Obstetrics: Post Natal Care

👶 Labour, birth and the postnatal period -most labours are normal and need support rather than intervention. The skills are recognising normal progress, spotting delay, reading a CTG, knowing when an assisted birth is needed, and caring well for women and babies afterwards. The year after birth is a time of high risk for mental illness: suicide is a leading cause of maternal death in the UK in the year after birth.
Your four questions for every patient: Is labour progressing normally (dilatation, descent, contractions)? Is the baby well (heart rate pattern)? Is the mother well (observations, bleeding, pain, mood)? What does she want -and has her consent been sought for each step?

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Stages of Labour

Stage	What happens
First stage -latent phase	Irregular, painful contractions; the cervix softens, shortens (effaces) and dilates up to 4 cm. Can last hours to days, especially in a first labour.
First stage -established (active) phase	Regular painful contractions and progressive dilatation from 4 cm to full dilatation (10 cm). Average about 8 hours (first labour, rarely over 18 hours) and 5 hours (later labours, rarely over 12 hours).
Second stage	From full dilatation to birth of the baby. Passive (descent without pushing) then active (pushing). Birth is expected within about 3 hours of the start of active second stage in a first labour, and 2 hours in later labours.
Third stage	From birth of the baby to delivery of the placenta and membranes.

• Signs of labour -regular painful contractions, a "show" (mucus plug), rupture of membranes (waters breaking).
• The three Ps that determine progress:
  • Power -contractions (frequency, strength, duration; ideally 3–4 in 10 minutes).
  • Passenger -the baby's size, presentation, position and attitude (flexion).
  • Passage -the pelvis and soft tissues.

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How the Baby Is Born

• Terms:
  • Lie -the long axis of the baby relative to the mother (longitudinal, transverse, oblique).
  • Presentation -the part entering the pelvis first (cephalic, breech, shoulder).
  • Position -the position of the denominator (occiput in a cephalic baby) relative to the pelvis -e.g. occipito-anterior (OA) is ideal; occipito-posterior (OP) or transverse (OT).
  • Station -level of the head relative to the ischial spines (−3 to +3); or fifths palpable abdominally (engaged when 2/5 or less is palpable).
  • Attitude -flexion of the head (a well-flexed head presents the smallest diameter).
• Mechanism of labour (cardinal movements of a cephalic baby):
  • Engagement (head enters the pelvis, usually occipito-transverse).
  • Descent and flexion.
  • Internal rotation to occipito-anterior.
  • Extension -the head is born.
  • Restitution and external rotation -the head turns to line up with the shoulders.
  • Delivery of the shoulders (anterior first) and body.

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Care in Normal Labour

• Place of birth (NICE) -women with uncomplicated pregnancies can choose:
  • Home, a freestanding or alongside midwifery unit, or an obstetric unit.
  • For women who have had a baby before, midwife-led settings are as safe for the baby and have fewer interventions.
  • For a first baby, a home birth has a small increase in adverse outcomes for the baby.
• Supportive care:
  • One-to-one midwifery care in established labour.
  • Encourage movement and upright positions; eat and drink lightly; empty the bladder regularly.
  • Water immersion for pain relief.
• Monitoring the mother -pulse hourly, BP and temperature 4-hourly, contractions every 30 minutes, vaginal examination about 4-hourly (or if concerns), fluid balance. Recorded on a partogram.
• Monitoring the baby -intermittent auscultation for low-risk labours; continuous CTG for higher risk (see below).
• Signs that need obstetric review:
  • Maternal fever (38 °C or more), tachycardia, raised BP.
  • Meconium-stained fluid (significant).
  • Fresh bleeding.
  • Abnormal fetal heart rate.
  • Delay in progress.
  • Malpresentation, cord presentation.
• Prelabour rupture of membranes at term -see the Obstetric Complications chapter.

