Volume 79, Number 2

OBSTETRICAL AND GYNECOLOGICAL SURVEY

Copyright © 2024 Wolters Kluwer Health,
Inc. All rights reserved. CME REVIEW ARTICLE
CHIEF EDITOR’S NOTE: This article is part of a series of continuing education activities in this Journal through which up to
3
36 AMA PRA Category 1 Credits™ can be earned in 2024. Instructions for how CME credits can be earned appear on the last page
of the Table of Contents.

Postnatal Care: A Comparative Review

of Guidelines
Sonia Giouleka, MSc,* Ioannis Tsakiridis, PhD,† Nikolaos Kostakis, MD,*
Eirini Boureka, MSc,* Apostolos Mamopoulos, PhD,‡ Ioannis Kalogiannidis, PhD,§
Apostolos Athanasiadis, PhD,‡ and Themistoklis Dagklis, PhD†
*Resident, †Assistant Professor, ‡Professor, and §Associate Professor, Third Department of Obstetrics and Gynaecology, School
of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece

Importance: Postnatal care refers to the ongoing health care provision of both the mother and her offspring
and contributes to the timely identification and effective management of complications in the postpartum period,
to secure maternal and infant short- and long-term well-being.
Objective: The aim of this study was to review and compare the most recently published influential guidelines
on postnatal care practices.
Evidence Acquisition: A comparative review of guidelines from the American College of Obstetricians and Gy-
necologists, the World Health Organization, the National Institute for Health and Care Excellence, and the Public
Health Agency of Canada regarding postnatal care was conducted.
Results: There is a consensus among the reviewed guidelines regarding the importance of health care provi-
sion in the postpartum period, including home visits and midwifery services, the use of telemedicine for the facil-
itation of communication with the patient, and the appropriate preparation for discharge, as well as the discharge
criteria. All medical societies also agree on the clinical aspects that should be evaluated at each postnatal visit,
although discrepancies exist with regard to the contact schedule. In addition, there is consistency regarding
the management of postpartum infections, perineal pain, fecal and urinary incontinence, and physical activity
guidance. Mental health issues should be addressed at each postnatal visit, according to all guidelines, but there
is disagreement regarding routine screening for depression. As for the optimal interpregnancy interval, the
American College of Obstetricians and Gynecologists recommends avoiding pregnancy for at least 6 months
postpartum, whereas the National Institute for Health and Care Excellence recommends a 12-month interval.
There is no common pathway regarding the recommended contraceptive methods, the nutrition guidance, and
the postpartum management of pregnancy complications. Of note, the World Health Organization alone provides
recommendations concerning the prevention of specific infections during the postnatal period.
Conclusions: Postnatal care remains a relatively underserved aspect of maternity care, although the puerpe-
rium is a critical period for the establishment of motherhood and the transition to primary care. Thus, the devel-
opment of consistent international protocols for the optimal care and support of women during the postnatal pe-
riod seems of insurmountable importance to safely guide clinical practice and subsequently reduce maternal and
neonatal morbidity.
Target Audience: Obstetricians and gynecologists, family physicians
Learning Objectives: After participating in this activity, the learner should be better able to describe all the as-
pects of postnatal care; explain the appropriate clinical evaluation plan during the postnatal period; and assess
the available postpartum care promotion techniques.

The postpartum period, also known as the puerpe-

rium or the “fourth trimester,” refers to the time after
All authors, faculty, and staff have no relevant financial relationships
with any ineligible organizations regarding this educational activity.
birth when the physiologic pregnancy-related changes
Correspondence requests to: Ioannis Tsakiridis, PhD, Konstantinoupoleos return to the nonpregnant state; the duration lacks uni-
49, 54642 Thessaloniki, Greece. E-mail: igtsakir@auth.gr. formity among medical societies and varies from 6 to
www.obgynsurvey.com | 105

