When should I refer a postnatal patient to a specialist for further evaluation of persistent physical symptoms?

Refer a postnatal patient to a specialist for further evaluation of persistent physical symptoms in the following situations:

• If there are ongoing or unresolved issues such as persistent perineal pain, wound healing problems, or wound breakdown, refer urgently to specialist maternity services for assessment and management to prevent complications ¹,².
• If the patient has symptoms or signs of infection (e.g., abdominal, pelvic or perineal pain, fever, shivering, or vaginal discharge with an unpleasant smell) that do not respond to treatment, consider referral for further evaluation ².
• If there is sudden, very heavy, or persistent vaginal bleeding, or passage of clots or placental tissue, which may indicate retained placental tissue or secondary postpartum haemorrhage, arrange referral and consider ultrasound assessment ¹,².
• If symptoms or signs suggest venous thromboembolism (leg swelling, tenderness, chest pain, or shortness of breath), refer urgently for specialist assessment ¹,².
• If there are urinary symptoms including urinary incontinence or vaginal prolapse that persist, offer referral to urogynaecology or physiotherapy depending on clinical judgement and patient preference ¹,².
• If there is ongoing pain or anal incontinence after childbirth, consider referral to a gynaecologist or colorectal surgeon ¹.
• If the patient has hypertension or pre-eclampsia in the postnatal period that requires ongoing management, refer according to NICE hypertension in pregnancy guidelines ¹,².
• If symptoms of postnatal mental health problems are suspected alongside physical symptoms, refer for appropriate mental health support or specialist perinatal mental health services ¹,³.

In all cases, clinical judgement should guide referral decisions, and the woman’s concerns should be taken seriously with appropriate timely referral to secondary care or specialist services as needed ¹,².