ACOG COMMITTEE OPINION

Number 736 • May 2018 (Replaces Committee Opinion Number 666, June 2016)

Presidential Task Force on Redefining the Postpartum Visit

Committee on Obstetric Practice
The Academy of Breastfeeding Medicine, the American College of Nurse-Midwives, the National Association of Nurse Practitioners in Women’s Health,
the Society for Academic Specialists in General Obstetrics and Gynecology, and the Society for Maternal–Fetal Medicine endorse this document. This
Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Presidential Task Force on Redefining the Postpartum
Visit and the Committee on Obstetric Practice in collaboration with task force members Alison Stuebe, MD, MSc; Tamika Auguste, MD; and
Martha Gulati, MD, MS.

Optimizing Postpartum Care

ABSTRACT: The weeks following birth are a critical period for a woman and her infant, setting the stage for
long-term health and well-being. To optimize the health of women and infants, postpartum care should become
an ongoing process, rather than a single encounter, with services and support tailored to each woman’s individual
needs. It is recommended that all women have contact with their obstetrician–gynecologists or other obstetric
care providers within the first 3 weeks postpartum. This initial assessment should be followed up with ongoing
care as needed, concluding with a comprehensive postpartum visit no later than 12 weeks after birth. The com-
prehensive postpartum visit should include a full assessment of physical, social, and psychological well-being,
including the following domains: mood and emotional well-being; infant care and feeding; sexuality, contracep-
tion, and birth spacing; sleep and fatigue; physical recovery from birth; chronic disease management; and health
maintenance. Women with chronic medical conditions such as hypertensive disorders, obesity, diabetes, thyroid
disorders, renal disease, and mood disorders should be counseled regarding the importance of timely follow-
up with their obstetrician–gynecologists or primary care providers for ongoing coordination of care. During the
postpartum period, the woman and her obstetrician–gynecologist or other obstetric care provider should identify
the health care provider who will assume primary responsibility for her ongoing care in her primary medical
home. Optimizing care and support for postpartum families will require policy changes. Changes in the scope
of postpartum care should be facilitated by reimbursement policies that support postpartum care as an ongoing
process, rather than an isolated visit. Obstetrician–gynecologists and other obstetric care providers should be in
the forefront of policy efforts to enable all women to recover from birth and nurture their infants. This Committee
Opinion has been revised to reinforce the importance of the “fourth trimester” and to propose a new paradigm
for postpartum care.

Recommendations and Conclusions • Prenatal discussions should include the woman’s

The American College of Obstetricians and Gynecologists reproductive life plans, including desire for and
makes the following recommendations and conclusions: timing of any future pregnancies. A woman’s future
• To optimize the health of women and infants, post- pregnancy intentions provide a context for shared
partum care should become an ongoing process, decision-making regarding contraceptive options.
rather than a single encounter, with services and • All women should ideally have contact with a mater-
support tailored to each woman’s individual needs. nal care provider within the first 3 weeks postpar-
• Anticipatory guidance should begin during preg- tum. This initial assessment should be followed up
nancy with development of a postpartum care plan with ongoing care as needed, concluding with a com-
that addresses the transition to parenthood and well- prehensive postpartum visit no later than 12 weeks
woman care. after birth.

