When to Refer Your Pregnant or Postpartum Client to Another Professional

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When working with pregnant and postpartum clients, remember that you are just one member of their healthcare team.

Your clients will be working with several health professionals throughout their pre- and postnatal experience including some or all of the following:

• General practitioner
• Obstetrician-Gynecologist
• Midwife
• Pelvic health physiotherapist
• Doula
• Registered dietitian
• Mental health professional
• Chiropractor
• Massage therapist
• Acupuncturist
• Urologist or urogynecologist

However, you’re in a unique position that allows you to spend a lot of time working with your clients, educating them about their bodies during the prenatal and postpartum periods.

Because you will likely spend more time with a client than any other member of her healthcare team, you will have many opportunities to ask how things are going, how she’s feeling, and how certain exercises make her body feel. You may be the first to hear about any pain, discomfort, or unusual symptoms. As her coach it’s important that you understand what is within and beyond your scope of practice, and to whom you could refer her for additional help.

You can ensure your pre- and postnatal clients get the best care possible by working closely with other members of their team and recommending they work with particular healthcare professionals if they are not already doing so.

Let’s take a closer look at the professionals who may be part of your client’s healthcare team.

Prenatal Care Providers

Your pregnant client will be seeing one or more of the following prenatal care providers, and it’s important for you to know what credentials and education each provider has, their role, and their scope of practice. In most cases, which provider your client works with is largely up to her. She may choose to see her family doctor for as long as possible, or she may begin a relationship with an OB-GYN, certified midwife, or nurse practitioner immediately.

Your client typically has the following options when deciding on a prenatal care provider:

• General practitioner or family physician
• Nurse practitioner
• Obstetrician-Gynecologist (OB-GYN)
• Midwife

General Practitioner

Most women see a general practitioner (GP) or family doctor for their general health concerns. Of the three medical practitioners involved in childbirth (GP, OB-GYN, and midwife), your client is probably most familiar with the GP. However, many GPs in the U.S. don’t provide pregnancy, labor, and delivery services. If that’s the case, your client may choose to switch to another medical doctor specializing in pregnancy or childbirth.

Obstetrician Gynecologist

A obstetrician-gynecologist (OB-GYN) specializes in female reproductive health organs and has completed four to five years of additional medical training in this specialty after obtaining their medical degree. An OB-GYN normally handles high-risk births and is trained to perform C-section births. The majority of women in the U.S. see this practitioner throughout their pregnancy. A perinatal specialist is an OB-GYN who specializes in high-risk pregnancies; they typically deal with more complicated issues, may often act as a consultant, and may also be present during childbirth.

Midwife

A midwife is a specialist in childbirth, postpartum, and well-woman healthcare services such as annual screenings, labs, and immunizations. If a pregnant woman requires care beyond the midwife’s scope of practice, the midwife will refer her to an OB-GYN, or a perinatologist if she has pregnancy-related complications.

There are several certifying bodies in the U.S., but the American Midwifery Certification Board (AMCB) is considered the gold standard. Within the AMCB, there are two types of midwives: a certified nurse-midwife (CNM) and a certified midwife (CM).

Certified nurse-midwives provide initial and ongoing comprehensive assessment, diagnosis, and treatment. CNMs perform physical examinations. They can also prescribe medications and contraceptives. They can admit and discharge patients as well as order and interpret laboratory and diagnostic tests. Medicaid reimbursement for CNMs is mandatory in all states, and most states mandate private insurance reimbursement. Your client will need to contact her insurance provider to determine what coverage she receives.

CNM services include:

• Primary care
• Gynecologic and family planning services
• Preconception care
• Care during pregnancy, childbirth, and the postpartum period
• Care of a healthy newborn during the first 28 days of life
• Treatment of male partners for sexually transmitted infections

To find a licenced midwife in the U.S., your client can go to the American College of Nurse Midwives website where she can search for a midwife. In Canada, she can search the Canadian Association of Midwives. In the U.K., midwives are often provided by the National Health Service, however there are independent midwife organizations such as Independent Midwives UK. In Australia, midwives are often provided as part of the national healthcare system.

Pelvic Health Physiotherapist

In addition to her prenatal care provider, your client may also be working with a pelvic health physiotherapist during and after her pregnancy. During pregnancy, a pelvic health physiotherapist can assist with any musculoskeletal pain, provide manual therapy and therapeutic exercise, review labor and delivery positions, work on breathing, and assess her pelvic floor for optimal function and support.

