Postnatal care and contraception after birth

• The postnatal period is a time of rapid physical and emotional change for the mother and of establishment of feeding and observation for the baby; most problems show in the first two weeks, but systematic follow-up runs to six to eight weeks and beyond.
• Good postnatal care listens to the woman, checks her general, mental, physical and pelvic health (including perineal healing and pelvic floor function), and examines the baby fully at least twice.
• Lochia (the normal postpartum vaginal discharge) is expected to lessen and change colour over weeks; sudden heavy bleeding, rising bleeding, clots or foul smell need urgent assessment.
• A woman can become pregnant again soon after birth even if she is breastfeeding. All women who do not wish to conceive should have a contraceptive plan started by 21 days after childbirth.
• Lactational amenorrhoea is a highly effective natural contraceptive while a woman is less than six months postnatal, amenorrhoeic and fully breastfeeding.

By the end of this topic you should be able to:

1. Describe the standard schedule of postnatal contacts and examinations for mother and baby, and the observations at each contact.
2. Recognise the normal course of lochia and the features of postpartum bleeding that require urgent review.
3. Explain the risk factors for pelvic floor dysfunction after birth and the preventive and therapeutic role of pelvic floor muscle training. ^[2]
4. Plan the postpartum health and illness checks for a newborn, including the red flags that indicate serious illness.
5. Counsel a woman on contraceptive options after birth, their earliest safe start dates, additional precautions, and the impact on breastfeeding.
6. Apply the criteria for lactational amenorrhoea and know its limitations.

Postnatal care spans two patients who influence each other: a recovering mother and a newborn adjusting to extrauterine life. It is not a single visit but a series of contacts that taper from intensive (the first days) to a structured community review. Because complications after birth are a leading cause of maternal death, and because the early days set feeding, bonding and family health in motion, every contact is an opportunity to screen, advise and refer.

A small but important point on language: the woman may not identify as female, and parents include anyone with main responsibility for the baby. The terms used here follow the NICE guideline, which is deliberately inclusive.

After a birth the woman and baby move from intensive care (delivery unit) to community care. NICE NG194 structures this in several specific steps.

• Before transfer from the maternity unit, or before the midwife leaves after a home birth, staff assess the woman's health, measure the volume of her first void (postpartum bladder function), assess the baby's health, and confirm a feeding plan that includes observing at least one effective feed. If the baby has not passed meconium, parents are advised that within 24 hours of birth this needs medical review.^[1]
• The first postnatal midwife visit takes place within 36 hours of transfer or home birth, face-to-face and usually at home.^[1]
• The first health visitor visit is considered between 7 and 14 days after transfer from midwifery care, so that contacts are spread rather than clustered.^[1]
• At 6 to 8 weeks after birth, a general practitioner carries out a comprehensive review of both mother and baby.^[1]

At each postnatal contact the woman should be asked about her general health and wellbeing, and given the chance to raise concerns. Topics include the normal postpartum course, mental health, physical symptoms, pelvic floor exercises, fatigue, nutrition and activity, contraception, sexual intercourse, and safeguarding including domestic abuse.^[1]

Her emotional and psychological wellbeing is assessed at every contact, with referral and follow-up when concerns arise.^[1] At each midwife contact her physical health is reviewed: infection, pain, vaginal discharge and bleeding, bladder and bowel function, breast problems, symptoms of thromboembolism, anaemia, pre-eclampsia, perineal healing after vaginal birth, and wound healing after caesarean section.^[1]

This broad screen matters because the postpartum risks do not all peak in the first week. Thromboembolic risk is highest in the early weeks; anaemia may only become symptomatic after discharge; and mood deterioration can first present at a six-week check.

Postpartum outcomes in the UK show marked inequalities. Compared with white women, the risk of maternal death during pregnancy and up to six weeks after birth is four times higher in Black women, three times higher in women of mixed ethnicity and two times higher in Asian women; women in the most deprived areas are more than two and a half times more likely to die than those in the least deprived. Neonatal mortality is around 50% higher in Black and Asian babies and almost twice as high in the most deprived areas compared with the least deprived.^[1] These figures are not a reason for different standards of care; they are a reason for closer attention to known risk groups, proactive follow-up and accessible communication.

