Postpartum Care: An Approach to the Fourth Trimester

Heather L. Paladine; Carol E. Blenning; Yorgos Strangas

HEATHER L. PALADINE, MD, MEd, CAROL E. BLENNING, MD, AND YORGOS STRANGAS, MD

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

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.^3–5 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.

Clinical recommendation	Evidence rating	Comments
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.^20–22	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

Timing and Frequency of Postpartum Visits

Historically, physicians have performed a single postpartum visit between four and six weeks after delivery to close the prenatal care relationship.¹ There is a growing consensus to initiate care within the first three weeks postpartum, and to extend the postpartum period to transition to care of chronic conditions.^6–8 The American College of Obstetricians and Gynecologists (ACOG) recommends a postpartum evaluation within the first three weeks after delivery in person or by phone, with a complete biopsychosocial assessment to be completed within 12 weeks postpartum.³ The World Health Organization recommends visits at three days, seven to 14 days, and six weeks postpartum, inclusive of newborn care.^3,9 A routine pelvic examination is not indicated unless there are patient concerns.

Postpartum Health Issues and Patient Concerns

Health issues in the postpartum period include medical complications, patient concerns, and conditions that may cause future health risks (Table 1).^4,10–52 Family physicians may need to continue to provide medical care for these conditions beyond 12 weeks after delivery. Complications that occur during the prenatal period may reveal areas for intervention and surveillance.^20,21