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106 Obstetrical and Gynecological Survey
12 weeks, as the effects of pregnancy on organ systems
have largely returned to baseline by this time.1,2 Despite
the efforts made in the past few decades by national and
international organizations to raise awareness and pro-
mote postnatal care, the burden of maternal and neona-
tal mortality and morbidity during this period remains
unacceptably high.3
Although the focus is often on pregnancy and child-
birth, the weeks and months following delivery are
equally important; it is a period with considerable chal-
lenges and great physical, emotional, functional, and
social changes for the mother.4,5 Becoming a mother is
one of the most transformative experiences in a woman's
life because the woman has to recover from childbirth,
adapt to hormonal changes, and learn to feed and care
for her neonate, as well as navigate preexisting health and
social issues.6 Notably, inadequate postpartum care is asso-
ciated with higher rates of depression, breastfeeding dif-
ficulties, and infant mortality.4,7
Postpartum care is usually fragmented to maternal
and neonatal care, with the first unfortunately remaining a
neglected aspect of the health care provision and therefore
leaving many new mothers unsupported, overwhelmed,
and isolated.8 This neglect reflects to the fact that more
than half of the pregnancy-related deaths occur after
delivery.9 The postnatal period should be focused on
fulfilling the adaptation to changes and enhancing the
capacity to thrive in the new integrated identity of
“woman and mother.”10 Toward this goal, the develop-
ment of consistent international evidence-based algo-
rithms for the optimization of health care provision in
the postpartum period seems of pivotal importance and
will hopefully lead to a reduction in the maternal and
neonatal morbidity rates. Hence, the aim of this descrip-
tive review was to synthesize and compare recommen-
dations from influential guidelines on the management
of postnatal care.
EVIDENCE ACQUISITION
The most recently published guidelines on postnatal
care were retrieved, and a comparative review was con-
ducted. More specifically, 4 guidelines were identified
from the American College of Obstetricians and Gyne-
cologists (ACOG 2018),2 the World Health Organization
(WHO 2022),3 the National Institute for Health and Care
Excellence (NICE 2021),11 and the Public Health Agency
of Canada (PHAC 2020).12
An overview of the recommendations is presented in
Table 1 (postpartum maternal care), Table 2 (postpartum
infection control), Table 3 (postpartum management of
pregnancy complications), and Table 4 (interventions
for postnatal care promotion).
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POSTPARTUM MATERNAL CARE
Clinical Evaluation
All guidelines, except ACOG, which makes no rele-
vant reference, point out the importance of maternal
clinical evaluation within the first 24 hours following
delivery. This evaluation should include a general as-
sessment of the woman's physical and physiological
well-being (NICE, PHAC), along with assessment of blad-
der function (WHO, NICE, PHAC); vital signs, vaginal
bleeding, fundal height, and uterine tone (WHO, PHAC);
and bowel function and breast condition (PHAC).13 WHO
emphasizes the need for a urine void evaluation within
the first 6 hours, and NICE recommends the measure-
ment of the volume of the first urine void. Notably, ac-
cording to WHO, the blood pressure should be mea-
sured shortly after delivery and remeasured in 6 hours
if it is within normal levels.
In case of delivery in health care settings, discharge
should be allowed when maternal and neonatal well-being
is ensured, and no signs of postnatal complications ex-
ist (WHO, NICE, PHAC). NICE points out that besides
maternal health and bladder function evaluation, it is
crucial to assess the neonate's health, appropriately in-
form the parents regarding meconium passing, and ob-
serve at least 1 effective feeding before transition from
the maternity unit to community care. Timing of dis-
charge should be discussed with the parents and be in-
dividualized based on women's preferences. Detailed
information regarding the available support should
also be provided (NICE). On the other hand, WHO men-
tions that the duration of hospital stay following de-
livery varies worldwide,14 but inpatient postnatal care
should be provided for at least 24 hours. Similarly, in
case of home birth, the first postnatal contact should
be made in the first 24 hours. A Cochrane review failed
to precisely define “early discharge” but concluded that
a short hospital stay, although slightly increasing the
number of infants readmitted within 28 days for neona-
tal morbidity (RR, 1.59; 95% confidence interval [CI],
1.27–1.98), it has little to no difference in women readmitted
within 6 weeks postpartum for complications related to
childbirth (relative risk [RR], 1.12; 95% CI, 0.82–1.54),
in the risk of depression within 6 months postpartum
(RR, 0.80; 95% CI, 0.46–1.42), and in women breast-
feeding at 6 weeks postpartum (RR, 1.04; 95% CI,
0.96–1.13).15 According to WHO, the ability of the
parents or the caregivers to provide appropriate care
to the mother and the neonate should also be assessed
along with social factors that could affect the postna-
tal care and the care-seeking behavior.16,17 PHAC
suggests that health care providers should discuss
the advantages and disadvantages of a shorter
 Postnatal Care • CME Review Article
TABLE 1
Summary of Recommendations on Postpartum Maternal Care
ACOG
Country United States International
Issued 2018 2022
Title Optimizing Postpartum Care WHO Recommendations on
Pages 10
References 133
Clinical evaluation Not discussed
at the first 24 h
Discharge criteria Not discussed
Postnatal contact Individualize. Provide
schedule postnatal care plan with
contact information and
instructions about the
timing of postnatal
contacts. First contact at
first 3 wk, following
ongoing care until the
comprehensive visit
<12 wk
Clinical evaluation Physical, social and
at postnatal psychological well-being.
contacts Sleep and fatigue.
Perineal or cesarean
incision. Urinary and fecal
continence. Infant care
and feeding. Sexuality,
contraception and birth
spacing. Chronic disease
management. Pelvic
examination and
Papanicolaou test
Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.
WHO
Maternal and Newborn
Care for a Positive
Postnatal Experience
240
284
Vaginal bleeding, fundal
height, uterine tonus,
temperature, heart rate. BP
measurement shortly after
birth and repeat after 6 h.
Urine void evaluation within
6h
24 h after vaginal delivery: (1) (1) Woman's health and
maternal and newborn
well-being, (2) parental and
caregivers' skills and
confidence for individual
and newborn care, (3)
home environment and
other factors affecting pp
care and care-seeking
behavior
Minimum 4 postnatal
contacts. First within 24 h
for home delivery. At least 3
additional postnatal
contacts between 48 and
72 h, between 7 and 14 d
and during week 6.
Individualize
General well-being,
micturition and urinary
incontinence, bowel
function, perineal wound
healing, headache, fatigue,
back pain, perineal pain
and hygiene, breast pain,
uterine tenderness and
lochia
NICE
United Kingdom
2021
Postnatal Care
64
0 334
Bladder function with
measurement of first void
after birth. Woman's health
assessment
bladder function, (2)
baby's health and
meconium passing, (3)
feeding plan and
observation of 1
successful feed. Inform
about postnatal period
available support. Discuss
the timing
First midwife visit at 36 h after Provide postnatal care plan
transfer of care or after
home birth. First health
care provided at 7–14 d
after midwifery care.
Comprehensive evaluation
by GP at 6–8 wk
General mental and physical Physical and emotional
well-being, fatigue, pelvic
floor exercises, nutrition,
physical activity, smoking,
alcohol consumption, drug
use, sexual intercourse,
contraception and
domestic abuse. Assess
signs and symptoms of
infection, pain, vaginal
discharge and bleeding,
bowel function, nipple and
breast discomfort, VTE,
anemia, preeclampsia,
perineal healing for vaginal
birth, wound healing or
infection for cesarean
delivery. Referral for further
evaluation if indicated.
107
PHAC
Canada
2020
Family-Centered Maternity
and Newborn Care:
National Guidelines
Chapter 5: Postpartum
Care
85
Assess physical and
psychological well-being.
Vital signs, uterine tone
and condition of perineum,
lochia, bladder and bowel
function, breasts and
nipples. Promote effective
feeding. Hydration and
nutrition
Review test results and
possible signs of pp
complications.
with contact information
and instructions for the
postnatal contacts.
Follow-up visit at 24–72 h
after discharge
well-being, vital signs,
uterine tone and condition
of perineum, lochia,
bladder and bowel
function, breasts and
nipples, rest, pain or
discomfort and a physical
examination. Clear and
consistent information
from health care provider
with individualized
approach
Continued next page
108 Obstetrical and Gynecological Survey

TABLE 1. (Continued)

ACOG WHO NICE PHAC

Mental health Anticipatory guidance for Screen for pp depression and Assess at each postnatal visit Screening for pp depression
prevention. Screen for pp anxiety with validated and refer if concerns. not routinely
depression and anxiety instrument (EPDS or PHQ- Whooley Questions for recommended. Increased
with validated instrument, 9) and follow up with Depression Screening vigilance and consistent
for tobacco or substance diagnostic and treatment and, if positive, EDPS or ongoing care are required.
use with referral as interventions as indicated. PHQ-9. Discuss smoking, Identify risk factors. Refer
indicated. Follow up Psychosocial and/or alcohol consumption and to specialist if required.
preexisting mental psychological interventions recreational drug use and Provide support. In case of
diseases, monitor mental recommended as provide appropriate care severe mental disorder,
health appointment preventive methods. professional support and
attendance, and titrate Mentoring and support treatment are needed
medications guidance recommended
regarding local resources
Postpartum vaginal Not discussed Regular assessment Provide discharge Provide discharge
bleeding information about information about
expected changes and expected changes and
amount of blood, the amount of blood pp, the
indications for concern, causes of concern and the
and further evaluation. need for further evaluation.
Consider readmission,
oxytocin, blood
transfusion, and surgical
intervention if needed
Endometritis Not discussed Routine antibiotic prophylaxis Inform about normal lochia Inform about normal lochia
not recommended. Careful and vaginal discharge as and vaginal discharge.
monitoring for signs of well as signs and Consider treatment with
endometritis symptoms of infection. antibiotics, rest, high fluid
Advise to seek medical intake, analgesia, and
care immediately. oxytocin
Breast Not discussed Responsive breastfeeding, Assess at each postnatal visit Encourage breastfeeding
engorgement— good positioning and continuation. Frequent
mastitis attachment to the breast, feeding, good positioning,
breast milk expression, and and latching. Antibiotics
either warm or cold may be needed
compresses.
Pharmacological agents
not routinely
recommended for
prevention
Perineal care and Assessment of pain Ice packs or cold pads for Assessment of perineal Evaluate perineal or vaginal
pain control presence with proper acute perineal pain relief wound healing, pain tears and examine for
guidance considering individual resolving and need for pain OASIS if more than
preferences. Intermittent reliefs, any unpleasant superficial. If OASIS,
application of crushed ice smell, swelling, or wound provide antibiotic
between layers of a pad or breakdown. Consider a prophylaxis, laxatives, and
a gel pack for 10–20 min in validated pain scale for referral to a
the first 48 h monitoring perineal pain. physiotherapist. Assess
Consider risk factors. any stinging, odor,
Refer for further evaluation incontinence, or
if any concerns or wound dyspareunia. Ice packs,
breakdown is presented self-inspection, warm
water sitz baths, and Kegel
exercises are
recommended
Continued next page

