Postpartum care

The postpartum period (fourth trimester) is the 12 weeks after childbirth in which the body recovers from the changes of pregnancy and labor. During this period, individuals are at risk of a range of postpartum complications, affecting physical and mental health. To assist in early detection of complications and to optimize maternal and infant health, all individuals should have a minimum of two postpartum contacts: the first within 3 weeks and a comprehensive postpartum visit at 4–12 weeks. The comprehensive postpartum visit consists of a detailed physical, social, and psychological evaluation to monitor for postpartum complications, manage chronic conditions, and assist with care of the newborn. Patients with preexisting medical conditions, complex pregnancies, or poor social support may require more frequent care during and beyond the postpartum period.

For management of the newborn after birth, see “The newborn infant,” “Infant nutrition and breastfeeding,” and “Well-child visits.”

See also “Postpartum complications.”

Low‑grade fever, shivering, and leukocytosis are common findings during the first 24 hours postpartum and do not necessarily indicate an infection.

Uterine involution

• 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 6^th–8^th week postpartum.

Lochia (postpartum vaginal discharge)

• Definition
  • The birthing process and placental detachment lead to uterine lesions, which discharge a special secretion when healing.
  • This secretion, together with the cervical mucus and other components, forms the lochia.
• Most women pass lochia for about 4 weeks after delivery; in some cases, this lasts for 6–8 weeks.
  • Lochia rubra: blood red; approx. the first 4 days after birth
  • Lochia serosa: brown red; watery consistency, lasts approx. 2–3 weeks
  • Lochia alba: yellow white; lasts approx. 1–2 weeks

Weight loss

• 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)

References:^{[1][2][3][4][5]}

Immediate postpartum care involves monitoring for postpartum complications, managing postpartum pain, and planning appropriate discharge from the hospital. See “Infant nutrition” for information on establishing feeding.

Personal care ^[6]

• Encourage as much sleep as possible.
• No dietary changes are advised.
• Patients may shower as soon after delivery as they want to.
• Encourage early ambulation to reduce the risk of DVT.

Monitoring ^[6]

• Vitals
  • Measure blood pressure and pulse at least every 15 minutes for 2 hours. ^[6]
  • Measure temperature every 4 hours for the first 8 hours, then every 8 hours. ^[6]
• Fluid status
  • For the first 24 hours, record urine output and ensure regular voiding of urine. ^[6]
  • For patients receiving IV fluids, perform a volume status assessment before discontinuation.

Postpartum pain management ^[6][7]

• Pain management requirements depend on the mode of delivery and presence of local trauma.
• Regional anesthesia can be continued for pain relief for the first 24 hours postpartum. ^[6]
• Patients requiring oral analgesia
  • First-line: acetaminophen or ibuprofen (see “Oral analgesia” for dosages)
  • Refractory pain: Consider adding a low-dose, short-acting opioid (e.g., oxycodone). ^[7][8]
    • Guidance on continuing breastfeeding while taking low-dose opioids is inconsistent; use shared decision-making. ^[7]
    • Advise individuals who are breastfeeding and taking opioids to seek immediate medical care if they notice signs of opioid toxicity in the infant. ^[8]
• For patients with perineal trauma, consider : ^[6]
  • Cold or ice baths or packs
  • Rectal suppositories
  • Topical anesthesia

Postpartum pain (due to, e.g., lacerations, uterine contractions, breast engorgement) is common and should be managed using a stepwise multimodal approach such as the WHO pain ladder.

Discharge planning ^[9]

• Provide education on normal postpartum changes and red flags during the postpartum period.
• Ensure hospital discharge criteria are met.
• Administer required immunizations before discharge.
• Review postpartum pain and plan for pain management after discharge.
• Discuss postpartum contraception.
• Arrange the first postpartum visit (see “Overview of postpartum contacts”).

The length of hospital stay after birth is typically 48 hours after vaginal delivery and 72 hours after cesarean delivery. ^[6]

Immunizations

• Review blood type and rhesus status of the mother, as well as the newborn if necessary.
  • For unsensitized Rh-negative individuals who give birth to Rh-positive babies: Provide RhIG within 72 hours of birth. ^[6][10]
  • For further information, including dosages, see “Management of RhD negative individuals during pregnancy.”
• Administer vaccines that were deferred or not given during pregnancy (e.g., live vaccines, Tdap). ^[11][12]
• See also “Immunizations in pregnancy and lactation.” ^[11][12]

Hospital discharge criteria ^[6]

• Physical examination
  • Normal vital signs
  • Normal lochia color and amount
  • Firm uterine fundus
  • No signs of infection in any wounds
  • No signs of physical or mental health complications
  • Adequate pain control
• The patient:
  • Is able to care for themselves and their newborn
  • Understands the plan for outpatient postpartum care
  • Understands when to seek emergency care for postpartum or infant complications
• Additional requirements depend on clinical need.
  • Postpartum hemorrhage: Ensure hemoglobin is stable and manage anemia if present. ^[13]
  • Hypertensive disorders of pregnancy: Ensure blood pressure is normal and that a plan for ongoing monitoring is in place.