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Delay in Labour

• Delay in the first stage (NICE) -suspected if:
  • Cervical dilatation of under 2 cm in 4 hours (first or later labours).
  • Slowing progress in a later labour.
  • Changes in descent or rotation, or in the strength, duration and frequency of contractions.
• Actions:
  • Amniotomy (if membranes intact) -reassess in 2 hours.
  • Oxytocin infusion (augmentation) if progress remains slow -with continuous CTG; reassess after 4 hours.
  • Caesarean if progress doesn't improve (or fetal concerns).
  • Check for obstruction -high head, moulding, caput, cervix not applied to the head (oxytocin is dangerous in obstruction, especially in women who have given birth before -rupture risk).
• Delay in the second stage:
  • First labour -suspected after 1 hour of active pushing; diagnosed if birth isn't imminent after 2 hours (refer at that point).
  • Later labours -suspected after 30 minutes; diagnosed after 1 hour.
  • Actions -obstetric review; consider oxytocin (first labour with poor contractions), position change; instrumental birth or caesarean.
• Causes -inefficient contractions (the commonest in a first labour), malposition (OP), deflexion, large baby, small pelvis (cephalopelvic disproportion), full bladder, exhaustion.

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Fetal Monitoring and the CTG

• Intermittent auscultation (low-risk labour) -listen with a Pinard or handheld Doppler for 1 minute after a contraction: every 15 minutes in the established first stage, every 5 minutes in the second stage; feel the maternal pulse to distinguish.
• Continuous CTG (cardiotocography) is recommended for:
  • Maternal factors -pre-eclampsia, diabetes, previous caesarean, fever, sepsis, APH, oxytocin, epidural (for 30 minutes after placement or top-ups), prolonged labour.
  • Fetal factors -FGR, preterm, breech, twins, meconium, reduced movements, abnormal auscultation.
• Reading a CTG (one way to remember -"Dr C BRAVADO": Define Risk, Contractions, Baseline RAte, Variability, Accelerations, Decelerations, Overall):

Feature	Normal and abnormal
Baseline rate	Normal 110–160 beats/min. Tachycardia -fever, infection, maternal tachycardia, hypoxia, drugs. Bradycardia under 100 for over 3 minutes -acute emergency.
Variability	Normal 5–25 beats/min. Reduced (under 5) for over 30–50 minutes is a concern (hypoxia, sleep, drugs like opioids). Increased (over 25) -"saltatory".
Accelerations	Rises of 15 beats/min for 15 seconds -reassuring. Their absence alone is not worrying.
Early decelerations	Mirror contractions (head compression) -usually benign.
Variable decelerations	Vary in shape and timing; cord compression. Concerning if lasting over 60 seconds, with reduced variability, or slow recovery.
Late decelerations	Start after the peak of a contraction and recover after it ends -placental insufficiency (hypoxia). Concerning.
Prolonged deceleration	Over 3 minutes -urgent action; over 5 minutes, deliver if not recovering (by 9 minutes).
Sinusoidal pattern	Smooth wave-like -severe fetal anaemia (vasa praevia, fetomaternal haemorrhage) -urgent.

• Overall assessment (NICE NG229) -consider the whole clinical picture (risk factors, progress, trends over time), not the CTG in isolation.
• Actions for concerning features:
  • Correct reversible causes -change position (left lateral), stop or reduce oxytocin, treat low BP (fluids after epidural), treat fever, tocolysis for hyperstimulation.
  • Senior review; consider expediting birth.
  • Fetal blood sampling (scalp lactate or pH) is now used less often.
  • Fetal scalp electrode if the external trace is poor.

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Pain Relief in Labour

• Non-drug -support, breathing, massage, movement, water (birth pool); TENS in early labour.
• Entonox (50% nitrous oxide and oxygen) -fast-acting; light-headedness, nausea.
• Opioids -IM pethidine or diamorphine: nausea and drowsiness; can cause breathing depression in the baby if given within a few hours of birth (naloxone for the baby); may reduce breastfeeding. Remifentanil patient-controlled analgesia (with one-to-one monitoring) if epidural isn't possible.
• Epidural -the most effective:
  • Low-dose local anaesthetic plus opioid into the epidural space.
  • Effects -longer second stage, more instrumental births (not more caesareans); low BP; itching; fever; urinary retention (catheter); leg weakness.
  • Complications -post-dural puncture headache (worse sitting up -epidural blood patch); rare high block, nerve damage, epidural haematoma or abscess.
  • Contraindications -patient refusal, coagulopathy or low platelets (e.g. under 75–80 × 10⁹/L), LMWH within 12 hours (prophylactic) or 24 hours (treatment dose), local infection, uncorrected hypovolaemia.
• Spinal anaesthetic -for caesarean and instrumental births in theatre (single injection, rapid, dense block).
• General anaesthesia -category 1 caesarean when regional isn't possible; risks of difficult airway and aspiration (antacid prophylaxis).

