Have you ever wondered how guidelines are set for the care that you should receive by your doctor during your pregnancy, at childbirth, and then after you deliver your child? The American College of Obstetricians and Gynecologists, otherwise known as ACOG, do set those guidelines, and they recently updated the information on their seventh edition book that you can find on Amazon, Your Pregnancy and Childbirth.
I interviewed Dr. Holly Cummings, who is an OB GYN, and she answers some of the questions around some of the surprising guidelines and how they came about and the role that women should play to ensure that they have a successful and healthy pregnancy, childbirth and postpartum care.
Georgie Kovacs: There has been a long overdue, but welcomed change to guidelines, where previously the recommendation has been that your first postpartum visit to your OB GYN is six weeks after delivery. Now, it is recommended that you can do it three to four weeks after delivery.
Dr Holly Cummings: I think that, historically, I wasn't around decades ago, when somebody decided that we could just see people at six weeks after delivery and everything would be okay. But there is a historic basis for the idea that most people have completed their physical recovery by six weeks. Certainly people will talk about that maybe that has some tradition, from even very few centuries ago in the Catholic Church, and antiquated ideas around when somebody could resume physical activity, including intercourse after delivery.
And it does hold true that a lot of people are physically, if they've had a childbirth, tear. Most people have healed by six weeks, but not everybody. And there's a lot more to the postpartum time period than just having your tear healed and having your stitches dissolve.
And so I think over the last few years, we've really realized that there's a lot of care that still needs to happen in the postpartum time period. And we're sort of calling it now the fourth trimester of pregnancy.
So the 12 weeks after delivery. And there's been increasing recognition that people still need a lot of assistance. There can be problems such as high blood pressure that can arise even after a baby is born. If somebody has had diabetes during pregnancy, that can still be a concern for everybody, we really worry about their emotions and their mood postpartum.
And as well as the physical recovery, plenty of people aren't physically healed by six weeks. And if you wait till six weeks to have your first contact with someone after delivery, then you may have missed opportunities to help them heal from all these different aspects.
And then certainly breastfeeding as well. If you've waited till six weeks to ask someone how breastfeeding is going, if someone's having trouble, you've lost the opportunity to help. In the last few years, we as a group of physicians, obstetrician gynecologists, along with other medical providers who help take care of pregnant patients have really increased our emphasis on the postpartum time period, and this emphasis on the fourth trimester, and tried to improve the care. And so I do think it's really great that ACOG has come out, we've actually come out with guidance in writing that we should touch base with our patients at those time periods that you mentioned.
The trimester is a 12 week time period, and you should have at least two checkouts in there.
I would love to be able to spend hours with every single one of my patients, and sometimes the practice setting doesn't allow for it. But when it's important, we should be able to take that time.
Georgie Kovacs: When these guidelines are put in place, how do all the OB GYN know about them? It's one thing for it to be written, and then there's another thing to change mindset.
Dr Holly Cummings: OB GYN is an interesting field. Most OB GYN’s in this country do belong to ACOG, the American College of Obstetricians and Gynecologists, In order to be board certified in obstetrics and gynecology, we undergo annual board certification updates, and some of that process involves making sure that we're up to date with ACOG’s guidance.
So ACOG publishes two different types of written guidance called practice bulletins and committee opinions. And those are available on their website, also through medical publications, and it's our responsibility as board certified OB GYN is to stay up to date with those recommendations.
Georgie Kovacs: I assume getting board certified involves answering many questions. How can the system ensure OB GYN’s know about this change to guidelines? It is an important one.
Dr Holly Cummings: Absolutely. I think there's a wide variety of practice settings in this country. Some some physicians are based at tertiary care academic centers. Other people are in community practice or solo practice. Some people practice in very rural settings, with very low resources. And so there is going to be a variety of practice patterns and practice settings.
However, sort of the commitment we've all made as OB GYN, as women's health providers, is that we are trying to do the right thing by our patients at all times. And so I do think it's reasonable for a patient to come to her care provider and say,” Look, this is what I understand the recommendations to be. Is this what I should expect from my experience with you, and if not, why?”
ACOG has done a lot with really taking into consideration all those different practice patterns. So for instance, it's very hard to mandate that you must be seen by your provider three weeks after childbirth. It might not be possible for that medical practice. And it actually might not even be possible for the patient to get to the office, but allowing for the opportunity of a telephone contact telemedicine visit that broadens the opportunities.
