Postpartum period

Infant nursing shortly after birth

Woman nurses twins six days after birth. The linea nigra is still visible.

Within about 10 seconds the infant takes its first breath and the caregiver places the baby on the mother's chest. The infant's condition is evaluated using the Apgar scale.[13] The Apgar score is determined by evaluating the newborn baby on five criteria which are summarized using words chosen to form an acronym (Appearance, Pulse, Grimace, Activity, Respiration). Until recently babies were routinely removed from their mothers following birth; however beginning around 2000, some authorities began to suggest that early skin-to-skin contact (placing the naked baby on the mother's chest) is of benefit to both mother and infant. As of 2014, early skin-to-skin contact, also called kangaroo care, is endorsed by all major organizations that are responsible for the well-being of infants. Thus, to help establish bonding and successful breastfeeding, the caregiver carries out immediate mother and infant assessments as the infant lies on the mother's chest and removes the infant for further observations only after they have had their first breastfeed, depending on the mother's preference. The World Health Organization (WHO) also encourages skin-to-skin contact for the first 24 hours after birth to help regulate the baby's temperature.[14]

In the first few days following childbirth, the risk of a deep vein thrombosis (DVT) is relatively high as hypercoagulability increases during pregnancy and is maximal in the postpartum period,[15] particularly for women with C-section with reduced mobility. Anti-coagulants or physical methods such as compression may be used in the hospital, particularly if the woman has risk factors, such as obesity, prolonged immobility, recent C-section, or first-degree relative with a history of thrombotic episode. For women with a history of thrombotic event in pregnancy or prior to pregnancy, anticoagulation is generally recommended.[16]

The increased vascularity (blood flow) and edema (swelling) of the woman's vagina gradually resolves in about three weeks. The cervix gradually narrows and lengths over a few weeks.[17] Postpartum infections can lead to sepsis and if untreated, death.[18] Postpartum urinary incontinence is experienced by about 33% of all women; women who deliver vaginally are about twice as likely to have urinary incontinence as women who give birth via a cesarean.[19] Urinary incontinence in this period increases the risk of long term incontinence.[2] Kegel exercises are recommended to strengthen the pelvic floor muscles and control urinary incontinence.[20]

Adult diapers may be worn in the subacute postpartum period for lochia, as well as urinary and fecal incontinence.

Discharge from the uterus, called lochia, will gradually decrease and turn from bright red, to brownish, to yellow and cease at around five or six weeks. Women are advised in this period to wear adult diapers or nappies, disposable maternity briefs, maternity pads or towels, or sanitary napkins. The use of tampons or menstrual cups are contraindicated as they may introduce bacteria and increase the risk of infection.[21] An increase in lochia between 7–14 days postpartum may indicate delayed postpartum hemorrhage.[1]

Hemorrhoids and constipation in this period are common, and stool softeners are routinely given.[22]

In the subacute postpartum period, 87% to 94% of women report at least one health problem.[6][7]

At two to four days postpartum, a woman's breastmilk will generally come in.[23] Historically, women who were not breastfeeding (nursing their babies) were given drugs to suppress lactation, but this is no longer medically indicated. In this period, difficulties with breastfeeding may arise. Maternal sleep is often disturbed as night waking is normal in the newborn, and newborns need to be fed every two to three hours, including during the night.[24] The lactation consultant, health visitor, monthly nurse, postnatal doula, or kraamverzorgster may be of assistance at this time.

During the subacute postpartum period, psychological disorders may emerge. Among these are postpartum depression, posttraumatic stress disorder, and in rare cases, postpartum psychosis.[25] Postpartum mental illness can affect both mothers and fathers, and is not uncommon.[26] Early detection and adequate treatment is required. Approximately 70–80% of postpartum women will experience the "baby blues" for a few days. Between 10 and 20 percent may experience clinical depression, with a higher risk among those women with a history of postpartum depression, clinical depression, anxiety, or other mood disorders.[27] Prevalence of PTSD following normal childbirth (excluding stillbirth or major complications) is estimated to be between 2.8% and 5.6% at six weeks postpartum.[28]

Various organizations across the world recommend routine postpartum evaluation in the postpartum period. The American College of Obstetricians and Gynecologists (ACOG) recognizes the postpartum period (the "fourth trimester") as critical for women and infants. Instead of the traditional single four- to six-week postpartum visit, ACOG, as of 2018, recommends that postpartum care be an ongoing process. They recommend that all women have contact (either in person or by phone) with their obstetric provider within the first three weeks postpartum to address acute issues, with subsequent care as needed. A more comprehensive postpartum visit should be done at four to twelve weeks postpartum to address the mother's mood and emotional well-being, physical recovery after birth, infant feeding, pregnancy spacing and contraception, chronic disease management, and preventive health care and health maintenance. Women with hypertensive disorders should have a blood pressure check within three to ten days postpartum. More than one half of postpartum strokes occur within ten days of discharge after delivery. Women with chronic medical (e.g., hypertensive disorders, diabetes, kidney disease, thyroid disease) and psychiatric conditions should continue to follow with their obstetric or primary care provider for ongoing disease management. Women with pregnancies complicated by hypertension, gestational diabetes, or preterm birth should undergo counseling and evaluation for cardiometabolic disease, as lifetime risk of cardiovascular disease is higher in these women.[9]

Similarly, the World Health Organization recommends postpartum evaluation of the mother and infant at three days, one to two weeks, and six weeks postpartum.[9]