CMECNE

ACOG Redefines the Postpartum Visit – The ‘Fourth Trimester’

Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Discuss the important difference between the previous approach to postpartum care and the new ACOG committee opinion on this topic
2. Apply the key elements of the postpartum care plan to your practice

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from May 7 2018 through 07/15/2022, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

SUMMARY:

Rather than an arbitrary ‘6-week check’, ACOG recommends postpartum care that is “individualized and women centered” over the first 12 weeks following delivery.

Timing of Visits

Within first 3 weeks

Initial assessment to identify acute concerns
- Can be either in person or by phone
High risk patients: Follow-up between 1 to 3 weeks
- For patients with complications | May require multiple visits
Hypertensive disorders of pregnancy
- No later than 7 to 10 days postpartum
- Severe: Within 72 hours
- Some expert opinion recommends 3 to 5 days

3 to 12 weeks

Ongoing follow-up as needed

No later than 12 weeks

Comprehensive well-woman visit which includes assessment of physical, social and psychological well-being
- Visit components are detailed in the ACOG Committee Opinion (see ‘Learn More – Primary Sources’ below)
The primary maternal care provider is responsible for patient’s care through to the comprehensive visit

Note: World Health Organization (WHO) recommends routine postpartum evaluation of all women/infants at 3 days, 1 to 2 weeks and 6 weeks; NICE recommends assessment for “Baby Blues” at 10 to 14 days

KEY POINTS:

Postpartum Care Plan

Begin discussions during pregnancy on the following topics

Infant feeding
Postpartum emotional health
Follow up for potential pregnancy complications
- Diabetes: Glucose screening
- Hypertension: BP check
- Further risk reduction strategies
Chronic health conditions, including
- Diabetes
- Hypertension
- Mental Health
- Risk recommendations for future pregnancies
Baseline arteriosclerotic cardiovascular disease (ASCVD) risk assessment in women who have had adverse pregnancy outcomes associated with ASCVD
- Preterm delivery
- Gestational diabetes
- Gestational hypertension | Preeclampsia | Eclampsia
Care team (postpartum) which includes
- Primary and specialty medical services
- Family and friends
- Detailed team member list can be found in Table 2 of ACOG Committee Opinion
Importance of postpartum care and follow up
- Time/Date/Location/Phone numbers to reschedule
Potential postpartum issues (e.g., pelvic floor exercises for stress urinary incontinence)

Reproductive Life Planning

Begin discussions during pregnancy on the following topics

Interest in future pregnancies
Encourage interpregnancy intervals ≥ 18 months (JAMA, 2006)
- Compared with interpregnancy intervals of 18 to 23 months
  - < 6 months associated with increased risks of preterm birth, low birth weight, and small for gestational age
  - 6 to 17 months and longer than 59 months were also associated with a significantly greater risk for the 3 adverse perinatal outcomes
- Short interpregnancy intervals are associated with reduced VBAC success
Take into account personal/mitigating circumstances such as age, fecundity, economic and social support systems
Contraception
- Provide full range of contraceptive options being sensitive to context and history of marginalized populations on this subject

Insurance coverage and Policy Considerations

ACOG endorses paid parental leave for 6 weeks, including full benefits and 100% pay and in addition

Insurance coverage policies should be aligned to support this tailored approach to “fourth trimester” care.

Optimizing care and support for postpartum families will require policy changes. Changes in the scope of postpartum care should be facilitated by reimbursement policies that support postpartum care as an ongoing process, rather than an isolated visit.

Learn More – Primary Sources:

ACOG Committee Opinion 736: Presidential Task Force on Redefining the Postpartum Visit

JAMA (2006): Birth Spacing and Risk of Adverse Perinatal Outcomes | A Meta-analysis

SMFM Special Statement: Checklist for postpartum discharge of women with hypertensive disorders

SMFM: Quality metric for timely postpartum follow-up after severe hypertension

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ACOG Redefines the Postpartum Visit – The ‘Fourth Trimester’