Postpartum Care

Within the first 24 hours after delivery, pulse rate begins to decrease, and 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 avoid infection, most clinicians advise against using tampons. Women should be told to contact their clinician if they are concerned about heavy or prolonged bleeding (late postpartum hemorrhage). These symptoms may be a sign of infection or retained placenta and should be evaluated.

The uterus involutes progressively; after 5 to 7 days, it is firm and no longer tender, with the fundus 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. During the first few days postpartum, contractions of the involuting uterus may be painful (afterpains) and may require analgesics.

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 blood loss is within the normal range. 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.

If delivery was uncomplicated, showering and bathing are allowed, but vaginal douching is prohibited (douching is not recommended for any woman, regardless of pregnancy). The vulva should be cleaned from front to back. Some patients find it helpful to use a bottle with a spout to squirt warm water on the perineum.

Later, warm sitz baths can be used several times a day.

Following cesarean delivery, patients should receive standard wound care and monitoring.

Typically, the bandage is removed within 1 to 2 days postoperatively. Patients may shower after the dressing is removed, but they are usually advised to defer immersing in a bath until the wound is fully healed. If surgical staples were used for wound closure and the skin incision is transverse, the staples can be removed after 4 to 6 days. Patients should be advised to call their clinician if there are signs of wound infection (erythema, induration, purulent discharge, fever) or dehiscence (separation of wound, serosanguinous discharge).

Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective for both perineal discomfort and uterine cramping (2

3). 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 or post-cesarean complications.

Regional (spinal or epidural) or general anesthesia may delay defecation and spontaneous urination, in part by delaying ambulation.

After the first 24 hours, recovery is rapid. After delivery, a regular diet may be given as soon the patient desires. Ambulation is encouraged as soon as possible.

Exercise recommendations are individualized depending on the mode of delivery, complications, perineal lacerations or episiotomy, and the presence of other disorders. Usually, exercise 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 (4). Whether pelvic floor muscle exercises (Kegel exercises) are helpful is unclear, but these exercises can begin as soon as the patient is ready.

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 and supportive nursing bra 24 hours/day

For women who are not going to breastfeed, the following are recommended:

• Tight binding of the breasts (eg, with a snug-fitting bra), cold packs, and analgesics as needed to control temporary symptoms while lactation is being suppressed

• 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

Suppression of lactation with medications is not recommended in the United States, but such medications are used in many countries (5).

Patients who develop mastitis will present with fever and breast symptoms: erythema, induration, tenderness, pain, swelling, and warmth to the touch. Mastitis is different from the pain and cracking of nipples that frequently accompanies the start of breastfeeding.

Sexual activity after vaginal delivery may be resumed as soon as desired and comfortable and after healing of any laceration or episiotomy repair. Sexual activity after cesarean delivery should be delayed until the surgical wound has healed.

Some data suggest that subsequent obstetric outcomes are improved by delaying conception for at least 6 months but preferably 18 months after delivery (6).

To minimize the chance of pregnancy, women who have sex with men should start using contraception before resuming sexual activity. 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.

Estrogen-progestin 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, condoms and spermicide 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 do not desire future fertility may choose tubal sterilization (7). Tubal sterilization can be done immediately postpartum, at the time of cesarean delivery, or after the postpartum period. This procedure is considered permanent and irreversible. Because removing the fallopian tubes (salpingectomy) is associated with a decreased risk of ovarian cancer, patients undergoing tubal sterilization should be offered salpingectomy (8).

1. 1. American College of Obstetricians and Gynecologists (ACOG): ACOG Committee Opinion No. 736: Optimizing Postpartum Care. Obstet Gynecol. 2018;131(5):e140-e150. Reaffirmed 2021. doi:10.1097/AOG.0000000000002633

2. 2. Pharmacologic Stepwise Multimodal Approach for Postpartum Pain Management: ACOG Clinical Consensus No. 1. Obstet Gynecol. 2021;138(3):507-517. doi:10.1097/AOG.0000000000004517

3. 3. 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

4. 4. Syed H, Slayman T, DuChene Thoma K: ACOG Committee Opinion No. 804: Physical Activity and Exercise During Pregnancy and the Postpartum Period. Obstet Gynecol. 2021;137(2):375-376. Reaffirmed 2023. doi:10.1097/AOG.0000000000004266

5. 5. Drugs and Lactation Database (LactMed®) [Internet]. Bethesda (MD)

6. 6. Hutcheon JA, Moskosky S, Ananth CV, et al: Good practices for the design, analysis, and interpretation of observational studies on birth spacing and perinatal health outcomes [published correction appears in Paediatr Perinat Epidemiol. 2020 May;34(3):376]. Paediatr Perinat Epidemiol. 2019;33(1):O15-O24. doi:10.1111/ppe.12512

