Mother's six-week postnatal check

This check should be patient-centred and should cover physical, psychological and social aspects of having a new baby. Written information should be available to take away if required.

The National Institute for Health and Care Excellence (NICE) last issued guidance on this in 2021.¹

Clinicians should be aware that the 2020 MBRACE report on maternal (and perinatal) mortality showed that women and babies from some minority ethnic backgrounds and those who live in deprived areas have an increased risk of death and may need closer monitoring.

Key findings included:²

• Compared with white women (8 per 100,000), the risk of maternal death during pregnancy and up to 6 weeks after birth is:

  • 4 times higher in black women (34 per 100,000).

  • 3 times higher in mixed ethnicity women (25 per 100,000).

  • 2 times higher in Asian women (15 per 100,000 - does not include Chinese women).

• Women living in the most deprived areas are more than 2.5 times more likely to die compared with women living in the least deprived areas (6 compared with 15 per 100,000).

• The neonatal mortality rate is around 50% higher in black and Asian babies compared with white babies (17 compared with 25 per 10,000). ³

• The neonatal mortality rate increases according to the level of deprivation in the area the mother lives in, with almost twice as many babies dying in the most deprived areas compared with the least deprived areas (12 compared with 22 per 10,000).

History

Physical symptoms

• Note how the baby was delivered.

• Ask whether there are any particular worries about her own health.

• Ask whether her perineum/caesarean section scar is healing well. Note whether there is any pain.

• Ask whether lochia is normal and/or whether periods have resumed. Lochia has usually ceased by six weeks postnatally. Periods do not resume until breastfeeding ceases in the majority.

• Discuss whether bowel and bladder are functioning normally. Ask whether there is any incontinence.

• Ask whether she is breastfeeding. If so, encourage her to continue, if appropriate.⁴ Ask about any problems such as soreness or engorgement.

Psychological problems

• Ask how the birth was. Check with her whether there are any issues that need to be talked through.

• Ask how her mood is. Screen for postnatal depression. Use a self-report questionnaire - eg, the Edinburgh Postnatal Depression Score or the Patient Health Questionnaire-9 (PHQ-9).⁵ Postpartum depression can be treated either pharmacologically or with psychological therapies such as cognitive behavioural therapy (CBT) or interpersonal psychotherapy (IPT). There is also some evidence for the role of exercise in reducing symptoms of depression. See the separate Postnatal Depression article for further information about detection and management of this condition.

• Ask whether there are any worries about the baby.

Social problems

• Ask whether she is well supported at home.

• Check with her on how she is sleeping. If this is a problem, consider how she might gain support from a partner or family. Expressing a night-time bottle might give her a break.

• Discuss the risks of co-sleeping or bed-sharing.⁶

• Encourage any household smokers to quit. Explain passive smoking increases risk of sudden infant death syndrome . Explain too that it increases risk of childhood asthma. Refer to a smoking cessation clinic if required.

• Provide the opportunity to talk without her partner present to give an opportunity where relevant to explore issues such as domestic violence. (Domestic violence often begins in pregnancy.⁷ )

Examination

• Palpate the abdomen - if able to feel the uterus, consider retained products of conception , or endometritis if tender.

• Check blood pressure - particularly if it was previously high.

• Perform vaginal examination if she has:
  

  • Problems with vaginal tears or episiotomy.⁸

  • Abnormal bleeding or vaginal discharge.

  • Pain on intercourse. (If all appears normal it may be the fear of pain after delivery. If breastfeeding there may be some atrophic vaginitis. Reassurance may be all that is required.)

  • Urinary or faecal incontinence.

• If smears are required, they are normally delayed until three months post-delivery.

• Weight. The National Institute for Health and Care Excellence (NICE) Quality Standard advises that women whose body mass index (BMI) is over 30 kg/m² should be offered referral for advice on healthy eating and physical activity.⁹

Also consider checking:

• Haemoglobin level if previously anaemic.

• Rubella status (vaccinate if found not to be immune during antenatal check).

• Glucose levels (fasting plasma glucose or HbA1c). The oral glucose tolerance test (GTT) is no longer routinely recommended for women who developed gestational diabetes.¹⁰

Sex and contraception

Ask if sexual intercourse has resumed with her partner. If not, reassure her that it is now safe to try.

Enquire whether contraception is required - full-time breastfeeding (the Lactational Amenorrhoea Method) provides good contraception for up to six months if she remains amenorrhoeic, but fertility soon returns if breastfeeding is reduced or discontinued. ¹¹ 'Fully breastfeeding' is defined for this purpose as at least four-hourly feeds in the day, and six-hourly feeds at night. If additional contraception is needed, the following are suitable:¹²

• Condoms.

• Intrauterine contraceptive device (IUCD).

• Levonorgestrel-releasing intrauterine system.

• Progestogen-only pills and implants.

• Combined oral contraceptive pill.

As women may not return for healthcare later, it is an opportunity to discuss family planning. However, there is mixed evidence of the efficacy of this approach. A compromise is to provide leaflets for the women to take away and refer to at home, when they are ready and able to consider the issues.

There is also a Postpartum Contraception article for further details on contraceptive choice at this time.

Pelvic floor exercises

Many incontinence problems begin during the antenatal period, but some women develop urinary incontinence after childbirth. Mode of delivery is important.¹³ When vaginal delivery is compared specifically with elective caesarean, the risk of stress urinary incontinence is over three times higher; however, there is no difference in risk when comparing instrumental vaginal delivery and spontaneous vaginal delivery.¹⁴ There is some evidence that pelvic floor exercises are helpful in the prevention of stress incontinence, particularly for those at higher risk of problems - eg, instrumental delivery, third-degree tear. ¹⁵ There is also evidence supporting the widespread recommendation for pelvic floor exercise programmes as first-line treatment. Provide leaflets or suggest performing the following as often as possible every day, for ever - as the effect of training is not long-lasting. Direct to the patient resource leaflet Pelvic floor exercises for full information. However, briefly, pelvic floor exercise advice is as follows:

• Slow contractions: advise pulling up her pelvic floor muscles as though she were trying to stop herself urinating or passing wind, and holding for 10 seconds. She may need to build up to this. Repeat 10 times, and do 3 times a day.

• Quick contractions: contracting pelvic muscles, as before, and relaxing them rapidly in succession 10 times. Do 3 times a day.

• Associate pelvic floor exercises with a regular activity to prompt remembering to do them; for example, with each feed, or cup of tea, or a meal.