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Postnatal care up to 8 weeks after birth

  • This Guidelines for Nurses summary includes recommendations that are relevant to the primary care setting. Please refer to the full guideline for the complete set of recommendations

 

Status levels

  • Emergency

    Life-threatening or potential life-threatening situation

  • Urgent

    Potentially serious situation, which needs appropriate action

  • Non-urgent

    Continue to monitor and assess

Planning the content and delivery of care

Principles of care

  • Each postnatal contact should be provided in accordance with the principles of individualised care. In order to deliver the core care recommended in this guideline, postnatal services should be planned locally to achieve the most efficient and effective service for women and their babies

  • A coordinating healthcare professional should be identified for each woman. Based on the changing needs of the woman and baby, this professional is likely to change over time

  • A documented, individualised postnatal care plan should be developed with the woman, ideally in the antenatal period or as soon as possible after birth. This should include:

    • relevant factors from the antenatal, intrapartum, and immediate postnatal period

    • details of the healthcare professionals involved in her care and that of her baby, including roles and contact details

    • plans for the postnatal period

    • this should be reviewed at each postnatal contact

  • Women should be offered an opportunity to talk about their birth experiences and to ask questions about the care they received during labour

  • Women should be offered relevant and timely information to enable them to promote their own and their babies’ health and wellbeing and to recognise and respond to problems

  • At each postnatal contact the healthcare professional should:

    • ask the woman about her health and wellbeing and that of her baby. This should include asking women about their experience of common physical health problems. Any symptoms reported by the woman or identified through clinical observations should be assessed

    • offer consistent information and clear explanations to empower the woman to take care of her own health and that of her baby, and to recognise symptoms that may require discussion

    • encourage the woman and her family to report any concerns in relation to their physical, social, mental or emotional health, discuss issues and ask questions

    • document in the care plan any specific problems and follow-up

  • Length of stay in a maternity unit should be discussed between the individual woman and her healthcare professional, taking into account the health and wellbeing of the woman and her baby and the level of support available following discharge

Professional communication

  • There should be local protocols about written communication, in particular about the transfer of care between clinical sectors and healthcare professionals. These protocols should be audited

  • Healthcare professionals should use hand-held maternity records, the postnatal care plans, and personal child health records, to promote communication with women

Competencies

  • All healthcare professionals who care for mothers and babies should work within the relevant competencies developed by Skills for Health. Relevant healthcare professionals should also have demonstrated competency and sufficient ongoing clinical experience in:

    • undertaking maternal and newborn physical examinations and recognising abnormalities

    • supporting breastfeeding women including a sound understanding of the physiology of lactation and neonatal metabolic adaptation and the ability to communicate this to parents

    • recognising the risks, signs, and symptoms of domestic abuse and whom to contact for advice and management, as recommended by Department of Health guidance

    • recognising the risks, signs, and symptoms of child abuse and whom to contact for advice and management, as recommended by Department of Health guidance

Maternal health

Information giving

  • At the first postnatal contact, women should be advised of the signs and symptoms of potentially life-threatening conditions and to contact their healthcare professional immediately or call for emergency help if any signs and symptoms occur

  • The Department of Health booklet ‘Birth to five’, which is a guide to parenthood and the first 5 years of a child’s life, should be given to all women within 3 days of birth (if it has not been received antenatally)

  • The personal child health record should be given to all women as soon as possible (if it has not been received antenatally) and its use explained

  • Women should be offered information and reassurance on:

    • the physiological process of recovery after birth (within the first 24 hours)

    • normal patterns of emotional changes in the postnatal period and that these usually resolve within 10–14 days of giving birth (within 3 days)

    • common health concerns as appropriate (weeks 2–8)

Life-threatening conditions: core care and raised concern

Postpartum haemorrhage

  • In the absence of abnormal vaginal loss, assessment of the uterus by abdominal palpation or measurement as a routine observation is unnecessary

Genital tract sepsis

  • In the absence of any signs and symptoms of infection, routine assessment of temperature is unnecessary

Thromboembolism

  • Women should be encouraged to mobilise as soon as appropriate following the birth