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 Postnatal Care • CME Review Article 109

TABLE 1. (Continued)

ACOG WHO NICE PHAC

Analgesics Not discussed Oral paracetamol as first-line Consider pain relief options Paracetamol and NSAIDs as
for perineal pain. If with respect to first-line for OASIS
paracetamol and cooling breastfeeding
agents are ineffective,
consider other agents. Oral
NSAIDs for uterine
cramping/involution
DRA Not discussed Not discussed Not discussed Exercise, pelvic floor
physiotherapy,
neuromuscular stimulation
and/or abdominoplasty.
Corsets/binders for
separations of at least 4
finger widths
recommended
Urinary/fecal Assess any incontinence Routine pelvic floor muscle Assess symptoms of pelvic Focus on prevention. Kegel
incontinence and refer to physiotherapy training not recommended floor dysfunction at exercises and follow-up
or urogynecologist for prevention. Inform postnatal care routine for effectiveness
about the benefits of assessment. Combine
unsupervised PFMT at with lifestyle changes and
home settings in urinary bladder training. Refer to
incontinence physiotherapy for fecal
incontinence
Constipation Not discussed Dietary advice and Not discussed Not discussed
information of constipation
related factors
recommended. Routine
use of laxatives not
recommended
Venous thromboembolism Not discussed Not discussed Risk assessment to define
the need for pp LMWH
and the duration of pp
prophylaxis (10 d to 6 wk).
Start 4 h after regional
anesthesia. Consider
antiembolism stockings if
traveling >4 h, if LMWH is
contraindicated,
combined with LMWH
after cesarean section or
at increased VTE risk
Not discussed
Nutrition Not discussed Oral iron supplementation Discuss at each postnatal Multivitamin containing
combined with folic acid or visit 400 μg folic acid
alone recommended for recommended for
6–12 wk pp for lowering breastfeeding women.
anemia risk in areas with Regular intake of
≥20% prevalence of vegetables, fruit, whole
gestational anemia. Vitamin grains, and protein foods
A not recommended pp recommended. Special
care of women with
obesity
Continued next page

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110 Obstetrical and Gynecological Survey

TABLE 1. (Continued)

ACOG WHO NICE PHAC

Physical activity Provide guidance for proper Regular physical activity Discuss at each postnatal Exercise during pregnancy
physical activity and ≥150 min/wk visit. Inform about the and pp reduces the risk for
healthy weight attainment recommended. Gradually importance of pelvic floor DRA. Kegel exercise to
increase of activity exercises. improve perineal tone
frequency, intensity, and
duration. Inform women
about signs for immediate
activity halt and special
considerations based on
individual's history
Family planning Discuss individual plans and Detailed, evidence-based Discuss contraceptive Discuss contraceptive
desires for future contraceptive information, methods at the postnatal methods at the postnatal
pregnancies. Avoid IPIs education, and counseling visits. Initiate visits. Assess sexual
<6 mo. Discuss risks and recommended contraceptive from health
benefits of repeat 21 d pp. Avoid IPIs <12 mo
pregnancy <18 mo.
Inform about
contraceptive methods
Contraceptive Not discussed LAM combined with other LAM recommended for the LAM recommended for the
methods contraceptive methods first 6 mo if amenorrhoeic first 6 mo if amenorrhoeic
recommended for the first and the baby is exclusively and the baby is exclusively
6 mo. Copper-IUD and breastfed. POP, IMP, and breastfed on demand. IUD
LNG-IUDs <48 h or >4 wk. POI immediately after inserted immediately after
POP, LNG, and ETG IMPs. birth. IUD <48 h or >4 wk. birth. Condoms. POPs
PVR if ≥4 wk and POIs if Additional contraceptives and COCPs from 3–4 w pp
>6 wk pp. CHCs if >3 wk if hormonal contraception
without risk factors for VTE starts ≥21 d pp. POPs
or >6 wk, but if safe. CHCs if >3 wk
breastfeeding not without risk factors for VTE
recommended up to 6 mo. or >6 wk pp if
COCPs, ulipristal acetate, breastfeeding or not. Oral
or LNG recommended as EC LNG and ulipristal
emergency contraception >21 d, copper-IUD
methods >28 d pp as emergency
contraception methods
BP, blood pressure; COCPs, combined oral contraceptive pills; ETG, etonogestrel; GP, general practitioner; IMP, implant; IV, intravenous;
LMWH, low-molecular-weight heparin; LNG, levonorgestrel; pp, postpartum; PVR, progesterone vaginal ring.

hospital stay with the mother before discharge along
with reviewing test results.
There is no common pathway regarding the recom-
mended time frame of the postnatal contacts; ACOG
recommends a first contact within the first 3 weeks
followed by ongoing care until the comprehensive visit
at 12 weeks postpartum, whereas PHAC recommends
a postnatal contact between 24 and 72 hours after
discharge.18 According to NICE, the first midwife visit
should take place 36 hours after community transfer,
followed by a health care provider contact at 7 to 14 days
and a comprehensive evaluation from a general practi-
tioner at 6 to 8 weeks postpartum. Similarly, WHO rec-
ommends postnatal contacts between 48 and 72 hours,
at 7 to 14 days, and during week 6. This recommenda-
tion is based on a recent Cochrane review, which showed
that 4 home visits resulted in lower infant referral to a
pediatrician and higher exclusive breastfeeding rates
for up to 6 weeks compared with only 1 home visit; this
review also concluded that an increased number of
postnatal visits and a more individualized care may im-
prove maternal satisfaction and outcomes.19 Providing
women with postnatal care plan and contact informa-
tion is advised by ACOG and PHAC and should be tai-
lored to the individual needs of each woman (ACOG
and WHO).4
With regard to the clinical evaluation during the post-
natal contacts, there is overall agreement that it should
include the assessment of physical, psychological, and
social well-being of the mother. More specifically, signs
and symptoms of infection, perineal and back pain, uter-
ine tone, vaginal discharge and lochia, bowel function,

