Postpartum Care
/Here’s the RoshReview Question of the Week:
A 23-year-old G1P1001 woman presents to the office for her routine postpartum visit. She is 6 weeks postpartum status post vaginal delivery of a healthy infant. Her pregnancy was complicated by diet-controlled gestational diabetes mellitus and obesity. She completes a 2-hour glucose tolerance test using a 75 g glucose load. Her fasting plasma glucose level is 85 mg/dL, and her 2-hour plasma glucose level is 130 mg/dL. Which of the following is the most likely diagnosis?
More Reading: ACOG Committee Opinion 736 from May 2018: Optimizing Postpartum Care
Why Do We Care About PP Care?
The days/weeks following birth are critical for patient and infant well-being
Multiple physical, social, and psychological changes
Recovery from delivery (either vaginal or cesarean)
Challenges of breastfeeding
Lack of sleep, fatigue, pain, stress
New or exacerbation to mental health disorders
Urinary or even anal incontinence
Challenges
Fragmented care between pediatric and obstetric care providers:
As an example of what babies get: day 1-2 of life, day 3-5 of life, 1 month check up, 2 month, 4 month, 6 month, 9 month, and 12 month
Just for well babies!
If other complications, maybe more visits!
Long time before we see our patients
Usually, will see them at 4-6 weeks postpartum
Initial lack of attention to maternal health needs - more than half of pregnancy related deaths occur after the birth of the infant!
Instead of ongoing care, we have fragmented, one or two time visits
A Call to Action
Because of these issues, ACOG has wanted to increase awareness for the fourth trimester
What we currently have - (FYI, this is me ranting about our current system because I’m a raging socialist. Feel free to chop as much as needed)
4-6 week visit x1
Edinburgh postpartum depression screens to try and catch postpartum blues, but administered in the hospital and again at 4-6 weeks - can miss depression in the first month after birth
With COVID, often not letting family members or infants come to postpartum visits
All pregnant patients receive health insurance through Medicaid, but this insurance stops at 6 weeks postpartum
The US is also one of 7 countries in the entire world without paid maternity leave (WTF)
On average, countries that provide paid maternity leave pay 77% of previous pay
The UK has paid maternity leave minimum of 39 weeks. Most places have a minimum paid maternity leave of 12 weeks to a full year, and on average, globally, the paid maternity leave is 29 weeks. Average paternity leave is 16 weeks
NY Times
What this results in
Less attendance of postpartum visits
Not wanting to use accrued family leave/sick days for appointments
Unable to find someone to care for themselves/their infants to go to appointments
Results in as many as 40% of patients don’t go to postpartum visits
23% of employed women return to work within 10 days postpartum, and an additional 22% return to work between 10-40 days pp!!!!!
Less anticipatory guidance
With decreased time during pregnancy (due to covid) and also with not going to postpartum visits and not having PP visits soon enough → on a national survey, less than ½ of patients attending a PPV reported the received enough info about depression, birth spacing, healthy eating, importance of exercise, changes to their sexual response and emotions
In randomized controlled trial, 15 minutes of anticipatory guidance before discharge, followed by phone call at 2 weeks reduced symptoms of depression and increased breastfeeding duration through 6 months among black and hispanic women
More maternal morbidity and mortality
What we want (and ACOG wants)
Timing of postpartum visit be individualized and woman centered
Initial assessment within 3 weeks postpartum to address acute issues
Follow this up with ongoing care as needed - ie. well woman visit no later than 12 weeks after birth
Insurance should allow for this care (don’t take it away after 6 weeks!)
American Rescue Plan Act - allows states to extend Medicaid coverage for pregnant people from 60 days to 1 year postpartum
As of 4/2022: currently in effect for 13 states
14 states and DC planning to implement a 12 month extension
4 states with limited overage extension approved or proposed
4 states pending legislation to seek federal approval
What should we be doing then for PP Care?
Start early - begin anticipatory guidance even in prenatal care!
Develop a postpartum care plan (Table 1 - can go through some of these things)
Reproductive life planning
Review desire for future pregnancies
Counsel pregnancy spacing (avoid short interval pregnancy, within 6 months, and risks and benefits of pregnancy sooner than 18 months)
Review contraception options if desired
Build a support system
Review: who will provide social and material support? Ie. family, friends
Can get social work involved if needed
Identify providers that patient can call with questions
Primary care provider, Ob provider, psychiatry provider
Pediatric provider
Lactation support
Care coordinator/case manager
Home visitation
Provide phone numbers or other contact information
Intrapartum to Postpartum Care
Early postpartum period contains substantial morbidity
Blood pressure evaluation no later than 7-10 days postpartum for those with hypertension
Great studies regarding postpartum blood pressure checks via text message - easy for both patients and clinicians
Decreases usage of emergency rooms
Those with severe hypertension should be seen within 72 hours!
In person follow up earlier for patients with complications such as:
Cesarean section or perineal wound infection
Lactation difficulties
Chronic conditions like seizures that may require postpartum medication titration
WHO recommends follow up of all women and infant dyads at 3 days, 1-2 weeks, and 6 weeks - we don’t do this in the US!
Based off of this ACOG recommends first contact within 3 weeks (does not have to be in person, can be by phone)
Can set up postpartum care either in the prenatal period (we will usually make pp appointments for patients in the hospital or right before delivery)
The components of postpartum care - these were really good from ACOG, so thought I would include
Mood and emotional well-being
Infant care
Sexuality, contraception, birth spacing
Sleep/fatigue
Physical recovery
Chronic disease management
Health maintenance
What about birth trauma?
Remember that trauma is in the eye of the beholder
Many healthcare providers may not even be aware that their patient experienced trauma
Allow patients to ask questions about their labor, childbirth course and review any complications
Complications should be reviewed and how they can best be avoided in next pregnancy if possible (ie. reduce risk of preterm birth, preeclampsia)
Referral to support group, mental health care specialist
Pregnancy loss
Remember to always review someone’s labor course and delivery!
May sound basic, but there are times when people miss a cesarean scar or even that someone had a pregnancy loss and congratulate the patient (omg)
Emotional support and bereavement counseling with referrals if appropriate
Review labs and path from loss
Order other labs if needed (look at our stillbirth episode)
Transition to ongoing care
Refer to ongoing well woman care within 12 weeks
Make sure that there is a good transition for birth control/continued prescriptions
Write this out in your notes/recommendations
Many patients all of a sudden don’t have access to get their birth control because their obstetrician or midwife isn’t seeing them anymore
Or, if their OB started them on an antidepressant, all of a sudden, they don’t get scripts anymore because they are not longer postpartum - make sure to help patients get appointments to their PCP or mental health care and transition them!
