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Ob-Gyns Stress the Importance of Postpartum Care: The Fourth Trimester

May 23, 2016

Washington, DC – Although it is recommended that all women undergo a comprehensive visit within the first 6 weeks after birth, as many as 40% of women do not attend a postpartum visit. In order to optimize postpartum care for patients and to promote continuation of care through a woman’s lifespan, today, the American College of Obstetricians and Gynecologists (ACOG) released a new Committee Opinion to guide women’s health care providers on how to best care for new mothers.

"Optimizing Postpartum Care," states that patient-centered, maternal postpartum care has the potential to improve outcomes for women, infants and families and to support ongoing health and well-being. In the weeks after birth, a woman must adapt to multiple physical, social and psychological changes. She must recover from childbirth, adjust to changing hormones, and learn to feed and care for her newborn. In addition to being a time of joy and excitement, this “fourth trimester” can present major challenges like lack of sleep, pain, depression, lack of sexual desire and urinary incontinence. Postpartum care visits with obstetrician-gynecologists or other obstetric care providers can help women navigate the challenges of motherhood.

While postpartum care visits occur after delivery, obstetric providers can and should begin counseling their patients during pregnancy. The patient and her obstetrician-gynecologist or other obstetric care provider together, should formulate a postpartum care plan and identify the health care professionals who will comprise the postpartum care team for the woman and her infant.

“We encourage providers to partner with women during pregnancy to begin planning for the Fourth Trimester," said Alison Stuebe, MD, lead author of the Committee Opinion. "Each woman has different postpartum needs, and we recommend that she and her provider identify members of her postpartum care team and develop an individualized postpartum care plan."

The postpartum care team may include the woman's family and friends, her maternity provider, her infant's provider, and community supports, such as home visitors, mothers' groups and peer counselors. The care plan addresses each woman's plans for infant feeding, future pregnancy plans, and specific health needs. Dr. Stuebe added, "As ob-gyns, we should leverage our community's resources to provide patient-centered care for new mothers."

For some women, such as those with hypertensive disorders of pregnancy or women at high risk of postpartum depression, follow-up one to two weeks after birth is recommended. For all women, a comprehensive postpartum visit should take place within the first 6 weeks after birth and should include a full assessment of physical, social and psychological well-being. This visit is an opportunity for the woman to ask questions about her birth and the implications of any complications for her future health. Providers should discuss reproductive life plans to ensure each woman can receive her desired form of contraception, if immediate postpartum long-acting reversible contraception placement was not done earlier. The visit also should include infant feeding, expressing breast milk if returning to work or school, postpartum weight retention, sexuality, physical activity and nutrition. For women who experience miscarriage or stillbirth, the visit should include emotional support and bereavement counseling.  

To maintain the continuity of care during the postpartum period, a single health care practice should assume the responsibility of coordinating a woman’s care. If responsibility is transferred to another primary care provider after the comprehensive postpartum visit, the ob-gyn 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 women’s future health and maintain continuity of care.

Committee Opinion #666, "Optimizing Postpartum Care," is published in the June issue of Obstetrics & Gynecology. Get more information on Postpartum Care.

 

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Other recommendations issued in the June Obstetrics & Gynecology:

 

Committee Opinion #663, Aromatase Inhibitors in Gynecologic Practice

Aromatase inhibitors have been used for the treatment of breast cancer, ovulation induction, endometriosis, and other estrogen-modulated conditions. For women with breast cancer, bone mineral density screening is recommended with long-term aromatase inhibitor use because of risk of osteoporosis due to estrogen deficiency. Based on long-term adverse effects and complication safety data, when compared with tamoxifen, aromatase inhibitors are associated with a reduced incidence of thrombosis, endometrial cancer, and vaginal bleeding. For women with polycystic ovary syndrome and a body mass index greater than 30, letrozole should be considered as first-line therapy for ovulation induction because of the increased live birth rate compared with clomiphene citrate. Lifestyle changes that result in weight loss should be strongly encouraged. Aromatase inhibitors are a promising therapeutic option that may be helpful for the management of endometriosis-associated pain in combination therapy with progestins.

