When to call

This is the list to act on. It is taken from NICE NG194, which requires midwives to give it to every woman at the first postnatal contact, and from the NHS, HSE and ACOG equivalents. NICE's wording is that these are “symptoms or signs of potentially serious conditions, and she should seek medical advice without delay if any of these occur”.

Call your local emergency number now

999 in the UK and Ireland, 911 in the US and Canada, 000 in Australia, 111 in New Zealand. The HSE says to call 112 or 999 if you are bleeding from your vagina after the birth and “the bleeding suddenly gets heavier” or “you feel faint, dizzy or have a pounding heart”. ACOG says to call 911 or seek emergency help right away if you:

Have chest pain
Are coughing or gasping for air
Have seizures
Have thoughts of hurting yourself or your baby
Have severe pain in your lower abdomen
Have pain, swelling and tenderness in your legs

Contact your midwife, GP or maternity unit the same day

NICE NG194's list, with the condition each one points to:

Sudden or very heavy vaginal bleeding, or persistent or increased bleeding — could indicate retained placental tissue or endometritis.
Abdominal, pelvic or perineal pain, fever, shivering, or vaginal discharge with an unpleasant smell — could indicate infection.
Leg swelling and tenderness, or shortness of breath — could indicate venous thromboembolism.
Chest pain — could indicate venous thromboembolism or a cardiac problem.
Persistent or severe headache — could indicate hypertension, pre-eclampsia, a post-dural-puncture headache, migraine, intracranial pathology or infection.
Worsening reddening and swelling of the breasts persisting for more than 24 hours despite self-management — could indicate mastitis.
Any symptoms or signs of potentially serious conditions that do not respond to treatment.

The HSE adds: pain when you pee, peeing more often or smelly urine, which can indicate a urinary tract infection; a temperature over 38°C; any problem with a wound or stitches, including redness, pus, or the wound appearing to open; and “headache, blurred vision or vomiting”, which can be signs of pre-eclampsia. The NHS's own table adds vision changes and vomiting alongside headache for pre-eclampsia, and a high temperature with a sore, tender tummy for infection.

Mental health is on this list, not beside it. The HSE: “if you have any thoughts of harming yourself or your baby, contact your GP immediately.” It also says to make contact if you simply “feel worried that something is not right”. ACOG treats thoughts of hurting yourself or your baby as a 911 call.

After a caesarean, add these

The NHS lists specific caesarean red flags: severe pain, leaking urine, pain when peeing, heavy vaginal bleeding, a wound that becomes more red, painful and swollen, a discharge of pus or foul-smelling fluid from the wound, a cough or shortness of breath, and swelling or pain in your lower leg. It notes these “may be the sign of an infection or blood clot, which should be treated as soon as possible”.

NICE NG192 tells clinicians to pay particular attention after a caesarean to respiratory symptoms such as cough or shortness of breath, and leg symptoms such as a painful swollen calf, because of the increased risk of thromboembolic disease. The HSE notes that clot risk is higher for the whole 6 weeks after a caesarean.

After a tear, episiotomy or assisted birth, add these

NICE NG194 asks about pain not resolving or worsening, an increasing need for pain relief, discharge with a strong or unpleasant smell, swelling, and wound breakdown. Its instruction is unusually urgent: “if the perineal wound breaks down or there are ongoing healing concerns, refer the woman urgently to specialist maternity services (to be seen the same day in the case of a perineal wound breakdown).”

Where the thresholds differ by country

The signs are the same everywhere; the numbers attached to them are not, and the routes differ.

Fever. The HSE uses 38°C; ACOG uses “a fever of more than 100.4°F”. These are the same figure expressed differently.
Bleeding. ACOG gives a quantified threshold the UK and Irish services do not: “heavy bleeding (bleeding that soaks through two sanitary pads an hour for more than an hour or two)”. The HSE's trigger is bleeding that suddenly gets heavier together with feeling faint, dizzy or a pounding heart.
Low mood. ACOG says to call your ob-gyn for “feelings of hopelessness that last more than 10 days after delivery”. NICE asks for psychological and emotional wellbeing to be assessed at every postnatal contact instead of setting a threshold.
Who you call. In the UK and Ireland it is your midwife, GP, public health nurse or maternity unit; in the US it is your ob-gyn or 911.

Two things that make waiting more dangerous

First, NICE NG194 asks clinicians to be aware of MBRRACE-UK data showing that compared with white women (8 per 100,000), the risk of maternal death during pregnancy and up to 6 weeks after birth is 4 times higher in black women (34 per 100,000), 3 times higher in women of mixed ethnicity (25 per 100,000) and 2 times higher in Asian women (15 per 100,000), and that women living in the most deprived areas are more than 2.5 times more likely to die than those in the least deprived areas. NICE's conclusion is that these groups “may need closer monitoring”. If you are being reassured and you do not feel reassured, that is a reason to escalate rather than to wait.

Second, symptoms that do not respond to treatment are themselves on NICE's list. Being told it is normal, trying the advice, and finding it does not work is a reason to go back.

What is not an emergency

Ordinary lochia that is gradually lightening, afterpains while feeding, tender breasts as milk comes in on day three or four, tiredness that lifts when you sleep, and a scar that is uncomfortable but improving are all expected. The HSE's summary applies: “it is normal to feel sore or tender after giving birth.” The distinction across all of these guidelines is direction of travel — things that are settling versus things that are getting worse.

What to do between now and your postnatal check

You do not have to wait for the 6-to-8-week check to raise anything. NICE requires a GP assessment at 6 to 8 weeks that covers physical and mental health and responds to concerns, including by referring on to specialist services such as physiotherapy — but it also requires midwives to assess your physical health at every contact before then, covering infection, pain, bleeding, bladder and bowel function, breast symptoms, thromboembolism, anaemia, pre-eclampsia and wound healing. Everything above is something to raise as it happens, not something to save up.

When to See a Doctor in the Weeks After Birth