Pregnancy and Postpartum Care 🤰

This section provides guidance to help jails ensure they are set up to meet the essential health care and support needs of pregnant individuals in custody. It is not intended to be a comprehensive guide to prenatal care delivery but provides tools for jails to ensure they can facilitate essential pregnancy-specific care.

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Key Points

HOW

  • Ensure you have access to a qualified perinatal clinician to provide routine and high-risk prenatal care.
  • Have an emergency delivery kit available at your jail—just in case!
    • If you provide onsite prenatal care, be sure to stock the necessary supplies for this (urine dipstick, disposable tape measures, handheld Doppler).
  • Create and coordinate a process for sharing medical records with offsite clinics for providing routine and high-risk pregnancy care, and with the nearby maternity hospital for delivery or emergency care. This includes offsite MOUD (also referred to as MAT) providers.
  • Make pregnancy (and postpartum) accommodations for patients including nutrition (supplemental food portions), housing arrangements, and job assignments.
  • Ensure that staff are trained to recognize, triage, and transfer pregnant (and postpartum) patients experiencing urgent maternal warning signs, including possible labor signs. Consider posting flyers.
  • Provide access to mental health care, both in pregnancy and the postpartum period.
  • Ensure all policies and services comply with your state’s laws—this includes topics of non-use of restraints in pregnancy (even during transport) and access to abortion services.

WHY 

  • Health care and substance use care in pregnancy is different than in a non-pregnant patient. Jails must be prepared to provide timely care for their unique needs to ensure healthy pregnancies and to avoid lawsuits.
  • Health care for pregnant patients with OUD encompasses MOUD/MAT services tailored to pregnancy, routine prenatal care, acute care for urgent pregnancy complaints, care for high-risk pregnancies, mental health care, and postpartum care.
  • Not all hospitals have maternity care services. Having a pre-existing arrangement with the closest hospital that can care for pregnant patients is essential.
  • Not all healthcare professionals are trained to care for pregnant patients. Jails must have plans in place for providing evidence-based care to pregnant patients with OUD, even if offsite.
  • Implementing and training staff in policies and procedures that are in line with best practices for pregnant patients with OUD can promote positive safe outcomes for mom and baby!

KEEP IN MIND

  • Arrangements for prenatal care, high-risk pregnancy care, and labor should be established before they are needed. This will allow you to provide timely care when a patient arrives at your facility.
  • It’s important to add detailed pregnancy protocols (i.e. what to do, who to call, where to go) to your official jail policies, both medical and custody, to facilitate compliance and act as a resource when an emergency or need arises.
  • We recommend you meet with community clinicians and hospital labor and delivery staff to discuss general policies, procedures, and practices to prepare for when there is a pregnant patient in custody. This way, everyone is on the same page ahead of time and things like restraints don’t need to be figured out in the heat of the moment with an actual patient.

