Six Week Check - Obstetrics

Six Week Check

·        Looking for problems that may not have been present at birth (ie don‟t check for imperforate anus, they‟d be dead by now!)

·        The main aim of the 6 week check is to:

o   Detect abnormalities in the baby that may have become clinically detectable since birth

o   Explain the advantages of immunisation for the baby and offer immunisation

o   Check the psychological and physical well-being of the mother

o   Promote breast feeding and healthy attachment

·        Checks for the baby:

o   General well-being including sleeping and feeding

o   Growth: check serial measurements in the Child Development Book

o   General physical inspection, including fontanelles

o   Neurological milestones:

§  Sight (do they follow an object, smile at a face, etc): at risk if premature or birth asphyxia 

§  Hearing (startles with loud noise, etc): at risk if family history, rubella, CMV, toxoplasmosis, <1500 gm, severe asphyxia

§  The mother is likely to be aware of the presence of absence of these

o   Heart: Ausciltate for murmurs, look for pallor, dyspnoea with feeds, failure to thrive (1% affected, VSD in 30% of these)

o  Hip dislocation: unstable hips may not present until after birth. 0.4%, girls = 5 * boys. Need to treat before they begin to walk. Investigate with US and Xray. Treat with Pavlik harness 

o  Genitals: Check boys for undescended testes (cryptorchidism) – 2%, especially if premature, spontaneous descent unlikely beyond 3 months, surgery at 9 – 12 months.

·        Checks for the mother:

o  History:

§  General well-being 

§  Signs of post-natal depression or adjustment disorder: poor sleep or appetite, feeling „low‟, anxious or guilty, thoughts of harming herself or the baby. Complete a screening survey such as the Edinburgh Postnatal Depression Questionnaire. 

§  Breastfeeding: Is this going well?

§  Bowel and urine continence – encourage pelvic floor exercises

§  Perineum: pain, dyspareunia, etc

§  Review of pregnancy and child-birth experience

o  Exam:

§  Weight: loss of 60% of weight gained during pregnancy

§  Examine breasts for infection or cracked nipples

§  Abdominal exam: involution of the uterus – should be at or approach pre-pregnant size 

§  Pelvic exam: healing of laceration or episiotomy, lochia assessed, size and tenderness of uterus 

§  Cervical smear if not up-to-date 

§  Check of other complications that may have arisen in pregnancy: BP, diabetes, anaemia, UTIs, etc

·        Contraceptive advice:

o  Low levels of sexual interest common

o  Return of fertility is variable.  If not breastfeeding ovulation can occur as soon as 28 days 

o  Complete breast feeding provides 98% protection for the first 6 months (provided they continue to have amenorrhoea). Normally start contraception at 3 months 

o   POP: Start in early puerperium. Very effective in conjunction with breast-feeding. Start CoC when feeding frequency has ¯ by half, when solid food started or with first bleed (whichever first).

o   Amount transferred to baby over 2 years = 1 tablet‟s worth 

o  COC: alters quantity and quality of milk. If not breast feeding start on day 21 (¯thrombosis risk and won‟t have ovulated yet) 

o  IUCD: Insert 4 - 8 weeks postpartum (higher expulsion rates if inserted after 3^rd stage, and C-section scar will have healed by then)

o  Sterilisation: wait a while – may change their mind

o  Natural family planning: problematic due to variable effect of lactation on periods

·        Immunisation is recommended for Diphtheria, Tetanus, Pertussis, Haemophilus Influenza type B, Hepatitis B and polio vaccine. If the mother is concerned about the baby being unsettled afterwards, prophylactic oral paracetamol can also be offered.