Mental health and wellbeing

  • At each postnatal contact, women should be asked about their emotional wellbeing, what family and social support they have and their usual coping strategies for dealing with day-to-day matters. Women and their families/partners should be encouraged to tell their healthcare professional about any changes in mood, emotional state, and behaviour that are outside of the woman’s normal pattern

  • Formal debriefing of the birth experience is not recommended

  • All healthcare professionals should be aware of signs and symptoms of maternal mental health problems that may be experienced in the weeks and months after the birth

  • At 10–14 days after birth, women should be asked about resolution of symptoms of baby blues (for example, tearfulness, feelings of anxiety, and low mood). If symptoms have not resolved, the woman should be assessed for postnatal depression, and if symptoms persist, evaluated further (urgent action)

  • Women should be encouraged to help look after their mental health by looking after themselves. This includes taking gentle exercise, taking time to rest, getting help with caring for the baby, talking to someone about their feelings, and ensuring they can access social support networks

Physical health and wellbeing

Perineal care

  • At each postnatal contact, women should be asked whether they have any concerns about the healing process of any perineal wound; this might include experience of perineal pain, discomfort or stinging, offensive odour, or dyspareunia

  • The healthcare professional should offer to assess the perineum if the woman has pain or discomfort

  • Women should be advised that topical cold therapy, for example crushed ice or gel pads, are effective methods of pain relief for perineal pain

  • If oral analgesia is required, paracetamol should be used in the first instance unless contraindicated

  • If cold therapy or paracetamol is not effective a prescription for oral or rectal non-steroidal anti-inflammatory (NSAID) medication should be considered in the absence of any contraindications (non-urgent action)

  • Signs and symptoms of infection, inadequate repair, wound breakdown, or non-healing should be evaluated (urgent action)

  • Women should be advised of importance of perineal hygiene, including frequent changing of sanitary pads, washing hands before and after doing this, and daily bathing or showering to keep their perineum clean

Dyspareunia

  • Women should be asked about resumption of sexual intercourse and possible dyspareunia 2–6 weeks after the birth

  • If a woman expresses anxiety about resuming intercourse, reasons for this should be explored

  • Women with perineal trauma who experience dyspareunia should be offered an assessment of the perineum. (See perineal care above)

  • A water-based lubricant gel to help ease discomfort during intercourse may be advised, particularly if a woman is breastfeeding

  • Women who continue to express anxiety about sexual health problems should be evaluated (non-urgent action)

Headache

  • Women should be asked about headache symptoms at each postnatal contact

  • Women who have had epidural or spinal anaesthesia should be advised to report any severe headache, particularly one which occurs while sitting or standing

  • Management of mild postnatal headache should be based on differential diagnosis of headache type and local treatment protocols

  • Women with tension or migraine headaches should be offered advice on relaxation and how to avoid factors associated with the onset of headaches

Fatigue

  • Women who report persistent fatigue should be asked about their general wellbeing, and offered advice on diet, exercise and planning activities, including spending time with her baby

  • If persistent postnatal fatigue impacts on the woman’s care of herself or baby, underlying physical, psychological, or social causes should be evaluated

  • If a woman has sustained a postpartum haemorrhage, or is experiencing persistent fatigue, her haemoglobin level should be evaluated and if low, treated according to local policy

Backache

  • Women experiencing backache in the postnatal period should be managed as in the general population

Constipation

  • Women should be asked if they have opened their bowels within 3 days of the birth

  • Women who are constipated and uncomfortable should have their diet and fluid intake assessed and offered advice on how to improve their diet

  • A gentle laxative may be recommended if dietary measures are not effective

Haemorrhoids

  • Women with haemorrhoids should be advised to take dietary measures to avoid constipation and should be offered management based on local treatment protocols

Urinary incontinence

  • Women with involuntary leakage of a small volume of urine should be taught pelvic floor exercises

  • Women with involuntary leakage of urine which does not resolve or becomes worse should be evaluated

Contraception

  • Methods and timing of resumption of contraception should be discussed within the first week of the birth

  • The coordinating healthcare professional should provide proactive assistance to women who may have difficulty accessing contraceptive care. This includes providing contact details for expert contraceptive advice

Immunisation

  • Women found to be sero-negative on antenatal screening for rubella should be offered an MMR (measles, mumps, rubella) vaccination following birth