Condition/concern	Diagnostic considerations	Treatment considerations	Notes
Secondary postpartum hemorrhage^10–12	Ultrasonography to look for retained placental fragments	Uterotonics are first-line treatment May need uterine curettage Antibiotics for endometritis if infection is suspected	Occurs in up to 2% of women in the postpartum period Hemorrhage can occur up to 12 weeks postpartum Risk factors include immediate postpartum hemorrhage, vaginal (vs. cesarean) delivery, and maternal age of 35 years or older
Endometritis^13,14	Fever with no other source, may be accompanied by uterine tenderness and vaginal discharge	Usually requires intravenous antibiotics, most evidence for clindamycin and gentamicin	Higher likelihood of anaerobic infection or chlamydia in late infections
Thromboembolic disease^15–17	Risk is five times higher during postpartum period than pregnancy Elevated risk persists up to 12 weeks postpartum	Avoid direct thrombin inhibitors and direct oral anticoagulants in women who are breastfeeding	—
Hypertensive disorders^4,18,19	Highest risk is < 48 hours after delivery Recommend office visit to check blood pressure within 7 days of delivery	Treat if blood pressure ≥ 150/100 mm Hg, can use oral nifedipine or labetalol Hospitalize if signs of end organ damage or blood pressure ≥ 160/110 mm Hg Recommend lifestyle changes and annual follow-up for blood pressure and body weight monitoring	Occurs in up to 10% of women in postpartum period Risk factor for future cardiovascular disease, cerebrovascular disease, and venous thromboembolism
Gestational diabetes mellitus^20–22	75-g, 2-hour fasting oral glucose tolerance test 4 to 12 weeks postpartum to detect type 2 diabetes mellitus, then screening every 1 to 3 years	Recommend lifestyle changes and annual follow-up	5% to 10% of women with gestational diabetes continue to have type 2 diabetes after delivery Lifetime risk of developing type 2 diabetes is multiplied at least eightfold after a diagnosis of gestational diabetes Risk increases with a higher body mass index, more abnormal glucose tolerance test results, nonwhite race, and older age
Thyroid disorders^23,24	Can have symptoms of hyperthyroidism or hypothyroidism Test thyroid-stimulating hormone and free thyroxine Positive thyroid-stimulating hormone receptor antibodies distinguish Graves disease from postpartum thyroiditis	Hyperthyroidism is transient and usually not treated Beta blockers can be used as needed for symptoms Hypothyroidism is treated with thyroid hormone therapy	Up to 10% of women develop postpartum thyroiditis Up to one-half of patients will be hypothyroid at one year postpartum, sometimes after initial recovery of thyroid function The American Thyroid Association recommends annual screening for hypothyroidism in women with a history of postpartum thyroiditis
Postpartum depression^25–29	Edinburgh Postnatal Depression Scale and Patient Health Questionnaire-2/9 are valid diagnostic tools for postpartum depression	Consider counseling and medication	Occurs in up to 10% of women in postpartum period Recommend counseling to prevent depression in high-risk women
Intimate partner violence^30,31	Use HARK (humiliation, afraid, rape, kick) or HITS (hurt, insult, threaten, scream) tools to evaluate for intimate partner violence	Consider counseling, home visits, and parenting support	Prioritize patient safety, consider referral to intimate partner violence prevention organizations
Urinary incontinence^32–34	Evaluation includes history, examination including cough stress test with a full bladder and assessment of urethral mobility, urinalysis, and measurement of postvoid residual urinary volume	Bladder training, weight loss, pelvic floor muscle exercises effective as first-line treatment	More than one-fourth ofwomen experience moderate or severe urinary incontinence in the first year postpartum
Hemorrhoids and constipation³⁵	Consider effects of medications and supplements such as iron	Increased dietary fiber and water intake Osmotic laxatives (polyethylene glycol [Miralax] or lactulose) recommended for constipation Stool softeners recommended for hemorrhoids May need excision or ligation for refractory hemorrhoids or grade III or higher	Constipation may affect up to 17% of women in the first year postpartum
Breastfeeding problems^36–38	Evaluate latch, swallow, nipple type and condition, and hold of the infant	Interventions include professional support, peer support, and formal education	—
Postpartum weight retention/metabolic risk^39,40	Women with higher gestational weight gain, black race, and lower socioeconomic status are at higher risk	Dietary changes, or diet and exercise in combination are effective	Increased risk of future obesity and type 2 diabetes
Sexuality ^41,42	Symptoms of low postpartum libido and reduced sexual function likely caused by low estrogen levels and multiple psychosocial factors	Reassurance usually appropriate Resolves over time	Address earlier return of sexual activity with contraception to avoid unintended closely spaced pregnancies
Contraception^41–52	—	For women who are breastfeeding: progestin-only methods can be used immediately postpartum (e.g., etonogestrel implant [Nexplanon], levonorgestrel-releasing intrauterine system [Mirena], medroxyprogesterone [Depo-Provera])	Immediate use is not harmful to the infant Can improve pregnancy spacing
		Adolescents: begin motivational interviewing, discussion of long-acting reversible contraception during pregnancy	Intervention during pregnancy is superior to postpartum period
		Timing: offer progestin-only methods immediately (no estrogen until three weeks postpartum) to all women regardless of lactation	Earlier introduction of contraception

SECONDARY POSTPARTUM HEMORRHAGE

Secondary postpartum hemorrhage is defined as significant vaginal bleeding that occurs beyond 24 hours postpartum. Rates may be as high as 2%,¹⁰ and retained placental tissue and infection are the most common causes. Women with secondary postpartum hemorrhage may need to be examined in the emergency department or hospital for prompt evaluation, including ultrasonography to investigate for retained placental tissue.¹¹ Treatment may include uterotonic medications, uterine curettage, or antibiotic treatment for endometritis.¹²

ENDOMETRITIS

Women with a fever and tachycardia during the postpartum period should be evaluated for endometritis. Patients may also have uterine tenderness or vaginal discharge. Late postpartum endometritis occurs more than seven days after delivery. Risk factors include chorioamnionitis and prolonged rupture of membranes.¹³ Endometritis usually requires treatment with intravenous antibiotics, with most evidence supporting the use of gentamicin and clindamycin.¹⁴

THROMBOEMBOLIC DISORDERS

The risk of venous thromboembolic disease, including deep venous thrombosis and pulmonary embolism, is five times higher during the six weeks postpartum than during pregnancy.¹⁷ A lesser degree of increased risk persists up to 12 weeks postpartum.⁵ Additional risk factors are increasing age, cesarean delivery, postpartum hemorrhage or infection, and a history of preeclampsia.¹⁵