Perineal healing is checked after vaginal birth. At each contact the woman is asked about:

• pain that is not resolving or is worsening;
• increasing need for pain relief;
• discharge with a strong or unpleasant smell;
• swelling;
• wound breakdown.^[1]

Good perineal hygiene is reinforced: daily showering of the perineum, frequent changing of sanitary pads, and hand washing before and after care. Pain relief choices should take breastfeeding into account.^[1] A validated pain scale can be used to monitor perineal pain.^[1] If there are concerns, an examination by a midwife or doctor should be offered. Perineal wound breakdown, or ongoing healing concerns, are referred urgently to maternity services on the same day.^[1]

Perineal pain that persists or worsens in the first weeks may be associated with depression, long-term perineal pain and psychosexual difficulties. Risk factors for persistent perineal pain include episiotomy or tear, assisted vaginal birth, wound infection or breakdown, and a birth experienced as traumatic.^[1]

Women should be told what vaginal bleeding to expect and advised to seek medical advice if:

• the bleeding is sudden or very heavy;
• the bleeding increases rather than decreases;
• they pass clots, placental tissue or membranes;
• they have symptoms of possible infection: abdominal, pelvic or perineal pain, fever, shivering, or discharge with an unpleasant smell;
• they have any concern about vaginal bleeding after the birth.^[1]

Heavy secondary postpartum haemorrhage (bleeding that comes back or increases after the first 24 hours) may indicate retained placental tissue or endometritis and should be assessed for severity, with particular attention to anaemia and low body weight.^[1]

At the first midwife contact the woman is warned that sudden or very heavy vaginal bleeding, abdominal, pelvic or perineal pain, fever, shivering, offensive discharge, leg swelling or tenderness, shortness of breath, chest pain, persistent or severe headache, or worsening breast inflammation beyond 24 hours may indicate a serious condition and need medical advice without delay.^[1]

The pelvic floor muscles support the bladder, anal canal and vagina, and the birth process can stretch, bruise or tear them. After delivery some women develop stress or mixed urinary incontinence, faecal incontinence, pelvic organ prolapse, painful intercourse or chronic pelvic pain. These problems are common, treatable and too often unreported because of embarrassment; raising them routinely reduces this.^[2]

Risk factors for pelvic floor dysfunction relevant to pregnancy and birth include:

• being over 30 years when having the baby; ^[2]
• having had previous births;
• an active second stage of labour taking more than one hour; ^[2]
• assisted vaginal birth (forceps or vacuum);
• a vaginal birth with the baby in the occipito-posterior position (face up);
• injury to the anal sphincter during birth.^[2]

Other contributors are a body mass index above 25 kg/m2, smoking, constipation, diabetes, and increasing age.^[2]

NICE NG210 recommends that pelvic floor dysfunction be discussed at each postnatal contact in hospital and in the community, and that women with recently given birth be asked about symptoms of pelvic floor dysfunction during routine care.^[2] Information on pelvic floor dysfunction should reach women in the booking pack and patient portal, at every midwife and obstetric consultation, and on the postnatal ward.^[2]

Pelvic floor muscle training means structured exercises to improve pelvic floor strength, endurance and relaxation. It should be encouraged during pregnancy and after birth, because long-term training helps prevent symptoms.^[2]

• A supervised three-month programme is considered from week 20 of pregnancy when there is a first-degree relative with pelvic floor dysfunction, and during postnatal care for women with assisted vaginal birth, an occipito-posterior position, or anal sphincter injury.^[2]
• Before discharge from maternity services, and during routine postnatal care, women are encouraged to do pelvic floor muscle training.^[2]
• Programmes are supervised by a physiotherapist or another professional with the appropriate expertise.^[2]

For symptoms that are present, NICE recommends offering a supervised programme for at least three months for stress or mixed urinary incontinence, and considering a supervised programme for at least four months for symptomatic pelvic organ prolapse limited to one centimetre beyond the hymen on straining, and for faecal incontinence with coexisting prolapse.^[2]

