11.3 Postnatal consultations

11.3.1 Timing of postnatal consultations

Two postnatal consultations, for the mother and neonate, should be offered within the first 6 weeks after delivery:

• The first within the first week, especially for women who delivered at home (Section 11.3.2 and Section 11.3.3). For patients who delivered in a health care facility and stayed there for more than 24 hours, the discharge consultation for the mother and neonate is considered the first postnatal consultation.

AND

• The second within 4 to 6 weeks for a routine clinical examination and to address any potential complications.

If the neonate weighs less than 2000 g, a weekly consultation is recommended for the first month, and then at 6 weeks.

11.3.2 For the mother

• Assess vital signs: heart rate, blood pressure, temperature, respiratory rate.
• Assess uterine involution.
• Assess the healing of the incision in cases of caesarean section.
• Examine the vulva and perineum: look for tears, assess the healing of episiotomy or sutured wound, and appearance and odour of lochia.
• Inquire about urination and bowel movement. In the event of urine leakage, look for potential fistula (Chapter 7, Section 7.2.5).
• Check for breast lesions.
• Look for signs of anaemia. If there is no clinical anaemia, continue iron + folic acid supplementation for 3 months (Chapter 1, Section 1.2.5). In the event of clinical anaemia, see Chapter 4, Section 4.1.
• If malnutrition is present (MUAC ≤ 230 mm), place the woman into a therapeutic feeding programme. In situations where food is scarce, food supplementation is recommended for all breast-feeding women even in absence of signs of malnutrition.
• Perform a dipstick urinalysis if there are any symptoms of urinary tract infection and/or fever and/or hypertension.
• Offer HIV counselling and testing if not done during pregnancy or delivery.
• Note the mother-infant interaction, and the mother’s psychological state.
• Provide information on contraception (time until fertility returns, available contraceptive methods, efficacy, benefits, constraints, and adverse effects of each method) and provide contraceptive if desired (Section 11.5).
• Administer vitamin A if indicated; only if not done after delivery (Section 11.2.2).
• Complete tetanus vaccination if necessary.
• Give information and advice: signs requiring immediate consultation (Section 11.2.1), hygiene, breastfeeding, use of insecticide-treated mosquito nets for mother and neonate.

11.3.3 For the neonate

• Repeat full clinical examination including:
  • Vital signs, danger signs, signs of neonatal infection (Chapter 10, Section 10.3.1), signs of infection transmissible from mother (Chapter 10, Section 10.4).
  • Weight, height, any abnormalities (Chapter 10, Section 10.1.1, Routine clinical examination).
• Check haemoglobin if any signs of anaemia (pallor of conjunctivae, palms of the hands and soles of the feet).
• Refer to neonatal care unit if:
  • Danger signs/signs of infection (start treatment while waiting for transfer)
  • Haemoglobin < 10 g/dl
• Evaluate risk factors for neonatal infection (Chapter 10, Section 10.3.2). Note that home delivery is, in itself, a (minor) risk factor for neonatal infection.
• Assess breastfeeding: attachment to breast, frequency/interval between feeds (Appendix 3), hydration status.
• Check if routine care was provided at birth. If the neonate was born at home and/or did not receive routine care at birth (Chapter 10, Section 10.1), complete the following:

1 - Cord care

• Clean cord with soap and water if soiled, then dry.
• Apply 7.1% chlorhexidine digluconate. 
• In settings where harmful practices to the cord are common, continue treatment at home as indicated in Section 10.6.

2 - Other routine care

• Tetracycline eye ointment (if neonate seen within 7 days after birth).
• Vitamin K_1.
• Routine vaccinations: BCG, hepatitis B monovalent, polio 0. 
• Provide vitamin D supplement until age 6 months (Chapter 10, Section 10.1.1).
• Ensure antiretroviral prophylaxis where necessary (Chapter 10, Section 10.4).

11.3.4 Postnatal care card

Register all relevant information on an individual postpartum follow-up card (Appendix 6).