What doctors wish patients knew about postpartum care

AMA News Wire

What doctors wish patients knew about postpartum care

May 17, 2024

Navigating the delicate phase following pregnancy can be challenging. From physical recovery to emotional well-being, the postpartum period—which begins after delivery demands careful attention and support. Despite advances in medical understanding and increased awareness, gaps in postpartum care persist, putting many women at higher risk of worse outcomes. Knowing what to expect and when to seek care is key to improving health outcomes and experiences postpartum.

While pregnancy and childbirth complications can affect people of any racial or ethnic background, Black individuals see deeply inequitable outcomes. in the period after childbirth, Black birthing people are three times more likely to be affected by health conditions such as postpartum depression.

Meanwhile, there also are inequities among Native American or Alaska Native individuals with regard to pregnancy-related deaths, with mental health conditions and hemorrhage accounting for 50% of deaths with a known underlying cause.

The Centers for Disease Control and Prevention (CDC) tracks deaths in pregnancy and postpartum. Of those deaths where information on timing was available, 22% happened during pregnancy and 25% on delivery day or within a week. But a majority—53%—happened sometime between a week to one year after pregnancy.

According to the CDC, the leading underlying causes of pregnancy-related death include:

• Mental health conditions, including suicide and overdose deaths: 23%.
• Excessive bleeding: 14%.
• Cardiac and coronary conditions: 13%.
• Infection: 9%.
• Thrombotic embolism: 9%.
• Cardiomyopathy: 9%.
• Hypertensive disorders of pregnancy: 7%.

As part of its advocacy to improve maternal health, the AMA has outlined concrete actions that should be taken to reduce and prevent rising rates of maternal mortality and serious or near-fatal maternal morbidity in the U.S.

The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines.

In this installment, Jennifer Heer Ford, MD, an ob-gyn with Baptist Health Medical Group in Louisville, Kentucky, shared what doctors wish patients knew about postpartum care. Baptist Health is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.

“One of the things I say most to my patients is that we underestimate this time in your life,” Dr. Ford said, noting when patients come in for their postpartum visits, “they look ridiculously exhausted and like they’ve been blindsided by something that they did not know was coming.”

“It is so many things merging at once. Then if they’re having issues with their health—whether their blood pressure is high, they’re scared about their health, they may be scared about their baby’s health,” she said. “It’s just a critically important time—from delivery to 12 weeks after.”

“People are not being seen early and frequent enough in general. The American College of Obstetricians and Gynecologists came out with a committee opinion a few years ago that said we really need to look at postpartum care differently,” Dr. Ford said. “We were waiting too long. Things were not in a good place by the time we saw these [patients] at six weeks.”

“If we can see them back a little sooner, we could really address some of these things sooner and not have them suffer for so long before we’re addressing things,” she said. “For C-section patients, you want to see them probably seven to 10 days for an incision check and then again for a six-week appointment.

“For my vaginal delivery patients, I am going to gear it toward the patient a lot because I feel like I know my patient better than anyone else,” Dr. Ford said. “People who are going through pregnancy for the first-time …, I’m seeing them within three weeks.”

It also helps to know if the patient has support during that postpartum period. If not, “I’ll see those patients earlier, even if it’s not their first  pregnancy,” she explained. “A lot of it I’m basing on individual needs, but most patients should be seen within those first three weeks.”

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Dr. Ford takes steps to normalize postpartum depression, which involves “telling patients that it’s very common and what the risk factors are for that.”

“The biggest one that I see is social isolation. If  … you don't have any community support, that's a big risk factor for postpartum depression,” she said.

Another is “a traumatic birth experience.” That can include wanting a natural birth, but having a C-section instead, or undergoing an emergency C-section where mom or baby’s life were at serious risk.

“Women underestimate the trauma to them, so a lot of times we'll talk about postpartum depression prior to delivery, especially in my patients who had any history of anxiety or depression,” Dr. Ford said. “Making sure that you ask for help is the biggest thing mentally for patients—and that you're talking to each other. A lot of times I'll look at their support person in the room and I'll say, ‘You're going to notice things a lot of times before she will notice things.’”

“For postpartum depression, those at risk are people who are isolated and do not have a lot of support, people with a history of anxiety or depression,” Dr. Ford said, noting “anyone with substance use disorder” is also at risk for complications.

