What to Expect At Your 6 Week Postpartum Appointment (And Why Postpartum Care Needs To Be Better)

I hit 6 weeks postpartum on Friday. As I always say, time flies sometimes. I still feel like I was pregnant yesterday and I can’t believe James is 6 weeks old and we’re officially discharged from midwife care. I always find the 6 week appointment bittersweet – it’s exciting because it means we’re moving forward and my body is healing (I won’t say fully healed or “back to normal” – although most things internally should be back to normal at 6 weeks, everyone’s trajectory is different and 6 weeks is not a magic number) but it’s also sad because I love our midwives and I’m always upset to see them go.

I thought I’d demystify the 6 week postpartum appointment and give people an idea what you should or might expect. This does not mean that your 6 week appointment will be exactly the same as mine or that all these expectations will be met – it will be shaped by your care provider, the healthcare system in which you live/are seen, your birth experience and… the pandemic.

Disclaimer: this is not medical advice. This blog is for informational purposes only. Please seek medical advice from your healthcare provider.

I know amidst the COVID-19 pandemic that some people have not been seen in person (or at all) for their 6 week appointment due to various reasons – virtual visits (which in my opinion don’t really cut it for a postpartum check) or because they haven’t been able to attend due to not being able to bring their other children with them (or sometimes even their newborn?!), or probably a slew of other reasons (having symptoms, troubles with scheduling, etc). I hope these challenges are starting to minimize – or that providers are making an extra effort to make sure postpartum patients get in to be seen. I really think it’s important to be seen in person because, in an ideal world, if you’ve had any type of incision or stitching (and even if you haven’t) a physical exam can be beneficial. A physical exam can assess for signs of any issues, infection, prolapse, or other concerns – which we often have a hard time seeing or assessing ourselves. That being said – we’ve had to work within the barriers in which we are living and maintain safety, of course. Virtual appointments do also increase accessibility for those living in rural areas, or who may not have access to transportation or childcare – so there are pros and cons to both sides.

The 6 week postpartum appointment is an opportunity for your provider to lay eyes on you one last time before they discharge you (in most cases – unless you’re being seen by a family doc who also delivers!) back to your general care provider. It’s important for the physical reasons I mention above, but also to check in on mental health – yes, this can be done over the phone but I’d daresay we sometimes miss physical behaviours that may indicate struggles when we do telephone assessments (especially if the person has not been seen since they gave birth – which for most obstetrical care in Canada and the USA is often the case). The opportunity is also good to provide a pap test if you are due for one – that way you don’t have to book a separate appointment for that.

Check out my podcast episode on the pap test here.

While we’re on the topic and before I dive in to the expectations of this appointment, I’d like to say firstly that Ontario Midwives actually see their postpartum patients multiple times and not just the once at 6 weeks. So if you’re being followed by midwives (and I think this is similar in other provinces, not sure what it’s like in the US due to the discrepancy between different types of midwifery care there) you can expect to be seen and assessed several times in the postpartum period. There is actually a lot of evidence supporting the benefit of frequent visits in the early postpartum days. Many patients will stay in the hospital for 24 hours (midwifery care patients with low risk births who are doing well can go home earlier), but beyond that many are now discharged home but then not seen again until 6 weeks postpartum.

In the first 72 hours to 1 week postpartum, there are many reasons to be seen for both the birthing person and the infant – for example, signs of endometritis (infection of the uterine lining) don’t usually appear until 2 to 4 days postpartum or up to weeks later. Postpartum hypertension is another concern – midwives check your blood pressure (BP) at their early postpartum visits, but obstetrical patients wouldn’t have theirs checked until – yep, 6 weeks, unless they’re going into to be seen for something else. Postpartum psychosis although not super common, is another concern that benefits from a visit and the assessment of knowledgeable eyes. I personally was asked how I was feeling and doing at every postpartum visit I received from my midwives over 6 weeks.

