Immediate postnatal care in obese women

43.1

Historical background

• Current models of postnatal care originated from the beginning of the 20th century, when there were concerns about the high maternal mortality rate in the postnatal period.

• Postnatal care provision is provided by both acute and primary healthcare sectors, with the majority of care taking place in the woman’s home.

• Midwife-led postnatal care in the United Kingdom continues to be a statutory requirement and is usually provided until 6–8 weeks postnatal.

• There has been limited research into the provision and content of postnatal care, with even less information on effective framework of care in obese woman of child-bearing age.

43.2

Implications of obesity in planning of postnatal care

• The implications of being obese for a woman’s postnatal health are likely to affect the content and planning of her individualised care, frequency of contact and what needs to be provided by the multiprofessional team.

• Overweight and obese women are at increased risk of starting pregnancy with existing medical comorbidity such as diabetes and hypertension and they may be already on medical treatments compared to women with normal weight.

• Furthermore new disorders such as gestational diabetes, new onset hypertension, and venous thrombosis (VTE) arise at a higher frequency when compared with normal weight women.

• Some of these existing prepregnancy morbidities are expected to worsen during pregnancy. There is an increased risk of operative intervention during labour, hence compounding risk of sepsis, VTE secondary to labour intervention and impaired mobility, impaired glucose metabolism, and difficulty in breastfeeding.

• The priorities for postnatal care should start during antenatal period of pregnancy and should continue to evolve throughout pregnancy, intrapartum period, and the postnatal phase.

• The key objective is to prevent and minimise potential postbirth complications and assist the woman and her baby to achieve the best possible outcome.

• Obstetric outcome data from a retrospective cohort of over 72,000 Australian women delivered in a tertiary centre are shown in Fig. 43.1 , stratified by body mass index (BMI).

  

• These data provide BMI subgroups stratified risks, and could assist in planning of the whole journey of pregnancy especially during the postdelivery phase.

43.3

Postpartum care plan

• Anticipatory guidance for postpartum care plan should start following booking visit and should continue to evolve as the pregnancy progresses, taking account of new complicating factors which may affect new parents.

• Anticipatory guidance should be based upon comprehensive needs assessment, including discussion about infant feeding especially breastfeeding, ‘baby blues’, postpartum emotional health, and the challenges of parenting and recovery during postpartum period.

• Prenatal discussions also should address plans for long-term management of chronic health conditions, such as mental health, diabetes, hypertension, including identification of a primary healthcare provider who will care for the patient.

• Mode of delivery, past birth experience, and length of stay in maternity unit, particularly in obese parturient, further define postnatal care.

• The American College of Obstetrics and Gynecology has proposed to coin the term of fourth trimester to the postpartum period and a shift of paradigm to 12 weeks rather than 6 weeks of postpartum care ( Table 43.1 ).

  Table 43.1

  Suggested components of the postpartum care plan ^a
  .

  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 (e.g. WIC, Lactation Warm Lines, Mothers’ groups), return-to-work resources
  Reproductive life plan and commensurate contraception	Desired number of children and timing of next pregnancy 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 followup or test results (e.g. glucose screening for gestational diabetes, blood pressure check for gestational hypertension), as well as risk reduction recommendations for any future pregnancies
  Adverse pregnancy outcomes associated with ASCVD	Adverse pregnancy outcomes associated with ASCVD will need baseline ASCVD risk assessment, as well as 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 (i.e. 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

  ASCVD , Atherosclerotic cardiovascular disease; WIC , Special Supplemental Nutrition Program for Women, Infants, and Children.

  a A Postpartum Care Plan Template is available as part of the ACOG Pregnancy Record.

Overweight and obese women are at increased risk of experiencing the following complications significantly more than women with normal BMI.