The postpartum (or postnatal) period begins after
childbirth
Childbirth, also known as labour and delivery, is the ending of pregnancy where one or more babies exits the internal environment of the mother via vaginal delivery or caesarean section. In 2019, there were about 140.11 million births glo ...
and is typically considered to end within 6 weeks as the mother's body, including
hormone
A hormone (from the Greek participle , "setting in motion") is a class of signaling molecules in multicellular organisms that are sent to distant organs by complex biological processes to regulate physiology and behavior. Hormones are required ...
levels and
uterus
The uterus (from Latin ''uterus'', plural ''uteri'') or womb () is the organ in the reproductive system of most female mammals, including humans that accommodates the embryonic and fetal development of one or more embryos until birth. The ...
size, returns to a non-pregnant state.
The terms puerperium, puerperal period, or immediate postpartum period are commonly used to refer to the first six weeks following childbirth.
The
World Health Organization
The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level o ...
(WHO) describes the postnatal period as the most critical and yet the most neglected phase in the lives of mothers and babies; most
maternal
]
A mother is the female parent of a child. A woman may be considered a mother by virtue of having given birth, by raising a child who may or may not be her biological offspring, or by supplying her ovum for fertilisation in the case of ges ...
and
infant mortality, newborn deaths occur during this period.
In scientific literature, the term is commonly abbreviated to P''x'', where ''x'' is a number; for example, "day P5" should be read as "the fifth day after birth". This is not to be confused with the medical nomenclature that uses G P to stand for number and outcomes of pregnancy (
gravidity and parity
In biology and human medicine, gravidity and parity are the number of times a woman is or has been pregnant (gravidity) and carried the pregnancies to a viable gestational age (parity). These terms are usually coupled, sometimes with additional ...
).
A female giving birth in a hospital may leave as soon as they are medically stable, which can be as early as a few hours postpartum, though the average for
a vaginal birth is one to two days. The average
caesarean section
Caesarean section, also known as C-section or caesarean delivery, is the surgical procedure by which one or more babies are delivered through an incision in the mother's abdomen, often performed because vaginal delivery would put the baby or ...
postnatal stay is three to four days. During this time, the mother is monitored for bleeding, bowel and bladder function, and baby care. The infant's health is also monitored.
Early postnatal hospital discharge is typically defined as discharge of the mother and newborn from the hospital within 48 hours of birth.
The postpartum period can be divided into three distinct stages; the initial or acute phase, 8–19 hours after childbirth; subacute postpartum period, which lasts two to six weeks, and the delayed postpartum period, which can last up to eight months.
In the subacute postpartum period, 87% to 94% of women report at least one health problem.
Long-term health problems (persisting after the delayed postpartum period) are reported by 31% of women.
Various organizations recommend routine postpartum evaluation at certain time intervals in the postpartum period.
Acute phase
The first 6 to 12 hours after childbirth is the initial or acute phase of the postpartum period.
During this time the mother is typically monitored by nurses or midwives as complications can arise.
The greatest health risk in the acute phase is
postpartum bleeding
Postpartum bleeding or postpartum hemorrhage (PPH) is often defined as the loss of more than 500 ml or 1,000 ml of blood following childbirth. Some have added the requirement that there also be signs or symptoms of low blood volume fo ...
. Following delivery the area where the placenta was attached to the uterine wall bleeds, and the uterus must contract to prevent blood loss. After contraction takes place the fundus (top) of the uterus can be palpated as a firm mass at the level of the navel. It is important that the uterus remains firm and the nurse or midwife will make frequent assessments of both the fundus and the amount of bleeding. Uterine massage is commonly used to help the uterus contract.
Following delivery if the mother had an
episiotomy
Episiotomy, also known as perineotomy, is a surgical incision of the perineum and the posterior vaginal wall generally done by a midwife or obstetrician. Episiotomy is usually performed during second stage of labor to quickly enlarge the opening ...
or tearing at the opening of the vagina, it is stitched. In the past, an episiotomy was routine. However, more recent research shows that routine episiotomy, when a normal delivery without complications or instrumentation is anticipated, does not offer benefits in terms of reducing perineal or vaginal trauma. Selective use of episiotomy results in less perineal trauma. A healthcare professional can recommend comfort measures to help to ease
perineal pain.