Giving birth is a recognised stressor and mental illness in the postpartum period is common, ranging from transient mood change to depression and psychosis. NICE NG194 therefore requires psychological and emotional assessment at every contact, with follow-up and referral when concerns arise; it also embeds family violence, disclosure and support. Women should be given ways to raise concerns privately, without a partner or relative present, and pathways to specialist services should be agreed in advance. Postnatal depression is covered in the dedicated topic on mental health; what matters here is the rule that routine screening and asking, not waiting for self-disclosure, is the standard.

Routine advice in the postpartum weeks includes:

• gentle return to activity, building up from walking, with heavy lifting and high-impact exercise deferred until healing and floor strength allow;
• attention to nutrition and fluids, particularly when breastfeeding;
• smoking cessation and alcohol guidance;
• support for fatigue and sleep;
• review of constipation, which is common after birth and after perineal trauma;
• sexual health: intercourse can be resumed when the woman is comfortable; non-hormonal contraception, such as condoms, remains necessary if she is not using another method.

Contraception needs are discussed in their own section below.

At each postnatal contact, parents are asked about the baby's general wellbeing, feeding and development, and the baby is assessed by history and examination.^[1] The complete physical examination is carried out within 72 hours of birth and again at six to eight weeks, covering the items of the national newborn and infant physical examination programme, including heart, hips, eyes, testes and general appearance.^[1]

In hospital or before transfer, vitamin K prophylaxis is offered to prevent vitamin K deficiency bleeding, newborn blood spot and hearing screening are undertaken, and immunisations are arranged according to the national schedule.^[1]

Useful objective markers in the first weeks:

• weight and head circumference are measured in the first week and at around eight weeks.^[1]
• the baby should pass meconium within 24 hours of birth; if not, this may indicate a serious disorder and needs medical advice.^[1]
• vitamin D and feeding advice are offered, including safe formula preparation when used.^[1]

Feeding is reviewed at every contact. For breastfeeding, this includes observation of a feed, attachment and milk transfer, weight gain, wet and dirty nappies, and prevention and treatment of common problems such as mastitis and pain.^[1] Formula-feeding parents receive one-to-one discussion of safe preparation, sterilisation and responsive bottle feeding.^[1] Lactation suppression is discussed when breastfeeding is contraindicated or not started.^[1]

NICE NG194 lists red flags of serious illness in young babies: looking ill to a healthcare professional, pallor, mottling or cyanosis, being unresponsive or unrousable, an abnormal cry (weak, high-pitched or continuous), abnormal breathing (grunting, a rate over 60 breaths per minute, chest indrawing), a temperature of 38 degrees Celsius or above or below 36 degrees Celsius, a non-blanching rash, a bulging fontanelle, neck stiffness, seizures, focal neurological signs, diarrhoea with dehydration, frequent projectile vomiting, or bilious (green or yellow-green) vomiting.^[1]

Where a baby is thought to be seriously unwell on a red flag or overall assessment, an immediate assessment by an appropriate emergency service is arranged, and emergency services are called if the condition is immediately life-threatening.^[1]

Parents are advised on established safer sleep practice, including not bed-sharing when the baby is low birthweight, when either parent has had two or more units of alcohol, smokes, has taken sedating medicines, or has used recreational drugs; and on a firm flat mattress, face-up positioning, and keeping pillows, duvets and other children or pets away from the baby in the bed.^[1]

Support for bonding and emotional attachment includes encouraging skin-to-skin contact, face-to-face interaction, responding to the baby's cues, while acknowledging the challenges of the period, including fatigue, feeding concerns and recovery from birth.^[1]

Childbirth does not confer a long period of infertility. Ovulation can occur before the first menstrual period returns even in a non-breastfeeding woman. An interpregnancy interval of less than 12 months between birth and the next conception is associated with an increased risk of preterm birth, low birthweight and small-for-gestational-age babies.^[3] The first three weeks after birth do not require contraception, because fertilisation before day 21 is not expected to result in a viable pregnancy, but a method should be chosen and in place by day 21.^[3]

Antenatal contraceptive counselling allows a woman to choose a method before the competing demands of new parenthood arise and makes immediate provision after birth more likely.

