The management and review of postnatal women are usually straightforward. There are a few points specific to postnatal women that are important to consider, which will be covered below.

Prior to Review

As with every patient, it is important to review the notes of postnatal women thoroughly.

Review the type of analgesia used during the labour and delivery process, specifically if an epidural or spinal block was used. This may increase the likelihood of certain complications that are important to look out for during the review.
Review what the type of delivery was (i.e. vaginal or caesarean section) and any instrumentation used (i.e. ventouse, forceps), as well as the circumstances of the delivery.
For a caesarean section delivery, look for the operation note as this detail any complications during the procedure and the reason for the procedure i.e. emergency or elective.
With all postnatal women, there will be documentation regarding the blood loss during the delivery. Blood loss over about 750ml is significant and will usually require repeat blood tests to monitor for further loss.
Look for any complications during the delivery such as 1st, 2nd or third-degree tears, massive haemorrhage or surgical complications.
Review the past medical history and drug history of women. Certain conditions such as pre-eclampsia can continue up to 6 weeks post-partum and therefore must be reviewed during a postnatal review.
Finally, check for any documentation regarding the health of the baby, as this will prevent any unnecessary emotional trauma brought up by asking about the baby’s wellbeing during a postnatal review.

Vaginal delivery

History

• Eating and drinking – ensure the patient is keeping well hydrated and managing to keep down food and fluid.
• Urinary and bowel habits – particularly ask for dysuria, hesitancy, volume, and frequency of urination. This helps to screen for infection and potential urinary retention. Always ensure to ask about bowel habits as a lack of bowel movements or passing wind could indicate constipation or an obstruction.
• Mobilising – ensure the woman can mobilise comfortably.
• Pain – always enquire about pain as an aid to ensure optimum analgesia is being given. Severe pain may indicate an underlying infection in the uterus or retained products which needs urgent management.
• Vaginal bleeding – It is vital to enquire about the volume of vaginal blood loss. Specifically, ask about sizes of a clot (significant if larger than a 10p piece), the number of pad changes and flooding. Generally, after a vaginal delivery, blood loss should be like that of a period or less. Anything more than this could indicate a secondary postpartum haemorrhage and therefore requires urgent investigation.
• Vaginal symptoms – Check specifically for abnormal discharge, that may be different in smell or appearance from the expected discharge. Foul discharge could be an early indicator of uterine infection.
• Breast symptoms – This is of less concern in an immediate postpartum woman, however generally if a woman has been breastfeeding, always enquire about breast pain, swelling, rashes or foul nipple discharge to screen for mastitis.
• Mood symptoms – Mood symptoms are a vital part of the history that are often missed. Always screen for postpartum depression or postpartum psychosis by enquiring about low mood, poor sleep, poor appetite and any hallucinations or delusions.

Examination

• Observations – always look out for any indications of hypovolemic shock i.e. hypotension and tachycardia, and indications of impending infection i.e. fever and/or tachycardia.
• Pallor and appearance – As with all patients review for any obvious abnormalities such as pallor or obvious indications of dehydration or shock.
• Abdominal examination – palpate all regions of the abdomen. In the suprapubic region palpate for the uterus. Usually, this should feel like a boggy mass and should be felt well below the umbilicus, around the size of a fist or melon. This indicates that the uterus has contracted down well post-delivery. If this is not the case, then the woman will require monitoring for signs of postpartum bleeding or infection.
• Vaginal examination – In women who have required suturing around the vagina secondary to tears it is important to do a vaginal examination. Always ensure you offer a chaperone before doing so. Examine the wound for any obvious signs of infection, gaping or bleeding. Look for evidence of abnormal swelling and if indicated palpate the region for any warmth, excessive tenderness or masses which could indicate an underlying abscess.

Investigations

• Urine dip/MSU – Only if urinary symptoms are present i.e. dysuria, haematuria, increased frequency, or urgency.
• High vaginal or low vaginal swab – If there is evidence of foul PV loss or abnormal vaginal symptoms.
• Bloods – Monitor haemoglobin levels in those who have had a third-degree tear or significant blood loss during the delivery. In women with low haemoglobin levels, check iron levels and replace accordingly.