Infant caring in the acute phase
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
The Apgar score is a quick way for doctors to evaluate the health of all newborns at 1 and 5 minutes after birth and in response to resuscitation. It was originally developed in 1952 by an anesthesiologist at Columbia University, Virginia Apgar, ...
. 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
Grimace may refer to:
*A type of facial expression usually of disgust, disapproval, or pain
*Grimace (composer), a French composer active in the mid-to-late 14th century
*Grimace (character)
McDonaldland is a McDonald's media franchise and the ...
, 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
Breastfeeding, or nursing, is the process by which human breast milk is fed to a child. Breast milk may be from the breast, or may be expressed by hand or pumped and fed to the infant. The World Health Organization (WHO) recommends that bre ...
, 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.
Subacute postpartum period
The subacute postpartum starts after the acute postpartum period concludes and can last for two to six weeks.
Physical recovery in the subacute postpartum period
In the first few days following childbirth, the risk of a
deep vein thrombosis
Deep vein thrombosis (DVT) is a type of venous thrombosis involving the formation of a blood clot in a deep vein, most commonly in the legs or pelvis. A minority of DVTs occur in the arms. Symptoms can include pain, swelling, redness, and e ...
(DVT) is relatively high as
hypercoagulability increases during pregnancy and is maximal in the postpartum period, 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.
The increased
vascularity
Vascularity, in bodybuilding, is the condition of having many highly visible, prominent, and often extensively-ramified superficial veins. The skin appears "thin"—sometimes virtually transparent—due to an extreme reduction of subcutaneous fa ...
(blood flow) and
edema
Edema, also spelled oedema, and also known as fluid retention, dropsy, hydropsy and swelling, is the build-up of fluid in the body's tissue. Most commonly, the legs or arms are affected. Symptoms may include skin which feels tight, the area ma ...
(swelling) of the woman's vagina gradually resolves in about three weeks. The
cervix
The cervix or cervix uteri (Latin, 'neck of the uterus') is the lower part of the uterus (womb) in the human female reproductive system. The cervix is usually 2 to 3 cm long (~1 inch) and roughly cylindrical in shape, which changes durin ...
gradually narrows and lengths over a few weeks.
Postpartum infections
Postpartum infections, also known as childbed fever and puerperal fever, are any bacterial infections of the female reproductive tract following childbirth or miscarriage. Signs and symptoms usually include a fever greater than , chills, lower ab ...
can lead to
sepsis
Sepsis, formerly known as septicemia (septicaemia in British English) or blood poisoning, is a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage is foll ...
and if untreated, death.
Postpartum
urinary incontinence
Urinary incontinence (UI), also known as involuntary urination, is any uncontrolled leakage of urine. It is a common and distressing problem, which may have a large impact on quality of life. It has been identified as an important issue in geri ...
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. Urinary incontinence in this period increases the risk of long term incontinence.
Kegel exercises are recommended to strengthen the pelvic floor muscles and control urinary 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 diaper
An adult diaper (or adult nappy in Australian English, British English, and Hiberno-English) is a diaper made to be worn by a person with a body larger than that of an infant or toddler. Diapers can be necessary for adults with various condition ...
s or nappies, disposable maternity briefs, maternity pads or towels, or
sanitary napkin
Sanitation refers to public health conditions related to clean drinking water and treatment and disposal of human excreta and sewage. Preventing human contact with feces is part of sanitation, as is hand washing with soap. Sanitation systems ...
s. The use of
tampons or
menstrual cups are contraindicated as they may introduce bacteria and increase the risk of infection. An increase in lochia between 7–14 days postpartum may indicate delayed postpartum
hemorrhage
Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, vag ...
.
Hemorrhoid
Hemorrhoids (or haemorrhoids), also known as piles, are vascular structures in the anal canal. In their normal state, they are cushions that help with stool control. They become a disease when swollen or inflamed; the unqualified term '' ...
s and
constipation
Constipation is a bowel dysfunction that makes bowel movements infrequent or hard to pass. The stool is often hard and dry. Other symptoms may include abdominal pain, bloating, and feeling as if one has not completely passed the bowel moveme ...
in this period are common, and
stool softeners
Laxatives, purgatives, or aperients are substances that loosen stools and increase bowel movements. They are used to treat and prevent constipation.