The FSRH guideline expects that every woman after birth is offered all appropriate methods, including long-acting reversible contraception, before she is discharged, by staff trained to provide them, with bridging methods and referral pathways where provision is not possible.^[3]

Selection depends on three things:

1. Medical eligibility. Postpartum physiology creates its own constraints: venous thromboembolism risk in the first six weeks, breastfeeding status, wound healing and anaemia.
2. Effectiveness. Long-acting reversible contraception (the copper and levonorgestrel intrauterine devices and the progestogen-only implant) is more effective at preventing unintended pregnancy than user-dependent methods.
3. Preference, including cultural, personal and practical factors. Women should never feel pressured toward a longer-acting method.

Medical eligibility is assessed against the UK Medical Eligibility Criteria for Contraceptive Use, as cross-referenced by the FSRH guideline.

The copper intrauterine device can also be inserted within the first 48 hours after birth; after that window it is delayed until 28 days, because the risks of insertion between 48 hours and 28 days generally outweigh the benefits.^[3] If contraception is started 21 days or more after birth, additional precautions are required until the method takes effect; no additional precautions are needed if it is started immediately or within 21 days, unless specifically advised.^[3]

Combined hormonal contraception needs particular care in the postpartum period because of venous thromboembolism risk. It is avoided by women with VTE risk factors for six weeks after childbirth, including immobility, transfusion at delivery, a body mass index of 30 kg/m2 or above, postpartum haemorrhage, caesarean delivery, pre-eclampsia or smoking. Women who are not breastfeeding and have no additional VTE risk factors should wait until 21 days before starting combined hormonal contraception; women who are breastfeeding should wait until six weeks.^[3]

Despite a theoretical concern about oestrogen and milk, the better quality studies of early initiation found no adverse effect on breastfeeding performance (duration of breastfeeding, exclusivity, or timing of starting supplementary feeding) or infant outcomes beyond the six-week restriction above.^[3]

Progestogen-only methods (the pill, implant, injectable and levonorgestrel intrauterine device) can be used at any time after birth, including immediately, and progestogen-only methods have no adverse effects on lactation, infant growth or development.^[3] This makes them the default choice for women who are breastfeeding and want hormonal contraception.

A complete discussion of each method's use outside the postpartum setting is in the contraception topic; here the focus is on timing.

A woman may be advised that if she is less than six months postpartum, amenorrhoeic (no menstrual bleeding after day 56) and fully breastfeeding, LAM is a highly effective method of contraception.^[3]

The risk of pregnancy rises if the frequency of breastfeeding decreases, for example stopping night feeds, starting or increasing supplementary feeding, using dummies or pacifiers, expressing milk, when menstruation returns, or beyond six months postpartum.^[3]

Important practice points:

• LAM does not protect against sexually transmitted infections.
• "Fully breastfeeding" means exclusive or almost exclusive breastfeeding day and night; partial breastfeeding or feeding schedules reduce effectiveness.
• As soon as one of the criteria fails, another method should already have been chosen.

Emergency contraception is indicated only from 21 days after childbirth: levonorgestrel 1.5 mg and ulipristal acetate 30 mg are safe from 21 days, and the copper intrauterine device for emergency contraception from 28 days. A woman who is breastfeeding should not breastfeed and should express and discard milk for a week after taking ulipristal acetate.^[3] Before day 21 no emergency contraception is needed, because pregnancy arising from intercourse in that window is not expected to succeed.^[3]

Copper or levonorgestrel intrauterine devices can be inserted immediately postpartum (within 10 minutes of placental delivery) or within the first 48 hours after birth; after 48 hours they are delayed to 28 days because insertion in the intervening window carries higher risks.^[3] The immediate approach is convenient, highly acceptable to women, associated with high continuation rates and reduces unintended pregnancy, but expulsion rates are higher than after an interval insertion, and women should be warned of this. Expulsion rates are lower after caesarean delivery than after vaginal insertion in some series; checking the device at follow-up is essential.

