By reaching out earlier and providing care that’s personalized to parents’ needs, Kaiser Permanente helps ease the “fourth trimester,” a time of intense change.
After a difficult pregnancy, Marivic Uytengsu was excited and relieved to give birth to a healthy baby girl in March 2021 at Kaiser Permanente Antioch Medical Center in Northern California.
Uytengsu had struggled with nausea and vomiting throughout her first trimester, twice needing intravenous fluids for dehydration. In her third trimester, she developed pain and numbness in her hands from carpal tunnel syndrome, a common issue in pregnancy.
The 29-year-old was looking forward to bonding with her daughter, Angelique. But there were more challenges ahead. Still coping with carpal tunnel syndrome, Uytengsu struggled to position the baby for breastfeeding.
“I wanted to breastfeed because I know it’s healthy for the baby, but she couldn’t latch on, and it was really hard,” she said. “We were home alone all day, and we were both struggling. When she would cry, I would cry.”
Uytengsu soon developed mastitis, an infection that can be caused by not fully emptying the breast, and noticed that her milk supply was decreasing.
Difficulty getting started with breastfeeding is one of many challenges parents may face in the 3 months after the birth of a child, a period sometimes referred to as the “fourth trimester.” It’s a time of intense physical, social, and emotional change.
“Even if you had a relatively easy birth, you’re dealing with physical changes as your body recovers,” said Kari Carlson, MD, chair of obstetrics and gynecology and director of women’s health for Kaiser Permanente in Northern California. “You’re also going through the transition of bringing a new baby home. Add to that the worries and stresses all parents experience, plus sleep deprivation, and it can be a difficult time.”
“We were home alone all day, and we were both struggling. When she would cry, I would cry.”
Recognizing how challenging the fourth trimester can be, the American College of Obstetricians and Gynecologists published new guidance on postpartum care in 2018, redefining it as “an ongoing process, rather than a single encounter, with services and support tailored to each woman’s individual needs.” The guidance recommends that women have contact with their care providers within 3 weeks after birth and a comprehensive postpartum visit by 12 weeks.
At Kaiser Permanente, efforts to better meet the needs of moms and newborns were already underway. In 2017, Kaiser Permanente pioneered a “couplet care” model in Hawaii, combining postpartum checkups for mom and baby.
“We were already seeing newborns 1 to 3 days after they left the hospital,” explained Mabel Wong, MD, chief of obstetrics and gynecology. “But most moms weren’t being seen for 4 weeks. Since most moms were bringing their babies to the first appointment, we decided that was an ideal time to check in on mom as well as baby.”
Today, moms and babies are seen at the Mom Newborn Center on Oahu 1 to 3 days after discharge. Women are checked for high blood pressure, a leading cause of maternal death in the postpartum period. Those who’ve had cesarean sections receive wound care. Certified lactation consultants help with breastfeeding.
The visit also includes a mental health and wellness assessment.
“The fourth trimester is a stressful time, so if there’s a risk of intimate partner violence, postpartum depression, or other struggles, that’s often when we see it,” Dr. Wong said.
When concerns are identified, clinicians at the Mom Newborn Center can seamlessly connect patients to higher-level care.
In Colorado and Georgia, Kaiser Permanente has used home visits to support new families. Maternal child health nurses travel to the patient’s home to examine mom and baby, help with breastfeeding, and address social and emotional concerns.
And in Northern California, Kaiser Permanente is piloting a range of options for keeping in closer contact with new moms — from post-discharge follow-up calls and emails to video and phone visits.
“Many of our moms tell us they prefer video visits, because they don’t have to pack up the baby or worry about exposure to COVID-19,” Dr. Carlson said. “For our clinicians, a video visit is a great way to get a more complete picture of how parents are doing because they can see their interactions with the baby and the rest of the family.”
For Uytengsu, a secure email exchange with Kimberly Klein, MD, was the turning point in her troubles.
A pediatrician and certified lactation consultant, Dr. Klein encouraged Uytengsu to use a breast pump to maintain and increase her milk supply — and to feed the milk to Angelique in a bottle.
Once her carpal tunnel syndrome improved, Uytengsu was able to get the baby to latch on using a breastfeeding position Dr. Klein demonstrated to her.
Now 5 months old, Angelique is breastfeeding exclusively, and her growth is right on track.
“I’m very happy and proud of myself for sticking with it,” said Uytengsu.
Find tips on the first few weeks at home with a new baby.