The postpartum or postnatal visit has evolved significantly over the decades. It remains a largely ill-defined, and poorly evidenced-based, episode of care. The value and content of the visit should be individualized to the patient.
In 1966, G.W. Morley wrote an influential article entitled, The important “Ten B’s” of post-partum hospital care. As the name suggests, the focus was on care of the mother while still in the hospital. Morley’s ‘B’s’ were the following:
- Breasts: breast feeding vs bottle feeding, which he concluded were equal in merit.
- Bladder: he repeated the false idea that a full bladder prevents the uterus from contracting down.
- Blood: monitoring for excessive lochia. He encouraged manual exploration of every uterus postpartum.
- Bowels: he encouraged liberal use of laxatives and suppositories.
- Bottom: inspection of the episiotomy (he encouraged its use) and care of hemorrhoids.
- Baby: follow-up and exam of the baby (along with the pediatrician).
- Blood relations: “How is your husband getting along?” He also encourages that the grandmother not be involved with care of the baby at home, but rather they should hire a housekeeper to do it. Hmm.
- Bed rest: “Pregnancy is a variation from the normal.” Double hmm. He encourages strict bed rest for some part of each day.
- Belly: he raises awareness about non-pregnancy related causes of abdominal pain.
- Blues: monitoring of postpartum “psychosis” which he says is caused when women are getting less attention after birth but at the same time having more responsibility. Triple Hmm.
It’s hard to not almost laugh at many of Morley’s comments. However, many of our practices today are just as absurd and based on equally unfounded logic. You’ll note that virtually every practice, endorsed above some 50 years ago, we would harshly criticize as unscientific, misogynistic, and anecdotal. Unfortunately, many of these attitudes still persist today. When the woman followed up for her postnatal visit at six weeks, she likely received an unnecessary physical exam, an unnecessary Pap smear, and tons of likely harmful advice.
Still a mnemonic is helpful and sticks in your head like a pop song. A popular, modern version of this list distributed by APGO-CREOG, includes the following Ten B’s:
- Bottom (episiotomy/lacerations)
- Bleeding (lochia /periods)
- Birth control
- Boinking (OK-not technically acceptable, but it starts with a B)
- Baby (doing well?)
The priorities of the postpartum visit will vary widely with each individual patient, but most of the above issues apply to all recently-pregnant women. Let’s start with these B’s, add a couple, and expand upon them.
- Bladder. The most common issue at a postnatal visit involving the bladder is stress incontinence. Many times the woman needs reassurance that she will continue to regain some control of her bladder over the next few months and that there are options available for her if she does not. Kegel exercises are often recommended, but their value is questionable, particularly early in the postpartum period.
- Bowel. Very few postnatal visits include specific complaints about the bowel, though constipation is not unusual. If there were an obstetric laceration extending into the anal sphincter, then questions about this system and function are critical.
- Bottom. This word can serve to remind the provider to ask questions about hemorrhoids as well as obstetric lacerations.
- Bleeding. Women often need reassurance that the amount of bleeding they’ve experienced since delivery is appropriate and will improve. Sometimes, questions about postpartum bleeding lead to discovery of an abnormality such as retained products of conception.
- Breasts/Breastfeeding. Unlike Dr. Morley, today we encourage breast-feeding as superior to bottle-feeding. A variety of breast and breast-feeding problems may be discovered at the six weeks postnatal visit. Obstetrician should not defer their responsibility for the mother’s breast-feeding to the pediatrician or the lactation consultant. Edcuation among obstetricians about this vital topic seems lacking. Women also frequently have questions or concerns related to cosmetic changes of their breasts.
- Blues. Screening for a variety of postpartum mood disorders, including depression, anxiety, OCD, and psychosis, is one of the most important functions of the postpartum visit. A healthy rapport with the patient as well as good, nonjudgmental interviewing skills are supremely important in exploring these areas. A variety of screening tools are also available.
- Birth control. Along with Blues, a discussion of birth control options is paramount in importance. Hopefully, this discussion started months previously and a plan is already in place. The provider should stress the importance of long-acting reversible contraceptives (LARCs) and hopefully have a utilization rate of Tier 1 birth control of over 80%. Women who choose to not use Tier 1 birth control should be counseled about short interval pregnancy complications.
- Boinking. Feel free to substitute another word that starts with B and means intercourse if you have one (I can think of two). A significant number of women have already had intercourse by the time of the postnatal visit, and others are expecting to become unrestricted to do so at the visit. Williams Obstetrics does not recommend restriction of intercourse beyond two weeks postpartum in women who had uncomplicated deliveries, if they so desire. Counseling the patient about pain or problems that they have already experienced with resumption of intercourse, or which they might experience when they do, should not be neglected.
- Baby. Questions about how the baby is doing are very important. Newborn complications like colic can have a profound impact on the new mother. More importantly, birth defects or other congenital disorders, which might have been discovered about the newborn since delivery, need to be discussed and reviewed with the mother.
- Bruises. I’ve replaced beaten/battered with the word bruises. Pregnant women, and women who recently had a baby in particular, are very vulnerable to intimate partner violence. The incidence of this type of abuse peaks during this time of a woman’s life. Screening for intimate partner violence should be routine at the postnatal visit.
Now we will add some B’s:
- Belly. We can re-appropriate Morley’s word for a new purpose. This word should serve as a reminder to evaluate Cesarean Delivery incisions or perhaps diastasis recti or umbilical hernias. Women often have questions and concerns about their diastases and their abdomens, stretch marks, etc.
- Blood pressure. Women who had gestational hypertension or chronic hypertension may need medications ended, reevaluated, or changed.
- Blood glucose. Women who had gestational diabetes should receive a two hour, 75 gram, glucose tolerance test at eight weeks postpartum.
- Broom. It used to be routine to do Pap smears at the postnatal visit, just as it was routine to do a Pap smear at the first OB visit. Today, we recognize the Pap smears should only be done at the appropriate screening interval, which is often every three years in women of reproductive age. Sometimes this interval falls around the time of the postnatal visit, and the word Broom can serve as a reminder to check if it’s time.
What else should happen at the visit?
- In an asymptomatic woman, physical exam of any sort is largely unnecessary. If any physical exam does occur, it should focus on the patient’s symptoms or specific complications of the pregnancy or delivery such as a fourth degree laceration.
- Review of the pre-pregnancy weight and the current weight with encouragement and instruction regarding weight loss is usually appropriate, clarifying the goal that she should attain pre-pregnancy weight at six months postpartum.
- Tobacco cessation and weaning of illicit drug use should be encouraged and supported.
- In women who had an unexplained spontaneous preterm birth, evaluation the uterine anatomy for congenital anomalies should be performed.
- In women who had a pregnancy complicated by an early or severe preeclampsia, severe IUGR, fetal demise, or other qualifying condition, screening for the antiphospholipid antibody syndrome should be performed.