Additionally, the visit allows for infant feeding methods to be assessed and supported. Although there are other resources for this (lactation consultants for example) they’re not always accessible, or covered/affordable. Your infant will likely see their GP or paediatrician at a few days old – but again, getting an additional appointment can be hard (if your forgot to ask specific questions about feeding, which lets be honest probably happens a lot) and though feeding is part of the initial assessment, it’s not always the same (being assessed in a clinic) as being assessed say in your home, where you will be feeding your baby most of the time. There is also no guarantee that all providers will assess your feeding in person.

Support for formula feeding in the community is also often limited. Recommendations for infant feeding may also be out of date depending on where you get information. I have seen this reported by many online. Or it may not be individualized (as in, your provider may just be giving the recommendations they give everyone vs doing a individualized assessment of how you are feeding your baby and where you/your baby may need help).

Even beyond a week, issues can pop up such as delayed hemorrhages (can occur up to 12 weeks postpartum), pulmonary embolism and mastitis. Postpartum depression is another big one – which can really occur anytime postpartum. Being assessed at a single point in time (6 weeks) may not catch many who are impacted.

Frequent postpartum visits offer the opportunity to check in with mom and baby to see how everything is going – feeding, physical health + recovery, bleeding, mood, family life, etc. If some are done at home – even better! Mom gets seen in their natural environment and it’s more convenient and accessible.

Each midwifery practice and each individualized case will be seen a different number of times but the recommendation is 3 visits the first week, followed by several more leading up to 6 weeks. For example – I received 6 in-person visits and 1 phone visit (days 1, 3, 5, 7 (phone), 10, 4 weeks and 6 weeks) for a total of 7 visits in the postpartum period. My extra visit was because we need a follow up for weight – and it was much appreciated.

My second point before I start on the actual content of this post was just to say – based on all this evidence – that I think that only 1 postpartum visit at 6 weeks is insufficient. If you read studies on patient satisfaction between obstetrical and midwifery care in the province of Ontario, you will see that many report higher satisfaction rates with midwifery care. I would bargain that a large part of this owes to the postpartum care – which is not only complete with multiple visits over time and individualized to the person and their baby; it’s also done in your home in the first few visits which is SO accessible and so supportive of birthing persons. It removes the barrier that many face even at 6 weeks postpartum of having a hard time travelling to a clinic, especially if you have multiple kids (and amidst the pandemic, are not allowed to bring the others to the appointment). It also just “gets” us, y’know? I did not want to go anywhere early postpartum – you’re often sore (think belly births too when you cannot lift your baby in a carseat, may not be able to drive for a period of time, etc) and you’re more than likely sleep deprived.

My midwives not only saw me earlier, but they saw my babies too – which means I didn’t have to go see my GP. With the pandemic ongoing, it also reduces risk for you and your new little one of sitting in a doctors office (although many now don’t have you sit in the waiting room which is great).

So it reduces number of visits and amount of travel for mom and baby; offers the opportunity for more individualized and complete care; and is in line with what patients want. It should be adopted by all care providers – nurses could provide this care in home. Something to consider adding in to home care and the healthcare budget, since there is certainly evidence supporting the benefits. End rant.

What to Expect At Your 6 Week Postpartum Visit

A Physical Exam – Incision, Reproductive Organs, and (hopefully) the Pelvic Floor

This part may be lacking in the COVID era – because some 6 week visits are being done virtually (or as per reports from moms, not at all). Although many women do have rather uneventful recoveries postpartum, there are some issues that can arise (some of which I mentioned above – before the 6 weeks but also around it).

Pelvic floor issues should be assessed and frequently are not – which is why we now see the trend of Instagram Influencers sharing that it’s OK to pee your pants. Really, it is common – but it is not a normal outcome of childbirth and assessment and referral to a pelvic physiotherapist can help. Some people will even need surgery if they have severe forms of prolapse – but a lack of physical assessment may delay this.

