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Neonatal abstinence syndrome is an expected and treatable outcome of in utero opioid exposure. Opioids are an essential but insufficient cause of NAS in part because maternal medication dose is not related to likelihood of developing NAS. Risk and protective factors for NAS are listed in Table 3.3.

Postpartum, or the fourth trimester, is a period of increased vulnerability to addiction recurrence, compounded by insurance churn, noncontinuation of medication, maternal mood changes, and withdrawal of care from prenatal care providers following delivery. For reasons that are unknown, people with opioid use disorder have almost four times the odds of death during the delivery hospitalization and overdose is one of the leading causes of maternal mortality in the US today.

Table 3.3 Risks and protective factors for neonatal abstinence syndrome (NAS)

Factors which increase likelihood, severity, and duration of NAS	Factors that decrease likelihood, severity, and duration of NAS
Maternal medications Gabapentin Benzodiazepines Selective serotonin reuptake inhibitorsMaternal smoking Fetal methylation of the mu‐opioid receptorNeonatal intensive care unit admission	Smoking cessation Rooming‐in BreastfeedingSkin‐to‐skin contact Preservation of the maternal–infant dyad