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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.
- 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 breast-feeding ceases in the majority.
- Discuss whether bowel and bladder are functioning normally. Ask whether there is any incontinence.
- Ask whether she is breast-feeding. If so, encourage her to continue, if appropriate.[1, 2]Ask about any problems such as soreness or engorgement.
- 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 - if in doubt.Other questionnaires which may be used as alternatives in assessment are the Patient Health Questionnaire-9 (PHQ-9) and the Hospital Anxiety and Depression Scale (HADS).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 article Postnatal Depression for further information about detection and management of this condition.
- Ask whether there are any worries about the baby.
- 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.
- 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. (30% of domestic violence begins in pregnancy.)
- 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.
- Abnormal bleeding or vaginal discharge.
- Pain on intercourse. (If all appears normal it may be the fear of pain after delivery. If breast-feeding 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. A 2013 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.
Also consider checking:
- Haemoglobin level if previously anaemic.
- Rubella status (vaccinate if found not to be immune during antenatal check).
- Glucose tolerance test (GTT) for women who developed gestational diabetes.
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 breast-feeding (the Lactational Amenorrhoea Method) provides good contraception for up to six months if she remains amenorrhoeic, but fertility soon returns if breast-feeding is reduced or discontinued. "Fully breast-feeding" 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:
- Intrauterine contraceptive device (IUCD).
- Levonorgestrel-releasing intrauterine system.
- Progestogen-only pills and implants.
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 Cochrane review has conflicting evidence about the effects of contraception education after childbirth and limited evidence of a decrease in unplanned pregnancy.Perhaps 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.
See the separate article Postpartum Contraception for further details on contraceptive choice at this time.
Pelvic floor exercises
Many incontinence problems begin during the antenatal period. Around a third of women experience urinary incontinence after childbirth, and around 10% faecal incontinence. 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. 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 information 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.
There is evidence of high levels (87%) of persistent perineal problems at 12 months post-delivery, particularly amongst women having instrumental births. Forceps deliveries are associated with higher levels of stress and urge urinary incontinence, flatus incontinence, sexual morbidity and dyspareunia.
Further reading and references
; UNICEF UK
; NICE Clinical Guideline (2006)
; World Health Organization (WHO), 2013
; University of California, San Francisco
; NICE Clinical Guideline (2007)
; Exercise for depression. Cochrane Database Syst Rev. 2013 Sep 129:CD004366. doi: 10.1002/14651858.CD004366.pub6.
; The Lullaby Trust
; Parental smoking and lung function in children: an international study. Am J Respir Crit Care Med. 2006 Jun 1173(11):1255-63. Epub 2006 Feb 16.
; Dept of Health, November 2009 (archived content)
; Guidelines for the NHS Cervical Screening Programme, May 2010
; NICE Quality Standards (July 2013)
; Faculty of Sexual and Reproductive Healthcare (2009)
; Intrauterine device insertion during the postpartum period: a systematic review. Contraception. 2009 Oct80(4):327-36. Epub 2009 Aug 29.
; Education for contraceptive use by women after childbirth. Cochrane Database Syst Rev. 2012 Aug 158:CD001863. doi: 10.1002/14651858.CD001863.pub3.
; Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database Syst Rev. 2012 Oct 1710:CD007471. doi: 10.1002/14651858.CD007471.pub2.
; Risk factors for fecal and urinary incontinence after childbirth: the childbirth and pelvic symptoms study. Am J Gastroenterol. 2007 Sep102(9):1998-2004. Epub 2007 Jun 15.
; The long-term effectiveness of antenatal pelvic floor muscle training: eight-year BJOG. 2008 Jul115(8):985-90.
; Oxford University Hospitals NHS Trust, May 2013
; The prevalence of enduring postnatal perineal morbidity and its relationship to type of birth and birth risk factors. J Clin Nurs. 2007 Mar16(3):549-61.
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