e140 VOL. 131, NO. 5, MAY 2018 OBSTETRICS & GYNECOLOGY

 • The timing of the comprehensive postpartum visit Committee Opinion has been revised to reinforce the
should be individualized and woman centered. importance of the “fourth trimester” and to propose a
• The comprehensive postpartum visit should include new paradigm for postpartum care.
a full assessment of physical, social, and psychologi-
cal well-being. Redefining Postpartum Care
• Women with pregnancies complicated by preterm Following birth, many cultures prescribe a 30–40-day
birth, gestational diabetes, or hypertensive disor- period of rest and recovery, with the woman and her
ders of pregnancy should be counseled that these newborn surrounded and supported by family and com-
disorders are associated with a higher lifetime risk of munity members (7). Many agrarian cultures enshrine
maternal cardiometabolic disease. postpartum rituals, including traditional foods and sup-
port for day-to-day household tasks. These traditions
• Women with chronic medical conditions, such as
have been sustained by some cultural groups, but for
hypertensive disorders, obesity, diabetes, thyroid
many women in the United States, the 6-week postpar-
disorders, renal disease, mood disorders, and sub-
tum visit punctuates a period devoid of formal or infor-
stance use disorders, should be counseled regard-
mal maternal support. Obstetrician–gynecologists and
ing the importance of timely follow-up with their
other women’s health care providers are uniquely quali-
obstetrician–gynecologists or primary care providers
fied to enable each woman to access the clinical and social
for ongoing coordination of care.
resources she needs to successfully navigate the transition
• For a woman who has experienced a miscarriage, from pregnancy to parenthood.
stillbirth, or neonatal death, it is essential to ensure To optimize the health of women and infants,
follow-up with an obstetrician–gynecologist or other postpartum care should become an ongoing process,
obstetric care provider. rather than a single encounter, with services and sup-
• Optimizing care and support for postpartum fami- port tailored to each woman’s individual needs. Indeed,
lies will require policy changes. Changes in the in qualitative studies, women have noted that there is
scope of postpartum care should be facilitated by an intense focus on women’s health prenatally but care
reimbursement policies that support postpartum during the postpartum period is infrequent and late (8).
care as an ongoing process, rather than an isolated Rather than an arbitrary “6-week check,” the American
visit. College of Obstetricians and Gynecologists recommends
that the timing of the comprehensive postpartum visit
Introduction be individualized and woman centered. To better meet
The weeks following birth are a critical period for a the needs of women in the postpartum period, care
woman and her infant, setting the stage for long-term would ideally include an initial assessment, either in
health and well-being. During this period, a woman is person or by phone, within the first 3 weeks postpartum
adapting to multiple physical, social, and psychologi- to address acute postpartum issues. This initial assess-
cal changes. She is recovering from childbirth, adjust- ment should be followed up with ongoing care as needed,
ing to changing hormones, and learning to feed and concluding with a comprehensive well-woman visit no
care for her newborn (1). In addition to being a time later than 12 weeks after birth (Fig. 1). Insurance cover-
of joy and excitement, this “fourth trimester” can pres- age policies should be aligned to support this tailored
ent considerable challenges for women, including lack approach to “fourth trimester” care (see Policy and
of sleep, fatigue, pain, breastfeeding difficulties, stress, Postpartum Care).
new onset or exacerbation of mental health disorders,
lack of sexual desire, and urinary incontinence (2–4). Increasing engagement
Women also may need to navigate preexisting health Currently, as many as 40% of women do not attend a
and social issues, such as substance dependence, intimate postpartum visit. Underutilization of postpartum care
partner violence, and other concerns. During this time, impedes management of chronic health conditions and
postpartum care often is fragmented among maternal access to effective contraception, which increases the risk
and pediatric health care providers, and communication of short interval pregnancy and preterm birth. Attendance
across the transition from inpatient to outpatient set- rates are lower among populations with limited resources
tings is often inconsistent (5). Home visits are provided (9, 10), which contributes to health disparities.
in some settings; however, currently, most women in Increasing attendance at postpartum visits is a devel-
the United States must independently navigate the post- opmental goal for Healthy People 2020. Strategies for
partum transition until the traditional postpartum visit increasing attendance include but are not limited to the
(4–6 weeks after delivery). This lack of attention to following measures: discussing the importance of post-
maternal health needs is of particular concern given that partum care during prenatal visits; using peer counsel-
more than one half of pregnancy-related deaths occur ors, intrapartum support staff, postpartum nurses, and
after the birth of the infant (6). Given the urgent need discharge planners to encourage postpartum follow-up;
to reduce severe maternal morbidity and mortality, this scheduling postpartum visits during prenatal care or

