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e140 VOL. 131, NO. 5, MAY 2018 OBSTETRICS & GYNECOLOGY

Recommendations and Conclusions The American College of Obstetricians and Gynecologists makes the following recommendations and conclusions: • To optimize the health of women and infants, post-

partum care should become an ongoing process, rather than a single encounter, with services and support tailored to each woman’s individual needs.

• Anticipatory guidance should begin during preg- nancy with development of a postpartum care plan that addresses the transition to parenthood and well- woman care.

• Prenatal discussions should include the woman’s reproductive life plans, including desire for and timing of any future pregnancies. A woman’s future pregnancy intentions provide a context for shared decision-making regarding contraceptive options.

• All women should ideally have contact with a mater- nal care provider within the first 3 weeks postpar- tum. This initial assessment should be followed up with ongoing care as needed, concluding with a com- prehensive postpartum visit no later than 12 weeks after birth.

ACOG COMMITTEE OPINION Number 736 • May 2018 (Replaces Committee Opinion Number 666, June 2016)

Presidential Task Force on Redefining the Postpartum Visit Committee on Obstetric Practice The Academy of Breastfeeding Medicine, the American College of Nurse-Midwives, the National Association of Nurse Practitioners in Women’s Health, the Society for Academic Specialists in General Obstetrics and Gynecology, and the Society for Maternal–Fetal Medicine endorse this document. This Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Presidential Task Force on Redefining the Postpartum Visit and the Committee on Obstetric Practice in collaboration with task force members Alison Stuebe, MD, MSc; Tamika Auguste, MD; and Martha Gulati, MD, MS.

Optimizing Postpartum Care ABSTRACT: The weeks following birth are a critical period for a woman and her infant, setting the stage for long-term health and well-being. 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. It is recommended that all women have contact with their obstetrician–gynecologists or other obstetric care providers within the first 3 weeks postpartum. This initial assessment should be followed up with ongoing care as needed, concluding with a comprehensive postpartum visit no later than 12 weeks after birth. The com- prehensive postpartum visit should include a full assessment of physical, social, and psychological well-being, including the following domains: mood and emotional well-being; infant care and feeding; sexuality, contracep- tion, and birth spacing; sleep and fatigue; physical recovery from birth; chronic disease management; and health maintenance. Women with chronic medical conditions such as hypertensive disorders, obesity, diabetes, thyroid disorders, renal disease, and mood disorders should be counseled regarding the importance of timely follow- up with their obstetrician–gynecologists or primary care providers for ongoing coordination of care. During the postpartum period, the woman and her obstetrician–gynecologist or other obstetric care provider should identify the health care provider who will assume primary responsibility for her ongoing care in her primary medical home. Optimizing care and support for postpartum families will require policy changes. Changes in the scope of postpartum care should be facilitated by reimbursement policies that support postpartum care as an ongoing process, rather than an isolated visit. Obstetrician–gynecologists and other obstetric care providers should be in the forefront of policy efforts to enable all women to recover from birth and nurture their infants. This Committee Opinion has been revised to reinforce the importance of the “fourth trimester” and to propose a new paradigm for postpartum care.

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• The timing of the comprehensive postpartum visit should be individualized and woman centered.

• The comprehensive postpartum visit should include a full assessment of physical, social, and psychologi- cal well-being.

• Women with pregnancies complicated by preterm birth, gestational diabetes, or hypertensive disor- ders of pregnancy should be counseled that these disorders are associated with a higher lifetime risk of maternal cardiometabolic disease.

• Women with chronic medical conditions, such as hypertensive disorders, obesity, diabetes, thyroid disorders, renal disease, mood disorders, and sub- stance use disorders, should be counseled regard- ing the importance of timely follow-up with their obstetrician–gynecologists or primary care providers for ongoing coordination of care.

• For a woman who has experienced a miscarriage, stillbirth, or neonatal death, it is essential to ensure follow-up with an obstetrician–gynecologist or other obstetric care provider.

