The clinical information presented is based on widely accepted principles and knowledge within the healthcare field, reflecting standard practices supported by clinical guidelines, peer-reviewed literature, and professional training.  Content derived from general clinical knowledge is not attributed to a single source but represents commonly taught and broadly recognized concepts in health care. 

 

We gratefully acknowledge the support of Merck for Mothers for funding this project to improve patient-centered outcomes. The content is the responsibility of the developers and does not necessarily represent the official views of Merck for Mothers.

 

Return to Caring for Postpartum Patients (Provider Resources)

Provider Resources for Postpartum Discharge by Topic

Resources for assessing, educating, and referring patients and families to provide quality care and improve outcomes.

All Patients

All Patients: Standardized Approach to Postpartum Assessment

Recommendation

1. Screen all patients for postpartum risk factors:

  • If risk identified, refer to Assessment – At-or High-Risk for additional recommendations.
  • Provide linkage to community services/resources prior to discharge.
  • Educate on the importance of timely follow-up with their OB and/or primary care provider for ongoing coordination of care.

2. Standardize mental health screening processes for all patients utilizing a validated tool.

  • Women and birthing people at risk for maternal mental health disorders include those who 1) may have exhibited depressive, anxiety or other mental health symptoms but scored below the cut-off for depressive or anxiety disorder on screening tests; 2) had previous episodes of depression or anxiety; or 3) have social risk factors such as low income, intimate partner violence, or being an adolescent.
  • Consider supportive measures for women who do not meet the threshold for treatment including mindfulness, sleep habits, and nutrition. Refer to Education - Changes, Preventative Measures, and Self-Care During Postpartum for additional information.

3. Assess maternal status day of discharge and discuss with the healthcare team if outside of normal range.

4. Discuss the appropriate level of maternity care facility for reassessment needs. Patients should return to the facility with OB/ED or OB Services to ensure the availability of an obstetrician/MFM specialist.

5. Screen for health-related social and community support needs.

 

Components

Risk factors

  • Medical
    • Hypertension
    • Heart disease
    • History of DVT or embolism
    • Sepsis
    • Hemorrhage
    • BMI <18 or >30
    • Maternal age <16 or >35
    • C-section/laceration (3rd/4th)
    • Substance use disorder
    • Smoking/alcohol
  • Social
    • Safety concerns
    • Food/housing insecurities
    • Lack of transportation
    • Adverse childhood/birthing experiences
    • Intimate partner violence
  • Mental health
    • Depression
    • Anxiety
    • Other mental health disorders

Maternal status day of discharge

  • Normal vital signs
  • Uterine involution and lochia are normal
  • Absence of signs and symptoms of wound or incisional infection
  • Urinary output appropriate
  • Ambulates without difficulty
  • Pain adequately controlled
  • Ability to void and pass gas
  • Ability to take fluids and food without difficulty

 

Examples of Tools

Washington State Prenatal Screening Tool

Florida Perinatal Quality Collaborative, Maternal Discharge Risk Assessment

FPCO, Postpartum Discharge Assessment

Illinois Perinatal Quality Collaborative, ILPQC Early Postpartum Visit: Maternal health safety checklist

Perinatal Mental Health Tools

All Patients: Standardized Approach to Postpartum Education

Recommendation

Provide standardized education for all patients, not just those with defined risk.

  • Integrate educational opportunities throughout the postpartum stay – educate during shift assessment.
  • Provide handout separately from other information or booklets (consider QR codes, a central hospital website, magnets/stickers, a tear-out sheet).
  • Instruct patients to recognize signs of potential complications and respond promptly.
  • Remind patients to tell all care providers about the date of birth.
  • Encourage self-advocacy.
  • Include a support system/family in education as much as possible.

Educate all patients on maternal mental health disorders (include support system/family as possible).

Educate all patients on normal changes and self-care elements. Refer to Changes, Preventative Measures, and Self-Care During Postpartum.

