Cesarean Delivery and Vaginal Birth After Cesarean Delivery Rates in a First Nations Community-Based Obstetrical Program in Northwestern Ontario.

OBJECTIVE: To examine rates of cesarean delivery (CD) and vaginal birth after cesarean delivery (VBAC) and the patient profile in a community-based obstetrical practice. METHODS: Retrospective data from 2012 to 2017 for the Sioux Lookout Meno Ya Win Health Centre (SLMHC) were compared to data from the 30 hospitals providing the same level of services (Maternity 1b: maternity care by family physicians/midwives with CD and VBAC capacity) and Ontario. SLMHC VBAC patients were then compared to the general SLMC obstetrical population. Data included maternal age, parity, comorbidities, CD, VBAC, neonatal birth weight, and Apgar scores. RESULTS: The SLMHC obstetrical population differed from comparable obstetrical programs, with significantly higher rates of alcohol, tobacco, and opioid use and a higher prevalence of diabetes. CD rates were significantly lower (25% vs. 28%), and women delivering at SLMHC chose a trial of labour after CD almost twice as often (46% vs. 27%), resulting in a significantly higher VBAC rate (31% vs. 16%). Patients in the VBAC population differed from the general SLMHC obstetrical population, being older (7 years) and of greater parity. The neonates of VBAC patients had equivalent Apgar scores but lower rates of macrosomia and lower birth weights, although the average VBAC birth weight at 3346 g was equivalent to the provincial average. CONCLUSION: The SLMHC obstetrical program has lower CD and higher VBAC rates than expected, despite prevalent risk factors typically associated with CD. Our study demonstrates that VBAC can be safely performed in well-screened and monitored patients in a rural setting with emergency CD capacity.

Nonpharmacological management of neonatal abstinence syndrome: a review of the literature.

BACKGROUND: Infants with neonatal abstinence syndrome (NAS) experience withdrawal that occurs as a result of termination of placental opioid supply following delivery. Common symptoms include restlessness, tremors, agitation and gastrointestinal disturbances. Severe NAS is often treated using opioids and/or sedatives. Although commonly employed effectively in neonatal care, there is a lack of published information regarding nonpharmacological management of the NAS infant. OBJECTIVE: The purpose of this review was to summarize the current literature on nonpharmacological management of NAS. METHODS: A literature search of Medline and EMBASE was performed for articles published between 2000 and June 2107. RESULTS: Nonpharmacological management encompasses "environmental control", "feeding methods", "social integration", "soothing techniques" and "therapeutic modalities". Several interventions, including: breastfeeding, swaddling, rooming-in, environmental control and skin to skin contact have proven to be effective in managing NAS and should be incorporated into standard of care for this population (Level I-III Evidence). These interventions can be effective when offered in combination with pharmacological therapy, or as stand-alone therapy for less severe cases of NAS (Finnegan score <8). CONCLUSIONS: Given the increasing body of evidence on its efficacy and ease of implementation, nonpharmacological treatment should universally be incorporated into standard of care for NAS.

Maternal opioid use disorder and neonatal abstinence syndrome in northwest Ontario: a 7-year retrospective analysis.

INTRODUCTION: Opioid use in pregnancy is increasing globally. In northwest Ontario, rates of neonatal abstinence syndrome (NAS) are alarmingly high. We sought to document the increasing rates of opioid exposure during pregnancy and associated cases of NAS over a 7-year period in northwest Ontario. METHODS: We conducted a retrospective chart review at the Sioux Lookout Meno Ya Win Health Centre catchment area (population 29 000) maternity program in northwest Ontario of mother-infant dyads of live births from Jan. 1, 2009, to Dec. 31, 2015. The Integrated Pregnancy Program provides maternal, neonatal and addiction care for obstetrical patients at the health centre. We collected data on prenatal opioid exposure due to illicit and opioid agonist therapy (OAT) from patient/prescription histories and urine toxicology reports. Rates of NAS (diagnosed as a Finnegan score > 7) were recorded retrospectively from neonatal hospital charts. RESULTS: There were 2743 live births during the study period. Opioid exposure occurred in 672 pregnancies (335 OAT, 337 illicit). The incidence of prenatal opioid exposure increased significantly between 2009 and 2012 (11.1% to 28.5%, p < 0.001) but remained relatively constant at around 30% thereafter. Despite this, absolute rates of NAS remained relatively stable, with an average of 22.2 cases per 1000 live births over the study period. In comparison, the North West Local Health Integration Network (LHIN) experienced an average of 52.8 cases of NAS per 1000 live births in 2009-2012. The incidence of NAS in our centre decreased significantly over the study period (17.6% of opioid-exposed pregnancies in 2009 v. 4.0% in 2015, p = 0.001). There was a gradual transition toward a preponderance of OAT- versus illicit-exposed pregnancies, increasing from 0% in 2009 to 76.9% in 2015 (p < 0.001). CONCLUSION: Despite our continually increasing rates of opioid exposure in pregnancy, rates of NAS decreased annually and were substantially lower than those of our regional LHIN. In contrast to 2009, most opioid exposure in our region is now iatrogenic as a result of OAT. These improvements may be attributable in part to the rural community-based prenatal and addictions services developed in our catchment area.