• Optimizing care and support for postpartum fami- lies will require policy changes. Changes in the scope of postpartum care should be facilitated by reimbursement policies that support postpartum care as an ongoing process, rather than an isolated visit.

Introduction 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 period, a woman is adapting to multiple physical, social, and psychologi- cal changes. She is recovering from childbirth, adjust- ing to changing hormones, and learning to feed and care for her newborn (1). In addition to being a time of joy and excitement, this “fourth trimester” can pres- ent considerable challenges for women, including lack of sleep, fatigue, pain, breastfeeding difficulties, stress, new onset or exacerbation of mental health disorders, lack of sexual desire, and urinary incontinence (2–4). Women also may need to navigate preexisting health and social 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 across the transition from inpatient to outpatient set- tings is often inconsistent (5). Home visits are provided in some settings; however, currently, most women in the United States must independently navigate the post- partum transition until the traditional postpartum visit (4–6 weeks after delivery). This lack of attention to maternal health needs is of particular concern given that more than one half of pregnancy-related deaths occur after the birth of the infant (6). Given the urgent need to reduce severe maternal morbidity and mortality, this

Committee Opinion has been revised to reinforce the importance of the “fourth trimester” and to propose a new paradigm for postpartum care.

Redefining Postpartum Care Following birth, many cultures prescribe a 30–40-day period of rest and recovery, with the woman and her newborn surrounded and supported by family and com- munity members (7). Many agrarian cultures enshrine postpartum rituals, including traditional foods and sup- port for day-to-day household tasks. These traditions have been sustained by some cultural groups, but for many women in the United States, the 6-week postpar- tum visit punctuates a period devoid of formal or infor- mal maternal support. Obstetrician–gynecologists and other women’s health care providers are uniquely quali- fied to enable each woman to access the clinical and social resources she needs to successfully navigate the transition from pregnancy to parenthood.

To optimize the health of women and infants, postpartum care should become an ongoing process, rather than a single encounter, with services and sup- port tailored to each woman’s individual needs. Indeed, in qualitative studies, women have noted that there is an intense focus on women’s health prenatally but care during the postpartum period is infrequent and late (8). Rather than an arbitrary “6-week check,” the American College of Obstetricians and Gynecologists recommends that the timing of the comprehensive postpartum visit be individualized and woman centered. To better meet the needs of women in the postpartum period, care would ideally include an initial assessment, either in person or by phone, within the first 3 weeks postpartum to address acute postpartum issues. This initial assess- ment should be followed up with ongoing care as needed, concluding with a comprehensive well-woman visit no later than 12 weeks after birth (Fig. 1). Insurance cover- age policies should be aligned to support this tailored approach to “fourth trimester” care (see Policy and Postpartum Care).

Increasing engagement Currently, as many as 40% of women 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 (9, 10), which contributes to health disparities.

Increasing attendance at postpartum visits is a devel- opmental goal for Healthy People 2020. Strategies for increasing attendance include but are not limited to the following measures: discussing the importance of post- partum care during prenatal visits; using peer counsel- ors, intrapartum support staff, postpartum nurses, and discharge planners to encourage postpartum follow-up; scheduling postpartum visits during prenatal care or

e142 Committee Opinion Optimizing Postpartum Care OBSTETRICS & GYNECOLOGY

Reproductive Life Planning Beginning in prenatal care, the patient and her obstetrician–gynecologist or other obstetric care pro- vider should discuss the woman’s reproductive life plans, including desire for and timing of any future pregnan- cies (19). Women should be advised to avoid inter- pregnancy intervals shorter than 6 months and should be counseled about the risks and benefits of repeat pregnancy sooner than 18 months (20). Short interpreg- nancy intervals also are associated with reduced vaginal birth after cesarean success for women undergoing trial of labor after cesarean (21).

