POSTPARTUM EXAMINATION OF MOTHER

Up to 6 Weeks

Ask, check record

  • When and where did you deliver?
  • How are you feeling?
  • Any pain or fever or bleeding since delivery?
  • Do you have any problem with passing urine?
  • Ask if the woman has started having sex with her partner
  • Have you decided on any contraception?
  • How do your breasts feel?
  • Do you have any other concerns?
  • Check records fo any complications during delivery, any treatments she is receiving, HIV status?
  • Ask about tobacco use and exposure to second-hand smoke

Look, listen feel

  • Measure blood pressure and temperature
  • Feel uterus. Is it hard and round?
  • Look at vulva and perineum for tear, swelling or pus
  • Look at pad for bleeding and lochia
    • Does it smell or is the bleeding profuse?
  • Look for pallor

Use the table below to examine mother at any postpartum visit

Classify and treat as directed below

SIGNS CLASSIFY AS TREAT AND ADVISE
  • Mother feeling well
  • Did not bleed >250 mL
  • Uterus well contracted
    and hard
  • No perineal swelling
  • Blood pressure, pulse
    and temperature
    normal
  • No pallor
  • No breast problem
  • No fever or pain or
    concern
  • No problem with
    urination
Normal
Postpartum
  • Make sure woman and family know what to
    watch for and when to seek care
  • Advise on postpartum care, hygiene, and
    nutrition
  • Reinforce counselling on safer sexual practices
    • Counsel on the importance of birth spacing and
      family planning
  • Dispense 3 months iron supply and counsel on
    compliance
  • Give any treatment or prophylaxis due, e.g. TT
  • Promote use of impregnated bednet for the
    mother and the baby
  • Advise on when to return to the health facility for
    the next visit
  • Advise to avoid use of tobacco, alcohol, drugs, and
    exposure to second-hand smoke

Respond to any observed or volunteered signs and problems

Check for hypertension

ASSESSMENT SIGNS CLASSIFY TREAT AND ADVISE

Blood pressure

  • History of
    eclampsia or
    pre-eclampsia
  • Diastolic BP
    ≥90 mmHg,
    repeat after
    an hour
  • Diastolic BP
    ≥110 mmHg
Severe
Hypertension
  • Assess and treat for pre-eclampsia
    (section 16.3.7). Refer to hospital
  • If not pre-eclampsia, give/continue
    appropriate antihypertensive as in
    non-pregnant women (section 4.1.6)
  • Diastolic BP
    ≥90 mmHg on
    2 readings
Moderate
Hypertension
  • Assess for pre-eclampsia
  • If no pre-eclampsia, give/continue
    appropriate antihypertensive as in
    non-pregnant women (see section
    4.1.6)
  • Review in one week
  • Diastolic BP
    <90 mmHg on
    2 readings
Blood Pressure
Normal
  • No additional treatment

Check for anaemia

ASSESSMENT SIGNS CLASSIFY TREAT AND ADVISE

Check for
anaemia

  • Check record
    for bleeding
    in pregnancy,
    delivery or
    after delivery
  • Ask any heavy
    bleeding since
    delivery?
  • Do you tire
    easily?
  • Are you
    breathless
    during routine
    housework?
  • Measure Hb
  • Look for
    conjuctival and
    palmar pallor
  • Count breaths
    per minute
  • Hb <7 g/dL
    And/or
  • Severe palmar
    or conjuctival
    pallor

Any pallor and
any of:

      • RR >30 breaths
      per minute

    • Tires easily
    • Breathlessness
      at rest
Severe
Anaemia
  • Give double dose of iron sulphate 200 mg
    (or Fefol) : 1 tablet 2-3 times daily for 3
    months
  • Refer urgently to hospital
  • Follow up in 2 weeks to check clinical
    progress and compliance with treatment
  • Hb 7-11 g/dL or
  • Palmar or
    conjuctival
    pallor
Moderate
Anaemia
  • Give double dose of ferrous sulphate
    200 mg (or Fefol) 1 tablet twice daily for 3
    months
  • Reassess in 4 weeks
  • If anaemia persists, refer to hospital
  • Hb >11 g/dL
  • No pallor
No
Anaemia
    • Continue treatment with ferrous
    • sulphate 200 mg (or Fefol) once daily to
    complete treatment duration of 3 months