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Malposition and Malpresentation in Labour

• Occipito-posterior (OP) -the commonest malposition:
  • Back pain, slow labour, early urge to push.
  • Most rotate to OA spontaneously; otherwise rotational instrumental birth (Kielland's forceps or ventouse), manual rotation, or caesarean; or born "face to pubis".
• Deflexed head -larger diameter presents; slow labour.
• Face presentation (fully extended head) -vaginal birth possible if mento-anterior; mento-posterior needs caesarean. Never use ventouse on a face.
• Brow presentation (partly extended) -largest diameter; caesarean unless it flexes.
• Transverse lie in labour -caesarean (risk of cord prolapse and obstructed labour).
• Cord presentation (cord below the presenting part with intact membranes) -caesarean.
• Obstructed labour -no progress despite good contractions; caput and moulding, high head, haematuria; risk of uterine rupture and fistula -caesarean.

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Instrumental Birth

• Indications:
  • Delay in the second stage.
  • Suspected fetal compromise.
  • Maternal reasons to shorten pushing -exhaustion, heart disease, severe hypertension, some neurological conditions (e.g. intracranial aneurysm), proliferative retinopathy.
• Prerequisites (RCOG):
  • Cervix fully dilated; membranes ruptured.
  • Head 1/5 or less palpable abdominally (0/5 ideal) and at or below the ischial spines.
  • Position known exactly.
  • Adequate analgesia; empty bladder; contractions present.
  • Informed consent; experienced operator; backup plan (theatre if a higher-risk "trial").
• Ventouse (vacuum cup):
  • Less maternal trauma than forceps; more likely to fail.
  • Not before 34 weeks (bleeding risk), and not for face presentations.
  • Baby -chignon (normal swelling), cephalhaematoma, subgaleal haemorrhage (rare, dangerous -boggy scalp swelling crossing suture lines, shock), jaundice, retinal haemorrhages.
• Forceps:
  • More successful; more perineal and anal sphincter tears.
  • Baby -facial bruising, facial nerve palsy (usually recovers), skull fracture (rare).
  • Rotational forceps (Kielland's) for OP/OT -experienced operators only.
• After instrumental birth -check for OASI; offer prophylactic antibiotics (single dose of co-amoxiclav -ANODE trial); VTE assessment; bladder care (retention after epidural); debrief.

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Caesarean Birth

• About a third or more of UK births are now caesarean.
• Urgency categories (NICE):

Category	Meaning and target
1	Immediate threat to the life of the mother or baby (e.g. prolonged bradycardia, cord prolapse, abruption, uterine rupture) -birth within 30 minutes of the decision
2	Maternal or fetal compromise that is not immediately life-threatening -within 75 minutes
3	No compromise but needs early birth (e.g. failed induction, labouring with a planned caesarean booked)
4	Planned (elective) -at a time to suit the woman and team (usually from 39 weeks to reduce baby breathing problems)

• Common reasons -previous caesarean, failure to progress, suspected fetal compromise, breech, placenta praevia, maternal request (should be supported after discussion), some maternal conditions (HIV with high viral load, primary herpes near term).
• Before surgery:
  • Consent (including risks below); FBC, group and save.
  • Antacid prophylaxis (H2 blocker or PPI, plus antiemetic).
  • Antibiotics before skin incision (e.g. cefuroxime).
  • Steroids for planned caesarean before 39 weeks (consider).
  • VTE prophylaxis -stockings, LMWH for most after surgery.
  • Usually spinal anaesthetic; low transverse (Pfannenstiel) incision; lower segment uterine incision.
• Risks:
  • Mother -bleeding, infection (wound, endometritis), VTE, bladder or bowel injury, longer recovery; future placenta praevia and accreta, uterine rupture.
  • Baby -transient tachypnoea (breathing problems, especially before 39 weeks), small skin cuts.
• Recovery -early eating and walking; catheter removal after about 12 hours; avoid heavy lifting; can drive when able to do an emergency stop comfortably; wait at least 12–18 months before another pregnancy.