Discharge and Follow up

Most women who have had uncomplicated vaginal deliveries do not require any additional follow up. They can be discharged either on the same day or the following day post-delivery if they are well, eating and drinking, passing urine, opening their bowels and mobilising. Women with second- or third-degree tears will need nurse follow-up from their GPs for wound inspection and suture removal.

Caesarean Section

History

• Eating and drinking.
• Urinary and bowel habits – This is especially important in a surgical delivery.
• Women are catheterised during delivery and you need to ensure that their catheter is removed once they are mobile. Always monitor urinary output to look for signs of shock or potential bladder damage during the procedure. Haematuria can also indicate damage to the bladder or urethra.
• Check that the woman is opening her bowels or passing wind to rule out bowel obstruction.
• Mobilising – early mobilisation is vital post-c-section to prevent the risk of venous thromboembolism.
• Pain – Always enquire about pain. As before, severe pain can indicate uterine infection or retained products. Furthermore, always remember to ask about pain at the scar site to screen for infection or wound rupture.
• Vaginal blood loss – Blood loss post caesarean section should be similar to that of a period. Again, ensure that she has no signs of flooding or large clot loss as this could indicate a secondary postpartum haemorrhage.
• Vaginal symptoms – Check for abnormal/foul discharge.
• Breast symptoms
• Mood symptoms

Examination

• Observations – always look out for any indications of hypovolemic shock i.e. hypotension and tachycardia, and indications of impending infection i.e. fever and/or tachycardia.
• Pallor and appearance – As with all patients review for any obvious abnormalities such as pallor or obvious indications of dehydration or shock.
• Abdominal examination – Generally look for signs of gross distension. Palpate all regions of the abdomen, checking for any evidence of peritonitis. In the suprapubic region palpate for the uterus. As before this should be felt well below the umbilicus, around the size of a fist or melon, which indicates that the uterus has contracted down well. Palpation above the uterus will be tender for the patient but tolerable. If the uterus is very tender several days post-delivery this could indicate an infection. Always auscultate for bowel sounds to rule out obstruction.
• Scar site – Check the C section scar for infection, increased bleeding or gaping. Ask the woman to cough whilst palpating the wound to ensure there is no incisional hernia.
• Vaginal examination – This is usually not indicated post-Caesarean section. If you suspect any vaginal infection or post-partum haemorrhage then it may be appropriate to do a vaginal examination. Always offer a chaperone and document the indications and findings of these examinations.
• Calves – check for tenderness and swelling at the calves, as women postnatally are more at risk of deep vein thrombosis. Also, check for any weakness or numbness by doing a gross neurological examination.

Investigations

• Urine dip/MSU
• High vaginal or low vaginal swab.
• ECG – this is only required if you suspect any cardiac involvement such as unexplained tachycardia or as part of a work-up for venous thromboembolism.
• Bloods – Monitor haemoglobin levels if there has been significant blood loss. Also, check renal function post-surgery to screen for acute kidney injury secondary to hypovolemia which requires treatment.
• Abdominal X-ray – this can be done if you suspect bowel obstruction.
• Chest X-ray – A chest X-ray can be used as part of the workup if you suspect a bowel perforation (to look for air under the diaphragm.) It can also be used as part of a septic screen.
• Ultrasound abdomen – This can be used if you suspect retained products post-delivery, if there is ongoing bleeding.
• Ultrasound doppler – If DVT is suspected.

Discharge and Follow up

Most women post-c-section can be sent home 1-2 days after delivery. This obviously varies based on local guidelines, but if the woman is mobilising, tolerating food and fluids, passing urine, and passing wind then it is safe to send them home.

Many women with a C section are sent home with VTE prophylaxis so ensure you review your local guidelines. Most women with a c-section do not require follow up, however, if you are concerned then they can usually be brought back to the maternity assessment unit or to their GP.

