Postpartum Care and Breastfeeding

The time immediately after birth is very sensitive and important—medically and emotionally. This section is not an exhaustive list of all postpartum care needs but includes the most important elements for people with OUD in jail.

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Key Points

HOW

  • Add a screening question to your medical intake to identify postpartum individuals; Ex: “Have you given birth in the last 12 months?” 
  • Discuss what postpartum health care will entail with the patient, including MOUD (also referred to as MAT).
  • Train correctional health and custody staff to respond to dangerous warning signs of possible postpartum complications by posting this flyer. Educate patients as well.
  • CONTINUE MOUD for postpartum patients unless they request otherwise and have been counseled about the risks.
    • MOUD doses will likely need to be adjusted postpartum and should be assessed by a qualified healthcare provider.
    • If discontinuing, it should be done gradually with a taper, NOT cold turkey.
  • Postpartum patients should have an initial postpartum appointment within 1 week of birth, followed by another visit 2-3 weeks postpartum. They should have ongoing appointments as needed, concluding with a comprehensive postpartum visit no later than 12 weeks after birth.
  • Managing pain from a vaginal delivery and cesarean section for individuals on MOUD may be tricky. Follow all hospital discharge instructions and do not ignore their pain!
  • Screen for postpartum depression with a validated instrument, such as the Edinburgh Postnatal Depression Scale (EPDS), at about 6 weeks after delivery. A score of 9 or more suggests minor or major depression is present. Screen for perinatal anxiety with a validated instrument, such as the Perinatal Anxiety Screening Scale. If they screen positive, refer them to a mental health specialist.
  • Obtain a breast pump and equipment and discuss possible methods of getting the breastmilk to the infant.
  • Discuss the patient’s desires for mother-infant bonding while she remains in custody.
  • Postpartum patients should receive counseling on future pregnancy planning and access to contraceptive methods while in custody.

WHY 

  • Most “maternal mortality” in the U.S. occurs within the postpartum period, not during pregnancy. Substance use and mental health conditions are the leading cause of maternal death.
  • The postpartum period is considered the first 12 months after delivery. Postpartum care is critical to make sure the mom remains healthy enough to take care of the child.
  • Medical complications and mental health stressors are common in the postpartum period. People who give birth in custody have significantly more added stressors related to infant separation, which increases their risk of postpartum depression.

KEEP IN MIND 

  • Screening for postpartum status (i.e. birth within the last 12 months) at intake for all females and trans males under age 55 is important to identify individuals who did not give birth in custody but are still high-risk for postpartum complications or depression.
  • NEVER put postpartum patients in isolation or medical housing due to potential psychological harm and to ensure timely access to medical care.
  • Allow patients to make free phone calls to the National Maternal Mental Health Hotline– 1-833-852-6262
  • Allow postpartum patients who want to breastfeed the chance to pump breast milk, even if that milk won’t get to the infant- this helps maintain the mother’s milk supply for when she gets released.
  • If the infant is having medical issues, ensure that the mother has phone access to communicate with the infant’s medical team, know updates from the caregiver, and provide consent for any medical procedures the infant might need.

Deeper Dive

HOW 

What should happen to the patient’s MOUD after giving birth?

  • DO NOT discontinue methadone or buprenorphine postpartum.
    • MOUD is recommended as a long-term treatment. Some patients may express a desire to stop MOUD after pregnancy, and they should be counseled about the risks of cessation and the benefits of MOUD. If the patient still chooses to discontinue MOUD, discuss a plan to taper her medications over time. Postpartum individuals should not be withdrawn from medications “cold turkey.”
  • Watch for signs of oversedation (extreme drowsiness, somnolence). A dose that was effective in pregnancy may be too high postpartum, and methadone and buprenorphine doses may need to be lowered postpartum. This should be done by an experienced clinician and in partnership with the patient.

How is postpartum pain control impacted by MOUD?

  • Pain control postpartum, especially after a cesarean delivery, can be challenging for patients with OUD, but it is very important not to ignore their pain.
  • After a vaginal delivery, most patients experience pain that can be easily managed with ibuprofen and/or acetaminophen. Follow hospital discharge instructions.
  • After a cesarean delivery, patients have just had major abdominal surgery and will need pain medications as they recover, usually for about 2 weeks. Most patients will need a combination of short-acting oral opioids (e.g. oxycodone) and ibuprofen and/or acetaminophen. It is safe and appropriate to give short-acting opioids on top of buprenorphine or methadone. Some clinicians may recommend splitting buprenorphine or methadone dose postpartum. Follow hospital discharge instructions.

How can jail staff identify postpartum depression and mental illness?

  • Screen for postpartum depression with a validated instrument, such as the Edinburgh Postnatal Depression Scale (EPDS), at the comprehensive postpartum visit (~6 weeks after delivery). If they screen positive, refer to them a mental health specialist. A score of 9 or more suggests minor or major depression is present. 
  • Screen for perinatal anxiety with a validated instrument, such as the Perinatal Anxiety Screening Scale
  • Postpartum patients should NEVER be put in isolation or restrictive housing to avoid harmful psychological effects and timely access to urgent medical care.