It does sometimes take more time in our conversations with the patient, but that's not a bad thing in itself. I would love to be able to spend hours with every single one of my patients, and sometimes the practice setting doesn't allow for it. But when it's important, we should be able to take that time.
Georgie Kovacs: When ACOG creates these guidelines, how does that translate into what is covered as a benefit with insurance companies?
Dr Holly Cummings: It's certainly a reality in this country, insurance coverage sometimes dictates what we're able to do. Part of the benefit of having recommendations like this in writing as an official stance of ACOG is so that we can, on the flip side, come back to the insurance companies and say, “Look, this is the right thing to do for our patients, and so you should cover it.”
We've seen since, the recommendations for that three week check-in postpartum have come out from ACOG, there are more insurance companies covering it. Historically, as part of the pregnancy care in the United States for a few decades now has been covered under what we call a global package. And so there's a single payment that the insurance company makes to the OB GYN for our delivery provider after delivery. And so that covers all nine months of prenatal care, and the delivery and six weeks of postpartum care.
And because of those historic guidelines, the six weeks of postpartum care was listed as a single office visit, which tied our hands as providers. We can't see everybody in extra time, if we're not going to get paid for it. That's not fair to us, as well. And so by having this recommendation in writing, we've been able to come back to the insurance companies and say, This is the right thing to do for our patients, therefore, you should also cover it. And so we're starting to see that with some of the payers now. That they are covering that additional visit, which is great. And that's how we slowly move the needle for everybody.
Georgie Kovacs: The next question is about vitamin D supplementation. I was surprised to learn that if you are breastfeeding, the milk does not necessarily produce all of what the baby needs. Thus, if you're breastfeeding, it's important to supplement the baby with vitamin D, but if you are using formula, you don't have to. The same goes for iron. Can you talk a bit more about this, especially since we are often told breast milk produces everything the baby needs.
Dr Holly Cummings: Breast milk is absolutely a complete form of nutrition for human babies, and we support exclusive breastfeeding and meeting everybody's breastfeeding goals. But we do know from breast milk analysis that vitamin D is the one thing that breast milk does not contain enough of under our normal diet.
Now, what's interesting is I don't know that we know if this is a product of the modern, 21st century industrial diet or is this something that, evolutionarily, was always a problem.
It is true that formula has been supplemented with enough vitamin D, but breast milk does not contain enough vitamin D, generally. And so we do recommend breastfeeding patients to either supplement the baby with vitamin D.
Alternatively, the adult breastfeeding person can take extra vitamin D supplementation. And that is what allows enough vitamin D to get into the breast milk into the baby.
Georgie Kovacs: The next question is related to kegels. I've had the fortune of interviewing a few folks who do pelvic floor physical therapy and pelvic floor rehabilitation. And one of the aha’s that I had is around the right kegels. What I learned is that it depends on what is happening with the pelvic floor because if you do what most people think of as the kegels, and that's not why you're having the issue, it can actually make things worse.
So I was curious about your thoughts and perhaps if there's some considerations for potential revisions of what's described here?
Dr Holly Cummings: The kegel exercises, as described here, are correct, .and that's generally how we counsel people, but I do agree that they're not necessarily for everyone.
So one of the things to talk about with your provider at your postpartum visit is:
Have I healed physically
Do I have any ongoing pain
Would I benefit from pelvic floor physical therapy
And I know the pelvic floor physical therapist would say everybody would benefit from physical therapy.
I'm aware that in other countries, it's sort of a routine postpartum follow up. And I do think there's a growing awareness that getting people in early after childbirth can help with so much of the physical recovery, the muscular spasms that can happen and the long term pain.
And I agree that if some people have sort of, depending on what their concerns are, are doing kegels in this way might not be the right thing. And so certainly, if you're trying to kegels at home and you're having more pain, then you know, don't keep doing that and seek help. Ask for a referral to pelvic floor PT.
Georgie Kovacs: With respect to prolapse, I interviewed a woman who recently wrote a book about urinary incontinence. And there's just all these things that can happen. When we live in our own body, we become very used to what is. We may not always know, until something really bad happens that it probably could have been caught earlier.
Outside of the luxury of being able to go to a pelvic floor physical therapist, in all cases, are there things people should look for outside of just pain that maybe should be a warning sign of probably not a grin and bear it kind of moment, this is a go see your doctor kind of moment?