Download a three-page flyer of key points to cover with all patients at discharge. (PDF version or customizable Word version)

 

Components

Components of the Standardized Discharge Summary

  • Name and age
  • Support person contact information
  • Place of birth
  • Gravida/para status
  • Date and type of birth, gestational age at birth, relevant conditions, and complications
  • Date of admission, date of discharge
  • Name, contact information and appointments for relevant providers, including OB/GYN specialists, mental health provider, etc.
  • Positive screening for medical risk factors, mental health, and substance use
  • Medications and supplements
  • Unmet actual and potential social health needs
  • Suggested community services and supports
  • Need for specific postpartum testing, such as glucose testing or CBC

Postpartum Warning Signs

  • Chest pain or fast heartbeat
  • Trouble breathing
  • Thoughts of harming yourself or baby
  • Bleeding, soaking through one pad/hour or blood clots the size of an egg or bigger
  • Incision that is not healing (increased pain, redness, drainage, or pus)
  • Swelling, redness, or pain in legs
  • Temperature of 100.4 degrees F or higher, or 96.8 degrees F or lower
  • Headache that does not get better or bad headache with vision changes
  • Dizziness of fainting
  • Extreme swelling of hands or face
  • Severe abdominal pain
  • Foul smelling bleeding or discharge from the vagina or incision
  • Severe nausea and vomiting

 

Examples of Tools

AWHONN

AIM

Other Resources

All Patients: Standardized Approach to Postpartum Follow-Up

Recommendation

Schedule postpartum visits prior to discharge.

Women who have experienced miscarriage, stillbirth or neonatal death must be seen by obstetric provider:

  • Emotional support and bereavement counseling;
  • Referral to support groups;
  • Review of lab/pathology reports;
  • Counseling regarding recurrent risk and future pregnancy planning/contraception.

 

Components

Postpartum visits (low risk)

  • First postpartum contact between 2-5 days after discharge. Provide a home or virtual visit (phone and/or telehealth).
  • Postpartum care visit for 3 weeks post discharge with provider.
  • Schedule Postpartum to Primary Care Transition visit for patients with chronic conditions in 4-12 weeks post discharge.
  • Schedule specialty care visit as needed prior to discharge.
  • Discuss the importance of postpartum care and potential barriers.
  • Consider home visitation or telehealth before the first visit regardless of income, age, or location of residence.

 

Examples of Tools

ACOG

Return to Zero Hope (perinatal loss resources)

Health-Related Social Needs (Social Determinants of Health) Assessment

Recommendation

Conduct screening for Social Determinants of Health (SDoH) needs for all patients before hospital discharge.

 

Components

Social determinants of health:

  • Housing insecurity
  • Food insecurity
  • Access to transportation
  • Difficulty paying for prescriptions or medical bills
  • Family relationships
  • Education and literacy
  • Employment and work

 

Examples of Tools

TJC, TJC: National Performance Goal #4 High Quality Safe Care for All

ACOG, Sample Screening Tool

Maven, Social Determinants of Health Short Screener

AAFP, Social Needs Screening Tool

CMS, Screening Tool Core Questions

National Association of Community Health Centers, PRAPARE® Screening Tool (license agreement required)

Health Related Social Needs (Social Determinants of Health) Follow-Up

Recommendation

Utilize county/regional resources to address needs. Address ongoing health needs after birth.

 

Components

Enter maternal geographic-specific information into the Find Help website for free or reduced-cost resources like food, housing, financial assistance, healthcare and more. Additional mechanisms to assess health needs and provide support after discharge include:

  • Home visits (including Home Health, Public Health Nursing)
  • Phone calls
    • Postpartum nurses
    • Perinatal nurse navigator
  • App-based support
  • Community organizations
    • CHW/Promotora
  • Postpartum doulas

 

Examples of Tools

Find Help    

Blue Shield of California, Maven Maternity, Reproductive, and Family Health Programs

DHCS Doula Directory

Black Infant Health Programs

Adolescent Family Life Program

Cal-Learn

National Association of Community Health Centers, PRAPARE® Screening Tool (license agreement required)

At or High-Risk Population

At- or High-Risk Patients: Education

Recommendation

Educate patients on any ante-, intra-, or postpartum complications that increase their risk for adverse outcomes post-discharge (i.e. anemia, hypertension, diabetes, sepsis, DVT, etc.).