Laxatives vary as to how they work and the side effects they may have. Certain stimulant, lubri ...
are routinely given.
In the subacute postpartum period, 87% to 94% of women report at least one health problem.
Infant caring in the subacute period
At two to four days postpartum, a woman's
breastmilk will generally come in. Historically, women who were not
breastfeeding
Breastfeeding, or nursing, is the process by which human breast milk is fed to a child. Breast milk may be from the breast, or may be expressed by hand or pumped and fed to the infant. The World Health Organization (WHO) recommends that bre ...
(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.
The
lactation consultant
A lactation consultant is a health professional who specializes in the clinical management of breastfeeding. The International Board of Lactation Consultant Examiners (IBLCE) certifies lactation consultants who meet its criteria and have passed ...
,
health visitor,
monthly nurse, postnatal
doula
A doula () is a trained professional who provides expert guidance for the service of others and who supports another person (the doula's client) through a significant health-related experience, such as childbirth, miscarriage, induced abortion or ...
, or ''
kraamverzorgster'' may be of assistance at this time.
Psychological disorders
During the subacute postpartum period, psychological disorders may emerge. Among these are
postpartum depression
Postpartum depression (PPD), also called postnatal depression, is a type of mood disorder associated with childbirth, which can affect both sexes. Symptoms may include extreme sadness, low energy, anxiety, crying episodes, irritability, and cha ...
,
posttraumatic stress disorder
Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on ...
, and in rare cases,
postpartum psychosis. Postpartum mental illness can affect both mothers and fathers, and is not uncommon. 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. 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.
Maternal-infant postpartum evaluation
Various organizations across the world recommend routine postpartum evaluation in the postpartum period. The
American College of Obstetricians and Gynecologists
The American College of Obstetricians and Gynecologists (ACOG) is a professional association of physicians specializing in obstetrics and gynecology in the United States. Several Latin American countries are also represented within Districts of ...
(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
Postpartum care or postnatal care is a service provided to individuals in the postpartum period, to help with postpartum recuperation and restoration.
Traditional postpartum care
Many traditional forms of postpartum confinement exist throughout ...
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
Birth control, also known as contraception, anticonception, and fertility control, is the use of methods or devices to prevent unwanted pregnancy. Birth control has been used since ancient times, but effective and safe methods of birth contr ...
, chronic disease management, and
preventive health care and health maintenance. Women with
hypertensive disorders
Hypertension (HTN or HT), also known as high blood pressure (HBP), is a long-term medical condition in which the blood pressure in the arteries is persistently elevated. High blood pressure usually does not cause symptoms. Long-term high blo ...
should have a blood pressure check within three to ten days postpartum. More than one half of postpartum
strokes
Stroke (also known as a cerebrovascular accident (CVA) or brain attack) is a medical condition in which poor blood flow to the brain causes cell death. There are two main types of stroke: ischemic, due to lack of blood flow, and hemorrhagic, ...
occur within ten days of discharge after delivery. Women with chronic medical (e.g., hypertensive disorders,
diabetes
Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level (hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ...
,
kidney disease
Kidney disease, or renal disease, technically referred to as nephropathy, is damage to or disease of a kidney. Nephritis is an inflammatory kidney disease and has several types according to the location of the inflammation. Inflammation can ...
,
thyroid disease
Thyroid disease is a medical condition that affects the function of the thyroid gland. The thyroid gland is located at the front of the neck and produces thyroid hormones that travel through the blood to help regulate many other organs, meaning ...
) 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
Gestational diabetes is a condition in which a woman without diabetes develops high blood sugar levels during pregnancy. Gestational diabetes generally results in few symptoms; however, it increases the risk of pre-eclampsia, depression, and o ...
, or
preterm birth
Preterm birth, also known as premature birth, is the birth of a baby at fewer than 37 weeks gestational age, as opposed to full-term delivery at approximately 40 weeks. Extreme preterm is less than 28 weeks, very early preterm birth is betwee ...
should undergo counseling and evaluation for cardiometabolic disease, as lifetime risk of
cardiovascular disease
Cardiovascular disease (CVD) is a class of diseases that involve the heart or blood vessels. CVD includes coronary artery diseases (CAD) such as angina and myocardial infarction (commonly known as a heart attack). Other CVDs include stroke, ...
is higher in these women.
