The maternal six week postnatal checkBMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l6482 (Published 02 December 2019) Cite this as: BMJ 2019;367:l6482
- Adam D Jakes, academic clinical fellow in obstetrics and gynaecology1,
- Pippa Oakeshott, professor of general practice2,
- Debra Bick, professor of maternal health3
- 1Guy’s & St Thomas’ Hospital NHS Trust, London, UK
- 2Population Health Research Institute, St George’s University of London, London, UK
- 3Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry UK
- Correspondence to A Jakes
What you need to know
The maternal six week postnatal check is an opportunity to review a woman’s physical, emotional, and social wellbeing, discuss contraception, and offer lifestyle advice
Conditions specific to pregnancy, such as gestational hypertension, pre-eclampsia, and gestational diabetes, require postnatal follow-up and education regarding the long term risks and the risk of recurrence in future pregnancies
One iron tablet daily for three months, combined with an iron rich diet, can be a practical way to manage postpartum anaemia, especially where side effects of iron supplementation are a problem
A 29 year old woman is seeing her general practitioner for a six week postnatal check after having her first baby. Her labour was induced at 41+0 weeks’ gestation for post-dates and she had a vaginal birth with a second degree tear. Her baby is well, exclusively breastfed, and gaining weight. Her partner has returned to work after parental leave and she has no family who live in the area.
The maternal six week postnatal check is a long established part of routine postnatal care. It typically includes a review of the woman’s physical and mental health, the events of her pregnancy and birth, and discussion of future health considerations.1 It is also an opportunity to identify the 10-15% of women who may develop postnatal depression,234 provide ongoing management of medical complications of pregnancy such as gestational hypertension or gestational diabetes,56 and discuss postpartum contraception. This article offers an approach to the maternal six week (or 6-8 week) postnatal check.
What you should cover
If possible, check the woman’s maternity care discharge summary before the consultation so that you are aware of her medical and previous pregnancy history, the circumstances surrounding the birth, and the health of her baby.
A 10 or 15 minute consultation is a short time to cover everything, but try to identify the most pressing needs of the woman. Start by asking some open ended questions: How is she finding parenthood? Has she any worries about her own or her baby’s health? Suggested answers to some common questions are given in box 1.
Questions women may ask at their six week check
When can I have sex again?
You can have sexual intercourse again when you feel emotionally and physically ready. Usually it takes a few weeks for any perineal stitches to heal, and it may take longer for you to feel interested in resuming sexual intercourse. If intercourse is painful, a lubricant may help
When can I start to do physical exercise again?
Start low impact exercise, such as brisk walking, as soon as you feel ready—typically within two weeks of vaginal delivery and after the six week check for women who have had a caesarean section. For exercise such as running, swimming, and cycling, build up gradually to your pre-pregnancy levels. Limit high impact exercise (for example, using heavy weights) until at least six weeks after childbirth
When will my periods start again?
Vaginal blood loss (lochia) following childbirth should have ceased by six weeks. If you are breastfeeding, your periods may not return until you reduce or stop breastfeeding
How do I do pelvic floor muscle exercises?
Squeeze and draw in your back passage as if you’re holding in wind
Squeeze around your vagina and bladder tube (urethra) as if you’re stopping the flow of urine or squeezing during intercourse
Do these exercises for up to 10 seconds or until the muscles get tired, at least four times a day. Consider setting reminders on your phone, or installing an app to help: https://www.nhs.uk/apps-library/squeezy/
• Social—explore the woman’s home circumstances and support. Does she have any family in the area, or friends with babies? Are there other children at home? Ask sensitively what support she is getting from her partner, family, or friends.
• Mood—ask about her emotional wellbeing and consider screening for postnatal depression using the following questions recommended by the National Institute for Health and Care Excellence (NICE)2:
During the past month, have you often been bothered by feeling down, depressed, or hopeless?
During the past month, have you often been bothered by having little interest or pleasure in doing things?
Take a more detailed history for possible postnatal depression if she says yes to either question, or if she is at risk of mental health problems because of a personal or family history, does not seem to be bonding with her baby, or you have other clinical concerns. Consider using the Edinburgh Postnatal Depression Scale, as this is a validated tool for assessing postpartum depression.23 Consider follow-up by GP and health visitor and/or refer to mental health services as appropriate.2
• Lifestyle—ask about smoking, or use of alcohol or illicit drugs.
• Sleep—is she getting any daytime sleep to supplement loss of night time sleep? Sleep disturbance is, of course, normal for new parents, but can precipitate or exacerbate postpartum depression and/or anxiety. If she is struggling to cope, explore practical solutions such as whether there are family members who can help with night time infant care.
• Labour and birth—is there anything she would like to discuss about her labour and birth?1 If she has concerns, would it be helpful to arrange a consultation with her midwife or obstetrician?
• Breastfeeding—ask if she is breastfeeding or formula feeding, and how it is going. Consider signposting to the health visitor or lactation consultant or observing lactation and latching if the woman has ongoing concerns with breastfeeding. Discuss symptoms of mastitis such as breast pain, redness, and fever/flu like symptoms, and stress the need for an urgent GP appointment if she develops these symptoms.
• Wound healing—does she feel that her perineal tear/episiotomy wound has healed? A caesarean section wound should be fully healed by six weeks but check the wound site if the woman reports pain or discomfort.
