Midwife Postnatal Notes

Postnatal Check for Mother: Mother: Sarah Initial Assessment: Sarah reports feeling well since her last appointment. She is managing well at home with the baby and is enjoying motherhood. Present at appointment: Sarah, baby, and midwife. Recent activities: Sarah has been resting at home and has not been on any outings. Gestation: Postnatal, 6 weeks. Physical Assessment of Mother: - BP: 120/70, Temp: 37.0°C, Resp Rate: 16, Oxygen Sats: 98%, HR: 72 - Breast and nipple condition: No pain, nipples intact. - PV loss: Lochia rubra, moderate flow. - Sleep: Sleeping 6-7 hours per night, quality good. - Diet: Eating a balanced diet, 3 meals a day, drinking plenty of water. - Perineum: Perineum healing well, no pain, no stitches, taking ibuprofen as needed. - C-section wound: Not applicable. - Bowels and bladder: Regular bowel movements, no bladder problems. Breastfeeding: - Latching well, feeding every 2-3 hours, no interventions needed. Bonding with Baby: - Bonding is good, Sarah is enjoying time with the baby, no concerns raised. Emotional and Social: - Mood is good, no signs of PND or anxiety, has support from partner and family, EPDS score 4, community engagement is good. Education (Mother): - Topics covered: Postpartum care, breastfeeding, baby care. - Contraception discussed: Combined oral contraceptive pill discussed, to be started 6 weeks postpartum, effectiveness 99% with perfect use, personal factors considered. Referrals: - No referrals made. Plan: - Follow-up appointment in 6 weeks, continue with current medications. Maternal Concerns: - No concerns raised. Baby Postnatal Assessment: Initial Assessment: Baby’s name: Emily Stories shared by parents: Emily has been sleeping well and is starting to smile more. She is enjoying time with her parents and is starting to recognise faces. Baby’s temperament: Settled. Pet reaction: Not applicable.