VOL. 131, NO. 5, MAY 2018 Committee Opinion Optimizing Postpartum Care e141
before hospital discharge; using technology (eg, email, Reproductive Life Planning
text, and apps) to remind women to schedule postpartum Beginning in prenatal care, the patient and her
follow-up (11); and increasing access to paid sick days obstetrician–gynecologist or other obstetric care pro-
and paid family leave. vider should discuss the woman’s reproductive life plans,
Optimal postpartum care provides an opportunity to including desire for and timing of any future pregnan-
promote the overall health and well-being of women, and cies (19). Women should be advised to avoid inter-
evidence suggests that current care falls short of that goal. pregnancy intervals shorter than 6 months and should
In a national survey, less than one half of women attend-
Primary
ing care visit
a postpartum provider
reported(also
that may be the enough• May
they received
be co-manage
counseled aboutchronic conditions
the risks (eg, of repeat
and benefits
pregnancy sooner than 18 months (20). Short interpreg-
obstetric provider)
information at the visit about postpartum depression,hypertension, diabetes,
nancy intervals also aredepression)
associated with during
reduced vaginal
birth spacing, healthy eating, the importance of exercise,postpartum period
birth after cesarean success for women undergoing trial
or changes in their sexual response and emotions (12).
Of note, anticipatory guidance improves maternal well-• Assumes
of labor primary responsibility
after cesarean (21). for ongoing
being: In a randomized controlled trial, 15 minutes of health care after comprehensive postpartum
A woman’s future pregnancy intentions provide a
context for shared decision-making regarding contra-
visit
Lactation support (professional IBCLC,
anticipatory guidance before hospital discharge, • Provides
fol- ceptive anticipatory
options (22). guidance and support brings
Shared decision-making for
certified counselors and educators, peer
lowed by a phone call at 2 weeks, reduced symptoms of
depression and increased breastfeeding duration through
breastfeeding
two experts to the table: the patient and the health care
6support)
months postpartum among African American and• Co-manages complications with pediatric and
provider. The health care provider is an expert in the
clinical evidence, and the patient is an expert in her
Hispanic women (13, 14). maternal providers
experiences and values (23). As affirmed by the World
Care coordinator/case
Prenatal Preparation manager • Coordinates health and
Health Organization, when social
making services among the
choices regarding
To optimize postpartum care, anticipatory guidancemembers of postpartum care team
timing of the next pregnancy, “Individuals and couples
should consider health risks and benefits along with
Home visitor (eg, Nurse Family
should begin during pregnancy with development of • Provides
a home visit services to meet specific
other circumstances such as their age, fecundity, fertility
postpartum care plan that addresses the transition to par-
Partnership, Health Start)
enthood and well-woman care (15) (Table 1). Anticipa- needs of mother–infant dyadservices,
aspirations, access to health after discharge from
child-rearing sup-
tory guidance should include discussion of infant feedingmaternity care
port, social and economic circumstances, and personal
Specialty
(16, 17), “babyconsultants (ie, maternal–fetal
blues,” postpartum emotional health, and• Co-manages
preferences”complex
(24). Givenmedical
the complexproblems
history ofduring
steriliza-
the challenges of parenting and postpartum recovery tion abuse (25) and fertility control among marginalized
medicine,
from internal
birth (18). Prenatalmedicine
discussionssubspecialist,
also should addresspostpartum period
women, care should be taken to ensure that every woman
behavioral health provider)
plans for long-term management of chronic health con- • Provides prepregnancy
is provided information on counseling
the full rangefor future
of contraceptive
ditions, such as mental health, diabetes, hypertension,pregnancies options so that she can select the method best suited to
and obesity, including identification of a primary health her needs (26).
Abbreviation:
care provider whoIBCLC, international
will care for board certified
the patient beyond the lactation consultant.
*Membersperiod.
postpartum of theWithin
care team may vary
this guidance, depending
health care on
Thethe needs of the
Postpartum Caremother–infant
Plan dyad and
locally available resources.
providers should discuss the purpose and value of post- Beginning during prenatal care, the woman and her
partum clinical care as well as the types of services and obstetrician–gynecologist or other obstetric care provider
support available. should develop a postpartum care plan and care team,
Postpartum Process

Primary maternal care provider assumes responsibility for woman’s care through the comprehensive postpartum visit

Contact with all women Ongoing follow-up as needed

within first 3 weeks 3–12 weeks

BP check High risk f/u Comprehensive postpartum visit and transition to well-woman care
3–10 days 1–3 weeks 4–12 weeks, timing individualized and woman-centered
Wks
6-Week Visit