Well wouldn’t the person know if something is wrong? Maybe and maybe not. A more severe prolapse may very well lead a woman to seek further assessment but a more minor prolapse may not. And with urinary incontinence being normalized in society – which is good for opening it up to discussion but bad for implying that it’s just something someone has to live with – it may be overlooked. There are other issues the pelvic floor can cause, whether it be too tight or too weak – and they may not present exactly as you would think. So we often see postpartum women living with these symptoms because they think it’s just “how it has to be” after childbirth, when in many cases it isn’t.

In regards to internal organs – pelvic exams are of course not mandatory as I spoke about in this post, however they may be suggested or beneficial in certain cases. If you are having a pap smear done at your visit anyways, a bimanual exam of the reproductive organs is (or can be) a part of that. External examinations of the reproductive organs at least are also helpful, to make sure everything is going back to baseline after pregnancy. With midwives – I was having my uterus checked for weeks after I gave birth, yet if you only get a single 6 week visit, you may not have had a check-in since you were discharged from the hospital, so a quick assessment can be important.Discuss with your provider if you have any concerns about any part of the exam, and remember that it is all a choice, and it should be an informed one!

Incisions also really benefit from in-person examination – this goes for both perineal tearing and C-section incisions. Ideally, they should be healed – but from reading through online forums and hearing people’s stories I know this is not always the case. Although you are provided with information about healing at discharge, sometimes it can be confusing and you may not be sure if everything is healing as it should. Your provider should be able to answer this question for you – and you may need to seek out their advice earlier than 6 weeks if you have any concerns or signs of infection.

Breasts (and Breastfeeding If Applicable)

Another part of the appointment that may occur is related to the breasts. This can be particularly important if you are breastfeeding – a check-in on how it’s going (yep – still important to ask mom) and how the breasts and nipples are looking.

I’ve read some places that people get a breast exam at this time – I have never had this. I have always done self-exams though and encourage others with breasts to do this regularly. If your provider doesn’t do this, you can use this appointment as an opportunity to address any breast related concerns – such as clogged ducts or sore nipples. Mastitis and clogs can still happen when you’re not breastfeeding so don’t be shy to bring up any questions during this appointment!

My midwives asked about my nipples at every visit (sounds funny to say, but it’s true), and asked how feeding was going. In the early postpartum visits, they also observed and offered assistance with feeding. It was very helpful and I think this type of 1-on-1 attention in the early days and the frequent check-ins would make breastfeeding journeys easier for some people. However, with only 1 6-week appointment, you more than likely are not getting the support you need from your provider. In this case, an IBCLC may be helpful to pursue through a public health clinic or privately (check to see if you have coverage through insurance).

As I mentioned earlier, formula feeding resources are not always great in the community (or at all unfortunately) – but you should ask your questions at this appointment or to your babies care provider where applicable. I also like this instagram page for more general information.

I hope that shaming isn’t happening (but have heard in some cases it does) – no matter how you’re feeding your baby (formula or breast – including pumping, or both!) you’re doing an amazing job. There should be resources and information available to you no matter what. Here is another great Instagram for exclusive pumping, and I know there are Facebook groups for all types of feeding that can be great resources!

Contraception

At your 6 week visit, you will almost certainly discuss contraception (or family planning). There is a lot of misconception around breastfeeding and the ability to conceive – I busted this myth previously (yes – even when exclusively breastfeeding you can get pregnant!!!!!). So, it makes sense that contraception is on the docket for discussion. There are lots of different options to choose from and you should be given information on the ones you are interested in and given time to ask questions.

If your are breastfeeding – there are still lots of options, you’re only really limited when it comes to oral contraception (the mini-pill is what is recommended, which is a progestin only pill).

My best advice here is to make sure you have all the information you need to make an informed decision. Also you can always follow up with your GP if more time is needed – just remember that breastfeeding is not an effective form of birth control.

Mental Health

This one is incredibly important – and can be done in a virtual appointment, though I do worry that sometimes cases of PPA/PPD and other perinatal mood disorders may slip through the cracks in this case.. however, it’s still better than nothing.

