Postnatal Care & the 6-Week Check

When the baby attends for the 6-week check, use the visit deliberately for the mother/parents too: maternal mood (EPDS), breastfeeding support, contraception, immunisation catch-up, and cardiometabolic follow-up after GDM or a hypertensive pregnancy — not just the infant check. Check parental concerns raised at either visit.

The postnatal period runs from delivery of the placenta to six weeks, though some groups extend it to 12 weeks as a “fourth trimester”. WHO recommends at least three postnatal contacts, the six-week visit among them.

Six weeks is the usual timing, but offer an earlier check at two weeks to anyone who wants one — fertility can return from three weeks postpartum, and feeding and wound-healing questions do not wait.

Red flags

Secondary postpartum haemorrhage, sepsis, thromboembolism and eclampsia all need urgent referral. If she is unstable, phone 000. If she is stable but needs immediate review: in the public system, phone the on-call obstetrics and gynaecology registrar if she is under 6 weeks postpartum, or the on-call gynaecology registrar if she is beyond 6 weeks; privately, phone her obstetrician.

History

Ask about the labour/delivery experience, blood loss, pain, urinary symptoms, bowel movements, rectal bleeding, nipple/breast tenderness, sleep and mood.

Common postnatal concerns in the first six months: vaginal blood loss; perineal or caesarean wound pain; tiredness and sleep; backache; urinary and bowel symptoms; rectal bleeding/haemorrhoids; breast and nipple tenderness; mood and psychological adjustment; sexual problems and contraception; relationship issues.

Other postpartum medical conditions to keep in mind: anaemia, endometritis, wound infection, urinary incontinence, thyroid disorders, mastitis/breast engorgement, postpartum depression, and complications of pregnancy-related conditions.

Examination

Essential: vital signs (particular focus on blood pressure if there was hypertensive disease in pregnancy), temperature, breasts (nipple damage, lumps, firm/red/hot areas), fundal height and uterine involution, abdominal examination including the caesarean wound and rectus divarication, and a cervical screening test if due.

Optional, depending on the presentation: pallor/signs of anaemia, and pelvic floor or perineal assessment if there are issues or complications (bruising, suture healing, oedema). Bimanual examination is not routine. Digital assessment of the pelvic floor muscles is reasonable from about 10 weeks postpartum.

Measure rectus separation by palpating the abdomen while she rises from supine — refer for women’s health physiotherapy if the gap exceeds 2 cm. Refer to a pelvic floor physiotherapist for perineal trauma, and see the third/fourth-degree tear pathway if that applies.

Investigations

There is limited evidence for routine postnatal investigations — test according to the presentation.

• Iron deficiency/anaemia in pregnancy, or heavy uterine bleeding/PPH → FBE and ferritin. Treat anaemia with iron.
• Suspected caesarean wound infection → wound swab.
• Suspected retained products or endometritis → pelvic ultrasound, plus cervical or high vaginal swabs for culture.
• Dysuria, dyspareunia, pelvic pain or urinary incontinence → MSU for microscopy, culture and sensitivity.
• Cervical screening test if overdue (HPV-based, 5-yearly from 25 — not the “Pap smear” terminology).
• Also consider by history: rubella antibodies (MMR if low), Rh antibodies, vitamin D (continue supplements while breastfeeding if low).

Follow-up of antenatal comorbidities

• Gestational diabetes: OGTT at six weeks postpartum, then OGTT every three years. Women with GDM carry roughly a 10-fold lifetime risk of type 2 diabetes.
• Hypertensive disease/pre-eclampsia: blood pressure check within seven days of delivery with evaluation for end-organ damage and the need for antihypertensives; recheck at the 6–8-week review; then annual blood pressure and periodic cardiovascular risk assessment.
• Hypothyroidism: reduce thyroxine to pre-pregnancy dose and monitor TFTs. Postpartum thyroiditis affects about one in 20 women and increases the risk of postnatal depression.
• Hyperthyroidism: monitor TFTs, as anti-thyroid dose reduction may be needed; consider infant monitoring.

Mental health

Screen for past or current maternal mental health problems with the Edinburgh Postnatal Depression Scale alongside a biopsychosocial assessment. Screen first at 6–12 weeks after birth and again at least once in the first postnatal year. Severity bands: 10–12 mild, 13–14 mild-to-moderate, and 15 or above severe or complex — as are puerperal psychosis and any thought of harming herself or the infant. A score of 1, 2 or 3 on question 10 (self-harm) needs a risk assessment regardless of the total. Pair it with a psychosocial tool such as the Antenatal/Postnatal Risk Questionnaire, noting that the ANRQ is not validated in First Nations or culturally and linguistically diverse populations. Suicide is one of the leading causes of maternal mortality in Australia. Look beyond mood disorder to pre-existing mental illness and complex biopsychosocial needs (relationship difficulty, domestic violence, trauma). Around 20% of domestic violence starts during a pregnancy, and pregnancy or the postpartum period can provoke or worsen it. Ask about the partner’s adjustment too — fathers are at significant risk of depression and anxiety where the mother is struggling.