• Condoms are safe at any time after birth, including for water birth or perineal trauma, and they offer infection protection.
• Diaphragm or cap should not be fitted until at least six weeks postpartum, because uterine size and pelvic dimensions are still changing.^[3]
• Female sterilisation is a safe permanent option after birth; consent should ideally be obtained and documented at least two weeks before an elective caesarean section, and women should be advised of LARC alternatives and of the greater regret risk with early sterilisation after delivery.^[3]
• Fertility awareness methods are difficult to use postpartum because ovulation may precede the first bleed and the temperature and cervical mucus patterns are unreliable while breastfeeding.^[3]

Contraceptive discussion should begin antenatally and continue through the postpartum contacts. Maternity services should be able to provide intrauterine contraception and progestogen-only methods, including implant, injectable and pill, before discharge, with enough trained staff, bridging methods where this is not possible, and agreed referral pathways to community sexual and reproductive health services for women with complex conditions.^[3]

Practical adaptations where staff or supplies are limited:

• Replace full examinations with focused checks on temperature, breathing, feeding, weight and yellowing, and systematic maternal danger sign questions at every contact.
• Where a midwife is unavailable, train community health workers to recognise postpartum haemorrhage, sepsis and pre-eclampsia, and to arrange referral.
• Offer the most effective methods that can be provided in a single contact (implant, intrauterine device) when women may not return; progestogen-only methods and intrauterine devices are particularly valuable after birth.
• Lactational amenorrhoea is highly practical but needs correct counselling about day and night feeding; when the first feed has not started or supplements are introduced early, a fallback method is required.
• Pelvic floor rehabilitation can be taught by any trained clinician; a short daily exercise habit learned before discharge is more useful than a detailed physiotherapy programme.

• After an operative or complex birth, wound review, pain, fatigue, and the timing of the first feed dominate; contraception should still be settled before discharge, because the six-week window closes quickly.
• After stillbirth or neonatal death, postnatal care continues, and lactation suppression should be discussed with information on milk production, self-care, and medicines that can suppress lactation. Consent and timing take additional importance.
• Adolescents and young women may need additional support and continuity of carer; contraception discussion should be confidential where possible, with safeguarding pathways when appropriate.
• Women with major perineal trauma need individual pelvic floor rehabilitation, bowel care and follow-up.
• Older women and those with pre-existing disease need coordinated follow-up, including for diabetes, hypertension and thrombosis risk.

• Postnatal care is a series of structured contacts rather than a single check: an early visit within 36 hours, a second between 7 and 14 days, and a comprehensive review at six to eight weeks.
• At every contact, mother and baby are assessed physically and emotionally; contraception, breastfeeding, pelvic floor and mental health are included.
• Lochia is expected to lighten and change colour over weeks; sudden, heavy, increasing or offensive bleeding needs urgent review.
• Pelvic floor muscle training, encouraged before discharge and supervised for women at risk, prevents and treats many postpartum continence and prolapse symptoms.
• A newborn is examined fully within 72 hours and again at six to eight weeks; weight and head circumference are checked in the first week and around eight weeks; passing meconium within 24 hours is expected.
• Fever may be absent in a seriously unwell young baby; temperature 38 degrees Celsius or above or below 36 degrees Celsius, breathing over 60 breaths per minute, or bilious vomiting are red flags. ^[1]
• Pregnancy can occur before the first period returns, and contraception should be in place by 21 days after birth.
• Long-acting reversible contraception is highly effective and can be provided immediately after birth; combined hormonal contraception must respect the postpartum venous thromboembolism risk and breastfeeding timing.
• Lactational amenorrhoea is highly effective only while the woman is under six months postpartum, amenorrhoeic and fully breastfeeding. ^[3]

Not yet covered on MedGrasp: postpartum depression and anxiety, contraception (general), sexually transmitted infections, breastfeeding difficulties, urinary incontinence in women, pelvic organ prolapse. These can be linked once published.