Labor and Birth

HOW

What can a jail do to prepare for labor and birth?

• Have an emergency birth kit available for unexpected birth emergencies on-site.
• All staff, medical and custody, who oversee pregnant patients should be knowledgeable of signs of labor.
• Have an existing arrangement with a hospital that provides obstetrical care.
• Have written policies and procedures in place and train medical and custody staff on how to respond if a pregnant patient is in labor. Posting a flyer that lists “warning signs” may help, especially if your jail only has pregnant patients every once in a while.

How can jail staff prepare pregnant patients for labor and childbirth?

• Counsel patients ahead of time about expectations during labor/birth. This patient fact sheet has helpful information about birth expectations and planning for patients with OUD.
• Methadone/buprenorphine should be continued at the current dose during the labor/birth hospitalization, although they do not treat pain from labor/birth.
• Pregnant patients with OUD need to be assured that they will receive adequate pain relief during labor and the postpartum period. Here is some patient information on pain relief options during labor.
• Breastfeeding is safe and recommended for patients on MOUD to reduce infant withdrawal symptoms.
• The baby may have some signs of withdrawal (NAS/NOWS). This can be distressing to patients, but hospital staff will guide them on things like skin-to-skin contact with the baby that can reduce symptoms. The baby may need to go to the NICU if it has a lot of symptoms that need medications. If the baby has NAS symptoms, this does not mean they will have long-term problems.
• It is important to continue methadone/buprenorphine postpartum, but the dose may need to be decreased.

What should be included in patient counseling for labor and childbirth?

Labor/birth patient counseling should include:

• While the decision for an elective induction > 39 weeks should be between the perinatal provider and patient, here are some helpful counseling points for patients about induction.
• Restraints and officer presence
• Rules about visitors in the hospital
• Time with baby in the hospital
• Baby care planning
• Social services may be called, depending on your state’s law, even if the patient is stable in treatment. Sometimes this is just to help make sure there is a safe plan and to provide additional resources.

What needs to happen when someone goes into labor in jail?

• TRANSPORT THE PATIENT TO THE HOSPITAL. Jail staff, whether medical or custody, must have a low threshold to transport a pregnant patient to the hospital for possible labor.
• At the hospital, it is best practice to have a custody officer stationed outside the patient’s hospital room during the birth hospitalization, not inside the room. At the very least, custody officers should leave the room during vaginal exams, during delivery (whether vaginal or c-section), and when patients are breastfeeding. This is for the patient’s safety and dignity, and reducing the risk of trauma. If an officer must be present in the room during exams or delivery, by federal law (PREA Standard § 115.15 (d)) it MUST BE A FEMALE OFFICER.
• Ideally, allow a support person to be in the delivery room with the patient. This could be a doula that your jail has vetted ahead of time. Or a family member, with appropriate security screening.
• Do not use custody restraints on pregnant patients, especially during transport, labor, delivery, and the postpartum period. Use alternative means to ensure public safety. At a minimum, custody and hospital staff must comply with their state’s law.

If someone has a c-section, can the custody officer be in the operating room?

• Extra people in the operating room who don’t need to be there is an infection risk during surgery.
• The patient will have anesthesia and is not a flight risk.
• On occasion, the patient may request the officer to be there as a support person. This is ok only if this is what the patient asks for. Remember, that birthing is stressful and this is her experience, not yours.

What do jail staff need to know about childbirth and medical exams regarding PREA?

• At the hospital, it is best practice to have a custody officer stationed outside the patient’s hospital room during the birth hospitalization, not inside the room. At the very least, custody officers should leave the room during vaginal exams, during delivery (whether vaginal or c-section), and when patients are breastfeeding. This is for the patient’s safety and dignity, and reducing the risk of trauma. If an officer must be present in the room during exams or delivery, by federal law (PREA Standard § 115.15 (d)) it MUST BE A FEMALE OFFICER.

WHY?

How is childbirth different for a pregnant patient who uses opioids compared to one who doesn’t?

When someone with OUD is in labor and gives birth, there are special considerations, for things like pain control during labor or a C-section, and what happens to their baby after birth. Jail staff can help with counseling patients on these expectations and optimize outcomes.

Birthing patients on MOUD can safely have lots of options for pain relief during labor and delivery, including epidural. After delivery, they benefit from “multi-modal treatment” with non-opioid pain relievers and, if needed (e.g. c-section or significant vaginal tear), additional opioids are safe.

Why must jails prepare for childbirth if it doesn’t happen very often?

Jails must be prepared for when a pregnant patient goes into labor so that they can transport them to the hospital in a timely fashion. No one wants a baby born in their jail!