A woman’s future pregnancy intentions provide a context for shared decision-making regarding contra- ceptive options (22). Shared decision-making brings two experts to the table: the patient and the health care provider. The health care provider is an expert in the clinical evidence, and the patient is an expert in her experiences and values (23). As affirmed by the World Health Organization, when making choices regarding the timing of the next pregnancy, “Individuals and couples should consider health risks and benefits along with other circumstances such as their age, fecundity, fertility aspirations, access to health services, child-rearing sup- port, social and economic circumstances, and personal preferences” (24). Given the complex history of steriliza- tion abuse (25) and fertility control among marginalized women, care should be taken to ensure that every woman is provided information on the full range of contraceptive options so that she can select the method best suited to her needs (26).

The Postpartum Care Plan Beginning during prenatal care, the woman and her obstetrician–gynecologist or other obstetric care provider should develop a postpartum care plan and care team,

before hospital discharge; using technology (eg, email, text, and apps) to remind women to schedule postpartum follow-up (11); and increasing access to paid sick days and paid family leave.

Optimal postpartum care provides an opportunity to promote the overall health and well-being of women, and evidence suggests that current care falls short of that goal. In a national survey, less than one half of women attend- ing a postpartum visit reported that they received enough information at the visit about postpartum depression, birth spacing, healthy eating, the importance of exercise, or changes in their sexual response and emotions (12). Of note, anticipatory guidance improves maternal well- being: In a randomized controlled trial, 15 minutes of anticipatory guidance before hospital discharge, fol- lowed by a phone call at 2 weeks, reduced symptoms of depression and increased breastfeeding duration through 6 months postpartum among African American and Hispanic women (13, 14).

Prenatal Preparation To optimize postpartum care, anticipatory guidance should begin during pregnancy with development of a postpartum care plan that addresses the transition to par- enthood and well-woman care (15) (Table 1). Anticipa- tory guidance should include discussion of infant feeding (16, 17), “baby blues,” postpartum emotional health, and the challenges of parenting and postpartum recovery from birth (18). Prenatal discussions also should address plans for long-term management of chronic health con- ditions, such as mental health, diabetes, hypertension, and obesity, including identification of a primary health care provider who will care for the patient beyond the postpartum period. Within this guidance, health care providers should discuss the purpose and value of post- partum clinical care as well as the types of services and support available.

Figure 1. Proposed paradigm shift for postpartum visits. The American College of Obstetricians and Gynecologists’ Presidential Task Force on Redefining the Postpartum Visit and the Committee on Obstetric Practice propose shifting the paradigm for postpartum care from a single 6-week visit (bottom) to a postpartum process (top). Abbreviations: BP, blood pressure; f/u, follow-up. ^

Primary care provider (also may be the obstetric provider)

• May co-manage chronic conditions (eg, hypertension, diabetes, depression) during postpartum period • Assumes primary responsibility for ongoing health care after comprehensive postpartum visit

Lactation support (professional IBCLC, certified counselors and educators, peer support)

• Provides anticipatory guidance and support for breastfeeding • Co-manages complications with pediatric and maternal providers

Care coordinator/case manager • Coordinates health and social services among members of postpartum care team

Home visitor (eg, Nurse Family Partnership, Health Start)

• Provides home visit services to meet specific needs of mother–infant dyad after discharge from maternity care

Specialty consultants (ie, maternal–fetal medicine, internal medicine subspecialist, behavioral health provider)

• Co-manages complex medical problems during postpartum period • Provides prepregnancy counseling for future pregnancies

Abbreviation: IBCLC, international board certified lactation consultant. *Members of the care team may vary depending on the needs of the mother–infant dyad and locally available resources.

Figure 1. Proposed paradigm shift for postpartum visits. The American College of Obstetricians and Gynecologists’ Redefining the Postpartum Visit Presidential Task Force and the Committee on Obstetric Practice propose shifting the paradigm for postpartum care from a single 6-week visit (bottom) to a postpartum process (top).

