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 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

• Women presenting in the postpartum period most commonly seek care within 3 weeks of delivery.

• Postpartum presentations requiring admission most frequently occur within 2 weeks of delivery.

• The most common diagnoses on presentation were hypentension, vaginal bleeding, and wound infections.

Keywords

postpartum - fourth trimester - emergency room - readmission

Publication History

Received: 05 August 2020

Accepted: 16 August 2020

Article published online:
29 September 2020

• References

• 1 ACOG Committee Opinion No. ACOG committee opinion no. 736: optimizing postpartum care. Obstet Gynecol 2018; 131 (05) e140-e150
• 2 Tully KP, Stuebe AM, Verbiest SB. The fourth trimester: a critical transition period with unmet maternal health needs. Am J Obstet Gynecol 2017; 217 (01) 37-41
• 3 Thompson JF, Roberts CL, Currie M, Ellwood DA. Prevalence and persistence of health problems after childbirth: associations with parity and method of birth. Birth 2002; 29 (02) 83-94
• 4 Brousseau EC, Danilack V, Cai F, Matteson KA. Emergency department visits for postpartum complications. J Womens Health (Larchmt) 2018; 27 (03) 253-257
• 5 Clark SL, Belfort MA, Dildy GA. et al. Emergency department use during the postpartum period: implications for current management of the puerperium. Am J Obstet Gynecol 2010; 203 (01) 38.e1-38.e6
• 6 Vikström A, Johansson SE, Barimani M. Postnatal ER visits within 30 days-pattern, risk factors and implications for care. J Clin Nurs 2018; 27 (3-4): 769-776
• 7 Clapp MA, Little SE, Zheng J, Robinson JN. A multi-state analysis of postpartum readmissions in the United States. Am J Obstet Gynecol 2016; 215 (01) 113.e1-113.e10
• 8 Aziz A, Gyamfi-Bannerman C, Siddiq Z. et al. Maternal outcomes by race during postpartum readmissions. Am J Obstet Gynecol 2019; 220 (05) 484.e1-484.e10
• 9 Harris A, Chang HY, Wang L. et al. Emergency room utilization after medically complicated pregnancies: a medicaid claims analysis. J Womens Health (Larchmt) 2015; 24 (09) 745-754
• 10 Smid MC, Kearney MS, Stamilio DM. Extreme obesity and postcesarean wound complications in the maternal-fetal medicine unit cesarean registry. Am J Perinatol 2015; 32 (14) 1336-1341
• 11 Ananth CV, Friedman AM, Keyes KM, Lavery JA, Hamilton A, Wright JD. Primary and repeat cesarean deliveries: a population-based study in the United States, 1979-2010. Epidemiology 2017; 28 (04) 567-574
• 12 Aoyama K, Pinto R, Ray JG. et al. Association of maternal age with severe maternal morbidity and mortality in Canada. JAMA Netw Open 2019; 2 (08) e199875
• 13 Admon LK, Winkelman TNA, Zivin K, Terplan M, Mhyre JM, Dalton VK. Racial and ethnic disparities in the incidence of severe maternal morbidity in the United States, 2012–2015. Obstet Gynecol 2018; 132 (05) 1158-1166
• 14 Gordon SH, Sommers BD, Wilson IB, Trivedi AN. Effects of medicaid expansion on postpartum coverage and outpatient utilization. Health Aff (Millwood) 2020; 39 (01) 77-84