 

Committee Opinion #664, Refusal of Medically Recommended Treatment During Pregnancy

One of the most challenging scenarios in obstetric care occurs when a pregnant patient refuses recommended medical treatment that aims to support her well-being, her fetus’s well-being, or both. In such circumstances, the obstetrician–gynecologist’s ethical obligation to safeguard the pregnant woman’s autonomy may conflict with the ethical desire to optimize the health of the fetus. Forced compliance—the alternative to respecting a patient’s refusal of treatment—raises profoundly important issues about patient rights, respect for autonomy, violations of bodily integrity, power differentials, and gender equality. The purpose of this document is to provide obstetrician–gynecologists with an ethical approach to addressing a pregnant woman’s decision to refuse recommended medical treatment that recognizes the centrality of the pregnant woman’s decisional authority and the interconnection between the pregnant woman and the fetus.

 

Committee Opinion #665, Guidelines for Adolescent Health Research

Considerable uncertainty exists about what constitutes appropriate levels of protection for adolescents as research participants and about the need for parental permission. The ethical principles that govern research include respect for individuals, beneficence, and justice, as articulated in the Belmont Report. Researchers should be familiar with and adhere to current federal regulations 45 C.F.R. § 46, and federal and state laws that affect research with minors. Investigators should understand the importance of caregiver permission—and ethically appropriate situations in which to waive caregiver permission—for the protection of adolescent research participants.

 

Obstetric Care Consensus #4, Periviable Birth (Interim Update)

Approximately 0.5% of all births occur before the third trimester of pregnancy, and these very early deliveries result in the majority of neonatal deaths and more than 40% of infant deaths. A recent executive summary of proceedings from a joint workshop defined periviable birth as delivery occurring from 20 0/7 weeks to 25 6/7 weeks of gestation. When delivery is anticipated near the limit of viability, families and health care teams are faced with complex and ethically challenging decisions. Multiple factors have been found to be associated with short-term and long-term outcomes of periviable births in addition to gestational age at birth. These include, but are not limited to, nonmodifiable factors (eg, fetal sex, weight, plurality), potentially modifiable antepartum and intrapartum factors (eg, location of delivery, intent to intervene by cesarean delivery or induction for delivery, administration of antenatal corticosteroids and magnesium sulfate), and postnatal management (eg, starting or withholding and continuing or withdrawing intensive care after birth). Antepartum and intrapartum management options vary depending upon the specific circumstances but may include short-term tocolytic therapy for preterm labor to allow time for administration of antenatal steroids, antibiotics to prolong latency after preterm premature rupture of membranes or for intrapartum group B streptococci prophylaxis, and delivery, including cesarean delivery, for concern regarding fetal well-being or fetal malpresentation. Whenever possible, periviable births for which maternal or neonatal intervention is planned should occur in centers that offer expertise in maternal and neonatal care and the needed infrastructure, including intensive care units, to support such services. This document describes newborn outcomes after periviable birth, provides current evidence and recommendations regarding interventions in this setting, and provides an outline for family counseling with the goal of incorporating informed patient preferences. Its intent is to provide support and guidance regarding decisions, including declining and accepting interventions and therapies, based on individual circumstances and patient values.

 

Practice Bulletin #164, Diagnosis and Management of Benign Breast Disorders

Breast-related symptoms are among the most common reasons women present to obstetrician–gynecologists. Obstetrician–gynecologists are in a favorable position to diagnose benign breast disease in their patients. The purpose of a thorough understanding of benign breast disease is threefold: 1) to alleviate, when possible, symptoms attributable to benign breast disease, 2) to distinguish benign from malignant breast disease, and 3) to identify patients with an increased risk of breast cancer so that increased surveillance or preventive therapy can be initiated. Obstetrician–gynecologists may perform diagnostic procedures when indicated or may make referrals to physicians who specialize in the diagnosis and treatment of breast disease. The purpose of this Practice Bulletin is to outline common benign breast disease symptoms in women who are not pregnant or lactating and discuss appropriate evaluation and management. The obstetrician–gynecologist’s role in the screening and management of breast cancer is beyond the scope of this document and is addressed in other publications of the American College of Obstetricians and Gynecologists (1–3).

The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 57,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. www.acog.org

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