• Planning for postpartum care begins during the prenatal period (see “Counseling related to peripartum care”). ^[9]
• Guidance now encourages earlier and more frequent contacts than the traditional single visit at 6 weeks postpartum to decrease the risk of: ^[9]
  • Pregnancy-related deaths
  • Postpartum complications (e.g., postpartum depression, early weaning of breastfeeding) ^[9]
• Postpartum care can be provided by the patient's OBGYN or primary care practitioner.

• Postnatal assessments can take place in-office or via telehealth; tailor based on clinical need and patient preference. ^[9]
• Recommendations vary on optimum intervals; the minimum recommended number of contacts is: ^[9][14]
  • Initial contact within 3 weeks
  • A comprehensive postpartum visit within 12 weeks
• The number and frequency of visits should be tailored based on patient factors, including: ^[6][9]
  • Preexisting health conditions
  • Presence of delivery complications
  • Risk factors for postnatal depression

Urgently assess for postpartum complications if a patient presents with red-flag symptoms immediately after delivery and/or during the postpartum period, e.g.: ^[15][16]

• Signs and symptoms of sepsis
• Extreme fatigue
• Red flags for nausea and vomiting
• Dizziness or syncope
• Headache red flags
• Visual changes
• Red flags for chest pain
• Palpitations
• Red flags for dyspnea
• Red flags for abdominal pain
• Heavy vaginal bleeding and/or change in discharge
• Changes in mood or thoughts of harming the baby (see “Differential diagnosis of postpartum low mood”)

General principles ^[6][9]

• Takes place between 4–12 weeks postpartum
• The focus is on assessing the individual's physical and mental well-being after delivery, including:
  • Assessment for red flags during the postpartum period and management of postpartum complications
  • Preventive healthcare including screening
• Care of the infant is discussed, including:
  • “Infant nutrition and breastfeeding”
  • “Anticipatory guidance for children”
  • “Anticipatory guidance for pediatric development”
• Follow-up visits are scheduled according to individual need.

The American Academy of Family Physicians recommends continuing postpartum care beyond 12 weeks. ^[17]

Routine health maintenance ^[9]

• Review vaccine history; ensure patient, and close contacts of the infant, are up-to-date (see “Immunizations in pregnancy and lactation”).
• Perform any screening that is due (see “Screening recommendations for nonpregnant women by age”).
• Complete an ASCVD risk assessment for individuals at risk of developing cardiovascular disease, i.e., a history of:
  • Preterm birth
  • Gestational diabetes
  • Hypertensive pregnancy disorders
  • Preeclampsia or eclampsia
• Ask about tobacco product use in pregnancy and postpartum and encourage cessation. ^[18]
• Discuss weight management. ^[17]

Management of chronic conditions ^[9]

• Continue care for chronic conditions and refer to specialists as needed.
• Review the LactMed database to ensure medications are compatible with breastfeeding.
• Hypertension in pregnancy: Patients should have had BP checked within 10 days of delivery.
• Gestational diabetes ^[17][19]
  • Screening is recommended at 4–12 weeks to ensure resolution.
  • See “Management of diabetes in pregnancy.”

Wellbeing

• Assess to see if material needs are being met; refer to social worker and local programs as needed. ^[9]
• Encourage self-care measures for well-being, such as: ^[20]
  • Prioritizing sleep ^[9][21]
  • Healthy diet (see “Principles of nutrition”)
  • Regular exercise ^[9][22]
  • Requesting help from friends and family to manage care responsibilities
• Screen for intimate partner violence (see also “Peripartum IPV”).

Mental health disorders

• For patients with preexisting mental health diagnoses, assess for deterioration. ^[6][17]
• Screen for development of mental health conditions. ^[23][24][25]

Before starting treatment for anxiety and postpartum depression, confirm whether the patient meets the diagnostic criteria for bipolar disorder. ^[24]

The most common causes of perinatal mortality are suicide, overdose, and poisoning. ^[24]

Postpartum reproductive health ^[6]

• Discuss any questions about labor and delivery.
• Assess the patient's reproductive life plan. ^[9]
  • Discuss options for contraception in postpartum individuals.
  • Provide counseling on the timing of subsequent pregnancy. ^[28]
    • Avoid another pregnancy within 6 months. ^[29]
    • Discuss the risks and benefits of planning a pregnancy in 6–18 months. ^[9][29]
• Evaluate and manage gynecologic and urologic complications. ^[9]
  • Assess perineal lacerations or the cesarean incision.
  • Manage urinary incontinence and/or fecal incontinence.
  • Recommend a water-based lubricant for postpartum dyspareunia.
• Perform an annual well-woman exam if due. ^[9]
• Discuss libido and sexuality; reassure individuals with low libido that this improves with time. ^[6][17]

A pelvic examination is not routinely performed, unless there are patient concerns or an annual examination is due. ^[9][17]

Postpartum care following stillbirth or neonatal death ^[9][30]

• Ensure appropriate postnatal care for medical complications.
• Acknowledge grief and offer referral to bereavement counseling.
• Review any studies investigating the loss.
• Discuss risk of recurrence and provide counseling on timing of subsequent pregnancies.