Check for vaginal bleeding and possible uterine/urinary tract or febrile infection

ASSESSMENT SIGNS CLASSIFY TREATMENT
  • Heavy vaginal
    bleeding
  • More than 1
    pad soaked in
    5 minutes
Postpartum
Bleeding
  • Give oxytocin 10 IU IM
  • Give appropriate IM/IV antibiotics
  • Refer urgently to hospital
  • See PPH section 16.4.6
  • Heavy/
    light vaginal
    bleeding after 6
    weeks
  • Still bleeding
    6 weeks after
    delivery
Postpartum
Bleeding
  • Refer urgently to hospital
  • See PPH section 16.4.6
  • Have you had
    fever?
  • Ask for
    presence of
    foul-smelling
    lochia, burning
    on urination or
    heavy bleeding
  • Feel lower
    abdomen and
    flanks and
    tenderness
  • Look for
    abnormal
    lochia, stiff
    neck and
    lethargy
  • Measure
    temperature

Temperature
>38°C and any
of:

  • Very weak
  • Abdominal
    tenderness
  • Foul-smelling
    lochia
  • Profuse lochia
  • Uterus not well
    contracted
  • Lower
    abdominal
    pain
  • History of
    heavy vaginal
    bleeding
Uterine
Infection/
Puerperal
Fever
  • Insert IV line and give fluids rapidly
  • Give appropriate IM/IV antibiotics
  • Refer urgently to hospital (See puerperal
    fever 16.4.7)
  • Do RDT or
    blood slide
    for malaria
    parasites

Fever >38 °C and
any of:

  • Burning on
    urination
  • Flank pain
    Upper
Urinary
Tract
Infection
  • Give appropriate IM/IV antibiotics
  • Refer urgently to hospital (See UTI in
    pregnancy 16.2.6)
  • Burning on
    urination

 

Lower
Urinary
Tract
Infection
  • Give appropriate oral antibiotic (See
    UTI in pregnancy 16.2.6)
  • Encourage her to drink more fluids
  • Follow up in 2 days
  • Fever >38°C
    and any of:

    • Stiff neck
    • Lethargy
    • RDT negative
Very Severe
Febrile
Disease
  • Insert IV line and give fluids rapidly +
    glucose
  • Give appropriate IM/IV antibiotics (See
    puerperal fever 16.4.7)
  • Refer urgently to hospital
  • Fever >38°C
  • RDT or
    blood slide
    for malaria
    parasites
    positive
Malaria
  • Give oral antimalarial (see section
    16.2.4)
  • Follow up in 2 days
  • Refer if not better in 2 days

Check for dribbling of urine

ASSESSMENT SIGNS CLASSIFY TREATMENT
Ask if dribbling
urine
Continuous
leaking of urine
(and/or faeces)
Suspect
Obstetric
Fistula
  • Refer for proper assessment and
    management (see section 16.6.4)
Non continuous
dribbling or
leaking urine
(urge, stress etc)
Urinary
Incontinence
  • Check perineal trauma
  • Assess for urinary tract infection and
    treat if appropriate
  • Recommend pelvic floor exercises
  • Refer if not improving

Check for perineal trauma/infection

ASSESSMENT SIGNS CLASSIFY TREATMENT
Ask if there is pus
or perineal pain
Excessive
swelling of vulva
or perineum
Perineal
Trauma
Refer to hospital
  • Pus in
    perineum
  • Pain in
    perineum
Perineal
Infection or
Pain
  • Remove sutures, if present
  • Clean wound
  • Counsel on care and hygiene
  • Give paracetamol for pain
  • Follow up in 2 days
    • If no improvement, refer to hospital