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Perineal Tears and Episiotomy

Degree	What is torn
First	Skin of the perineum or vaginal lining only
Second	Perineal muscles (not the anal sphincter); episiotomy is the same depth
Third	Anal sphincter: 3a -under 50% of external sphincter; 3b -over 50%; 3c -internal sphincter too
Fourth	Anal sphincter complex and the anal lining (rectal mucosa)

• Obstetric anal sphincter injury (OASI) -third and fourth degree tears:
  • Risk factors -first vaginal birth, forceps, large baby (over 4 kg), OP position, prolonged second stage, shoulder dystocia, South Asian ethnicity.
  • Examine the perineum and rectum after every vaginal birth.
  • Repair in theatre by an experienced clinician; IV antibiotics; laxatives; analgesia (avoid codeine -constipation).
  • Follow-up -pelvic floor physiotherapy; review at 6–12 weeks (faecal incontinence, pain); future birth plans (endoanal ultrasound and manometry).
  • Prevention -hands-on control of the head, warm compresses, mediolateral episiotomy at instrumental birth.
• Episiotomy -a mediolateral cut (at about 60° from the midline when the head is crowning) for instrumental birth or fetal compromise; not routine.
• Other -labial and periurethral tears; vulval haematoma (severe pain, swelling after birth -drain); obstetric fistula (prolonged obstructed labour, low-income countries).

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The Third Stage and the Newborn

• Active management of the third stage (recommended -halves PPH risk):
  • Oxytocin 10 IU IM as the baby's anterior shoulder is born or straight after birth (Syntometrine -oxytocin with ergometrine -can be used if no hypertension).
  • Deferred cord clamping -wait at least 1 minute (and up to 5 minutes) if the baby is well.
  • Controlled cord traction after signs of separation.
  • Placenta usually delivered within 30 minutes.
• Physiological third stage -no drugs, placenta delivered by maternal effort; prolonged if over 1 hour.
• Retained placenta -not delivered within 30 minutes (active) or 1 hour (physiological): IV access, bloods, empty bladder; manual removal in theatre (regional anaesthetic); antibiotics. Heavy bleeding -emergency.
• Check the placenta is complete (missing parts -retained tissue, PPH).
• Newborn care:
  • Skin-to-skin contact; dry and keep warm; early breastfeeding.
  • Apgar score at 1 and 5 minutes (heart rate, breathing, tone, reflex irritability, colour).
  • Vitamin K (IM or oral) to prevent haemorrhagic disease of the newborn -with consent.
  • Newborn physical examination within 72 hours (see the Neonatology chapter).

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Postnatal Care

• Normal changes:
  • Lochia -blood loss: red for a few days, then brown and pale; up to about 6 weeks.
  • Uterine involution -the womb shrinks back into the pelvis by about 2 weeks; "afterpains" (worse with breastfeeding).
  • Breast milk -colostrum first, milk "comes in" at day 2–4.
  • "Baby blues" -tearful, emotional days 3–10; settles by 2 weeks.
• Postnatal checks (NICE NG194):
  • Midwife visits at home in the first days; health visitor from 10–14 days.
  • BP (pre-eclampsia can start after birth), temperature, pulse, bleeding, perineum or wound, bladder and bowels, legs (VTE), breasts, mood, pain.
  • Passed urine within 6 hours of birth -if not, bladder scan or catheter (retention).
  • 6–8 week GP check -physical and mental health, contraception, cervical screening if due, pelvic floor, BP, diabetes test after GDM.
• Warning signs to tell women about:
  • Heavy or sudden increase in bleeding, clots, smelly discharge.
  • Fever, rigors, feeling very unwell (sepsis).
  • Headache, visual changes, epigastric pain (pre-eclampsia).
  • Calf pain or swelling, breathlessness, chest pain (VTE).
  • Thoughts of self-harm, feeling very low, unusual or frightening thoughts.
• Other advice -pelvic floor exercises; sex when comfortable; safe sleep for the baby; vitamin D; immunisation (MMR if not rubella immune).

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Contraception After Birth

• Fertility returns as early as day 21 after birth -contraception is needed from then.
• Lactational amenorrhoea method (LAM) -over 98% effective if all three apply: fully (or nearly fully) breastfeeding, no periods, and baby under 6 months.
• Progestogen-only methods -the pill, implant -can start any time after birth (including straight away); safe with breastfeeding. Injection can also start any time (but may increase heavy bleeding if given early).
• Combined hormonal contraception:
  • Breastfeeding -avoid until 6 weeks (UKMEC 4 before 6 weeks).
  • Not breastfeeding -avoid before day 21 (VTE risk); from 21 days if no other VTE risk factors (from 6 weeks if risk factors).
• IUD or IUS -within 48 hours of birth (including at caesarean), or from 4 weeks after birth (not in between -higher expulsion and perforation risk).
• Sterilisation -usually not at caesarean (regret higher; less effective than LARC) unless planned well in advance.
• Pregnancy spacing -ideally at least 12–18 months between birth and the next conception.