7. 7. American College of Obstetricians and Gynecologists (ACOG): ACOG Committee Opinion, Number 827: Access to Postpartum Sterilization. Obstet Gynecol. 2021;137(6):e169-e176. doi:10.1097/AOG.0000000000004381

8. 8. American College of Obstetricians and Gynecologists (ACOG): ACOG Committee Opinion No. 774: Opportunistic Salpingectomy as a Strategy for Epithelial Ovarian Cancer Prevention. Obstet Gynecol. 2019;133(4):e279-e284. Reaffirmed 2020. doi:10.1097/AOG.0000000000003164

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 alloimmunization.

Vaccinations are given postpartum if

• Vaccination was recommended but not received during pregnancy.

• A patient is unvaccinated or is insufficiently vaccinated or nonimmune (eg, did not complete a full vaccine series or is seronegative despite prior vaccination), and the vaccine is contraindicated during pregnancy.

The tetanus-diphtheria-acellular pertussis (Tdap) vaccine is recommended between 27 and 36 weeks 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 (1).

In August 2023, the U.S. Food and Drug Administration approved use of a respiratory syncytial virus (RSV) vaccine in pregnant patients between 32 and 36 weeks gestation, with a warning to avoid use prior to 32 weeks (2). There is no current recommendation to give the RSV vaccine postpartum to women who did not receive it during pregnancy.

The measles-mumps-rubella vaccine (MMR) and varicella vaccine are live attenuated vaccines and should not be given during pregnancy. Patients who are seronegative for antibodies for measles, rubella, or varicella should be vaccinated postpartum (usually on the day of discharge).

A postpartum hospital stay or outpatient visit also provides an opportunity for women to receive any needed routine vaccinations (eg, influenza, COVID-19, hepatitis B, human papillomavirus) that are recommended either for all patients or for certain patients based on risk factors for particular infections.

(See also Vaccines During Pregnancy,Guidelines for Vaccinating Pregnant Women, and CDC: COVID-19 Vaccines While Pregnant or Breastfeeding.)

1. 1. American College of Obstetricians and Gynecologists (ACOG): Committee Opinion No. 718: Update on Immunization and Pregnancy: Tetanus, Diphtheria, and Pertussis Vaccination. Obstet Gynecol. 2017;130(3):e153-e157. Reaffirmed 2022. doi:10.1097/AOG.0000000000002301

2. 2. U.S. Food and Drug Administration (FDA): FDA Approves First Vaccine for Pregnant Individuals to Prevent RSV in Infants. FDA News Release, August 21, 2023.

Immediate postpartum hemorrhage

Minimizing bleeding is the first priority; measures include

• Uterine massage

During the first hour after the third stage of labor, the uterine fundus is massaged through the abdomen periodically to ensure that it contracts, preventing excessive bleeding.

1).

If severe bleeding continues, vital signs are monitored, and hemodynamic support with IV fluids and oxygen is given. A complete blood count and coagulation tests are done. Blood products are given if needed. Clinicians should monitor the patient for disseminated intravascular coagulation. If fever is present, antibiotics are given if appropriate.

After a vaginal birth, an internal uterine examination is done to check for retained membranes or placental fragments. After cesarean delivery, surgical complications are considered.

(For further information, see Postpartum Hemorrhage.)

Late postpartum hemorrhage

Patients may experience postpartum hemorrhage days or weeks after delivery. Late postpartum hemorrhage may be caused by retained products of conception, infection, or coagulation disorders. Patients should be educated about when to call a health care professional or go to an emergency department. Common guidance is that patients should seek medical care if they are soaking a pad or tampon every 1 to 2 hours, passing large (> 2.5 cm) blood clots and/or feeling faint.

When patients present with significant late postpartum bleeding, the history of the recent pregnancy is reviewed, including mode of delivery and any complications during pregnancy or delivery. Overall obstetric history and medical history are also reviewed, particularly for risk factors for bleeding disorders.

Patients are evaluated as for immediate postpartum hemorrhage, and hemodynamic support is given. For late postpartum bleeding, manual exploration of the uterus is not done. Pelvic ultrasonography may reveal retained products of conception that require surgical evacuation, uterotonics, or antibiotics.

Preeclampsia can develop after delivery. Signs and symptoms are similar to preeclampsia during pregnancy (new-onset hypertension) combined with new unexplained proteinuria and/or signs or symptoms of end-organ damage (eg, thrombocytopenia, impaired liver function, renal insufficiency, pulmonary edema, headache, visual symptoms). Women should be counseled to call their health care professional if they experience these symptoms postpartum.

