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Revamping Postpartum Care

The American College of Obstetricians and Gynecologists (ACOG) has proposed a redesigned guideline for postpartum care to help reduce the rising incidence of mortality in women during the first three months after childbirth. More than one-half of pregnancy-related deaths occur during this time.

Traditionally, a woman sees her obstetrician for a single postpartum visit at six weeks after childbirth. The new approach calls for women to see their specialists within the first three weeks postpartum for an initial assessment. Following that exam, she will continue to receive individualized care. At 12 weeks after childbirth, the patient will see her doctor again for a final and comprehensive exam that will include an assessment of her physical, social and mental health, and plans for follow-up care to address any identified problems.

Camaryn Chrisman Robbins, MD, a Washington University obstetrician and gynecologist at Barnes-Jewish  Hospital, says women are especially vulnerable to health problems in the three months following childbirth, as they transition from pregnancy to parenthood. Common health issues that can occur during this period, often called the fourth trimester, include high blood pressure, diabetes and postpartum depression.

One of the reasons for the increase in postpartum mortality, Chrisman Robbins notes, is the age at which women give birth. “We’re seeing a different group of pregnant women than we were 20 years ago,” she says, noting that many women are waiting until later in life to have children. And some of these women are coming into pregnancy already managing complex medical conditions.

“Pregnancy is hard on a woman’s body,” Chrisman Robbins says. More than half of postpartum strokes occur within 10 days after childbirth. For women at risk for hypertensive disorders, blood-pressure evaluation is recommended within 72 hours and no later than three to 10 days postpartum, Chrisman Robbins notes. And she adds that high blood pressure, which can cause pre-eclampsia, eclampsia and stroke, often declines significantly between four and 12 weeks postpartum.

In addition to identifying and treating risk factors such as high blood pressure and diabetes, this redesigned standard of care also will help identify women at risk for postpartum depression. Specialists will have additional opportunities to evaluate their patients for warning signs, including crying, irritability, anger outbursts, guilt, feelings of detachment from the newborn baby and thoughts of self-harm or harming the infant.

Chrisman Robbins says the new guideline will require changes to insurance reimbursement. Currently the majority of health-insurance plans offer reimbursement for a single doctor visit at six weeks postpartum; additional visits are not yet reimbursed.

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