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 mild and temporary and should not be confused with pathologic conditions.
Postpartum complications are rare. The most common are
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; comfortably fitting intravaginal tampons (changed frequently) or external pads may be used to absorb it. Tampons should not be used if they might inhibit healing of perineal or vaginal lacerations. 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.
During the first week, urine temporarily increases in volume; care must be taken when interpreting urinalysis results because lochia can interfere.
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) count 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.
Normal Postpartum Changes
Risk of infection, hemorrhage, and 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 extractor, or cesarean) or if the delivery was not completely routine.
(For further information, see Postpartum Hemorrhage.)
Minimizing bleeding is the first priority; measures include
During the first hour after the 3rd stage of labor, the uterus is massaged periodically to ensure that it contracts, preventing excessive bleeding.
If the uterus does not contract after massage alone, oxytocin 10 units IM or a dilute oxytocin IV infusion (10 or 20 [up to 80] units/1000 mL of IV fluid) at 125 to 200 mL/hour is given immediately after delivery of the placenta. The drug is continued until the uterus is firm; then it is decreased or stopped. Oxytocin should not be given as an IV bolus because severe hypotension may occur.
If bleeding increases, methergine 0.2 mg IM every 2 to 4 hours or misoprostol 600 to 1000 mcg given orally, sublingually, or rectally once can be used to increase uterine tone. Methergine 0.2 mg orally every 6 to 8 hours can be continued for up to 7 days if needed. Tranexamic acid 1 g IV can be given in addition; it must be given within 3 hours of delivery to be effective.
For all women, the following must be available during the recovery period
If blood loss was excessive, 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.
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. Curl-ups, done in bed with the hips and knees flexed, tighten only abdominal muscles, usually without causing backache. Whether pelvic floor (eg, Kegel) exercises are helpful is unclear, but these exercises can begin as soon as the patient is ready.
If delivery was uncomplicated, showering and bathing are allowed, but vaginal douching is prohibited in the early puerperium. The vulva should be cleaned from front to back.
Immediately after delivery, ice packs may help reduce pain and edema at the site of an episiotomy or repaired laceration; sometimes lidocaine cream or spray can be used to relieve pain.
Later, warm sitz baths can be used several times a day.
Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen 400 mg orally every 4 to 6 hours, work effectively on both perineal discomfort and uterine cramping. Acetaminophen 500 to 1000 mg orally every 4 to 6 hours can also be used. Acetaminophen and ibuprofen appear to be relatively safe during breastfeeding. Many other analgesics are secreted in breast milk.
After surgery or repair of significant laceration, acetaminophen 650 mg IV every 4 hours or 1000 mg IV every 6 to 8 hours (not to exceed 4 g/day) may be used. Infusion should occur over ≥ 15 minutes. IV acetaminophen reduces the opioid requirement (1). Some women may 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.
Urine retention, bladder overdistention, and catheterization should be avoided if possible. Rapid diuresis may occur, especially when oxytocin is stopped. Voiding must be encouraged and monitored to prevent asymptomatic bladder overfilling. A midline mass palpable in the suprapubic region or elevation of the uterine fundus above the umbilicus suggests bladder overdistention. If overdistention occurs, catheterization is necessary to promptly relieve discomfort and to prevent long-term urinary dysfunction. If overdistention recurs, an indwelling or intermittent catheter may be needed.
Women are encouraged to defecate before leaving the hospital, although with early discharge, this recommendation is often impractical. If defecation has not occurred within 3 days, a mild cathartic (eg, psyllium, docusate, bisacodyl) can be given. Avoiding constipation can prevent or help relieve existing hemorrhoids, which can also be treated with warm sitz baths. Women with an extensive perineal laceration repair involving the rectum or anal sphincter can be given stool softeners (eg, docusate).
Regional (spinal or epidural) or general anesthesia may delay defecation and spontaneous urination, in part by delaying ambulation.
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 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.
Milk accumulation may cause painful breast engorgement during early lactation. Breastfeeding helps reduce engorgement.
For women who are going to breastfeed, the following are recommended until milk production adjusts to the infant's needs:
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.
Transient depression (baby blues) is 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.
1. Altenau B, Crisp CC, Devaiah CG, Lambers DS: Randomized controlled trial of intravenous acetaminophen for postcesarean delivery pain control. Am 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.
The woman and infant can be discharged within 24 to 48 hours postpartum; many family-centered 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 is necessary. A routine postpartum visit is usually scheduled at 6 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.
Intercourse after vaginal delivery may be resumed as soon as desired and comfortable; however, a laceration or episiotomy repair must be allowed to heal first. Intercourse after cesarean delivery should be delayed until the surgical wound has healed.
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.
Breastfeeding status affects choice of contraceptive. For breastfeeding women, nonhormonal methods are usually preferred; among hormonal methods, progestin-only oral contraceptives, depot medroxyprogesterone acetate injections, and progestin implants are preferred because they do not affect milk production. Estrogen-progesterone contraceptives can interfere with milk production and should not be initiated until milk production is well-established. Combined estrogen-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 are typically best placed after 4 to 6 weeks postpartum to minimize risk of expulsion.