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.

At- or High-Risk Patients

1. Screen patients for postpartum risk factors:

• 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 and methods to address a positive screen within 2-5 days of discharge. 

• 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.

3. Clinicians should initiate the Plan of Safe Care with pregnant women and birthing people with an active substance use disorder, and with families of infants born exposed to substances, whether they require a report to Social Services or not.

4. Assess maternal status day of discharge and discuss with the healthcare 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.
• Blood pressure within normal range.
• Lab tests have been reviewed and within normal limits.
• FPCO, Postpartum Discharge Assessment

5. Include pathways in EMR that alert nurse/provider for reassessment/referral needs including hypertension, cumulative hemorrhage, sepsis, and thromboembolic disorders.

6. 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.

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

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.

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

Clinicians should initiate the Plan of Safe Care with pregnant women and birthing people with an active substance use disorder, and with families of infants born exposed to substances, whether they require a report to Social Services or not.

• Continue the outpatient plan of care or initiate a plan of care.
• Provide education to patients and families on the use of the PLan of Safe Care and treatment options.
• Increase nursing education on substance exposure reporting requirements.

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)

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.

Educate all patients/family on the importance of safe, stable, and nurturing relationships between parents/baby.

Educate all patients on normal/abnormal changes in the postpartum period using the Postpartum Discharge Handout:

• Micturition and urinary incontinence
• Bowel function
• Healing of perineal wound, pelvic floor, therapy/exercises
• Nerve changes/damage/tenderness along CS surgical incision
• Headache
• Fatigue
• Pain (Back, perineal, breast, incisional)
• Recovery and movement/OT
• Pillow splinting after surgery to relieve incisional pain
• Techniques for getting in/out of bed (rolling, pulling up legs)
• Pain management
• Perineal hygiene (peribottles, witch hazel, ice, etc.)
• Uterine tenderness and lochia
• Physical activity

Educate all patients on preventative measures for:

• Mastitis
• Constipation
• Peripartum infection
• Depression and anxiety
• Encourage patient to seek immediate attention if experiencing severe symptoms, including sleep disturbances, heightened irritability, confusion or feelings of being lost, difficulty communicating effectively, severe anxiety or agitation, rapid mood swings, obsessive thoughts about the baby, urges or impulses to harm self or baby, hallucinations, delusions, or unusual beliefs not based in reality
• Instruct patients to trust their instincts when they feel something is not right and reach out to a healthcare provider, or use emergency resources

Determine the patient’s social support circle/people, and include in education.

Discuss a plan for birth spacing/contraception.

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.

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.

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.

Complete the postpartum care plan and discuss with patients.

Provide all patients with a standardized discharge summary that highlights risk factors, complications or diagnoses, necessary follow-up, and health system contact information.

Share delivery and discharge information with the obstetrician, midwife, primary care provider, and/or specialists, including cardiology, care manager, etc.

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.

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

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

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

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

Schedule postpartum visits prior to discharge for patients who have experienced pregnancy and/or postpartum complications such as postpartum depression, hemorrhage, hypertension/preeclampsia, cesarean or perineal wound infection, depression, lactation difficulties, or seizure disorders needing medication titration.

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).