social worker to initiate detailed psychosocial assessment.

¨   Request chemical dependency services consult if social worker and physician
     believe it is warranted.

¨   Request psychiatry consult if mental health concerns are present.

¨   Verbally communicate risk status to labor and delivery staff and to newborn
     nursery or NICU staff.

¨   Attach a copy of this completed form to labor and delivery form and send to the
     newborn nursery or NICU with the baby.
 

If NO to all questions above, or staff has confidently determined that identified risk factors are secondary to conditions other than perinatal illicit drug use:

¨   Document this in the chart.

¨   Inform neonatal staff that they may defer testing the newborn.
 

Newborn Nursery or NICU

                               Newborn assessment: Risk factors

¨ Yes

o No

Maternal risk factor(s) present

¨ Yes

o No

Mother has been tested during this pregnancy or labor for illicit drugs

¨ Yes

o No

Mother tested positive for illicit drugs during this pregnancy

¨ Yes

o No

Pre-term delivery with gestation of 37 or fewer weeks (unexplained)

¨ Yes

o No

Birth weight less than 10^th percentile for gestational age (unexplained)

¨ Yes

o No

Head circumference less than 10^th percentile for gestational age (unexplained) 

¨ Yes

o No

Seizures, stroke, or brain infarction (unexplained)

¨ Yes

o No

Congenital malformations involving genitourinary tract, abdominal wall, or gastrointestinal tract (unexplained)

¨ Yes

o No

Unexplained symptoms that  suggest drug withdrawal/intoxication:

If YES to any of the questions above: 

      ¨   Order meconium and urine screening tests for illicit drugs.

If NO to all questions above, or staff has confidently determined that identified risk factors are secondary to conditions other than in-utero exposure to illicit drugs: 

     ¨   Document this in the chart.
 

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