Clinical Review

2019 Update on Obstetrics

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References

ACOG's recommendations

Ongoing process. ACOG's first proposed change concerns the structure of the postpartum visit itself, which traditionally has been a single visit with a provider at approximately 6 weeks postpartum. Postpartum care plans actually should be started before birth, during regular prenatal care, and adjusted in the hospital as needed so that the provider can educate patients about the issues they may face and resources they may need during this time. This prenatal preparation hopefully will encourage more patients to attend their postpartum visits.


Increased provider contact. Another proposed change is that after delivery, the patient should have contact with a provider within the first 3 weeks postpartum. For high-risk patients, this may involve an in-person clinic visit as soon as 3 to 10 days postpartum (for hypertensive disorders of pregnancy) or at 1 to 2 weeks (for postpartum depression screening, incision checks, and lactation issues). For lower-risk patients, a phone call may be appropriate and/or preferred. Ongoing follow-up for all patients before the final postpartum visit should be individualized.


Postpartum visit and care transition. ACOG recommends a comprehensive postpartum visit at 4 to 12 weeks to fully evaluate the woman's physical, social, and psychologic well-being and to serve as a transition from pregnancy care to well-woman care. This is a large order and includes evaluation 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 and transition to primary care provider
  • health maintenance
  • review of labor and delivery course if needed
  • review of risks and recommendations for future pregnancies.

After these components are addressed, it is expected that the patient will be transitioned to a primary care provider (who may continue to be the ObGyn, as appropriate) to coordinate her future care in the primary medical home.

Useful resource for adopting new paradigm

ACOG's recommendations are somewhat daunting, and these changes will require education and resources, a significant increase in obstetric provider time and effort, and consideration of policy change regarding such issues as parental leave and postpartum care reimbursement. As a start, ACOG has developed an online aid for health care providers called "Postpartum toolkit" (https://www.acog.org/About-ACOG/ACOG-Departments/Toolkits-for-Health-Car...), which provides education and resources for all steps in the process and can be individualized for each practice and patient.7

WHAT THIS EVIDENCE MEANS FOR PRACTICE
Postpartum care should be seen as an ongoing process to address both short- and long-term health outcomes for the patient, her newborn, and their family. This process should begin with planning in the antenatal period, continue with close individualized follow-up within the first 3 weeks of birth, and conclude with a comprehensive postpartum evaluation and transition to well-woman care. Shifting the paradigm of postpartum care will take considerable commitment and resources on the part of obstetric providers and their practices. In my practice, we routinely see hypertensive patients within the first week postpartum and patients at risk for postpartum depression within the first 2 weeks in our clinics. We have a standard 6-week postpartum visit for all patients as well. Going forward, we need to further determine how and when we can implement ACOG’s extensive new recommendations for optimizing postpartum care.

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