Wks

Po st

pa rtu

m P

ro ce

ss Primary maternal care provider assumes responsibility for woman’s care through the comprehensive postpartum visit

Contact with all women within first 3 weeks

Ongoing follow-up as needed 3–12 weeks

6-week visit6-

W ee

k Vi

si t

Traditional period of rest and recuperation from birth 0–6 weeks

BP check 3–10 days

High risk f/u 1–3 weeks

Comprehensive postpartum visit and transition to well-woman care 4–12 weeks, timing individualized and woman-centered

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Primary maternal care provider assumes responsibility for woman’s care through the comprehensive postpartum visit

should assume responsibility for her postpartum care (15). This individual or practice is the primary point of contact for the woman, for other members of the post- partum care team, and for any maternal health concerns noted by the infant’s health care provider. When the woman is discharged from inpatient care but prolonged infant hospitalization remote from the woman’s home is anticipated, a local obstetrician–gynecologist or other health care provider should be identified as a point of contact and an appropriate hand off should occur. Such a referral should occur even if delivery did not take place at a local hospital.

Substantial morbidity occurs in the early postpartum period; more than one half of pregnancy-related maternal deaths occur after the birth of the infant (6). Blood pres- sure evaluation is recommended for women with hyper- tensive disorders of pregnancy no later than 7–10 days postpartum (28), and women with severe hypertension should be seen within 72 hours; other experts have rec- ommended follow-up at 3–5 days (29). Such assessment is critical given that more than one half of postpartum strokes occur within 10 days of discharge (30). In-person follow-up also may be beneficial for women at high risk of complications, such as postpartum depression (31), cesarean or perineal wound infection, lactation difficul- ties, or chronic conditions such as seizure disorders that require postpartum medication titration. For women

inclusive of family and friends who will provide social and material support in the months following birth, as well as the medical provider(s), who will be primarily responsible for care of the woman and her infant after birth (19). Suggested components of the postpartum care team and care plan are listed in Table 1 and Table 2. The care plan should identify the primary care provider and other medical providers (eg, psychiatrist) who will assume care of chronic medical issues after the post- partum period. If the obstetrician–gynecologist serves as the primary care provider, then transition to another primary care physician is unnecessary.

Transition From Intrapartum to Postpartum Care The postpartum care plan should be reviewed and updated after the woman gives birth. Women often are uncertain about whom to contact for postpartum con- cerns (27). 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 (12). Therefore, it is suggested that the care plan include contact information and written instruc- tions regarding the timing of follow-up postpartum care. Just as a health care provider or health care practice leads the woman’s care during pregnancy, a primary obstetrician–gynecologist or other health care provider

Table 1. Suggested Components of the Postpartum Care Plan* ^

Element Components

Care team Name, phone number, and office or clinic address for each member of care team

Postpartum visits Time, date, and location for postpartum visit(s); phone number to call to schedule or reschedule appointments

Infant feeding plan Intended method of infant feeding, resources for community support (eg, WIC, Lactation Warm Lines, Mothers’ groups), return-to-work resources

Reproductive life plan and Desired number of children and timing of next pregnancy commensurate contraception Method of contraception, instructions for when to initiate, effectiveness, potential adverse effects, and care team member to contact with questions

Pregnancy complications Pregnancy complications and recommended follow-up or test results (eg, glucose screening for gestational diabetes, blood pressure check for gestational hypertension), as well as risk reduction recommendations for any future pregnancies

Adverse pregnancy outcomes Adverse pregnancy outcomes associated with ASCVD will need baseline ASCVD risk assessment, as well as associated with ASCVD discussion of need for ongoing annual assessment and need for ASCVD prevention over lifetime.

Mental health Anticipatory guidance regarding signs and symptoms of perinatal depression or anxiety; management recommendations for women with anxiety, depression, or other psychiatric issues identified during pregnancy or in the postpartum period

Postpartum problems Recommendations for management of postpartum problems (ie, pelvic floor exercises for stress urinary incontinence, water-based lubricant for dyspareunia)

Chronic health conditions Treatment plan for ongoing physical and mental health conditions and the care team member responsible for follow-up

Abbreviations: ASCVD, atherosclerotic cardiovascular disease; WIC, Special Supplemental Nutrition Program for Women, Infants, and Children.

