The Fourth Trimester: Optimizing Postpartum Care What New Moms Need to Know

As a practicing obstetrician and brand new first-time mommy, the importance of comprehensive postpartum care could not seem more pertinent. Oftentimes women and their caregivers are so focused on their beloved new babies, that the care of the new mother may be somewhat overlooked. There are so many physical, social, and psychological changes that occur in the weeks following childbirth that it is essential to establish a postpartum care plan before the baby is even born.  The American College of Obstetricians and Gynecologists recommends a strategy of "anticipatory guidance" in the prenatal period to optimize care of the woman postpartum. It is further recommended that all women undergo a comprehensive postpartum follow-up visit with a maternal care provider within 4-6 weeks after giving birth, with earlier follow up recommended for women with certain high-risk complications such as high blood pressure, depression, or other medical concerns.

What can new mothers expect at their postpartum follow up appointment?

A postpartum follow-up check should include a global assessment of maternal well-being. This should include an assessment of the mother's physical recovery from childbirth, which may require a pelvic exam if the mother experienced a bad perineal tear at the time of delivery, an evaluation of the abdominal incision for women who required a cesarean section, and assessment of any ongoing pain symptoms or other maternal concerns.

Any pregnancy complications should be addressed at the postpartum visit with respect to implications for future pregnancies and requirements for ongoing medical care. For example, women who were diagnosed with gestational diabetes need to be scheduled for a 2-hour glucose tolerance test to exclude persistent diabetes outside of the pregnancy. Additionally, women with gestational diabetes and pregnancy-associated hypertension should be counseled that they are at a higher lifetime risk of metabolic and cardiovascular disease.

Obstetric providers should inquire about newborn feeding habits and sleep patterns, and address any concerns or challenges associated with breastfeeding. This may include management of problems such as breast engorgement, mastitis, breast abscesses, clogged ducts, or decreased milk supply. Patients should be directed to resources for lactation support and should be counseled on plans for breast milk expression and storage if she plans to return to work.

The postpartum visit should include a discussion of family planning and optimal timing of future pregnancies. Oftentimes couples are unaware that the ideal interval between delivery and subsequent pregnancy is 18 months to 5 years. This recommendation is made to reduce the risks of preterm birth and low birth weight babies associated with short-interval pregnancies. Mothers should also expect a discussion of postpartum weight loss strategies, nutrition, and advice on when it is safe to return to physical activity and sexual intercourse.

Many women suffer from ongoing issues with urinary incontinence, pelvic discomfort, and sexual dysfunction after childbirth. Women with signs of pelvic floor weakness or instability may benefit from referral to a physical therapist who specializes in pelvic rehabilitation. While women are often familiar with the famed “Kegel exercises”, pelvic physical therapists have a wide range of activities that can help to strengthen and stabilize the muscles of the pelvic floor. They can also help with core strengthening and management of rectus diastasis (that pesky belly bulge which results from abnormal separation of the abdominal muscles after pregnancy). For women with vaginal dryness symptoms contributing to painful intercourse, a common complaint amongst nursing mothers, there are also various lubricants and creams available to help manage these symptoms. New mothers often feel embarrassed and do not bring these concerns to their provider’s attention, however, women should be encouraged to speak with their obstetric providers about these issues as they are generally treatable.

It is also critically important that new mothers be evaluated for any signs of postpartum blues or postpartum depression, as mood disturbances in the postpartum period are extremely common. According to the National Institute of Mental Health, "baby blues" can affect up to 80% of women, with postpartum depression affecting as many as 1 in 7 women. Women who experience "baby blues" typically have relatively mild symptoms of worry, unhappiness, and fatigue that typically persist for a week or two and they resolve on their own. Given the demands of caring for a newborn, sleep deprivation, and the hormonal changes of the postpartum period, it is not surprising that new mothers may have such an emotional adjustment period. With postpartum depression, however, feelings of sadness and anxiety tend to be more extreme. When these symptoms become so severe that they are interfering with a woman's ability to care for herself or her family it often requires treatment with either counseling and/or medication. Family members, friends, and loved ones may be the first to recognize these symptoms and should encourage new mothers to speak with their healthcare providers.

Lastly, it is essential for the obstetric provider to determine who will assume responsibility for the patient's continued medical care following the postpartum visit. Good communication between providers is necessary to ensure a smooth transition of care, and a referral to a primary care provider may be warranted.