Patients with a history of thromboembolism should be treated with anticoagulation for at least the first six weeks postpartum, and potentially longer if there are other risk factors. Warfarin (Coumadin) is teratogenic during pregnancy; however, it is minimally excreted in breast milk and is considered safe for women who are breastfeeding. There is a lack of data on the use of direct oral anticoagulants in breastfeeding, and they are not recommended for these patients.¹⁶

HYPERTENSIVE DISORDERS

Up to 10% of women have elevated blood pressure during pregnancy, including chronic hypertension, gestational hypertension, and preeclampsia. Women with hypertensive disorders of pregnancy should have a follow-up blood pressure check within seven days of delivery and be evaluated for signs or symptoms of end organ damage such as hepatic injury or pulmonary edema.^4,18 Patients with new-onset blood pressure of 150/100 mm Hg or higher or with signs of end organ damage should be treated with antihypertensive medications. Patients with signs of end organ damage or a blood pressure of 160/110 mm Hg or higher should be hospitalized and treated with parenteral magnesium sulfate to prevent eclampsia.¹⁸ Nonsteroidal anti-inflammatory drugs are preferred over opioid analgesia and have been shown to be safe for women with a history of hypertension in pregnancy.^19,53,54

Women with hypertensive disorders have an increased risk of cardiovascular events later in life.^18,55,56 They also have an elevated risk of cardiovascular disease, cerebrovascular disease, and venous thromboembolic disorders, and are at risk of these complications at an earlier age than the general population. All patients with a history of hypertensive disorders of pregnancy should be counseled on behavior modification and have blood pressure and body weight monitored at least once a year.^18,55

GESTATIONAL DIABETES MELLITUS

Gestational diabetes mellitus is a significant risk factor for the development of type 2 diabetes mellitus, hypertension, and subsequent heart disease. A woman with a history of gestational diabetes has an eight- to 20-fold risk of developing type 2 diabetes during her lifetime.^20,21 Women with gestational diabetes should be screened for impaired glucose tolerance with a 75-g two-hour fasting oral glucose tolerance test at four to 12 weeks postpartum, and should be evaluated for development of hypertension with blood pressure monitoring.^20,53 They should continue to be screened for diabetes every one to three years because the risk of type 2 diabetes is elevated.²¹

THYROID DISORDERS

Postpartum thyroiditis can affect up to 10% of women during the first year postpartum, with similar rates of hyperthyroidism and hypothyroidism.²³ Postpartum hyperthyroidism is usually transient and does not need to be treated. Hypothyroidism is treated with thyroid hormone therapy. The risk of Graves disease is also increased postpartum, and women with a history of this disease are more likely to relapse. Positive thyroid-stimulating hormone receptor antibodies can distinguish Graves disease from postpartum thyroiditis. Infants of women who are breastfeeding and being treated for thyroid disorders should be monitored for growth and development; however, laboratory monitoring of infants' thyroid function is not necessary.^23,24 The American Thyroid Association recommends annual thyroid function screening in women with a history of postpartum thyroiditis.²³

POSTPARTUM DEPRESSION

Up to 10% of women will experience depression in the first year postpartum. The U.S. Preventive Services Task Force (USPSTF), ACOG, and American Academy of Pediatrics recommend one or more screening examinations for postpartum depression in settings where systems are in place to ensure diagnosis, treatment, and follow-up.^25–27 The American Academy of Pediatrics has specific recommendations for timing of screening at the one-, two-, four-, and six-month well-child visits. The Patient Health Questionnaire-2, Patient Health Questionnaire-9, and Edinburgh Postpartum Depression Scale are appropriate screening tools.