*A Postpartum Care Plan Template is available as part of the ACOG Pregnancy Record.

e144 Committee Opinion Optimizing Postpartum Care OBSTETRICS & GYNECOLOGY

Assessment need not occur as an office visit, and the usefulness of an in-person assessment should be weighed against the burden of traveling to and attending an office visit with a neonate. Additional mechanisms for assess- ing women’s health needs after birth include home visits (34), phone support (35, 36), text messages (37), remote blood pressure monitoring (38, 39), and app-based sup- port (40). Phone support during the postpartum period appears to reduce depression scores, improve breastfeed- ing outcomes, and increase patient satisfaction, although the evidence is mixed (35, 36).

The Comprehensive Postpartum Visit and Transition to Well-Woman Care

Visit Timing 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 (41).

with complex medical problems, multiple visits may be required to facilitate recovery from birth.

Of note, even among women without risk factors, problems such as heavy bleeding, pain, physical exhaus- tion, and urinary incontinence are common (12). World Health Organization guidelines for postnatal care include routine postpartum evaluation of all women and infant dyads at 3 days, 1–2 weeks, and 6 weeks (32). The National Institute for Health and Care Excellence guidelines rec- ommend screening all women for resolution of the “Baby Blues” at 10–14 days after birth to facilitate early identification of and treatment for postpartum depres- sion (15). Contact in the first few weeks also may enable women to meet their breastfeeding goals: Among women with early, undesired weaning, 20% had discontinued breastfeeding by 6 weeks postpartum (33), when tradi- tionally timed visits occurred. To address these common postpartum concerns, all women should ideally have contact with a maternal care provider within the first 3 weeks postpartum.

Table 2. Postpartum Care Team* ^

Team Member Role

Family and friends • Ensures woman has assistance for infant care, breastfeeding support, care of older children • Assists with practical needs such as meals, household chores, and transportation • Monitors for signs and symptoms of complications, including mental health

Primary maternal care provider (obstetrician–gynecologist, • Ensures patient’s postpartum needs are assessed and met during the certified nurse midwife, family physician, women’s health postpartum period and that the comprehensive postpartum visit is completed nurse practitioner) • “First call” for acute concerns during postpartum period • Also may provide ongoing routine well-woman care after comprehensive postpartum visit

Infant’s health care provider (pediatrician, family physician, • Primary care provider for infant after discharge from maternity care pediatric nurse practitioner)

Primary care provider (also may be the obstetric care provider) • May co-manage chronic conditions (eg, hypertension, diabetes, depression) during postpartum period • Assumes primary responsibility for ongoing health care after comprehensive postpartum visit

Lactation support (professional IBCLC, certified counselors • Provides anticipatory guidance and support for breastfeeding and educators, peer support) • Co-manages complications with pediatric and maternal care providers

Care coordinator or case manager • Coordinates health and social services among members of postpartum care team

Home visitor (eg, Nurse Family Partnership, Health Start) • Provides home visit services to meet specific needs of mother–infant dyad after discharge from maternity care

Specialty consultants (ie, maternal–fetal medicine, internal • Co-manages complex medical problems during postpartum period medicine subspecialist, behavioral health care provider) • Provides prepregnancy counseling for future pregnancies

Abbreviation: IBCLC, international board certified lactation consultant. *Members of the care team may vary depending on the needs of the mother–infant dyad and locally available resources.

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ensure that women, their families, and their employ- ers understand that completion of the comprehensive postpartum visit does not obviate the need for continued recovery and support through 6 weeks postpartum and beyond.

Visit Components The comprehensive postpartum visit should include a full assessment of physical, social, and psychological well- being, including the following domains (Box 1): mood and emotional well-being; infant care and feeding; sexu- ality, contraception, and birth spacing; sleep and fatigue; physical recovery from birth; chronic disease manage- ment; and health maintenance.

