Midwife Postnatal Notes

Postnatal Check for Mother

Mother: Chloe

Initial Assessment

Chloe reports feeling much more rested and confident since her last appointment on 14/05/2024. Her energy levels are improving, though she still experiences mild fatigue in the late afternoons.

Partner (Liam) and maternal grandmother (Susan) present at the appointment.

Walked to the local cafe yesterday for the first time since delivery.

Delivered at 39+2 weeks gestation (currently Day 10 postnatal).

Physical Assessment of Mother

• BP 118/74 mmHg, Temp 36.7 °C, RR 16 bpm, SpO2 99 % on RA, HR 72 bpm.
• Breasts soft, non-tender, no erythema or signs of mastitis. Nipples intact, mild tenderness on initial latch on the right side, resolving during the feed.
• Lochia serosa, light flow, pink/brown in colour, no clots or offensive odour.
• Sleeping in 3-hour blocks overnight, totalling approx 6 hours per 24-hour period; reports sleep quality is good when baby settles.
• Eating 3 balanced meals daily plus snacks; fluid intake > 2.5 L water/day.
• Second-degree perineal tear healing well, sutures intact, edges well-approximated, minimal oedema, no signs of infection. Taking paracetamol (Panadol®) 1,000 mg PO QID PRN and ibuprofen (Nurofen®) 400 mg PO TID PRN for mild perineal discomfort.
• Passing urine without dysuria or incontinence; bowels opening regularly without pain or constipation.

Breastfeeding

• Exclusive breastfeeding on demand, 8–10 times per 24 hours, lasting 15–25 minutes per feed. Shallow latch noted on RHS; repositioned using cradle hold with good effect. Not currently expressing or using nipple shields/formula top-ups.

Bonding with Baby

• Good maternal-infant attachment observed; Chloe responds promptly to cues and speaks warmly to baby. Reassured regarding normal newborn cluster feeding in the evenings.

Emotional and Social

• Mood euthymic, affect bright. No indicators of PND or anxiety. EPDS score 4/30. Well supported at home by partner Liam (on parental leave) and mother Susan. Planning to join local Plunket parents' group next month.

Education (Mother)

• Discussed pelvic floor exercises, mastitis red flags, safe sleep practices (SUDI prevention), and postpartum contraception options.
• Discussed the progestogen-only pill (desogestrel, Cerazette®), which is > 99 % effective when taken correctly and can be started immediately postpartum without affecting lactation. Chloe prefers an oral contraceptive method prior to considering a LARC at her 6-week GP check.

Referrals

• Referral sent to Women's Health Physiotherapy for routine postnatal pelvic floor assessment following second-degree tear.

Plan

• Next home visit scheduled for 24/05/2024 at 10:00. Script provided for desogestrel (Cerazette®) 75 mcg PO daily. Continue simple analgesia PRN. Handover to Well Child Tamariki Ora (Plunket) planned at 4–6 weeks.

Maternal Concerns

• Expressed concern regarding evening cluster feeding and whether milk supply is adequate; reassured that this is normal newborn behaviour and that baby's weight gain and output confirm sufficient milk transfer.

Baby Postnatal Assessment

Initial Assessment

Noah

Chloe and Liam shared that Noah had his first bath two days ago and really enjoyed the warm water, staying completely calm the whole time. Grandparents visited over the weekend for cuddles, and Noah slept right through the commotion.

Alert during examination, settles easily with cuddling, generally content between feeds.

Baxter (Golden Retriever) has been very gentle, mostly sniffing Noah's feet and sleeping next to the bassinet.