ACOG Stresses 'Fourth Trimester' for Better Postpartum Care

Diana Phillips

April 27, 2018

Comprehensive pregnancy care should extend into the "fourth trimester" of pregnancy and include ongoing communication between new mothers and their obstetric care providers during the first 3 months after birth, according to the American College of Obstetricians and Gynecologists (ACOG).

In a new Committee Opinion addressing optimal postpartum care, ACOG stresses that better care for women's physical and mental health after giving birth may help reduce maternal morbidity and mortality.

"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," Alison Stuebe, MD, an associate professor of maternal-fetal medicine at the University of North Carolina in Chapel Hill, and colleagues write in the Committee Opinion, which was published online April 23 in Obstetrics & Gynecology.

"New mothers need ongoing care. We want to replace the one-off checkup at 6 weeks with a period of sustained, holistic support for growing families," added Stuebe in an ACOG statement. "Our goal is for every new family to have a comprehensive care plan and a care team that supports the mother's strengths and addresses her multiple, intersecting needs following birth."

Previously, ACOG recommended a single, comprehensive postpartum visit within the first 6 weeks after giving birth. Under the revised opinion, appropriate postpartum care is considered a process versus a singular event.

In fact, the guidance indicates that optimal postpartum care begins prior to delivery. "Anticipatory guidance should begin during pregnancy with development of a postpartum care plan that addresses the transition to parenthood and well-woman care," the authors stress.

New Paradigm to Address Fragmented Postpartum Care in United States

The new guidance is specifically designed to correct the inconsistent, fragmented nature of postpartum care in the United States. Currently, as many as 40% of women who have given birth do not attend a postpartum visit, and attendance rates are lower among populations with limited resources, which contributes to health disparities, ACOG notes.

"Most women in the United States must independently navigate the postpartum transition until the traditional postpartum visit (4–6 weeks after delivery)," the authors write. "This lack of attention to maternal health needs is of particular concern given that more than one half of pregnancy-related deaths occur after the birth of the infant. Given the urgent need to reduce severe maternal morbidity and mortality, this Committee Opinion has been revised to reinforce the importance of the 'fourth trimester' and to propose a new paradigm for post-partum care."

Under the new paradigm, women should have an initial contact with their care provider within 3 weeks of childbirth for an early assessment of their well-being, the authors write. The 3-week touchpoint allows providers to assess women's risk for postpartum depression, they note. It also offers an opportunity to address breastfeeding challenges, which, if unresolved, often lead new mothers to stop breastfeeding altogether prior to the 6-week visit.

In addition to the 3-week check-in, ongoing support should be provided as needed and a comprehensive visit should take place within 12 weeks of childbirth, say Stuebe and coauthors.

A constellation of factors including lack of sleep, fatigue, pain, urinary incontinence, breastfeeding challenges, lack of sexual desire, new or worsening mental health symptoms, stress, anxiety, and uncertainty can contribute to an increased vulnerability to physical and/or psychological problems in new mothers, they stress.

The weeks following childbirth are therefore a critical period for new mothers, and so the comprehensive visit should consist of a thorough assessment, including:

  • Physical recovery from birth

  • Mood and emotional well-being

  • Infant care and feeding

  • Sleep and fatigue

  • Sexuality, contraception, and birth spacing

  • Chronic disease management

  • Health maintenance

Complicated Pregnancies, Chronic Conditions, and Adverse Birth Outcomes

The revised management approach supports the delivery of care that is "individualized and woman-centered," the authors write.

In this regard, specific guidance is offered for women with complicated pregnancies, chronic medical conditions, or adverse birth outcomes.

For example, "Women with pregnancies complicated by preterm birth, gestational diabetes, or hypertensive disorders of pregnancy should be counseled that these disorders are associated with a higher lifetime risk of maternal cardiometabolic disease," say the researchers.

In particular, ACOG recommends that women with hypertensive disorders of pregnancy have a postpartum visit within 7 to 10 days after birth to evaluate their blood pressure and a follow-up visit within 72 hours for those with severe hypertension.

"Such assessment is critical given that more than one half of postpartum strokes occur within 10 days of discharge," the authors write.

In-person early follow-up also may be beneficial for women at high risk of complications, such as postpartum depression, cesarean or perineal wound infection, lactation difficulties, or chronic conditions such as seizure disorders that require postpartum medication titration.

And women who have experienced a miscarriage, stillbirth, or neonatal death should be encouraged to follow up with their provider and directed to resources for emotional support and referrals as needed, as well as testing and counseling regarding future risks and pregnancies, the authors state.

Similarly, women with chronic medical conditions such as obesity, diabetes, kidney disease, thyroid problems, mood disorders, substance use disorders, or seizure disorders, among others, should be counseled to follow up with their ob/gyn or primary care provider to ensure ongoing coordinated care.

Continuity of Care, Communication Between Physicians, Reimbursement

The transition to "ongoing well-woman care" should also be planned during the postpartum period.

"Appropriate referrals to other members of her healthcare team should also be made during this transitional period. If responsibility is transferred to another primary care provider, the obstetrician-gynecologist or other obstetric care provider is responsible for ensuring that there is communication with the primary care provider so that he or she can understand the implications of any pregnancy complications for the woman's future health and maintain continuity of care."

In addition to this new clinical guidance for postpartum care, the Committee Opinion advocates for "reimbursement policies that support the postpartum care as an ongoing process, rather than an isolated visit."

And, "More broadly, provisions for paid parental leave are essential to the health of women and children and reduce disparities."

The authors note that ACOG endorses paid parental leave — full benefits and 100% of pay for at least 6 weeks — as essential.

"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 ACOG Committee Opinion is also endorsed by the Academy of Breastfeeding Medicine, American College of Nurse-Midwives, National Association of Nurse Practitioners in Women's Health, Society for Academic Specialists in General Obstetrics and Gynecology, and Society for Maternal-Fetal Medicine. The authors have reported no relevant financial relationships.

Obstet Gynecol. 2018;131:e140-e150. Full text

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