COLUMN: Birthing with Bridget - The six week post natal check

Hello again, I hope this article finds you all safe and well.

Last week was my initial article the 1st trimester of pregnancy. I hope you found it interesting and informative.

Today we are going to talk about the six-week postnatal Mum check-up.

Mum and baby are entitled to a check-up at six-weeks after birth. They are both free and they are officially the last appointments of your pregnancy.

Your GP or midwife will carry out Mum’s check-up, however, it must be the GP that performs the baby’s check-up.

It is important to remember that it is your responsibility to make these appointments, as they will not be automatically sent out to you.

Currently, due to Covid 19, in the Buncrana Medical Centre, where I work, the midwife/ GP is carrying out Mum’s check over the phone at six weeks after birth approx.

The baby’s check takes place when the baby is 2 calendar months old by the GP and the first set of baby vaccinations are offered and advised directly after this check-up, provided all is well with baby.

Routinely, it is the practice nurse that administers the baby vaccinations, after a detailed discussion with the Mum and the Mum has given her signed consent.

Mum’s six-week check is all about Mum. This often comes as a surprise to new Mum’s as the previous six-weeks may have been all about the baby. Health promotion, physically and emotionally wellbeing are the main focus of this check-up.

The maternity unit will have sent a detailed discharge summary to you GP/midwife. It will outline details of your birth experience.

Important points about your stay in hospital and a brief outline of the baby’s health at birth and afterwards. Your notes or the “the green folder”, as we call them, will stay in your maternity unit.

Your public health nurse will care for you and your baby at home. It is routine practice for the public health nurse to visit new mums within the first 48-72 hours home from hospital.

If there are any concerns with Mum or baby, then an appointment to see the GP will be required before the six-week check. Often the six, or currently 8/9-week check is the first time the GP will meet the baby.

The physical health of the mum is assessed at the check. Blood pressure will be assessed. A urine sample may be checked, especially if there were any concerns or if blood or protein were present in the urine antenatally or in hospital.

The midwife will assess to see that the womb has gone back down into shape. Medically called involuated. This should have happened well before six-weeks postnatally, especially if the mum is or did breastfeed. This is a painless exam. The mum will rest on the exam couch and the midwife will gently touch her stomach, with one hand, to make sure the top of the womb, called the fundus, can no longer be felt.

The non-pregnant womb is on average the size of your clenched fist, is pear shaped and lives in your pelvis. If the mum had a C-section then the scar will be examined. By six-weeks postnatal it should be clean and well healed.

If mum had a vaginal delivery, especially if this was her first vaginal delivery, she may have needed stitches to her perineum (the area of skin between your front and back passage). These stitches are always dissolvable, so you never have to get them taken out. The secret to healing these stitches is to keep them clean and dry.

Bugs love moist environments and as women we are great at washing everything but often forget to dry these hard to reach areas well.

By the six-week check these stitches should be fully dissolved and giving you no trouble. Your midwife may ask to see this area at your check.

It is your decision, like every examination or procedure, to give your consent or not. If you are concerned that this area does not feel right, maybe since delivery, please speak out about this at your check-up and your midwife/ GP will examine the area gently.

Often your bladder and bowel function will be discussed at the check. Both should be functioning normally and should not be causing you concern or embarrassment.

There was as a study carried out in Ireland in 2016. It looked at the health and wellbeing of first-time mums. It was called The Maternal Health and Maternal Morbidity in Ireland (MAMMI) Study. 2,600 Mums took part, that was 10% of all Mums who gave birth in Ireland that year.

Urinary incontinence was a key finding of this study. Almost 60% of the women surveyed leaked urine at 3 months postnatal, while 12% had leaked urine or stool in the first 3 months after having a baby.

Leaking urine or stool is not normal, but it is very common and nothing to be embarrassed about. Please be honest at your check-up, if this is happening to you, we can help.

Practicing pelvic floor exercises otherwise called Kegel’s exercises, is a great starting point. The pelvic floor is a sheet of muscles that extend from your pubic bones at the front to your tail bone. It is like a hammock holding everything up. It provides the floor to your pelvis and supports the contents of your pelvis- your bladder, womb and back passage.

Pelvic floor exercises will be discussed at your 6-week check, both their importance and how to do these exercises. Women who do Pilates or yoga may be familiar with pelvic floor exercises.

The emotional wellbeing of a new mum is really important. Pregnancy, birth and the postnatal period are times of adaption, psychologically, physically and socially, as women explore their roles as new mothers. Midwives have a central role to support and facilitate this transition for mothers.

After giving birth, most Mums experience some degree of mood changes. There are 3 main types of postnatal mood changes.

1. BABY BLUES
The “baby blues” also called the day 3 blues are so common they are considered normal for new Mums. They usually begin 2-4 days after your baby is born. You may have crying spells, increased feelings of vulnerability, irritability, loneliness or weariness.
Although you may find it distressing, and not what you were expecting to feel like as a new Mum, the baby blues will pass quickly, usually within a few weeks. Support from your partner, family and friends and rest will help you get through this. In the current climate, your sister or friends can not be physically present like they had hoped to be.
However, regular brief phone calls to check in and see how you are doing or a hot dinner dropped to the door are excellent ways of showing you care and that a new Mum is very much in your thoughts.

