The postpartum period refers to the six-to-eight-week period after the birth of a baby in which the body recovers from the changes caused by pregnancy and birth. During this time, the body undergoes several physiological changes, such as uterine involution, discharge of lochia (postpartum vaginal discharge), and the beginning of the lactation process. Women are also susceptible to complications during the postpartum period, such as infection, thrombosis, insufficient postpartum recovery, and postpartum depression. The fundal height measurement and the appearance of lochia provide important clues to possible underlying conditions.
Normal postpartum changes
- Begins immediately after birth and the delivery of the placenta
- Afterpains: painful cramps from contractions of the uterus following childbirth
- The uterus returns to its normal size by the 6th–8th week postpartum.
Lochia (postpartum vaginal discharge)
- Most women pass lochia for about 4 weeks after delivery; in some cases, this lasts for 6–8 weeks.
|Fundal height postpartum||Lochia|
|Right after birth||Between the navel and symphysis||Blood red|
|After the 1st day||Navel||Blood red|
|3rd day||3 fingerbreadths under the navel (descends 1 fingerbreadth per day)||Blood red to brown-red|
|7th day||Between the navel and symphysis||Brown-red|
- Mean weight loss after delivery of the baby, amniotic fluid, and placenta: approx. 6 kg (13 lbs)
- Additional weight loss due to lochia discharge and uterine involution: approx. 2–7 kg (5–15 lbs)
- It is recommended that infants be exclusively breastfed up to the age of 6 months.
- On-demand feeds are recommended.
- Breastfeeding plays an important role in mother-child bonding.
Physiology of lactation
- Lactogenesis: the process of mammary epithelial cell differentiation and milk production in the mammary gland that begins mid pregnancy as a result of increased estrogen and progesterone levels
- Lactation is initiated by the delivery of the placenta → abrupt ↓ progesterone levels → ↑ prolactin → stimulation of milk secretion
- Maintaining lactation requires suckling, which stimulates the secretion of:
Breast milk composition
- Colostrum: the first milk produced during late pregnancy until 3–4 days postpartum; rich in proteins and immunoglobulins
- Mature milk is composed of:
Mature milk (from the 14th day)
|Unsaturated fatty acids||1.6||1.3|
Benefits of breastfeeding 
Infant benefits 
- Decreased risk of middle-ear, respiratory, gastrointestinal, and urinary tract infections
- Better gastrointestinal function and motility
- Lower risk of asthma, allergies, obesity, and diabetes mellitus
- Maternal benefits
Contraindications to breastfeeding 
- Maternal factors
- Infant factors: phenylketonuria, and maple syrup urine disease
Breastfeeding complications and problems
- Inadequate milk production or intake
- Epidemiology: most common in primiparous women; usually occurs in the early postpartum period
- Etiology: may occur due to a poor latch, poor infant positioning, tongue-tie, infection, or vasospasm
- Clinical features: persistent pain during lactation, breast engorgement, nipple bruises, cracks, blisters, and possible bleeding
- Complications: mastitis, anxiety, depression, early cessation of breastfeeding
- Prevention: anticipatory lactation counseling
- Clinical features: tenderness, firmness, and fullness of the breast
- Complications: mastitis
Formula feeds 
- Supplementation with formula is only recommended if:
- Lactose protein-based formulas should be fortified with iron to satisfy the infant's iron needs.
Vitamin D supplementation 
- Exclusively breastfed infants should receive 400 IU vitamin D supplementation daily. 
- Supplementation can be stopped once the infant is started on vitamin D fortified cow milk (usually after 1 year of age).
- Infants on vitamin D fortified formula feeds do not require further supplementation with vitamin D.
- Iron supplementation 
- Vitamin B12 supplementation: if the mother has vitamin B12 deficiency (e.g., due to vegetarian diet) 
- Solid foods should be slowly initiated in infants between 4–6 months of age, with continued breast/formula feeding.
- The recommended initial weaning food is rice cereal fortified with iron.
- One new food should be introduced per week to allow easy identification of food allergies.
- Pureed meat, green leafy vegetables, and dried beans are good sources of iron and zinc.
- Honey should not be given to infants because of the risk of botulism.
