The American College of Obstetricians and Gynecologists makes the following recommendations and conclusions:
- Currently, as many as 40% of women do not attend a postpartum visit. Active engagement in patient-centered, maternal postpartum care has the potential to improve outcomes for women, infants, and families and support ongoing health and well-being.
- To optimize postpartum care, anticipatory guidance should begin during pregnancy. During antenatal care, it is recommended that the patient and her obstetrician–gynecologist or other obstetric care provider formulate a postpartum care plan and identify the health care professionals who will comprise the postpartum care team for the woman and her infant.
- Ideally, during the postpartum period, a single health care practice assumes responsibility for coordinating the woman’s care. At discharge from maternity care, the woman should receive contact information for her postpartum care team and written instructions regarding the timing of follow-up postpartum care.
- Early postpartum follow-up is recommended for women with hypertensive disorders of pregnancy. Early follow-up also may be beneficial for women at high risk of complications.
- It is recommended that all women undergo a comprehensive postpartum visit within the first 6 weeks after birth. This visit should include a full assessment of physical, social, and psychological well-being.
- Systems should be in place to ensure that women who desire long-acting reversible contraception or any other form of contraception can receive it during the comprehensive postpartum visit, if immediate postpartum placement was not done earlier.
- Recommended anticipatory guidance at the postpartum visit includes infant feeding, expressing breast milk if returning to work or school, postpartum weight retention, sexuality, physical activity, and nutrition.
- Any pregnancy complications should be discussed with respect to risks for future pregnancies, and recommendations should be made to optimize maternal health during the interconception period.
- At the conclusion of the postpartum visit, the woman and her obstetrician–gynecologist or other obstetric care provider should determine who will assume primary responsibility for her ongoing care. If responsibility is transferred to another primary care provider, the obstetrician–gynecologist 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 woman’s future health and maintain continuity of care.
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 (1). In addition to being a time of joy and excitement, this “fourth trimester” can present considerable challenges for women, including lack of sleep, fatigue, pain, breastfeeding difficulties, stress, depression, lack of sexual desire, and urinary incontinence (2–4). Women also may need to navigate preexisting health issues, such as substance dependence, intimate partner violence, and other concerns. During this time, postpartum care often is fragmented among maternal and pediatric health care providers, and communication between inpatient and outpatient settings is inconsistent (5). Although home visits are provided in some settings, most women in the United States must independently navigate the postpartum transition until the first postpartum visit 4–6 weeks after delivery.
All women should attend a postpartum visit; however, attendance is poor at visits scheduled for 4–6 weeks after birth, with as many as 40% of women not attending a postpartum visit. Attendance rates are lower among populations with limited resources (6, 7), which contributes to health disparities. Increasing attendance at postpartum visits is a developmental goal for Healthy People 2020, and postpartum visit rates are tracked as a Healthcare Effectiveness Data and Information Set measure. Strategies for increasing attendance include, but are not limited to the following measures: discussing the importance of the postpartum visit during prenatal care; using peer counselors, intrapartum support staff, postpartum nurses, and discharge planners to encourage postpartum follow-up; scheduling postpartum visits during prenatal care or before hospital discharge; and using technology (eg, e-mail, text, apps) to remind women to schedule postpartum follow-up (8). When women do attend postpartum visits, they report unmet needs: less than one half of women report that they received enough information at their postpartum visit about postpartum depression, birth spacing, healthy eating, the importance of exercise, or changes in their sexual response and emotions (9). Active engagement in patient-centered, maternal postpartum care has the potential to improve outcomes for women, infants, and families and support ongoing health and well-being.
In the absence of evidence-based studies of optimal maternal and infant postpartum management, the measures for anticipatory guidance and care coordination suggested in this Committee Opinion are based largely on expert opinion and observational studies. Ongoing research is needed to determine how to most effectively address the unmet needs of women during the postpartum transition.
