Clinical manifestations during the puerperium (6-wk 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 h, 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 wk 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 wk, it is no longer palpable abdominally and typically by 4 to 6 wk 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 as lochia can interfere.
Because blood volume is redistributed, Hct may fluctuate, although it tends to remain in the prepregnancy range if women do not hemorrhage. Because WBC count increases during labor, marked leukocytosis (up to 20,000 to 30,000/μL) occurs in the first 24 h postpartum; WBC count returns to normal within 1 wk. Plasma fibrinogen and 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 h 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/h 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 h or misoprostol 800 mcg given rectally once can be used to increase uterine tone. Methergine 0.2 mg po q 6 to 8 h can be continued for up to 7 days if needed.
For all women, the following must be available during the recovery period
If blood loss was excessive, a 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 h, 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 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.
NSAIDs, such as ibuprofen 400 mg po q 4 to 6 h, work effectively on both perineal discomfort and uterine cramping. Acetaminophen 500 to 1000 mg po q 4 to 6 h 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, women may require opioids to relieve discomfort.
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.
If women have not yet received tetanus-diphtheria-acellular pertussis (Tdap) vaccination (ideally given between wk 27 and 36 of each pregnancy) and have not had a tetanus and diphtheria toxoids (Td) booster in ≥ 2 yr, 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 to immunize them against pertussis.
If women with Rh-negative blood have an infant with Rh-positive blood but are not sensitized, they should be given Rh0(D) immune globulin 300 mcg IM within 72 h of delivery to prevent sensitization (see Erythroblastosis Fetalis : Prevention).
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 milk production
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 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 wk 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.
A preexisting mental disorder, including prior postpartum depression, is likely to recur or worsen during the puerperium, so affected women should be monitored closely.
The woman and infant can be discharged within 24 to 48 h postpartum; many family-centered obstetric units discharge them as early as 6 h 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 h is necessary. A routine postpartum visit is usually scheduled at 6 wk 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 mo if women were vaccinated against rubella or varicella. Also, subsequent obstetric outcomes are improved by delaying conception for at least 6 mo but preferably 18 mo 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 wk postpartum, 2 wk before the first menses. However, ovulation can occur earlier; women have conceived as early as 2 wk postpartum. Women who are breastfeeding tend to ovulate and menstruate later, usually closer to 6 mo 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 wk postpartum if women are not breastfeeding.
A diaphragm should be fitted only after complete involution of the uterus, at 6 to 8 wk; meanwhile, foams, jellies, and condoms should be used.
Intrauterine devices are typically best placed after 4 to 6 wk postpartum to minimize risk of expulsion.