Blood loss and pain

Postnatal vaginal loss is variable and lasts about 24 days on average. Advise review if lochia becomes heavy, bright red or offensive, or if clots pass.

What counts as abnormal: a sudden and continued increase in loss or large clots; a sudden change to brighter red; heavy loss (soaking more than one maxi-pad every two hours) with symptoms of hypovolaemia; or offensive discharge.

Secondary PPH is blood loss >500 mL more than 24 hours after birth and up to 12 weeks postnatally — usually endometritis, but also retained products, uterine atony, haematoma or a coagulation disorder. If haemodynamically stable, empirical antibiotics plus ultrasound for retained products is reasonable, with swabs to direct therapy; refer promptly if concerns persist.

Non-severe postpartum endometritis can be treated in the community if she is clinically well with prolonged mild-to-moderate bleeding and uterine tenderness. Most endometritis presents in the first week, but around 15% presents between weeks 1 and 6 as a late postpartum haemorrhage. Ask her to self-collect a swab for MCS, and prescribe seven days of:

• amoxicillin + clavulanic acid 875 + 125 mg twice daily, or
• for penicillin hypersensitivity, trimethoprim + sulfamethoxazole 160 + 800 mg twice daily plus metronidazole 400 mg twice daily.

Review at seven days. If she has not improved, has heavy loss, or retained products are strongly suspected, arrange a scan — bearing in mind that postpartum pelvic ultrasound is difficult to interpret.

Ibuprofen and paracetamol are appropriate first-line analgesics and are safe in breastfeeding. Avoid aspirin while breastfeeding, and avoid opioids in the postnatal primary care setting.

Tiredness

Tiredness and fatigue are the commonest problems new mothers report. Screen for anaemia, postpartum depression and thyroid disorders. Set realistic expectations about sleep disruption; there is no evidence that formula feeding improves sleep.

Returning to fertility

Ovulation timing varies and may precede the first period, so start the contraception conversation early rather than waiting for the 6-week visit. Lactational amenorrhoea is highly effective in the first 6 months if fully demand-breastfeeding, but it is not a substitute for a planned method.

• Levonorgestrel IUD: can be inserted within 48 hours of delivery, or otherwise from 28 days. Lasts up to five years.
• Copper IUD: same insertion timing as the LNG-IUD, and lasts up to 10 years. Increased pelvic infection risk in the three weeks after insertion.
• Implant: can be inserted immediately postnatally; lasts up to three years.
• POP: does not reduce breastmilk production and can be started immediately postnatally — counsel on strict dosing timing and continuous (no sugar pill) use.
• Depot injection: can be used immediately postnatally; 12-weekly IM. Return to fertility after depot may be delayed by 12–18 months.
• Barrier methods: safe immediately postpartum; a diaphragm should be fitted no earlier than six weeks, as the size needed changes as the uterus involutes.
• COCP: avoid in the first 21 days and while breastfeeding early on; generally acceptable beyond 6 months postpartum in a breastfeeding woman (WHO MEC category 2), and an option for those exclusively formula feeding.
• Tubal ligation can be done at elective LUSCS or from 6 weeks postpartum.

Ask about sex if it has resumed. Counsel that reduced lubrication and initial discomfort are expected and improve — suggest a water- or silicone-based lubricant, and topical oestrogen if she is breastfeeding. For persistent discomfort, consider a women’s health physiotherapist and guided pelvic floor relaxation.

Immunisation

Check what she had antenatally and what is outstanding.

• Pertussis (dTpa) — should have been given from week 20 of the pregnancy.
• RSV (Abrysvo) — should have been given at 28–36 weeks. Where it wasn’t, infants can still be protected: nirsevimab (Beyfortus) is NSW-funded from 17 March 2025 for all children meeting the eligibility criteria, including those whose mother was not vaccinated.
• Rubella — MMR may have been given in hospital postnatally; order a titre to confirm seroconversion before a subsequent pregnancy.
• Influenza and varicella as indicated, for her and the family.

If she received a blood transfusion, withhold live vaccines for 3 to 11 months so the immune response is adequate.

Interconception care

Interconception care is care between one pregnancy and the next, aimed at optimising health before the next conception. Almost half of Australian pregnancies are unintended, so it should not wait for a preconception visit.

An interpregnancy interval under 12 months carries increased risk — placental abruption, placenta praevia, uterine rupture after a previous caesarean, gestational diabetes, and neonatally stillbirth, small-for-gestational-age, preterm delivery and neonatal death. Long intervals (>60 months) are associated with pre-eclampsia and labour dystocia. Discuss birth spacing explicitly; women are often told to avoid rapid conception after caesarean but rarely given a target interval.

Cover the preconception checklist at the same visit: folic acid and diet, BMI and weight, 150 minutes of exercise per week, modifiable risks from the last pregnancy, genetic carrier screening if indicated, and smoking/alcohol/drug use.

Source (local): Maternal Postnatal Check, Community HealthPathways Hunter New England, last updated 4 June 2026 (registry: hne-healthpathways-maternal-postnatal-check; verified 2026-08-31). Red flags and escalation routes, endometritis antibiotics, the rectus divarication threshold, EPDS bands and the immunisation/transfusion rules come from this pathway.