What medical care do postpartum individuals require?

  • Postpartum patients should have an initial postpartum appointment within 1 week of birth, followed by another visit 2-3 weeks postpartum. They should have ongoing appointments as needed, concluding with a comprehensive postpartum visit no later than 12 weeks after birth.
  • Depending on the method of delivery (vaginal birth vs cesarean section) there are specific care steps and warning signs to look out for.
  • Medical appointments or emergency care should happen sooner if people experience dangerous warning signs like fever, severe headache, and heavy vaginal bleeding.

Should postpartum patients on MOUD breastfeed? Is it safe?

  • YES! When possible, allow postpartum patients to breastfeed their infants at contact visits directly. Breastfeeding while on MOUD is safe and recommended for infant health.
  • Jails should have a breast pump and supplies available and private space for pumping.
  • Patients should be given the option to express their breast milk via pumping to maintain their supply in preparation for release and to avoid complications like infection or clogged milk ducts.
  • Ideally, jails should help facilitate getting pumped milk to the infant by allowing patients to store breastmilk onsite that can be picked up by/sent to the infant’s caregiver.

What are the signs of a postpartum emergency?

  • Train correctional health and custody staff and educate patients to
  • Respond to dangerous warning signs of possible postpartum complications by posting this flyer.
  • Patients with warning signs should be evaluated by a qualified clinician promptly.

How can jails support mother-infant bonding?

  • Allowing the birthing patient as much time as possible in the hospital for mother-infant attachment is critical for the mother’s mental health and for the infant’s psychological development. The default should be that the mother and baby are in the hospital room together unless there are medical reasons for the infant or mother to need a higher level of care.
  • Once she returns to jail, staff should facilitate frequent (i.e. several times a week) contact visits if the mother and infant’s caregiver are amenable.

Do postpartum patients need contraception?

  • Postpartum patients should receive counseling on future pregnancy planning and contraceptive methods. Here is a good counseling resource, and here is a good medical resource on the safety of contraceptive methods for people with underlying medical conditions.
  • If they would like to use contraception, they should have access to start any FDA-approved, reversible method of contraception before release.
  • Do not pressure postpartum patients in jail to start a method of contraception. Avoid permanent contraception (i.e. tubal ligation) methods for patients in jail, especially since it is illegal in some states to do so for a patient in custody.

What things must jails consider for individuals who experience a miscarriage or abortion while in custody?

  • Some pregnant individuals will have miscarriages or abortions while they are in jail. They should still be started and continued on MOUD in custody since this is an important, life-saving treatment, regardless of pregnancy status. See MOMCARE Miscarriage and Pregnancy Loss for more information. 
  • Patients who experience a miscarriage may feel grief and should be provided with emotional support and resources. If someone needs support after an abortion, they should also be provided with resources.
  • Use this MOMCARE 1-pager, Abortion in Custody: FAQs for Correctional Staff, to educate correctional staff on why someone might seek an abortion and what jail staff need to know if someone requests and obtains an abortion in custody. 

WHY 

Why is postpartum care important?

If a pregnant patient remains in custody after giving birth or enters jail having recently given birth (within the last 12 months), there are unique physical and mental health care needs that jail staff should be attuned to. This will help improve the outcomes for the mother and child and reduce the impact of the trauma experienced while birthing in custody and separation from their infant.

The postpartum period is a very high-risk time. Most “maternal mortality” in the U.S. occurs within the postpartum period, not during pregnancy.

The most common dangerous and preventable postpartum conditions include opioid overdose, mental health complications, hemorrhage, infection, pulmonary embolus, and pre-eclampsia. Without timely screening and treatment, these conditions can cause serious and life-threatening issues.

Why is continuation of MOUD postpartum important?

Postpartum patients with OUD have a significantly increased risk of fatal overdose.

  • Some reasons for this include hormonal changes that make it hard to determine the best MOUD dose; being viewed as a lower priority when they are postpartum compared to when pregnant; shame and stigma if their newborns go through withdrawal; stopping MOUD; and postpartum depression. All of these things can lead to return to use and overdose.
  • Postpartum patients must be allowed to continue their MOUD!
    • The infant needs a mother who is healthy and stable in recovery
    • Continuing MOUD postpartum reduces the risk of relapse and overdose

What should jail staff know about postpartum depression?

  • Postpartum depression (depression that occurs within 12 months of delivery) rates are high in people with OUD and people in jail. Not only do incarcerated women have high rates of existing mental health conditions, but being separated from their babies after birth when they return to jail is very traumatic. Screening and treating for postpartum depression are essential.

What other things should jail staff know about caring for postpartum individuals with OUD?

  • Breastfeeding is safe and recommended for babies born to moms on MOUD, and it can reduce symptoms of neonatal opioid withdrawal syndrome (NOWS).
  • Jails must be ready to recognize and refer for postpartum complications that might arise, like excessive bleeding, infections, post-operative care if someone had a C-section, and high blood pressure.
  • Postpartum contraception is important to help patients avoid unintended pregnancy and to promote safe birth spacing of at least 18 months between birth and the next pregnancy.

Resources