Traditional period of rest and recuperation from birth

0–6 weeks
6-week
visit
Figure 1. Proposed paradigm shift for postpartum visits. The American College of Obstetricians and Gynecologists’
Figure 1. Proposed
Presidential Task Force paradigm shift
on Redefining the for postpartum
Postpartum visits.
Visit and The American
the Committee College
on Obstetric of Obstetricians
Practice propose shifting
and Gynecologists’ Redefining the Postpartum Visit Presidential Task Force and the Committee
the paradigm for postpartum care from a single 6-week visit (bottom) to a postpartum process (top). Abbreviations: BP,
blood pressure; f/u, follow-up. ^
on Obstetric Practice propose shifting the paradigm for postpartum care from a single 6-week
visit (bottom) to a postpartum process (top).
e142 Committee Opinion Optimizing Postpartum Care OBSTETRICS & GYNECOLOGY
inclusive of family and friends who will provide social should assume responsibility for her postpartum care
and material support in the months following birth, as (15). This individual or practice is the primary point of
well as the medical provider(s), who will be primarily contact for the woman, for other members of the post-
responsible for care of the woman and her infant after partum care team, and for any maternal health concerns
birth (19). Suggested components of the postpartum noted by the infant’s health care provider. When the
care team and care plan are listed in Table 1 and Table 2. woman is discharged from inpatient care but prolonged
The care plan should identify the primary care provider infant hospitalization remote from the woman’s home
and other medical providers (eg, psychiatrist) who will is anticipated, a local obstetrician–gynecologist or other
assume care of chronic medical issues after the post- health care provider should be identified as a point of
partum period. If the obstetrician–gynecologist serves contact and an appropriate hand off should occur. Such
as the primary care provider, then transition to another a referral should occur even if delivery did not take place
primary care physician is unnecessary. at a local hospital.
Substantial morbidity occurs in the early postpartum
Transition From Intrapartum to period; more than one half of pregnancy-related maternal
Postpartum Care deaths occur after the birth of the infant (6). Blood pres-
The postpartum care plan should be reviewed and sure evaluation is recommended for women with hyper-
updated after the woman gives birth. Women often are tensive disorders of pregnancy no later than 7–10 days
uncertain about whom to contact for postpartum con- postpartum (28), and women with severe hypertension
cerns (27). In a recent U.S. survey, one in four postpartum should be seen within 72 hours; other experts have rec-
women did not have a phone number for a health care ommended follow-up at 3–5 days (29). Such assessment
provider to contact for any concerns about themselves or is critical given that more than one half of postpartum
their infants (12). Therefore, it is suggested that the care strokes occur within 10 days of discharge (30). In-person
plan include contact information and written instruc- follow-up also may be beneficial for women at high risk
tions regarding the timing of follow-up postpartum care. of complications, such as postpartum depression (31),
Just as a health care provider or health care practice cesarean or perineal wound infection, lactation difficul-
leads the woman’s care during pregnancy, a primary ties, or chronic conditions such as seizure disorders that
obstetrician–gynecologist or other health care provider require postpartum medication titration. For women

Table 1. Suggested Components of the Postpartum Care Plan* ^

Element Components

Care team Name, phone number, and office or clinic address for each member of care team
Postpartum visits Time, date, and location for postpartum visit(s); phone number to call to schedule or reschedule appointments
Infant feeding plan Intended method of infant feeding, resources for community support (eg, WIC, Lactation Warm Lines,
Mothers’ groups), return-to-work resources
Reproductive life plan and Desired number of children and timing of next pregnancy
commensurate contraception Method of contraception, instructions for when to initiate, effectiveness, potential adverse effects,
and care team member to contact with questions
Pregnancy complications Pregnancy complications and recommended follow-up or test results (eg, glucose screening for gestational
diabetes, blood pressure check for gestational hypertension), as well as risk reduction recommendations for
any future pregnancies
Adverse pregnancy outcomes Adverse pregnancy outcomes associated with ASCVD will need baseline ASCVD risk assessment, as well as
associated with ASCVD discussion of need for ongoing annual assessment and need for ASCVD prevention over lifetime.
Mental health Anticipatory guidance regarding signs and symptoms of perinatal depression or anxiety; management
recommendations for women with anxiety, depression, or other psychiatric issues identified during pregnancy
or in the postpartum period
Postpartum problems Recommendations for management of postpartum problems (ie, pelvic floor exercises for stress urinary
incontinence, water-based lubricant for dyspareunia)
Chronic health conditions Treatment plan for ongoing physical and mental health conditions and the care team member responsible for
follow-up

Abbreviations: ASCVD, atherosclerotic cardiovascular disease; WIC, Special Supplemental Nutrition Program for Women, Infants, and Children.
*A Postpartum Care Plan Template is available as part of the ACOG Pregnancy Record.

VOL. 131, NO. 5, MAY 2018 Committee Opinion Optimizing Postpartum Care e143
Table 2. Postpartum Care Team* ^

