Population Management

Postpartum Care and the Transition to Well Woman Care

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Postpartum Care and the Transition to Well Woman Care: Content Guidance for Elements of Comprehensive Postpartum Visit

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Postpartum Care and the Transition to Well Woman Care: Ongoing Health Insurance Coverage; Care Beyond Postpartum Period

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Postpartum Care and the Transition to Well Woman Care: Medicaid Reimbursement in the Postpartum Period

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Postpartum Care and the Transition to Well Woman Care: Resources for Postpartum Care

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PMH Care Pathways: Postpartum Care and the Transition to Well Woman Care

February 2015

Background

Postpartum care offers an opportunity to promote the health and well-being of women. While there is incomplete evidence on optimal content and timing of postpartum care, a number of elements of well-woman care are evidence-based. These include postpartum depression screening, reproductive health planning to promote healthy birth spacing, screening for chronic diseases, promoting smoking cessation, and providing appropriate vaccinations. The postpartum period is an important opportunity to provide preventive care and to promote a smooth transition to well woman care.

Care transitions in the postpartum period

1. Prior to discharge from the hospital post-delivery, provide contact information for the postpartum care provider and educate about reasons to contact the provider. Reasons may include but are not limited to: lactation difficulties, signs of infection, hemorrhage, or signs/symptoms of postpartum preeclampsia.
a. Review immunization history prior to discharge and provide necessary counseling and vaccines. Ideally, indicated vaccines should be given during pregnancy (influenza, Tdap) or prior to discharge from the hospital (MMR, varicella).
b. Address smoking cessation strategy, if indicated (see PMH Care Pathway: Management of Perinatal Tobacco Use); give pneumococcal vaccine to smokers who were not previously vaccinated.
c. Signs and symptoms of preeclampsia warrant timely evaluation. When associated with new onset hypertension, close observation and consideration of anti-hypertensive therapy and/or magnesium sulfate therapy are indicated.

2. Schedule a comprehensive postpartum visit for ALL women at 14-42 days post-delivery. See pages 3-5 for an outline of the content of the comprehensive visit.
a. Visit completion rates may improve by scheduling a first visit early enough to allow rescheduling if necessary. 
b. Women with specific characteristics, including multiparous women and those who experienced a poor birth outcome, are more likely to miss the postpartum visit and may merit targeted interventions to improve adherence to the visit.
c. Engage Pregnancy Care Managers to promote postpartum visit attendance.

3. Schedule early post-delivery follow-up for women with the following risk factors:
a. Gestational hypertension or preeclampsia in the index pregnancy [1].
i. Women with gestational hypertension or preeclampsia should be re-evaluated for postpartum preeclampsia and have blood pressure measurement at 7-10 days post-delivery. [1,4] 
A. Initiate or adjust anti-hypertensive medication if blood pressure is >150 systolic or >100 diastolic [1].
a. Consider home blood pressure monitoring or return visit for blood pressure measurement in 1-2 weeks following adjustment or initiation of antihypertensive therapy. 
b. High risk for postpartum depression [2]. Conduct a depression screening with a validated tool at 7-14 days postpartum for patients meeting one or more of the following criteria (See Appendix A for guidance on management of depression screening results):
i. History of depression or other psychiatric illness
ii. Lack of social support
iii. Recent stressful life event, including adverse pregnancy outcome or birth experience
iv. Other patients may be deemed at elevated risk at the judgment of the postpartum care provider, particularly if they have additional social stressors, such as childcare difficulties, history of trauma, and/or low self-esteem.
c. Other factor(s) which the provider feels warrant an early follow-up visit, such as operative delivery, 3rd or 4th degree perineal lacerations, diabetes, or lactation difficulties.

4. Schedule follow-up diabetes screening at 6 to 12 weeks postpartum for patients with gestational diabetes. Perform either a fasting blood glucose or a 2-hour glucose tolerance test with a 75 gram glucose load. [3] (See Appendix A for guidance on follow-up of patients with gestational diabetes based on diabetes screening results in the postpartum period.)

