The postpartum period involves a wide range of physical and emotional changes, most of which are normal and self-limiting. A smaller but clinically significant number of symptoms are not normal — they are warning signs that require prompt or immediate professional assessment. Knowing the difference can be lifesaving.
Physical red flags
Postpartum haemorrhage
Heavy bleeding after the first 24 hours postpartum (secondary postpartum haemorrhage) may indicate retained products of conception, uterine subinvolution, or infection. Warning signs include: soaking more than one pad per hour; passing large blood clots (larger than a golf ball); lochia that returns to bright red after transitioning to pink or brown; and any bleeding accompanied by fever, foul-smelling discharge, or pelvic pain.1
Infection
Postpartum infection can affect the uterus (endometritis), the perineal wound, the caesarean incision, the urinary tract, or the breast (mastitis). Red flags include: temperature above 38°C on two or more occasions or a single reading above 38.5°C; wound redness, swelling, increasing pain, or purulent discharge; foul-smelling lochia; and flu-like symptoms (chills, body aches, fatigue) beyond the first 24 hours.1
Venous thromboembolism
The postpartum period carries an elevated risk of deep vein thrombosis (DVT) and pulmonary embolism (PE). NICE NG194 identifies the following as requiring urgent assessment: unilateral calf pain or swelling; chest pain or sudden-onset breathlessness; and collapse or altered consciousness. These symptoms require same-day assessment in all cases.1
Pre-eclampsia
Pre-eclampsia can persist or first present in the postpartum period. Red flags include: severe, persistent headache not relieved by simple analgesia; visual disturbances (blurred vision, flashing lights, spots); epigastric or right upper quadrant pain; and sudden facial or limb oedema. These require urgent blood pressure assessment and investigation.1
Mental health red flags
Postpartum depression
While baby blues resolve within two weeks, the following warrant clinical assessment for postpartum depression: persistent low mood lasting more than two weeks; inability to enjoy activities that were previously pleasurable; significant changes in appetite or sleep (beyond normal newborn disruption); feelings of worthlessness, excessive guilt, or hopelessness; difficulty bonding with the infant; and withdrawal from partner, family, or social contact.2
Postpartum anxiety
Red flags for clinically significant postpartum anxiety include: inability to sleep even when the infant is sleeping and the opportunity exists; persistent hypervigilance that interferes with rest, eating, or daily function; panic attacks (sudden episodes of intense fear with physical symptoms); and avoidance of normal activities or situations due to anxiety about the infant's safety.2
Postpartum psychosis
Postpartum psychosis is a psychiatric emergency. It affects approximately 1 to 2 per 1,000 births, with onset typically within the first two weeks postpartum.3 It develops rapidly and requires immediate assessment and treatment. Warning signs include: sudden-onset confusion, disorientation, or an inability to recognise familiar people; hallucinations (hearing voices, seeing things that are not there); delusions (fixed false beliefs — often paranoid or grandiose); severe mood swings (rapidly alternating between elation and despair); bizarre or out-of-character behaviour; and significant sleep disturbance (beyond normal newborn-related disruption), particularly if the mother does not feel tired despite not sleeping.3
More than half of women who develop postpartum psychosis have no prior psychiatric history.4 A personal or family history of bipolar disorder is the strongest known risk factor. Any suspicion of psychosis requires same-day psychiatric assessment — this is not a condition that can wait for a routine appointment.
How and where to access help
United Kingdom: Contact your GP, midwife, or health visitor. For urgent concerns, call 111 (NHS non-emergency). For emergencies (postpartum psychosis, suicidal thoughts, severe physical symptoms), call 999 or go to A&E. Specialist perinatal mental health teams are available through NHS referral.1
United States: Contact your OB-GYN or midwife. The Postpartum Support International helpline (1-800-944-4773) provides support and referral. For emergencies, call 911. The 988 Suicide and Crisis Lifeline (call or text 988) is available 24/7. Crisis text support: text HOME to 741741.2
European Union: Contact your GP, midwife, or maternity care provider. Emergency numbers vary by country (112 is the universal EU emergency number). Many EU countries have dedicated perinatal mental health services accessible through primary care referral.
Australia: Contact your GP, midwife, or child health nurse. PANDA (Perinatal Anxiety and Depression Australia) helpline: 1300 726 306. For emergencies, call 000. Lifeline: 13 11 14.
The principle
When in doubt, seek assessment. No clinician will fault a new mother for presenting with a concern that turns out to be normal. The cost of missed intervention, however, can be severe. The red flags listed above are not exhaustive, and individual clinical judgement matters — if something feels wrong, that is sufficient reason to ask a professional.
The SHORE planner's Module 4 (Mental Health & PMADs) and Module 3 (Physical Recovery) include red flag checklists and symptom tracking designed to support timely identification and structured conversations with healthcare providers.