ACOG advises earlier, more comprehensive postpartum care

 

It’s time to introduce a new paradigm for comprehensive care of women’s physical and mental health in the 3 months after giving birth, according to the American College of Obstetricians and Gynecologists.

In their newly revised committee opinion on postpartum care, ACOG encouraged doctors to think of a woman’s immediate postpartum period as a “fourth trimester” during which better care for women may help reduce maternal deaths and morbidity. That care includes a 3-week postpartum visit and a more comprehensive one within 3 months post partum.

“In addition to being a time of joy and excitement, this ‘fourth trimester’ can present considerable challenges for women, including lack of sleep, fatigue, pain, breastfeeding difficulties, stress, new onset or exacerbation of mental health disorders, lack of sexual desire, and urinary incontinence,” wrote Alison Stuebe, MD, MSc, an associate professor of maternal-fetal medicine at the University of North Carolina in Chapel Hill, and fellow ACOG members who authored the updated committee opinion. “Changes in the scope of postpartum care should be facilitated by reimbursement policies that support postpartum care as an ongoing process, rather than [as] an isolated visit,” they wrote.

Despite common practices in many other cultures that provide intense, dedicated support to women during the 30-40 days after giving birth, U.S. women typically only see their ob.gyn. at a single 6-week postpartum visit and receive little to no other formal maternal support. Beyond that visit, U.S. postpartum care typically is fragmented and inconsistent, split sporadically among pediatric and maternal providers and with little support in the transition from inpatient to outpatient care, the committee wrote.

Further, 40% of women do not attend a postpartum visit at all, and more than half of maternal deaths occur after the baby’s birth. The committee aims to overhaul maternal care and potentially help reduce those numbers. That process begins with prenatal discussions about the mother’s transition to parenthood, caring for herself and her health, her reproductive life plans, her desires related to future children, the timing of future pregnancies, and appropriate contraceptive options and decisions.

“Underutilization of postpartum care impedes management of chronic health conditions and access to effective contraception, which increases the risk of short interval pregnancy and preterm birth,” the committee wrote. “Attendance rates are lower among populations with limited resources, which contributes to health disparities.”

 

Components of comprehensive postpartum care

ACOG recommends the prenatal preparation for the postpartum period include discussions about infant feeding, “baby blues,” postpartum emotional health, parenting challenges, postpartum recovery from birth, long-term management of chronic health conditions, choosing a primary care provider for the mother’s ongoing care, her reproductive desires and choices, and any concerns about interpersonal or partner violence.

Before giving birth, a woman should develop a postpartum care plan with her physician and assemble a care team that includes her primary care providers along with family and friends who can provide support. The plan should include contact information for questions and written instructions about postpartum visits and follow-up care.

Prenatal planning also provides an opportunity to discuss a woman’s breastfeeding plans, goals, and questions as well as common physical problems that women may experience in the weeks after giving birth, such as heavy bleeding, pain, physical exhaustion, and urinary incontinence.

Physicians should inform women of the risks and benefits of becoming pregnant within 18 months and advise them not to have pregnancy intervals of less than 6 months. They should also ensure women know all their contraceptive options and should provide any information necessary for women to determine which methods best meet her needs.

The committee recommended a postpartum visit within the first 3 weeks after birth, instead of the current “6-week check,” that is timed and tailored to each woman’s particular needs. This visit allows assessment of postpartum depression risk and/or treatment and discussion of breastfeeding goals and/or difficulties. Approximately one in five women who stopped breastfeeding earlier than they wanted to had ceased within first 6 weeks post partum.

Woman-centered follow-up should be tailored to women’s individual needs and include a comprehensive postpartum visit no later than 12 weeks after giving birth. The comprehensive visit should include a complete assessment of the woman’s physical, social, and psychological well-being, including discussion of “mood and emotional well-being, infant care and feeding, sexuality, contraception, birth spacing, sleep and fatigue, physical recovery from birth, chronic disease management, and health maintenance,” the committee wrote.

