Postpartum Complications and the Fourth Trimester

The U.S. has one of the worst rates for maternal death in the developed world. Ninety-nine percent of U.S. births are in hospital settings with only 1% of births occurring at home. 

A recent study released by the Centers for Disease Control and Prevention indicates that 84% of pregnancy-related deaths were deemed preventable. What’s even more staggering is that 54% of deaths occurred between seven days to a year after delivery; well after the patient left the hospital. 

Postpartum complications should always be a concern, yet, in the U.S. there seems to be a lack in postpartum care for the mother. As nurse-midwife Karen Sheffield-Abdullah put it, “Once the baby is here, it’s almost like the mother is discarded. Like a Resse’s Peanut Butter Cup. The mom is the wrapper, and the baby is the candy. Once you remove the wrapper, you just discard the wrapper. And what we really need to be thinking about is that fourth trimester, that time after the baby is born.” 

A story from a Figure 1 member and midwife illustrates this point quite clearly.

“Today I almost lost a client. A 35-year-old, with an overall healthy pregnancy with gravida 1 and para 0, a gestation of 39 +1 weeks, and was negative for GBS, planned for a home birth. The decision was made to transport to hospital after 24 hours of labor for failure to progress and dehydration. Both the mother and baby were stable and all vitals during labor were normal. Hospital management for the next 7 hours involved IV fluids, followed by epidural, followed by pitocin, followed by late decels of FHT and finally by C section delivery of a healthy boy. There was minimal blood loss during surgery, and minimal vaginal blood loss post surgery. The patient had a hemoglobin (HGB) level of 12.4 pre surgery, and HGB of 8.8 at 1 hour post surgery. The doctor advised this as in the range of normal as there was blood thinning from IV fluids. The patient at the time reports shortness of breath that was diagnosed as anxiety and post epidural pressure is within normal limits, and they are encouraged to take deep breaths. Their blood pressure was 89/50 p 130, with a diagnosis of exhaustion from a 5 hour pushing stage before transport to hospital. The patient’s family and labor-management team advocated for the staff to pay attention to her lack of stability. At 7 hours post surgery her vitals crashed, 2 units of blood administered immediately on the way to the OR. She had a postpartum hemorrhage of 2 vessels bleeding into her abdomen. 4 units of blood administered in surgery. Luckily she made it through and the mother was stable in ICU.”

This case created a lot of discussion on Figure 1, with most people supporting the author’s decisions. One member said, “Speaking as a sister midwife, from the facts you presented, you transported appropriately. She had a necessary c-sec and your advocacy saved her life. I am standing by you in support. Good work.” 

However, a big topic of conversation was why the patient’s symptoms after birth were dismissed. A physiotherapist asked, “What do you think led to the missed diagnoses earlier on before family pushed for more attention? Lack of resources? Lack of staff? Exhausted physicians? Do healthier women going into births get less attention?” While some claim that there would have been less risk if the birthing process started in a hospital to begin with, many take the opinion that it was the dismissal of the patient’s symptoms after birth that led to an emergency operation.

One registered nurse said they were “Surprised they accepted low BP and high pulse rate as exhaustion, classic hemorrhage signs. Low Hb too, 12.4 to 8.8 is some drop, that’s higher than average isn’t it.” And, the author stated that “the hemorrhage was in the abdominal cavity. Not a uterine hemorrhage, thus the minimal vaginal blood loss. The surgeon left a bleeding vessel. Mistakes do happen in surgery, it’s the immediate post surgical care she received that put her at the greatest risk.” They go on to say, “It is a larger discussion of woman not being listened to in the medical setting because they are ‘anxious, emotional, exhausted, scared.’” Overall, the Figure 1 community seems to agree that in this case, it was a lack of proper post-OP care that led to an emergency situation for the patient.

What Does the Figure 1 Community Think?

The case above is just one of many instances where a lack of postpartum care for patients caused significant problems. Knowing there are many issues tied to pregnancy-related injury, and even death, we asked the Figure 1 community for their thoughts.

We posed the statistics of the CDC study which found 84% of pregnancy-related deaths were preventable and asked if they found this surprising. The results were quite mixed. While 48% of the respondents stated that this was something they’ve heard before, 45% said yes, this information was a surprise, and only 8% remained neutral. 

While there were mixed results on the knowledge of postpartum complications, there is much more agreement on the solution to the problem. We asked our members if they agree with the recommendation of providing postpartum care for up to a year after delivery and the majority agreed. A total of 86% said they do agree with the recommendation, only 6% did not agree, and 8% remained unsure.

One member responded saying that “I think having more frequent follow ups postpartum is a must! Mamas getting the ‘ok’ to return to normal activity pre-pregnancy at 6 weeks and no further follow up care isn’t adequate care. We expect pregnant individuals to have prenatal visits every month, 2 weeks, and then weekly until baby arrives, but then wipe our hands of them following delivery, when they need to be checked on the most! That fourth trimester is the most crucial in my opinion.” 

Another midwife stated, “It is … still unbelievable to me as a European that there is no universal health care insurance in the USA. I work as a midwife in Amsterdam. Though of course problems are everywhere; insurance and therefore lack of care is never ever the issue. The first 8 days a nurse comes to your house 4-8 hours to help new parents and their baby get started and midwives visit 4 times that week. More and for a longer period if needed. Preventive care is the cornerstone.”

Published March 20, 2023

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