Postnatal Care

Key Recommendations

• Individualised postnatal care plan developed before discharge
• Minimum contacts: within 36 hours of birth, then at least 3 further contacts in the first 8 weeks
• Comprehensive assessment at each contact: maternal physical, emotional, and social wellbeing

Routine Postnatal Observations

Maternal

• Temperature, pulse, blood pressure
• Uterine involution (fundus should be non-palpable by 2 weeks)
• Lochia: assess amount, colour, odour (foul-smelling = infection)
• Perineal wound or caesarean wound assessment
• Breast examination if breastfeeding concerns
• Urinary and bowel function
• Emotional wellbeing and bonding
• VTE risk assessment

Warning Signs (Red Flags)

• Sudden or profuse vaginal bleeding / persistent heavy lochia
• Pyrexia >38C, rigors, offensive lochia (puerperal sepsis)
• Severe headache, visual disturbance, epigastric pain (pre-eclampsia can present postnatally)
• Unilateral leg pain/swelling, chest pain, breathlessness (VTE)
• Thoughts of self-harm, suicidal ideation, psychotic symptoms (postnatal mental health crisis)

Breastfeeding

• Support breastfeeding initiation within 1 hour of birth (skin-to-skin)
• Assess positioning and attachment at every postnatal contact
• Common problems: sore nipples (usually positional), engorgement, mastitis, tongue-tie
• Mastitis: antibiotics if symptoms >24 hours despite improved drainage, or systemically unwell
• Advise exclusive breastfeeding for first 6 months (WHO recommendation)
• Contraindications to breastfeeding: HIV (in UK — different in resource-limited settings), active herpes lesion on breast, certain medications (cytotoxic drugs, lithium — check BNF)

Postnatal Mental Health

• Assess emotional wellbeing at every postnatal contact
• "Baby blues": common (day 3-5), self-limiting, affects up to 80% of women
• Postnatal depression: persistent low mood, anhedonia, guilt, poor concentration — onset typically 4-6 weeks
• Puerperal psychosis: psychiatric emergency, onset usually within first 2 weeks, affects 1 in 500 births; symptoms include confusion, hallucinations, delusions, mania
• Risk factors for puerperal psychosis: personal/family history of bipolar disorder or puerperal psychosis
• Urgent referral to perinatal mental health team if: psychotic symptoms, severe depression with suicidal ideation, significant functional impairment

Contraception Counselling

• Discuss contraception before discharge and at postnatal contacts
• Fertility can return from 21 days postpartum
• UKMEC guidance (UK Medical Eligibility Criteria for Contraceptive Use):
  • <21 days postpartum: avoid combined hormonal contraception (CHC) — VTE risk (UKMEC 4)
  • 21-42 days postpartum: CHC generally avoided if additional VTE risk factors (UKMEC 3)
  • >42 days postpartum: CHC usually acceptable (UKMEC 2 if breastfeeding, UKMEC 1 if not)
  • Progesterone-only methods: safe from day 1 postpartum (POP, implant, injection)
  • IUD/IUS: can be inserted within 48 hours of delivery OR from 4 weeks postpartum (avoid 48 hours to 4 weeks — perforation risk)
• Breastfeeding is NOT reliable contraception (LAM criteria: exclusive breastfeeding, amenorrhoeic, <6 months postpartum — 98% effective only if ALL criteria met)

Perineal Care

• Assess perineal wound (episiotomy or tear repair) at each contact
• Warning signs: increasing pain, wound dehiscence, offensive discharge, haematoma
• Advise analgesia (paracetamol + ibuprofen), ice packs, pelvic floor exercises
• 3rd and 4th degree tears: follow-up at 6-12 weeks, referral to specialist perineal clinic
• Offer physiotherapy for pelvic floor rehabilitation

6-8 Week Postnatal Check

• GP appointment covering:
  • Maternal physical health review
  • Mental health assessment (PHQ-9 or Edinburgh Postnatal Depression Scale)
  • Blood pressure check (especially if hypertensive in pregnancy)
  • Contraception review
  • Cervical screening if due
  • Infant health check (weight, development, feeding)
• For women with GDM: 6-13 week postnatal OGTT to exclude persistent diabetes
• For women with pre-eclampsia: blood pressure monitoring, discuss long-term cardiovascular risk

Important Facts for MRCOG

• Puerperal psychosis: onset usually within 2 weeks, 1 in 500, psychiatric emergency
• Baby blues (day 3-5) is self-limiting; postnatal depression is persistent (4-6 weeks onset)
• CHC contraindicated <21 days postpartum (UKMEC 4)
• IUD/IUS: within 48 hours or after 4 weeks (avoid interval between)
• POP/implant/injection: safe from day 1 postpartum
• Pre-eclampsia can present postnatally — monitor BP
• GDM: postnatal OGTT at 6-13 weeks
• Exclusive breastfeeding recommended for 6 months
• 3rd/4th degree tears need specialist follow-up

Source: NICE CG37 / NG194 (2021)

Read the original on nice.org.uk

Clinically reviewed by NHS obstetricians and gynaecologists · Source last updated 2021

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