There is something called the Edinburgh Postnatal Depression Scale (EPDS), which may be used as a tool to screen postpartum women for postpartum depression and anxiety. You can read more about it here and also access translated versions. There is also the Postpartum Depression Screening Scale (PDSS) and the Perinatal Anxiety Screening Scale (PASS), among others – but EPDS seems to remain best practice here.

Screening tools like this are not always used though – your provider may simply assess you, which has been reported in some cases to lead to missed diagnoses. Ideally – a screening tool + clinical judgment would probably render the best results for capturing those at risk.

Perinatal mood disorders can occur at any time – although there is something called “baby blues”, which generally occurs and is limited to those first 1-2 weeks postpartum and with fewer and more mild symptoms, studies show that scales like the EPDS can still be administered early on to identify those at risk for postpartum depression. So – again, we see that a visit at 6 weeks may not be sufficient for screening for mental health in the postpartum period, especially when there is no screening tools used.

As I mentioned, perinatal mood disorders can pop up at any time, which means – yes – you can develop postpartum depression for example, after 6 weeks. This is another reason why postpartum care is incomplete – because many people are left with nothing or very little afterwards. Or they are expected to help themselves by booking appointments for further assessment – sometimes this doesn’t happen. A check-in service could be helpful, or ongoing support/mom groups. I also always suggest in postpartum education sessions I facilitate to have your main support person or partner be aware of the symptoms of perinatal mood disorders, so they can help to identify them and get help.

For resources – I really like the Happy As a Mother podcast and instagram page. They really break down potential symptoms of perinatal mood disorders, even ones you may not traditionally associate with them (like postpartum rage). Another good one is Moms Maternal Health.

Referrals (if needed)

If you need any referrals, these should be made at your 6 week appointment. This could be for mental health supports, for example, but you may also be provided with a referral to a community program or be given information on community resources.

A Pap Smear (If You’re Due)

As I mentioned earlier, if you are due for your pap (which are done every 3 years unless you have had an abnormal result and been told to have one sooner) this can be done at your 6-week visit to kill two birds with one stone. That way you don’t have to book that separate appointment with your gynaecologist or GP to have this done.

I had mine done this time at 6 weeks, as I became due literally the day I gave birth. It was nice to not have to worry about arranging it at a later date. I was also able to breastfeed during my pap because James was there and getting fussy – it was amazing! I felt calm and the baby did too.

If you have any concerns about pap smears or experience pain, discuss with your provider to make your experience the best it can be. I shared some tips for this in the podcast episode.

With Midwives: Infant Health & Care

When you see midwives in Ontario, you can also expect your baby to have a physical exam at your final appointment – since they care for both yourself and your baby. If you are seeing an OB, then you will see a paediatrician or your GP for this care (you usually see them within 2 days of the birth if you are discharged from hospital).

James had a full exam and all measurements redone at this appointment (head, length and weight). We got a discharge document with all this information and some from the birth to provide to James’ GP at his 2-month visit.

And that is about it – as I mentioned, each provider and each birth may mean other things get added to this list (or removed). Additionally, virtual visits mean some things cannot be done or not done the same way (there are sometimes work arounds for certain aspects). So it is not necessarily complete, but it gives an overview of what you might expect.

If you have questions or concerns, talk to your provider or their office in advance. As always – don’t be afraid to ask questions about your health and wellbeing postpartum. I know that appointment times are limited and we are in the thick of motherhood (and at that time, often sleep deprivation) and cannot always remember everything we want to ask. Yet more reasons why one visit at 6 weeks postpartum is insufficient. There are always nurse lines like Telehealth you can call if anything concerning comes up, public health resources locally to lean on, and when it comes to less health related questions and more motherhood related ones, mom groups in your community and online can be helpful. As always, just remember that these resources are not intended to be medical advice for your unique health situation.

Additional Resources

Association of Ontario Midwives – Postpartum Visit Schedule

AOM – Postpartum Care with Midwives

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