Knowledge Area 9 | Postpartum Problems
(Aligned with RCOG Core Curriculum 2019)
The postpartum period is high-risk for the woman. Many maternal morbidities and mortalities occur after delivery, particularly within the first 7–14 days. This knowledge area focuses exclusively on complications and clinical care during the puerperium.
What the RCOG Curriculum Expects
The updated RCOG core curriculum emphasises:
- Early recognition of maternal deterioration
- Risk stratification and escalation
- Multidisciplinary management
- Continuity of care from antenatal to postnatal period
- Psychological wellbeing
- Contraceptive planning
- Safe discharge and community follow-up
How to Structure Your Revision
- Create a master folder: “Postpartum Problems”
- Suggested subfolders:
- Postnatal Care & Maternal Assessment
- Postpartum Haemorrhage (Secondary included)
- Postpartum Sepsis
- Venous Thromboembolism
- Perinatal Mental Health
- Postpartum Bladder & Bowel Problems
- Breast & Lactation Problems
- Postpartum Hypertension & Medical Disorders
- Contraception After Pregnancy
- Neonatal Assessment (maternal relevance focus)
- Your notes should emphasise: Risk factors; Early warning signs; Investigations; Escalation pathways; MDT involvement; Follow-up planning
Routine Postnatal Care
- Core competencies expected: Systematic maternal review; Identification of red flag symptoms; Wound assessment (CS, perineal tears); Bladder and bowel function; Breastfeeding support; Blood pressure monitoring; Thromboprophylaxis review; Mental health screening
- The curriculum stresses safe discharge planning and community handover.
Postpartum Haemorrhage (PPH)
- You must know: Primary vs Secondary PPH; 4 Ts (Tone, Tissue, Trauma, Thrombin); Massive obstetric haemorrhage protocol; Tranexamic acid timing; Uterotonics hierarchy; Balloon tamponade; Surgical options; Role of interventional radiology
- Also important: Secondary PPH (retained products, infection); Anaemia management; Debriefing and counselling
- The exam increasingly tests escalation, teamwork and situational awareness.
Postpartum Sepsis
- Maternal sepsis is a leading cause of preventable mortality
- High-yield areas: Early recognition (tachycardia may be first sign); Sepsis 6 bundle; Group A Streptococcus; Endometritis; Wound infection; Mastitis vs abscess; Necrotising fasciitis (red flag)
- You must know: Early broad-spectrum IV antibiotics; Lactate measurement; Escalation to critical care
Venous Thromboembolism (VTE)
- Key points to cover: Risk assessment tool; Postnatal thromboprophylaxis duration; LMWH dosing; Management of suspected PE; Role of imaging postpartum; Ovarian vein thrombosis
- The curriculum emphasises: Individualised risk assessment; Clear documentation; Patient counselling
Perinatal Mental Health
- There is more emphasis in the updated curriculum.
- Must cover: Postnatal blues; Postnatal depression; Postpartum psychosis (psychiatric emergency); Risk factors; Safeguarding; Mother and Baby Units
- Know how to: Ask screening questions; Identify red flags (suicidal ideation, delusions); Escalate urgently; Coordinate psychiatric input
- Exam questions frequently test risk recognition and referral pathways.
Breast & Lactation Problems
- Commonly tested but often underestimated.
- Includes: Engorgement; Mastitis; Breast abscess; Cracked nipples; Galactocele
- You must know: When antibiotics are needed; When to continue breastfeeding; Indications for drainage of abscess
Bladder & Bowel Problems
- Important postpartum issues include: Urinary retention; Incontinence; Anal sphincter injury sequelae; Constipation; Fistula (rare but critical)
- You must understand: Trial with catheter protocols; Referral to pelvic floor physiotherapy; Follow-up after OASI
Postpartum Hypertension & Medical Disorders
- Although initiated antenatally, management continues postpartum.
- Topics to cover include: Postpartum pre-eclampsia; Eclampsia risk; Antihypertensive choices compatible with breastfeeding; Magnesium sulphate continuation; Follow-up planning
- The curriculum stresses long-term cardiovascular risk counselling.
