Postpartum Care: An Approach to the Fourth Trimester

 

Am Fam Physician. 2019 Oct 15;100(8):485-491.

  Patient information: A handout on this topic is available at https://familydoctor.org/recovering-from-delivery.

Related editorial: What Family Physicians Can Do to Reduce Maternal Mortality.

Author disclosure: No relevant financial affiliations.

The postpartum period, defined as the 12 weeks after delivery, is an important time for a new mother and her family and can be considered a fourth trimester. Outpatient postpartum care should be initiated within three weeks after delivery in person or by phone, and may require multiple contacts with the patient to fully address needs and concerns. A full assessment is recommended within 12 weeks. Care should initially focus on acute needs and risks for morbidity and mortality and then transition to care for chronic conditions and health maintenance. Complications of pregnancy, such as hypertensive disorders and gestational diabetes mellitus, affect a woman's long-term health and require specific attention. Women diagnosed with gestational diabetes should receive a 75-g two-hour fasting oral glucose tolerance test between four and 12 weeks postpartum. Patients with hypertensive disorders of pregnancy should have a blood pressure check performed within seven days of delivery. All women should have a biopsychosocial assessment (e.g., depression, intimate partner violence) screening in the postpartum period, and preventive counseling should be offered to women at high risk. Additional patient concerns may include urinary incontinence, constipation, breastfeeding, sexuality, and contraception. Treating these issues during the postpartum period is important to the new mother's immediate and long-term health.

The 12 weeks after delivery, known as the postpartum period or the fourth trimester, are a critical time in the life of a mother and her infant. Maternal mortality, which is defined as deaths that occur during pregnancy and the first year postpartum, is highest in the first 42 days postpartum and represents 45% of total maternal mortality.1,2 Early postpartum visits should evaluate complications from pregnancy as well as common postpartum medical complications.35 Subsequent care should include a full biopsychosocial assessment and be tailored to individual patient needs going forward.3 Family physicians should be aware of the importance of social determinants of health and disparities in maternal outcomes according to race, ethnicity, and public health insurance status.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Initial follow-up should be within three weeks after delivery, in person or by phone. A comprehensive visit should occur within 12 weeks postpartum and include a biopsychosocial assessment.3,9

C

American College of Obstetricians and Gynecologists and World Health Organization expert consensus

Women with hypertensive disorders should have a blood pressure check within seven days postpartum.18,19

C

Narrative reviews and expert consensus

Women with gestational diabetes mellitus should be screened for diabetes with a 75-g two-hour fasting oral glucose tolerance test at four to 12 weeks postpartum.2022

C

Longitudinal cohort studies and expert consensus

All women should be screened in the postpartum period for depression in settings where systems are in place to ensure diagnosis, treatment, and follow-up.25

B

USPSTF recommendation statement

Women at high risk of perinatal depression should receive preventive counseling in the postpartum period.28

B

USPSTF recommendation statement


USPSTF = U.S. Preventive Services Task Force.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Initial follow-up should be within three weeks after delivery, in person or by phone. A comprehensive visit should occur within 12 weeks postpartum and include a biopsychosocial assessment.3,9

C

American College of Obstetricians and Gynecologists and World Health Organization expert consensus

Women with hypertensive disorders should have a blood pressure check within seven days postpartum.18,19

C

Narrative reviews and expert consensus

Women with gestational diabetes mellitus should be screened for diabetes with a 75-g two-hour fasting oral glucose tolerance test at four to 12 weeks postpartum.2022

C

Longitudinal cohort studies and expert consensus

All women should be screened in the postpartum period for depression in settings where systems are in place to ensure diagnosis, treatment, and follow-up.25

B

USPSTF recommendation statement

Women at high risk of perinatal depression should receive preventive counseling in the postpartum period.28

B

USPSTF recommendation statement


USPSTF = U.S. Preventive Services Task Force.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice,

The Authors

show all author info

HEATHER L. PALADINE, MD, MEd, is the director of the New York Presbyterian–Columbia Family Medicine Residency Program, and an assistant professor in the Center for Family and Community Medicine at Columbia University Irving Medical Center, New York, NY....

CAROL E. BLENNING, MD, is an associate professor in the Department of Family Medicine at Oregon Health and Science University School of Medicine, Portland.

YORGOS STRANGAS, MD, is an assistant professor in the Center for Family and Community Medicine at Columbia University Irving Medical Center.

Address correspondence to Heather L. Paladine, MD, MEd, 610 W. 158 St., New York, NY 10032 (email: hlp222@gmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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show all references

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