Custody Guidance

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Custody Guidance

This page provides vital information for custody officers on how to manage issues they may encounter with pregnant patients with OUD in custody. We know custody officers are not medical personnel, and this page helps you know when to call medical or refer for a higher level of care, and what to do until they get there.

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Custody Guidance

HOW

  • If you’re an officer who performs custody intake for new detainees, use the MOMCARE Initial Pregnancy & OUD Screening and Care at Jail Intake algorithm for best practices.
  • Alert medical staff to conduct a full evaluation and possible referral for a higher level of care if a pregnant patient reports or you observe any of the following things:
    • Urgent maternal warning signs– such as a headache that won’t go away, chest pain or trouble breathing, severe nausea/throwing up, baby’s movement stopping, fever.
    • Signs of unwell– “unwell” means that someone has observed signs and symptoms that are obvious to a layperson that they are physically or psychologically sick, including signs of self-reported intoxication or substance withdrawal. See the BJA training video (7 mins) on how to identify if someone in jail is unwell. 
    • Labor signs– such as abdominal pain/cramping, contractions that come and go, any amount of vaginal bleeding or leaking fluid
  • Know when to transport pregnant patients, including those with OUD, offsite for a higher level of care. See MOMCARE When to Transport for more details. Briefly, offsite transport is required for instances where onsite medical is not available (or lacks necessary training and expertise):
    • Urgent maternal warning signs, signs of being unwell, or labor.
    • Pregnant patients starting MOUD/MAT
    • Pregnant patient going through withdrawal
  • In most states, it is prohibited to use restraints (handcuffs, belly chains, ankle chains) on pregnant patients in custody who are in labor, even during transport offsite. Many states prohibit restraints at other points in pregnancy also. Know your state’s law and your jail’s policy to avoid litigation.
  • Pregnant patients with OUD who are undergoing medically supervised withdrawal should have continuous access to fluids like water or Gatorade.
  • Avoid housing pregnant patients in isolation, administrative segregation, or restrictive housing.
  • Recognize that addiction is a condition with biological basis, not a moral failing, and recovery is a long process. It does not mean that someone is not fit to be a mother.
    • Use non-judgmental, humanizing language when interacting with pregnant patients with OUD. This means using non-stigmatizing language and avoiding words like “addict/junkie/user” and “addicted baby/drug baby/born addicted to heroin.”
    • See MOMCARE Communicating with Patients for more details.

WHY

  • Custody staff are often the first line of contact if there is an issue or emergency. It’s important to be aware of warning signs that can mean a dangerous pregnancy condition or that a pregnant patient is unwell, and signs of labor (both preterm and term labor) so you can respond timely and appropriately.
  • The things you say are powerful and matter. How custody and medical personnel interact with pregnant patients can influence whether they seek prenatal care and treatment for OUD, and how they think about themselves.
  • You can have a positive impact on pregnant patients and their babies!

KEEP IN MIND

  • In pregnancy, many things that appear to be minor signs or symptoms that you wouldn’t worry much about for a non-pregnant patient may actually indicate a dangerous issue with the pregnant patient or their fetus. Take medical-related complaints from pregnant patients seriously. They are time-sensitive.
  • Symptoms of opioid withdrawal can sometimes look the same as symptoms of pregnancy—nausea, vomiting, abdominal pain, for instance. Custody officers aren’t trained to know the difference, so have a low threshold for referring patients for a higher level of care.
  • Using restraints in pregnancy and ignoring labor and other serious pregnancy symptoms in jail can lead to lawsuits.

 HOW

What should custody officers performing jail intake know regarding pregnancy and opioid use?

  • If you’re an officer who performs custody intake for new detainees, use the MOMCARE Initial Pregnancy & OUD Screening and Care at Jail Intake algorithm for best practices in screening for pregnancy and opioid use.
  • Sometimes people do not know they are pregnant when they get to jail. Therefore, we recommend offering a urine pregnancy test on every female (or trans-male) younger than 55 years old.
  • Pregnant patients who use drugs may be hesitant to share their substance use with jail staff, due to fear of consequences like having their baby taken away, added jail time, or being negatively judged. Therefore, we recommend screening for drug use using a standardized questionnaire.
    • National guidelines recommend that you should NOT do a urine drug test because it can be inaccurate, take time, and delay someone getting timely care.
    • However, we know that some jails still prefer to require a urine drug test. If your jail does this, we recommend (and some states require this by law) getting informed consent from the patient. Here is some sample language:

“Do you give your permission for us to run a urine drug test? The test results will allow your healthcare team to understand what substances you and your baby were exposed to in order to provide the highest quality of care to you and your baby. A provider will discuss the results with you and offer suggestions for your care. You have the right to decline a drug test. If you choose not to be tested, there will not be a delay in your care, but it may delay the treatment of substance use disorder, which could increase the risk of harm to you and your baby. Again, the test will not have any effect on your legal case and we will not share the results. It is only for medical treatment purposes.”

  • If the pregnant patient appears unwell or shows signs of abdominal or pelvic pain at intake, alert medical immediately for evaluation. If you are at a jail without 24/7 medical coverage, call EMS.

 

What should custody officers do if a pregnant patient is complaining of abdominal/pelvic pain? What about vaginal bleeding?