2. PUERPERAL PSYCHOSIS
This is the most extreme and rarest form of postnatal mood change. If affects approx. 1 in 500 new Mums. Symptoms begin soon after birth, usually with the Mum becoming restless.
Other symptoms include feeling paranoid, experiencing delusions or hallucinations, confused thinking and persistently not being able to sleep even while the baby is content and asleep.
Contact your GP urgently if you are experiencing these symptoms. Treatment usually involves medication and care from mental health experts.

3. POSTNATAL DEPRESSION (PND)
Postnatal depression (PND) falls somewhere between the baby blues and puerperal psychosis. It may affect up to 1 in 7 new Mums, although, some experts believe it affects even more. Symptoms may start as baby blues and then get worse, or they may take time to develop. PND is often coupled with feelings of guilt and fear. The earlier it is recognised, diagnosed and treated, the faster you will recover. Often a family member or friend will notice that there is something wrong before you do.

At the 6-week check your midwife or GP will ask you how you are doing? Be honest tell them how you are really doing. It is normal to feel tired and feel that motherhood is different to what you had expected- great but different. However, if you are struggling please reach out and be honest, we are here to help and there is nothing to be embarrassed about.
Health promotion is also a part of the 6-week check. Breast awareness will be discussed, ideally, talking the women through how to perform a breast check herself. Here are a few points to be focus on when being breast aware:
-know what is normal for you
-know what changes to look for
-look and feel your breast (a good time to do this is 1 week after your
period, or around the same time every month if you are no longer
having periods).
-discuss any changes with you GP without delay.

Remember- 9 out of 10 breast lumps are harmless but every lump should be checked by your GP.

A discussion about contraception will also be part of your 6week check. Contraception is always the woman’s choice. The World Health Organisation (WHO) guidelines recommend an ideal interval of 24 months and no fewer than 18 months between the birth of your babies. However, this is a recommendation and it will not apply to all women. Individual circumstances such as the age of the woman, the type of her last delivery i.e. C-section, or trauma from a pervious birth experience may affect the spacing of her family.

At the 6-week check, if the woman wants to discuss contraception, then different types of contraception will be discussed, and her questions answered. Sometimes a follow-up appointment to see a GP will be made i.e. to discuss a longer acting form of contraception such as a Mirena coil.

We are lucky that may GP’s are skilled in providing these services locally for women. Even if a Mum is breastfeeding, there is still a type of oral contraception available for her. No matter what space you are hoping to have between your children, it is important to remember that most women are very fertile after having a baby and even though nature may be ready, Mums need to physically and emotionally recover from the previous pregnancy.

The current recommendations are that women aged between 25-45 are invited every 3years for a free cervical screening test, commonly called a smear test. It used to be thought that after every baby you needed a smear. This is incorrect. If your smear was due in the pregnancy, then you will need it postnatally.

Smears are not routinely performed in pregnancy and you must wait a minimum of 3 months after the birth of your baby before having a routine smear.

Due to Covid 19, all routine screening programmes, including cervical screening are on hold at present. Remember screening is for people who have no symptoms. If you are concerned about abnormal bleeding do not hesitate to speak to your GP.

Every time a midwife or GP meets with a woman, it is an opportunity for a chat. Domestic violence is real and the longer it goes unsaid the longer it continues. One in five Irish women experience abuse by a current or former partner. Domestic violence refers to physical, emotional, sexual or financial abuse within a close adult relationship, most often an intimate relationship.

Pregnancy has been identified as a high-risk period when domestic abuse often begins or intensifies. Please remember you are not alone and at any antenatal, postnatal or child appointment you can reach out to a nurse, a midwife or to your GP. We will be here to listen and help if that’s what you want.

Woman Aid provide a direct service to women experiencing domestic violence through a National Freephone Helpline - 1800 341 900, 24 hr a day, 7 days a week. Here in Donegal there is a special domestic violence service too, also a phone number 1800 262 677, also 24 hrs, 7 days a week. If you feel you can not speak to your midwife/ GP yet, please call one of these numbers above this may be your first step to freedom.

Lastly, your baby’s vaccinations may be discussed. Babies are due their 1st set of vaccinations when they are 2 calendar months old. These vaccinations are due if they were born at full term or if they were preterm. Babies must have their check-up from the GP before they can receive the vaccinations and their Mum must give signed informed consent.

www.immunisation.ie is an incredibly good Irish website to get accurate, up-to-date information about vaccinations in Ireland. We are advised by public health experts to keep going with the children’s vaccination programme during Covid 19.

As we want to keep our children as well as possible, trying to prevent illness and reducing the need for them to go to hospital.

I really hope that you have found this article informative. Remember it is a guide.

If you are concerned about anything please speak to your GP, hospital doctor or midwife.

If you wish to contact me regarding antenatal classes or article feedback, please do not hesitate. My email address is: birthingwithbridget@gmail.com.

Until next week, take care, Bridget the midwife.