Deeper Dive

HOW 

Routine prenatal care: Providers

  • Jails should have a qualified provider who is available for routine pregnancy care (on or offsite) at least weekly. It may need to be more often if your jail has more than 5 pregnant patients at a time.
  • If you have a qualified perinatal clinician in your community who is also experienced in treating addiction, try to contract/hire this person to work with your population!
  • To ensure that you can provide pregnant patients with access to routine prenatal care by a qualified perinatal clinician, you have a variety of options. Some of this may be determined by your healthcare contractor and your community’s local pool of perinatal providers.
    • Hire or contract with a qualified perinatal clinician in your community to come to your jail weekly to see pregnant patients.
      • Minimizes the need for offsite transports.
      • Good for jails that consistently have at least several pregnant patients at a time.
    • Contract with a community perinatal care practice to see patients offsite at their community clinic or hospital-based clinic.
      • Requires jail resources for offsite transports for prenatal visits. This includes compliance with state laws prohibiting the use of restraints in pregnancy.
      • Good for jails that only occasionally house pregnant patients, or jails that are in communities where there is no perinatal care provider willing to come to the jail.
    • Transport pregnant patients to their community perinatal care provider.
      • If someone has been receiving prenatal care in the community, it may be easiest for your jail to simply transport them to this provider for their regular prenatal visits.
      • Good for jails that only occasionally house pregnant patients.
    • Telehealth visits with a perinatal provider may be appropriate in some circumstances, but the jail will need supplies and someone onsite who is trained to check blood pressure, do a urine dipstick, accurately measure uterine size, and check for fetal heart rate.
    • Contract with a nearby academic medical center that has a labor and delivery unit. They often have perinatal care providers who see patients in a hospital-based clinic.
    • If you are not sure how to find a qualified perinatal care provider in your community, you can use this Ob/Gyn locator from ACOG.
Routine Prenatal Care: Materials and Services
  • It is beyond the scope of MOMCARE to enumerate all aspects of prenatal care. Here is a 700 (!) page book from the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics that lists all aspects of what is considered the community standard of prenatal care. You can navigate to what you need by using the Table of Contents on pages vii-x.  
  • Here are considerations for enabling the ancillary parts of prenatal care:
    • If you provide prenatal care on site, be sure your clinic has purchased the following supplies:
      • urine dipsticks and cups
      • disposable paper tape measures (for measuring fetal size)
      • portable Doppler machine and gel (for fetal heart rate)
    • To facilitate prenatal ultrasounds, you can utilize a radiology service that your perinatal care provider recommends, or check to see if the radiology service you use for non-pregnant patients also does pregnancy ultrasounds. Another option is to transport patients to a hospital ultrasound department.
    • To facilitate the required laboratory tests in pregnancy, make sure that the laboratory vendor you use for non-pregnant patients will run all the tests that pregnant patients need. Beyond standard labs like CBC and STI screening, pregnant patients need access to genetic screening (e.g. “NIPT”), type and screen, and Glucola (glucose load) diabetes screen. If your jail does not have nursing staff and supplies to allow for onsite blood draws, you may have to take pregnant patients offsite for lab draws.
Routine Prenatal Care: Documentation
  • If you use an electronic medical record (EMR) system, have your IT specialist build a prenatal care visit template and flowsheets with the key elements as recommended on pages 581-592 of the ACOG Perinatal Care Guidelines.
  • If you use paper charts, consider using the ACOG Patient Record Forms, which can be found on pages 581-592 of the ACOG Perinatal Care Guidelines.
  • Create a communication plan with your jail’s perinatal care provider to ensure a smooth and timely transfer of information about prenatal visits, especially if they are offsite.
Pregnancy housing, nutrition, and activity level
  • Confirm that your policies and procedures explicitly state that pregnant patients should NEVER be put in isolation or restrictive housing to avoid harmful psychological effects and ensure timely access to urgent medical care.
  • Pregnant patients should receive an additional portion of food during mealtime, access to snacks in between mealtimes, and nutrients that are required in pregnancy. Be sure that your jail has a “pregnancy diet” for pregnant and postpartum patients that is in line with national guidelines. Chapter 5 of these national guidelines is all about pregnancy and postpartum.
  • Pregnant patients must be allowed to exercise. Activity levels may vary by trimester, but bed rest is not recommended in pregnancy due to risks. Medical should assess for this, make a note in the patient’s chart, and communicate with custody staff.
High-risk pregnancy care
  • Pregnant patients with OUD will need specialized care for their OUD needs.
    • If your perinatal clinician does not have expertise in treating OUD and will not be primarily managing the patient’s MOUD dosing, create a line of communication between the MOUD provider and the perinatal clinician. This can be via weekly multi-disciplinary case conference meetings, in person or via Zoom; weekly one-on-one phone calls between the MOUD provider and perinatal clinician; or weekly secure email correspondence.
  • Some pregnant patients have other medical or obstetrical conditions that make their pregnancies “high-risk” for adverse outcomes and that therefore require a higher level of care.
    • The perinatal clinician’s intake visit with the patient will identify many conditions including those that are high-risk. However, some conditions develop in pregnancy. Jails must have systems in place for when consultation is required.
  • Here are some ways that you can arrange for high-risk pregnancy consultation care:
    • Ask your perinatal clinician if they have a Maternal Fetal Medicine (MFM) practice that they refer their community patients to.
    • Find out if your nearest maternity hospital has a high-risk MFM provider. If so, contact that physician to be your referral, or point person for high-risk care.
    • Visits with the MFM may be conducted via telehealth, depending on the nature of the high-risk condition.
    • Visits may also take place offsite, or you can arrange for the MFM specialist to come to your jail for a visit if they are able.
    • You will need to work out payment/reimbursement as you would with any specialist physician that you refer your incarcerated patients to.