The comprehensive visit should include the following components:

• Postpartum depression and anxiety screening.
• Screening for tobacco use and substance use.
• Follow-up on preexisting mental and physical health conditions.
• Assessment of mother’s confidence and comfort with newborn care, including feeding method, childcare strategy, identification of the child’s medical home, and recommended immunizations for all caregivers.
• Comfort and confidence with breastfeeding and management of any challenges, such as breastfeeding-associated pain; logistics and legal rights after returning to work or school; and fertility and contraception with breastfeeding.
• Assessment of material needs, including housing, utilities, food, and diapers.
• Guidance on sexuality, dyspareunia, reproductive life plans, contraception, and management of recurrent pregnancy complications, such as daily low-dose aspirin to reduce preeclampsia risk and 17a-hydroxyprogesterone caproate to reduce recurrent preterm birth.
• Sleep, fatigue, and coping options.
• Physical recovery from birth, including assessment of urinary and fecal continence and guidance on physical activity and a healthy weight.
• Chronic disease management and long-term implications of those conditions.
• Health maintenance, including review of vaccination history, needed vaccinations, and well-woman screenings, including Pap test and pelvic examination as indicated.

 

“However timed, the comprehensive postpartum visit is a medical appointment; it is not an ‘all-clear’ signal,” the authors wrote. “Obstetrician-gynecologists and other obstetric care providers should ensure that women, their families, and their employers understand that completion of the comprehensive postpartum visit does not obviate the need for continued recovery and support through 6 weeks’ post partum and beyond.”

Women with comorbidities or adverse birth outcomes

Women who had gestational diabetes, gestational hypertension, preeclampsia, eclampsia, or a preterm birth should be informed of their increased lifetime risk of cardiovascular and metabolic disease, the committee recommended. Women who have experienced a miscarriage, stillbirth, or neonatal death should also follow up with their provider, who can offer resources for emotional support and bereavement counseling, referrals as needed, a review of any laboratory or pathology results related to the loss and counseling regarding future risks and pregnancies.

The committee recommended that women with chronic medical conditions follow up with their ob.gyn. or other primary care providers to ensure ongoing coordinated care for hypertension, obesity, diabetes, thyroid disorders, renal disease, mood disorders, substance use disorders, seizure disorders, and any other chronic issues. Care should include assessment of medications, including antiepileptics and psychotropic drugs, that may require adjustment for postpartum physiology and, if relevant, breastfeeding.

Since half of postpartum strokes occur within the first 10 days after discharge, ACOG recommends women with other hypertensive disorders of pregnancy have a postpartum visit within 7-10 days after birth to assess blood pressure. A follow-up visit should occur within 72 hours for those with severe hypertension.

ACOG also recommended early postpartum follow-up for women with increased risk of complications, including postpartum depression, cesarean or perennial wound infections, lactation difficulties, or chronic conditions.

 

The committee opinion concluded with a call for public policy changes, including endorsement of guaranteed 100% paid parental leave for a minimum of 6 weeks with full benefits. Currently, 23% of employed mothers return to work in the first 10 days after giving birth, and another 22% return within 10-30 days, the committee cited. Close to half of employed mothers therefore go back to work before the 6-week postpartum follow-up visit.

“Obstetrician-gynecologists and other obstetric care providers should be in the forefront of policy efforts to enable all women to recover from birth and nurture their infants,” the committee wrote.

The ACOG Presidential Task Force on Redefining the Postpartum Visit and the Committee on Obstetrics Practice developed the new clinical opinion, which is endorsed by the Academy of Breastfeeding Medicine, the American College of Nurse-Midwives, the National Association of Nurse Practitioners in Women’s Health, the Society for Academic Specialists in General Obstetrics and Gynecology, and the Society for Maternal-Fetal Medicine. The committee opinion did not require external funding, and the authors did not report any disclosures.