To optimize postpartum care, anticipatory guidance should begin during pregnancy, with discussion of family planning, infant feeding, and postpartum recovery from birth. This guidance should include discussion of the purpose and value of the postpartum visit. The patient and her obstetrician–gynecologist or other obstetric care provider should discuss the woman’s reproductive life plans, including desire for and timing of any future pregnancies (10). The optimal interval between delivery and subsequent pregnancy is 18 months to 5 years; the greatest risk of low birth weight and preterm birth occurs when the interconception interval is less than 6 months (11, 12). The patient’s reproductive life plan provides context for discussing contraceptive options (13).Comprehensive prenatal counseling also addresses infant feeding plans (14) and offers anticipatory guidance about the challenges of parenting and recovery from childbirth (15). The primary source of support for a pregnant or postpartum woman is often her family. The term “family” as it is used here includes the expectant woman and her support system, which may include any or all of the following individuals: a spouse or partner, relatives, and friends (16). To the extent that the woman desires, her family should participate with her and her obstetrician–gynecologist or other obstetric care provider in formulating a postpartum care plan (17) (Table 1). This plan identifies the family members and health professionals who will support the woman and the infant after birth (Table 2). In addition, the plan identifies the primary care provider who will assume care of chronic medical issues after the postpartum period. If the obstetrician–gynecologist serves as the primary care provider, then transition to another primary care physician is unnecessary.
The postpartum care plan should be reviewed and updated after birth. Women are often uncertain about whom to contact for postpartum concerns (18). In a recent U.S. survey, one in four postpartum women did not have a phone number for a health care provider to contact for any concerns about themselves or their infants (9). Therefore, it is suggested that the care plan include contact information and written instructions regarding the timing of follow-up postpartum care. Just as a health care professional or health care practice leads the woman’s care during pregnancy, a primary maternal care provider should assume responsibility for her postpartum care (17). This individual or practice is the primary point of contact for the woman, for other members of the postpartum care team, and for any maternal health concerns noted by the infant’s health care provider. When prolonged infant hospitalization is anticipated and is far from the woman’s home, it is recommended that a local maternity health care provider be identified for postpartum care and support, even if delivery did not take place at a local hospital.
Timing of Postpartum Visits
There is considerable variation in recommendations for timing of postpartum visits (4). Early follow-up is recommended for women with hypertensive disorders of pregnancy, with blood pressure evaluation no later than 7–10 days postpartum (19); other experts have recommended follow-up at 3–5 days (20). Early follow-up also may be beneficial for women at high risk of complications, such as postpartum depression (21), cesarean or perineal wound infection, lactation difficulties, or chronic conditions such as seizure disorders that require postpartum medication titration. These problem-oriented visits, which in some cases may be conducted through home nursing evaluations, do not obviate the need for a comprehensive postpartum visit. Phone support during the postpartum period appears to reduce depression scores, improve breastfeeding outcomes, and increase patient satisfaction, although evidence is mixed (22, 23).
The comprehensive postpartum visit has typically been scheduled between 4 weeks and 6 weeks after delivery, a time frame that likely reflects cultural traditions of 40 days of convalescence for women and their infants (24). Earlier focused or comprehensive postpartum visits, however, provide the opportunity to address concerns that arise before 6 weeks postpartum, and earlier visits also allow time to reschedule any missed appointments. At all visits, obstetrician–gynecologists and other obstetric care providers should consider the need for future follow-up and time additional visits accordingly. Whenever it occurs, the comprehensive postpartum visit includes a full assessment of physical, social, and psychological well-being, with screening for postpartum depression using a validated instrument, such as the Edinburgh Postnatal Depression Scale (21, 25). Birth spacing recommendations and reproductive life plans should be reviewed and a commensurate contraceptive method provided. Systems should be in place to ensure that women who desire long-acting reversible contraception or another form of contraception can receive it during the comprehensive postpartum visit if immediate postpartum placement was not done earlier. Vaccination history should be reviewed and immunizations provided as needed. Women should be asked about common postpartum concerns, including perineal or cesarean wound pain, incontinence, dyspareunia, fatigue, depression, anxiety, and infant feeding problems (26); identified concerns should be addressed. Suggested topics for anticipatory guidance include infant feeding, expressing breast milk if returning to work or school (14), postpartum weight retention, sexuality, physical activity, and nutrition. Smoking and substance use cessation should be addressed.
