The postpartum period
The postpartum period is typically defined as the period of time following an obstetric delivery:
- Begins with delivery of the infant
- Duration: 6–12 weeks (Expert opinions vary on when the postpartum period officially ends.)
During the postpartum period, the mother’s body physically returns to its prepregnant state. There are a number of potential complications that can occur during this time, some of which can cause significant morbidity and mortality. Some of the most important include:
- Postpartum hemorrhage
- Postpartum fever (typically from infection)
- Postpartum psychiatric disorders
- Changes/complications in the reproductive system:
- Uterine involution
- Perineal pain
- Resumption of ovulation and the need for contraception
- Urinary system:
- Urinary retention
- Urinary incontinence
- Urinary tract infections (UTIs)
- Cardiovascular and pulmonary systems:
- Return to prepregnant state
- Deep vein thrombosis (DVT) and/or pulmonary embolism (PE)
- Postpartum cardiomyopathy
- Hypertensive disorders
- GI system:
- Clostridioides difficile infection/fulminant colitis
- Endocrine system:
- Postpartum thyroiditis
- Sheehan syndrome (hypopituitarism)
- Nervous system:
- Complications of neuraxial anesthesia
- Strokes and seizures
Summary of the most important complications
Three of the most important complications are postpartum hemorrhage, postpartum fever, and postpartum psychiatric disorders; each of these is discussed in full detail on their own pages, but highlights are briefly summarized below.
- Primary causes include (the 4 Ts):
- Tone: uterine atony (by far the most common)
- Tissue: retained membranes and/or placental fragments
- Trauma: bleeding lacerations of the perineum, vagina, and/or cervix; uterine rupture
- Thrombin: coagulopathies (e.g., DIC; undiagnosed von Willebrand disease)
- Uterotonic agents: oxytocin, misoprostol, methergine, hemabate
- Manual compression of the uterus
- Uterine tamponade (e.g., with Bakri balloon)
- Surgically placed compression sutures
- Hysterectomy (last resort)
- Primary causes (the 7 Ws):
- Womb: endometritis (most common, presents with fever + uterine tenderness)
- Wound: surgical or perineal laceration wound infection
- Woobies: mastitis
- Water: UTI
- Wind: atelectasis, aspiration pneumonia, pulmonary embolism
- Walking: septic pelvic thrombophlebitis and/or DVT
- Wonder drugs: drug fever
- Treat infections with antibiotics that are safe for breastfeeding mothers.
- For endometritis, the standard regimen is gentamicin + clindamycin +/– ampicillin.
- Infected wounds and abscesses may need to be opened, irrigated/debrided, and either reclosed or allowed to heal by secondary intention.
- In mastitis, women need to keep breastfeeding/pumping (milk stasis worsens mastitis) in addition to taking antibiotics.
Postpartum psychiatric disorders:
|PP blues||PP depression||PP psychosis|
|Epidemiology||50%–80% of pregnancies||10%–25% of pregnancies||< 1% of pregnancies|
|Common symptoms||Guilt, crying, feeling of being overwhelmed||Inability to cope, disinterest in self, disinterest in infant||Visual or auditory hallucinations|
|Onset||Birth to 2 weeks PP||2 weeks to 1 year after delivery||Days to 1 year after delivery|
|Treatment||Resolves spontaneously||Psychotherapy, antidepressants||Antipsychotics|
- Definition: return of the uterus to its normal prepregnancy size starting immediately after delivery of the fetus and continuing for the next 6–8 weeks
- Contraction of the overlapping myometrial muscle fibers constricts blood flow.
- Myometrial retraction (a unique characteristic of the uterus) allows the muscle fibers to maintain shorter lengths following successive contractions.
- Uterus goes from 1 kg immediately following delivery to approximately 60 g.
- Accelerated by oxytocin in breastfeeding women
- Uterine cramping, which is normal
- Sometimes referred to as “afterpains”
- Uterus should be generally nontender (or only mildly tender); significant tenderness presents a concern for infection (i.e., endometritis).