The evaluation is similar to that done during pregnancy, including blood pressure monitoring and laboratory evaluation.

In cases that meet criteria for severe preeclampsia, patients are hospitalized and treated with IV magnesium sulfate for 24 hours to prevent seizures.

Patients with fever or other symptoms or signs of infection postpartum should be promptly evaluated and treated. Prior to discharge from the hospital, patients should be counseled about how to recognize symptoms of infection and when to seek medical attention.

Postpartum infections may include

• Endometritis

• Wound infection

• Mastitis

• Urinary tract infection (cystitis or pyelonephritis)

• Clostridioides difficile colitis (in patients who received antibiotics during or after labor and delivery)

Endometritis, mastitis, and postpartum pyelonephritis are discussed in detail separately.

Wound infection of abdominal incisions may develop after cesarean delivery or postpartum tubal sterilization. Perineal repairs may also become infected. In severe cases, infection may cause cellulitis, abscess, or necrotizing fasciitis.

Thromboembolic disorders—deep venous thrombosis (DVT) or pulmonary embolism (PE)—are a leading cause of maternal mortality.

Most pregnancy-associated thromboemboli develop postpartum and result from vascular trauma during delivery (2). The risk of developing a thromboembolic disorder is increased for about 6 weeks after delivery. Cesarean delivery also increases risk. Postpartum patients should be monitored for signs and symptoms of thromboembolism and counseled about how to recognize these signs and when to see medical attention.

Some patients experience a headache due to leakage of cerebrospinal fluid from spinal anesthesia or puncture of the dura during epidural anesthesia (referred to as spinal headache or postdural puncture headache). The headache is positional and should be differentiated from other etiologies (eg, preeclampsia).

3). If the headache is severe, it may be treated with an epidural blood patch (4).

Women may develop the following complications of the perineal repair after perineal laceration or episiotomy:

• Hematoma

• Wound infection

• Wound dehiscence

• Chronic pain

Perineal, vulvar, or vaginal hematoma may develop after vaginal delivery. These complications typically present as a mass accompanied by increasing pain. Nonexpanding hematomas are managed conservatively with ice packs and observation. If a hematoma is expanding or there is suspicion of retroperitoneal bleeding, surgical intervention is required.

Perineal repairs may separate or become infected. In such cases, evaluation is done for infection and damage to the anal sphincter. Management may include antibiotics, debridement, re-suturing, and/or leaving the wound open to heal by secondary intention.

Some women experience chronic pain or dyspareunia at the site of perineal repair. First-line management is with pelvic floor muscle exercises. If exercises are not effective, the patient should be referred to a urogynecologist or other gynecologist experienced in chronic pain and pelvic reconstructive surgery.

Transient depressive symptoms (postpartum 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 postpartum.

Clinicians 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 psychiatric disorder may be present. During the comprehensive postpartum visit, all women should be screened for postpartum mood and anxiety disorders using a validated tool (5).

Patients with hallucinations, delusions, or psychotic behavior should be evaluated for postpartum psychosis. Women who have postpartum psychosis may need to be hospitalized, preferably in a supervised unit that allows the infant to remain with them. Antipsychotic medications may be needed as well as antidepressants.

A preexisting psychiatric disorder, including prior postpartum depression, is likely to recur or worsen during the puerperium, so affected women should be monitored closely.

1. 1. Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet Gynecol. 2017;130(4):e168-e186. doi:10.1097/AOG.0000000000002351

2. 2. American College of Obstetricians and Gynecologists (ACOG): ACOG Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin No. 196: Thromboembolism in Pregnancy [published correction appears in Obstet Gynecol. 2018 Oct;132(4):1068]. Obstet Gynecol. 2018;132(1):e1-e17. doi:10.1097/AOG.0000000000002706

3. 3. Ona XB, Osorio D, Cosp XB: Drug therapy for treating post-dural puncture headache. Cochrane Database Syst Rev. 2015 Jul 15;2015(7):CD007887. doi: 10.1002/14651858.CD007887.pub3.

4. 4. American College of Obstetricians and Gynecologists (ACOG): Headaches in Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 3 [published correction appears in Obstet Gynecol. 2022 Aug 1;140(2):344]. Obstet Gynecol. 2022;139(5):944-972. doi:10.1097/AOG.0000000000004766

5. 5. American College of Obstetricians and Gynecologists (ACOG): Screening and Diagnosis of Mental Health Conditions During Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 4. Obstet Gynecol. 2023;141(6):1232-1261. doi:10.1097/AOG.0000000000005200