Substance use in pregnancy — structured oral station (12 minutes)

Opening prompt — "Tell me how you open this consultation."

Model response — say it in this order: ^[1][15]

• "I would frame the questions as routine and universal: 'I ask all my patients about alcohol, smoking and other drugs, because it changes how I look after you. What you tell me is confidential unless I'm worried about your safety.'"
• "I would screen with AUDIT-C for alcohol and the 4Ps Plus for substances, take the what-when-how-much-last use-route history by trimester, and screen in parallel for mental health, intimate partner violence, blood-borne viruses, housing and nutrition."
• "My stance is non-judgemental and trauma-informed — she shuts down about her partner, so I am alert to coercion and child-protection history, and I earn the history before I reach for the urine drug screen."^[14][15]

Examiner is listening for: universal framing, validated tools, and the explicit stance — not a punitive 'tox screen on everyone'. ^[15]

Probe 1 — "She binges on alcohol. What do you tell her about the fetal risk?"

• "There is no identified safe threshold for alcohol in pregnancy. The harm spans the fetal alcohol spectrum disorder range — full fetal alcohol syndrome, partial FAS, alcohol-related neurodevelopmental disorder and alcohol-related birth defects. The risk is highest in the first trimester, often before pregnancy recognition, but persists throughout."^[13]
• "I would advise abstinence explicitly, start folic acid 5 mg daily, refer to addiction medicine, and book a detailed anomaly scan with cardiac views. There is no approved pharmacotherapy for alcohol use disorder that I would routinely use in pregnancy."^[13]

Probe 2 — "She uses heroin intermittently. What is your pharmacological management?"

• "Opioid agonist therapy is first-line — methadone or buprenorphine maintenance. Detox in pregnancy is rarely indicated because of the relapse, fetal distress and fetal demise risk."^[1]
• "Methadone 60 to 120 mg orally daily, titrated to no withdrawal, no craving, no euphoria, once daily under supervised consumption; or buprenorphine 8 to 24 mg sublingually daily as the mono-product, started only once she is in mild withdrawal to avoid precipitated withdrawal."^[1]

Probe 3 — "Is buprenorphine better for the baby than methadone?"

• "The MOTHER trial randomised 175 opioid-dependent pregnant women to methadone versus buprenorphine. Buprenorphine-exposed neonates needed significantly less morphine — 1.1 versus 10.4 mg — had a shorter hospital stay — 10 versus 17.5 days — and a shorter NAS treatment duration — 4.1 versus 9.9 days."^[2]
• "The trade-off was a higher maternal discontinuation rate with buprenorphine — 33% versus 18%. Neither agent is clearly superior overall; I would individualise the choice with her and the addiction team."^[2]

Probe 4 — "She is terrified her baby will be taken again. How do you respond?"

This is a scored domain, not a courtesy. Demonstrate it out loud: ^[1][15]

• Sit at her eye level, use her name, acknowledge the fear plainly: "I can see this is frightening. My job is to look after you and the baby, and to keep you together wherever that is safe. Engaging with treatment and the team is the thing that protects your family — not avoiding care."
• Be honest about mandatory reporting where it applies, avoid promises you cannot keep, allocate a support worker, and commit to a plan she helps shape.
• Do not conduct the conversation with your back turned or your eyes on the screen. ^[15]

Probe 5 — "What is the plan for the birth, the baby and afterwards?"

• Birth: plan in a unit with neonatal expertise; avoid mixed agonist-antagonists in labour (they precipitate withdrawal); neuraxial analgesia preferred; alert the neonatal team; her labour analgesia is not covered by her agonist dose. ^[1]
• Neonate: anticipate NAS (onset 12 to 48 hours for buprenorphine, 24 to 72 hours for methadone); rooming-in, breastfeeding if stable, non-pharmacological care first — the Eat Sleep Console model — and pharmacotherapy only if she is not eating, sleeping or consoling. ^[16]
• Postpartum: the period of highest overdose-death risk. Prescribe take-home naloxone, place a long-acting reversible contraceptive before discharge, book a postnatal review within the first week, and warm-handover to addiction medicine and the GP. ^[1]