SOURCE: Obstet Gynecol 2018;131:e140-50.

 

It’s time to introduce a new paradigm for comprehensive care of women’s physical and mental health in the 3 months after giving birth, according to the American College of Obstetricians and Gynecologists.

In their newly revised committee opinion on postpartum care, ACOG encouraged doctors to think of a woman’s immediate postpartum period as a “fourth trimester” during which better care for women may help reduce maternal deaths and morbidity. That care includes a 3-week postpartum visit and a more comprehensive one within 3 months post partum.

“In addition to being a time of joy and excitement, this ‘fourth trimester’ can present considerable challenges for women, including lack of sleep, fatigue, pain, breastfeeding difficulties, stress, new onset or exacerbation of mental health disorders, lack of sexual desire, and urinary incontinence,” wrote Alison Stuebe, MD, MSc, an associate professor of maternal-fetal medicine at the University of North Carolina in Chapel Hill, and fellow ACOG members who authored the updated committee opinion. “Changes in the scope of postpartum care should be facilitated by reimbursement policies that support postpartum care as an ongoing process, rather than [as] an isolated visit,” they wrote.

Despite common practices in many other cultures that provide intense, dedicated support to women during the 30-40 days after giving birth, U.S. women typically only see their ob.gyn. at a single 6-week postpartum visit and receive little to no other formal maternal support. Beyond that visit, U.S. postpartum care typically is fragmented and inconsistent, split sporadically among pediatric and maternal providers and with little support in the transition from inpatient to outpatient care, the committee wrote.

Further, 40% of women do not attend a postpartum visit at all, and more than half of maternal deaths occur after the baby’s birth. The committee aims to overhaul maternal care and potentially help reduce those numbers. That process begins with prenatal discussions about the mother’s transition to parenthood, caring for herself and her health, her reproductive life plans, her desires related to future children, the timing of future pregnancies, and appropriate contraceptive options and decisions.

“Underutilization of postpartum care impedes management of chronic health conditions and access to effective contraception, which increases the risk of short interval pregnancy and preterm birth,” the committee wrote. “Attendance rates are lower among populations with limited resources, which contributes to health disparities.”

 

Components of comprehensive postpartum care

ACOG recommends the prenatal preparation for the postpartum period include discussions about infant feeding, “baby blues,” postpartum emotional health, parenting challenges, postpartum recovery from birth, long-term management of chronic health conditions, choosing a primary care provider for the mother’s ongoing care, her reproductive desires and choices, and any concerns about interpersonal or partner violence.

Before giving birth, a woman should develop a postpartum care plan with her physician and assemble a care team that includes her primary care providers along with family and friends who can provide support. The plan should include contact information for questions and written instructions about postpartum visits and follow-up care.

Prenatal planning also provides an opportunity to discuss a woman’s breastfeeding plans, goals, and questions as well as common physical problems that women may experience in the weeks after giving birth, such as heavy bleeding, pain, physical exhaustion, and urinary incontinence.

Physicians should inform women of the risks and benefits of becoming pregnant within 18 months and advise them not to have pregnancy intervals of less than 6 months. They should also ensure women know all their contraceptive options and should provide any information necessary for women to determine which methods best meet her needs.

The committee recommended a postpartum visit within the first 3 weeks after birth, instead of the current “6-week check,” that is timed and tailored to each woman’s particular needs. This visit allows assessment of postpartum depression risk and/or treatment and discussion of breastfeeding goals and/or difficulties. Approximately one in five women who stopped breastfeeding earlier than they wanted to had ceased within first 6 weeks post partum.

Woman-centered follow-up should be tailored to women’s individual needs and include a comprehensive postpartum visit no later than 12 weeks after giving birth. The comprehensive visit should include a complete assessment of the woman’s physical, social, and psychological well-being, including discussion of “mood and emotional well-being, infant care and feeding, sexuality, contraception, birth spacing, sleep and fatigue, physical recovery from birth, chronic disease management, and health maintenance,” the committee wrote.