The USPSTF also recommends preventive counseling for women at high risk of perinatal depression.²⁸ Risk factors include a personal or family history of depression, a history of intimate partner violence, stressful life events including unplanned or undesired pregnancy, poor social or financial support, and medical complications. A previous American Family Physician (AFP) article reviewed identification and management of peripartum depression.²⁹

INTIMATE PARTNER VIOLENCE

The USPSTF recommends screening women of reproductive age for intimate partner violence with a validated screening tool such as HARK (humiliation, afraid, rape, kick; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2034562/table/T1/) or HITS (hurt, insult, threaten, scream; https://www.aafp.org/afp/2016/1015/p646.html#afp20161015p646-t2), followed by referral to support services if indicated.³⁰ Interventions such as counseling and home visits can reduce intimate partner violence for women postpartum.

URINARY INCONTINENCE

In one large cohort study, 28.5% of women reported moderate or severe urinary incontinence in the first year postpartum.³² Bladder training, fluid management, body weight loss, and pelvic floor muscle exercises improve symptoms for all types of urinary incontinence, but studies have included women who are perimenopausal and not postpartum.³⁴ It is uncertain whether pelvic floor muscle training during the postpartum period has an effect on urinary incontinence; however, it does reduce postpartum urinary incontinence by about one-third when initiated prenatally.³³

HEMORRHOIDS AND CONSTIPATION

Hemorrhoids may be caused by constipation or by pushing during the second stage of labor. Initial therapy involves treatment for constipation.³⁵ Up to 17% of women report constipation in the first six weeks postpartum. Iron supplements taken orally during pregnancy can be a contributing factor. First-line treatments include increased intake of water and fiber, and osmotic laxatives such as polyethylene glycol (Miralax) or lactulose. Patients with hemorrhoids should also be treated with stool softeners.

BREASTFEEDING PROBLEMS

A previous AFP article addressed breastfeeding recommendations and common problems.³⁶ The USPSTF found moderate evidence that primary care–based interventions to increase breastfeeding are beneficial.³⁷ Individual-level interventions have stronger evidence of effectiveness. These include professional support by physicians, midwives, or lactation counselors; peer support; or formal education sessions. A Cochrane review found that support by trained personnel (e.g., medical professionals, volunteers), face-to-face interventions, and interventions that took place over multiple encounters were more effective.³⁸

POSTPARTUM WEIGHT RETENTION AND METABOLIC RISK

Although data are limited on postpartum body weight retention, a National Academy of Sciences report estimates that most women at six months postpartum will weigh about 11.8 pounds (5.4 kg) more than their prepregnancy body weight. Risk factors for higher postpartum weight retention include more body weight gain during pregnancy, black race, and lower socioeconomic status. Postpartum weight retention is a risk factor for later metabolic risk including development of obesity, higher weight in future pregnancies, and type 2 diabetes in women who have previously had gestational diabetes.³⁹ Counseling about dietary modifications or dietary and exercise modifications together are effective in helping women lose weight postpartum.⁴⁰

SEXUALITY AND CONTRACEPTION

Libido and sexuality are common concerns during the postpartum period.⁴¹ Some studies have shown that pre-pregnancy estrogen levels may not return for as long as one year postpartum, particularly in women who are breastfeeding, which may contribute to a low libido.^41,42 The length of time for women to wait to have intercourse following delivery is variable; the average is six to eight weeks in the United States.^41,42 No consistent correlation exists between delivery complications (e.g., vaginal lacerations) and a delay in resuming intercourse.^41,42 Because most patients report some type of sexual problem postpartum,⁴² it is important to assess patients, validate concerns, address contributing factors, reassure when appropriate, and offer support including counseling.