  • Integrate educational opportunities throughout the postpartum stay – educate during shift assessment
  • Provide handout separate from other information or booklets (consider QR codes, central hospital website, magnets/stickers, tear-out sheet)
  • Instruct patient to recognize signs of potential complications and respond promptly
  • Remember to tell all care providers about date of birth
  • Encourage self-advocacy
  • Include support system/family in education as much as possible

Educate patients at risk for cardiovascular disease (i.e. preterm birth, gestational diabetes or hypertension, preeclampsia/eclampsia) on the importance of ongoing follow-up due to increased risk later in life.

 

Components

Postpartum warning signs:

  • Chest pain or fast heartbeat
  • Trouble breathing
  • Thoughts of harming yourself or baby
  • Bleeding, soaking through one pad/hour or blood clots the size of an egg or bigger
  • Incision that is not healing
  • Swelling, redness, or pain in legs
  • Temperature of 100.4 degrees F or higher or 96.8 degrees F or lower
  • Headache that does not get better or bad headache with vision changes
  • Dizziness of fainting
  • Extreme swelling of hands or face
  • Severe abdominal pain
  • Severe nausea and vomiting

 

Examples of Tools

AWHONN

AIM

Other Resources

Preeclampsia Foundation

CMQCC

Maternal Mental Health

Maternal Mental Health Assessment

Recommendation

Women at risk for maternal mental health disorders include those who (1) may have exhibited depressive, anxiety or other mental health symptoms but scored below the cut-off for depressive or anxiety disorder on screening tests, (2) had previous episodes of depression or anxiety, or (3) have social risk factors such as low income, intimate partner violence or being an adolescent

Standardize mental health screening processes for all patients in postpartum prior to discharge and methods to address positive screen within 2-5 days of discharge

 

Components

  • Mental health
    • Depression
    • Anxiety
    • Other mental health disorders

Education for nurses on mental health disorders

 

Examples of Tools

Victoria State Department of Health, Edinburgh Postnatal Depression Scale (Multiple languages)

Orange County Health Care Agency, PHQ9

Massachusetts Child Psychiatry Access Program For Moms, Summary of Emotional Complications During Pregnancy and Postpartum

Maternal Mental Health Education

Recommendation

Educate all patients on maternal mental health disorders (include support system/family as possible).

Standardized treatment should begin before discharge for all patients with positive screen.

Utilize methods for addressing positive screens:

  • Automated referral process for nurses/social workers;
  • Immediate referral to a mental health clinician if screened as high-risk;
  • Development of protocols to address emergency situations, like suicidality.

Patients with mood disorders should be provided education on the importance of follow-up care.

 

Components

Maternal Mental Health Disorders

  • Depression, Anxiety, Childbirth Post-Traumatic Stress Disorder (CB-PTSD)

 

Examples of Tools

Orange County Health Care Agency (California), PMAD Treatment Pathway

Massachusetts Child Psychiatry Access Program For Moms, Summary of Emotional Complications During Pregnancy and Postpartum

National Maternal Mental Health Hotline (NMMHH), NMMHH Promotional Poster

Maternal Mental Health Now, Speak Up Brochure

ACOG, ACOG Lifeline for Moms

National Maternal Mental Health Hotline: 1-833-852-6262

Maternal Mental Health Follow-Up

Recommendation

Provide postpartum mental health resources and support

Standardized treatment should begin before discharge for all patients with positive screen

Utilize methods for addressing positive screens 

  • Automate referral process for nurse/social work
  • Immediate referral to mental health clinician if screened high-risk

All patients should have access to maternal mental health support classes

 

Components

Remind new parents to add the National Maternal Mental Health Hotline to their contact list.

  • Hotline is free, confidential, and available 24/7 to help new parents and loved ones. Call or text.

 

Examples of Tools

Orange County Health Care Agency (California), PMAD Treatment Pathway

National Mental Health Hotline

Peer Support – Sana Sana (Direct referral - LA County only)

Postpartum Health Alliance (San Diego)

Postpartum Support International

Hypertension in Pregnancy

Hypertension in Pregnancy Assessment

Recommendation

Assess maternal status on day of discharge and discuss with the health care team if outside of normal range.

  • Standardize nursing protocols and order sets to allow for additional lab assessments
  • Automatically cancels discharge order until further assessment conducted

Include pathways in EMR that alert nurse/provider for reassessment/referral needs for hypertension.