Team Member Role

Family and friends • Ensures woman has assistance for infant care, breastfeeding support,
care of older children
• Assists with practical needs such as meals, household chores, and
transportation
• Monitors for signs and symptoms of complications, including mental health
Primary maternal care provider (obstetrician–gynecologist, • Ensures patient’s postpartum needs are assessed and met during the
certified nurse midwife, family physician, women’s health postpartum period and that the comprehensive postpartum visit is completed
nurse practitioner) • “First call” for acute concerns during postpartum period
• Also may provide ongoing routine well-woman care after comprehensive
postpartum visit
Infant’s health care provider (pediatrician, family physician, • Primary care provider for infant after discharge from maternity care
pediatric nurse practitioner)
Primary care provider (also may be the obstetric care provider) • May co-manage chronic conditions (eg, hypertension, diabetes, depression)
during postpartum period
• Assumes primary responsibility for ongoing health care after comprehensive
postpartum visit
Lactation support (professional IBCLC, certified counselors • Provides anticipatory guidance and support for breastfeeding
and educators, peer support) • Co-manages complications with pediatric and maternal care providers
Care coordinator or case manager • Coordinates health and social services among members of postpartum
care team
Home visitor (eg, Nurse Family Partnership, Health Start) • Provides home visit services to meet specific needs of mother–infant dyad
after discharge from maternity care
Specialty consultants (ie, maternal–fetal medicine, internal • Co-manages complex medical problems during postpartum period
medicine subspecialist, behavioral health care provider) • Provides prepregnancy counseling for future pregnancies
Abbreviation: IBCLC, international board certified lactation consultant.
*Members of the care team may vary depending on the needs of the mother–infant dyad and locally available resources.

with complex medical problems, multiple visits may be Assessment need not occur as an office visit, and the
required to facilitate recovery from birth. usefulness of an in-person assessment should be weighed
Of note, even among women without risk factors, against the burden of traveling to and attending an office
problems such as heavy bleeding, pain, physical exhaus- visit with a neonate. Additional mechanisms for assess-
tion, and urinary incontinence are common (12). World ing women’s health needs after birth include home visits
Health Organization guidelines for postnatal care include (34), phone support (35, 36), text messages (37), remote
routine postpartum evaluation of all women and infant blood pressure monitoring (38, 39), and app-based sup-
dyads at 3 days, 1–2 weeks, and 6 weeks (32). The National port (40). Phone support during the postpartum period
Institute for Health and Care Excellence guidelines rec- appears to reduce depression scores, improve breastfeed-
ommend screening all women for resolution of the ing outcomes, and increase patient satisfaction, although
“Baby Blues” at 10–14 days after birth to facilitate early the evidence is mixed (35, 36).
identification of and treatment for postpartum depres-
sion (15). Contact in the first few weeks also may enable The Comprehensive Postpartum Visit
women to meet their breastfeeding goals: Among women and Transition to Well-Woman Care
with early, undesired weaning, 20% had discontinued
breastfeeding by 6 weeks postpartum (33), when tradi- Visit Timing
tionally timed visits occurred. To address these common The comprehensive postpartum visit has typically been
postpartum concerns, all women should ideally have scheduled between 4 weeks and 6 weeks after delivery,
contact with a maternal care provider within the first a time frame that likely reflects cultural traditions of 40
3 weeks postpartum. days of convalescence for women and their infants (41).

e144 Committee Opinion Optimizing Postpartum Care OBSTETRICS & GYNECOLOGY

Today, however, 23% of employed women return to work ensure that women, their families, and their employ-
within 10 days postpartum and an additional 22% return ers understand that completion of the comprehensive
to work between 10 days and 40 days (42). Therefore, postpartum visit does not obviate the need for continued
timing of the comprehensive postpartum visit should recovery and support through 6 weeks postpartum and
be individualized and woman centered, occurring no beyond.
later than 12 weeks from birth. Timing also should take
into account any changes in insurance coverage anticip- Visit Components
ated after delivery. At all postpartum encounters, The comprehensive postpartum visit should include a
obstetrician–gynecologists and other obstetric care full assessment of physical, social, and psychological well-
providers should consider the need for future follow- being, including the following domains (Box 1): mood
up and time additional visits accordingly. However and emotional well-being; infant care and feeding; sexu-
timed, the comprehensive postpartum visit is a medical ality, contraception, and birth spacing; sleep and fatigue;
appointment; it is not an “all-clear” signal. Obstetrician– physical recovery from birth; chronic disease manage-
gynecologists and other obstetric care providers should ment; and health maintenance.

