The Postpartum Exam: Q&A with Dr. Suetsugu
/Dr. Tracee Suetsugu, a Honolulu-based OBGYN, shares with us what happens at the postpartum follow up exam and why it’s important to go. She says the transition from pregnancy to motherhood in that first month is one of the toughest things women go through. I think it’s safe to say that most of us would agree.
Check out our conversation below, where Dr. Suetsugu talks about everything from when to go to your postpartum visit, contraception, breastfeeding, depression, the pelvic exam, and how her personal observations enrich her practice.
WHEN TO GO
When should women go to their postpartum checkup? Is it the same for all women or does it matter if you had a C-section or vaginal delivery?
Dr. S: So it does matter how you delivered and complications surrounding your pregnancy and delivery. If it’s a normal delivery without complications, then the 6-week check is all that’s necessary. If you had a C-section we’d want to see you in 1-2 weeks mainly to check the incision and to make sure everything is healing okay. If you have high blood pressure, we’d want to see you within the week you go home. If we’re worried about high risk of postpartum depression we’d want to see you right away.
If a woman wants to check in before the 6-week followup, is that okay?
Dr. S: There are certain insurance companies that require you to have a big reason but I think difficulties with breastfeeding or worries about postpartum depression are reasons enough to be seen sooner. Different areas treat things differently but I don’t know how much of that is based on insurance coverage.
We have to make sure that if they had any tears that they are healing well, that the cervix looks okay, and that the uterus is returning to normal size.
THE CHECK UP: AN OVERVIEW
Can you tell me what a typical checkup is like?
Dr. S: Well there are certain things that we do for everyone during that 6-week postpartum follow up. One being some sort of depression screening because postpartum depression is a problem and we want to make sure we are able to help our patients who might be experiencing some issues with that. So, for my office we do a standardized depression screening, which is a series of questions like, “Have you felt down?” “Do you feel like things are getting on top of you?” “Do you feel like you’re crying most of the time?” There’s even a question on there, “Have you ever thought of hurting yourself?” And it’s a standardized depression scale. So if numbers are high then we know that we need to get that person in to see a behavioral specialist as soon as possible.
Usually, we’ll talk about breastfeeding, contraception, sleep. We also make sure mom is taking care of herself, which I know if tough and if she’s going to the bathroom okay. Most people will have vaginal bleeding and it can be up to a month postpartum and even longer, and we want to make sure that it’s progressing as it should. And then we usually will do a pelvic exam, which is tough for some women. We have to make sure that if they had any tears that they’re healing well, that the cervix looks okay, and that the uterus is returning to normal size. At 6 weeks postpartum the uterus should be close to pre-pregnancy size.
During this visit when something is not quite right, what happens next for these women?
Dr. S: It depends on the problem. Usually, we try to refer the women to the appropriate people. So if we’re worried about postpartum depression we’d refer her to a behavioral health specialist who can see her. A lot of people refuse, and in that case I have a lot of patients come back at pretty frequent intervals just to make sure that things are getting better, to make sure they have a safety plan, and if they ever have feelings of being so overwhelmed that they feel like hurting themselves, that they have a plan in place to take care of that. For incontinence issues, they’ll have close follow up with their OBGYN just to see if it gets better, and if not then a referral either to a urogynecologist or a pelvic physical therapist.
ANXIETY AROUND THE PELVIC EXAM
For me that aspect of the exam was the most anxiety provoking because I had a third degree tears. Do you find that aspect of the exam is also difficult for your patients? And do they ever vocalize that they feel anxious about the pelvic exam?
Dr. S: I think a lot of women feel anxious about the pelvic exam regardless of the circumstances. I think it’s important for patients to tell the doc if they’re really anxious, worried or having pain prior to the exam. But most likely you’re still going to have to have the exam, especially if you’re having pain to make sure everything is as it should be.
You mentioned the term “pelvic rest.” What does that mean exactly?
Dr. S: So usually what I tell my patients is nothing in the vagina for 6 weeks. So no ocean, no pool, not even really sitting in a bath tub. Mainly for infection control, especially ocean and the pool. The cervix was just opened to the uterus and most people have tears even if they’re small we want to make sure they heal well and don’t get infected or disturbed.
FAMILY PLANNING & CONTRACEPTION
I was floored when my doctor talked about family planning so early on, partly because I wasn’t ready for anything to go in “down there,” which I know isn’t always the case for others. I also thought breastfeeding would have contraceptive effects.
Dr. S: I’ve seen people get pregnant in that first month, even though they’re supposed to be on pelvic rest for those first 6 weeks. I’ve seen patients get pregnant very very quickly after. If you aren’t exclusively breastfeeding, then that breastfeeding protection isn’t there and you may not have regular periods and so people may think they’re protected. If a patient is exclusively breastfeeding and has no menses, they have contraception protection for up to 6 months.
Ideally you want 18 months between pregnancies for the body to heal, but the biggest thing is talking to the patient about what their plans are for having children so that they’re not overwhelmed with two kids under the age of two. It’s not something that’s on anybody’s mind so it’s our job to bring it up and talk about it. The main goal is to make sure women have children when they’re ready to have children.
I've seen people get pregnant in that first month, even though they're supposed to be on pelvic rest for those 6 weeks.
ON FEEDING
Dr. S: It’s definitely really important to check up and make sure all aspects of mom are well, and that mom is receiving breastfeeding support to take care of the baby. Sometimes it’s even letting the mom know that if she has to supplement if baby isn’t growing or for other reasons that it’s okay. I know there’s a lot of anxiety among moms feeling like failures if they can’t exclusively breastfeed their baby, but that there are reasons to supplement, that it’s okay.
BEYOND THE CHECK-UP
Is there anything else about the 6-week checkup that you’d want other people to know?
Dr. S: If they had gestational diabetes they may want to do another glucose challenge test to make sure they don’t have diabetes when they’re not pregnant. We want to make sure they’re not diabetic outside of pregnancy.
Is it standard for those who’ve had gestational diabetes to do the test at the 6-week mark?
Dr. S: It’s usually 6-8 weeks when they’ll want to do the follow up test and it’s something that should be done. The effects of pregnancy can last that long so if at 8 weeks they test positive, then it’s probably more than just from the pregnancy. For a lot of women who have diabetes during pregnancy, once they deliver their baby they don’t have to worry about it too much, so the test gets forgotten or they have better things to do like take care of their babies.
Has your personal life experience impacted your practice?
Dr. S: I’ve had a few close friends go through pregnancy and give birth in the last two years, and that’s helped my practice a lot. I think I’ve gained more empathy for my patients. Having people tell me the everyday problems definitely makes me check in on my moms a little more. I think that every time someone shares their personal experience it helps me as a doctor, since I haven’t had children…I appreciate when my patients share because it helps me take care of the next patient who may be going through similar challenges.
I appreciate when my patients share because it helps me take care of the next patient who may be going through similar challenges.
**Medical disclaimer: This interview is provided as an information resource only, and is not to be used or relied on for any diagnostic or treatment purposes. This information should not be used as a substitute for professional diagnosis, treatment, or advice. Always seek the guidance of your physician or other qualified health care provider with any questions you may have regarding your postpartum care and conditions.
I looked at my vagina for the first time since giving birth the week before my 6-week postpartum checkup.
I'm so glad I did.
I won’t lie, this scared me a little. I had a third degree tear and many stitches along my perineum. They eventually dissolved but turned into bumpy granulation tissue. When I touched my perineum during showers, it felt swollen, tight, and irritated.