Washington, DC—Given the urgent need to reduce severe maternal morbidity and mortality, the American College of Obstetricians and Gynecologists (ACOG) released today a revised Committee Opinion to reinforce the importance of the “fourth trimester,” and to propose a new paradigm for postpartum care. Redefining postpartum care is an initiative set forth by ACOG President Haywood L. Brown, M.D.
Previously, ACOG recommended a comprehensive postpartum visit take place within the first six weeks after birth. ACOG now recommends that postpartum care should be an ongoing process, rather than a single encounter and that all women have contact with their ob-gyns or other obstetric care providers within the first three weeks postpartum.
Timely follow-up is particularly important for women with chronic medical conditions. The initial assessment should be followed up with ongoing care as needed, concluding with a comprehensive postpartum visit no later than 12 weeks after birth. This visit should serve as a transition to ongoing well-woman care and the timing of the visit should be individualized, woman-centered and the follow-up should include a full assessment of the following:
- mood and emotional well-being
- infant care and feeding
- sexuality contraception and birth spacing
- sleep and fatigue
- physical recovery from birth
- chronic disease management
- health maintenance
The weeks following birth are a critical period for a woman and her infant, setting the stage for long-term health and well-being. During this time, a woman is adapting to multiple physical, social and psychological changes. She is recovering from childbirth, adjusting to changing hormones and learning to feed and care for her newborn. Postpartum care visits with ob-gyns or other obstetric care providers can help women navigate the new challenges of motherhood. To optimize the health of women and infants, postpartum care should become an ongoing process, rather than a single encounter, with services and support tailored to each woman’s individual needs.
“New mothers need ongoing care during the ‘fourth trimester.’ We want to replace the one-off checkup at six weeks with a period of sustained, holistic support for growing families,” said Alison Stuebe, M.D., lead author of the Committee Opinion. “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.”
Currently, as many as 40 percent of women who have given birth do not attend a postpartum visit. Underutilization of postpartum care impedes management of chronic health conditions and access to effective contraception, which increases the risk of short interval pregnancy and preterm birth. Attendance rates are lower among populations with limited resources, which contributes to health disparities.
“This revised guidance is important because the new recommended structure is intended to consider and cater to the postpartum needs of all women, including those most at risk of falling out of care,” stated Dr. Brown. “As the nation’s leading group of physicians providing health care for women, we must use the postpartum period as gateway opportunity to counsel women on long-term health implications.”
While postpartum care visits occur after delivery, obstetric providers should begin counseling their patients during pregnancy. Prenatal discussions should include the woman’s reproductive life plans, including the desire for and timing of any future pregnancies.
Committee Opinion #736, “Optimizing Postpartum Care” is published in the May issue of Obstetrics & Gynecology.
Other recommendations issued in the May Obstetrics & Gynecology:
Cancer of the endometrium is the most common type of gynecologic cancer in the United States. Vaginal bleeding is the presenting sign in more than 90% of postmenopausal women with endometrial carcinoma. Clinical risk factors for endometrial cancer, including but not limited to age, obesity, use of unopposed estrogen, specific medical comorbidities (eg, polycystic ovary syndrome, type 2 diabetes mellitus, atypical glandular cells on screening cervical cytology), and family history of gynecologic malignancy also should be considered when evaluating postmenopausal bleeding. The clinical approach to postmenopausal bleeding requires prompt and efficient evaluation to exclude or diagnose endometrial carcinoma and endometrial intraepithelial neoplasia. Transvaginal ultrasonography usually is sufficient for an initial evaluation of postmenopausal bleeding if the ultrasound images reveal a thin endometrial echo (less than or equal to 4 mm), given that an endometrial thickness of 4 mm or less has a greater than 99% negative predictive value for endometrial cancer. Transvaginal ultrasonography is a reasonable alternative to endometrial sampling as a first approach in evaluating a postmenopausal woman with an initial episode of bleeding. If blind sampling does not reveal endometrial hyperplasia or malignancy, further testing, such as hysteroscopy with dilation and curettage, is warranted in the evaluation of women with persistent or recurrent bleeding. An endometrial measurement greater than 4 mm that is incidentally discovered in a postmenopausal patient without bleeding need not routinely trigger evaluation, although an individualized assessment based on patient characteristics and risk factors is appropriate. Transvaginal ultrasonography is not an appropriate screening tool for endometrial cancer in postmenopausal women without bleeding.
The phenomenon of adolescent childbearing is complex and far reaching, affecting not only the adolescents but also their children and their community. The prevalence and public health effect of adolescent pregnancy reflect complex structural social problems and an unmet need for acceptable and effective contraceptive methods in this population. In 2006–2010, 82% of adolescents at risk of unintended pregnancy were currently using contraception, but only 59% used a highly effective method, including any hormonal method or intrauterine device. Long-acting reversible contraceptives (LARC) have higher efficacy, higher continuation rates, and higher satisfaction rates compared with short-acting contraceptives among adolescents who choose to use them. Complications of intrauterine devices and contraceptive implants are rare and differ little between adolescents and women, which makes these methods safe for adolescents. Barriers to use of LARC by adolescents include patients’ lack of familiarity with or understanding about the methods, potentially high cost of initiation, lack of access, low parental acceptance, and obstetrician–gynecologists’ and other health care providers’ misconceptions about the safety of LARC use in adolescents. Because adolescents are at higher risk of sexually transmitted infections (STIs), obstetrician–gynecologists should continue to follow standard guidelines for STI screening. They should advise adolescents who choose LARC methods to use male or female condoms consistently (dual method use) to decrease the risk of STIs, including human immunodeficiency virus (HIV). Obstetrician–gynecologists should counsel all sexually active adolescents who do not seek pregnancy on the range of reversible contraceptive methods, including LARC, and should help make these contraceptives readily accessible to them.
The American College of Obstetricians and Gynecologists (ACOG) is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 58,000 members, ACOG 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. www.acog.org