- Cow's milk can be introduced into the diet after 1 year of age.
Postpartum endometritis 
- Definition: : inflammation of the endometrium, possibly also including the myometrium and parametrium
- Risk factors
- Etiology: : mostly polymicrobial (2–3 ascending organisms, e.g., Gardnerella vaginalis, Staphylococcus epidermidis, group B Streptococcus, and/or Ureaplasma urealyticum, all of which are usually found in the normal vaginal flora.)
- Pathophysiology: : lochia retention → ideal breeding ground for infection → postpartum endometritis/postpartum endomyometritis → postpartum sepsis
- Clinical features
- Diagnostics: primarily clinical; in some cases, the following tests can be used to confirm the diagnosis:
- Antibiotic treatment: IV clindamycin and gentamicin
- Uterine curettage to remove retained products of conception.
- Hysterectomy in case of life-threatening complications or no response to conservative therapeutic measures.
- Further complications
Postpartum sexual dysfunction
- Definition: the decline of sexual function after delivery that may not return to its baseline levels during the postpartum period
- Prepregnancy dyspareunia
- Delivery mode (e.g., vacuum-assisted vaginal delivery, emergency cesarean delivery)
- Perineal trauma (e.g., second and third-degree perineal tears)
- Breastfeeding (associated with decreasing vaginal lubrication, causing vaginal atrophy and loss of interest in sexual activity)
- Postpartum physiological and psychological changes (e.g., postpartum mood changes, postpartum depression, fatigue)
- Childbirth complications (e.g., postpartum genital infections, postpartum hemorrhage, obstructed labor)
Other uterine complications
Subinvolution of the uterus
- Impaired retraction of the uterine muscles
- Can cause severe bleeding
- Placental remnants; that have not yet been expelled may lead to prolonged or periodic hemorrhage.
- These remnants also lead to uterine subinvolution.
Septic pelvic thrombophlebitis 
- Definition: : a rare condition characterized by inflammation and thrombosis of the pelvic veins that most commonly occurs in the postpartum period
- Risk factors
- Clinical features: Onset is usually within one week of delivery.
- Treatment: antibiotics (e.g., clindamycin, gentamicin) and anticoagulation (e.g., LMWH or UFH)
- Complications: Pulmonary emboli are rare.
Other thromboembolic complications
Puerperal sepsis 
- Definition: maternal sepsis that develops in the timeframe between birth and 6 weeks postpartum
- Risk factors 
Common source sites
- Genital tract (e.g., endometritis)
- Urinary tract (e.g., acute pyelonephritis)
- Respiratory tract (e.g., severe pneumonia)
- Breast (e.g., mastitis) and other skin/soft-tissue infections (e.g., episiotomy wound, IV site, indwelling catheters)
- Group A beta-hemolytic streptococcal infection (S. pyogenes) acquisition or carriage
- Gastrointestinal tract
- Pathogens 
- Clinical features: two or more of the following should be present 
- Broad-spectrum antibiotics (ideally within the first hour of diagnosis)
- For more detailed information, see “Management” in “ .”
- Urinary insufficiency
- Urinary retention
- Definition: a > 2 cm separation of the right and left rectus abdominis muscles resulting in protrusion of abdominal organs on straining
- Risk factors
- Clinical features
- Postpartum exercise: Initiating an exercise program 6–8 weeks postpartum can help strengthen the abdominal rectus muscles and reduce the abnormal extension of the linea alba.
- Weight loss: may be appropriate in patients who develop diastasis recti due to obesity.
- Surgical repair (e.g., abdominoplasty)
- Complications: pelvic organ prolapse
- Definition: a rare complication of the postpartum period leading to a loosening of the pelvic ring, causing pain when walking and severe tenderness of the symphysis; the patient has difficulty standing on one leg.
- Diagnostics: may be confirmed with an ultrasound or pelvic x‑ray.
- Treatment: analgesics and reduced physical activity for 1–2 weeks
The 7 Ws of postpartum fever: Womb (endometritis), Wind (pneumonia), Water (UTI), Walk (DVT, pulmonary embolism), Wound (incision, episiotomy), Weaning (breast abscess, mastitis), Wonder drugs (drug fever)