Obstetrics and Gynaecology — Postnatal Care, NMC MBBS licence examination syllabus (Nepal Medical Council).
The postnatal period: the weeks everyone stops watching
Delivery feels like the end of the story. Physiologically it is the most dangerous part of it.
Once a baby is safely delivered, attention shifts almost entirely to the newborn, and the mother — who has just sustained a large physiological insult and an open wound in her uterus — is often discharged with little more than congratulations. That instinct is understandable and it is wrong: a large share of maternal and newborn deaths occur in the days immediately after birth, and the postnatal period is consistently the least reliably delivered part of the continuum of care.
This chapter is therefore about vigilance in a period that feels like recovery: the complications that present after discharge, feeding, mood, and the conversation about contraception that has to happen before she leaves.
🩺 Where this lives: The family is the monitoring system after discharge. In settings where postnatal review may be a long journey away, whether a woman survives a secondary haemorrhage or her baby survives sepsis often depends on whether somebody at home recognises the danger sign and acts. That makes the discharge conversation a clinical intervention in its own right — teaching a specific list of things that mean "come back now" is more valuable than a general instruction to seek help if worried.
💡 A note on numbers. This chapter gives no doses, no exclusive breastfeeding duration, no recommended birth interval and no postnatal visit schedule — these are set by national policy and WHO guidance and are revised over time. What is taught is why each matters. Primary postpartum haemorrhage and pre-eclampsia are covered in the Obstetric Emergencies chapter, newborn resuscitation and jaundice in the Newborn chapter, and contraceptive methods in the Antenatal Care and Gynaecology chapter.
Why these days are dangerous
Two points deserve emphasis. First, pre-eclampsia does not end at delivery — it can present for the first time, or worsen, in the postnatal period, so headache, visual disturbance or fits after birth must be taken as seriously as before it. Second, the danger signs are worth teaching explicitly and by name to the woman and her family before discharge. "Come back if you are worried" is a much weaker instruction than a specific list.
Secondary haemorrhage and sepsis
FEVER AFTER DELIVERY
PUERPERAL SEPSIS is a leading direct cause of maternal
death, and the pattern that makes it dangerous is familiar
from the obstetric emergencies chapter: a young, previously
healthy woman compensates well and then decompensates
abruptly.
THE GENITAL TRACT PICTURE:
Fever, lower abdominal pain, FOUL-SMELLING LOCHIA, a
tender bulky uterus, and often heavy or prolonged
bleeding.
BUT ALWAYS EXAMINE MORE WIDELY. Postnatal fever also comes
from:
BREAST — mastitis or abscess
URINARY tract — common after catheterisation
CHEST — particularly after general anaesthesia
WOUND — perineal tear, episiotomy, or caesarean wound
LEGS — deep vein thrombosis; pregnancy and the puerperium
are prothrombotic states, and venous thromboembolism is
a major cause of maternal death
SECONDARY POSTPARTUM HAEMORRHAGE — bleeding from 24 hours
after delivery up to several weeks — is usually caused by
RETAINED PRODUCTS OF CONCEPTION, ENDOMETRITIS, or both
together, which is why it is frequently managed as an
infection and a retained-products problem simultaneously.
THE RULE: FEVER AFTER DELIVERY IS SEPSIS UNTIL PROVEN
OTHERWISE. Resuscitate, take cultures, give antibiotics
early per national guidance, and look for a source that
needs draining or removing — the source control principle
again.
Breastfeeding
💡 Exam angle: the practical point examiners like is that most breastfeeding problems are problems of positioning and attachment. Sore cracked nipples, poor milk transfer and the very common complaint of "not enough milk" usually resolve when a skilled observer watches a feed and corrects the attachment. Reaching for formula without doing that is the wrong answer. Note also the counterintuitive rule in mastitis: continue feeding or expressing from the affected breast — stopping causes stasis and makes it worse.
