11.5 Postnatal Care, Breastfeeding Support & Family Planning
Key Takeaways
- WHO recommends at least 24 hours of facility care after vaginal birth and postnatal contacts around day 3, days 7–14 and six weeks.
- Lochia progresses from rubra (days 1–3/4) to serosa (about days 4–10) to alba (about day 10 to 4–6 weeks).
- Good breastfeeding attachment shows a wide-open mouth, turned-out lower lip, chin touching the breast and more areola above the mouth.
- The lactational amenorrhoea method works only if periods have not returned, feeding is full or nearly full, and the baby is under 6 months.
- Postpartum psychosis is a psychiatric emergency in which mother and baby must not be left alone and urgent referral is needed.
11.5 Postnatal Care, Breastfeeding Support & Family Planning
Quick Answer: The puerperium lasts about six weeks. WHO recommends that healthy women and newborns stay in the facility for at least 24 hours after a vaginal birth and receive at least three more postnatal contacts—around day 3 (48–72 hours), days 7–14 and 6 weeks. At each contact check the mother's vital signs, uterine involution, lochia, perineum, breasts, bladder and bowels, legs and mood, and the baby's feeding, cord, colour and temperature. Support early and exclusive breastfeeding by teaching good attachment, and offer family planning before discharge—the lactational amenorrhoea method (LAM) works only while all three of its conditions are met.
Postnatal Contacts
| Timing | Focus |
|---|---|
| First 24 hours (in facility) | Bleeding, fundus, vital signs, bladder; breastfeeding within the first hour; newborn examination, vitamin K and birth vaccines |
| Day 3 (48–72 hours) | Feeding problems, jaundice, maternal fever, perineal pain, mood |
| Days 7–14 | Involution, lochia, wound healing, newborn weight, cord separation |
| 6 weeks | Recovery, family planning, blood pressure, mental health, infant immunisation |
In Ghana, community health officers also make postnatal home visits (section 13.1).
Assessing the Mother
Uterine involution: immediately after birth the fundus is at about the level of the umbilicus. It descends roughly 1 cm (one finger-breadth) a day and is usually no longer palpable above the symphysis pubis by about day 10–14. A soft, high or tender uterus suggests retained products, infection or a full bladder.
Lochia:
| Type | Timing (approximate) | Appearance |
|---|---|---|
| Lochia rubra | Days 1–3/4 | Red, may contain small clots |
| Lochia serosa | Days 4–10 | Pinkish-brown |
| Lochia alba | Day 10 to about 4–6 weeks | Yellowish-white |
Report heavy bleeding, large clots, a return to bright red lochia after it has become pale, or offensive lochia—these suggest secondary postpartum haemorrhage or infection (section 11.3).
Perineum and wounds: use REEDA (Redness, Edema, Ecchymosis, Discharge, Approximation) to assess an episiotomy, tear or caesarean wound; teach perineal hygiene and pad changes.
Other checks: temperature and pulse (fever may mean puerperal sepsis, mastitis or urinary infection), blood pressure (pre-eclampsia can appear after birth), voiding within 6 hours, bowel function, calf pain or swelling (DVT), and anaemia.
Mood:
- "Baby blues": tearfulness and mood swings in the first days, settling within about two weeks;
- Postpartum depression: persistent low mood, loss of interest, poor sleep or appetite—screen and refer;
- Postpartum psychosis: an emergency, usually within the first weeks—confusion, hallucinations, bizarre behaviour; never leave the mother and baby alone and refer urgently.
Maternal Danger Signs to Teach
Seek care immediately for heavy vaginal bleeding, fever or chills, foul-smelling discharge, severe headache or blurred vision, convulsions, difficulty breathing, a painful swollen calf, or thoughts of harming herself or the baby.
Supporting Breastfeeding
Recommendations: start breastfeeding within the first hour after birth, breastfeed exclusively for six months (no water, other liquids or foods), and continue breastfeeding with safe complementary foods up to two years or beyond.
Signs of good attachment:
- The baby's mouth is wide open with the lower lip turned outward;
- The chin touches the breast;
- More areola is visible above the baby's mouth than below;
- Slow, deep sucks with pauses and audible swallowing; no pain for the mother.
Common problems:
| Problem | Likely cause | Nursing advice |
|---|---|---|
| Sore or cracked nipples | Poor attachment | Correct positioning and attachment; apply a little breast milk after feeds; continue feeding |
| Engorgement | Infrequent or ineffective feeding | Feed frequently on demand; express a little to soften the areola |
| Mastitis | Milk stasis ± infection | Keep breastfeeding or expressing from the affected breast; rest, fluids, analgesia; antibiotics as prescribed |
| "Not enough milk" | Often a perception; infrequent feeds | Check weight gain and wet nappies (about six or more a day after the first week); feed more often |
HIV-positive mothers taking ART are counselled on exclusive breastfeeding under Ghana's national guidance (section 7.3).
Family Planning
Counsel with a structured approach such as GATHER: Greet, Ask about needs, Tell about methods, Help her choose, Explain how to use the chosen method, and Return for follow-up. The WHO Medical Eligibility Criteria classify each method for each condition from category 1 (no restriction) to category 4 (unacceptable risk). WHO recommends waiting at least 24 months after a live birth before trying for the next pregnancy.
| Method | Postpartum and breastfeeding notes |
|---|---|
| Lactational amenorrhoea method (LAM) | Effective only if all three apply: periods have not returned, the baby is fully or nearly fully breastfed day and night, and the baby is under 6 months |
| Progestogen-only pills | Suitable while breastfeeding; must be taken at the same time daily |
| Implants (e.g., Jadelle, Implanon) | Long-acting and reversible; can be inserted after birth while breastfeeding |
| Injectables (DMPA-IM, self-injectable DMPA-SC/Sayana Press) | Every 3 months; return of fertility may be delayed |
| Copper IUD | Insert within 48 hours of birth or from 4 weeks after birth |
| Combined oral contraceptive pills | Generally avoided in breastfeeding women during the first 6 months because oestrogen can reduce milk supply and raises early postpartum clot risk |
| Condoms | Also protect against STIs and HIV |
| Female sterilisation / vasectomy | Permanent; requires careful counselling and informed consent |
| Emergency contraception | Levonorgestrel pill as soon as possible (licensed within 72 hours) or a copper IUD within 5 days of unprotected sex |
Exam Traps at a Glance
- LAM fails as soon as periods return, feeding is supplemented or the baby reaches 6 months.
- Bright red lochia returning after day 10 is abnormal.
- Sore nipples usually mean poor attachment, not "too much sucking".
- Postpartum psychosis is a psychiatric emergency—do not leave mother and baby alone.
A mother who is 4 months postpartum wants to use the lactational amenorrhoea method (LAM). Which set of conditions must all be present for LAM to be effective?
On day 2 after a normal vaginal birth, which finding is expected?
A first-time mother complains of cracked, painful nipples on day 3. What is the most appropriate nursing action?