  • Alert medical immediately for proper evaluation if a pregnant patient reports or you observe:
    • Urgent maternal warning signs– such as a headache that won’t go away, chest pain or trouble breathing, severe nausea/throwing up, baby’s movement stopping, fever.
    • Signs of unwell– “unwell” means that someone has observed signs and symptoms that are obvious to a layperson that they are physically or psychologically sick, including signs of self-reported intoxication or substance withdrawal.
    • Labor signs- such as abdominal pain/cramping, contractions that come and go, any amount of vaginal bleeding or leaking fluid.
  • Abdominal/pelvic pain or discomfort in pregnancy can be an emergency. So can vaginal bleeding, even if it is not heavy. Take medical-related complaints from pregnant patients seriously and call for help—custody officers are not expected to make medical diagnoses!
    • In the first trimester, severe abdominal/pelvic pain or bleeding can be a sign of a miscarriage, an ectopic pregnancy, or a pregnancy in the tubes, which is a life-threatening condition.
    • Abdominal/pelvic pain, even mild cramping, might be a sign of preterm (less than 37 weeks) or term labor.
      • If the patient is preterm (less than 37 weeks pregnant) and reports cramping, new back pain that comes and goes, or contractions, have them time them. If they are less than 10 minutes apart, they should be evaluated by medical personnel. If they are more than 10 minutes apart, they should rest for an hour, drink cold water, and see if they go away, If not, they should be evaluated by medical personnel.
      • If the patient is term (more than 37 weeks pregnant) and reports cramping new back pain that comes and goes, or contractions that are less than 10 minutes apart, they should be evaluated by medical personnel—especially if they have had babies before (these labors go faster!).
    • For any amount of bleeding, notify medical personnel.

Can custody officers use restraints on pregnant patients in jail? What if they need to be transported offsite?

  • Due to medical risks, custody restraints should not be used during pregnancy, childbirth, and the postpartum period (see MOMCARE Labor and Birth for more details). Most states have enacted laws that prohibit restraints during labor, and many of these laws also prohibit restraints at other points in pregnancy, transport, and the postpartum period. These laws may apply when taking a pregnant patient to an OTP for a daily methadone dose, for instance.
  • Under NO circumstances should a pregnant patient be restrained with handcuffs behind their back, around their belly, around their ankles, or to another person. If the individual has attempted to escape or hurt others and restraints are deemed necessary, the least restrictive restraints should be used in front. 
  • NO patient who is in labor and giving birth (vaginal or c-section) should be restrained with any custody restraints under any circumstances (medical restraints for patients with psychiatric issues are addressed by hospital policies). See MOMCARE Legal and Regulatory for more details.

What do custody staff need to know about accompanying pregnant patients to offsite medical appointments and childbirth hospital stays?

  • When a pregnant, birthing, or postpartum patient is undergoing a vaginal exam or is actively giving birth, a male custody officer cannot be present. Doing so would violate PREA Standard § 115.15, which restricts staff of the opposite gender from viewing an incarcerated person’s genitals.
  • In general, it is best practice to have the officer, whether male or female, stationed outside the patient’s hospital room to allow for privacy during the very sensitive and emotional process of childbirth.
  • If a patient is undergoing a cesarean section, the officer should be stationed outside of the operating room, not inside, to reduce the risk of surgical infection.

Should MOUD/MAT be withheld if a pregnant patient is caught diverting or has any other behavioral infractions in custody?

No. MOUD treatment should not be terminated for any reason other than if the treatment is harming the patient. It is important to understand reasons why some people in a MOUD program in jail might divert because diversion is usually a symptom of something else going on.

  • Saving dose– Occasionally, people may divert to save a large enough dose to feel euphoria. More commonly, patients might divert their medication so they can split their dose to take some during the assigned dose time and some later if they feel they are having withdrawal symptoms before their next MOUD dose. Adjusting their dose can often address this.  
  • Coercion by another incarcerated individual- Someone receiving MOUD may be bullied by another incarcerated individual to divert and give them their dose, sometimes for a high or because they have opioid cravings—and would benefit from medically authorized MOUD.

See MOMCARE Preventing and Managing Diversion for more details.

What are some best practices for interacting with incarcerated pregnant patients with OUD?

  • How you interact with pregnant patients influences how they seek care or ask for help and how they think about themselves. The things you say are impactful and matter.
  • Research has shown that when medical personnel or custody officers use judgmental or stigmatizing language toward pregnant patients with OUD, they are less likely to get prenatal care or treatment for their substance use, which can lead to overdose.
  • Communications with patients should be person-centered, meaning that they are first a human being rather than their circumstances or experiences.
  • Jail staff should refrain from casting judgment, whether verbal or nonverbal, on pregnant patients with OUD in custody. See MOMCARE Communicating with Patients for more details.

What other things are important to know about pregnant patients in custody?

  • Access to fluids– Hydration is very important in pregnancy. Dehydration can lead to contractions, low blood pressure, and other conditions. All pregnant patients, especially those with OUD, should have continuous access to fluids. Allowing access to ice makes them more likely to drink the water.
  • Restrictive housing/isolation- No pregnant patients should be put in isolation. Isolation increases the likelihood of psychological distress, may limit access to emergency medical care, is not good for maternal health, and national guidelines recommend against it during pregnancy.
  • Bottom bunk assignments– All pregnant patients in custody should be assigned to a bottom bunk to reduce the risk of harm to the pregnant patient and the baby if they fall out of the bed.
  • Work assignments– Some pregnant patients may need a light work assignment, especially as the pregnancy progresses. Others may not be able to work at all. Consult with medical.
  • Breastfeeding– Postpartum individuals in custody who are breastfeeding should have time, privacy, and equipment to pump milk every 3-4 hours.

WHY

What role do custody officers play in caring for pregnant patients in custody?

  • Custody staff are often the first line of contact if there is an issue or emergency. It’s important to be aware of urgent maternal warning signs, signs of being unwell, and labor signs when housing pregnant individuals so you can respond timely and appropriately.
  • Custody staff have a unique opportunity to help a pregnant patient with OUD get and stay in recovery. This has a lasting, positive impact on the mother and her baby!

 

 Restraint Use 

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