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 Postnatal Care • CME Review Article
TABLE 2
Summary of Recommendations on Postpartum Infection Control
WHO
HIV follow-up testing Recommended in high HIV prevalence
settings if HIV-negative or of
unknown status and missed early
antenatal testing or third-trimester
retesting. Consider in low HIV
prevalence settings for
HIV-negative or of unknown status
women with missed early antenatal
testing or third trimester retesting
who have a non–virally suppressed
partner on ART or other ongoing
HIV risks at third trimester.
Oral pre-exposure Start or continue oral TDF for
prophylaxis for HIV postpartum and/or lactating women
prevention at substantial risk as part of
combination HIV prevention
approaches.
Screening for tuberculosis Consider if TB prevalence is ≥0.1%
and in cases of household or other
close contact with TB-infected
individuals.
Helminth infection prevention Annual/biannual dose of 400 mg
albendazole or 500 mg
mebendazole in postpartum and/or
lactating women in areas with
≥20% prevalence of
soil-transmitted helminth infection.
Schistosomiasis prevention Single annual dose of praziquantel for
postpartum and/or lactating women
in areas with ≥10% prevalence. If
prevalence <10%, either test and
treat or continue preventive
chemotherapy.
ART, antiretroviral therapy; TB, tuberculosis; TDF, tenofovir
disoproxil fumarate.
urine and fecal incontinence, nipple and breast dis-
comfort, breastfeeding, perineal healing for vaginal
birth, wound healing or infection for cesarean section,
fatigue, and sleep deprivation should be evaluated, ac-
cording to the reviewed guidelines. Furthermore, NICE
states that the mother should also be assessed for ane-
mia and preeclampsia. Other issues including nutri-
tion, physical activity, smoking, alcohol consumption,
drug use, sexual intercourse, and domestic abuse should
be addressed as well, and a referral for further evalu-
ation should be made if indicated (NICE). Further-
more, NICE, along with ACOG, highlights the im-
portance of contraception and interpregnancy interval
(IPI) counseling during the postnatal contacts. Of note,
ACOG mentions that the appropriate management of
chronic diseases and the performance of a Papanicolaou
test and pelvic examination are integral parts of the
postnatal care.
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111
Mental Health
Depression and anxiety constitute major causes of dis-
ability among women in the postpartum period, having a
prevalence of 13% and 20% in high- and low-income
countries, respectively.20 Therefore, ACOG and WHO
recommend universal screening for postpartum depres-
sion and anxiety using validated instruments, such as
the Edinburgh Postnatal Depression Scale (EPDS) or
Patient Health Questionnaire 9 (PHQ-9), based on a
meta-analysis that showed this strategy, when com-
pared with usual care, reduces the rate of postpartum
depression (odds ratio, 0.53; 95% CI, 0.45–0.62) and
anxiety (median, 0.28 fewer; 95% CI, 0.44–0.11) and im-
proves the quality of life.21 Following a positive screening
result, appropriate guidance, support, and diagnostic ser-
vices are required. WHO also recommends the use of psy-
chological and psychosocial interventions as preventive
measures for women considered at high risk for mental
health disorders. This recommendation is based on a ran-
domized controlled trial that found these interventions are
effective in reducing the proportion of at-risk women with
a 6-month EPDS score ≥12.22 Moreover, ACOG refers
to preexisting mental illness and recommends adequate
monitoring with attendance to mental health–related ap-
pointments along with titration of the medication in the
postpartum period. Moreover, ACOG, along with NICE,
highlights the importance of screening for tobacco use,
alcohol consumption, and substance use disorders, as the
relapse risk increases in the puerperium.23
A slightly different approach in mental health screen-
ing is proposed by NICE. More specifically, according
to NICE, screening with Whooley Questions for Depres-
sion should be considered, and if positive, a full assess-
ment using EDPS or PHQ-9 may be performed. Similarly,
screening with the 2-item Generalized Anxiety Disorder
(GAD-2) scale for anxiety should be considered, and if
positive, the GAD-7 scale for a more detailed evaluation
may be used. A positive screening result justifies the re-
ferral to the woman's general practitioner or a mental
health specialist.
On the contrary, the PHAC does not support routine
postpartum depression screening, but instead, it recom-
mends increased vigilance and consistent ongoing care,
to timely identify any potential risk factors or symptoms
of mental disorders, exclude other medical conditions
that may cause or contribute to the symptoms, provide
appropriate psychological support, and refer to special-
ist, if required.24 As for anxiety, PHAC, although rec-
ognizing that GAD-2 questionnaire is a useful tool for
identifying generalized anxiety disorder and that anxi-
ety is prevalent in the postpartum period, makes no spe-
cific recommendation.
112
TABLE 3
Summary of Recommendations on Postpartum Management of Pregnancy Complications
Hypertensive disorders:
advice and follow up
Preeclampsia: (Α) Blood
pressure measurement
(B) Laboratory tests
Gestational hypertension
Chronic hypertension
Antihypertensive treatment Not discussed
Gestational diabetes mellitus FPG test or 75 g 2-h OGTT Stop treatment immediately pp. Test persisting
Obstetrical and Gynecological Survey
ACOG NICE PHAC
Inform about higher risk of Inform about overall risk of recurrence, higher risk Important pp monitoring
ASCVD of ASCVD and the interventions to reduce it
Recommended at 7–10 d pp Women without antihypertensive treatment: 4 per Recommended at 3–6 d pp
(or in 72 h for severe day at hospital, once at 3–5 d. On alternate days
hypertension) and in if abnormal BP at 3–5 d. Start treatment if BP
1–3 wk if high risk ≥150/100 mm Hg. Ask for severe headache and
epigastric pain at postnatal contacts. Women
with treatment: 4 per day at hospital, every
1–2 d up to 2 wk until treatment and
hypertension cease. Reduce dose if BP <130/
80 mm Hg and consider if BP <140/90 mm Hg.
Change methyldopa within 2 d pp. Transfer to
community care if no symptoms of
preeclampsia, BP ≤150/100 mm Hg, and blood
tests stable/improved. Review by GP at 2 and
at 6–8 wk
Not discussed Platelets, transaminases and serum creatinine Not discussed
recommended at 48–72 h after birth/step-down
from critical care and repeat until normal.
Urinary-reagent strip at 6–8 wk. If proteinuria
≥1+, GP review and assessment of kidney
function at 3 mo. Consider referral to kidney
specialist if abnormal kidney function
Recommended at 7–10 d pp BP measurement daily for 2 d, once at 3–5 d and BP measurement
(or in 72 h for severe as indicated after treatment change. recommended at 3–6 d pp
hypertension) and in Antihypertensive treatment: start if BP
1–3 wk if high risk 150/100 mm Hg, lower if BP <130/80 mm Hg,
same duration as antenatally. Change
methyldopa within 2 d postpartum. Review
treatment in 2 wk
Timely follow-up BP measurement daily for 2 d, once at 3–5 d and BP measurement
recommended as indicated after treatment change. recommended at 3–6 d pp
Antihypertensive treatment: continue as
indicated with BP goal <140/90 mm Hg.
Change methyldopa within 2 d postpartum.
Review treatment in 2 wk
Individualize. Avoid diuretics and angiotensin Not discussed
receptor blockers if breastfeeding. Enalapril
recommended while monitoring renal function
and serum potassium. Nifedipine/amlodipine
considered for Black African or Caribbean
women. Consider combination if BP not
normalized. Swap/add atenolol/labetalol if
combination not tolerated/effective. Prefer
agents taken once daily
75 g OGTT recommended at
recommended. Inform hyperglycemia before community care transfer. 6 wk and 6 mo pp
about higher risk of Inform about hyperglycemia symptoms and
ASCVD recurrence risk. Lifestyle advice. FPG test at
6–13 wk if normal glucose after birth. FPG or
HbA1c after 13 wk if missed. Annual HbA1c if
tested negative. OGTT not routinely
recommended. Early glucose self-monitoring or
OGTT recommended at future pregnancies.
Subsequent OGTT recommended if the first
is normal
Continued next page
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 Postnatal Care • CME Review Article 113

TABLE 3. (Continued)

ACOG NICE PHAC

Pregestational diabetes Timely follow-up Type I: (1) titrate insulin according to glucose Type I: Screen for
mellitus recommended levels, (2) inform about increased risk of pp postpartum thyroiditis with
hypoglycemia. Advise meal/snack during/ TSH test at 6–8 wk. Type
before feeds. Type ΙΙ: resume metformin after 2: (1) breastfeeding, (2)
birth. Avoid other blood glycose-lowering careful monitoring due to
agents and agents for diabetes complications. increased risk of
Need for contraception and preconception care hypoglycemia, (3) safety of
metformin and glyburide
while breastfeeding, (4)
assessment of
triglycerides late pp
Pregnancy loss Proper follow-up and Not discussed Not discussed
emotional support.
Counseling and review of
laboratory and pathology
studies related to the loss.
Documentation.
Counseling regarding
recurrence
ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; GP, general practitioner; pp, postpartum; TSH, thyroid-stimulating
hormone.