The prenatal period is the best time to discuss postpartum contraception. A 2015 Cochrane review reported low-quality evidence for the effectiveness of birth control method education in the postpartum period; however, a more recent study demonstrated the effectiveness of motivational interviewing resulting in a decrease in rapid repeat pregnancy and a higher use of long-acting reversible contraception in pregnant adolescents.^43,44

Women who are breastfeeding may also use the lactational amenorrhea method, alone or with other forms of contraception. The woman must be breastfeeding exclusively on demand, be amenorrheic (i.e., no vaginal bleeding after eight weeks postpartum), and have an infant younger than six months. This method is less reliable once the infant starts eating solid food. The failure rate is less than 2% if these criteria are fulfilled.^45,46

This article updates a previous article on this topic by Blenning and Paladine.^¹

Data Sources: PubMed searches were done using the terms postpartum care, secondary/late postpartum hemorrhage/hemorrhage, postpartum endometritis, postpartum thyroid, hypertensive disorders of pregnancy, postpartum thromboembolism, postpartum mood disorders, postpartum substance use, postpartum urinary incontinence, postpartum constipation, postpartum hemorrhoids, breastfeeding, postpartum weight, postpartum sexuality, postpartum contraception, maternal infant dyad, and postpartum complications. Also searched were the Cochrane database, Essential Evidence Plus, and recommendations from the American College of Obstetricians and Gynecologists, the Centers for Disease Control and Prevention, the U.S. Preventive Services Task Force, and the World Health Organization. Search dates: July and September 2018, and June 2019.

Blenning CE, Paladine H. An approach to the postpartum office visit. Am Fam Physician. 2005;72(12):2491-2496. https://www.aafp.org/afp/2005/1215/p2491.html

Zaharatos J, St Pierre A, Cornell A, et al. Building U.S. capacity to review and prevent maternal deaths. J Womens Health (Larchmt). 2018;27(1):1-5.

McKinney J, Keyser L, Clinton S, et al. ACOG committee opinion no. 736: optimizing postpartum care. Obstet Gynecol. 2018;132(3):784-785.

Leeman L, Dresang LT, Fontaine P. Hypertensive disorders of pregnancy. Am Fam Physician. 2016;93(2):121-127.

Kamel H, Navi BB, Sriram N, et al. Risk of a thrombotic event after the 6-week postpartum period. N Engl J Med. 2014;370(14):1307-1315.

Declercq ER, Sakala C, Corry MP, et al. Major survey findings of listening to mothers(sm) iii: new mothers speak out: report of national surveys of women's childbearing experiences conducted October–December 2012 and January–April 2013. J Perinat Educ. 2014;23(1):17-24.

Tully KP, Stuebe AM, Verbiest SB. The fourth trimester: a critical transition period with unmet maternal health needs. Am J Obstet Gynecol. 2017;217(1):37-41.

Martin A, Horowitz C, Balbierz A, et al. Views of women and clinicians on postpartum preparation and recovery. Matern Child Health J. 2014;18(3):707-713.

World Health Organization. WHO recommendations on postnatal care of the mother and newborn. Accessed September 1, 2018. https://www.who.int/maternal_child_adolescent/documents/postnatal-care-recommendations/en/

Debost-Legrand A, Rivière O, Dossou M, et al. Risk factors for severe secondary postpartum hemorrhages: a historical cohort study. Birth. 2015;42(3):235-241.

Alexander J, Thomas P, Sanghera J. Treatments for secondary postpartum haemorrhage. Cochrane Database Syst Rev. 2002(1):CD002867.

Committee on Practice Bulletins-Obstetrics. Practice bulletin no. 183: postpartum hemorrhage. Obstet Gynecol. 2017;130(4):e168-e186.

Faro S. Postpartum endometritis. Clin Perinatol. 2005;32(3):803-814.

Mackeen AD, Packard RE, Ota E, et al. Antibiotic regimens for postpartum endometritis. Cochrane Database Syst Rev. 2015(2):CD001067.

Tepper NK, Boulet SL, Whiteman MK, et al. Postpartum venous thromboembolism: incidence and risk factors. Obstet Gynecol. 2014;123(5):987-996.

Bates SM, Greer IA, Middeldorp S, et al. VTE, thrombophilia, antithrombotic therapy, and pregnancy: antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2 suppl):e691S-e736S.

Heit JA, Kobbervig CE, James AH, et al. Trends in the incidence of venous thromboembolism during pregnancy or postpartum: a 30-year population-based study. Ann Intern Med. 2005;143(10):697-706.