The postpartum visit provides an opportunity for women to ask questions about their labor, childbirth, and any complications (17). These complications should be discussed with respect to risks for future pregnancies, and recommendations should be made to optimize maternal health during the interconception period (27). It is important that women with gestational diabetes, hypertensive disorders of pregnancy, or preterm birth be counseled that these disorders are associated with a higher lifetime risk of maternal cardiometabolic disease (28, 29). It is recommended that women with gestational diabetes undergo glucose screening with a fasting plasma glucose or 75 g, 2-hour oral glucose tolerance test (30). Women with chronic medical conditions such as hypertensive disorders, obesity, diabetes, and renal disease should be counseled regarding the importance of follow-up with their primary care provider in a timely fashion for ongoing coordination of care.
For women experiencing a miscarriage, stillbirth, or neonatal death, it is essential to ensure follow-up with an obstetrician–gynecologist or other obstetric care provider. Elements of this visit include emotional support and bereavement counseling; referral, if appropriate, to counselors and support groups; review of any laboratory and pathology studies related to the loss; and counseling regarding recurrent risk and future pregnancy planning (31).
At the conclusion of the postpartum visit, the woman and her health care provider should adapt her post-partum care plan to identify the health care pro-fessional who will assume primary responsibility for her ongoing care in her primary care medical home. If the obstetrician–gynecologist or other obstetric care provider also is her primary care provider, no transfer of responsibility is necessary. If responsibility is transferred to another primary care provider, the obstetrician–gynecologist 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 woman’s future health and maintain continuity of care. Documentation of any history of pregnancy complications in the woman’s electronic medical record is suggested to facilitate effective transition of care and to inform future screening and treatment. Written recommendations for follow-up for well-woman care and for any ongoing medical issues should be documented in the medical record, provided to the patient, and communicated to appropriate members of the postpartum care team, including her primary care medical home provider.
For More Information
The American College of Obstetricians and Gynecolo-gists has identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients. You may view these resources at www.acog.org/More-Info/Optimizing PostpartumCare.
These resources are for information only and are not meant to be comprehensive. Referral to these resources does not imply the American College of Obstetricians and Gynecologists’ endorsement of the organization, the organization’s web site, or the content of the resource. The resources may change without notice.
1. Aber C, Weiss M, Fawcett J. Contemporary women’s adaptation to motherhood: the first 3 to 6 weeks postpartum. Nurs Sci Q 2013;26:344–51.
2. Burgio KL, Zyczynski H, Locher JL, Richter HE, Redden DT, Wright KC. Urinary incontinence in the 12-month postpartum period. Obstet Gynecol 2003;102:1291–8.
3. Declercq ER, Sakala C, Corry MP, Applebaum S, Herrlich A. Major survey findings of Listening to Mothers III: New Mothers Speak Out: Report of National Surveys of Women’s Childbearing Experiences, Conducted October–December 2012 and January–April 2013. J Perinat Educ 2014;23:17–24.
4. Haran C, van Driel M, Mitchell BL, Brodribb WE. Clinical guidelines for postpartum women and infants in primary care—a systematic review. BMC Pregnancy Childbirth 2014;14:51.
5. Wise PH. Transforming preconceptional, prenatal, and interconceptional care into a comprehensive commitment to women’s health. Womens Health Issues 2008;18:S13–8.
6. Bennett WL, Chang HY, Levine DM, Wang L, Neale D, Werner EF, et al.. Utilization of primary and obstetric care after medically complicated pregnancies: an analysis of medical claims data. J Gen Intern Med 2014;29:636–45.
7. Bryant AS, Haas JS, McElrath TF, McCormick MC. Predictors of compliance with the postpartum visit among women living in healthy start project areas. Matern Child Health J 2006;10:511–6.
8. Centers for Medicare and Medicaid Services. Resources on strategies to improve postpartum care among Medicaid and CHIP populations. Baltimore (MD): CMS; 2015. Available at: https://www.medicaid.gov/medicaid-chip-program-information/by-topics/quality-of-care/downloads/strategies-to-improve-postpartum-care.pdf
. Retrieved February 17, 2016.
9. Declercq ER, Sakala C, Corry MP, Applebaum S, Herrlich A. Listening to mothers III: new mothers speak out. New York (NY): Childbirth Connection; 2013. Available at: http://transform.childbirthconnection.org/wp-content/uploads/2013/06/LTM-III_NMSO.pdf
. Retrieved February 11, 2016.