• Vaginal bleeding—lochia after childbirth should have stopped by six weeks. If ongoing or purulent, consider referral to the emergency gynaecology unit for assessment.
• Bladder function—does she leak small amounts of urine when she coughs or sneezes? Prevalence of urinary incontinence is estimated at up to 47% in the first 12 months postpartum but usually improves over time.7 Encourage regular pelvic floor muscle exercises and explain how to perform them correctly (box 1). If urinary symptoms are severe and/or persist, consider referral to physiotherapy or pelvic floor therapy for further assessment.
• Bowel function—ask about constipation and offer laxatives if dietary measures have not been effective. Haemorrhoids may also be a problem. Ask about problems with loss of bowel control, especially if the woman had an instrumental vaginal birth and/or gave birth to a large baby.7
• Venous thromboembolism—A relatively hypercoagulable state persists for up to 12 weeks postpartum.8 Dyspnoea or calf pain/swelling warrants further examination.
Sexual intercourse and contraception
• Sex—has she resumed sexual intercourse? Less than half of postnatal women had resumed sex by 6 weeks in a recent prospective study.9 Stating that she can have sex again when she feels ready can be helpful, as some women may be waiting for the “all clear” from their doctor.
• Contraception—discuss contraception options, taking into account whether she is breastfeeding (table 1).10 Remind her that, if she wishes to avoid pregnancy, using a contraceptive method is advisable even if her periods have not resumed.
• Smear test—if she is due for a cervical smear, this should be performed around three months after the birth.12
• Vaccination status—women who were found to be non-immune to rubella during their pregnancy should be offered the MMR vaccine, unless there is the possibility of a new pregnancy.1 The vaccine is safe in breastfeeding women and can prevent fetal rubella syndrome in a future pregnancy.13
What you should do
Offer a focused examination, tailored to the woman’s concerns and likelihood of postpartum complications. Check
• Blood pressure (if needed for contraception or monitoring after gestational hypertension).
• Weight and body mass index—if BMI >30, NICE recommends offering referral to a structured weight management programme or dietitian.14 Do this in a sensitive and non-judgmental manner.
• Urine—check for proteinuria if the woman had pre-eclampsia or a history of renal dysfunction. If there is proteinuria (1+ or more) review again at three months postpartum to assess renal function and seek specialist advice if necessary.5
• Perineal tear/episiotomy wound—offer an examination, particularly if she reports pain, abnormal bleeding, or vaginal discharge, to assess for signs of infection or delayed/poor healing.1
• Offer contraception as appropriate (table 1).
Specific pregnancy complications
Anaemia (haemoglobin <100 g/L)
Women who were anaemic during pregnancy and prescribed oral iron replacement should continue this until six weeks postpartum.15
Current guidance on postpartum anaemia from the British Society of Haematology is to prescribe 100-200 mg elemental iron daily for three months (eg, ferrous sulphate 200 mg tablets twice daily).15
Nausea, epigastric discomfort, and constipation are common side effects of iron supplementation, especially at doses above 45 mg of elemental iron per day.16 Taking just one iron tablet daily combined with a diet of iron-rich foods may be sufficient where higher doses are not tolerated.17
Iron absorption can be maximised by taking supplements one hour before meals and with a source of vitamin C such as orange juice. Avoid taking antacids, calcium supplements, tea, and coffee at the same time as they can impair absorption.
A full blood count and ferritin should be measured at the end of the recommended three months to ensure haemoglobin and iron stores are replete.15 In practice this may not be necessary if the woman has no symptoms of anaemia.
Women who develop gestational diabetes in pregnancy have a sevenfold increased lifetime risk of developing type 2 diabetes.18 For women with a history of gestational diabetes, recommend a fasting plasma glucose test between 6 and 13 weeks postpartum.6 Annual screening using HbA1c is recommended thereafter.6
Offer lifestyle advice, including weight control, diet, and exercise to reduce the risk of developing diabetes.
Gestational hypertension and pre-eclampsia
Gestational hypertension or pre-eclampsia may develop in a future pregnancy, and these conditions are associated with double the risk of developing high blood pressure, heart disease, and stroke in later life.5
Recommend a healthy diet, support for weight management (if needed), regular physical exercise, and annual blood pressure checks.
Advise that she take aspirin 75 mg daily from 12 weeks’ gestation in any future pregnancy to reduce her risk of pre-eclampsia.5
Education into practice
What proportion of postnatal women at your practice attend their 6-8 week postnatal check?
Do you ensure that pregnancy complications such as gestational diabetes are coded in the problem summary of the patient’s health record?
Do you have a recall system for women who have had hypertensive disorders in pregnancy to offer annual blood pressure checks, and in women who have had gestational diabetes to offer an annual HbA1C?
How patients were involved in the creation of this article
Twenty women who gave birth at St Thomas’ Hospital in London were approached and asked to feed back their experiences from their maternal six week postnatal check. They were asked about what questions they wanted answering at this review, and the top four were included in box 1. They were also asked to read and comment on the article, which resulted in our inclusion of box 1 and the “physical symptoms” section being expanded.
This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs.
Competing interests The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: none.
Further details of The BMJ policy on financial interests are here: https://www.bmj.com/about-bmj/resources-authors/forms-policies-and-checklists/declaration-competing-interests
Provenance and peer review: commissioned; externally peer reviewed.