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Breastfeeding

• WHO and UK advice -exclusive breastfeeding for around 6 months, then continued alongside solid foods.
• Benefits for the baby -fewer infections (gastroenteritis, chest and ear infections), lower risk of sudden infant death, NEC (preterm babies), obesity and diabetes.
• Benefits for the mother -lower risk of breast and ovarian cancer, type 2 diabetes, cardiovascular disease; helps bonding; free.
• Good attachment -baby's mouth wide open, chin touching the breast, more areola visible above the top lip, cheeks full, rhythmic sucking and swallowing; feeding shouldn't hurt.
• Signs of good feeding -at least 6 wet nappies a day after day 5, yellow stools, weight regained by about 2 weeks (babies can lose up to 10% of birth weight in the first days).
• When not to breastfeed -HIV (unless supported and virally suppressed), some drugs (e.g. cytotoxics, lithium without specialist plan), galactosaemia in the baby, active untreated TB (until treated for 2 weeks).
• Formula feeding -support all feeding choices; teach safe preparation (water at 70 °C or more, sterile bottles); responsive feeding.
• UNICEF Baby Friendly Initiative standards in UK maternity units.

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Breastfeeding Problems and Mastitis

• Sore, cracked nipples -usually poor attachment; get feeding support; check for tongue-tie (frenotomy if it causes feeding problems).
• Engorgement -full, hard, painful breasts (days 3–5); frequent feeding, hand expression, cold compresses, paracetamol or ibuprofen.
• Blocked duct -tender lump; keep feeding, massage towards the nipple.
• Mastitis -painful, red, hot wedge of breast, with fever and flu-like symptoms:
  • Keep breastfeeding (or expressing) from the affected side; analgesia (ibuprofen is fine).
  • Antibiotics -flucloxacillin 500 mg four times daily for 10–14 days (erythromycin or clarithromycin if allergic) if symptoms don't improve within 12–24 hours, if there is a cracked nipple that looks infected, or if culture is positive.
  • Admit if septic.
• Breast abscess -a tender, fluctuant mass; ultrasound; needle aspiration or drainage plus antibiotics; breastfeeding can usually continue.
• Nipple thrush -burning, shooting pain after feeds, shiny skin; baby has oral thrush: treat both (miconazole for mother's nipples, miconazole or nystatin for the baby).
• Low milk supply -usually from infrequent feeds or poor attachment; feeding support.
• Persistent lump -after treatment, breast cancer can present in pregnancy or breastfeeding: ultrasound.

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Postnatal Complications

• Secondary PPH -abnormal bleeding from 24 hours to 12 weeks after birth:
  • Causes -retained placental tissue and endometritis (infection).
  • Management -observations, swabs, FBC, CRP; ultrasound; antibiotics; surgical evacuation if retained tissue and heavy bleeding.
• Endometritis -fever, lower abdominal pain, offensive lochia, tender womb; more common after caesarean; IV or oral antibiotics (e.g. co-amoxiclav, or clindamycin with gentamicin); think group A streptococcus if very unwell.
• Wound infection after caesarean -redness, discharge; swab, antibiotics, check for collection.
• Urinary retention -after epidural or instrumental birth; catheterise (prevents long-term bladder damage).
• Urinary and faecal incontinence -pelvic floor exercises; OASI follow-up.
• VTE -highest risk in the first 6 weeks.
• Postnatal pre-eclampsia -BP checks.
• Headache -post-dural puncture, pre-eclampsia, cerebral venous sinus thrombosis, subarachnoid haemorrhage, migraine -investigate new severe headache.
• Sheehan's syndrome -pituitary infarction after massive PPH: failure to lactate, tiredness, amenorrhoea, low BP and sodium (adrenal insufficiency) -see the Pituitary chapter.
• Postpartum thyroiditis, peripartum cardiomyopathy -see the Medical Problems in Pregnancy chapter.