Check for vaginal discharge 4 weeks after delivery

ASSESSMENT SIGNS CLASSIFY TREATMENT

If vaginal discharge 4 weeks
after delivery, ask

  • Any itching of the vulva?
  • Has your partner had a
    urinary problem?
  • If partner is present in the
    clinic, ask him if he has:
    urethral discharge or pus,
    burning on passing urine
  • If partner could not be
    approached, explain
    importance of partner
    assessment and treatment to
    avoid reinfection
  • Separate the labia and
    look for abnormal vaginal
    discharge: amount, colour,
    odour and smell
  • If no discharge is seen,
    examine with a gloved finger
    and look at the discharge on
    the glove
  • Abnormal
    vaginal
    discharge,
    and partner
    has urethral
    discharge or
    burning on
    passing urine
Possible
Gonorrhoea
and/or
Chlamydia
Infection
  • Give appropriate oral
    antibiotics to woman
  • Treat partner with
    appropriate oral
    antibiotics
  • Counsel on safer sex
    including use of condoms
  • Curd-like
    vaginal
    discharge
    and/or
  • Intense
    vulval itching
Possible
Candida
Infection
(see section
2.2.1)
  • Give clotrimazole
    pessaries 1 each evening
    for 6 days
  • Counsel on safer sex
    including use of condoms
  • If no improvement, refer
    the woman to hospital
  • Abnormal
    vaginal
    discharge
Possible
Bacterial or
Trichomonas
Infection (see
section 3.2.2)
  • Give metronidazole 2 g
    single dose to woman
  • Counsel on safer sex
    including use of condoms

Check for HIV infection

ASSESSMENT SIGNS CLASSIFY TREATMENT
Do counseling and testing if
never tested before
See chapter 3 HIV Negative Counsel on safe sex and
staying negative
Encourage partner testing
HIV Positive Manage mother and baby as
per eMTCT guidelines (see
section 16.2.2)

Check for breast problems

ASSESSMENT SIGNS CLASSIFY TREATMENT
Ask

  • How do your breasts feel?
  • Look at the nipple for
    fissure
  • Look at the breasts for:
    swelling, shininess,
    redness
  • Feel gently for painful
    part of the breast
  • Measure temperature
  • Observe a breastfeed if
    not yet done
  • Nipple sore or
    fissured
  • Baby not well
    attached
Nipple
Soreness or
Fissure
  • Encourage the mother to
    continue breastfeeding
  • Teach correct positioning
    and attachment
  • Reassess after 2 feeds (or
    1 day). If not better, teach
    the mother how to express
    breast milk from the
    affected breast and feed
    baby by cup, and continue
    breastfeeding on the
    healthy side
  • Both or one
    breasts are
    swollen, shiny
    and patchy red
  • Temperature
    <38°C
  • Baby not well
    attached
  • Not yet
    breastfeeding

Breast
Engorgement

  • Encourage the mother to
    continue breastfeeding
  • Teach correct positioning
    and attachment
  • Advise to feed more
    frequently
  • Reassess after 2 feeds
    (1 day) If not better, teach
    mother how to express
    enough breast milk
    before the feed to relieve
    discomfort
  • Painfulbreast
    swollen and red
  • Temperature
    >38°C
  • Feels ill
Mastitis See section 16.6.3

Check for any psychosocial problems

ASSESSMENT SIGNS CLASSIFY TREAT
Ask if feeling unhappy or
crying easily, low energy, sleep
problems, lack of concetration,
unable to do usual work or
take care of the baby, negatve
feeling towards the baby or
herself, generalized body pains
not otherwise explained
2 of the
described
signs/
symptoms,
for more than
2 weeks
Possible
Postnatal
Depression
  • See section 16.6.2
Any of the
described signs
and symptoms,
during the 1st
week after
delivery
Possible
Baby Blues
  • Counsel, reassure and
    review in 2 weeks
  • If persisting see section
    16.6.2
Ask if current or previous
smoking, alochol, drug abuse,
previous or current history of
violence
Possible
Psychosocial
Problem
  • Counselling and refer for
    specialist management