postpartum

6 weeks

• Discharge summary from hospital – scan into MD3 
• Mother and baby check
• Pap Smear
• Contraception / family planning choices
• Immunisation Mother: check dTpa , MMR, Varicella , Influenza status . 
• Discuss pelvic floor protection 
• Repeat GTT required if GDM ( at 6 weeks ) 
• Follow up any maternal referrals, if identified during pregnancy. 
• VTE postnatal screen check 

BABY CHECK

1. Biometrics: Weight, Length, HC
2. neonatal hearing screening test
3. Neonatal Screen Test (NNST)
4. immunisations
5. urine and stools

2. Head to toe systematic examination
   1. dysmorphism
   2. fontanelle
   3. skin, jaundice
   4. head to toe 
   5. including red eye reflex, cleft palate, neural tube defects, hips, anus, testicles
   6. including organ systems for heart murmurs, organomegaly etc

3. EDUCATION
   1. SIDS education
   2. car safety seats
   3. smoking
   4. SAFETY-  mandatory reporting for child abuse

MOTHER

1. Sleep, nutrition, exercise, overall health
2. postpartum Medical check
   1. Pregnancy complications
      1. Heavy uterine bleeding/postpartum haemorrhage
      2. Labour and mode of delivery
      3. Perineal tears
      4. caesarean section wound infection
      5. hypertension correction
         1. Blood pressure check within seven days of delivery 
         2. evaluation for signs of end organ damage and the need for antihypertensive medication
         3. Recheck at 6–8-week postnatal review
      6. Bowel and bladder issues – constipation management
      7. Length of hospital stay
   2. Endometritis
      1. retained products of conception
      2. Hygiene – wash perineal area 2x day
   3. Breast concerns – Mastiits
      1. pain with feeding
      2. infant attachment
      3. nipple damage
   4. DVTs
   5. GDM
      1. OGTT at six weeks postpartum
      2. OGTT every three years
   6. Hypothyroidism
      1. Reduce thyroxine dose to pre-pregnancy levels
      2. Regular monitoring of TFTs
   7. Hyperthyroidism
      1. Regular monitoring of TFTs as dose reduction of anti-thyroid medication may be required
      2. Consider infant monitoring
   8. smoking, alcohol, drugs
3. Bloods
   1. Hb, Fe studies
   2. TFTs
4. Vaccines
   1. whooping cough vaccine
5. coping
   1. bonding
   2. feeding
   3. coping
6. Functional Activities
   1. refrain from heavy lifting and strenuous exercise for 6 weeks after being discharged from the hospital
   2. Refrain from sexual intercourse until 4 weeks after delivery.
7. psychosocial review
   1.  postnatal depression screen – Edinburgh Postnatal Depression Scale

• Possible Depression: 10 or greater
• Always look at item 10 (suicidal thoughts)

2. domestic violence screen
3. contraception and reproductive planning
   1. STI screen
   2. PAP smear
   3. future pregnancy planning
      1. Extremes of interpregnancy intervals are associated with adverse outcomes, with research suggesting an interval minimum of 12 months as ideal
   4. Breastfeeding
      1. does not work effectively as a contraception
      2. Condoms only have a 60-70% success rate

• Contraception

Contraceptive options
Contraceptive type	Notes	Contraindications
Options for all women, including those breastfeeding
Levonorgestrel intrauterine device	Lasts up to five yearsFrequent spotting or bleeding in the first 3–5 months is common; thereafter, the device significantly reduces menstrual bleedingHigh level of effectivenessCan be inserted <48 hours postpartum/immediately after delivery if desired (MEC category 2)	Insertion 48 hours to four weeks post deliveryCurrent breast cancer, or breast cancer within the past five yearsIschaemic heart disease or strokeUnexplained vaginal bleedingGestational trophoblastic diseaseCervical, endometrial or ovarian cancerDistortion of uterine cavity (eg large fibroids)Current pelvic inflammatory diseaseChlamydial or gonorrhoeal infectionSevere liver disease
Contraceptive implant	Can be inserted immediately postnatallyUnpredictable bleeding patterns are common; one in five women may experience amenorrhoeaLasts up to three yearsHigh level of effectiveness, especially if inserted immediately after delivery	Personal history of, or current, breast cancerDevelopment of ischaemic heart disease, stroke or transient ischaemic attack during useUnexplained vaginal bleedingSevere liver disease
Copper intrauterine device	Can be inserted <48 hours postpartum/immediately after delivery if desiredAfter 48 hours, insertion should be delayed until 28 days after childbirthCan last up to 10 yearsIncreased risk of pelvic infection in the three weeks after insertion	Structural uterine abnormalitiesCaution in those with a history of dysmenorrhoea or high risk of sexually transmissible infections
Progesterone-only oral contraceptive pill	Does not reduce breastmilk productionCan be started immediately postnatallyCounsel women on strict dosing timing to improve efficacy and that the pills are taken continuously (no sugar pills)	Breast cancerUnexplained vaginal bleedingSevere liver disease
Depot contraceptive injection	Can be used in the immediate postnatal period Administered intramuscularly every 12 weeksNot recommended as first line for women aged <18 years or >45 yearsMay be associated with weight gainMay have delayed return to fertility of 12–18 monthsUp to 70% of women develop amenorrhoea by 12 months	Personal history of, or current, breast cancerPast/current history of ischaemic heart disease, stroke or transient ischaemic attackMultiple risk factors for cardiovascular diseaseHypertension with vascular diseaseUnexplained vaginal bleedingSevere liver disease
Barrier methods: male or female condoms, diaphragm	Can be safely used immediately postpartumCondoms, with typical use, have a high failure rateWomen choosing to use a diaphragm should be advised to wait at least six weeks after childbirth before having it fitted because the size of the diaphragm required may change as the uterus returns to normal size	Diaphragm: <6 weeks postpartum
Options for those exclusively formula feeding
Combined oral contraceptive pill	Counsel women on risks and signs of venous thromboembolism, missed pills management and factors affecting efficacyGenerally safe to use if >6 months postpartum and breastfeeding (MEC category 2)	Breastfeeding or immediate postnatal period (first 21 days)Significant risk factors for arterial diseaseMigraine with auraDiabetes with vascular complicationsUncontrolled hypertensionSmoker and aged >35 years
Etonogestrel with ethyinylestradiol-releasing vaginal ring	Can be used once the mother feels comfortable inserting it from >4 weeks postpartumCommon side effects include vaginitis, change in vaginal discharge or irregular bleedingWomen should check for the ring regularly to ensure it has not been expelled	<4 weeks postpartumAnato