Today, however, 23% of employed women return to work within 10 days postpartum and an additional 22% return to work between 10 days and 40 days (42). Therefore, timing of the comprehensive postpartum visit should be individualized and woman centered, occurring no later than 12 weeks from birth. Timing also should take into account any changes in insurance coverage anticip- ated after delivery. At all postpartum encounters, obstetrician–gynecologists and other obstetric care providers should consider the need for future follow- up and time additional visits accordingly. However timed, the comprehensive postpartum visit is a medical appointment; it is not an “all-clear” signal. Obstetrician– gynecologists and other obstetric care providers should

Box 1. Components of Postpartum Care

Mood and emotional well-being • Screen for postpartum depression and anxiety with a validated instrument1,2 • Provide guidance regarding local resources for mentoring and support • Screen for tobacco use; counsel regarding relapse risk in postpartum period3 • Screen for substance use disorder and refer as indicated4 • Follow-up on preexisting mental health disorders, refer for or confirm attendance at mental health-related appointments, and

titrate medications as appropriate for the postpartum period

Infant care and feeding • Assess comfort and confidence with caring for newborn, including

— feeding method — child care strategy if returning to work or school — ensuring infant has a pediatric medical home — ensuring that all caregivers are immunized5

• Assess comfort and confidence with breastfeeding, including — breastfeeding-associated pain6 — guidance on logistics of and legal rights to milk expression if returning to work or school7,8 — guidance regarding return to fertility while lactating; pregnancy is unlikely if menses have not returned, infant is less

than 6 months old, and infant is fully or nearly fully breastfeeding with no interval of more than 4–6 hours between breastfeeding sessions9

— review theoretical concerns regarding hormonal contraception and breastfeeding, within the context of each woman’s desire to breastfeed and her risk of unplanned pregnancy7

• Assess material needs, such as stable housing, utilities, food, and diapers, with referral to resources as needed

Sexuality, contraception, and birth spacing • Provide guidance regarding sexuality, management of dyspareunia, and resumption of intercourse • Assess desire for future pregnancies and reproductive life plan10 • Explain the rationale for avoiding an interpregnancy interval of less than 6 months and discuss the risks and benefits of repeat

pregnancy sooner than 18 months • Review recommendations for prevention of recurrent pregnancy complications, such as 17α-hydroxyprogesterone caproate

to reduce risk of recurrent preterm birth, or aspirin to reduce risk of preeclampsia • Select a contraceptive method that reflects patient’s stated needs and preferences, with same-day placement of LARC, if

desired11

(continued)

e146 Committee Opinion Optimizing Postpartum Care OBSTETRICS & GYNECOLOGY

Box 1. Components of Postpartum Care (continued)

Sleep and fatigue • Discuss coping options for fatigue and sleep disruption • Engage family and friends in assisting with care responsibilities

Physical recovery from birth • Assess presence of perineal or cesarean incision pain; provide guidance regarding normal versus prolonged recovery12 • Assess for presence of urinary and fecal continence, with referral to physical therapy or urogynecology as indicated13,14 • Provide actionable guidance regarding resumption of physical activity and attainment of healthy weight15

Chronic disease management • Discuss pregnancy complications, if any, and their implications for future childbearing and long-term maternal health,

including ASCVD • Perform glucose screening for women with GDM: a fasting plasma glucose test or 75 g, 2-hour oral glucose tolerance test16

• Review medication selection and dose outside of pregnancy, including consideration of whether the patient is breastfeeding, using a reliable resource such as LactMed

• Refer for follow-up care with primary care or subspecialist health care providers, as indicated

Health maintenance • Review vaccination history and provide indicated immunizations, including completing series initiated antepartum or

postpartum17 • Perform well-woman screening, including Pap test and pelvic examination, as indicated18

Abbreviations: ASCVD, arteriosclerotic cardiovascular disease; GDM, gestational diabetes mellitus; LARC, long-acting reversible contracep- tive. 1Screening for perinatal depression. Committee Opinion No. 630. American College of Obstetricians and Gynecologists. Obstet Gynecol