5. Coordinate the transition to primary care.
a. Provide all patients with guidance about value and timing of primary care follow-up.
i. Yearly visits for all women
ii. More frequent for women with medical complications such as diabetes or hypertension
iii. Identify appropriate care setting for continuing primary care outside of pregnancy, within the current practice or provide referral. (See Appendix B for information about coverage beyond the postpartum period for patients in the Medicaid for Pregnant Women category.)

Content of the comprehensive postpartum visit

1. Review any complications of pregnancy and/or delivery. Educate the patient about risks for future pregnancies and any long-term health implications. Examples may include: cesarean delivery with information on labor after cesarean, gestational diabetes, growth restriction, preterm birth, hypertension, fetal anomalies.

2. Blood pressure screen: The comprehensive postpartum visit includes blood pressure measurement, performed after the patient has rested for 5 minutes. See Appendix A for follow up based on screening results.

3. Postpartum depression screening: Screen all patients for postpartum depression using a validated tool. See Appendix A for screening tools, management of positive screen and resources for referral.

4. Reproductive life planning: Encourage all women (and their partners, if available) to discuss their pregnancy intentions in the short and long term and their chance of conceiving (whether intended or not). See Appendix D for reproductive life planning questions for providers, a printable provider tool, and a patient worksheet.
a. Encourage patients to consider the following factors in their reproductive life plan: age, educational goals, career plans, living situation, financial situation, social support, relationship with partner, readiness to parent additional children, current health status, breastfeeding status, hereditary risk factors, and health behaviors.
b. For women who anticipate future pregnancy, promote optimal birth spacing (conception in 18 months to 5 years after a previous birth) to decrease risk of preterm birth and other complications in future pregnancies. Conception less than 6 months after delivery is associated with the strongest risk of low birth weight and preterm birth.[6]
c. Assist women to select a contraceptive method that aligns with their reproductive life plan. See Appendix A for information about timing of safe use for different contraceptives in the postpartum period.
d. Provide access to the patient’s preferred contraceptive method. Create a referral plan for all methods not provided by your practice.

5. Conduct immunization review and provide necessary vaccinations: See CDC Guidelines for Vaccinating Pregnant Women for recommended vaccinations.
a. Review influenza, Tdap, MMR and varicella immunization status and provide counseling and immunization if indicated.
b. Additional vaccines may be indicated for women of reproductive age who have specific risk factors. These include Pneumococcal vaccines, Meningococcal vaccine, Hepatitis A vaccine, Hepatitis B vaccine, Haeomphilus Influenza type b vaccine and Human Papilloma Virus.

6. Offer breastfeeding support: In addition to benefits to the infant, breastfeeding leads to decreased risk of breast cancer, ovarian cancer, diabetes, hypertension and myocardial infarction, yet up to 60% of mothers wean earlier than recommended. [7] Providers should promote alignment in their delivery facilities with baby-friendly recommendations, such as encouraging skin-to-skin contact at delivery, including cesarean deliveries, and discouraging routine separation of mother and baby.
a. Evaluate and treat breastfeeding problems promptly. After discharge, the perinatal care provider’s office should be a resource for 24-hour assistance with breastfeeding problems or should provide links to other resources in the community. [8] See Appendix D for additional resources, including WIC.
b. At the comprehensive postpartum visit, ask about breastfeeding, address any concerns and specifically discuss a woman’s plans to return to work and how that will impact breastfeeding.

7. Address smoking cessation for patients who are current smokers and for those who quit during pregnancy (see the PMH Care Pathway: Management of Perinatal Tobacco Use for details):
a. Ask all patients about current smoking status.
b. For current smokers, provide a brief intervention (see Appendix A for an overview of the 5 A’s model), consider pharmacotherapy as it improves quit rates, and initiate a referral to the North Carolina Quitline. [9] See Appendix D, Resources, for details about how to make a proactive referral and other assistance available from NC Quitline.
c. For patients who quit during pregnancy, focus on the benefits of staying quit on the woman’s own health and on that of her infant, and consider nicotine replacement therapy as appropriate, due to the high rate of postpartum recidivism to smoking.