TABLE 4
Summary of the Recommendations on the Interventions for Postpartum Care Promotion
ACOG
Discharge Recruit peer counselors,
preparation support staff, discharge
planners, and schedule
postnatal contacts. Identify
primary HCP. Anticipatory
counseling during pregnancy
Home visits Recommended
Midwifery services Recommended. Provide routine Midwife-led continuity-of-
ongoing care. “First call” for
acute concerns
Digital Recommended for reminding
communication women to schedule postnatal
follow-up. Phone support,
text messages, remote blood
pressure monitoring, and
application-based support
recommended for assessing
woman's health issues
HCP, health care provider.
WHO
Provide information,
counseling, and
educational interventions
to parents and caregivers.
Educational materials
should be available.
Include partners
according to woman's
wishes
Recommended for the first
week pp. If not feasible or
preferred, outpatient
postnatal care
recommended
care models
recommended in settings
with well-functioning
midwifery programs
Recommended for behavior
change concerning
sexual, reproductive,
maternal, newborn, and
child health only if
concerns about sensitive
content and data privacy
are adequately addressed
NICE PHAC
Include partners according Identify primary HCP.
to woman's wishes. Written or verbal
Inform about seeking information about
care for any concerns. symptoms and signs that
Ensure communication will raise concern, steps,
between HCP and precautions to take.
Discuss risks and benefits
of shorter stay. Parenting
courses. Peer support
Recommended 3 home visits from midwives
recommended at first
week
Recommended for 3 home visits from midwives
information about recommended at first
postnatal period and week
home visits
Digital information should Secured electronic
be provided for communication.
breastfeeding and Telephone support
formula feeding support