2015;125:1268–71. 2Earls 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. 3American College of Obstetricians and Gynecologists. Tobacco and nicotine cessation toolkit. Washington, DC: American College of

Obstetricians and Gynecologists; 2016. 4Opioid use and opioid use disorder in pregnancy. Committee Opinion No. 711. American College of Obstetricians and Gynecologists. Obstet

Gynecol 2017;130:e81–94. 5American Academy of Pediatrics. Protect infants against pertussis: cocooning through Tdap vaccination. Washington, DC: AAP. Available at:

https://www.aap.org/en-us/Documents/immunization_protect_infants_against_pertussis.pdf. Retrieved January 23, 2018. 6Berens P, Eglash A, Malloy M, Steube AM. ABM Clinical Protocol #26: persistent pain with breastfeeding. Breastfeed Med 2016;11:46–53. 7Optimizing support for breastfeeding as part of obstetric practice. Committee Opinion No. 658. American College of Obstetricians and

Gynecologists. Obstet Gynecol 2016;127:e86–92. 8Breastfeeding in underserved women: increasing initiation and continuation of breastfeeding. Committee Opinion No. 570. American College

of Obstetricians and Gynecologists. Obstet Gynecol 2013;122:423–8. 9Centers for Disease Control and Prevention. Lactational amenorrhea method. In: US medical eligibility criteria (US MEC) for contraceptive

use. Atlanta (GA): CDC; 2017. 10Reproductive life planning to reduce unintended pregnancy. Committee Opinion No. 654. American College of Obstetricians and

Gynecologists. Obstet Gynecol 2016;127:e66–9. 11Immediate postpartum long-acting reversible contraception. Committee Opinion No. 670. American College of Obstetricians and

Gynecologists. Obstet Gynecol 2016;128:e32–7. 12MacArthur 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.

13Prevention and management of obstetric lacerations at vaginal delivery. Practice Bulletin No. 165. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;128:e1–15.

14Urinary incontinence in women. Practice Bulletin No. 155. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;126:e66–81.

15American College of Obstetricians and Gynecologists. Obesity toolkit. Washington, DC: American College of Obstetricians and Gynecologists; 2016.

16Gestational diabetes mellitus. ACOG Practice Bulletin No. 190. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;131:e49–64.

17American College of Obstetricians and Gynecologists. Immunization for women. Washington, DC: American College of Obstetricians and Gynecologists; 2017.

18Conry J, Brown H. Well-Woman Task Force: Components of the Well-Woman Visit. Obstet Gynecol 2015;126:697–701.

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agents should be reviewed to ensure that the dosage has been adjusted to reflect postpartum physiology and that the agents selected are compatible for women who are breastfeeding. The U.S. National Library of Medicine’s LactMed is a free online resource that provides high- quality guidance on medication safety during lactation (www.toxnet.nlm.nih.gov/newtoxnet/lactmed.htm).

Pregnancy Loss For a woman who has experienced a miscarriage, still- birth, or neonatal death, it is essential to ensure follow-up with an obstetrician–gynecologist or other obstetric care provider. Key elements of this visit include emotional support and bereavement counseling; referral, if appro- priate, 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 (50).

Transition to Ongoing Well-Woman Care During the postpartum period, the woman and her obstetrician–gynecologist or other obstetric care provider should modify her postpartum care plan to identify the health care provider who will assume primary responsi- bility for her ongoing care in her primary medical home. Appropriate referrals to other members of her health care team should also be made during this transitional period. If the obstetrician–gynecologist or other obstetric care provider is also 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 respon- sible 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.

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. By providing comprehen- sive, woman-centered care after childbirth, obstetrician– gynecologists and other obstetric care providers can enable every woman to optimize her long-term health and well-being.

