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.
- How was the baby delivered?
- Any particular worries about her own health?
- Is her perineum/Caesarean 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.
- Add notes to any clinical page and create a reflective diary
- Automatically track and log every page you have viewed
- Print and export a summary to use in your appraisal
- How was the birth? Are there any issues that need to be talked through?
- How is her mood? Consider postnatal depression. Use a postnatal screening questionnaire, eg the Edinburgh Postnatal Depression Score if in doubt.. Postpartum depression can be treated either pharmacologically or with counselling. Exercise and omega-3 fatty acids are emerging as potentially effective alternatives.
- 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 the baby's vision or hearing?
- 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 syndrome and childhood asthma. Refer to a smoking cessation clinic if required.
- 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.
- Pain on intercourse.
- If required, cervical smear may be performed as early as 6-8 weeks. Routine tests are better delayed to 3 months post-delivery.
Also consider checking:
- Haemoglobin level if previously anaemic.
- Rubella status (vaccinate if found not to be immune during antenatal check).
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 6 months if she remains amenorrhoeic, but fertility soon returns if reduced or discontinued. 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 found little evidence about the effects of contraception education after childbirth and, in particular, no 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.
Pelvic floor exercises
Many incontinence problems begin during the antenatal period. Approximately 30% of new mothers still experience continence problems 6 weeks after the birth, with further improvement within six months. 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. Provide leaflets or suggest performing the following as often as possible everyday, forever - as the effect of training is not long-lasting:
- Pulling up her pelvic floor muscles as though she were 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.
Further reading & references
- Murray L, Carothers AD; The validation of the Edinburgh Post-natal Depression Scale on a community sample. Br J Psychiatry. 1990 Aug;157:288-90.
- Postnatal care: Routine postnatal care of women and their babies, NICE Clinical Guideline (2006)
- Cox JL, Holden JM, Sagovsky R; Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987 Jun;150:782-6.
- Edinburgh Postnatal Depression Scale, University of California, San Francisco
- Shaw E, Kaczorowski J; Postpartum care--what's new? Curr Opin Obstet Gynecol. 2007 Dec;19(6):561-7.
- Anderson HR, Cook DG; Passive smoking and sudden infant death syndrome: review of the epidemiological evidence. Thorax. 1997 Nov;52(11):1003-9.
- Moshammer H, Hoek G, Luttmann-Gibson H, et al; Parental smoking and lung function in children: an international study. Am J Respir Crit Care Med. 2006 Jun 1;173(11):1255-63. Epub 2006 Feb 16.
- Barrett G, Pendry E, Peacock J, et al; Women's sexual health after childbirth. BJOG. 2000 Feb;107(2):186-95.
- Peterson AE, Perez-Escamilla R, Labboka MH, et al; Multicenter study of the lactational amenorrhea method (LAM) III: effectiveness, duration, and satisfaction with reduced client-provider contact. Contraception. 2000 Nov;62(5):221-30.
- Amy JJ, Tripathi V; Contraception for women: an evidence based overview. BMJ. 2009 Aug 7;339:b2895. doi: 10.1136/bmj.b2895.
- Guillebaud J, Contraception. 3rd ed, Churchill Livingstone (1999) 124-127
- Kapp N, Curtis KM; Intrauterine device insertion during the postpartum period: a systematic review. Contraception. 2009 Oct;80(4):327-36. Epub 2009 Aug 29.
- Hiller JE, Griffith E, Jenner F. Education for contraceptive use by women after childbirth. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD001863. DOI: 10.1002/14651858.CD001863.pub2
- Spellacy E; Urinary incontinence in pregnancy and the puerperium. J Obstet Gynecol Neonatal Nurs. 2001 Nov-Dec;30(6):634-41.
- Burgio KL, Borello-France D, Richter HE, et al; Risk factors for fecal and urinary incontinence after childbirth: the childbirth and pelvic symptoms study. Am J Gastroenterol. 2007 Sep;102(9):1998-2004. Epub 2007 Jun 15.
- Hay-Smith J, Morkved S, Fairbrother KA, et al; Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD007471.
- Agur WI, Steggles P, Waterfield M, et al; The long-term effectiveness of antenatal pelvic floor muscle training: eight-year BJOG. 2008 Jul;115(8):985-90.
- Williams A, Herron-Marx S, Knibb R; The prevalence of enduring postnatal perineal morbidity and its relationship to type of birth and birth risk factors. J Clin Nurs. 2007 Mar;16(3):549-61.
|Original Author: Dr Hayley Willacy||Current Version: Dr Hayley Willacy|
|Last Checked: 26/10/2010||Document ID: 2468 Version: 22||© EMIS|
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