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Clinical manifestations during the puerperium (6-wk period after delivery) generally reflect reversal of the physiologic changes that occurred during pregnancy. These changes are mild and temporary and should not be confused with pathologic conditions.
Clinical parameters:
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 (see Abnormalities and Complications of Labor and Delivery: Postpartum Hemorrhage) may be 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.
Laboratory
parameters:
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.
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Table 1
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Normal Postpartum Changes
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Parameter
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First 24 h
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First 3–4 days
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5 days–2 wk
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After 2 wk
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After 4 wk
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Clinical
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Heart rate
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Starts decreasing
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Decreased to baseline
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Baseline
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Baseline
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Baseline
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Temperature
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Slightly elevated
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Usually baseline
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Baseline
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Baseline
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Baseline
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Vaginal discharge
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Bloody (lochia rubra)
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Bloody (lochia rubra)
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Pale brown (lochia serosa)*
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Pale brown to yellowish white (lochia alba)
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Yellowish white to normal
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Urine volume
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Increased
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Increased
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Decreasing to Baseline
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Baseline
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Baseline
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Uterus
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Begins involution
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Continues involution
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Firm, no longer tender
Located about midway between symphysis and umbilicus
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Not palpable in abdomen
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Prepregnancy size
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Mood
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Baby blues
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Baby blues
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Normal by 7 to 10 days
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Baseline
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Baseline
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Breasts (if not breastfeeding)
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Slightly enlarged
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Engorged
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Decreasing
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Baseline
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Baseline
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Ovulation (in nonlactating women)
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Unlikely
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Unlikely
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Unlikely
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Unlikely but possible
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Possible
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Laboratory
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WBC count
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Up to 20,000–30,000/μL
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Decreasing
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Decreasing to baseline
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Baseline
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Baseline
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Plasma fibrinogen and ESR
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Elevated
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Elevated
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Decreasing to normal after 7 days
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Baseline
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Baseline
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*Placental site sloughing may result in blood loss of about 250 mL at 7–14 days.
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Initial
Management
Risk of infection, hemorrhage, and pain must be minimized. Women are typically observed for at least 1 h after the 3rd stage of labor, and for several hours longer if general anesthesia was used during delivery (eg, by forceps, vacuum extractor, or cesarean section).
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 remain contracted 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.
For all women, O2, type O-negative blood or blood tested for compatibility, and IV fluids 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.
Diet and activity:
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 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 section. 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 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 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; later, warm sitz baths can be used several times a day.
Analgesics:
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 (see Approach to the Care of Normal Infants and Children: Drugs). Women who are postoperative or underwent significant laceration repair may require opioids to relieve discomfort.
Bladder and
bowel function:
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.
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) anesthesia may delay defecation and spontaneous urination, in part by delaying ambulation.
Vaccination
and Rh desensitization:
Women seronegative for rubella should be vaccinated against rubella on the day of discharge. Women who have not yet received Tdap (tetanus-diphtheria-acellular pertussis) vaccination and are at least 2 yr since their last Td (tetanus and diphtheria toxoids) booster should receive Tdap prior to discharge from the hospital or birthing center, regardless of their breastfeeding status.
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 μg IM within 72 h of delivery to prevent sensitization (see Abnormalities of Pregnancy: Prevention).
Breast engorgement:
Milk accumulation may cause painful breast engorgement during early lactation. Breastfeeding helps reduce engorgement. Expressing milk by hand in a warm shower or using a breast pump between feedings can relieve pressure temporarily. However, doing so tends to encourage lactation, so it should be done only when necessary.
For women who are not going to breastfeed, firm support of the breasts is recommended to suppress lactation; gravity stimulates the let-down reflex and encourages milk flow. For many women, tight binding of the breasts, cold packs, and analgesics as needed, followed by firm support, effectively control temporary symptoms while lactation is being suppressed. Suppression of lactation with drugs is not recommended.
Mental disorders:
Transient depression (baby blues) is very common during the first week after delivery. Symptoms 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 (see Postpartum Care: Postpartum Depression) or another mental disorder may be present. A preexisting mental disorder is likely to recur or worsen during the puerperium, so affected women should be monitored closely.
Management
at Home
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. Normal activities may be resumed as soon as the woman feels ready. A routine postpartum visit is usually scheduled at 6 wk for women with an uncomplicated vaginal delivery. For women undergoing cesarean delivery or who have other complications, follow-up may be scheduled sooner.
Intercourse may be resumed as soon as desired and comfortable; however, a laceration or episiotomy repair must be allowed to heal first.
Family planning:
Pregnancy must be delayed for 1 mo if women were vaccinated against rubella at hospital discharge; also, subsequent obstetric outcomes are improved by delaying conception for at least 6 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 for expulsion.
Last full review/revision November 2008 by Julie S. Moldenhauer, MD
Content last modified November 2008
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