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Perinatal Mental Health

• Why it matters: Mental illness affects up to 1 in 5 women in pregnancy and the year after birth. Suicide is a leading cause of maternal death in the UK in the first year after birth (MBRRACE-UK).
• Ask at every contact -mood, anxiety, sleep, past history (especially bipolar disorder or previous puerperal psychosis), family history.
• Baby blues -days 3–10; up to 80% of women; tearful, labile mood; settles within 2 weeks; reassurance and support.
• Postnatal depression:
  • About 1 in 10 women; usually within the first few months (can start in pregnancy).
  • Low mood, loss of interest, poor sleep (even when baby sleeps), guilt, anxiety about the baby, poor bonding, thoughts of self-harm.
  • Screening -Whooley questions; Edinburgh Postnatal Depression Scale (EPDS); GAD-2 for anxiety.
  • Treatment -support, guided self-help, CBT or interpersonal therapy; SSRIs (sertraline is often used in breastfeeding).
  • Also affects fathers and partners.
• Puerperal (postpartum) psychosis -a psychiatric emergency:
  • About 1–2 in 1,000 births; usually within the first 2 weeks (often days 3–7).
  • Rapid onset -confusion, agitation, mania, delusions (often about the baby), hallucinations, severe insomnia, rapidly changing mood.
  • Highest risk -bipolar disorder (about 1 in 4), previous puerperal psychosis, family history.
  • Same-day psychiatric assessment; admission to a mother and baby unit; antipsychotics, mood stabilisers, sometimes ECT; risk assessment for mother and baby; safeguarding.
  • Prevention -pre-pregnancy and antenatal plans with the perinatal mental health team for women at high risk.
• Other conditions -perinatal anxiety, OCD (intrusive thoughts of harming the baby -distressing but not acted on), PTSD after traumatic birth (debrief, trauma-focused therapy), tokophobia (fear of birth), eating disorders.
• Red flags for urgent review:
  • Recent significant change in mental state or new symptoms.
  • New thoughts or acts of violent self-harm.
  • New and persistent feelings of being incompetent as a mother or estranged from the baby.
• Medicines in pregnancy and breastfeeding -weigh the risks of untreated illness; avoid valproate; specialist advice for lithium.

⚠️ Safety Pearl: Rapidly changing mood, confusion or strange beliefs in the first weeks after birth -especially with a history of bipolar disorder -is puerperal psychosis until proven otherwise. Arrange same-day psychiatric assessment.

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Drug Reference Table

Drug	Key points
Oxytocin 10 IU IM	Active management of the third stage; IV infusion for augmentation (continuous CTG).
Syntometrine (oxytocin + ergometrine)	Third stage; avoid in hypertension and pre-eclampsia.
Entonox	Nitrous oxide and oxygen; quick on and off.
Pethidine / diamorphine IM	Labour analgesia; neonatal breathing depression (naloxone for baby).
Epidural (bupivacaine + fentanyl)	Most effective analgesia; low BP, longer second stage, fever, PDPH.
Cefuroxime (or local choice)	Before caesarean skin incision.
Co-amoxiclav single IV dose	After instrumental birth (reduces infection).
Ranitidine / omeprazole + metoclopramide	Antacid prophylaxis before caesarean.
Vitamin K (phytomenadione)	Newborn -1 mg IM at birth (or oral regimen).
Flucloxacillin 500 mg four times daily	Mastitis not settling in 12–24 hours; 10–14 days.
Lactulose / ispaghula	After OASI repair to avoid constipation.
Sertraline	Postnatal depression; compatible with breastfeeding.
Desogestrel / implant	Can start any time after birth, including breastfeeding.

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Spot the Diagnosis

Clue	Diagnosis
Cervix 5 cm, then 6 cm 4 hours later in a first labour	Delay in the first stage -amniotomy, then oxytocin
Back pain, slow labour and early urge to push	Occipito-posterior position
Decelerations starting after each contraction peak	Late decelerations -placental insufficiency
Fetal tachycardia 175 with maternal fever 38.5 °C	Intrapartum infection (chorioamnionitis)
Smooth sine-wave CTG after membranes rupture with bleeding	Vasa praevia -fetal anaemia
Headache worse sitting up 2 days after an epidural	Post-dural puncture headache
Boggy scalp swelling crossing sutures and pallor after ventouse	Subgaleal haemorrhage
Tear through the external sphincter, more than half	Third-degree tear (3b)
Placenta not delivered 40 minutes after active management	Retained placenta -manual removal
Offensive lochia, fever and tender womb on day 5	Endometritis
Red, hot wedge of breast with fever on day 12	Mastitis
Tearful on day 4, settles by day 10	Baby blues
Confused, agitated and believing the baby is possessed on day 5	Puerperal psychosis
Failure to lactate and low sodium after massive PPH	Sheehan's syndrome

