The postpartum period begins soon after the delivery of the baby and usually lasts six to eight weeks and ends when the mother’s body has nearly returned to its pre-pregnant state. The postpartum period for a woman and her newborn is very important for both short-term and long-term health and well-being. This activity should help the interprofessional team on how to provide comprehensive postpartum care for the new mother. Objectives:
The postpartum period begins soon after the baby's delivery and usually lasts six to eight weeks and ends when the mother’s body has nearly returned to its pre-pregnant state.[1] The weeks following birth lay the foundation of long-term health and well-being for both the woman and her infant. Therefore, it is critical to establish a reliable postpartum (afterbirth) period that should be tailored into on-going, continuous, comprehensive care. Most maternal and infant deaths occur in the first month after birth. Hence effective postpartum care is mandatory to improve both short-term and long-term health consequences of mother and newborn.[2] Timing of Postnatal Visits In April 2018, The American College of Obstetrics and Gynecology (ACOG) recommends12 weeks of support, rather than a single six-week postpartum visit. ACOG also recommends postpartum evaluation within the first 3 weeks after delivery in-person or by phone, which later is followed up with ongoing care as needed, concluding with a comprehensive postpartum visit no later than 12 weeks.[3] Components of Postpartum Care
Common Postpartum Concerns
According to ACOG, at least 40% of women do not seek postpartum care. Several factors contribute towards this trend, such as cultural differences, lack of insurance, lack of adequate family support, low socioeconomic status, poor anticipatory guidance, race, lack of good transitional care management, and poor access to home visits. According to the Pregnancy Mortality Surveillance System (PMSS), Nonhispanic blacks have the highest maternal mortality.[24][25][26] During the first week of the postnatal period, severe hypertension, severe bleeding, and infection are the most common contributors to maternal deaths, while the cardiovascular cause is the leading cause of late deaths.[27] When compared with other developed countries such as Norway and New Zealand, the US has significantly lagged behind with providing adequate prenatal care and US mortality and morbidity is significantly higher ( 17.4 % vs. 1.7 % ), and the US has a significantly lower number of maternal health care providers such as obstetricians and midwives ( 19 vs. 65 per 1000 live births ). Earlier postpartum visits are mandatory to evaluate for resolution of postpartum blues and other chronic medical conditions such as hypertension and diabetes and to improve both maternal and neonatal mortality and morbidity. Health Issues that Arise During Pregnancy 1. Pregnancy-induced hypertension: Hypertensive disorder risk is higher < 48hrs after delivery. An office visit is recommended within the first 7 days after delivery. Blood Pressure (BP) ≥150/100 mmHg can be treated with oral medication such as nifedipine or labetalol. Hospitalize if signs of end-organ (liver injury or pulmonary edema) or BP ≥ 160/110. Recommend lifestyle modification and annual BP and bodyweight monitoring follow-ups. 2. Gestational diabetes mellitus (GDM): Women with GDM are at a very high risk of developing diabetes. ACOG recommends women with GDM should have a 75-g, 2-hour fasting oral glucose tolerance test 4 to 12 weeks postpartum to screen for type 2 DM.[28] 3. Thyroid disorders: Mother can experience symptoms of hypo- or hyperthyroidism. The diagnosis of postpartum thyroiditis depends on clinical presentation and elevated free T4 and low TSH. Hyperthyroidism is transient and usually not treated. Beta-blocker can be used if needed for symptoms. Hypothyroidism is treated with levothyroxine. The American Thyroid Association recommends annual testing in women with hypothyroidism with a history of postpartum thyroiditis.[29] In 2013, WHO released the following recommendations regarding the postpartum care: 1. Provide postnatal care in the first 24 hours to all mothers and babies-regardless of where the birth occurs.2. Ensure healthy women and their newborns stay at a health care facility for at least one day after the delivery. 3. All mothers and newborns need at least four postpartum visits in the first 6 weeks.4. If birth is at home, the first postnatal contact should be as early as possible, within 24 hours of birth.5. Ensure at least 3 postnatal visits for all mothers and babies, on day 3 (48 to 72 hours), between days 7 to 14, and 6 weeks after birth.6. All women should be educated about the physiological process of recovery after birth and mention that some health problems are common, with advice to report any health concerns to a health care provider, in particular, signs and symptoms of infection, postpartum hemorrhage, pre-eclampsia/eclampsia, and thromboembolism.7. The use of prophylactic antibiotics among women with a vaginal delivery and a third or fourth-degree perineal tear is recommended to prevent wound complications.8. Advise women to apply topical chlorhexidine application to the umbilical cord stump daily during the first week of life is recommended for newborns born at home in settings with high neonatal mortality (30 or more neonatal deaths per 1,000 live births). Ultimately, providing the optimum level of healthcare and support for postpartum families will require local, state-wide, and national-level policy changes. Even though the affordable care act improved maternal care access, the US still needs a major change in policies to provide appropriate, evidence-based, and culturally competent universal access to maternity care.[30] Expanding eligibility for Medicaid, which pays for almost half of U.S. deliveries, can improve postpartum coverage.[31] This should be facilitated through mutual support between healthcare providers and insurance platforms by appropriate reimbursement levels that support—and indeed fosters—postpartum care as a continuous, rather than an isolated, process, which undoubtedly leads to positive outcomes for the community as a whole.[32] Review Questions1. Kalra B, Sawhney K, Kalra S. Management of thyroid disorders in pregnancy: Recommendations made simple. J Pak Med Assoc. 2017 Sep;67(9):1452-1455. [PubMed: 28924295] Haran C, van Driel M, Mitchell BL, Brodribb WE. Clinical guidelines for postpartum women and infants in primary care-a systematic review. 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