 

Components

Maternal status on day of discharge

  • Blood pressure within normal range
  • Lab tests have been reviewed and within normal limits

 

Examples of Tools

CMQCC, Improving Health Care Response to Hypertensive Disorders of Pregnancy Toolkit (2021, rev. 2024) (Scroll down to Toolkit)

Society for Maternal-Fetal Medicine, SMFM Checklist for Postpartum Discharge of Women with HPD

Hypertension in Pregnancy Education

Recommendation

Instruct patient to recognize signs of potential complications and respond promptly:

  • Remind patient to tell all care providers about date of birth
  • Encourage self-advocacy
  • Include support system/family in education as much as possible

Educate patients at risk for cardiovascular disease (i.e. preterm birth, gestational diabetes or hypertension, preeclampsia/eclampsia) on the importance of ongoing follow-up due to increased risk later in life.

Discuss the use of low-dose aspirin in subsequent pregnancies to prevent preeclampsia.

 

Components

Postpartum warning signs:

  • Headache that does not get better or bad headache with vision changes
  • Dizziness of fainting
  • Extreme swelling of hands or face
  • Severe abdominal pain

 

Examples of Tools

ACOG Heart Disease in Pregnancy or after Pregnancy Patient Education

Preeclampsia Foundation

CMQCC

Hypertension in Pregnancy Follow-Up

Recommendation

Schedule postpartum visits prior to discharge for patients who have experienced hypertension/preeclampsia.

 

Components

Follow up with OB or relevant specialist within 2-3 days.

Schedule all patients with diagnosed cardiac disorders or at-risk for atherosclerotic cardiovascular disease (ASCVD)--preterm birth, diabetes, hypertension, preeclampsia, and eclampsia--for appointments within 7 days with a cardiologist prior to discharge.

Educate patients at risk for cardiovascular disease (i.e. preterm birth, gestational diabetes or hypertension, preeclampsia/eclampsia) on the importance of ongoing follow-up, due to increased risk later in life.

Consider remote BP monitoring for women and birthing people with known preeclampsia and/or elevated BP during pregnancy/labor. 

  • Provide education on BP home monitoring
  • Provide BP cuff at discharge for home monitoring
  • Provide call number for reporting of BP results
  • Provide patient with Blue Band and/or wallet card for easy provider identification of preeclampsia risk
  • Provide emergency call number for hypertensive disorders of pregnancy warning signs and symptoms
  • Instruct patient to return for BP check in ED/OB Triage or with provider no later than 7-10 days (3-5 days if severe) if unable to be monitored at home

 

Examples of Tools

Preeclampsia Foundation

Preeclampsia awareness tools

Disability/Leave

Disability/Leave Education

Recommendation

Assess patient’s understanding of disability rights.

Educate patient/family on disability/parental leave options to support newborn bonding/rearing, recovery plans for postpartum, and chronic and mental health conditions.

Assist patients in obtaining required approvals and documentation needed to apply for benefits.

 

Components

Disability/Parental Leave

The following may be eligible for paid time off, job protection, and/or work-related accommodation:

  • Postpartum birthing person
  • Spouses/fathers
  • Foster parents
  • Adopting parents
  • LGBTQ+ parents
  • Families experiencing pregnancy loss
  • NICU families
  • Lactation

 

Examples of Tools

Postpartum Disability Leave Patient Education

Taking Leave from Work

Sample letters (Search by Resource Type > Sample Letters)

Disability and Extended Disability

Accommodations for Pregnancy, Childbirth, and Lactation

Medi-Cal Services

Services for Medi-Cal Members Follow-Up

Recommendation

Guidance from DHCS

All Medi‑Cal members enrolled in a managed care plan (MCP) are eligible to receive Transitional Care Services (TCS) when they transfer between care settings, such as after a hospital discharge. For members who are pregnant, TCS is provided throughout pregnancy and after the end of pregnancy, regardless of how, or where, that pregnancy ends, until members are connected to all needed services and supports. This includes:

  1. Care coordination of appointments and follow-up visits for birthing Medi-Cal member and infant.
  2. Obtaining medications and medical supplies (medication reconciliation).
  3. Completion of all tasks in the discharge instructions. 
  4. Referrals to an array of services, including doula services, WIC, lactation supports, CalFresh, paid family leave, home visiting, transportation services, and other needs, as specified in the Birthing Supports Checklist (below).

