A Guide to Implementing Fourth-Trimester Care in a Family Medicine Practice

The maternal morbidity and mortality crisis is worsening in the U.S. The Centers for Disease Control and Prevention (CDC) reports that 84% of maternal deaths are preventable and more than half occur in the postpartum period.¹ Unfortunately, 40% of women do not attend a single postpartum visit.² In response to this crisis, the American College of Obstetrics and Gynecology (ACOG) and the American Academy of Family Physicians (AAFP) have called for a reinvention of postpartum care.³ The cornerstone of the new standard of care is contact with a clinician within three weeks of delivery in addition to the traditional six-to-eight-week postpartum visit.^2–4

The IMPLICIT Network, a group of more than 30 family medicine and pediatric practices, has developed and successfully implemented a “fourth trimester” model (covering the three months postpartum, immediately following childbirth) at 12 family medicine practices in Pennsylvania and New York.⁵ In our practices, it has led to a more than 80% increase in the percentage of maternity patients who attend a postpartum visit within three weeks and a more than 20% increase in the percentage of maternity patients who attend any postpartum visits. In addition, we have seen improvements in feeding and contraception intention matching, meaning greater alignment between patients’ prenatal plans and actual postpartum behavior. This earlier contact with the health care team is an important intervention to assess patients for possible complications and prevent maternal morbidity. Below, we offer a fourth-trimester implementation guide.

The fourth-trimester care model involves four stages.

Third-trimester planning (36 weeks): Just as regular follow-up visits are more likely to occur when we schedule them prior to patients leaving the office, postpartum-visit attendance is improved when we schedule the appointments in advance. In the third trimester, typically at 36 weeks, we encourage patients to schedule all of their remaining prenatal visits (weekly until delivery) and two postpartum visits (one at two to three weeks post-delivery and another at six to eight weeks). If a patient delivers before 40 weeks, one of the scheduled prenatal visits can be used for the early postpartum visit instead. Clinicians can begin to create a plan for the postpartum period by having patients complete a questionnaire that asks about items such as postpartum feeding plans, contraception plans, and anticipated needs for support based on patient risk factors (see Table 1).