I read a recent committee opinion from the American College of Obstetricians and Gynecologists (ACOG), that made a positive impression on me. They were basically addressing the importance of optimal postpartum care, that provides more attention to a woman’s physical and mental health.
They point out correctly, that the “fourth trimester” can be very challenging for women, including lack of sleep, fatigue, pain, breastfeeding difficulties, stress, new or return or worsening of depression/anxiety, lack of sexual desire, and urinary incontinence.
It’s not just the new baby that needs care, and it’s not just a one-time 6-week
postpartum check for mom… it should be a more comprehensive care plan that supports the mother and her multiple needs. This is now being asserted by ACOG as well. Previously, ACOG recommended just a single, comprehensive postpartum visit within the first 6 weeks after giving birth. With their new opinion/recommendations, postpartum care will be considered an ongoing process. This is especially important to be stressed during the pregnancy, given that in the U.S., as many as 40% of women who have given birth do not attend a postpartum visit. In addition, those visits are especially low among populations of women with limited resources.
On an especially serious note, related to this, more than one half of pregnancy-related deaths occur after the birth of the infant. The new concept is that women should have an initial contact with their care provider within 3 weeks of childbirth for an early assessment of their mental and physical health. This is an especially important time to make contact with women regarding their risk for postpartum depression. It is also a key time to address breastfeeding challenges, which, if remain unresolved, often then to a cessation of breastfeeding prior to 6 weeks postpartum.
ACOG goes on to recommend that in addition to the 3-week check-in, ongoing support should be provided as needed and then another comprehensive visit should take place within 12 weeks of childbirth.
Each visit should address common factors including lack of sleep, lack of good nutrition and exercise, fatigue, pain, urinary incontinence, breastfeeding challenges, lack of sexual desire, new or worsening mental health symptoms, stress, depression and anxiety.
Here is their recommendation for a comprehensive visit:
· Physical recovery from birth
· Mood and emotional well-being
· Infant care and feeding
· Sleep and fatigue
· Sexuality, contraception, and birth spacing
· Chronic disease management
· Health maintenance
Another key point that is made, that is music to my ears, is a very naturopathic approach that is "individualized and woman-centered."
Some women with more complicated pregnancies, chronic medical conditions and/or adverse birth outcomes will need very specific care due to the potential serious consequences and experiences they are having. For example, if a woman had high blood pressure during pregnancy, she would need a visit within the first 7-10 days after the birth and even as soon as 72 hours, if she had severe high blood pressure. Seizure disorders, thyroid disorders, C- sections, diabetes, substance abuse, postpartum depression or psychosis are all examples of those who need care sooner and more often. Women who have experienced a miscarriage, stillbirth, or neonatal death should be encouraged to follow up soon and acquire professional emotional support and referrals.
Referrals should be made responsibly and efficiently for women in need of a broader health care team. This is an important transition time and providers and patients need to work together to devise the optimal plan. The obstetrician/gynecologist or other obstetric provider may no longer be in the best position to provide all the resources needed, but should be seen as the “coach”, and ensure communication and transfer of information to other providers that are brought into the team.
ACOG also advocates for reimbursement policies that support this concept of a new and improved postpartum care process, and not just a one-time office visit. ACOG also endorses paid parental leave… which is full benefits and 100% pay for at least 6 weeks. While this could be viewed as optimal, if not essential, and I do agree with it, there are many employers, especially of small businesses, that just cannot afford this.
This new ACOG Committee Opinion is also endorsed by the Academy of Breastfeeding Medicine, American College of Nurse-Midwives, National Association of Nurse Practitioners in Women’s Health, Society for Academic Specialists in General Obstetrics and Gynecology, Society for Maternal-Fetal Medicine…….. and little ole me.
Postpartum care for most naturopathic physicians, would already include this “fourth trimester” concept… which is why we attend so closely to nutrition/exercise/mental health/emotional support, routine supplementation (continuing the prenatal vitamin and fish oils that we would have had a pregnant woman taking during her pregnancy), and then initiating or continuing botanicals/nutraceuticals that address her individual medical issues of old or now of new.
Reference:
Obstet Gynecol. 2018;131:e140-e150.