American College of Obstetricians and Gynecologists Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Obstet Gynecol. 2013;122(5):1122-1131.

ACOG Practice bulletin No. 202: gestational hypertension and preeclampsia. Obstet Gynecol. 2019;133(1):e1-e25.

Daly B, Toulis KA, Thomas N, et al. Increased risk of ischemic heart disease, hypertension, and type 2 diabetes in women with previous gestational diabetes mellitus, a target group in general practice for preventive interventions: a population-based cohort study. PLoS Med. 2018;15(1):e1002488.

Chodick G, Elchalal U, Sella T, et al. The risk of overt diabetes mellitus among women with gestational diabetes: a population-based study. Diabet Med. 2010;27(7):779-785.

Committee on Practice Bulletins—Obstetrics. ACOG practice bulletin no. 190: gestational diabetes mellitus. Obstet Gynecol. 2018;131(2):e49-e64.

Alexander EK, Pearce EN, Brent GA, et al. 2017 Guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and the postpartum [published correction appears in Thyroid. 2017;27(9):1212]. Thyroid. 2017;27(3):315-389.

American College of Obstetricians and Gynecologists. Practice bulletin no. 148: thyroid disease in pregnancy. Obstet Gynecol. 2015;125(4):996-1005.

Siu AL, Bibbins-Domingo K, Grossman DC, et al.; US Preventive Services Task Force (USPSTF). Screening for depression in adults: US Preventive Services Task Force recommendation statement. JAMA. 2016;315(4):380-387.

Earls MF, Yogman MW, Mattson G, et al.; Committee on Psychosocial Aspects of Child and Family Health. Incorporating recognition and management of perinatal depression into pediatric practice. Pediatrics. 2019;143(1):e20183259.

ACOG Committee opinion no. 757: screening for perinatal depression. Obstet Gynecol. 2018;132(5):e208-e212.

Curry SJ, Krist AH, Owens DK, et al.; US Preventive Services Task Force. Interventions to prevent perinatal depression: US Preventive Services Task Force recommendation statement. JAMA. 2019;321(6):580-587.

Langan R, Goodbred AJ. Identification and management of peripartum depression. Am Fam Physician. 2016;93(10):852-858. https://www.aafp.org/afp/2016/0515/p852.html

Feltner C, Wallace I, Berkman N, et al. Screening for intimate partner violence, elder abuse, and abuse of vulnerable adults: evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2018;320(16):1688-1701.

Curry SJ, Krist AH, Owens DK, et al.; US Preventive Services Task Force. Screening for intimate partner violence, elder abuse, and abuse of vulnerable adults: US Preventive Services Task Force final recommendation statement. JAMA. 2018;320(16):1678-1687.

Woodley SJ, Boyle R, Cody JD, et al. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in ante-natal and postnatal women. Cochrane Database Syst Rev. 2017(12):CD007471.

Committee on Practice Bulletins—Gynecology and the American Urogynecologic Society. ACOG practice bulletin no. 155: urinary incontinence in women. Obstet Gynecol. 2015;126(5):e66-e81.

Shin GH, Toto EL, Schey R. Pregnancy and postpartum bowel changes: constipation and fecal incontinence. Am J Gastroenterol. 2015;110(4):521-529.

Gartland D, MacArthur C, Woolhouse H, et al. Frequency, severity and risk factors for urinary and faecal incontinence at 4 years postpartum: a prospective cohort. BJOG. 2016;123(7):1203-1211.

Keister D, Roberts KT, Werner SL. Strategies for breastfeeding success. Am Fam Physician. 2008;78(2):225-232. https://www.aafp.org/afp/2008/0715/p225.html

Bibbins-Domingo K, Grossman DC, Curry SJ, et al.; US Preventive Services Task Force. Primary care interventions to support breastfeeding: US Preventive Services Task Force recommendation statement. JAMA. 2016;316(16):1688-1693.

