Timing of Emergency Postpartum Hospital Visits in the Fourth Trimester

Abstract

Objective The concept of the “fourth trimester” emphasizes the importance of individualized postpartum follow-up. Women seek care for urgent issues during this critical time period. Our objective was to evaluate trends in presenting complaints and admissions in an emergency setting over the first 42 days following delivery. Study Design Postpartum hospital encounters within 42 days of delivery at our institution from 2015 to 2019 were studied. Demographic information, delivery route, and emergent hospital encounter details were obtained from the electronic medical record. The postpartum encounters were analyzed by week of presentation. Statistical analysis included Student's t-test and Mantel–Haenszel test with p <0.05 considered significant. Results Of the 8,589 deliveries, 491 (5.7%) were complicated by an emergent hospital presentation within 42 days of delivery resulting in 576 hospital encounters. 35.9% of these visits occurred in the first week and 75.5% occurred within the first 3 weeks. Women presenting to the hospital were more commonly African American, higher body mass index, and delivered via cesarean. The most common chief complaints were fever, headache, abdominal pain, vaginal bleeding, hypertension, and wound concerns with temporal trends noted. 72% of admissions occur within 14 days of delivery and drop dramatically thereafter (p = 0.001). The most common admission diagnoses were hypertension/preeclampsia with severe features, vaginal bleeding/delayed postpartum hemorrhage, and wound infection. Conclusion We observed important trends in presenting complaints and admission diagnoses of emergency postpartum visits in the first 42 days. The majority of hospital visits and admissions occur within the first 2 weeks postpartum. Understanding maternal conditions and reasons for accessing care through an emergency setting allows for tailoring of routine postpartum follow-up. Key Points

Early Postpartum Hospital Encounters among Patients with Genitourinary and Wound Infections during Hospitalization for Birth

“…Infection is a leading cause of mortality and severe morbidity in the postpartum period, 1 and is one of the most common causes of a postpartum readmission or emergency department (ED) visit. [2][3][4][5][6][7][8] Readmissions and emergency department visits are most likely to occur during the first weeks after birth, with the largest proportion occurring within the first several days after discharge from the birth hospitalization. [2][3][4][5][6][7][8] Prevention of unscheduled hospital encounters, and the associated mortality and severe morbidity, during this early postpartum period is an opportunity to improve health outcomes for postpartum individuals.…”

“…These infections include wound infections, major puerperal infections, urinary system infections, inflammatory diseases of reproductive organs, and amniotic cavity infections. Additionally, the risk of a postpartum hospital encounter is further influenced by other conditions and procedures during the birth hospitalization, such as mode of birth, 6,[8][9][10][11] body mass index (BMI), 5,6,12,13 hemorrhage, 14,15 and severe obstetrical morbidity. 4,11,16 The ability to identify which genitourinary and wound infection patients are most at risk of an unscheduled postpartum hospital encounter is needed to inform prevention efforts.…”

A Nurse-Navigated, Postpartum Support Text Messaging Intervention

“…1,2 In a retrospective study, researchers noted that 491 of 8589 births (5.7%) resulted in at least 1 presentation to the hospital within the first 42 days postpartum with 75.5% occurring during the first 3 weeks after childbirth. 14 An associated risk factor for seeking postpartum hospital care included cesarean delivery surgery. 14 In 2013, the World Health Organization declared postnatal health and well-being support of women and newborns as a global priority.…”

“…14 An associated risk factor for seeking postpartum hospital care included cesarean delivery surgery. 14 In 2013, the World Health Organization declared postnatal health and well-being support of women and newborns as a global priority. 15 Bingham et al 16 suggested priority strategies to decrease maternal mortality and morbidity in the first year following childbirth including (1) standardizing hospital discharge postpartum education; (2) increasing awareness of potential complications; and (3) enhancing social and mental health support.…”

“…Of the 50% of maternal deaths occurring up to 1 year after childbirth, nearly 40% of these deaths occur during the first 6 weeks postpartum 1,2. In a retrospective study, researchers noted that 491 of 8589 births (5.7%) resulted in at least 1 presentation to the hospital within the first 42 days postpartum with 75.5% occurring during the first 3 weeks after childbirth 14. An associated risk factor for seeking postpartum hospital care included cesarean delivery surgery 14.…”