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Exam-style Scenarios

1. A 27-year-old in her first labour has been fully dilated and pushing for 2 hours. The head is 0/5 palpable, at +1 station, OA position, with an epidural. CTG shows recurrent variable decelerations.
Answer: Delay in the second stage with suspected fetal compromise.

• Prerequisites met -instrumental birth (ventouse or forceps) with consent, empty bladder.
• Check for OASI afterwards; single-dose co-amoxiclav; bladder care.

2. A woman in established labour on oxytocin has a CTG with baseline 150, variability 3 for 60 minutes, and late decelerations with most contractions.
Answer: Concerning CTG suggesting fetal hypoxia.

• Stop or reduce oxytocin; left lateral position; check maternal BP and temperature.
• Senior obstetric review; expedite birth if no improvement (instrumental if fully dilated, otherwise caesarean).

3. A 31-year-old on day 10 after birth has a painful, red, hot area on the left breast and a temperature of 38.4 °C. She is breastfeeding.
Answer: Mastitis.

• Continue breastfeeding or expressing; analgesia; check attachment.
• Flucloxacillin if not improving within 12–24 hours (or infected cracked nipple).
• Ultrasound if a fluctuant lump (abscess); admit if septic.

4. A woman with bipolar disorder is brought in by her partner on day 6 after birth. She hasn't slept, is talking rapidly and says the baby is not hers.
Answer: Puerperal psychosis.

• Same-day psychiatric assessment; don't leave her alone with the baby; risk assessment.
• Admission to a mother and baby unit; antipsychotic or mood stabiliser.
• Safeguarding; plan for future pregnancies.

5. A 25-year-old, fully breastfeeding, 3 weeks after birth, asks about contraception.
Answer: Postnatal contraception.

• LAM is effective while fully breastfeeding, no periods and baby under 6 months.
• Progestogen-only pill or implant can start now.
• Avoid combined methods until 6 weeks; IUD or IUS from 4 weeks.

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Key Points

• Established labour starts at 4 cm with regular contractions; delay is under 2 cm in 4 hours.
• Delay in the first stage: amniotomy, then oxytocin with continuous CTG, then caesarean if no progress.
• Second stage: birth expected within about 3 hours (first labour) or 2 hours (later labours) of active pushing.
• CTG: baseline 110–160, variability 5–25; late decelerations and reduced variability are concerning; interpret in context.
• Epidural: most effective; longer second stage and more instrumental births; low BP, fever, PDPH.
• Instrumental birth needs full dilatation, head 1/5 or less palpable, known position, analgesia, empty bladder and consent.
• Caesarean categories: 1 (within 30 min), 2 (within 75 min), 3, 4 (planned from 39 weeks).
• OASI: third and fourth degree tears -repair in theatre, antibiotics, laxatives, physiotherapy.
• Active third stage: oxytocin 10 IU IM, deferred cord clamping, controlled cord traction.
• Fertility returns from day 21; progestogen-only methods any time; no combined methods before 6 weeks if breastfeeding.
• Mastitis: keep breastfeeding; flucloxacillin if not improving.
• Secondary PPH: retained tissue or endometritis -antibiotics ± evacuation.
• Puerperal psychosis is an emergency -same-day psychiatry and mother and baby unit; highest risk with bipolar disorder.

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Guidelines and Further Reading

• NICE NG235: Intrapartum care
• NICE NG229: Fetal monitoring in labour
• NICE NG192: Caesarean birth
• NICE NG194: Postnatal care
• RCOG Green-top Guideline 26: Assisted vaginal birth
• RCOG Green-top Guideline 29: Third- and fourth-degree perineal tears
• NICE CG192: Antenatal and postnatal mental health
• FSRH guideline: Contraception after pregnancy
• UNICEF UK Baby Friendly Initiative; MBRRACE-UK reports
• BNF -for current doses

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