INTRODUCTION
A National Institute for Health and Care Excellence (NICE) guideline for postnatal care1 published in 2021 supersedes its 15-year-old predecessor.2 NICE says ‘Postnatal care has for long been regarded as a “Cinderella service” where in comparison with some other European countries, provision is scanty and inadequate.’ 1 Its publication is timely with the 6–8-week postnatal maternal check now mandated in the GP contract,3 and the results of the 2020 MBRRACE-UK report4 reminding us of the continuing risk to women in the first year after giving birth when most have stopped having contact with specialist services. The postnatal mortality rate is largely unchanged over the last decade: 67% of maternal deaths occur postnatally.4 With suicide a leading cause between 6 weeks and 1 year, timely identification and management of perinatal mental illness is critical. Postnatal care should be sensitive and inclusive for all families and people who have given birth, and NICE highlights the importance of listening to women and parents.
In line with Royal College of General Practitioners (RCGP) guidance to continue postnatal checks, infant examination, and routine childhood vaccinations throughout the COVID-19 pandemic,5 it is reassuring that a National Childbirth Trust survey6 found no reduction in numbers of new mothers being offered a GP postnatal check, although given the change in contract this may have been expected to rise. Less encouraging was that 25% of mothers reported they had not been formally asked about their emotional or mental health.
The guideline covers the routine postnatal care that women and their babies should receive in the first 8 weeks after the birth. Of particular relevance to GPs are recommendations around the 6–8-week maternal and infant checks. NICE specifies, for the first time, that the maternal check should be carried out by a GP. There are many specific points for both mother and baby that should be covered including physical health topics, assessment of maternal mental health, and providing opportunity to discuss the birth. In addition, there are important topics not mandated to be covered at this appointment, but that often arise: bed sharing; emotional attachment; and babies’ feeding. This implies an in-depth, detailed, and potentially complex consultation. Even in straightforward cases, skill and expertise are required from the GP in supporting a transition and adjustment for the family. These consultations can provide joy and satisfaction but also the risk of missing or normalising pathology. Fulfilling all of these recommendations in one or two 10-minute consultations can be a challenge for GPs.
ORGANISATION AND DELIVERY OF POSTNATAL CARE
NICE asks those caring for women to be aware of the 2020 MBRRACE-UK report on maternal and perinatal mortality,4 highlighting the need for healthcare professionals to understand inequalities and the increased risks for some, particularly Black, Asian, and mixed ethnicity women and babies, and those with high social deprivation. Increased risk of adverse outcomes is also reported in those who do not speak English and those with a history of domestic abuse. Provision of interpreters and effective identification of domestic abuse is essential.
There is a requirement to ensure prompt communication between professionals including a list of information to share. Although this is an obvious standard throughout health care, the postnatal period presents unique challenges with multiple providers — community midwifery, birth team midwifery, health visitor, and GP — from separate organisations at different locations all delivering care within days or weeks of each other. Not only does poor quality information transfer make for unsatisfactory consultations for both patient and healthcare professional, but it also introduces risk.
POSTNATAL CARE OF THE MOTHER
There are recommendations defining principles of care for women including specific recommendations about what topics should be covered in postnatal contacts with the midwife and at the GP 6–8-week check. Guidance around followup of pregnancy-related pathology such as venous thromboembolism, mental health problems, complex social factors, hypertension, and diabetes is signposted. There are at least 25 topics suggested for the GP to cover in the maternal 6–8-week check — a lot to include — and like so much of general practice, a seemingly ‘routine’ consultation can become complex when multiple problems are identified, or there are comorbidities to be followed-up appropriately, and it is important not to rush or omit things.
Perineal health has a dedicated set of recommendations including specific aspects to assess at each postnatal contact. The guideline highlights the increased risk of depression, chronic pain, and psychosexual difficulties in women for whom perineal pain persists or worsens within the first few weeks. Importantly, from a GP perspective, there is a recommendation to refer women with a perineal wound breakdown for same day assessment; GPs should have straightforward access to secondary care teams in order to support this.