- Delayed involution may occur due to:
- A full bladder or loaded rectum (delays immediate involution in the delivery room)
- Uterine infection
- Retained products of conception
- Risks of delayed involution:
- Postpartum hemorrhage
- Definition: the normal bleeding and vaginal discharge shed during the first few weeks postpartum
- Lochia rubra (red): the initial discharge, which is red and contains blood, endometrial tissue, and mucus and typically lasts about 1–4 days
- Lochia serosa (pink, yellow, or pale brown): follows lochia rubra and consists of mostly blood, mucus, and leukocytes
- Lochia alba (white): discharge contains mostly mucus
- Normal postpartum bleeding patterns:
- Lochia can last anywhere from 10 days to about 5 weeks postpartum.
- Bleeding usually starts out heavier than a normal period and gradually lightens over time (though this is often somewhat irregular and different from the periods the woman is typically used to).
- Bleeding may increase for about a day, typically 1–3 weeks after delivery, as the placental eschar is expelled.
- Abnormal lochia:
- Prolonged or heavy red bleeding:
- Bleeding should not exceed filling a pad in 1 hour for ≥ 2 hours in a row.
- Consider retained products of conception, infection, and subinvolution of the uterus.
- Foul-smelling discharge, especially in the setting of uterine tenderness, suggests infection.
- Prolonged or heavy red bleeding:
- Perineal and vaginal pain is common, and mild to moderate levels of pain can be “normal”:
- Should be appropriately treated with analgesics.
- Typically due to lacerations, episiotomies, and/or edema
- Other causes of perineal pain that require medical attention include:
- The perineum should routinely be gently evaluated postpartum, typically with simple visual inspection, to rule out pain due to complications.
- Typically NSAIDs and/or acetaminophen (e.g., Tylenol) are adequate.
- For significant laceration repairs, narcotics may be appropriate.
- Ice packs
- Sitz baths: soak the perineum in comfortably hot water; may add some magnesium chloride salts (epsom salts) → keeps the area clean and ↑ blood flow for healing
- Witch hazel pads
- Ambulation to mobilize fluid and reduce edema
- Treat any complications (e.g., antibiotics for infections).
Contraception and resumption of ovulation
- Although ovulation typically remains suppressed for several months while breastfeeding due to ↑ prolactin levels, it can resume as early as 3 weeks postpartum.
- Pelvic rest (“nothing in the vagina”) is recommended for all patients for at least 2 weeks postpartum, though some patients do not wait this long before engaging in intercourse.
- Contraception should be discussed with all patients prior to leaving the hospital.
- Barrier methods (e.g., condoms) are effective and should be considered in patients who wish to avoid hormonal contraception.
- Progestin-only methods:
- Preferred agents to prevent complications associated with estrogen in the early postpartum period
- “Mini-pill” is typically a low-dose norethindrone pill commonly chosen by breastfeeding women:
- Should be started 2 weeks postpartum
- Not associated with changes in breast-milk production
- Women should switch to a combined oral contraceptive pill (OCP) for better contraceptive efficacy once they stop breastfeeding.
- Other options include:
- Medroxyprogesterone acetate (Depo-Provera) injections
- Etonogestrel implantable rod (Nexplanon)
- Intrauterine contraceptive devices (IUDs): higher risk of uterine perforation when inserted immediately postpartum
- Estrogen-containing methods (pills, patch, vaginal ring):
- Can ↓ milk supply if started too early
- ↑ Risk of DVT
- Should be started 4 weeks postpartum
- Patients who are at high risk for close-interval pregnancies can be offered Depo-Provera, Nexplanon, or IUD insertion prior to leaving the hospital.
Overview of urinary system issues
- Dilation of the ureters and renal pelves return to prepregnant state over 2–8 weeks after delivery.
- Despite edema in the genitourinary tract, patients should be able to void spontaneously within 6 hours after a vaginal delivery or removal of an indwelling catheter.