Policy and Postpartum Care Optimizing care and support for postpartum families will require policy changes. Changes in the scope of postpartum care should be facilitated by reimbursement policies that support postpartum care as an ongoing process, rather than an isolated visit. More broadly, pro- visions for paid parental leave are essential to improve the health of women and children and reduce dispari- ties. As one study (51) has noted, “The lack of policies

The comprehensive postpartum visit provides an opportunity for a woman to ask questions about her labor, childbirth, and any complications (15). Relevant details should be reviewed and documented in the medical record. A traumatic birth experience can cause postpartum posttraumatic stress disorder, which affects 3–16% of women (43). Trauma is in the eye of the beholder, and health care providers should be aware that a woman may experience a birth as traumatic even if she and her infant are healthy. Complications should be discussed with respect to risks for future pregnancies, such as recommendations for 17α-hydroxyprogesterone caproate to reduce risk of recurrent preterm birth, or aspirin to reduce risk of preeclampsia. Any placental pathology reports should be reviewed and shared with the patient. Recommendations should be made to opti- mize maternal health during the interpregnancy period (44), such as controlling diabetes and attaining optimal weight (45).

Adverse Pregnancy Outcomes and Cardiovascular Risk There are risk factors for cardiovascular disease that appear during pregnancy, and these risk factors are emerging as an important predictor of future arterioscle- rotic cardiovascular disease (ASCVD) risk. Complications such as preterm delivery, gestational diabetes, gestational hypertension, preeclampsia, and eclampsia are associated with greater risk of ASCVD (46). Pregnancy is, therefore, a natural “stress test” identifying at-risk women, but because these conditions often resolve postpartum, the increased cardiovascular disease risk is not consistently communicated to women. These adverse pregnancy out- comes are also not assessed when using current ASCVD risk assessment tools. Therefore, women with pregnan- cies complicated by preterm birth, gestational diabetes, or hypertensive disorders of pregnancy should be coun- seled that these disorders are associated with a higher lifetime risk of maternal cardiometabolic disease. These women should undergo ASCVD risk assessment (47, 48), with particular attention to the effect of social determi- nants of health on cardiometabolic disease (49). All post- partum women with gestational diabetes should undergo glucose screening with a fasting plasma glucose test or a 75-g, 2-hour oral glucose tolerance test (45). Any history of pregnancy complications should be documented in the woman’s electronic medical record to facilitate effec- tive transition of care and to inform future screening and treatment.

Chronic Health Conditions Women with chronic medical conditions, such as hyper- tensive disorders, obesity, diabetes, thyroid disorders, renal disease, mood disorders, and substance use disor- ders, should be counseled regarding the importance of timely follow-up with their obstetrician–gynecologists or primary care providers for ongoing coordination of care. Medications such as antiepileptics and psychotropic

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9. 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. ^

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substantially benefitting early life in the United States constitutes a grave social injustice: those who are already most disadvantaged in our society bear the greatest burden.” The American College of Obstetricians and Gynecologists endorses paid parental leave as essential, including maintenance of full benefits and 100% of pay for at least 6 weeks (52). Obstetrician–gynecologists and other obstetric care providers should be in the forefront of policy efforts to enable all women to recover from birth and nurture their infants.

For More Information The American College of Obstetricians and Gynecologists 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/OptimizingPost partumCare.

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 website, or the content of the resource. The resources may change without notice.

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46. Gulati M. Improving the cardiovascular health of women in the nation: moving beyond the bikini boundaries. Circulation 2017;135:495–8. ^

47. 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 [published erratum appears in Circulation 2011;124:e427]. Circulation 2011;123:1243–62. ^

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Optimizing postpartum care. ACOG Committee Opinion No. 736. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;131:e140–50.

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This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its publica- tions may not reflect the most recent evidence. Any updates to this document can be found on www.acog.org or by calling the ACOG Resource Center.

While ACOG makes every effort to present accurate and reliable information, this publication is provided “as is” without any warranty of accuracy, reliability, or otherwise, either express or implied. ACOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither ACOG nor its officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabili- ties, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.

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