Postnatal care
Exam Tips
- In OSCEs, always open with red-flag screening: bleeding volume, sepsis symptoms, VTE symptoms, and acute mental state risk.
- Ask specifically about sleep, anxiety/irritability, and unusual thoughts: early postpartum psychosis can present before overt delusions.
- Differentiate normal lochia progression from pathological bleeding by timeline, volume, clots/tissue passage, and systemic symptoms.
- Include bladder, bowel, and perineal/caesarean wound questions; these are commonly missed but high-yield for marks.
- State postpartum contraception timing clearly: fertility can return quickly; if eligible, contraception can start immediately and should be established by day 21 if avoiding pregnancy.
- Mention inequality-aware care: ethnicity, deprivation, and social support affect risk and should shape follow-up intensity.
Definition
Postnatal care is the planned clinical and psychosocial care of the mother (and infant interface) from birth to 8 weeks postpartum, aimed at detecting complications early while supporting recovery, feeding, mental health, and contraception. In UK practice it includes repeated risk-based review of bleeding, infection, thromboembolism, perineal/caesarean wound healing, bladder-bowel function, and emotional wellbeing, with rapid escalation for red-flag symptoms.
Pathophysiology
The puerperium is a dynamic recovery phase: uterine involution, placental-site healing, and lochia progression occur alongside major endocrine shifts (rapid fall in progesterone/oestrogen, prolactin-driven lactation), creating vulnerability to mood disturbance, lactation problems, and irregular bleeding. Pregnancy-related hypercoagulability persists for weeks after delivery, increasing VTE risk, while tissue trauma (perineum, uterus, caesarean wound) and retained products can predispose to secondary postpartum haemorrhage and sepsis. Pelvic floor and anal sphincter injury may cause urinary/fecal incontinence and chronic perineal pain if not identified and rehabilitated early (see diagram of postpartum uterine involution/lochia timeline in core obstetrics texts, often presented in postpartum physiology figures).
Risk Factors
- Previous postpartum haemorrhage or retained placenta
- Maternal haemoglobin <85 g/L at onset of labour
- BMI >35 kg/m2
- Grand multiparity (parity >=4)
- Antepartum haemorrhage, low-lying placenta, uterine overdistension (multiple pregnancy/polyhydramnios/macrosomia), uterine abnormalities
- Age >=35 years
- Induction, prolonged labour, oxytocin use, operative vaginal birth or caesarean section, precipitate labour
- Obesity, diabetes/non-diabetic hyperglycaemia, immunocompromise, anaemia
- Prolonged rupture of membranes, invasive procedures (for example amniocentesis/cerclage), retained products, perineal trauma or wound haematoma
- Close contact with Streptococcus pyogenes
- Risk factors for obstetric anal sphincter injury: nulliparity, Asian ethnicity, birthweight >4 kg, shoulder dystocia, occipito-posterior position, prolonged second stage, instrumental birth
- Traumatic birth, episiotomy/perineal tear, wound infection or breakdown (risk of persistent perineal pain)
- Social vulnerability, domestic abuse risk, reduced support networks, and deprivation (linked to poorer maternal outcomes)
Clinical Features
Symptoms
- Heavy, sudden, persistent, or increasing vaginal bleeding; passage of clots/tissue
- Persistent severe abdominal, pelvic, or perineal pain
- Fever, rigors, offensive vaginal discharge, or feeling systemically unwell
- Breastfeeding difficulties, nipple/breast pain
- Urinary symptoms (dysuria, retention, incontinence) and bowel symptoms (constipation, faecal incontinence, haemorrhoids)
- Perineal wound pain/swelling/discharge or caesarean wound pain, erythema, discharge
- Dyspareunia, sexual dysfunction, concern about contraception
- Low mood, anxiety, insomnia, irritability, poor bonding, intrusive/abnormal thoughts
Signs
- Pyrexia, tachycardia, hypotension, tachypnoea, or other sepsis physiology
- Pallor or postural symptoms suggesting anaemia/hypovolaemia
- Uterine tenderness, abdominal tenderness, offensive lochia
- Perineal wound breakdown, infection, or haematoma; caesarean wound erythema/discharge
