Mother's 6 Week Postnatal Check

This check should be patient-centred and should cover physical, psychological and social aspects of having a new baby.¹ Written information should be available to take away, if required.

Physical symptoms

• How was the baby delivered?
• Any particular worries about her own health?
• Is her perineum / Caesarian section scar healing well?
• Lochia normal and/or periods resumed?
• Bowel and bladder functioning normally?
• Is she breast feeding? If so encourage her to continue, if appropriate. Ask about any problems such as soreness or engorgement.

Psychological problems

• How was the birth? Are there any issues that need to be talked through?
• How is her mood? Consider postnatal depression. Use postnatal screening questionnaire if in doubt.^2,3 (See also our integrated Calculator). Postpartum depression can be treated either pharmacologically or with counselling. Exercise and omega-3 fatty acids are emerging as potentially effective alternatives.⁴
• Any worries about the baby?
  • Is the baby content?
  • Is the baby healthy?
  • Is the baby growing? Regular weighing with the midwife may alert professionals to a potential problem.
  • Is the baby responsive? Are there any concerns over vision or hearing?

Social problems

• Is she well supported at home?
• How is she sleeping? If this is a problem consider how she might gain support from partner or family. Expressing a night-time bottle might give her a break.
• Encourage any household smokers to quit. Discuss increased risks of sudden infant death syndrome⁵ and childhood asthma.⁶ Refer to smoking cessation clinic if required.

• Palpate abdomen - if able to feel uterus consider retained products of conception or endometritis, if tender.
• Check blood pressure - particularly if previously high.
• Perform vaginal examination if she has:
  • Problems with vaginal tears or episiotomy
  • Abnormal bleeding
  • Pain on intercourse⁷
  If all appears normal it may be the fear of pain after delivery. Reassurance may be required.
• Cervical smear if indicated

Also consider checking:

• Haemoglobin level if previously anaemic
• Rubella status (vaccinate if found not to be immune during antenatal check)

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

Enquire whether contraception is required - full time breast feeding (The Lactation Amenorrhoea Method) provides good contraception for up to 6 months if she remains amenorrhoeic, but fertility soon returns if reduced or discontinued.⁸ If additional contraception is needed the following are suitable:⁹

• Condoms
• IUCD
• Levonorgestrel-releasing intra-uterine system
• Progestogen-only pills and implants

As women may not return for health care later, it is an opportunity to discuss family planning. However, there is mixed evidence of the efficacy of this approach. A Cochrane review found little evidence about the effects of contraception education after childbirth and in particular no evidence of a decrease in unplanned pregnancy.¹⁰ 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.

Many incontinence problems begin during the antenatal period. Approximately 30% of new mothers still experience continence problems 6 weeks after birth, with further improvement within six months.¹¹
There is some evidence that pelvic-floor exercises are helpful in the prevention of stress incontinence, particularly for those at higher risk of problems e.g. instrumental delivery, 3rd degree tear.^12,13 Provide leaflets or suggest performing the following as often as possible everyday, forever:¹⁴

• Pulling up her pelvic floor muscles as though she was trying to stop herself urinating and holding for 10 seconds.
• Contracting pelvic muscles, as before, and relaxing them rapidly in succession 4 times.

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.¹⁵