  • See the Public Health England/Department of Health guidance, Immunisation against infectious disease (2013) (the Green Book) for guidance on the timing of MMR vaccination in women who are sero-negative for rubella who also require anti-D immunoglobulin injection

  • Women should be advised that pregnancy should be avoided for 1 month after receiving MMR, but that breastfeeding may continue

Safety

Domestic abuse

  • Healthcare professionals should be aware of the risks, signs and symptoms of domestic abuse and know who to contact for advice and management, following guidance from the Department of Health

6–8-week check

  • At the end of the postnatal period, the coordinating healthcare professional should ensure that the woman’s physical, emotional, and social wellbeing is reviewed. Screening and medical history should also be taken into account

Infant feeding

Box 1. Breastfeeding

  • Indicators of good attachment and positioning:

    • mouth wide open

    • less areola visible underneath the chin than above the nipple

    • chin touching the breast, lower lip rolled down, and nose free

    • no pain

  • Indicators of successful feeding in babies:

    • audible and visible swallowing

    • sustained rhythmic suck

    • relaxed arms and hands

    • moist mouth

    • regular soaked/heavy nappies

  • Indicators of successful breastfeeding in women:

    • breast softening

    • no compression of the nipple at the end of the feed

    • woman feels relaxed and sleepy

Expression and storage of breast milk

  • All breastfeeding women should be shown how to hand express their colostrum or breast milk and advised on how to correctly store and freeze it

  • Breast pumps should be available in hospital, particularly for women who have been separated from their babies, to establish lactation. All women who use a breast pump should be offered instructions on how to use it

Preventing, identifying, and treating breastfeeding concerns

Nipple pain

  • Women should be advised that if their nipples are painful or cracked, it is probably due to incorrect attachment

  • If nipple pain persists after repositioning and re-attachment, assessment for thrush should be considered

Engorgement

  • Women should be advised that their breasts may feel tender, firm, and painful when milk ‘comes in’ at or around 3 days after birth

  • A woman should be advised to wear a well-fitting bra that does not restrict her breasts

  • Breast engorgement should be treated with:

    • frequent unlimited breastfeeding including prolonged feeding from the affected breast

    • breast massage and, if necessary, hand expression

    • analgesia

Mastitis

  • Women should be advised to report any signs and symptoms of mastitis including flu like symptoms, red, tender and painful breasts to their healthcare professional urgently

  • Women with signs and symptoms of mastitis should be offered assistance with positioning and attachment and advised to: 

    • continue breastfeeding and/or hand expression to ensure effective milk removal; if necessary, this should be with gentle massaging of the breast to overcome any blockage

    • take analgesia compatible with breastfeeding, for example paracetamol

    • increase fluid intake

  • If signs and symptoms of mastitis continue for more than a few hours of self management, a woman should be advised to contact her healthcare professional again (urgent action)

  • If the signs and symptoms of mastitis have not eased, the woman should be evaluated as she may need antibiotic therapy (urgent action)

Inverted nipples

  • Women with inverted nipples should receive extra support and care to ensure successful breastfeeding

Ankyloglossia (tongue tie)

  • Evaluation for ankyloglossia should be made if breastfeeding concerns persist after a review of positioning and attachment by a skilled healthcare professional or peer counsellor

  • Babies who appear to have ankyloglossia should be evaluated further (non-urgent action)

Sleepy baby

  • Women should be advised that skin-to-skin contact or massaging a baby’s feet should be used to wake the baby. The baby’s general health should be assessed if there is no improvement

Formula feeding

  • All parents and carers who are giving their babies formula feed should be offered appropriate and tailored advice on formula feeding to ensure this is undertaken as safely as possible, in order to enhance infant development and health, and fulfil nutritional needs

  • A woman who wishes to feed her baby formula milk should be taught how to make feeds using correct, measured quantities of formula, as based on the manufacturer’s instructions, and how to clean and sterilise bottles and teats and how to store formula milk

  • Parents and family members should be advised that milk, either expressed milk or formula should not be warmed in a microwave

  • Breastfeeding women who want information on how to prepare formula feeds should be advised on how to do this