 

Components

TCS is provided to all Medi‑Cal members any time they move from one place or level of care to another. When a member is admitted, discharged or transferred, the MCP determines what level of support is needed and works with the care team to review the discharge plan, arrange timely follow-up, and help the member get connected to care.

For pregnant and postpartum members, TCS is provided for any transition of care during pregnancy and through 12 months postpartum. Transitional care events include both hospital discharge events and the end of pregnancy, regardless of how, or where, that pregnancy ends. The completion of the TCS Birthing Supports Checklist is required for every pregnant and postpartum member. 

TCS Birthing Supports Checklist

The TCS Birthing Supports Checklist helps make sure every pregnant or postpartum member gets connected to the medical, behavioral health, and whole-person supports they need. The MCP’s care team will help arrange referrals and/or warm hand-offs based on the member’s needs and preferences:

  • Medical Supports

    • Perinatal/postpartum visits according to the American College of Obstetricians and Gynecologists (ACOG)/United States Preventive Services Task Force (USPSTF) guidelines

      • Validated behavioral health screenings

      • Intimate partner violence (IPV) screening using evidence-based tool

      • Reproductive life planning

    • Pediatric visits according to the American Academy of Pediatrics (AAP) Bright Futures schedule through two-month well-child visit

    • Other follow-up visits recommended by a provider or included in the discharge summary/instructions

    • Primary care provider visit scheduled (if no visit scheduled within the past one year)

  • Whole-Person Needs
    • Food, Nutrition Education, and Breastfeeding Supports
      • Women, Infants, and Children (WIC)
      • CalFresh
      • Lactation services
    • Managed Care Plan (MCP) Benefits
      • Transportation services
      • Doula services
      • Appointment assistance
      • Breast pumps
      • Enhanced care management (ECM)**
      • Community supports**
      • Community Health Worker (CHW) services 
    • Family Support Services
      • Paid Family Leave (PFL)
      • Home visiting^
      • Parenting resources§
    • Infant Support
      • Health insurance for infants
      • WIC (including infant formula)
  • Behavioral Health Needs (This includes access to culturally and linguistically aligned services and supports, consistent with Medi-Cal policy.)

    • Behavioral health supports (e.g., Non-Specialty Mental Health Services (NSMHS), Specialty Mental Health Services (SMHS), Drug Medi-Cal Organized Delivery System (DMC-ODS), Drug Medi-Cal (DMC))

    • Dyadic services

**DHCS’ Closed Loop Referral (CLR) policy requires MCPs to close the loop for Enhanced Care Management (ECM) and Community Supports services.

^Home visiting services include (but are not limited to) California Department of Public Health (CDPH) California Home Visiting Program (CHVP), California Department of Social Services (CDSS) California Work Opportunity and Responsibility to Kids Home Visiting Program (CalWORKs HVP), American Indian Maternal Support Services (AIMSS), and county First 5s, as eligible.

§Parenting resources include (but are not limited to) Home Visiting services, MCP educational information, First 5, and Black Infant Health.

 

Hospital's Role

  1. Notify the MCP of any admission, discharge, or transfer for a managed care Medi-Cal member so that the MCP can initiate TCS. Admissions/discharges/transfers refer to both delivery and non-delivery events. MCPs are required to have a dedicated TCS call-line, so work with the MCPs in your geographical area to understand workflows.
  2. The member’s MCP should provide the member’s point of contact information for inclusion in the discharge packet. Encourage the member to reach out to their plan for help with follow‑up care and services.
  3. Notify the MCP when a pregnant member is identified, so the MCP can initiate TCS. 
  4. Hospitals can help link members to services on the TCS Birthing Supports Checklist, such as lactation support, home visiting, breast pumps, Paid Family Leave (PFL) forms, infant Medi-Cal enrollment through Newborn Gateway, coordination of follow-up appointments, and social needs screenings. Hospitals should coordinate with MCPs or the primary maternity clinic to ensure members are connected to needed supports.

 

Examples of Tools