Postnatal mental health
The three conditions here are genuinely different, and confusing them has consequences. Baby blues is common, mild and self-limiting, needing support rather than treatment. Postnatal depression is persistent, affects bonding and the child's development, and is treatable — see the Depression chapter. Puerperal psychosis is a psychiatric emergency: rapid onset, often within the first two weeks, with confusion, delusions and severe mood disturbance, and a real risk to both mother and baby requiring urgent specialist assessment.
Contraception and birth spacing
WHY THE CONVERSATION HAPPENS BEFORE DISCHARGE
FERTILITY RETURNS BEFORE THE FIRST PERIOD. Ovulation
precedes menstruation, so a woman who waits for her period
to resume before thinking about contraception may already
be pregnant.
SHORT BIRTH INTERVALS carry real risk for both:
For the BABY — higher risk of preterm birth, low birth
weight and poorer outcomes
For the MOTHER — anaemia, nutritional depletion, and the
cumulative risk of repeated pregnancies
BREASTFEEDING provides some contraceptive effect, but it is
conditional and NOT RELIABLE as a sole method for most
women — it should not be offered as a plan without
explaining its limits.
METHOD CHOICE WITH BREASTFEEDING:
PROGESTOGEN-ONLY methods are compatible
COMBINED hormonal methods are generally deferred in the
early postpartum period
See the contraception section of the Antenatal Care and
Gynaecology chapter for the fuller discussion.
AND THE PRACTICAL REALITY: a woman discharged without a
plan may not return, particularly if she lives far away or
needs someone else's agreement to travel. The postnatal
contact you have is the one you can rely on.
Clinical reasoning: four presentations
🔍 Case 1 — bleeding two weeks later
PresentationA woman returns twelve days after delivery with heavy vaginal bleeding, offensive discharge, fever and lower abdominal pain. The uterus is bulky and tender. She is given oral antibiotics and sent home.
DiagnosisSecondary postpartum haemorrhage with endometritis.
ReasoningBleeding after 24 hours with fever and offensive lochia indicates retained products, infection, or both. She is a young woman who will compensate until she does not, and outpatient oral antibiotics underestimate the risk.
AnswerAssess circulation, take cultures, give antibiotics per national guidance, and assess for retained products requiring evacuation. Treat this as potential sepsis rather than a minor problem.
🔍 Case 2 — "I don't have enough milk"
PresentationA first-time mother says her milk is insufficient and her nipples are cracked and painful. The baby feeds frequently and briefly and seems unsettled. She is advised to start formula.
Step missedNobody watched a feed.
ReasoningCracked nipples and poor transfer are the classic signature of poor attachment, and frequent brief unsatisfying feeds follow from it. Introducing formula reduces stimulation and genuinely reduces supply — making the perceived problem real.
AnswerObserve a full feed and correct positioning and attachment with skilled support. Assess the baby's weight and output objectively before concluding that supply is inadequate.
🔍 Case 3 — confused on day eight
PresentationEight days after delivery a woman becomes agitated and confused, believes her baby has been swapped, and is not sleeping. Her family are told this is normal tiredness and baby blues.
Key featuresRapid onset, delusions, confusion.
ReasoningThis is puerperal psychosis, not baby blues. Blues is mild, self-limiting and does not involve delusions or confusion. Psychosis carries a real risk to both mother and baby.
AnswerUrgent psychiatric assessment and admission per local pathway, with the baby's safety explicitly considered. Also exclude organic causes — infection, sepsis and eclampsia can present with confusion after delivery.
🔍 Case 4 — "she'll come back when her periods start"
PresentationA woman with four children under six is discharged after delivery. Contraception is not discussed, on the basis that she is breastfeeding and can attend the clinic when her periods return. She lives several hours away.
Two errorsRelying on lactation, and deferring the conversation.
ReasoningOvulation precedes the first period, so waiting for menstruation is waiting too long. Breastfeeding gives conditional and unreliable protection. And a woman who must travel hours may not return.
AnswerDiscuss contraception before discharge, explain that fertility returns before periods do, and offer a method compatible with breastfeeding per national guidance. Short birth intervals carry real risk for both her and the next baby.