Recognizing, triaging, and referring urgent pregnancy concerns, including labor

Mental Health Care
  • Allow patients to make free phone calls, in a private space, preferably in the clinic area, to the National Maternal Mental Health Hotline– 1-833-852-6262
  • Mental health care staff serving your jail must be aware of the safety and importance of psychiatric medications in pregnancy. See MOMCARE Behavioral Health and Peer Support for more details. Some medications require additional monitoring in pregnancy, and jail providers may need to consult with a perinatal mental health expert- ask your high-risk OB provider for contact information.
  • Mental health care staff serving your jail should develop lines of communication with the patient’s community psychiatrist to ensure continuity on jail arrival and upon release.
Abortion access
  • If abortion is legal in your state, then your jail must have written policies and procedures that provide access that is concordant with what is legal for non-incarcerated women.
    • Review your current policies on abortion access and make sure they are concordant with your state law. Work with your department’s legal team.
    • Make a connection ahead of time with the nearest abortion clinic. You can use this verified, updated search tool to find a clinic. When a patient requests an abortion, try to streamline the referral process as best you can.
    • Cover the cost of the abortion procedure as you would any other medical procedure that is necessary in custody. There may be abortion funds in your community that can help pay for part of the procedure.
  • Train medical staff to know what’s allowed in your state in terms of abortion. Patients may ask!
  • Train medical staff to ask pregnant patients who are early in their pregnancies if they want to continue the pregnancy or seek abortion.
  • If you are in a state where abortion has been banned or severely restricted, work with your legal team to understand options for care, especially when there is an emergency medical indication for an abortion procedure.
  • While some people have historically thought of abortion as “elective” or not medically necessary, the medical community and the National Commission on Correctional Health Care do consider this essential health care and non-elective procedures.

 

Hospital collaboration
  • Identify a hospital that you will take pregnant patients to if they have complications or go into labor. Find out if the hospital you take your non-pregnant patients to has maternity services. If not, ask them for a recommendation. Create a memorandum of understanding for them to provide care to your jail’s pregnant patients. See MOMCARE MOU for more details.
  • Establish a point person at the maternity hospital—this could be the nursing supervisor of the labor and delivery unit. This person can be your point of contact for individual patient issues or general operational issues.
  • Create a line of communication and process (e.g. print copies of records) for ensuring that jail prenatal records and laboratory tests accompany a pregnant patient from jail to the hospital.
  • Convene a face-to-face meeting with labor and delivery unit staff (nursing leadership, nurses, physician/midwives), custody leadership, and even some CO’s if possible, and jail medical leadership. Face-to-face discussions that are not in the heat of the moment of actual patient care will reduce stress and confusion when there is a patient. Outline in written documents the policies and procedures for the jail and hospital to make sure they are aligned on:
    • Non-use of restraints in pregnant patients, especially in labor and delivery; chain of command for reporting issues; ensure policies comply with your state’s law.
    • Location of CO’s, ideally outside of the patient’s room. If it is required that they are in the patient room, they should leave during vaginal examinations and actual delivery.
    • Note that if an officer must be present during vaginal exams or birth, PREA Standard § 115.15 (d) requires that it be a female officer.
    • Whether visitors are allowed during labor, birth, and postpartum stay, including doulas.
    • Allowing the newborn to stay in the hospital room with the mother during postpartum recovery, as long as the baby does not need NICU-level care.
    • Allowing the postpartum patient to breastfeed while in the hospital post-birth recovery.
    • Avoid routinely scheduling elective (non-medically indicated) cesarean sections or inductions of labor simply for the convenience of the jail.
Postpartum care
  • Ensure that your jail policies and partnerships with MOUD providers allow postpartum individuals to continue their methadone or buprenorphine that they were taking during pregnancy.
  • Develop a protocol for a dose evaluation once the patient returns from the hospital after birth. If there are signs of oversedation, the dose may need to be decreased.
  • Educate staff on why continuing MOUD postpartum is important and prevents death, and is safe in breastfeeding so that they can counsel patients about continuing.
  • If patients choose to stop taking MOUD postpartum, ensure that protocols utilize medically supervised withdrawal for gradual tapers, NOT cold turkey withdrawal.
  • Clinical protocols should include routine postpartum medical visits upon return from the hospital within 3 weeks and 6-12 weeks postpartum.
  • Medical staff review discharge paperwork from the hospital to determine if there are non-routine postpartum issues that must be addressed (e.g. BP check in 1 week, C-section incision, lactation problems/breast symptoms)
  • Provide clinical staff with paper copies, or links, or build the screening into your EMR to screen for postpartum depression with the Edinburgh Perinatal Depression Scale. They should screen at the 6-12 week visit.
  • Post flyers for urgent maternal warning signs and educate staff that these also apply to people who have had a baby within the last 12 months.
  • Develop systems that enable postpartum people to breastfeed, or at least maintain milk supply while they are in custody. Key things you’ll need to do:
    • See this incredible, comprehensive, jail-specific toolkit on how to establish breastfeeding/pumping support programs at your jail!
    • Purchase pumping equipment and have a place to store it
    • Figure out a private place where people can pump milk several times a day
    • Have a freezer that can store pumped milk
    • Write protocols for pumping, labeling, storing, and getting milk to the infant’s caregiver
    • Identify a lactation consultant at the birthing hospital who can do telehealth visits if women are having problems. Have that person train a champion at your jail to be an onsite resource.
    • Have visitation policies that allow frequent contact visits between moms and newborns, several times a week.
  • Postpartum visit record elements can be populated into EMR or paper charts, see pages 593-595 for forms from ACOG.
  • Have policies and procedures that allow postpartum patients to start a reversible method of contraception if they desire.
    • Models to provide this care include partnering with a community provider (Ob/Gyn, Family Physician, Planned Parenthood) or having the jail’s clinicians counsel patients. Often the Ob/Gyn’s at the delivery hospital will talk to patients about contraception. For people who want an intrauterine device or Nexplanon device, you will need to contract with a trained provider who can insert these methods.
    • Ensure your jail’s formulary has birth control pills and the Depo Provera shot for people who want to use these methods.
    • We recommend having policies and procedures that do not allow sterilization (e.g. “tubal ligation” or “tubes tied) while in custody. There are ethical issues and considerations regarding permanent contraception.
  • See MOMCARE Postpartum Care and Breastfeeding for more details.
Compliance with state laws
  • Many states have laws that relate to pregnancy care that directly impact jails. Here is how you can learn about some of the kinds of legal mandates in your state that jails need to abide by:
  • To comply with state laws:
    • Consult with your county’s legal department
    • Review your health care and other operational policies to make sure they are concordant with state law
    • Meet with someone in maternity services leadership (e.g. director of Labor and Delivery Unit) at the hospital where you transport pregnant patients, to make sure their hospital policies, especially with regards to restraints laws. See the above “Hospital Collaboration” section.