Box 1. Components of Postpartum Care

Mood and emotional well-being
• Screen for postpartum depression and anxiety with a validated instrument 1,2
• Provide guidance regarding local resources for mentoring and support
• Screen for tobacco use; counsel regarding relapse risk in postpartum period3
• Screen for substance use disorder and refer as indicated4
• Follow-up on preexisting mental health disorders, refer for or confirm attendance at mental health-related appointments, and
titrate medications as appropriate for the postpartum period
Infant care and feeding
• Assess comfort and confidence with caring for newborn, including
— feeding method
— child care strategy if returning to work or school
— ensuring infant has a pediatric medical home
— ensuring that all caregivers are immunized5
• Assess comfort and confidence with breastfeeding, including
— breastfeeding-associated pain6
— guidance on logistics of and legal rights to milk expression if returning to work or school7,8
— guidance regarding return to fertility while lactating; pregnancy is unlikely if menses have not returned, infant is less
than 6 months old, and infant is fully or nearly fully breastfeeding with no interval of more than 4–6 hours between
breastfeeding sessions9
— review theoretical concerns regarding hormonal contraception and breastfeeding, within the context of each
woman’s desire to breastfeed and her risk of unplanned pregnancy7
• Assess material needs, such as stable housing, utilities, food, and diapers, with referral to resources as needed
Sexuality, contraception, and birth spacing
• Provide guidance regarding sexuality, management of dyspareunia, and resumption of intercourse
• Assess desire for future pregnancies and reproductive life plan10
• Explain the rationale for avoiding an interpregnancy interval of less than 6 months and discuss the risks and benefits of repeat
pregnancy sooner than 18 months
• Review recommendations for prevention of recurrent pregnancy complications, such as 17α-hydroxyprogesterone caproate
to reduce risk of recurrent preterm birth, or aspirin to reduce risk of preeclampsia
• Select a contraceptive method that reflects patient’s stated needs and preferences, with same-day placement of LARC, if
desired11

(continued)

VOL. 131, NO. 5, MAY 2018 Committee Opinion Optimizing Postpartum Care e145
 Box 1. Components of Postpartum Care (continued)
Sleep and fatigue
• Discuss coping options for fatigue and sleep disruption
• Engage family and friends in assisting with care responsibilities
Physical recovery from birth
• Assess presence of perineal or cesarean incision pain; provide guidance regarding normal versus prolonged recovery 12
• Assess for presence of urinary and fecal continence, with referral to physical therapy or urogynecology as indicated 13,14
• Provide actionable guidance regarding resumption of physical activity and attainment of healthy weight15
Chronic disease management
• Discuss pregnancy complications, if any, and their implications for future childbearing and long-term maternal health,
including ASCVD
• Perform glucose screening for women with GDM: a fasting plasma glucose test or 75 g, 2-hour oral glucose tolerance test 16
• Review medication selection and dose outside of pregnancy, including consideration of whether the patient is breastfeeding,
using a reliable resource such as LactMed
• Refer for follow-up care with primary care or subspecialist health care providers, as indicated
Health maintenance
• Review vaccination history and provide indicated immunizations, including completing series initiated antepartum or
postpartum17
• Perform well-woman screening, including Pap test and pelvic examination, as indicated18
Abbreviations: ASCVD, arteriosclerotic cardiovascular disease; GDM, gestational diabetes mellitus; LARC, long-acting reversible contracep-
tive.
1
Screening for perinatal depression. Committee Opinion No. 630. American College of Obstetricians and Gynecologists. Obstet Gynecol
2015;125:1268–71.
2
Earls MF. Incorporating recognition and management of perinatal and postpartum depression into pediatric practice. Committee on
Psychosocial Aspects of Child and Family Health American Academy of Pediatrics. Pediatrics 2010;126:1032–9.
3
American College of Obstetricians and Gynecologists. Tobacco and nicotine cessation toolkit. Washington, DC: American College of
Obstetricians and Gynecologists; 2016.
4
Opioid use and opioid use disorder in pregnancy. Committee Opinion No. 711. American College of Obstetricians and Gynecologists. Obstet
Gynecol 2017;130:e81–94.
5
American Academy of Pediatrics. Protect infants against pertussis: cocooning through Tdap vaccination. Washington, DC: AAP. Available at:
https://www.aap.org/en-us/Documents/immunization_protect_infants_against_pertussis.pdf. Retrieved January 23, 2018.
6
Berens P, Eglash A, Malloy M, Steube AM. ABM Clinical Protocol #26: persistent pain with breastfeeding. Breastfeed Med 2016;11:46–53.
7
Optimizing support for breastfeeding as part of obstetric practice. Committee Opinion No. 658. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2016;127:e86–92.
8
Breastfeeding in underserved women: increasing initiation and continuation of breastfeeding. Committee Opinion No. 570. American College
of Obstetricians and Gynecologists. Obstet Gynecol 2013;122:423–8.
9
Centers for Disease Control and Prevention. Lactational amenorrhea method. In: US medical eligibility criteria (US MEC) for contraceptive
use. Atlanta (GA): CDC; 2017.
10
Reproductive life planning to reduce unintended pregnancy. Committee Opinion No. 654. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2016;127:e66–9.
11
Immediate postpartum long-acting reversible contraception. Committee Opinion No. 670. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2016;128:e32–7.
12
MacArthur C, Winter HR, Bick DE, Lilford RJ, Lancashire RJ, Knowles H, et al. Redesigning postnatal care: a randomised controlled trial of
protocol-based midwifery-led care focused on individual women’s physical and psychological health needs. Health Technol Assess 2003;
7:1–98.
13
Prevention and management of obstetric lacerations at vaginal delivery. Practice Bulletin No. 165. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2016;128:e1–15.
14
Urinary incontinence in women. Practice Bulletin No. 155. American College of Obstetricians and Gynecologists. Obstet Gynecol
2015;126:e66–81.
15
American College of Obstetricians and Gynecologists. Obesity toolkit. Washington, DC: American College of Obstetricians and Gynecologists;
2016.
16
Gestational diabetes mellitus. ACOG Practice Bulletin No. 190. American College of Obstetricians and Gynecologists. Obstet Gynecol
2018;131:e49–64.
17
American College of Obstetricians and Gynecologists. Immunization for women. Washington, DC: American College of Obstetricians and
Gynecologists; 2017.
18
Conry J, Brown H. Well-Woman Task Force: Components of the Well-Woman Visit. Obstet Gynecol 2015;126:697–701.