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114 Obstetrical and Gynecological Survey
Postpartum Vaginal Bleeding
Postpartum hemorrhage is the leading cause of mater-
nal mortality, accounting for approximately 30% of all
maternal deaths and a significant contributor of mater-
nal morbidity.25 Consequently, to ensure early detection
and prompt management of this obstetric complication,
NICE and PHAC recommend providing women detailed
discharge information about the expected changes in
lochia, the normal amount of bleeding, the warning signs,
and the indications for seeking further medical attention.
Treatment may include oxytocin administration, blood
transfusion, and/or surgical intervention, and readmis-
sion in case of late postpartum hemorrhage may be re-
quired (PHAC).25,26
Infections—Endometritis, Mastitis
There is a consensus among the reviewed guidelines
(except ACOG, which makes no relevant reference)
that the provision of adequate information during the
postnatal contacts concerning the normal lochia and
vaginal discharge is crucial for women to timely recog-
nize any deviation and identify any warning symptoms,
such as persistent or increasing vaginal bleeding, fever,
perineal, abdominal or pelvic pain, and unpleasant vag-
inal odor, which should prompt immediate medical ad-
vice. Routine antibiotic prophylaxis for the prevention
of endometritis in case of uncomplicated vaginal delivery
is not recommended, according to WHO, as a Cochrane
review failed to provide strong evidence that this strat-
egy reduces the risk of endometritis in all health care
settings.27 However, endometritis treatment should in-
clude antibiotic administration,28 as well as rest, high
fluid intake, appropriate analgesia, and use of oxytocin
to keep the uterus contracted (PHAC).
With regard to mastitis prevention, WHO recommends
against routine oral or topical antibiotic administration,
as a Cochrane review showed that the risk of mastitis is
similar between antibiotics and usual care or placebo
groups (RR, 0.37; 95% CI, 0.10–1.34).29 In contrast, prac-
tices including responsive and frequent breastfeeding,
good positioning and attachment of the baby to the nip-
ple, manual expression of breast milk, and the use of
warm or cold compresses should be encouraged as ef-
fective preventive measures, especially in case of breast
engorgement (WHO, PHAC). It is essential to advise
women not to cease breastfeeding even in case of antibiotic
treatment, as emptying the breast is beneficial, and the milk
is safe for the baby (PHAC). NICE points out that breast
reddening and swelling getting worse or persisting more
than 24 hours despite conservative self-management may
indicate infection, and medical advice should be sought.
Moreover, pharmacological interventions such as oxytocin
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and proteolytic enzymes, for the treatment of breast en-
gorgement during lactation, are discouraged by WHO,
as a Cochrane review found insufficient evidence to
support this strategy.30
Perineal Care and Pain Control
ACOG and NICE agree that the assessment and mon-
itoring of the perineal pain should be integral parts of
the postnatal care, with NICE recommending the use
of a validated pain scale to help identify any persistent
or deteriorating pain and the evaluation of risk factors
that could increase the pain. The perineal and vaginal
tears should also be inspected, according to PHAC, and
those found to be more than superficial should be further
investigated for the presence of obstetric anal sphincter
injury (OASIS). In case of OASIS, the woman should
be prescribed analgesics (paracetamol and nonsteroidal
anti-inflammatory drugs [NSAIDs]), laxatives, and a sin-
gle dose of intravenous antibiotics to prevent wound in-
fection and promote uncomplicated healing.31 In addition,
the process of wound healing, along with the presence of
any unpleasant smell, stinging, dyspareunia, swelling, or
wound breakdown, should be carefully evaluated at each
postnatal contact (NICE and PHAC). Moreover, the NICE
guideline mentions that health care professionals should
stress the need for good perineal hygiene to the women
and refer to specialist maternity services if any concerns
arise regarding the wound healing.
Nonpharmacological interventions, such as self-
inspection, warm water sitz baths, Kegel exercises (PHAC),
and ice packs (WHO and PHAC), are recommended for
perineal pain management. According to WHO, crushed
ice can be applied intermittently for 10 to 20 minutes for
the first 24 to 48 hours by placing it between layers of a
pad or a gel pack, as a Cochrane review found local cooling
to be effective in reducing moderate to severe pain in the
first 24 to 48 hours postpartum when compared with no
intervention (RR, 0.73; 95% CI, 0.57–0.94).32 The same
review also concluded that cold gel pads with compres-
sion were more effective than uncooled gel pads with
compression in reducing pain within 24 to 48 hours
(median, 0.43 lower; 95% CI, −0.73 to −0.13).32 Oral
paracetamol should be the first-line oral analgesic for
perineal pain, according to WHO, with alternative options
suggested if it is not effective. Several meta-analyses were
undertaken to assess the efficacy of pain relief choices
such as paracetamol,33 aspirin,34 and NSAIDs.35 These
reviews proved that, compared with placebo, single doses
of paracetamol (RR, 2.14; 95% CI, 1.59–2.89), aspirin
(RR, 2.03; 95% CI, 1.69–2.42), and NSAIDs (RR, 1.92;
95% CI; 1.69–2.17) were more effective in achieving ad-
equate pain relief.33–35 The discussion of the available
 Postnatal Care • CME Review Article
pain relief options should always take into consideration
the safety for breastfeeding (NICE). Aspirin is contrain-
dicated in case of breastfeeding because of the harmful
effects of its metabolites, which are excreted in breast
milk (WHO).
Of note, WHO recommends the use of oral NSAIDs
for the management of uterine involution pain. This rec-
ommendation is based on a Cochrane review, which
proved that NSAIDs are more effective than placebo,
paracetamol, and opioids in relieving pain from uterine
cramping.36
Diastasis Recti Abdominis
PHAC is the only medical society that provides rec-
ommendations on the management of diastasis recti
abdominis (DRA) and mentions that exercise, pelvic
floor physiotherapy, and neuromuscular stimulation should
be offered to patients suffering from this condition.37 A
systematic review showed that exercise during the ante-
natal period reduced the occurrence of DRA by 35%
(RR, 0.65; 95% CI, 0.46–0.92) and that DRA width may
be reduced by exercising during both the antenatal and
postnatal periods.38 In cases with at least 4-finger-width
separations, PHAC supports the use of corsets or binders.
For symptomatic patients not responding to conservative
treatment, abdominoplasty may be a suitable option.
Bladder and Bowel Dysfunction
All the reviewed guidelines recommend the assessment
for urinary and fecal incontinence during the postnatal
visits, as a referral to a physiotherapist or a urogynecolo-
gist may be required (ACOG, PHAC). However, whereas
PHAC highlights the importance of focusing on preven-
tion by implementing muscle toning techniques, WHO
does not endorse routine pelvic floor muscle training
(PFMT) as a preventive measure for incontinence, based
on a Cochrane review that failed to prove that antenatal
and postnatal PFMT can reduce urinary and fecal inconti-
nence in the late postnatal period, compared with no inter-
vention or usual care.39 Regarding treatment of urinary
incontinence, PHAC recommends the use of Kegel exer-
cises along with lifestyle changes and bladder training. A
follow-up for the assessment of their effectiveness is also
justified. On the other hand, WHO, although making no
clear recommendation, states that women with involun-
tary loss of small volumes of urine after delivery should
be informed about the potential benefits of the unsuper-
vised PFMT at home for the improvement of urinary in-
continence and sexual function.
With regard to prevention of constipation, WHO sup-
ports the provision of dietary advice, such as the ade-
quate intake of water and fibers, the encouragement of
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115
low impact physical activity, and the education on healthy
toilet habits. This medical society recommends against
the routine use of laxatives, unless the dietary modifica-
tions fail to relieve the symptoms.
Venous Thromboembolism
According to NICE, a risk assessment should be car-
ried out to all women following delivery to define the
need for venous thromboembolism (VTE) prophylaxis,
as well as the adequate duration, which may vary from
10 days to 6 weeks postpartum. In case of regional anes-
thesia during labor, thromboprophylaxis, that is, low-
molecular-weight heparin, should commence 4 hours af-
ter the spinal anesthesia or the epidural catheter removal.
Antiembolism stockings should be considered in case of
contraindications to low-molecular-weight heparin use
and traveling longer than 4 hours. They should also be
used in combination to low-molecular-weight heparin
post–cesarean delivery to women at particularly high risk
of VTE.40 Of note, no recommendations on VTE preven-
tion in the puerperium are provided by ACOG, WHO,
and PHAC.
Diet and Exercise
Minor discrepancies were identified regarding nutri-
tional recommendations. PHAC recommends the in-
take of multivitamins with 400 μg of folic acid for all
breastfeeding women, whereas WHO suggests oral iron
supplementation combined with or without folic acid
for a duration of 6 to 12 weeks to reduce the risk of anemia
in areas with higher than 20% prevalence of gestational
anemia.41 In addition, WHO discourages the postpartum
administration of vitamin A.42 WHO, along with PHAC,
underline the need for a healthy, balanced diet with reg-
ular intake of vegetables, fruit, whole grains, and protein
foods in the postnatal period.
Furthermore, postnatal care should include advice on
the appropriate physical activity and weight management
(ACOG, NICE), as well as on the importance of pelvic
floor exercises (NICE).43 WHO recommends at least
150 minutes of physical activity per week, incorporat-
ing muscle-strengthening and stretching exercises and
gradually increasing the frequency, intensity, and duration
of workouts.44 In case of cesarean delivery, a cautious and
gradual return to physical activity in consultation with a
health care provider is recommended. Individual con-
siderations and warning signs that may require exercise
