Normal puerperium and postnatal care — structured SAQ (15 marks)

(a) Immediate assessment and governing principle (3 marks)

The principle earns one mark; the assessment earns two. ^[1]

• The principle: a woman who says she feels dreadful with a normal early-warning score is a woman you examine, not a woman you reassure. A composite score can be normal while one parameter — usually respiratory rate — is frankly abnormal.^[1]
• Assessment: full set of observations including respiratory rate on a maternity early-warning chart; focused examination of uterus, lochia, perineum, calves, chest and breasts; review of her intrapartum course (the 900 mL primary PPH puts her at higher risk of secondary haemorrhage, anaemia and infection).^[4]
• Reasoning mark: state that postpartum readmission is around 2% at a mean of 7 days after discharge, led by infection, hypertension and psychiatric illness — so day 4 is within the window where deterioration is common, not rare.^[4]

(b) The structured postnatal review (5 marks)

One mark per component named, up to five — say them as a sequence ("BUBBLE-HEM"). ^[1]

• Breasts — engorgement versus a unilateral tender segment; is feeding effective?^[5]
• Uterus — fundal height against the puerperal day, tone, tenderness.
• Bladder and bowels — voiding volumes, retention, constipation, continence.
• Lochia — colour, volume, odour, clots; heavy or restarted bleeding is retained tissue or endometritis until proven otherwise.
• Episiotomy or wound — pain trajectory, discharge, breakdown.
• Homans and legs, Emotional state, Medication and contraception — the three registrars skip; respiratory rate and mood asked directly every contact.^[1]

(c) The contact schedule after discharge (4 marks)

Name the guideline, then the timings. One mark for naming NICE NG194; one mark each for three timings. ^[1]

• NICE NG194: first postnatal midwife visit, face to face (usually at home), within 36 hours of transfer of care.^[1]
• A health visitor or community contact between 7 and 14 days.^[1]
• A general practitioner maternal review at 6 to 8 weeks, covering mood, continence, contraception, feeding and chronic-disease follow-up.^[1]
• WHO's complementary schedule: contacts at 24 hours, 48 to 72 hours, 7 to 14 days and around 6 weeks, framed as a continuum of care.^[2]

(d) Combined oral contraception timing (3 marks)

One mark for the timing, one for the reasoning, one for naming the alternative. ^[6]

• Combined hormonal contraception may be started from 21 days postpartum in a woman with no venous thromboembolism risk factors, because postpartum VTE risk falls but does not return to baseline by then.^[6]
• It should not be started before 6 weeks in a woman with VTE risk factors — and her recent primary PPH and forceps birth are relevant to that risk assessment.^[6]
• Progestogen-only methods (pill, implant, injectable) may be started at any time after birth, including immediately, and are the safer default while she is establishing feeding and recovering.^[6]