Clinical manifestations during the puerperium (6-week period after delivery) generally reflect reversal of the physiologic changes that occurred during pregnancy (see table Normal Postpartum Changes). These changes are temporary and should not be confused with pathologic conditions.
Serious postpartum complications are rare. The most common complications are
Clinical parameters
Within the first 24 hours, the woman’s pulse rate begins to drop, and her temperature may be slightly elevated.
Vaginal discharge is grossly bloody (lochia rubra) for 3 to 4 days, then becomes pale brown (lochia serosa), and after the next 10 to 12 days, it changes to yellowish white (lochia alba).
About 1 to 2 weeks after delivery, eschar from the placental site sloughs off and bleeding occurs; bleeding is usually self-limited. Total blood loss is about 250 mL; external pads may be used to absorb it. Tampons may be used only if the woman's practitioner approves their use. They are not used if they might inhibit healing of perineal or vaginal lacerations. Women should be told to contact their practitioner if they are concerned about heavy bleeding. Prolonged bleeding (postpartum hemorrhage) may be a sign of infection or retained placenta and should be investigated.
The uterus involutes progressively; after 5 to 7 days, it is firm and no longer tender, extending midway between the symphysis and umbilicus. By 2 weeks, it is no longer palpable abdominally and typically by 4 to 6 weeks returns to a prepregancy size. Contractions of the involuting uterus, if painful (afterpains), may require analgesics.
Laboratory parameters
During the first week, urine temporarily increases in volume and becomes more dilute as the additional plasma volume of pregnancy is excreted. Care must be taken when interpreting urinalysis results because lochia can contaminate the urine.
Because blood volume is redistributed, hematocrit may fluctuate, although it tends to remain in the prepregnancy range if women do not hemorrhage. Because the white blood count (WBC) increases during labor, marked leukocytosis (up to 20,000 to 30,000/mcL) occurs in the first 24 hours postpartum; WBC count returns to normal within 1 week. Plasma fibrinogen and erythrocyte sedimentation rate (ESR) remain elevated during the first week postpartum.
Initial Management
Risk of infection, hemorrhage, and excessive pain must be minimized. Women are typically observed for at least 1 to 2 hours after the 3rd stage of labor and for several hours longer if regional or general anesthesia was used during delivery (eg, by forceps, vacuum, or cesarean) or if the delivery was not completely routine.
Hemorrhage
(For further information, see Postpartum Hemorrhage.)
Minimizing bleeding is the first priority; measures include
Uterine massage
During the first hour after the 3rd stage of labor, the uterus is massaged periodically to ensure that it contracts, preventing excessive bleeding.
For all women, the following must be available during the recovery period
Oxygen
Type O-negative blood or blood tested for compatibility
IV fluids
If blood loss was excessive (≥ 500 mL), a complete blood count (CBC) to verify that women are not anemic is required before discharge. If blood loss was not excessive, CBC is not required.
Diet and activity
After the first 24 hours, recovery is rapid. A regular diet should be offered as soon as women desire food. Full ambulation is encouraged as soon as possible.
Exercise recommendations are individualized depending on the presence of other maternal disorders or complications. Usually, exercises to strengthen abdominal muscles can be started once the discomfort of delivery has subsided, typically within 1 day for women who deliver vaginally and later (typically after 6 weeks) for those who deliver by cesarean. Whether pelvic floor (eg, Kegel) exercises are helpful is unclear, but these exercises can begin as soon as the patient is ready.
Perineal care
If delivery was uncomplicated, showering and bathing are allowed, but vaginal douching is prohibited. The vulva should be cleaned from front to back.
Later, warm sitz baths can be used several times a day.
Discomfort and pain
1). Some women require opioids to relieve discomfort; the lowest effective dose should be used.
If pain is significantly worsening, women should be evaluated for complications such as vulvar hematoma.
Bladder and bowel function
Regional (spinal or epidural) or general anesthesia may delay defecation and spontaneous urination, in part by delaying ambulation.
Vaccination and Rh desensitization
(See also Vaccines During Pregnancy,Guidelines for Vaccinating Pregnant Women, and CDC: COVID-19 Vaccines While Pregnant or Breastfeeding.)
Women who are seronegative for rubella should be vaccinated against rubella on the day of discharge.
Ideally, the tetanus-diphtheria-acellular pertussis (Tdap) vaccine is given between week 27 and 36 of each pregnancy; the Tdap vaccine helps boost the maternal immune response and passive transfer of antibodies to the neonate. If women have never been vaccinated with the Tdap vaccine (not during the current or a previous pregnancy nor as an adolescent or adult), they should be given Tdap before discharge from the hospital or birthing center, regardless of their breastfeeding status. If family members who anticipate having contact with the neonate have not previously received Tdap, they should be given Tdap at least 2 weeks before they come into contact with the neonate to immunize them against pertussis (2).
Pregnant women who do not have evidence of immunity should be given the first dose of the varicella vaccine after delivery and the 2nd dose 4 to 8 weeks after the first dose.