e146 Committee Opinion Optimizing Postpartum Care OBSTETRICS & GYNECOLOGY

 The comprehensive postpartum visit provides an agents should be reviewed to ensure that the dosage has
opportunity for a woman to ask questions about her been adjusted to reflect postpartum physiology and that
labor, childbirth, and any complications (15). Relevant the agents selected are compatible for women who are
details should be reviewed and documented in the breastfeeding. The U.S. National Library of Medicine’s
medical record. A traumatic birth experience can cause LactMed is a free online resource that provides high-
postpartum posttraumatic stress disorder, which affects quality guidance on medication safety during lactation
3–16% of women (43). Trauma is in the eye of the (www.toxnet.nlm.nih.gov/newtoxnet/lactmed.htm).
beholder, and health care providers should be aware
that a woman may experience a birth as traumatic even Pregnancy Loss
if she and her infant are healthy. Complications should For a woman who has experienced a miscarriage, still-
be discussed with respect to risks for future pregnancies, birth, or neonatal death, it is essential to ensure follow-up
such as recommendations for 17α-hydroxyprogesterone with an obstetrician–gynecologist or other obstetric care
caproate to reduce risk of recurrent preterm birth, or provider. Key elements of this visit include emotional
aspirin to reduce risk of preeclampsia. Any placental support and bereavement counseling; referral, if appro-
pathology reports should be reviewed and shared with priate, to counselors and support groups; review of any
the patient. Recommendations should be made to opti- laboratory and pathology studies related to the loss; and
mize maternal health during the interpregnancy period counseling regarding recurrent risk and future pregnancy
(44), such as controlling diabetes and attaining optimal planning (50).
weight (45).
Transition to Ongoing Well-Woman
Adverse Pregnancy Outcomes and Cardiovascular Risk Care
There are risk factors for cardiovascular disease that During the postpartum period, the woman and her
appear during pregnancy, and these risk factors are obstetrician–gynecologist or other obstetric care provider
emerging as an important predictor of future arterioscle- should modify her postpartum care plan to identify the
rotic cardiovascular disease (ASCVD) risk. Complications health care provider who will assume primary responsi-
such as preterm delivery, gestational diabetes, gestational bility for her ongoing care in her primary medical home.
hypertension, preeclampsia, and eclampsia are associated Appropriate referrals to other members of her health care
with greater risk of ASCVD (46). Pregnancy is, therefore, team should also be made during this transitional period.
a natural “stress test” identifying at-risk women, but If the obstetrician–gynecologist or other obstetric care
because these conditions often resolve postpartum, the provider is also her primary care provider, no transfer of
increased cardiovascular disease risk is not consistently responsibility is necessary. If responsibility is transferred
communicated to women. These adverse pregnancy out- to another primary care provider, the obstetrician–
comes are also not assessed when using current ASCVD gynecologist or other obstetric care provider is respon-
risk assessment tools. Therefore, women with pregnan- sible for ensuring that there is communication with the
cies complicated by preterm birth, gestational diabetes, primary care provider so that he or she can understand
or hypertensive disorders of pregnancy should be coun- the implications of any pregnancy complications for the
seled that these disorders are associated with a higher woman’s future health and maintain continuity of care.
lifetime risk of maternal cardiometabolic disease. These Written recommendations for follow-up for well-
women should undergo ASCVD risk assessment (47, 48), woman care and for any ongoing medical issues should
with particular attention to the effect of social determi- be documented in the medical record, provided to the
nants of health on cardiometabolic disease (49). All post- patient, and communicated to appropriate members
partum women with gestational diabetes should undergo of the postpartum care team, including her primary
glucose screening with a fasting plasma glucose test or a care medical home provider. By providing comprehen-
75-g, 2-hour oral glucose tolerance test (45). Any history sive, woman-centered care after childbirth, obstetrician–
of pregnancy complications should be documented in gynecologists and other obstetric care providers can
the woman’s electronic medical record to facilitate effec- enable every woman to optimize her long-term health
tive transition of care and to inform future screening and and well-being.
treatment.
Policy and Postpartum Care
Chronic Health Conditions Optimizing care and support for postpartum families
Women with chronic medical conditions, such as hyper- will require policy changes. Changes in the scope of
tensive disorders, obesity, diabetes, thyroid disorders, postpartum care should be facilitated by reimbursement
renal disease, mood disorders, and substance use disor- policies that support postpartum care as an ongoing
ders, should be counseled regarding the importance of process, rather than an isolated visit. More broadly, pro-
timely follow-up with their obstetrician–gynecologists visions for paid parental leave are essential to improve
or primary care providers for ongoing coordination of the health of women and children and reduce dispari-
care. Medications such as antiepileptics and psychotropic ties. As one study (51) has noted, “The lack of policies