In the postpartum phase the physiotherapist will be able to assess your client’s pelvic floor muscles vaginally and rectally to identify any dysfunction such as incontinence (urinary or fecal), pelvic organ prolapse (POP), diastasis recti, or pelvic pain. They can also review any musculoskeletal dysfunction present such as neck or low back pain, pelvic girdle pain due to sacroiliac joint dysfunction or pubic symphysis dysfunction, hip pain, and tailbone pain.

We highly recommend that your pregnant and postpartum clients work with a pelvic health physiotherapist if they are not already doing so. Their input is important since they are the ones educated and qualified in screening for and identifying a number of symptoms of conditions that even doctors are not aware of.

Other Professionals Who May Be Involved in Pre- and Postnatal Care

If you’re referring your client to any of the following professionals, and the client wants to use insurance, make sure she understands that she may first need to obtain a referral from a doctor, and some office visits and treatments may not be covered by insurance at all. Advise her to check her coverage and referral requirements for the specific practitioner or service before making an appointment.

Doula or Birthing Coach

A doula, also known as a birth companion or post-birth supporter, is a non-medical assistant who helps women before, during, and after childbirth as needed. Doulas provide physical and emotional support to the entire family, not just the mother and newborn infant. Research suggests that a doula’s support during labor and childbirth often results in less need for pain relief and improved maternal and fetal health. They may offer ongoing support to a family for several years.

A doula’s role can include helping educate the mother on her choices for birth (like opting between a birthing center or hospital, a water birth or home birth, epidural or not, etc.), helping define baseline goals (i.e., “it is important to me that my baby be given to me immediately for skin-to-skin contact”), in-the-moment coaching for the partner or loved one in how to support and assist the laboring mother, employing techniques for pain relief and stress management, guiding the birthing woman to advocate for herself, offering support and guidance for establishing lactation, etc.

Mental Health Professional

Clinical psychologists and psychiatrists are who most people think of as mental health professionals, but many other professionals provide therapy or counseling including: clinical social workers, therapists, nurse psychotherapists, counselors (licensed professional counselors, mental health counselors, certified alcohol and drug abuse counselors, and pastoral counselors).

Your client may find it helpful to work with one of these mental health professionals. Generally only psychiatrists can prescribe medications, though in some locations psychologists can also prescribe medication.

Registered Dietitian or Nutritionist

A registered dietitian is a nutritionist (though one can be a nutritionist without being a registered dietitian). Both registered dietitians and nutritionists can provide your client with helpful nutrition information, but by law only registered dietitians (called RD or RDN) can provide medical nutritional therapy.

Chiropractor

Graduates of chiropractic schools receive the degree Doctor of Chiropractic (DC). Chiropractors treat issues with the musculoskeletal system using mainly manual therapy or manipulation therapy of the joints (primarily the spine).

Massage Therapist

Registered or licensed massage therapists work on soft tissues in the body (muscle, fascia, tendons, and ligaments) by stroking, kneading, or applying pressure to improve function. There are many different kinds of therapeutic massage treatments.

Acupuncturist

Acupuncturists are trained in a form of traditional Chinese medicine (TCM) called acupuncture, a system of complementary medicine that involves pricking the skin or tissues with needles. It’s commonly used to alleviate pain and to treat various physical, mental, and emotional conditions.

Anecdotally, many pregnant women have reported decreased nausea, pain, anxiety, and fatigue when receiving regular acupuncture treatments. That said, while a 2014 systematic review of acupuncture during pregnancy shows that it is very safe when correctly performed, the review doesn’t discuss any direct benefits.

If your client decides to try acupuncture, strongly encourage her to work with an acupuncturist who is licensed (requirements vary depending on the geographical location) and has experience working with pregnant women. She should make sure the practitioner knows she is pregnant.

To Whom Should You Refer Your Client?

If you’re not sure who is on a client’s prenatal healthcare team, it may be best to first refer her to her primary prenatal healthcare provider. The following guidelines can help you determine when a client’s symptoms warrant a referral and to whom you should refer them.

Pelvic Girdle Pain During Exercise

Within your scope: No.

What you should do: Provide modifications or variations for that exercise. If there is no relief, refer.

To whom should client be referred: Pelvic health physiotherapist or musculoskeletal physiotherapist experienced with pregnancy-related issues.

Who should refer the client: In many areas, you can refer your client directly to a trusted physiotherapist in your referral network. However, their services may or may not be covered by insurance without a doctor’s referral.

Leaking Urine During Exercise

Within your scope: No.