8. Provide healthy lifestyle behavioral advice (see Appendix A for detailed guidance):
a. Calculate BMI at the comprehensive postpartum visit and provide weight loss counseling to women with a BMI >/= 25.
b. Recommend adequate physical activity [10].
c. Recommend a multivitamin with at least 400mcg of folic acid daily.
d. Recommend a high quality, healthful diet for ALL women. [11] Breastfeeding women should expect to add 500kcal/day to their normal diet.

9. Perform pap smear only if indicated [12,13]
a. Every 3 years for women 21-65
b. Do not do HPV screening for women <30 years old
c. Women 30-65 may have pap smears with high risk HPV screening every 5 years if both tests are negative

Note: Pregnancy Medical Home Care Pathways are intended to assist providers of obstetrical care in the clinical management of problems that can occur during pregnancy. They are intended to support the safest maternal and fetal outcomes for patients receiving care at North Carolina Pregnancy Medical Home practices. This pathway was developed after reviewing the Society for Maternal-Fetal Medicine and the American College of Obstetricians and Gynecologists resources such as practice bulletins, committee opinions, and Guidelines for Perinatal Care as well as current obstetrical literature. PMH Care Pathways offer a framework for the provision of obstetrical care, rather than an inflexible set of mandates. Clinicians should use their professional knowledge and judgment when applying pathway recommendations to their management of individual patients.

References:
1. American College of Obstetricians and Gynecologists. Task force on hypertension in pregnancy. Hypertension in pregnancy. ACOG 2013. Available at: http://www.acog.org/Resources_And_Publications/Task_Force_and_Work_Group_Reports/Hypertension_in_Pregnancy. Accessed 6.4.14.

2. American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. 7th ed. ACOG 2012. Available at: http://www.acog.org/Resources_And_Publications/Guidelines_for_Perinatal_Care. Accessed 6.4.14.

3. American College of Obstetricians and Gynecologists Committee on Practice Bulletins—Obstetrics. Practice Bulletin No. 137: Gestational Diabetes Mellitus. Obstet Gynecol 2013;122(2 Pt 1):406-16.

4. Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood pressure. Seventh Report. JNC 7 Express. US Department of Health and Human Services. NIH Publication No. 03-5233. December 2003. Available at: http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf. Accessed 6.4.14.

5. American College of Obstetricians and Gynecologists Committee on Obstetric Practice. Committee Opinion No. 453. Screening for depression during and after pregnancy. Obstet Gynecol 2010;115(2 Pt 1): 394-5.

6. Conde-Algudelo A, Rosas-Bermudez A, Kafury-Goeta AC. Birth spacing and risk of adverse perinatal outcomes: a meta-analysis. JAMA 2006; 295(15):1809-23.

7. Stuebe AM. Enabling women to achieve their breastfeeding goals. Obstet Gynecol 2014;123(3):643-52.

8. American College of Obstetricians and Gynecologists Committee on Obstetric Practice. Committee Opinion No. 361. Breastfeeding: maternal and infant aspects. Obstet Gynecol 2007;109(2 Pt 1): 479-80.

9. U.S. Preventive Services Task Force. Counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women: U.S. Preventive Services Task Force Reaffirmation Recommendation Statement. Ann Intern Med 2009;150(8):551-555. Available at: http://www.uspreventiveservicestaskforce.org/uspstf09/tobacco/tobaccors2.pdf. Accessed 6.4.14

10. U.S. Department of Health and Human Services. 2008 Physical activity guidelines for Americans. Available at: http://www.health.gov/paguidelines/pdf/paguide.pdf. Accessed 6.4.14.

11. Mozaffarian D, Appel LJ, and Van Horn L. Components of a cardioprotective diet: new insights. Circulation 2011;123:2870-2891. Available at: http://circ.ahajournals.org/content/123/24/2870.full.pdf+html. Accessed 6.4.14.

12. American College of Obstetricians and Gynecologists. Practice Bulletin No. 131: Screening for cervical cancer. Obstet Gynecol 2012;120(5):1222-38.

13. American Society for Cytology and Cervical Pathology Screening Guidelines. Available at: http://www.asccp.org/Guidelines/Screening-Guidelines. Accessed 2.17.15.