WHY 

  • Pregnant individuals, especially those with OUD and other substance use conditions, have unique, time-sensitive healthcare needs. This includes providing MOUD/MAT services tailored to pregnancy, routine prenatal care, acute care for urgent pregnancy complaints, care for high-risk pregnancies, mental health care, and postpartum care. Jails must have systems in place, whether offsite, onsite, or a combination to meet these needs.
  • There may be legal consequences for jails that do not have systems in place or staff that can provide access to standard and emergency pregnancy care.
  • Pregnant individuals may go into labor while in custody or may experience pregnancy complications that require urgent medical attention. Jails must have staff who have basic abilities to recognize the signs and symptoms of when a pregnant patient needs urgent medical attention. Some of the concerning symptoms of pregnancy are ones that, in a non-pregnant person, are not worrisome—like a headache. But in a pregnant patient, can be a sign of a life-threatening condition.
  • When a pregnant patient in custody is taken to the hospital, the accompanying security officer and the hospital staff must be on the same page about security procedures, privacy, visitors, the baby being in the room, and what is and is not allowed.
  • Not all healthcare professionals have received the training necessary to care for pregnant patients. Having a pre-existing arrangement with a qualified perinatal clinician means that your jail is prepared to provide access to appropriate care when you house pregnant patients.
    • A qualified perinatal clinician is an Ob/Gyn, Family Medicine Physician, Certified Nurse Midwife, or NP/PA who has received training in pregnancy care.
  • Perinatal mood and anxiety disorders are really common in this population. And mental health conditions are the number one cause of pregnancy-related death in the United States! That includes suicide, substance use (including opioid overdose), and other complications from mental health disorders. Most psychiatric medications are safe in pregnancy, but having a mental health provider who knows this and is comfortable with pregnant patients is essential.
  • Whether you have one pregnant patient a year or forty, your jail needs to be prepared!