POSTNATAL CARE OF THE BABY
A number of specific physical examination checks are recommended to be carried out at 72 hours and again at 6–8 weeks, in addition to the key components of the Newborn and Infant Physical Examination Screening.7 Weight and head circumference should be measured and plotted at this age and it could be the health visitor or GP who does so. Many electronic patient record systems can plot coded measurements, removing the possibility of error with manual input.
Sleep is a common concern for parents of young babies. NICE includes a recommendation to ‘Discuss with parents safer practices for bed sharing’, with specific circumstances listed for discussion to promote safe sleeping and clear circumstances in which bed sharing is strongly advised against.
SYMPTOMS AND SIGNS OF ILLNESS IN BABIES
The new guideline recommends considering use of the Baby Check scoring system as a supplementary part of clinical assessment. The Lullaby Trust has a freely available Baby Check app8 including guidance on its use for professionals and parents. The recommendation highlights its value as an adjunct to, and not a replacement for, professional judgement.
PLANNING AND SUPPORTING BABIES’ FEEDING
Infant feeding frequently becomes a central issue in postnatal consultations, sometimes with specific aspects of feeding, sometimes its surrounding clinical and emotional impacts such as parental wellbeing, sleep, growth, and complications of breastfeeding or prescribing for lactating women. This guideline outlines principles to be followed when discussing feeding, including ‘acknowledge the parents’ emotional, social, financial and environmental concerns about feeding options … be respectful of parents’ choices’. There is detailed guidance on supporting women to breastfeed, assessing breastfeeding, and on formula feeding. There is a recommendation about healthcare professionals’ knowledge and understanding of lactation, which augments the brief RCGP curriculum statement: ‘Breastfeeding, including common problems’.9 Vitamin D supplements are recommended for breastfeeding women, in line with pre-existing guidance.10 Knowledge of appropriate resources for safe medicine use and prescribing for breastfeeding women is included, specifically looking beyond the British National Formulary, when needed, to trusted sources including the NHS UK Drugs in Lactation Advisory Service, and the Breastfeeding Network Drugs in Breastmilk Information Service.
PROMOTING EMOTIONAL ATTACHMENT
The importance of promoting emotional attachment is covered by the guideline, including what to discuss with families and the importance of recognising factors that can impact on the development of bonding and attachment. Highlighted are those who are more likely to require additional support such as parents who have themselves experienced adverse childhood events.
CONCLUSION
This guideline emphasises the importance of listening to women, sharing decision making, and asks healthcare professionals to be actively aware of health inequalities impacting the postnatal population. The postnatal period represents a time of opportunity to promote health and strengthen GP–patient relationships: given that many GPs have no part in routine antenatal care, the 6–8-week check can be a pivotal consultation but may be further improved if GPs are enabled to play a role antenatally. As stated, there are specific skills and knowledge required for GPs caring for women and babies to be addressed in postgraduate and continuing education. The recommended 6–8-week postnatal and baby checks are comprehensive and need time to be completed to the mutual satisfaction of patients and GPs.
Acknowledgments
The guideline referred to in this article was produced by the NGA at the RCOG for NICE. The other members of the NICE postnatal care guideline committee were: Nina Khazaezadeh (topic advisor), Gwyneth Eanor, Peter Fleming, Debra Kroll, Denise Pemberton, Catherine Pullan, Elizabeth Punter, Emily Stow, Charlotte Barry (co-opted member), Naomi Cotton (co-opted member), Lucinda Donaldson (co-opted member), Nicola Murphy (co-opted member), Deepa Panjwani (co-opted member).
Notes
Provenance
Freely submitted; externally peer reviewed.
Competing interests
Clare Macdonald, Sunita Sharma, and David Jewell were members of the Guideline Committee for the NICE postnatal care guideline;1 Maija Kallioinen was the Guideline Lead. Clare Macdonald is funded by the National Institute for Health Research (NIHR) West Midlands Applied Research Collaboration (https://warwick.ac.uk/fac/sci/med/about/centres/arc-wm). The views expressed are those of the authors and not necessarily those of the NIHR, NICE, National Guideline Alliance (NGA), Royal College of Obstetricians and Gynaecologists (RCOG), or the Department of Health and Social Care. All other authors have declared no competing interests.
- © British Journal of General Practice 2021