Reception: Mothers post natal form

Congratulations on the birth of your baby.

This can be a wonderful but also tricky time and there is a lot of support available.

We hope you have already been seen (and possibly discharged) by your midwife and have been in contact with your health visiting team.

We look forward to seeing you at the surgery for your 6-8 week check.

This 'six-week check' is part of the NHS Newborn and Infant Physical Examination (NIPE) programme. Along with the newborn examination, it is an essential part of the 'Healthy Child Programme', the Department of Health guideline for promotion of child health.

It is an important opportunity for us to examine your baby but also to make sure that you feel well and are recovering properly. We recommend you read this information to know what to expect during your 6-8 week check: What happens at your 6-8 week check?

To help us complete this check we ask if you could complete this form online a week or two before the appointment.

Please bring your red book to your appointment.

And if you have had twins please complete a form for EACH baby.

If you were due to have your cervical smear while you were pregnant this can be done >12 weeks post delivery. Book your cervical smear appointment.

Request an implant/copper coil/hormonal coil fitting

Please do not write any clinical queries on this form. Any clinical queries or request for appointments via this form will be discarded. To make an appointment either book online via the NHS app/Patient access or by calling reception 01926 316711. On receipt of your form we will update your clinical records. If you are not a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations.

Reception: Mothers post natal form

Babies Full Name

Babies Date of Birth (DD/MM/YYYY):

Where were they born?

Were there any pregnancy complications?For example were you under shared care with a hospital consultant during your pregnancy? Please give as many details as you can

How were they delivered and were there any complications around the delivery?For example where you induced? Did you have a vaginal delivery or a caesarean section? Was this a planned c-section or an emergency?

Did your baby have to spend any time in the special care baby unit?

How much did your baby weigh at birth (in kg)?

Feeding methods

How is your baby feeding? For example breast feeding, bottle feeding or mixed feeding? Have you any problems (such as breast engorgement) or concerns about your babies feeding or weight? How often are they feeding during the day and night? And how much milk are they having (if known)?

Baby's development

Have you seen your baby smile yet?

Did your baby have their hearing checked after birth (the newborn hearing test)?If yes, were there any problems identified?

Did your baby have the Vitamin K injection after birth?

Are there any genetic conditions which run in your family? If yes please give as many details as possible

Has your baby had a hip scan or has one been organised?

Some babies may need to have a hip scan to look for a condition called developmental dysplasia of the hip. The following are risk factors for this condition. Please select any which might apply

There have been childhood hip problems in your family (parents, brothers or sisters)

Your baby was in the breech position (feet or bottom downwards) in the last month of pregnancy

Your baby was born in the breech position

Have you received the result of the heel prick test yet?This test is normally done when your baby is around 5 days old and is a quick blood test taken from their heel

Was this result normal?

Risk of SIDS

Adjusting to having a new baby can be very difficult. Especially if they want to party all night!

The Lullaby Trust has lots of information about safe sleep and how to reduce the risk of Sudden Infant Death Syndrome.

Please see their website for more information: https://www.lullabytrust.org.uk/safer-sleep-advice/

Is your baby sleeping on their back?Sleeping your baby on their back (known as the supine position) every night is one of the most protective actions you can take to ensure your baby is sleeping as safely as possible.

Does anyone in the household smoke?Smoking can increase the risk of SIDS. If someone in the household does smoke and would like support to stop please contact the surgery and arrange a smoking cessation appointment with one of our nurses who would be pleased to help

Mother's information

Mothers Full Name

Mothers Date of Birth (DD/MM/YYYY)

Having a new baby can be a very challenging time and it is important to also look after your own health.

Please complete this information as best you can so we can discuss it in your appointment.

Has your vaginal bleeding stopped? If no, are you having any usual or unusually heavy bleeding?

If you have had a C section or any stitches following a vaginal delivery do you have any concerns about their healing?

Are you currently breastfeeding your baby?

Did you have any problems with your blood pressure during pregnancy, around the time of delivery or after birth?If your blood pressure has been high it is useful to measure it at home. If you have a home blood pressure monitor please could you take it at home and record the result here

Have you ever been diagnosed with gestational diabetes?

How is your mood?It can be completely normal to feel upset or emotional following birth. Sometimes instead of getting better these feelings can worsen. If this is the case we want to be able to offer support. Please seek help from us or your midwife/health visitor as soon as possible

Have you a support network?Family and friends are very important, especially in the post natal period. Do you live with anyone? Have you friends or family locally who are able to offer support?

Are you doing your pelvic floor exercises?These can be very easy to forget but are very important to do!

Have you thought about contraception?Contraception post partum is very important. This might be condoms, the pill or a longer acting method such as a coil or implant. Are they any methods you would like to discuss?

Do you feel safe at home?This is crucially important. If you do not feel safe please contact the surgery urgently. The IRIS website also has lots of information and support services: https://irisi.org/

Other information

Is there anything else you would like to add or ask?

Thank you for completing this form.

We look forward to meeting you and your baby at your appointment.

If you do have any concerns and would like to speak with a GP or nurse in the meantime please contact the surgery.

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Reception: Mothers post natal form

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