10. Centers for Disease Control and Prevention. Reproductive life plan tool for health professionals. Available at: http://www.cdc.gov/preconception/rlptool.html
. Retrieved February 17, 2016.
11. Conde-Agudelo A, Rosas-Bermudez A, Kafury-Goeta AC. Birth spacing and risk of adverse perinatal outcomes: a meta-analysis. JAMA 2006;295:1809–23.
12. Grisaru-Granovsky S, Gordon ES, Haklai Z, Samueloff A, Schimmel MM. Effect of interpregnancy interval on adverse perinatal outcomes—a national study. Contraception 2009;80:512–8.
13. Block DE, Kurtzman C. Family planning in a healthy, married population: operationalizing the human rights approach in an Israeli health service setting. Am J Public Health 1984;74:830–3.
14. Optimizing support for breastfeeding as part of obstetric practice. Committee Opinion No. 658. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016; 127:e86–92.
15. Martin A, Horowitz C, Balbierz A, Howell EA. Views of women and clinicians on postpartum preparation and recovery. Matern Child Health J 2014;18:707–13.
16. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for perinatal care. 7th ed. Elk Grove Village (IL): AAP; Washington, DC: American College of Obstetricians and Gynecologists; 2012.
17. National Institute for Health and Care Excellence. Postnatal care. NICE Quality Standard QS37. London: NICE; 2013. Available at: https://www.nice.org.uk/guidance/qs37
. Retrieved February 19, 2016.
18. Brodribb W, Zadoroznyj M, Dane A. The views of mothers and GPs about postpartum care in Australian general practice. BMC Fam Pract 2013;14:139.
19. American College of Obstetricians and Gynecologists. Hypertension in pregnancy. Washington, DC: American College of Obstetricians and Gynecologists; 2013.
20. New York State Department of Health. Hypertensive disorders in pregnancy. Guideline Summary. Albany (NY): NYSDOH; 2013. Available at: https://www.health.ny.gov/professionals/protocols_and_guidelines/hypertensive_disorders/2013_hdp_guideline_summary.pdf
. Retrieved March 4, 2016.
21. Screening for perinatal depression. Committee Opinion No. 630. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;125:1268–71.
22. Lavender T, Richens Y, Milan SJ, Smyth R, Dowswell T. Telephone support for women during pregnancy and the first six weeks postpartum. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD009338. DOI: 10.1002/14651858.CD009338.pub2.
23. Miller YD, Dane AC, Thompson R. A call for better care: the impact of postnatal contact services on women’s parenting confidence and experiences of postpartum care in Queensland, Australia. BMC Health Serv Res 2014;14:635.
24. World Health Organization. Postpartum care of the mother and newborn: a practical guide. Geneva: WHO; 1998. Available at: http://apps.who.int/iris/bitstream/10665/66439/1/WHO_RHT_MSM_98.3.pdf
. Retrieved February 17, 2016.
25. Earls MF. Incorporating recognition and management of perinatal and postpartum depression into pediatric practice. Committee on Psychosocial Aspects of Child and Family Health American Academy of Pediatrics. Pediatrics 2010;126:1032–9.
26. MacArthur C, Winter HR, Bick DE, Lilford RJ, Lancashire RJ, Knowles H, et al.. Redesigning postnatal care: a randomised controlled trial of protocol-based midwifery-led care focused on individual women’s physical and psychological health needs. Health Technol Assess 2003;7:1–98.
27. Lu MC, Kotelchuck M, Culhane JF, Hobel CJ, Klerman LV, Thorp JM Jr. Preconception care between pregnancies: the content of internatal care. Matern Child Health J 2006;10:S107–22.
28. Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd-Jones DM, et al.. Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 update: a guideline from the American Heart Association. Circulation 2011;123:1243–62.
29. Rich-Edwards JW, Fraser A, Lawlor DA, Catov JM. Pregnancy characteristics and women’s future cardiovascular health: an underused opportunity to improve women’s health? Epidemiol Rev 2014;36:57–70.
30. Gestational diabetes mellitus. Practice Bulletin No. 137. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;122:406–16.
31. Management of stillbirth. ACOG Practice Bulletin No. 102. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;113:748–61.