McFadden A, Gavine A, Renfrew MJ, et al. Support for healthy breast-feeding mothers with healthy term babies. Cochrane Database Syst Rev. 2017(2):CD001141.

Institute of Medicine (US) and National Research Council (US) committee to reexamine IOM pregnancy weight guidelines. Weight gain during pregnancy: reexamining the guidelines. The National Academies Press; 2009.

Amorim Adegboye AR, Linne YM. Diet or exercise, or both, for weight reduction in women after childbirth. Cochrane Database Syst Rev. 2013(7):CD005627.

Glazener CM. Sexual function after childbirth: women's experiences, persistent morbidity and lack of professional recognition. Br J Obstet Gynaecol. 1997;104(3):330-335.

von Sydow K. Sexuality during pregnancy and after childbirth: a meta-content analysis of 59 studies. J Psychosom Res. 1999;47(1):27-49.

Lopez LM, Grey TW, Hiller JE, et al. Education for contraceptive use by women after childbirth. Cochrane Database Syst Rev. 2015(7):CD001863.

Stevens J, Lutz R, Osuagwu N, et al. A randomized trial of motivational interviewing and facilitated contraceptive access to prevent rapid repeat pregnancy among adolescent mothers. Am J Obstet Gynecol. 2017;217(4):423.e1-423.e9.

Trussell J. Contraceptive failure in the United States. Contraception. 2011;83(5):397-404.

U.S. Department of Health and Human Services. Office of Population Affairs. Lactational amenorrhea method (LAM). Accessed March 19, 2019. https://www.hhs.gov/opa/pregnancy-prevention/birth-control-methods/lam/index.html

Averbach S, Kakaire O, Kayiga H, et al. Immediate versus delayed post-partum use of levonorgestrel contraceptive implants: a randomized controlled trial in Uganda. Am J Obstet Gynecol. 2017;217(5):568. e1-568.e7.

Levitt C, Shaw E, Wong S, et al.; McMaster University Postpartum Research Group. Systematic review of the literature on postpartum care: selected contraception methods, postpartum Papanicolaou test, and rubella immunization. Birth. 2004;31(3):203-212.

Turok DK, Leeman L, Sanders JN, et al. Immediate postpartum levonorgestrel intrauterine device insertion and breast-feeding outcomes: a noninferiority randomized controlled trial. Am J Obstet Gynecol. 2017;217(6):665.e1-665.e8.

Committee on Health Care for Underserved Women, American College of Obstetricians and Gynecologists. ACOG Committee opinion no. 361: breastfeeding: maternal and infant aspects. Obstet Gynecol. 2007;109(2 pt 1):479-480.

Carmo LS, Braga GC, Ferriani RA, et al. Timing of etonogestrel-releasing implants and growth of breastfed infants: a randomized controlled trial. Obstet Gynecol. 2017;130(1):100-107.

Lopez LM, Grey TW, Stuebe AM, et al. Combined hormonal versus nonhormonal versus progestin-only contraception in lactation. Cochrane Database Syst Rev. 2015(3):CD003988.

Blue NR, Murray-Krezan C, Drake-Lavelle S, et al. Effect of ibuprofen vs acetaminophen on postpartum hypertension in preeclampsia with severe features: a double-masked, randomized controlled trial. Am J Obstet Gynecol. 2018;218(6):616.e1-616.e8.

Viteri OA, England JA, Alrais MA, et al. Association of nonsteroidal anti-inflammatory drugs and postpartum hypertension in women with preeclampsia with severe features. Obstet Gynecol. 2017;130(4):830-835.

Spaan J, Peeters L, Spaanderman M, et al. Cardiovascular risk management after a hypertensive disorder of pregnancy. Hypertension. 2012;60(6):1368-1373.

Tooher J, Thornton C, Makris A, et al. Hypertension in pregnancy and long-term cardiovascular mortality: a retrospective cohort study. Am J Obstet Gynecol. 2016;214(6):722.e1-722.e6.