Commonly confused
Confusion
The distinction
Why it matters
Delivery vs safety
The days after birth are the most dangerous
Attention shifts exactly when risk peaks.
Pre-eclampsia before vs after delivery
It can present or worsen postnatally
Fits after birth are still eclampsia.
Primary vs secondary PPH
Secondary is after 24 hours
Usually retained products or endometritis.
Genital vs other sources of fever
Breast, urine, chest, wound, legs
Examine widely, including for thrombosis.
Low supply vs poor attachment
Watch a feed before concluding
Formula reduces stimulation and supply.
Mastitis vs stopping feeding
Continue feeding or expressing
Stasis makes mastitis worse.
Baby blues vs psychosis
Delusions, confusion and rapid onset
One needs support; one is an emergency.
Periods vs return of fertility
Ovulation comes first
Waiting for a period is waiting too long.
Rapid revision
MUST-KNOW FACTS
1. A large share of maternal and newborn deaths occur in the FIRST DAYS.
2. Postnatal care is usually the WEAKEST link in the continuum.
3. Maternal danger signs: HEAVY BLEEDING, FEVER, foul discharge.
4. Also severe headache, fits, breathlessness.
5. Newborn danger signs: NOT FEEDING, lethargy, fever or LOW temperature.
6. Also fast breathing, jaundice, fits.
7. TEACH the danger signs to the family before discharge.
8. PRE-ECLAMPSIA can present or worsen AFTER delivery.
9. SECONDARY PPH: bleeding after 24 hours up to several weeks.
10. Usually RETAINED PRODUCTS, ENDOMETRITIS, or both.
11. PUERPERAL SEPSIS is a leading direct cause of maternal death.
12. Fever, abdominal pain, FOUL-SMELLING LOCHIA, tender bulky uterus.
13. FEVER AFTER DELIVERY IS SEPSIS UNTIL PROVEN OTHERWISE.
14. Also examine breast, urinary tract, chest, wound and LEGS.
15. Pregnancy and the puerperium are PROTHROMBOTIC — consider VTE.
16. Start breastfeeding EARLY, within the first hour, skin-to-skin.
17. COLOSTRUM matters.
18. Breast milk protects against infection and against NEC in preterm babies.
19. MOST FEEDING PROBLEMS ARE POSITIONING AND ATTACHMENT.
20. WATCH A FEED before advising formula.
21. Formula reduces stimulation and genuinely reduces supply.
22. MASTITIS: KEEP FEEDING OR EXPRESSING — stopping worsens it.
23. BABY BLUES: mild, self-limiting, needs support not treatment.
24. POSTNATAL DEPRESSION: persistent, affects bonding, TREATABLE.
25. PUERPERAL PSYCHOSIS: rapid onset, delusions, confusion — EMERGENCY.
26. Puerperal psychosis carries risk to mother AND baby.
27. Exclude organic causes of postnatal confusion — sepsis, eclampsia.
28. Ask about mood at EVERY postnatal contact.
29. FERTILITY RETURNS BEFORE THE FIRST PERIOD.
30. Breastfeeding gives conditional, NOT RELIABLE, contraception.
31. Short birth intervals harm both mother and child.
32. PROGESTOGEN-ONLY methods are compatible with breastfeeding.
33. DISCUSS CONTRACEPTION BEFORE DISCHARGE — she may not return.
34. Take durations, intervals and visit schedules from national guidance.
💡 Exam angle: three threads run through this chapter. Fever after delivery is sepsis. A feeding problem is an attachment problem until someone has watched a feed. And confusion with delusions in the first two weeks is puerperal psychosis, not tiredness.
Syllabus points
Why the postnatal days are dangerous
Maternal and newborn danger signs
Pre-eclampsia after delivery
Secondary postpartum haemorrhage
Puerperal sepsis
Other sources of postnatal fever
Venous thromboembolism in the puerperium
Early and exclusive breastfeeding
Positioning and attachment
Mastitis and why feeding continues
Baby blues, depression and psychosis
Why fertility returns before periods
Birth spacing and discussing it before discharge
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