Finally, don’t forget to ask about plans for future pregnancies and whether they would like any advice on contraception!

Common conditions/ emergencies in postnatal patients

Post-partum haemorrhage

This is one of the commonest emergencies post vaginal or surgical delivery.

The commonest cause of this uterine atony i.e. poor uterine contraction. Other causes include retained products of conception and uterine infection. First-line management of post-partum haemorrhage is uterine massage. As a junior doctor, if there is persistent vaginal bleeding or signs of hemodynamic instability manage the case in an A to E format. Ensure you have adequate IV access, IV fluids or blood if appropriate, bloods – FBC, CRP, U&Es, Group and Save and clotting. Get help early. The major haemorrhage protocol can be activated if you are concerned about a massive haemorrhage.
 
Pre-eclampsia
Pre-eclampsia is often forgotten about post-delivery, but it is vital to remember that the symptoms of this condition can often persist up to 6 weeks post-delivery. In all women with a history of pre-eclampsia, their blood pressure must be monitored regularly post-delivery. If the blood pressure exceeds 140/90 then check their urine for protein. Along with this do a full set of bloods including liver function, full blood count, renal function and clotting. This is to check for a condition called HELLP (haemolysis, elevated liver enzymes and low platelet count) which is an often life-threatening complication of pre-eclampsia. In pre-eclampsia, blood pressure must be controlled with antihypertensives. Check local guidelines for recommendations on medications to be used.
Pre-eclampsia can rapidly deteriorate to eclampsia in which women will have uncontrolled seizures. If a woman is symptomatic with headaches, nausea, abdominal pain, visual changes and uncontrolled hypertension then get senior help immediately. They will often require 2g magnesium sulphate to control impending seizures or treat seizures
Endometritis
Endometritis is an infection of the endometrial tissue; it is common post-surgical or instrumental delivery in women. If a woman has signs of infection, persistent vaginal bleeding, a disproportionately tender uterus and foul vaginal loss then always screen for endometritis. Take a high and low vaginal swab and treat them empirically with antibiotics based on local guidelines. Endometritis can rapidly progress to further systemic infection, so it is vital to treat this early.
Deep vein thrombosis (DVT)
Pregnant women are naturally in a state of pro-coagulation, making them more prone to developing thrombi. This extends in the early post-partum period combined with poor mobility. Ensure that you are prescribing either mechanical or pharmacological VTE prophylaxis whilst the patient is in hospital. In surgical patients extend this to post-discharge. Investigate with an USS doppler if you suspect a DVT.
Neuropathic pain 
The pelvis has many nerves running through and around it to the lower limbs. Many of these nerves can be impinged or affected during delivery. Neuropathic lower limb pain can commonly occur post-delivery. This usually self resolves within 6 weeks. However, in some women, this can be excruciating and therefore they may need the prescription of neuropathic pain relief such as gabapentin. Always ensure to check if they are breastfeeding as many of these medications are not suitable during breastfeeding.
Ensure you rule out cauda equina syndrome in any woman postpartum presenting with neuropathic leg pain. Cauda equina syndrome occurs when there is compression of the spinal nerve roots and requires urgent surgical decompression to preserve lower limb function. This can occur more commonly in surgical deliveries or if there has been a complicated epidural/spinal anaesthetic administered. Screening for cauda equina syndrome requires a full neurological lower limb examination, PR exam and sometimes catheterising the patient if they are retaining urine. If you suspect cauda equina then escalate immediately and arrange an urgent MRI spine. Keep the patient nil by mouth until you get the results of the imaging as they may later require surgical decompression.

Further Reading

https://patient.info/doctor/postnatal-care-puerperium
https://www.uptodate.com/contents/overview-of-the-postpartum-period-physiology-complications-and-maternal-care
https://pathways.nice.org.uk/pathways/postnatal-care

Written by Dr Thujina Nathan (FY2)