The comprehensive visit should include the following components:

• Postpartum depression and anxiety screening.
• Screening for tobacco use and substance use.
• Follow-up on preexisting mental and physical health conditions.
• Assessment of mother’s confidence and comfort with newborn care, including feeding method, childcare strategy, identification of the child’s medical home, and recommended immunizations for all caregivers.
• Comfort and confidence with breastfeeding and management of any challenges, such as breastfeeding-associated pain; logistics and legal rights after returning to work or school; and fertility and contraception with breastfeeding.
• Assessment of material needs, including housing, utilities, food, and diapers.
• Guidance on sexuality, dyspareunia, reproductive life plans, contraception, and management of recurrent pregnancy complications, such as daily low-dose aspirin to reduce preeclampsia risk and 17a-hydroxyprogesterone caproate to reduce recurrent preterm birth.
• Sleep, fatigue, and coping options.
• Physical recovery from birth, including assessment of urinary and fecal continence and guidance on physical activity and a healthy weight.
• Chronic disease management and long-term implications of those conditions.
• Health maintenance, including review of vaccination history, needed vaccinations, and well-woman screenings, including Pap test and pelvic examination as indicated.

 

“However timed, the comprehensive postpartum visit is a medical appointment; it is not an ‘all-clear’ signal,” the authors wrote. “Obstetrician-gynecologists and other obstetric care providers should ensure that women, their families, and their employers understand that completion of the comprehensive postpartum visit does not obviate the need for continued recovery and support through 6 weeks’ post partum and beyond.”

Women with comorbidities or adverse birth outcomes

Women who had gestational diabetes, gestational hypertension, preeclampsia, eclampsia, or a preterm birth should be informed of their increased lifetime risk of cardiovascular and metabolic disease, the committee recommended. Women who have experienced a miscarriage, stillbirth, or neonatal death should also follow up with their provider, who can offer resources for emotional support and bereavement counseling, referrals as needed, a review of any laboratory or pathology results related to the loss and counseling regarding future risks and pregnancies.

The committee recommended that women with chronic medical conditions follow up with their ob.gyn. or other primary care providers to ensure ongoing coordinated care for hypertension, obesity, diabetes, thyroid disorders, renal disease, mood disorders, substance use disorders, seizure disorders, and any other chronic issues. Care should include assessment of medications, including antiepileptics and psychotropic drugs, that may require adjustment for postpartum physiology and, if relevant, breastfeeding.

Since half of postpartum strokes occur within the first 10 days after discharge, ACOG recommends women with other hypertensive disorders of pregnancy have a postpartum visit within 7-10 days after birth to assess blood pressure. A follow-up visit should occur within 72 hours for those with severe hypertension.

ACOG also recommended early postpartum follow-up for women with increased risk of complications, including postpartum depression, cesarean or perennial wound infections, lactation difficulties, or chronic conditions.

 

The committee opinion concluded with a call for public policy changes, including endorsement of guaranteed 100% paid parental leave for a minimum of 6 weeks with full benefits. Currently, 23% of employed mothers return to work in the first 10 days after giving birth, and another 22% return within 10-30 days, the committee cited. Close to half of employed mothers therefore go back to work before the 6-week postpartum follow-up visit.

“Obstetrician-gynecologists and other obstetric care providers should be in the forefront of policy efforts to enable all women to recover from birth and nurture their infants,” the committee wrote.

The ACOG Presidential Task Force on Redefining the Postpartum Visit and the Committee on Obstetrics Practice developed the new clinical opinion, which is endorsed by the Academy of Breastfeeding Medicine, the American College of Nurse-Midwives, the National Association of Nurse Practitioners in Women’s Health, the Society for Academic Specialists in General Obstetrics and Gynecology, and the Society for Maternal-Fetal Medicine. The committee opinion did not require external funding, and the authors did not report any disclosures.

SOURCE: Obstet Gynecol 2018;131:e140-50.