• Diagnosing when someone is in labor or would otherwise need to go to the hospital for delivery is not always straightforward!
• Sometimes labor pains are obvious, but sometimes they can be subtle, like back pain, cramping, light bleeding, or leaking fluid (water breaking)—especially when someone is preterm (less than 37 weeks).
• If you don’t transport a patient who might be in labor, they could give birth at the jail—which is dangerous for the birthing patient and the baby and can result in lawsuits for the jail.
• While hospital transports can be a hassle and jails understandably want to avoid unnecessary transports if someone is not in labor, it is still better to err on the side of caution with pregnant patients.

Can jails schedule an elective induction of labor (instead of waiting for the patient to go into labor on her own) to avoid the possibility of a birth in jail or for other reasons?

• Sometimes, perinatal care providers may recommend that a patient have an induction of labor for certain medical or obstetrical conditions. This is not elective. Other times, patients may choose to have an “elective” induction of labor after 39 weeks gestation.
• Elective inductions are safe, and patients should have the option for this, but the pros and cons should be discussed with the patient and not be pressured to choose one over the other. Scheduled elective inductions should NOT be the jail’s default routine.

What can jail staff do immediately after childbirth to make sure the mother and infant’s physical and mental health are maximized?

The time immediately after birth is crucial for mother-baby bonding and is proven to reduce the infant’s suffering from neonatal opioid withdrawal syndrome (NOWS, sometimes called NAS). Frequent skin-to-skin contact between the mother and baby and breastfeeding are evidence-based strategies to reduce symptoms of NOWS (the “eat, sleep, console” model).

What should happen to the patient’s MOUD after childbirth?

Methadone and buprenorphine should be continued during labor and after delivery.

• Discontinuing the medication creates dangers for the birthing patient and the baby, including a risk of the mother overdosing if she relapses, which is common.
• Because of physiologic changes after birth, someone’s MOUD dose may need to be adjusted. This should be done by an experienced provider.

Can pregnant patients be restrained while in labor and childbirth?

NO. Custody restraints should NEVER be used on pregnant patients during labor, delivery (whether vaginal or c-section), postpartum period, and transport. They should also be avoided throughout pregnancy.

• There are many medical dangers for the fetus and pregnant patient if custody restraints are used during labor and delivery (and other points in pregnancy and postpartum).
• Emergencies can arise suddenly during labor and restraints can interfere with life-saving medical interventions like emergency C-sections.
• Most states have laws that prohibit the use of custody restraints in labor, and most healthcare organizations, including the National Institute of Corrections and the National Commission on Correctional Health Care all say it should not occur.

• MOMCARE Labor Signs chart for correctional staff. Jails should have a low threshold to transport pregnant patients if they suspect labor. 
• Emergency birth kit – Link for purchase. Jails should have them available for unexpected birth emergencies on-site
• Elective induction of labor FAQs – Counseling points for patients about induction of labor from the American College of Obstetricians and Gynecologists.
• Implement evidence-based anesthesia practices in the peripartum period for opioid use disorder in pregnancy – Toolkit on how to implement evidence-based best practices for anesthesia care and pain relief for pregnant women with OUD including counseling points for patients.
• PREA Standard § 115.15 (d) Limits to cross-gender viewing and searches – Federal law requires that if an officer must be present during exams (or birth) when a patient’s vagina and/or breasts are exposed, it must be a female officer.
• Eat, Sleep, Console Approach: A Family-Centered Model for the Treatment of Neonatal Abstinence Syndrome – A new ESC model developed to focus on the comfort and care of drug-exposed infants who are at risk for developing NAS by maximizing nonpharmacologic methods, increasing family involvement in the treatment of their infant, an open or “as needed” use of morphine 
• Restraint Use 
  • Map and resource table of state laws around restraints in pregnancy – Provides detailed information with an interactive map displaying the current laws for each state around the non-use of custody restraints during labor, delivery, and other points in pregnancy.
  • Best Practices in the Use of Restraints with Pregnant Women Under Correctional Custody
  • Nonuse of Restraints for Pregnant and Postpartum Incarcerated Individuals (2020) – National Commission on Correctional Health Care position statement on the nonuse of restraints for pregnant and postpartum individuals in custody. 
• Patient Education 
  • Labor and birth expectations for people with OUD – Patient fact sheet about birth expectations and planning for patients with OUD from the American Society of Addiction Medicine.
  • Caring for your Newborn with Neonatal Abstinence Syndrome (NAS).– Patient education on strategies to reduce NAS/NOWS symptoms when the baby is born (printable).
  • Childbirth, Breastfeeding, and Infant Care: Methadone and Buprenorphine – Patient fact sheet about birth expectations and planning for patients with OUD from the American Society of Addiction Medicine.