- Common complications include:
- Postpartum urinary retention
- Urinary incontinence
Postpartum urinary retention
- May be due to:
- Bladder trauma related to prolonged labor
- Pudendal nerve injury during birth
- Bladder atony
- Compression of the urethra by edema
- No spontaneous micturition within 6 hours after vaginal delivery or removal of an indwelling catheter
- Elevated postvoid residual volumes (PVRs) of urine within the bladder of > 150 mL (determined with catheterization or ultrasonography)
- Risk factors:
- Epidural anesthesia
- Operative vaginal delivery (e.g., forceps or vacuum-assisted deliveries)
- Presentation: small voided volumes, slow stream, urinary frequency or urgency, bladder pain, urinary incontinence, sense of incomplete emptying, no urge to void
- Intermittent catheterization (e.g., every 4–6 hours)
- Typically self-limited; resolves within 1 week in most patients
- Common in the immediate postpartum period
- May be urge incontinence, stress incontinence, or a mixture of the 2
- Generally improves over weeks, though may persist long term
- Due to injury of the nerves, fascia, and/or pelvic floor musculature
- Risks of long-term incontinence:
- Vaginal delivery (over cesarean delivery)
- Operative vaginal delivery, especially with forceps
- Increasing maternal age
- Large-birth-weight infants
Urinary tract infections
- Typically due to frequent or prolonged catheterization during labor
- Presents with dysuria, urgency, and/or increased urinary frequency
- Diagnosed via urinalysis and/or urine culture
- Treatment is with antibiotics:
- If patients are breastfeeding, take care to choose a safe antibiotic based on the infant’s age (e.g., nitrofurantoin and trimethoprim–sulfamethoxazole are generally avoided in the 1st month of life).
- Monitor for signs of developing pyelonephritis.
Cardiovascular and Pulmonary Systems
- Blood volume ↑ by 50% in pregnancy → returns to normal postpartum
- As the uterus involutes, blood that was contained within the uterine vessels is pushed back into circulation (a form of “autotransfusion”).
- Fluid begins to mobilize several days postpartum → slight ↑ in BP as extracellular fluid moves into the intravascular space
- BP should still be within normal ranges.
- Followed by ↑ diuresis (may be up to 3 L/day)
- ↑ Preload, as compression of the inferior vena cava is relieved by delivery of the infant
DVT and PE are important causes of peripartum morbidity and mortality. Additionally, amniotic fluid embolism (AFE) may present similarly to PE.
- PE should be suspected in patients with:
- Sudden cardiopulmonary collapse
- Acute-onset dyspnea
- Pleuritic chest pain
- Unilateral lower-extremity edema (in cases of DVT)
- Abnormal vital signs and oxygenation: ↓ O2, tachycardia, tachypnea
- Lower-extremity Doppler ultrasonography to look for DVT
- Chest CT to identify PE
- D-dimer is frequently elevated in pregnancy and the postpartum period, so is less helpful.
- Support the ABCs (airway, breathing, and circulation).
- Treat with anticoagulants.
- Early ambulation
- Compression stockings or sequential compression devices (SCDs) while in bed
- The development of heart failure toward the end of pregnancy (typically > 36 weeks) or within 5 months after delivery
- Left ventricular (LV) ejection fraction < 45%
- Etiology unclear
- Clinical presentations:
- Dyspnea (especially paroxysmal nocturnal dyspnea)
- Cough and/or hemoptysis
- Pedal edema
- Echocardiogram showing left ventricular (LV) systolic dysfunction
- ECG: shows nonspecific findings
- Similar to normal management of heart failure
- Avoid ACEis/ARBs, which are contraindicated in pregnancy/lactation.
- BP should be monitored in all postpartum patients.
- Pre-eclampsia, eclampsia, and HELLP syndrome (hemolysis, elevated liver enzymes, low platelets in pregnancy) can all develop for the 1st time postpartum and are a leading cause of peripartum mortality.