 

It’s time to introduce a new paradigm for comprehensive care of women’s physical and mental health in the 3 months after giving birth, according to the American College of Obstetricians and Gynecologists.

In their newly revised committee opinion on postpartum care, ACOG encouraged doctors to think of a woman’s immediate postpartum period as a “fourth trimester” during which better care for women may help reduce maternal deaths and morbidity. That care includes a 3-week postpartum visit and a more comprehensive one within 3 months post partum.

“In addition to being a time of joy and excitement, this ‘fourth trimester’ can present considerable challenges for women, including lack of sleep, fatigue, pain, breastfeeding difficulties, stress, new onset or exacerbation of mental health disorders, lack of sexual desire, and urinary incontinence,” wrote Alison Stuebe, MD, MSc, an associate professor of maternal-fetal medicine at the University of North Carolina in Chapel Hill, and fellow ACOG members who authored the updated committee opinion. “Changes in the scope of postpartum care should be facilitated by reimbursement policies that support postpartum care as an ongoing process, rather than [as] an isolated visit,” they wrote.

Despite common practices in many other cultures that provide intense, dedicated support to women during the 30-40 days after giving birth, U.S. women typically only see their ob.gyn. at a single 6-week postpartum visit and receive little to no other formal maternal support. Beyond that visit, U.S. postpartum care typically is fragmented and inconsistent, split sporadically among pediatric and maternal providers and with little support in the transition from inpatient to outpatient care, the committee wrote.

Further, 40% of women do not attend a postpartum visit at all, and more than half of maternal deaths occur after the baby’s birth. The committee aims to overhaul maternal care and potentially help reduce those numbers. That process begins with prenatal discussions about the mother’s transition to parenthood, caring for herself and her health, her reproductive life plans, her desires related to future children, the timing of future pregnancies, and appropriate contraceptive options and decisions.

“Underutilization of postpartum care impedes management of chronic health conditions and access to effective contraception, which increases the risk of short interval pregnancy and preterm birth,” the committee wrote. “Attendance rates are lower among populations with limited resources, which contributes to health disparities.”

 

Components of comprehensive postpartum care

ACOG recommends the prenatal preparation for the postpartum period include discussions about infant feeding, “baby blues,” postpartum emotional health, parenting challenges, postpartum recovery from birth, long-term management of chronic health conditions, choosing a primary care provider for the mother’s ongoing care, her reproductive desires and choices, and any concerns about interpersonal or partner violence.

Before giving birth, a woman should develop a postpartum care plan with her physician and assemble a care team that includes her primary care providers along with family and friends who can provide support. The plan should include contact information for questions and written instructions about postpartum visits and follow-up care.

Prenatal planning also provides an opportunity to discuss a woman’s breastfeeding plans, goals, and questions as well as common physical problems that women may experience in the weeks after giving birth, such as heavy bleeding, pain, physical exhaustion, and urinary incontinence.

Physicians should inform women of the risks and benefits of becoming pregnant within 18 months and advise them not to have pregnancy intervals of less than 6 months. They should also ensure women know all their contraceptive options and should provide any information necessary for women to determine which methods best meet her needs.

The committee recommended a postpartum visit within the first 3 weeks after birth, instead of the current “6-week check,” that is timed and tailored to each woman’s particular needs. This visit allows assessment of postpartum depression risk and/or treatment and discussion of breastfeeding goals and/or difficulties. Approximately one in five women who stopped breastfeeding earlier than they wanted to had ceased within first 6 weeks post partum.

Woman-centered follow-up should be tailored to women’s individual needs and include a comprehensive postpartum visit no later than 12 weeks after giving birth. The comprehensive visit should include a complete assessment of the woman’s physical, social, and psychological well-being, including discussion of “mood and emotional well-being, infant care and feeding, sexuality, contraception, birth spacing, sleep and fatigue, physical recovery from birth, chronic disease management, and health maintenance,” the committee wrote.