Similarly, the
World Health Organization
The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level o ...
recommends postpartum evaluation of the mother and infant at three days, one to two weeks, and six weeks postpartum.
Delayed postpartum period
The delayed postpartum period starts after the subacute postpartum period and lasts up to six months.
During this time, muscles and connective tissue returns to a pre-pregnancy state. Recovery from childbirth complications in this period, such as urinary and
fecal incontinence
Fecal incontinence (FI), or in some forms encopresis, is a lack of control over defecation, leading to involuntary loss of bowel contents, both liquid stool elements and mucus, or solid feces. When this loss includes flatus (gas), it is referre ...
,
painful intercourse, and
pelvic prolapse, are typically very slow and in some cases may not resolve.
Symptoms of PTSD often subside in this period, dropping from 2.8% and 5.6% at six weeks postpartum to 1.5% at six months postpartum.
Approximately three months after giving birth (typically between two and five months),
estrogen
Estrogen or oestrogen is a category of sex hormone responsible for the development and regulation of the female reproductive system and secondary sex characteristics. There are three major endogenous estrogens that have estrogenic hormonal a ...
levels drop and large amounts of
hair loss
Hair loss, also known as alopecia or baldness, refers to a loss of hair from part of the head or body. Typically at least the head is involved. The severity of hair loss can vary from a small area to the entire body. Inflammation or scarr ...
is common, particularly in the
temple
A temple (from the Latin ) is a building reserved for spiritual rituals and activities such as prayer and sacrifice. Religions which erect temples include Christianity (whose temples are typically called church (building), churches), Hindui ...
area (postpartum alopecia). Hair typically grows back normally and treatment is not indicated. Other conditions that may arise in this period include
postpartum thyroiditis.
During this period, infant sleep during the night gradually increases and maternal sleep generally improves.
Long-term health problems (persisting after the delayed postpartum period) are reported by 31% of women.
Ongoing physical and mental health evaluation, risk factor identification, and preventive health care should be provided, as detailed above .
Cultures
Postpartum confinement refers to a system for recovery following childbirth. It begins immediately after the birth, and lasts for a culturally variable length: typically for one month or 30 days,
up to 40 days, two months or 100 days. This postnatal recuperation can include "traditional health beliefs, taboos, rituals, and proscriptions."
The practice used to be known as "
lying-in
Lying-in is the term given to the European forms of postpartum confinement, the traditional practice involving long bed rest before and after giving birth. The term and the practice it describes are old-fashioned or archaic, but it used to be co ...
", which, as the term suggests, centres around
bed rest
Bed rest, also referred to as the rest-cure, is a medical treatment in which a person lies in bed for most of the time to try to cure an illness. Bed rest refers to voluntarily lying in bed as a treatment and not being confined to bed because of ...
. (
Maternity hospital
A maternity hospital specializes in caring for women during pregnancy and childbirth. It also provides care for newborn infants, and may act as a centre for clinical training in midwifery and obstetrics. Formerly known as lying-in hospitals, m ...
s used to use this phrase, as in the
General Lying-in Hospital.) Postpartum confinement customs are well-practiced in China, where it is known as "sitting the month", and similar customs manifest all over the world. A modern version of this rest period has evolved, to give maximum support to the new mother, especially if she is recovering from a difficult labour and delivery.
See also
*
Parental leave
Parental leave, or family leave, is an employee benefit available in almost all countries. The term "parental leave" may include maternity, paternity, and adoption leave; or may be used distinctively from "maternity leave" and "paternity l ...
*
Postpartum physiological changes
*
Puerperal disorder
*
Sex after pregnancy
References
External links
eMedicine: Normal and Abnormal PuerperiumPatient UK: Postnatal Care (Puerperium)* NHS
Postnatal post-traumatic stress disorderPostpartum care of mother and newborn WHO
Postpartum period: First 6 Weeks After Childbirth Uofmhealth
{{Authority control
Childbirth
Human pregnancy
Maternal health
Midwifery
Motherhood
Obstetrics
Women's culture
Women's health