Additional vaccines may be recommended depending on maternal vaccination and health history.
If women with Rh-negative blood have an infant with Rh-positive blood but are not sensitized, they should be given Rho(D) immune globulin 300 mcg IM within 72 hours of delivery to prevent sensitization.
Breast engorgement
Milk accumulation may cause painful breast engorgement during early lactation.
For women who are going to breastfeed, the following are recommended until milk production adjusts to the infant's needs:
Expressing milk by hand in a warm shower or using a breast pump between feedings to relieve pressure temporarily (however, doing so tends to encourage lactation, so it should be done only when necessary)
Breastfeeding the infant on a regular schedule
Wearing a comfortable nursing bra 24 hours/day
For women who are not going to breastfeed, the following are recommended:
Firm support of the breasts to suppress lactation because gravity stimulates the let-down reflex and encourages milk flow
Refraining from nipple stimulation and manual expression, which can increase lactation
Tight binding of the breasts (eg, with a snug-fitting bra), cold packs, and analgesics as needed, followed by firm support, to control temporary symptoms while lactation is being suppressed
Suppression of lactation with drugs is not recommended.
Mental disorders
Transient depressive symptoms (baby blues) are very common during the first week after delivery. Symptoms (eg, mood swings, irritability, anxiety, difficulty concentrating, insomnia, crying spells) are typically mild and usually subside by 7 to 10 days.
Physicians should ask women about symptoms of depression before and after delivery and should be alert to recognizing symptoms of depression, which may resemble the normal effects of new motherhood (eg, fatigue, difficulty concentrating). They should also advise women to contact them if depressive symptoms continue for > 2 weeks or interfere with daily activities or if women have suicidal or homicidal thoughts. In such cases, postpartum depression or another mental disorder may be present. During the comprehensive postpartum visit, all women should be screened for postpartum mood and anxiety disorders using a validated tool (3).
A preexisting mental disorder, including prior postpartum depression, is likely to recur or worsen during the puerperium, so affected women should be monitored closely.
Initial management references
1. Altenau B, Crisp CC, Devaiah CG, Lambers DSAm J Obstet Gynecol 217 (3):362.e1–362.e6, 2017. doi: 10.1016/j.ajog.2017.04.030 Epub 2017 Apr 25.
2. American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice, Immunization and Emerging Infections Expert Work Group: Committee Opinion No. 718: Update on Immunization and Pregnancy: Tetanus, Diphtheria, and Pertussis Vaccination. Obstet Gynecol 130 (3):e153–e157, 2017. doi: 10.1097/AOG.0000000000002301
3. American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice: Committee Opinion No. 757: Screening for Perinatal Depression. Obstet Gynecol 130 (3): 132 (5):e208–e212, 2018. doi: 10.1097/AOG.0000000000002927
Management at Home
The woman and infant may be discharged within 24 to 48 hours postpartum; some obstetric units discharge them as early as 6 hours postpartum if major anesthesia was not used and no complications occurred.
Serious problems are rare, but a home visit, office visit, or phone call within 24 to 48 hours helps screen for complications. A routine postpartum visit is usually scheduled at 3 to 8 weeks for women with an uncomplicated vaginal delivery. If delivery was cesarean or if other complications occurred, follow-up may be scheduled sooner.
Normal activities may be resumed as soon as the woman feels ready.
Sexual activity after vaginal delivery may be resumed as soon as desired and comfortable; however, a laceration or episiotomy repair must be allowed to heal first. Sexual activity after cesarean delivery should be delayed until the surgical wound has healed.
Family planning
Pregnancy must be delayed for 1 month if women were vaccinated against rubella or varicella. Also, subsequent obstetric outcomes are improved by delaying conception for at least 6 months but preferably 18 months after delivery.
To minimize the chance of pregnancy, women should start using contraception as soon as they are discharged. If women are not breastfeeding, ovulation usually occurs about 4 to 6 weeks postpartum, 2 weeks before the first menses. However, ovulation can occur earlier; women have conceived as early as 2 weeks postpartum. Women who are breastfeeding tend to ovulate and menstruate later, usually closer to 6 months postpartum, although a few ovulate and menstruate (and become pregnant) as quickly as those who are not breastfeeding.
Women should choose a method of contraception based on the specific risks and benefits of various options.
Estrogenestrogen-progestin vaginal rings can be used after 4 weeks postpartum if women are not breastfeeding.
A diaphragm should be fitted only after complete involution of the uterus, at 6 to 8 weeks; meanwhile, foams, jellies, and condoms should be used.
Intrauterine devices may be placed as soon as immediately after delivery of the placenta, but placement after 4 to 6 weeks postpartum minimizes risk of expulsion.
Women who have completed their family may choose permanent contraception, which are surgical procedures that involve resecting or ligating part of the fallopian tubes. The procedures can be done during the postpartum period, at the time of cesarean delivery, or after the postpartum period. These procedures are considered permanent and irreversible.
