Pregnancy Screening and Treatment Pathway

The AUD pregnancy treatment pathway begins with inviting a conversation, then screening and diagnosis, followed by assessment of the patient’s goals and care planning. Note: For care options, psychosocial supports is inclusive of cultural practices.

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Screening Tools

Health care providers should ask all pregnant people about alcohol use at the earliest opportunity and in a non-judgmental way (please see Principles of Care for more information) to allow for timely intervention and appropriate management. All pregnant individuals with high-risk drinking or alcohol use disorder should be screened for co-occurring substance use (see this resource).

Example:

“I discuss the effects that alcohol have on health and pregnancy with all my patients. Would it be ok to talk about this?”

If the client consents, asking open-ended questions is a respectful way to continue. Example:

“How does alcohol fit into your life?”

Clinicians can gauge the client’s comfort and interest in learning more and then decide whether to continue the discussion and conduct a screening test (e.g., AUDIT-C, T-ACE, TWEAK).

More information: guidance for starting the conversation

The following tools are validated for screening alcohol use during pregnancy.

If screening indicates high-risk use, a diagnostic interview should be conducted, following the criteria in the DSM-5. As shown on the treatment pathway above, the severity of AUD will determine the next steps in the treatment plan.

AUDIT-C (online calculator)

AUDIT-C (PDF)

T-ACE (PDF)

TWEAK (PDF)

CRAFFT - for youth (online calculator)

CRAFFT - for youth (PDF)

Brief Intervention

Any amount of drinking during pregnancy, whether it’s considered low-, moderate-, or high-risk should be addressed, as there are risks to the fetus with any amount. Brief intervention is an effective approach to increasing motivation and behaviour change. The 5A’s is a well-studied model for providing brief intervention.

The 5A’s are:

Ask —> Advise —> Assess —> Assist —> Arrange

The “Ask” step consists of the screening and diagnosis process. The remaining steps are where the motivational dialogue and treatment planning occur.

A condensed guide is presented below. Greater details and examples can be found on the brief intervention page.

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Trauma-Informed Practice Tips

Pregnancy is a period of particular vulnerability for individuals who have experienced trauma, and trauma has been linked to higher prevalence of alcohol use disorder. The screening, diagnosis, and treatment planning process can be challenging for patients – they may have had previous negative experiences in healthcare settings and have experienced judgement and stigma (or even violence) related to alcohol use in many areas of their lives. It’s important to be mindful of the impact our behaviors, communication, and body language can have on people with a history of trauma. Below is a list of tips to help deliver brief intervention in a non-judgmental, supportive, and compassionate manner.

Assure the patient that all conversations are private and confidential.
Utilize universal precautions for creating a calm and welcoming environment. This includes minimizing noise, decreasing clutter, maintaining a comfortable temperature
Be aware of your internal emotions and thoughts and focus on those that bolster support for the patient
Be aware of your tone of voice and physical space as you introduce yourself and your role and explain the collaborative process planned (Practical note: ensure that you do not physically block the patent’s pathway to the door)
Respond and communicate respectfully
Listen intently to understand their responses and their context
Commit to setting aside your own judgements and thoughts about screening results
Maintain awareness of your language and tone of voice when responding. Remember to use terminology and gender pronouns that reflect the patient’s preference.

- - For example, ask what name they would like to be called, their gender, their partner’s gender, and what pronouns they prefer. Validate patient’s gender identity, sexual orientation, and preferences for how they wish to be addressed)
  - Use person-first language and avoid stigmatizing terms. For example, use “alcohol poisoning” instead of “overdose”. Use “person with AUD” instead of “addict” or “alcoholic”. Use “unhealthy alcohol use” instead of “alcohol misuse”

Be sensitive about the patient’s reproductive intentions. It is important not to assume that the patient intends to carry the fetus to term or become a parent. Accommodate the patient’s reproductive intention (e.g., terminating pregnancy, placing infant for adoption) in your advice process
Empower them to describe and drive their own readiness for change. Avoid judging them for not seeming ready for being reluctant to change at that moment. With support and encouragement, they may feel more ready at a future visit.
Identify positive health assets and strengths that can contribute to better health and pregnancy outcomes
Utilize strengths-oriented open-ended questions: “How have you been successful in the past?” “What coping skills have you learned from your life experiences?”
Identifying strengths rather than deficits will enhance change talk; use this approach when discussing how to achieve a higher number if that’s their goal
Recognize that anything the patient is willing to do to address the issue is a step in the right direction
Promote resilience through language choices (I have, I am, I can); model and practice with your patient
Connect the patient to others who may be able to meet any needs that are outside your scope of practice
Reinforce that you are here to help and that this is an ongoing discussion. Ideally, you want patients to always feel comfortable to discuss these issues with you during visits
Document the agreed upon plan so you can engage in informed follow-up during the next appointment