INTRODUCTION: La consommation d'opioïdes pendant la grossesse est à la hausse dans le monde entier. Dans le nord-ouest de l'Ontario, le taux de syndrome de sevrage néonatal est alarmant. Nous avons tenté de documenter les taux croissants d'exposition aux opioïdes pendant la grossesse et les cas associés de syndrome de sevrage néonatal sur une période de sept ans dans le nord-ouest de l'Ontario. METHODS: Nous avons mené une étude rétrospective des dossiers des patientes du programme obstétrical de la région desservie par le Centre de santé Meno Ya Win de Sioux Lookout (population de 29 000), dans le nord-ouest de l'Ontario, et des naissances vivantes de la dyade mère­nourrisson pour la période du 1er janvier 2009 au 31 décembre 2015. Des soins maternels, néonataux et de traitement de la toxicomanie sont offerts aux patientes en obstétrique du Centre de santé dans le cadre d'un programme de soins intégrés pendant la grossesse. Nous avons obtenu des données sur l'exposition prénatale aux opioïdes due à la consommation d'opioïdes illégaux et aux traitements par agonistes opioïdes dans les antécédents des patientes, l'historique des médicaments prescrits et les rapports de toxicologie des dépistages urinaires. Le taux de syndrome de sevrage néonatal (diagnostiqué selon un score de Finnegan > 7) a été obtenu et consigné de manière rétrospective à partir des dossiers néonataux d'hôpitaux. RESULTS: Il y a eu 2743 naissances vivantes pendant la période de l'étude et 672 grossesses exposées aux opioïdes (335 aux traitements par agonistes opioïdes, 337 aux opioïdes illégaux). L'incidence de l'exposition prénatale aux opioïdes a augmenté de façon importante entre 2009 et 2012 (11,1 % à 28,5 %, p < 0,001), mais est ensuite demeurée relativement constante à environ 30 % par la suite. Malgré cela, le taux absolu de syndrome de sevrage néonatal est demeuré relativement stable, soit une moyenne de 22,2 cas par 1000 naissances vivantes pendant la période de l'étude. Par comparaison, le Réseau local d'intégration des services de santé (RLISS) du Nord-Ouest a enregistré une moyenne de 52,8 cas de syndrome de sevrage néonatal par 1000 naissances vivantes entre 2009 et 2012. L'incidence du syndrome de sevrage néonatal dans notre centre a diminué considérablement au cours de la période de l'étude (17,6 % de grossesses exposées aux opioïdes en 2009 contre 4 % en 2015, p = 0,001). Nous avons observé une transition graduelle vers la prépondérance des grossesses exposées aux traitements par agonistes opioïdes par rapport aux grossesses exposées aux opioïdes illégaux. Leur taux est passé de 0 % en 2009 à 76,9 % en 2015 (p < 0,001). CONCLUSION: Malgré la croissance continue de l'exposition aux opioïdes pendant la grossesse, notre taux de syndrome de sevrage néonatal a diminué annuellement et était nettement inférieur au taux du RLISS de la région. Par comparaison à 2009, la plupart des cas d'exposition aux opioïdes dans notre région sont maintenant d'origine iatrogène et liés aux traitements par agonistes opioïdes. Ces améliorations pourraient s'expliquer en partie par la création de services communautaires de soins prénataux et de traitement de la toxicomanie en régions rurales dans notre circonscription hospitalière.

Maternal-Fetal Monitoring of Opioid-Exposed Pregnancies: Analysis of a Pilot Community-Based Protocol and Review of the Literature.

OBJECTIVES: To describe/analyse a novel, community-based prenatal monitoring protocol for opioid-exposed pregnancies developed by our centre in 2014 to optimize prenatal care for this population. A literature review of published monitoring protocols for this population is also presented. METHODS: Retrospective comparison of pre-protocol (n = 215) and post-protocol (n = 251) cohorts. Medline and Embase were searched between 2000-2016 using MeSH terms: [fetal monitoring OR prenatal care] AND [opioid-related disorders OR substance-related disorders] in Medline and [fetal monitoring OR prenatal care] AND [opiate addiction OR substance abuse] in Embase, producing 518 results. Thirteen studies included protocols for monitoring opioid-exposed pregnancies. No comprehensive monitoring protocols with high-quality supporting evidence were found. RESULTS: We evaluated 466 opioid-exposed pregnancies, 215 before and 251 after introduction of the protocol. Since implementation, there was a significant increase in the number of opioid-exposed patients who have underwent urine drug screening (72.6% to 89.2%, P < 0.0001); a significant reduction in the number of urine drug screenings positive for illicit opioids (50.2% to 29.1%, P < 0.0001); and a significant increase in the number of patients who discontinued illicit opioid use by the time of delivery (24.7% to 39.4%, P < 0.01). There was no difference in the CS rate (27.4% vs. 26.3%, P > 0.05). There were no observed differences in the rate of preterm birth, birth weight <2500 g, or Apgar score <7 (P > 0.05). CONCLUSIONS: Care of women with increased opioid use during pregnancy is an important but under-studied health issue. A novel protocol for focused antenatal care provision for women with opioid-exposed pregnancies improves standard of care and maternal/fetal outcomes.