- Raised blood pressure where hypertensive disorder persists postpartum
- Calf swelling/tenderness or unilateral leg oedema (possible DVT)
- Reduced affect, psychomotor change, thought disorder, or psychotic features on mental state assessment
Investigations
Management
Lifestyle Modifications
- Provide safety-net advice on urgent red flags: heavy bleeding, fever, offensive discharge, chest pain/dyspnoea, unilateral leg swelling, severe headache/visual symptoms, suicidal or psychotic symptoms
- Support feeding plan (breast/formula/mixed) and early referral for breastfeeding support if painful latch or poor transfer
- Encourage structured pelvic floor muscle training soon after birth to reduce urinary incontinence/prolapse risk
- Address sleep, fatigue, social support, safeguarding concerns, and domestic abuse risk
- Discuss smoking cessation, alcohol/drug use, nutrition, graded physical activity, and weight management
- Offer contraception counselling; if medically eligible, method can start immediately postpartum and should be in place by day 21 if pregnancy prevention is desired; discuss optimal interpregnancy interval (>12 months)
Pharmacological Treatment
Simple analgesia for perineal/caesarean wound pain
- Paracetamol 1 g orally every 4-6 hours when required (max 4 g/day)
- Ibuprofen 400 mg orally three times daily with food when required (max 2.4 g/day)
First-line postpartum analgesia if no contraindications. Avoid NSAIDs in active peptic ulceration, severe renal impairment, NSAID-sensitive asthma, or high bleeding risk.
VTE prophylaxis/treatment when indicated by obstetric risk assessment
- Enoxaparin 40 mg subcutaneously once daily for prophylaxis (dose-adjust by weight/renal function as per local protocol)
Contraindications include active major bleeding and previous heparin-induced thrombocytopenia; use caution in renal impairment and around neuraxial anaesthesia timing.
Iron replacement after postpartum blood loss/iron-deficiency anaemia
- Ferrous sulfate 200 mg orally once to three times daily (titrate to tolerance and Hb response)
Common adverse effects are constipation, nausea, and dark stools; continue for about 3 months after Hb normalises to replenish stores.
Vitamin supplementation in breastfeeding
- Colecalciferol (vitamin D) 10 micrograms (400 units) orally once daily
Recommended for breastfeeding women in UK guidance; check for additional deficiency risk factors.
Antibiotics when postpartum infection is diagnosed
- Use syndrome-specific local antimicrobial guidance (for example endometritis, wound infection, UTI, mastitis)
Do not delay broad-spectrum treatment in suspected sepsis; account for allergy status, breastfeeding compatibility, and culture results.
Surgical / Interventional
- Examination under anaesthesia and evacuation of retained products for secondary postpartum haemorrhage when indicated
- Repair of perineal wound dehiscence or obstetric anal sphincter injury complications
- Incision and drainage of wound/perineal abscess if present
- Return to theatre/interventional management for ongoing severe haemorrhage
Complications
- Iron-deficiency anaemia, fatigue, and orthostatic symptoms after blood loss
- Endometritis, wound infection, and progression to maternal sepsis
- Venous thromboembolism (DVT/PE)
- Persistent perineal pain, dyspareunia, sexual dysfunction, and impaired breastfeeding/caregiving
- Faecal incontinence and anal pain after obstetric anal sphincter injury
- Postnatal depression, PTSD, and postpartum psychosis (with risk of self-harm/infanticide in severe illness)
- Maternal mortality (notably cardiac, neurological, and thromboembolic causes)
Prognosis
Most women recover well by 6-8 weeks with proactive review, analgesia, feeding support, pelvic floor rehabilitation, and mental health screening. Prognosis worsens when haemorrhage, infection, VTE, or severe psychiatric illness is missed; early recognition and escalation markedly reduce long-term morbidity and maternal mortality.
Sources & References
🏥BMJ Best Practice(2)
✅NICE Guidelines(1)
- Postnatal care[overview]
📖Textbook References(2)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1278, 1279)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 212)[context]