Maintaining infant health

  • Healthy babies should have normal colour for their ethnicity, maintain a stable body temperature, and pass urine and stools at regular intervals. They initiate feeds, suck well on the breast (or bottle), and settle between feeds. They are not excessively irritable, tense, sleepy, or floppy. The vital signs of a healthy baby should fall within the following ranges:

    • respiratory rate normally 30−60 breaths per minute

    • heart rate normally between 100 and 160 beats per minute in a newborn

    • temperature in a normal room environment of around 37°C (if measured)

  • At each postnatal contact, parents should be offered information and advice to enable them to:

    • assess their baby’s general condition

    • identify signs and symptoms of common health problems seen in babies

    • contact a healthcare professional or emergency service if required

  • Parents, family members and carers should be offered information and reassurance on:

    • the availability, access, and aims of all postnatal peer, statutory and voluntary groups and organisations in their local community (within 2–8 weeks)

  • Both parents should be encouraged to be present during any physical examination of their baby to promote participation of both parents in the care of their baby and enable them to learn more about their baby’s needs

Parenting and emotional attachment

  • Assessment for emotional attachment should be carried out at each postnatal contact

  • Home visits should be used as an opportunity to promote parent- or mother-to-baby emotional attachment

  • Women should be encouraged to develop social networks as this promotes positive mother−baby interaction

  • Group based parent-training programmes designed to promote emotional attachment and improve parenting skills should be available to parents who wish to access them

  • Healthcare providers should offer fathers information and support in adjusting to their new role and responsibilities within the family unit

Physical examination and screening

  • The aims of any physical examination should be fully explained and the results shared with the parents and recorded in the postnatal care plan and the personal child health record

  • A complete examination of the baby should take place within 72 hours of birth. This examination should incorporate a review of parental concerns and the baby’s medical history should also be reviewed including: family, maternal, antenatal, and perinatal history; fetal, neonatal, and infant history including any previously plotted birth-weight and head circumference; whether the baby has passed meconium and urine (and urine stream in a boy). Appropriate recommendations made by the UK National Screening Committee should also be carried out

  • A physical examination should also be carried out. This should include checking the baby’s:

    • appearance including colour, breathing, behaviour, activity, and posture

    • head (including fontanelles), face, nose, mouth including palate, ears, neck, and general symmetry of head and facial features. Measure and plot head circumference

    • eyes; check opacities and red reflex

    • neck and clavicles, limbs, hands, feet, and digits; assess proportions and symmetry

    • heart; check position, heart rate, rhythm and sounds, murmurs, and femoral pulse volume

    • lungs; check effort, rate, and lung sounds

    • abdomen; check shape and palpate to identify any organomegaly; also check condition of umbilical cord

    • genitalia and anus; check for completeness and patency and undescended testes in males

    • spine; inspect and palpate bony structures and check integrity of the skin

    • skin; note colour and texture as well as any birthmarks or rashes

    • central nervous system; observe tone, behaviour, movements, and posture. Elicit newborn reflexes only if concerned

    • hips; check symmetry of the limbs and skin folds (perform Barlow and Ortolani’s manoeuvres)

    • cry; note sound

    • weight; measure and plot

  • The newborn blood spot test should be offered to parents when their baby is 5–8 days old

  • At 6–8 weeks, an examination, comprising the items listed for the physical examination above, should be carried out. In addition, an assessment of social smiling and visual fixing and following should be carried out

  • A hearing screen should be completed by week 5 in the community programme

  • Parents should be offered routine immunisations for their baby according to the schedule recommended by the Department of Health

Physical health and wellbeing

Jaundice

  • Parents should be advised to contact their healthcare professional if their baby is jaundiced, their jaundice is worsening, or their baby is passing pale stools

  • If jaundice develops in babies aged 24 hours and older, its intensity should be monitored and systematically recorded along with the baby’s overall wellbeing with particular regard to hydration and alertness

  • The mother of a breastfed baby who has signs of jaundice should be actively encouraged to breastfeed frequently, and the baby awakened to feed if necessary

  • Breastfed babies with jaundice should not be routinely supplemented with formula, water, or dextrose water

  • If a baby is significantly jaundiced or appears unwell, evaluation of the serum bilirubin level should be carried out

  • If jaundice first develops after 7 days or jaundice remains after 14 days in an otherwise healthy baby and a cause has not already been identified, it should be evaluated (urgent action)