Observational study of the safety of buprenorphine+naloxone in pregnancy in a rural and remote population.

OBJECTIVES: To describe the effect of in utero exposure to the buprenorphine+naloxone combination product in a rural and remote population. SETTING: A district hospital that services rural and remote, fly-in communities in Northwestern Ontario, Canada. PARTICIPANTS: A retrospective cohort study was conducted of 855 mother infant dyads between 1 July 2013 and 30 June 2015. Cases included all women who had exposure to buprenorphine+naloxone during pregnancy (n=62). 2 control groups were identified; the first included women with no opioid exposure in pregnancy (n=618) and the second included women with opioid exposure other than buprenorphine+naloxone (n=159). Women were excluded if they had multiple pregnancy or if they were part of a methadone programme (n=16). The majority of women came from Indigenous communities. OUTCOMES: The primary outcomes were birth weight, preterm delivery, congenital anomalies and stillbirth. Secondary neonatal outcomes included gestational age at delivery, Apgar scores at 1 and 5 min, NAS Score >7 and treatment for neonatal abstinence syndrome (NAS). Secondary maternal outcomes included the number of caesarean sections, postpartum haemorrhages, out of hospital deliveries and transfer of care to tertiary centres. RESULTS: No difference was found in the primary outcomes or in the Apgar score and caesarean section rate between in utero buprenorphine+naloxone exposure versus no opioid exposure in pregnancy. Compared to women taking other opioids, women taking buprenorphine+naloxone had higher birthweight babies (p=0.001) and less exposure to marijuana (p<0.001) during pregnancy. CONCLUSIONS: Retrospective data suggest that there likely is no harm from taking buprenorphine+naloxone opioid agonist treatment in pregnancy. Larger, prospective studies are needed to further assess safety.

Narcotic tapering in pregnancy using long-acting morphine: an 18-month prospective cohort study in northwestern Ontario.

OBJECTIVE: To document the management of and outcomes for patients receiving narcotic replacement and tapering with long-acting morphine preparations during pregnancy. DESIGN: A prospective cohort study over 18 months. SETTING: Northwestern Ontario. PARTICIPANTS: All 600 births at Meno Ya Win Health Centre in Sioux Lookout, Ont, from January 1, 2012, to June 30, 2013, including 166 narcotic-exposed pregnancies. INTERVENTION: Narcotic replacement and tapering of narcotic use with long-acting morphine preparations. MAIN OUTCOME MEASURES: Prenatal management of maternal narcotic use, incidence of neonatal abstinence syndrome, and other neonatal outcomes. RESULTS: The incidence of neonatal abstinence syndrome fell significantly to 18.1% of pregnancies exposed to narcotics (from 29.5% in a previous 2010 study, P = .003) among patients using narcotic replacement and tapering with long-acting morphine preparations. Neonatal outcomes were otherwise equivalent to those of the nonexposed pregnancies. CONCLUSION: In many patients, long-acting morphine preparations can be safely used and tapered in pregnancy, with a subsequent decrease in observed neonatal withdrawal symptoms.

Incidence of narcotic abuse during pregnancy in northwestern Ontario: three-year prospective cohort study.

OBJECTIVE: To document the incidence and outcomes of narcotic use during pregnancy in northwestern Ontario. DESIGN: Three-year prospective cohort study. SETTING: Sioux Lookout and surrounding communities in northwestern Ontario. PARTICIPANTS: A total of 1206 consecutive births in a catchment area of 28 000 First Nations patients. MAIN OUTCOME MEASURES: Incidence of narcotic use, and maternal and neonatal outcomes. RESULTS: Incidence of narcotic use in pregnancy has risen to 28.6% (P < .001) and incidence of neonatal abstinence syndrome has fallen to 18.0% of narcotic-exposed births (P = .003). Daily intravenous drug use is now a common pattern of abuse. CONCLUSION: Narcotic abuse in pregnancy has dramatically increased in northwestern Ontario. Neonatal outcomes have improved as a result of a family medicine-based prenatal and obstetric program that includes a narcotic replacement and tapering program.