Postpartum Care – The ‘Fourth Trimester’

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: Optimizing Postpartum Care  

SMFM Special Statement: Postpartum visit checklists for normal pregnancy and complicated pregnancy

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

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