Almost everything that goes seriously wrong after a birth is recognisable, and it is usually missed because somebody decided it was normal for the moment.

Is this normal for today?

Set how long ago the birth was, then describe what is happening. The same observation is read against the day it is happening on, because that is what decides what it means. Nothing here can examine anybody, and nothing here should delay a call — if something in the red block below is happening, that block is the answer.

The signs that do not depend on the day at all

The last two are the ones nobody is warned about, and they are the two where the person who notices is almost always somebody else. Everything further down this page assumes those have been ruled out.

Bleeding, and what the days do to it

• Heavy on the first day, then steadily less. Bright red for the first few days, then browner, then pinkish or watery for two to six weeks. The direction of travel matters more than any single day: bleeding that is getting heavier rather than lighter is the thing to report, whichever day it is.
• The pad-an-hour rule. Soaking a maternity pad in an hour or less, at any point, is an emergency — not a call for advice. So is passing clots bigger than a plum, or bleeding with feeling faint, cold, shaky or breathless.
• A gush when you stand up, or when feeding, is usual in the first week. Lying down pools it; standing releases it; oxytocin from feeding contracts the uterus. That is not a haemorrhage, and it is worth knowing so it does not cause a panic at 4am.
• Bleeding that stops and then restarts bright red after a week or two is worth a call the same day, not because it is always serious but because retained tissue and infection both present that way and both are simple to treat early.
• Smell is a specific signal. Lochia has a smell; offensive is different from strong, and offensive with any fever, or with pain, is a same-day call.
• Later than six weeks, heavy bleeding is still worth asking about. A first period can arrive around then and be much heavier than usual, which is expected; what should be checked is bleeding that soaks pads, or comes with pain or fever.

The condition that arrives after the birth

• Pre-eclampsia and its complications can begin, or get worse, after delivery — typically in the first days but up to six weeks. Delivering the baby is the treatment during pregnancy, which is precisely why nobody expects it afterwards, and why postnatal cases are the ones that get missed.
• The presentation is a headache that is not a normal headache: severe, persistent, not helped by simple painkillers, often with visual disturbance — flashing lights, blurring, spots — and sometimes vomiting or pain under the ribs on the right side.
• Swelling of the face and hands that comes on quickly is different from the ordinary puffy ankles of the first week. Sudden, above the waist, and with any of the symptoms above: that is an emergency assessment, not a wait-and-see.
• It is diagnosed with a blood-pressure cuff and a urine dip, which is a two-minute job anywhere. That is the reason to go: the test is trivial and the untreated condition is not.
• If you had raised blood pressure in pregnancy, you are in the group to watch, and you should have a plan for who checks your blood pressure and when in the days after discharge. If nobody gave you one, ask for it.
• A stroke in a young person after birth is rare and does happen. Sudden face droop, arm weakness or speech trouble at any point is an emergency call, exactly as it would be at any other age.

Clots: the highest-risk weeks of a lifetime

• The postnatal weeks carry the highest risk of venous thrombosis a healthy person will ever have, and the risk is greatest in the first few weeks. Caesarean birth, a long labour, immobility, dehydration, obesity and a family history all add to it.
• In the leg: pain, swelling, warmth or redness in one calf or thigh — one side, not both — is how a clot presents, and it is the presentation to act on today. Both ankles swelling is common and unremarkable; one hot painful calf is not.
• In the lung: sudden breathlessness, chest pain worse on breathing in, a racing heart, coughing up blood, feeling faint. This is a 112 call, and it is the one where hesitation costs most.
• Do not talk yourself out of it because you feel foolish. Breathlessness after birth is often anaemia or deconditioning, and that is fine — it is also how a clot presents, and telling the two apart needs a test rather than a judgement.
• Move, drink, and use the stockings if you were given them. If you were prescribed injections to take home after a caesarean, finishing the course matters; they are not optional because you feel well.

Infection, and the fever that is not the baby's

• Sepsis after birth is one of the small number of things that kills healthy young people, and it moves quickly. A temperature above 38°C, shaking chills, feeling much worse rather than gradually better, a fast heartbeat, or severe abdominal pain: same day at the latest, and immediately if there are chills or confusion.
• Wounds: caesarean scars and perineal stitches. Increasing pain rather than decreasing, spreading redness, heat, a gaping edge, or discharge that is not clear: a same-day look. Stitches that feel like they have given way are a call, not something to be endured.
• Mastitis versus an abscess. A red, hot, painful wedge of breast with flu-like aching is mastitis, and it needs feeding or expressing to continue, plus antibiotics if it does not settle within a day. A tense lump that is getting worse on antibiotics may be an abscess, which needs draining — that is a same-day call rather than a longer wait.
• Burning on passing urine, or not passing urine at all. Both are common and neither should be left: infection is easy to treat, and a bladder that will not empty after a birth is a specific and urgent problem that has nothing to do with willpower.
• You will be told to expect to feel unwell. That is only true up to a point. Exhausted, sore and emotional is expected; ill is not. “I feel ill, not just tired” is a sentence worth using, because it moves you out of the category everybody is placed in by default.

The two things that get called the same thing

The things nobody warns about, which are still worth fixing

• Leaking urine is common and is not something to accept for life. Referral to a pelvic-health physiotherapist works, and it works far better at three months than at three years. Leaking stool or wind, or a feeling of something coming down, should be said out loud at the six-week check — those are the ones women most often take home permanently for want of a single sentence.
• Pain during sex later on is a treatable problem, not a verdict. Scar tissue, dryness from breastfeeding hormones and pelvic-floor tension all have specific treatments.
• Constipation and haemorrhoids after birth are near-universal and respond to unglamorous measures: fluids, fibre, a stool softener, and not waiting. Straining on stitches is what makes the first weeks worse than they need to be.
• Night sweats, hair loss at three months, and afterpains that are worse with each baby are all expected and all pass. Knowing that in advance removes a surprising amount of fear.
• The six-week check is for her as well as for the baby, and in many systems the two are separate appointments. If only the baby was examined, ask for the other one; mood, bleeding, wounds, continence and contraception are all supposed to be in it.
• Iron matters more than people expect. Heavy blood loss plus a newborn produces an exhaustion that is often treated as inevitable and is sometimes a blood count away from being fixed.

Getting taken seriously, which is a separate skill

1. Lead with the birth. “I gave birth eleven days ago.” That single fact changes the triage category on any line you call, and it is the fact most often left out.
2. Say the worst symptom first, not the story in order. “I am soaking a pad an hour” before the account of the night. Whoever answers is sorting, not listening for a narrative.
3. Name what you are worried about. “I am worried this is an infection” or “I am worried this is a clot” is not overstepping; it makes the concern impossible to file away, and clinicians are trained to respond to it.
4. Ask the two questions that create a record. “What should make me call back?” and “What are we assuming this is?” The answers give you a threshold and a diagnosis to disagree with later.
5. If you are dismissed and you are still frightened, escalate rather than accept. Call the maternity unit directly, go in, or call the emergency number. Going in and being sent home is a small cost with no downside; the reverse is not true.
6. Whoever is with her: you are allowed to make the call. Somebody exhausted and unwell is the worst-placed person in the room to judge how unwell she is, and in psychosis she may be the only one who cannot see it.

The drill: 16 decisions

Sixteen ordinary moments in the six weeks — a gush of blood standing up on day two, a headache on day nine, a hot calf, a friend who has not slept and is full of energy. Most have an instinctive answer that is reasonable and wrong for the day it is. Pick your move; every answer explains why.

The card

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