- May lead to stroke, coagulopathies, and renal and liver failure
- Key symptoms:
- Visual changes (especially scotomata)
- RUQ or epigastric pain
- Treated with:
- Magnesium infusion (seizure prophylaxis)
- Antihypertensive agents (typically labetalol, hydralazine, or nifedipine)
- Gestational hypertension:
- Should resolve within 12 weeks postpartum
- If hypertension persists → diagnosed with chronic hypertension
Constipation and/or hemorrhoids
Both constipation and hemorrhoids are extremely common in the immediate postpartum period.
- Constipation is due to:
- ↓ GI motility
- Perineal pain
- Loss of body fluids
- Hemorrhoids develop due to:
- ↑ Pressure in the anal vasculature during pregnancy due to presence of the fetus
- Straining during delivery
- Oral hydration
- ↑ Fiber (either in the diet or with bulk-forming laxatives such as psyllium)
- Stool softeners
- Topical steroids and/or witch hazel pads for hemorrhoids
Clostridioides difficile infection
Formerly known as Clostridium difficile:
- Colonization with C. difficile may occur after antibiotic therapy, which alters the normal gut flora.
- Findings typically include:
- Profuse diarrhea
- Abdominal pain and distention
- Marked leukocytosis
- Can result in fulminant colitis
- Contact precautions
- Discontinue inciting antibiotics
- Support fluid, nutrition, and electrolytes due to GI losses
- Oral (not IV) vancomycin or fidaxomicin
- Definition: a destructive autoimmune disorder developing within the 1st year after delivery involving antibodies against the thyroid
- A variant of chronic autoimmune thyroiditis (i.e., Hashimoto’s thyroiditis)
- Prevalence: approximately 8%
- Transient hyperthyroidism alone: fatigue, weight loss, palpitations, heat intolerance, anxiety
- Hypothyroidism alone: fatigue, cold intolerance, constipation, dry skin
- Transient hyperthyroidism followed by hypothyroidism
- Natural history:
- “Classic sequence”: hyperthyroidism beginning 1–4 months postpartum and lasting 2–8 weeks → hypothyroidism lasting 2 weeks to 6 months → recovery
- Most women recover spontaneously within 1 year
- Some women become permanently hypothyroid and/or develop a goiter.
- Diagnosis: thyroid function testing
- Thyroid-stimulating hormone (TSH) and FT4 (screening tests)
- In hyperthyroidism, also obtain:
- Serum thyrotropin receptor antibodies
- Consider a radioiodine uptake scan (contraindicated in breastfeeding women) to differentiate postpartum thyroiditis from Graves’ disease.
- In hypothyroidism, also obtain: T3 concentrations
- Careful observation with TSH/FT4 testing every 4–8 weeks; many patients do not require treatment.
- Symptomatic hyperthyroid patients: propranolol
- Symptomatic hypothyroidism: levothyroxine
Hypopituitarism (Sheehan syndrome)
- Definition: Sheehan syndrome is hypopituitarism (deficiency of pituitary hormones) in the postpartum patient due to ischemia and infarction of the pituitary gland during obstetric hemorrhage.
- Presentation: ↓ pituitary hormones
- ↓ Prolactin: difficulty with lactation and breastfeeding
- ↓ Follicle-stimulating hormone (FSH) and luteinizing hormone (LH): amenorrhea
- ↓ TSH: hypothyroidism
- ↓ Adrenocorticotropic hormone (ACTH): adrenal insufficiency
- Management: hormone replacement therapy (e.g., corticosteroids, levothyroxine, estrogen)
- Typically, mononeuropathies that develop during delivery
- Clinical presentation: pain, weakness, and/or sensory abnormalities, typically in the lower extremities, depending on the affected nerve (see table below)
- Risk factors:
- Fetal macrosomia
- Sensory blockade (impairing recognition of discomfort)
- Prolonged lithotomy/2nd stage of labor (i.e., pushing)
- NSAIDs for pain
- Neuropathic agents can be considered.