Dr Holly Cummings: Any sort of incontinence, and by that we mean leaking, leaking anything that you don't want to be leaking, which can include leaking urine, stool, or gas. So if you don't have control of those bodily functions, you should absolutely seek medical attention. It can be a sign that the muscles haven't healed properly after delivery, or maybe if you had stitches, additional healing needs to take place. And these are things that the earlier they can be identified, the better the outcomes are at fixing them. And sometimes, it's a combination of physical therapy, sometimes it involves surgical procedures, but you really want to have that very detailed evaluation either by your childbirth provider or OB GYN provider, or there are specialists within the field of gynecology, often referred to as urogynecologists who specialize specifically in the pelvic floor musculature.
Georgie Kovacs: When is incontinence a concern given that birth already impacts a woman’s body.
Dr Holly Cummings: I agree that it's very common to see leaking, particularly urinary leaking for the first few weeks after delivery. And that can be whether somebody has a vaginal birth or cesarean delivery, because the pelvis and the pelvic muscles have just gone through a lot. And so it takes some time for strength and sensation to recover.
But if by the time of a six week or certainly 12 week check-in, you're still having that leaking, you should mention it. I would say even sooner if you're having any fecal incontinence, of stool incontinence, or fleetest, or what we call gas incontinence. So if you're leaking stool or gas, you should let your provider know sooner.
The other symptoms I think about are in addition to pain or leaking, I think about a pressure sensation, or people will describe a heaviness in the vagina. or certainly if you feel any tissue bulging out that didn't used to bulge out, that's a classic symptom. That's the definition of prolapse, and so that deserves a dedicated exam as well. Oftentimes, over the first few weeks to months after delivery, it all resolves, but sometimes it doesn't. And so you want to be proactive.
Georgie Kovacs Let’s talk about induction and why someone may need to be induced.
Dr Holly Cummings: We think about pregnancy as a natural process, and eventually at some point, your body will go into labor on its own. The issue arises if there are reasons that it would be better to deliver to not wait for the body to do it on its own.
Historically, it was done for three major reasons, it was to identify three big problems.
Preeclampsia (blood pressure problems). What people knew, even hundreds of years ago, could be what was termed toxemia of pregnancy. So you know, everything seemed to be fine. And then somebody got really puffy. They couldn't measure blood pressure centuries ago, but horrible things like seizures could happen, you know, obviously, not good outcomes. And we now know that that's a process called preeclampsia.
Diabetes. So hundreds of years ago, you couldn't check your, you know, prick your finger and check the sugar in your blood. But people knew that if somebody had sweet tasting or sweet smelling urine, it was a sign that there was too much sugar in the system, and that could cause pregnancy problems.
Stillbirth. This is not something that obviously, it's sort of the most tragic thing that can happen. And it's something that we want to prevent if we can. We know that if somebody stays pregnant on their own, for as long as possible, yes, eventually the body will go into labor, but bad things could happen along the way.
Georgie Kovacs: When should medical intervention occur in pregnancy to get the baby out? Tell us about the concerns in being overdue.
Dr. Holly Cummings: And so we want to be judicious about making sure that those bad things don't happen without intervening too much. And so, you know, in the absence of a medical problem in either the pregnant patient or the fetus, we generally don't necessarily recommend induction without, you know, a good reason or conversation with your care provider.
One of those reasons is being overdue. Yes, eventually your body will go into labor, but the longer you stay pregnant past your due date, unfortunately, the risk of stillbirth can go up. And so that's probably the most common reason that people may be having the conversation with their care providers about should I be induced and why and when?
There is an increasing frequency to induce patients at 39 weeks, or at least talk about inducing people at 39 weeks sort of what we call electively. And this came out of a study that was done here in the United States a few years ago at multiple medical centers called the ARRIVE Trial. And what it showed was that if you induce patients who otherwise didn't have medical problems, if you induce them at 39 weeks, they had lower rates of C-section and lower rates of a few other outcomes like preeclampsia and stillbirth. Then if you let the patient stay pregnant and wait till they went into labor on their own, historically, we tried not to induce people, again, if there wasn't a good reason, because we worried that the process of inducing them could increase the C-section rate. And so what this study showed is that that's not true. So it did not increase the C-section rate if you were induced. And so it has sort of given us the permission to say, if you would like to be induced, we know that this is probably not harmful to you.
I can't speak for all OB GYN in the country, but I can say that when I talk to my own patients, I don't talk to them about induction at 39 weeks as a way of decreasi