Postnatal care at a PHC: Medical Officer checklist

Follow-up schedule

• Keep a healthy mother and newborn at the facility for at least 24 hours after birth, if possible.
• Postnatal contacts: within 24 hours, 48-72 hours (day 3), day 7-14, and 6 weeks. Coordinate home visits with ANM/ASHA. Low-birth-weight babies need more frequent follow-up, commonly on days 0, 3, 7, 14, 21 and 28. WHO postnatal recommendations
• Record all findings in the MCP card/register and ensure referral and follow-up compliance.

1. Mother: assessment at every visit

History

• Heavy bleeding, clots, foul-smelling lochia
• Fever, lower abdominal pain, burning urine
• Severe headache, blurred vision, epigastric pain, breathlessness, seizures
• Breast pain, cracked nipples, poor milk flow
• Perineal or cesarean wound pain/discharge
• Constipation, urinary retention/incontinence
• Sadness, anxiety, poor sleep, thoughts of self-harm or harm to baby
• Feeding, rest, family support and contraception needs

Examination

• General condition, pallor, temperature, pulse, respiratory rate, blood pressure
• Uterine size and tone, abdominal tenderness
• Lochia: amount, color, smell
• Perineal/episiotomy or cesarean wound
• Breast and nipple examination, observe a breastfeed
• Check legs for unilateral swelling/tenderness if thromboembolism suspected
• Check Hb where clinically indicated, especially pallor, excessive blood loss, or antenatal anaemia.

2. Routine treatment and counselling for the mother

• Breastfeeding: start and support exclusive breastfeeding for the first 6 months. Observe positioning and attachment. No pre-lacteal feeds.
• Nutrition: balanced extra meal, adequate fluids, rest, hygiene.
• Iron-folic acid: continue postpartum IFA according to national/state programme, particularly if anaemic. In India, this is generally 60 mg elemental iron plus 500 micrograms folic acid daily for 180 days postpartum. Treat moderate/severe anaemia according to Hb, symptoms, and referral capacity.
• Pain relief: paracetamol or ibuprofen if no contraindication. Encourage perineal hygiene and sitz bath for episiotomy discomfort.
• Constipation: fluids, fibre, early ambulation; stool softener if needed.
• Family planning: counsel and provide a suitable method before discharge or at the first visit:
  • Lactational amenorrhoea method only if all criteria are met: exclusive breastfeeding, amenorrhoea, baby <6 months.
  • Condoms, progestin-only pill, injectable, implant, IUCD or sterilization, according to eligibility and informed choice.
• Screen for and address domestic violence, depression, poor support, and substance use.

3. Maternal danger signs: treat immediately and refer to FRU/district hospital

A. Postpartum haemorrhage

1. Call for help, ABC assessment, oxygen if needed.
2. Two wide-bore IV lines, send blood if available, keep woman warm.
3. Rapid IV crystalloids and monitor pulse, BP, urine output.
4. Uterine massage and empty bladder.
5. Oxytocin 10 IU IM or slow IV as first uterotonic, if available.
6. If bleeding continues, use additional uterotonics only after checking contraindications and according to local protocol:
   • Misoprostol
   • Methylergometrine: avoid in hypertension/pre-eclampsia
   • Carboprost: avoid in asthma
7. Tranexamic acid 1 g IV over 10 minutes within 3 hours of birth where available; a second 1 g dose may be given if bleeding continues after 30 minutes or restarts within 24 hours.
8. Look for the 4 Ts: Tone (atony), Tissue (retained placenta), Trauma, Thrombin.
9. Urgent referral with staff escort, referral note, IV line maintained, and prior communication to receiving facility.

B. Suspected postpartum sepsis

• Take samples if this does not delay care.
• Start IV broad-spectrum antibiotics according to state/FRU protocol.
• Give IV fluids and antipyretic.
• Refer urgently if toxic, hypotensive, post-cesarean, or no early improvement.

C. Postpartum hypertension, pre-eclampsia or eclampsia

• Stabilize airway and breathing, place in left lateral position if fitting.
• Give magnesium sulfate loading dose as per Pritchard/local protocol if trained and available.
• Give antihypertensive for severe hypertension as per protocol.
• Immediate referral to FRU/district hospital. Do not send an unstable patient unaccompanied.

D. Other urgent maternal referrals

• Breathlessness, chest pain, cyanosis, syncope
• Unilateral swollen painful leg
• Severe pallor, weakness, dizziness
• Suicidal ideas, psychosis, confusion, or risk to baby

4. Newborn assessment at every visit

Check

• Temperature, respiratory rate, heart rate, color, activity and tone
• Weight and weight trend
• Feeding frequency and quality, urine/stool output
• Observe breastfeeding and correct attachment
• Umbilical cord for redness, pus, bleeding or foul odor
• Jaundice, pallor, skin lesions, congenital anomalies
• Ask whether birth immunizations were received.

Essential newborn care

• Keep baby warm: skin-to-skin contact, adequate clothing, delayed bathing.
• Exclusive breastfeeding on demand, at least 8-12 feeds/day. No water, honey, animal milk or other feeds.
• Dry cord care: keep clean and dry, do not apply ash, oil, powder, dung, or other substances.
• Ensure birth doses as per UIP: BCG, OPV-0 and Hepatitis B birth dose, where due/available.
• For low birth weight or preterm baby: promote kangaroo mother care, frequent breastfeeding or expressed breast milk, weight monitoring, and early referral if feeding/temperature problems occur.

5. Newborn danger signs: urgent referral to SNCU/NBSU

• Not feeding well or unable to suck
• Convulsions
• Fast breathing, more than 60/min
• Severe chest indrawing, grunting, apnoea or cyanosis
• Fever, more than 37.5°C
• Hypothermia, below 35.5°C
• Lethargy, no spontaneous movement, weak cry
• Jaundice in the first 24 hours, or jaundice of palms/soles at any age
• Persistent vomiting, abdominal distension
• Umbilical redness spreading to skin, pus, or skin pustules
• Weight <1.8 kg, prematurity, or poor weight gain

6. PHC team responsibilities

• Ensure ANM/ASHA home visits and tracking of missed visits.
• Maintain a line list of high-risk mother-baby pairs: anaemia, hypertensive disorder, PPH, cesarean birth, adolescent mother, twin birth, low birth weight, preterm baby, congenital anomaly.
• Keep emergency drugs/equipment ready: oxytocin, misoprostol, magnesium sulfate, antihypertensives, IV fluids, antibiotics, neonatal bag-mask, oxygen, radiant warmer/heat source, glucometer, referral transport contacts.
• Counsel family about danger signs and give a clear when-and-where-to-return plan.
• Confirm that the referral facility has been informed before transfer.