- Physical therapy
- Prognosis: Most women recover spontaneously within days to months (median recovery time: 8 weeks).
|Affected nerve||Mechanism of injury||Symptoms|
|Femoral nerve||Prolonged pushing with extreme hip flexion|
|Lateral femoral cutaneous nerve||Prolonged pushing with extreme hip flexion|
|Peroneal nerve||Foot drop|
Complications of neuraxial anesthesia
- Nerve injury
- Back pain
- Postdural puncture headaches (positional headaches that are worse when upright, occurring within 6–72 hours after dural puncture)
- Urinary retention
- Transient neurologic symptoms: pain and/or dysesthesias in the buttocks and lower extremities
- Spinal epidural hematoma
- Spinal epidural abscess
Stroke and seizure
- Hemorrhagic strokes due to hypertensive emergency related to pre-eclampsia/eclampsia
- Ischemic strokes due to thromboembolic disease
- Present with focal neurologic findings
- Management is similar to that for nonpregnant patients.
- Due to eclampsia (see earlier section on Hypertensive disorders)
- Treat with IV magnesium sulfate.
- Can use IV benzodiazepines (typically, diazepam) when seizures do not resolve with magnesium
- Control hypertension.
Clinical Relevance and Discharge Counseling
Giving patients appropriate anticipatory guidance about what to expect when they go home postpartum is critically important to help patients identify serious complications early while avoiding unnecessary medical visits for normal processes.
Routine discharge counseling
Important topics to address include:
- When to seek medical attention
- General restrictions
- What to expect, especially in terms of pain, bleeding, and returning to normal
- Contraception counseling
When to seek medical attention
Patients should be instructed to seek medical attention for:
- Fevers > 38°C (100.4°F)
- Chest pain or shortness of breath: need to rule out PE, postpartum pre-eclampsia, and peripartum cardiomyopathy
- Major signs/symptoms of pre-eclampsia:
- Visual changes
- Shortness of breath
- RUQ/epigastric pain
- Increased vaginal bleeding (> 1 pad per hour for ≥ 2 hours in a row): should be assessed for postpartum hemorrhage
- Worsening abdominal and/or pelvic pain: need to rule out infection
- Inability to void (concern for urinary retention)
- Severe nausea and/or vomiting
- Depression symptoms, thoughts of self-harm, and/or infant harm
Patients should typically be advised to:
- Avoid intercourse and/or anything in the vagina (i.e., “pelvic rest”) to allow time for healing.
- Avoid heavy lifting (anything that requires straining) until they are comfortable to do so.
- Avoid driving until:
- No longer taking narcotics
- Comfortable with slamming on the brakes in an emergency
- Typically 2–3 weeks
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- Berens, P. (2021). Overview of the postpartum period: Normal physiology and routine maternal care. In Barss, V.A. (Ed.) UpToDate. Retrieved June 24, 2021, from https://www.uptodate.com/contents/overview-of-the-postpartum-period-normal-physiology-and-routine-maternal-care
- Tsang, W., Lang, R. (2020). Peripartum cardiomyopathy: etiology, clinical manifestations, and diagnosis. In Yeon, S. (Ed.), UpToDate. Retrieved June 24, 2021, from https://www.uptodate.com/contents/peripartum-cardiomyopathy-etiology-clinical-manifestations-and-diagnosis
- Burman, K. D. (2019). Postpartum thyroiditis. In Mulder, J.E. (Ed.), UpToDate. Retrieved June 24, 2021, from https://www.uptodate.com/contents/postpartum-thyroiditis
- Chauhan, G. (2020). Physiology, postpartum changes. In StatPearls. Retrieved June 24, 2021, from https://www.statpearls.com/articlelibrary/viewarticle/27550/
- Kansky, C. (2016). Normal and abnormal puerperium. Medscape. Retrieved June 24, 2021, from https://emedicine.medscape.com/article/260187-overview#a2
- Wong, A. (2019). Postpartum infections. Medscape. Retrieved June 24, 2021, from https://emedicine.medscape.com/article/796892-overview