Contraception After Pregnancy
- Refer to CoSRH guidance.
- Must know: Immediate postpartum contraception options; Timing of IUD insertion; Progesterone-only methods; Lactational amenorrhoea method; Combined hormonal contraception timing; VTE considerations
- Counselling should begin antenatally but be reinforced postpartum.
Neonatal Considerations (Maternal Relevance)
- While neonatal care is primarily paediatric, you must understand: Immediate newborn assessment; Neonatal resuscitation principles; Indications for neonatal referral; Communication with paediatric team
- Focus on maternal–neonatal interface and documentation.
How This Knowledge Area Is Tested in MRCOG
Questions typically assess:
- Recognition of deterioration
- Prioritisation
- Initial management steps
- Escalation decisions
- Communication with seniors
- Guideline-based care
- Safe discharge planning
Final words
- Carefully read scenarios — postpartum questions are often subtle and time-sensitive.
- Postpartum problems are about anticipation, vigilance and escalation.
- The curriculum strongly reflects lessons from maternal mortality reviews. Therefore: Think safety first; Document risk assessment; Escalate early; Involve MDT; Ensure follow-up
- Organise your notes in concise algorithms and escalation pathways.
- Practise question scenarios focusing on prioritisation and emergency management.
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The Postpartum Period |
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NICE |
NG194 Postnatal Care 2021 |
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Postpartum Haemorrhage |
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GTG |
#52 Postpartum Haemorrhage, Prevention and Management 2016 |
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GP |
#6 The role of emergency and elective interventional radiology in PPH 2007 |
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TOG |
Which uterine compression suture should I use for atonic PPH 2025 Quantification of blood loss in obstetric haemorrhage 2023 Pelvic and vaginal packing for intractable venous obstetrics hemorrhage 2014 The surgical approach to postpartum haemorrhage 2009 Acute Inversion of Uterus 2009 |
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Perineal Tear |
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GTG |
#29 Management of Third-and-Fourth-degree Perineal Tears |
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CA |
#9 Repair of Third-and-Fourth- degree Perineal Tears following childbirth |
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TOG |
Obstetrics pelvic floor and anal sphincter injuries 2012 |
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PostPartum Sepsis |
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GTG |
#64a Bacterial Sepsis in Pregnancy #64b Bacterial Sepsis following Pregnancy, 2012 |
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TOG |
Postpartum perineal wound dehiscence 2023 Maternal Sepsis Update 2020 Genital Tract Sepsis: early diagnosis, managment and prevention 2012 Group A streptococcal puerperal sepsis: management and prevention 2012 |
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Thromboembolism |
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GTG |
#37a Reducing Risk of thrombosis and embolism during pregnancy and puerperium #37b The Acute Management of thrombosis and embolism during pregnancy and puerperium |
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NICE |
NG#89 VTE in over 16s: reducing risk of hospital-acquired DVT or PE TOG Postpartum ovarian vein thrombosis 2016 |
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Perinatal Mental Health |
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NICE |
#192 Antenatal and Postnatal Mental Health 2014 |
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TOG |
Perinatal mental health 2025 Use of psychotropic medication in perinatal period 2024 Perinatal mental health: how to ask and how to help 2017 Postpartum psychosis 2013 |
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GP |
#14 Management of women with mental health issues during pregnancy and postnatal period |
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SIGN |
#127 Management of perinatal mood disorders 2012 |
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Newborn Care |
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NICE |
CG98 Jaundice in newborn babies under 28 days 2023 NG195 Neonatal infection: antibiotics for prevention and treatment 2021 |
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TOG |
Newborn screening and role of genomic testing: what obstetrician need to know 2025 |
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PostPartum Contraception |
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FSRH |
Contraception After Pregnancy Executive Summary Contraception After Pregnancy |
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TOG |
Postpartum Contraception 2018 |
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BPP |
#1 Postpartum Family Planning |
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Breastfeeding |
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TOG |
Breastfeeding and drugs 2021 |