“Medically, you’re going to have your patients who have other comorbidities such as obesity, people who have gestational diabetes or preexisting diabetes, people who have high blood pressure or preeclampsia” are also at risk for complications, she said.

“Patients who are teenagers are also going to be at risk for medical complications,” Dr. Ford said. “On the opposite side, patients older than 40 are going to be more at risk for medical complications too.”

Meanwhile, Black individuals are three times more likely to die from pregnancy-related causes—such as preeclampsia—than white individuals, according to the CDC.

“Any patients who have preeclampsia or preexisting high blood pressure during pregnancy are more at risk for cardiovascular disease later in life, whether it’s a year after … or 10 years after,” Dr. Ford said, noting even if a patient’s blood pressure is controlled six weeks postpartum, “something was happening in your body that predisposed you to this that is now going to set you up for complications later.”

“Cardiomyopathy and other things can present within that first year of pregnancy,” she said, adding that “stroke is a huge cause of death in the first year postpartum because of uncontrolled blood pressure.”

“There are certain high blood-pressure diseases during pregnancy. So, you have your chronic hypertension, which is somebody who walks in the door pregnant and they already have high blood pressure,” Dr. Ford said. Then there is “gestational hypertension, where they did not walk in the door pregnant with high blood pressure, but sometime after 20 weeks their blood pressure starts going up.

“And then you have preeclampsia. Preeclampsia can only be diagnosed after 20 weeks’ gestation,” she added, noting “a lot of patients do not realize that with preeclampsia, one-third of it is during pregnancy, one-third of it is the time of delivery and one-third of it is postpartum.”

“Patients are often very shocked when their pressure goes up after delivery because they think it’s all over and it’s done,” Dr. Ford said. “In prenatal care, we start seeing patients every week starting at 35 to 36 weeks. The reason for that is because that’s when most of these hypertensive diseases of pregnancy present.”

The warning signs are “blurred vision, seeing spots or floaters, right upper quadrant pain, severe headache that Tylenol doesn’t relieve,” she said. “If you have of any of these symptoms, you go straight to labor and delivery.”

One of the largest topics of questions and concerns for patients “in postpartum care is breastfeeding,” Dr. Ford said, noting “when it's not going well, patients may feel like they're doing something wrong.”

“We try to talk about how breastfeeding doesn’t go well for everybody. It’s OK,” she said. “There are certain things that you may have to let go of or change your expectations on. Being loved and fed is what’s most important.”

“Physically, listen to your body and don’t overdo it,” Dr. Ford said. “Remember that you just went through a very difficult, challenging course and that your body needs to heal.”

When it comes to physical activity postpartum, “it doesn’t have to be extreme,” Dr. Ford said. “It doesn’t have to be that you’re going to the gym and doing the elliptical for an hour.”

But how soon can you return to physical activity? “It depends,” she said, emphasizing it is important to, listen to your body because you’re going to know best.”

Typically, the recommendation is “anywhere from two to six weeks after a C-section. Again, depending on how fit the patient is, depending on how well they recover,” Dr. Ford said, noting “a lot of patients will start walking two weeks after a C-section,  but still listen to your body. If something doesn’t feel good to you, then don’t do it.”

“With vaginal deliveries, it depends a little bit. Sometimes women can have more extensive [vaginal] tears, and some can often have even more discomfort than our C-section patients,” she said. “Doing what feels good for your body is key.” “Walking is one of my favorite things to tell people to do. It doesn’t have to be fast walking. Just get out and move a little bit and you can also bring your baby,” Dr. Ford said.

“If someone has a vaginal delivery and they do have a tear, we will usually say six weeks because it’s going to take an entire six weeks for the body to heal properly,” Dr. Ford said, noting “you’re not going to feel like this forever, but right now your hormones are not in the place they’re going to be a year from now.”

Additionally, “the vaginal area is going to be a little more dry and uncomfortable,” she said, emphasizing it is important to “wait until you’re mentally and physically ready. There’s no magic time.”

“One of the things I do tell patients—and this is really important for them to hear—is this is going to get better,” Dr. Ford said. “You will not feel like this six months down the road.”

“There is the expectation that you have a newborn baby and it's all happy and it's all wonderful,” she said. “And because that's the myth that we've given”, patients can “feel like something's wrong when they're not feeling that way.”