cessation should be explained to the women.45
Contraception
There is an overall agreement that appropriate counsel-
ing regarding the individual reproductive plans and
116 Obstetrical and Gynecological Survey
desires, the sexual health, and the available contraceptive
methods should be provided in the context of postnatal
care.46 However, the optimal IPI is a matter of debate.
More specifically, the NICE guideline recommends an
interval of 12 months between successive pregnancies,
as a review on live births and 3 studies on stillbirth from
low- and high-income countries found that an IPI of less
than 12 months is consistently associated with preterm
delivery, premature rupture of membranes, and small-
for-gestational-age neonates.47 In contrast, ACOG sup-
ports that a subsequent pregnancy should be deferred
for at least 6 months; it also states that for IPI less than
18 months, a thorough discussion on the risks and ben-
efits should be made with the woman and her partner.
There is no common pathway regarding the recom-
mended contraceptive methods in the postpartum period.
According to NICE and PHAC, lactational amenorrhea
method is recommended for the first 6 months after de-
livery, if the period has not returned and the baby is ex-
clusively breastfed on demand during the day and night
without prolonged intervals between breastfeeding.48
On the other hand, WHO supports the use of lactational
amenorrhea method only in combination with other con-
traceptive methods.49
Intrauterine devices (IUDs), either of copper or levonor-
gestrel, can be safely inserted immediately after birth, dur-
ing the first 48 hours (WHO, NICE, PHAC) or after the
first 4 weeks postpartum (WHO, NICE). A systematic
review showed that IUDs do not affect breastfeeding;
however, as they are associated with increased perfora-
tion rate, they should be inserted with caution.50 In ad-
dition, a decision-analysis model that used data from
the United States showed that immediate postpartum
IUD placement prevented 88 unintended pregnancies
per 1000 women over 2 years.51
As for hormonal contraceptives, WHO and NICE
recommend the use of progesterone-only pills (POPs),
etonogestrel, and levonorgestrel implants immediately
after birth.52 PHAC mentions that all hormonal contra-
ceptives including POP should start 3 to 4 weeks post-
partum for nonbreastfeeding women. According to WHO,
the progesterone vaginal ring may be used without re-
striction even in case of breastfeeding 4 weeks following
delivery, and the progesterone-only injectable contracep-
tives should be commenced from 6 weeks postpartum.49
Moreover, there is a consensus that the combined hor-
monal contraceptives (CHCs) should be universally
avoided for the first 3 weeks. However, after this period,
women with no risk factors for VTE should be allowed
to start on this contraceptive method, whereas those with
additional risk factors should defer their use until 6 weeks
postpartum.52 For breastfeeding women, WHO and NICE
disagree on the optimal time of CHCs initiation, with
Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.
WHO discouraging their use for the first 6 months and
NICE allowing their use from 6 weeks postpartum. Of
note, PHAC points out that the current CHCs do not al-
ter the quality and quantity of breast milk as long as lac-
tation is established. This statement is endorsed by a
Cochrane review that concluded there is no statistically
significant difference among CHCs and other contracep-
tive methods on breastfeeding duration and infant growth,
although currently no consistent evidence exists.53
Concerning barrier methods, condoms can be used at
any time for both breastfeeding and nonbreastfeeding
women and have the additional benefit of sexually trans-
mitted disease protection (PHAC), whereas diaphragm
should be inserted at least 6 weeks following childbirth
to allow the adequate size selection after the uterus invo-
lution (NICE). Barrier methods are also required when
hormonal contraceptive methods are started after the first
21 days (NICE).
With regard to emergency contraception, lactating
women can use CHCs (WHO) and ulipristal acetate and
levonorgestrel (WHO, NICE) ideally after 21 days
postpartum or copper-IUD (NICE).54 NICE also sug-
gests that women who breastfeed should be advised to
express and discard the milk for a week after they have
taken ulipristal, as this medication is excreted in breast
milk and its effect on infants has not been studied yet.
INFECTION CONTROL
WHO is the only medical society that provides rec-
ommendations regarding the management of several in-
fectious diseases during the postpartum period.
HIV
In high HIV prevalence settings, WHO recommends
postpartum HIV testing for all negative or of unknown
status women who had missed the routine antenatal test-
ing in the early pregnancy or the retesting in the third
trimester. On the other hand, in settings with low HIV
burden, testing for HIV is not recommended as part of
the routine postnatal care, but it could be considered if
the antenatal screening was missed, if ongoing risk fac-
tors in late pregnancy exist or if there is a serodiscordant
relationship with a non–virally suppressed partner on an-
tiretroviral therapy.55 Postpartum women considered to
be at substantial risk of HIV infection should initiate or
continue taking oral pre-exposure prophylaxis, which
contains tenofovir disoproxil fumarate, regardless of
their breastfeeding status.56
Tuberculosis
According to WHO, postpartum screening for tuber-
culosis should be considered for women living in areas
 Postnatal Care • CME Review Article
with a prevalence of 0.1% or higher, as well as for those
who have close contact with infected individuals.57
Parasitic Diseases
WHO states that preventive anthelminthic treatment
should be provided to postpartum and/or lactating women
living in areas with a 20% minimum prevalence of any
soil-transmitted helminth infection. This prophylactic
therapy should include a single dose of 400 mg of
albendazole or 500 mg of mebendazole annually or
biannually.58 Moreover, in areas with at least 10%
prevalence of schistosomiasis, preventive chemother-
apy containing a single annual dose of praziquantel is
recommended, whereas in endemic communities with
a prevalence of less than 10%, both test-and-treat and
preventive treatment are acceptable options.59
POSTPARTUM MANAGEMENT OF
PREGNANCY COMPLICATIONS
Hypertensive Disorders
There is an agreement between ACOG and NICE that
women who developed hypertensive disorders during
pregnancy (HDPs) should be thoroughly informed
about their increased risk of future atherosclerotic car-
diovascular disease60 and the available interventions
that can be implemented to reduce this risk.61 Accord-
ing to NICE, the high recurrence rate of HDP in subse-
quent pregnancies, which is approximately 20%, should
be also highlighted to the women in the context of the
postnatal care.
However, there is no common pathway regarding post-
partum monitoring of women with HDP. More specifically,
ACOG recommends blood pressure evaluation within 7
to 10 days from delivery or within the first 72 hours in
case of severe hypertension and a follow-up at 1 to 3 weeks
for high-risk patients, while PHAC recommends the mea-
surement of blood pressure 3 to 6 days after birth.62 On
the other hand, the NICE guideline provides different
recommendations for women treated with antihyperten-
sive agents and those without treatment. In particular, it
suggests that the blood pressure of women with preeclamp-
sia who did not receive antihypertensive treatment during
pregnancy should be monitored 4 times daily during hos-
pitalization, followed by 1 measurement at 3 to 5 days and
alternate-day measurements if this value is abnormal. If
the blood pressure exceeds 150/100 mm Hg, antihyper-
tensive treatment should be initiated, and the women
should be monitored for severe headache and epigastric
pain during the postnatal visits. Furthermore, women who
required antihypertensive treatment during pregnancy
should have their blood pressure monitored 4 times a
Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.
117
day while in hospital and every 1 to 2 days up to 2 weeks,
until the treatment stops and the blood pressure normal-
izes. A gradual dosage reduction is recommended if the
blood pressure falls less than 130/80 mm Hg and should
be considered at values less than 140/90 mm Hg. If
methyldopa was used during pregnancy, it should be
changed within 2 days following delivery. The trans-
fer to community care should be allowed when no
symptoms of preeclampsia exist, the blood pressure
levels are at or below 150/100 mm Hg, and the blood
tests are stable or improved. In addition, a medical re-
view with a general practitioner should be arranged at
2 weeks and at 6 to 8 weeks postpartum. Except for
blood pressure measurement, NICE recommends the
performance of laboratory tests including platelet count,
transaminases, and serum creatinine within 48 to
72 hours from delivery. The tests should be repeated
until normal values are achieved. In addition, a urinary
reagent strip test should be conducted at 6 to 8 weeks
postpartum, and the kidney function should be assessed
at 3 months if proteinuria of at least +1 is present, with
referral to a nephrologist, if deemed necessary.63 As for
the postnatal monitoring of women with gestational hy-
pertension, NICE states that their blood pressure should
be measured daily for the first 2 days, once at 3 to
5 days, and as indicated following any treatment modi-
fications. The antihypertensive medication should start
when blood pressure levels surpass 150/100 mm Hg
and should be reduced when the blood pressure drops
less than 130/80 mm Hg. NICE points out that the post-
partum treatment duration is usually equal to the ante-
natal one and that women with gestational hypertension
should have a medical review with their general practi-
tioner 2 weeks after delivery, similarly to those with
preeclampsia.63 For patients with chronic hypertension,
NICE recommends a monitoring schedule identical to
that of patients with gestational hypertension, with a blood
pressure treatment target of 140/90 mm Hg.63 Moreover,
ACOG underlines the need for timely follow-up and
ongoing provision of care for all mothers with a history
of chronic hypertension.64
For women with hypertension in the postnatal pe-
riod, enalapril is recommended with appropriate mon-
itoring of maternal renal function and serum potassium
levels, whereas diuretics and angiotensin receptor