What you should do: Provide modifications or variations for that exercise so that leaking does not occur. Avoid any movement or exercise that cause incontinence. The fact that leaking occurs at all is reason enough to believe there is some degree of pelvic floor dysfunction and thus, refer.

To whom should client be referred: Urogynecologist or pelvic health physiotherapist.

Who should refer the client: In most cases, you can refer your client directly to a trusted pelvic health physiotherapist in your referral network. In some cases, a doctor’s referral may be required. Referrals to urogynecologist must be made by hospital-based physicians, family practitioners, or specialists.

Muscle Tension

Within your scope: Not unless you are licensed to perform soft tissue work.

What you should do: Teach your client how to do self-administered soft tissue work such as foam rolling and using a stick or lacrosse ball. If this doesn’t relieve tension, refer.

To whom should client be referred: Massage therapist.

Who should refer the client: You can refer your client directly to a trusted massage therapist in  your referral network. Some massage therapist accept insurance. Advise your client to find out if she will need a doctor’s referral for massage in order to have it covered by her insurance.

Depression or Mood Swings

Within your scope: Not unless you are licensed to perform soft tissue work.

What you should do: If your client seems to exhibit depression or mood swings for longer than two weeks, or if she reports irritability, a change in appetite, or changes in her sleeping patterns, you should ask her how she’s feeling and encourage her to seek help from a professional.

To whom should client be referred: Mental health professional. Advise your client to also mention these symptoms to her primary care physician or seek help from an integrative medicine doctor who specializes in thyroid disease. Thyroid dysfunction or postpartum thyroiditis can contribute to anxiety or depression, and the client may need to start medication or have her dose adjusted during or after pregnancy.

Who should refer the client: In most cases, you can refer your client directly to a trusted mental health professional in your referral network who specializes in issues related to pregnancy and postpartum. In some cases, a doctor’s referral may be required. However, unless you have a great relationship with a mental health professional who specializes in these issues, it’s probably best to that your client obtain a referral from her OB-GYN, who can screen for mental health concerns and refer to a mental health professional specializing in mental health issues related to pregnancy and postpartum if necessary.

Gestational Diabetes

Within your scope: Not unless you’re an exercise physiologist.

What you should do: Ask if the doctor who diagnosed her referred her to a professional to manage the condition.

To whom should client be referred: Registered dietitian, exercise physiologist with a master’s or doctoral-level degree, or a licensed healthcare professional with graduate training in exercise physiology.

Who should refer the client: If the doctor who diagnosed her hasn’t referred her to a registered dietitian, you can suggest she ask for a referral. Her doctor should also be able to refer her to an exercise physiologist.

Pelvic Organ Prolapse

Within your scope: Not unless you’re an exercise physiologist.

What you should do: Modify programming and make sure your client is breathing properly to avoid excess intra-abdominal pressure (the valsalva maneuver). You can work in collaboration with a pelvic health physiotherapist for modifications if needed.

To whom should client be referred: Pelvic health physiotherapist.

Who should refer the client: In most cases, you can refer your client to a trusted pelvic health physiotherapist in your referral network. In some cases a doctor’s referral may be required.

Musculoskeletal Concerns and Injuries

These may include neck pain and headaches, upper back or rib pain, carpal tunnel syndrome, low back pain or pelvic girdle pain (SI joints or pubic symphysis dysfunction), and hip pain.

Within your scope: Not unless you’re an exercise physiologist.

What you should do: Modify programming as needed.

To whom should client be referred: Musculoskeletal physiotherapist experienced with pregnancy-related issues, or pelvic health physiotherapist.

Who should refer the client: In most cases, you can refer your client directly to a trusted nurse practitioner, gynecologist, physical therapist, or primary healthcare provider in your referral network who may then refer her to a physical therapist.

In the end, having an extensive and varied network of trusted wellness professionals not only helps your clients get the complete care they need, but also places you as a responsible and serious professional with connections and an extensive network; this increases your credibility and value as a fitness pro, and the learning opportunities that will come from working hand-in-hand with other health professionals will positively impact your practices and business in ways that will surprise you.

References

Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2012 Oct 17;10:CD003766.

Park J, Sohn Y, White AR, Lee H. The safety of acupuncture during pregnancy: a systematic review. Acupunct Med. 2014 Jun;32(3):257–66.

Types of Mental Health Professionals. Mental Health America. 2013 [cited 2017 Jun 30]. http://www.mentalhealthamerica.net/types-mental-health-professionals

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