VOL. 131, NO. 5, MAY 2018 Committee Opinion Optimizing Postpartum Care e147
substantially benefitting early life in the United States 9. Bennett WL, Chang HY, Levine DM, Wang L, Neale D,
constitutes a grave social injustice: those who are already Werner EF, et al. Utilization of primary and obstetric care
most disadvantaged in our society bear the greatest after medically complicated pregnancies: an analysis of
burden.” The American College of Obstetricians and medical claims data. J Gen Intern Med 2014;29:636–45. ^
Gynecologists endorses paid parental leave as essential, 10. Bryant AS, Haas JS, McElrath TF, McCormick MC.
including maintenance of full benefits and 100% of pay Predictors of compliance with the postpartum visit among
for at least 6 weeks (52). Obstetrician–gynecologists and women living in healthy start project areas. Matern Child
other obstetric care providers should be in the forefront Health J 2006;10:511–6. ^
of policy efforts to enable all women to recover from birth 11. Centers for Medicare and Medicaid Services. Resources on
and nurture their infants. strategies to improve postpartum care among Medicaid
and CHIP populations. Baltimore (MD): CMS; 2015. ^
For More Information 12. Declercq ER, Sakala C, Corry MP, Applebaum S, Herrlich
The American College of Obstetricians and Gynecologists A. Listening to Mothers(SM) III: new mothers speak out.
has identified additional resources on topics related to New York (NY): Childbirth Connection; 2013. ^
this document that may be helpful for ob–gyns, other 13. Howell EA, Balbierz A, Wang J, Parides M, Zlotnick C,
health care providers, and patients. You may view these Leventhal H. Reducing postpartum depressive symptoms
resources at www.acog.org/More-Info/OptimizingPost among black and Latina mothers: a randomized controlled
partumCare. trial. Obstet Gynecol 2012;119:942–9. ^
These resources are for information only and are not 14. Howell EA, Bodnar-Deren S, Balbierz A, Parides M, Bickell
meant to be comprehensive. Referral to these resources N. An intervention to extend breastfeeding among black
does not imply the American College of Obstetricians and Latina mothers after delivery. Am J Obstet Gynecol
and Gynecologists’ endorsement of the organization, the 2014;210:239.e1–5. ^
organization’s website, or the content of the resource. 15. National Institute for Health and Care Excellence. Postnatal
The resources may change without notice. care. Quality standard. Manchester: NICE; 2013. ^
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view study exploring their experiences of telemedicine after
American College of Obstetricians and Gynecologists.
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This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is
voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care.
It is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in
the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or
advances in knowledge or technology. The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its publica-
tions may not reflect the most recent evidence. Any updates to this document can be found on www.acog.org or by calling the ACOG Resource Center.
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e150 Committee Opinion Optimizing Postpartum Care OBSTETRICS & GYNECOLOGY