The comprehensive visit should include the following components:

• Postpartum depression and anxiety screening.
• Screening for tobacco use and substance use.
• Follow-up on preexisting mental and physical health conditions.
• Assessment of mother’s confidence and comfort with newborn care, including feeding method, childcare strategy, identification of the child’s medical home, and recommended immunizations for all caregivers.
• Comfort and confidence with breastfeeding and management of any challenges, such as breastfeeding-associated pain; logistics and legal rights after returning to work or school; and fertility and contraception with breastfeeding.
• Assessment of material needs, including housing, utilities, food, and diapers.
• Guidance on sexuality, dyspareunia, reproductive life plans, contraception, and management of recurrent pregnancy complications, such as daily low-dose aspirin to reduce preeclampsia risk and 17a-hydroxyprogesterone caproate to reduce recurrent preterm birth.
• Sleep, fatigue, and coping options.
• Physical recovery from birth, including assessment of urinary and fecal continence and guidance on physical activity and a healthy weight.
• Chronic disease management and long-term implications of those conditions.
• Health maintenance, including review of vaccination history, needed vaccinations, and well-woman screenings, including Pap test and pelvic examination as indicated.

 

“However timed, the comprehensive postpartum visit is a medical appointment; it is not an ‘all-clear’ signal,” the authors wrote. “Obstetrician-gynecologists and other obstetric care providers should ensure that women, their families, and their employers understand that completion of the comprehensive postpartum visit does not obviate the need for continued recovery and support through 6 weeks’ post partum and beyond.”

Women with comorbidities or adverse birth outcomes

Women who had gestational diabetes, gestational hypertension, preeclampsia, eclampsia, or a preterm birth should be informed of their increased lifetime risk of cardiovascular and metabolic disease, the committee recommended. Women who have experienced a miscarriage, stillbirth, or neonatal death should also follow up with their provider, who can offer resources for emotional support and bereavement counseling, referrals as needed, a review of any laboratory or pathology results related to the loss and counseling regarding future risks and pregnancies.

The committee recommended that women with chronic medical conditions follow up with their ob.gyn. or other primary care providers to ensure ongoing coordinated care for hypertension, obesity, diabetes, thyroid disorders, renal disease, mood disorders, substance use disorders, seizure disorders, and any other chronic issues. Care should include assessment of medications, including antiepileptics and psychotropic drugs, that may require adjustment for postpartum physiology and, if relevant, breastfeeding.

Since half of postpartum strokes occur within the first 10 days after discharge, ACOG recommends women with other hypertensive disorders of pregnancy have a postpartum visit within 7-10 days after birth to assess blood pressure. A follow-up visit should occur within 72 hours for those with severe hypertension.

ACOG also recommended early postpartum follow-up for women with increased risk of complications, including postpartum depression, cesarean or perennial wound infections, lactation difficulties, or chronic conditions.

 

The committee opinion concluded with a call for public policy changes, including endorsement of guaranteed 100% paid parental leave for a minimum of 6 weeks with full benefits. Currently, 23% of employed mothers return to work in the first 10 days after giving birth, and another 22% return within 10-30 days, the committee cited. Close to half of employed mothers therefore go back to work before the 6-week postpartum follow-up visit.

“Obstetrician-gynecologists and other obstetric care providers should be in the forefront of policy efforts to enable all women to recover from birth and nurture their infants,” the committee wrote.

The ACOG Presidential Task Force on Redefining the Postpartum Visit and the Committee on Obstetrics Practice developed the new clinical opinion, which is endorsed by the Academy of Breastfeeding Medicine, the American College of Nurse-Midwives, the National Association of Nurse Practitioners in Women’s Health, the Society for Academic Specialists in General Obstetrics and Gynecology, and the Society for Maternal-Fetal Medicine. The committee opinion did not require external funding, and the authors did not report any disclosures.

SOURCE: Obstet Gynecol 2018;131:e140-50.