Skin

  • Parents should be advised that cleansing agents should not be added to a baby’s bath water nor should lotions or medicated wipes be used. The only cleansing agent suggested, where it is needed, is a mild non-perfumed soap

  • Parents should be advised how to keep the umbilical cord clean and dry and that antiseptics should not be used routinely

Thrush

  • If thrush is identified in the baby, the breastfeeding woman should be offered information and guidance about relevant hygiene practices

  • Thrush should be treated with an appropriate antifungal medication if the symptoms are causing pain to the woman or the baby or feeding concerns to either

  • If thrush is non-symptomatic, women should be advised that antifungal treatment is not required

Nappy rash

  • For babies with nappy rash the following possible causes should be considered:

    • hygiene and skin care

    • sensitivity to detergents, fabric softeners, or external products that have contact with the skin

    • presence of infection

  • If painful nappy rash persists it is usually caused by thrush, and treatment with antifungal treatment should be considered

  • If after a course of treatment the rash does not resolve, it should be evaluated further (non-urgent action)

Constipation

  • If a baby is constipated and is formula fed the following should be evaluated: (urgent action)

    • feed preparation technique

    • quantity of fluid taken

    • frequency of feeding

    • composition of feed

Diarrhoea

  • A baby who is experiencing increased frequency and/or looser stools than usual should be evaluated (urgent action)

Colic

  • A baby who is crying excessively and inconsolably, most often during the evening, either drawing its knees up to its abdomen or arching its back, should be assessed for an underlying cause, including infant colic (urgent action)

  • Assessment of excessive and inconsolable crying should include:

    • general health of the baby

    • antenatal and perinatal history

    • onset and length of crying

    • nature of the stools

    • feeding assessment

    • woman’s diet if breastfeeding

    • family history of allergy

    • parent’s response to the baby’s crying

    • any factors which lessen or worsen the crying

  • Healthcare professionals should reassure parents of babies with colic that the baby is not rejecting them and that colic is usually a phase that will pass. Parents should be advised that holding the baby through the crying episode, and accessing peer support may be helpful

  • Use of hypoallergenic formula in bottle-fed babies should be considered for treating colic, but only under medical guidance

  • Dicycloverine (dicyclomine) should not be used in the treatment of colic due to side effects such as breathing difficulties and coma

Fever

  • The temperature of a baby does not need to be taken, unless there are specific risk factors, for example maternal pyrexia during labour

  • When a baby is suspected of being unwell, the temperature should be measured using electronic devices that have been properly calibrated and are used appropriately

  • A temperature of 38°C or more is abnormal and the cause should be evaluated (emergency action). A full assessment, including physical examination, should be undertaken

Safety

  • All home visits should be used as an opportunity to assess relevant safety issues for all family members in the home and environment and promote safety education

  • The healthcare professional should promote the correct use of basic safety equipment, including, for example, infant seats and smoke alarms and facilitate access to local schemes for provision of safety equipment

Co-sleeping and sudden infant death syndrome

  • Recognise that co-sleeping can be intentional or unintentional. Discuss this with parents and carers and inform them that there is an association between co-sleeping (parents or carers sleeping on a bed or sofa or chair with an infant) and sudden infant death syndrome (SIDS)

  • Inform parents and carers that the association between co-sleeping (sleeping on a bed or sofa or chair with an infant) and SIDS is likely to be greater when they, or their partner, smoke

  • Inform parents and carers that the association between co-sleeping (sleeping on a bed or sofa or chair with an infant) and SIDS may be greater with:

    • parental or carer recent alcohol consumption, or

    • parental or carer drug use, or

    • low birth weight or premature infants

Pacifier use

  • If a baby has become accustomed to using a pacifier (dummy) while sleeping, it should not be stopped suddenly during the first 26 weeks

Child abuse

  • Healthcare professionals should be alert to risk factors and signs and symptoms of child abuse

  • If there is raised concern, the healthcare professional should follow local child protection policies

full guideline available from…

National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT

www.nice.org.uk/guidance/cg37

National Institute for Health and Care Excellence. Postnatal care up to 8 weeks after birth. February 2015.

First included: April 2017.