blockers should be avoided during lactation (NICE).
If blood pressure fails to be controlled with a single
medication, a combination of agents should be con-
sidered. Labetalol or atenolol can be added or replace
other agents if the combination therapy is not effective or
well tolerated.63 In case of Black African or Caribbean
women, nifedipine or amlodipine are the preferred treat-
ment options.
118 Obstetrical and Gynecological Survey
Diabetes
Gestational diabetes mellitus is associated with high
risk of developing metabolic syndrome, cardiovascular
disease, and type 2 diabetes mellitus later in life, as proved
by a meta-analysis (RR, 7.43; 95% CI, 4.79–11.51).65
The increased awareness of this risk highlights the need
for appropriate glucose screening as part of the postna-
tal care.66 However, the reviewed guidelines provide
inconsistent recommendations on this field. More pre-
cisely, PHAC is in favor of the performance of a 75-g
2-hour oral glucose tolerance test (OGTT) between 6 weeks
and 6 months after birth,67 ACOG mentions that either
an OGTT or a fasting plasma glucose (FPG) test can be
chosen,68 whereas NICE discourages the routine use of
OGTT, as a postpartum screening method.69 According
to NICE, treatment for gestational diabetes should stop
immediately after birth, and the glucose levels should be
measured before transfer to community care to exclude
the possibility of persistent hyperglycemia. Lifestyle ad-
vice, including weight control, diet, and exercise, should
be given along with appropriate counseling regarding the
symptoms of hyperglycemia and the recurrence risk.
Subsequently, an FPG test should be performed at 6 to
13 weeks postpartum. After 13 weeks, an FPG test should
be offered, in case the previous test was missed, or a hemo-
globin A1c (HbA1c) test if the FPG is not possible. NICE
also suggests the performance of annual HbA1c testing
if the mother tested negative for diabetes postnatally.69
As for the management of future pregnancies, NICE
recommends early self-monitoring of blood glucose levels
or an early OGTT. A second OGTT should be performed
later in pregnancy if the first was normal.69
Of note, PHAC states that the immediate initiation of
breastfeeding should be supported for women with ges-
tational and pregestational diabetes, as it prevents the
development of neonatal hypoglycemia.70
As for the postnatal management of pregestational di-
abetes mellitus, NICE recommends insulin reduction and
titration based on the monitoring of blood glucose levels.71
The increased risk of postpartum hypoglycemia, especially
when breastfeeding, should be explained to women, and
they should be encouraged to have a meal or snack be-
fore or during feeds. As for women with preexisting type
2 diabetes mellitus treated with metformin, NICE men-
tions that they should be allowed to continue or resume
their treatment after birth, even if they are breastfeeding.
According to NICE, the use of other oral hypoglycemic
agents, as well as medication for diabetes complications,
should be avoided during lactation.69 On the other hand,
PHAC mentions that except from metformin, glyburide is
a safe treatment option for breastfeeding women with diabe-
tes. Notably, PHAC recommends screening for postpartum
Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.
thyroiditis with a thyroid-stimulating hormone test at 6
to 8 weeks postpartum for women with type 1 diabetes
mellitus and triglyceride assessment in the late postpartum
period for all women with pregestational diabetes.
Pregnancy Loss
ACOG refers to the postpartum management of women
who experienced a miscarriage, stillbirth, or neonatal death.
More specifically, ACOG underlines the importance of a
proper follow-up and emotional support. Moreover, any labo-
ratory and pathology reports related to the loss should be re-
viewed to provide appropriate counseling regarding the risk
of recurrence and the management of future pregnancies.72
POSTPARTUM CARE PROMOTION
Discharge Preparation
There is an overall agreement that adequate parental
preparation for the postpartum period is the cornerstone
for the optimization of both maternal and neonatal health
outcomes. Therefore, ACOG, NICE, and PHAC recom-
mend the identification of a primary health care pro-
vider responsible to organize the postnatal care before
discharge. Peer counselors, support staff, and discharge
planners may help to effectively schedule the postnatal
visits and subsequently increase the engagement with
appropriate follow-up (ACOG, PHAC). In addition, par-
ents and caregivers should be provided with adequate
information and counseling for the postnatal period. To-
ward this goal, educational interventions, including job
aids, pictorials for semiliterate people, and written or dig-
ital education booklets, are suggested by WHO, as a
study concluded that written education booklets increase
the postpartum visits to a health care provider and the
maternal satisfaction, compared with control leaflets.17
ACOG recommends that the anticipatory guidance re-
garding infant feeding, emotional and physical chal-
lenges, and transition to parenthood should commence
during pregnancy, based on data that showed this strat-
egy results in a reduction of depressive symptoms and
an increase of breastfeeding duration through the first
6 months postpartum.73,74 WHO and NICE state that
it is crucial for partners to be included in the postpartum
care of both the mother and the neonate, according to
the mothers' wishes. Finally, NICE and PHAC point out
that before discharge the women should be advised not
only of the signs and symptoms that should raise concern,
but also of the optimal seeking care pathway.
Home Visits—Midwifery Services
Home visits represent an integral part of the postpar-
tum care promotion, according to all the reviewed
 Postnatal Care • CME Review Article
medical societies, although, as previously mentioned,
there is disagreement on their frequency and timing.
Home visits may be performed by either skilled health
care workers or midwives and should empower the in-
dividualized care that meets the specific needs of both
the mother and the newborn. A randomized controlled
trial of 4777 deliveries showed that a brief universal
home-visiting program implemented with high penetra-
tion and fidelity resulted in lower costly emergency med-
ical care and improved family outcomes.75 Moreover, a
meta-analysis concluded that home visits by community
health workers is cost-effective in improving neonate
health outcomes for low- and middle-income countries
and is also associated with reduced neonatal mortality
and increased practice of exclusive breastfeeding.76
However, if this strategy is not feasible or preferred by
the family, outpatient postnatal care should be provided
instead (WHO). The crucial role of the midwives during
the postnatal period is highlighted by all the reviewed
guidelines, not only regarding the scheduled home visits,
but also for the anticipatory parental education and the
provision of care in case of acute concerns. In settings
with well-functioning midwifery programs, WHO sug-
gests the implementation of the midwife-led continuity-
of-care model, in which a known group of midwives
provides support throughout the antenatal, intrapartum,
and postnatal periods.77
Digital Targeted Communication
There is a consensus that digital communication, in-
cluding phone support, text messages, remote blood
pressure monitoring, and app-based support, should be
used to support in-person assessment for the optimization
of postnatal care. This approach may be helpful for
supporting breastfeeding and formula feeding (NICE)
and reminding mothers to schedule postnatal follow-up
(ACOG). A Cochrane review reported that although, to
date, there is insufficient evidence to warrant investment
in resources, routine telephone support is beneficial in
terms of reduced depression scores, breastfeeding dura-
tion, and increased overall satisfaction.52 In addition, a
qualitative interview study that investigated the benefits
of an app including chat, a knowledge base, and auto-
mated messages in case of early discharge after child-
birth concluded that the use of telemedicine shows po-
tential for enhancing self-efficacy and postnatal sense
of security.78 WHO recommends the use of digital targeted
patient communication for the behavioral change con-
cerning sexual, reproductive, maternal, neonate, and in-
fant health, but points out that concerns about sensitive
content and data privacy should be duly considered be-
fore its use.79
Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.
119
CONCLUSIONS
To summarize, the importance of postpartum care provi-
sion for the optimization of maternal and neonatal health
outcomes is clearly outlined by all the reviewed guide-
lines. There is an agreement that home visits, incorpora-
tion of midwifery services, appropriate parental discharge
preparation, and use of telemedicine are useful tools for
the promotion of postnatal care. There is also consensus
concerning the clinical aspects that should be assessed at
each postnatal visit, the management of postpartum com-
plications, the increased vigilance for mental health is-
sues, and the guidance for physical activity.
On the other hand, several discrepancies were identi-
fied with regard to the optimal postnatal contact sched-
ule, the recommended contraceptive methods, the nutri-
tional supplements, the routine postpartum screening
for depression, and the ideal IPI. The postpartum man-
agement of HDP and diabetes is also a matter of keen
debate. Notably, screening for HIV, tuberculosis, and
parasitic infections in the postnatal period is addressed
only by WHO.
Childbirth is a major life event that requires consider-
able physical, emotional, and social adjustment. How-
ever, postnatal care has for long been known as “the
Cinderella service,” highlighting how neglected and in-
adequate it was. This is also reflected by the fact that
most maternal and infant deaths still occur in the first
month after delivery. Therefore, there is a pressing need
for ongoing research and collaboration to develop con-
sistent, evidence-based, culturally competent, interna-
tional and local guidelines for the postpartum manage-
ment of women to ensure they all receive the optimum
level of health care and support. Toward this goal, a
sustained coordination among health care providers,
policymakers, and researchers, to identify and imple-
ment best practices in postnatal care, is required.
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