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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 glob ...
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 require ...
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 of ...
(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 gestat ...
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 t ...
). 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 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 Early postnatal hospital discharge generally refers to the postpartum hospital discharge of the mother and newborn within 48 hours. The duration of what is considered "early discharge" varies between countries from 12 to 72 hours due to the diffe ...
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 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 Kangaroo care also called skin-to-skin contact (SSC), is a technique of newborn care where babies are kept chest-to-chest and skin-to-skin with a parent, typically their mother (occasionally their father). Kangaroo care, named for the similarity ...
, 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 br ...
, 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 enla ...
(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 Compression may refer to: Physical science *Compression (physics), size reduction due to forces *Compression member, a structural element such as a column *Compressibility, susceptibility to compression * Gas compression *Compression ratio, of a ...
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 (swelling) of the woman's vagina gradually resolves in about three weeks. The cervix gradually narrows and lengths over a few weeks. Postpartum infections 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 follo ...
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 In the field of obstetrics, lochia is the vaginal discharge after giving birth, containing blood, mucus, and uterine tissue. Lochia discharge typically continues for four to eight weeks after childbirth, a time known as the postpartum period or pue ...
, 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 conditions, ...
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
tampon A tampon is a menstrual product designed to absorb blood and vaginal secretions by insertion into the vagina during menstruation. Unlike a pad, it is placed internally, inside of the vaginal canal. Once inserted correctly, a tampon is held in ...
s or
menstrual cup A menstrual cup is a menstrual hygiene device which is inserted into the vagina during menstruation. Its purpose is to collect menstrual fluid (blood from the uterine lining mixed with other fluids). Menstrual cups are usually made of flexible ...
s 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, v ...
. Hemorrhoids 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 movement ...
in this period are common, and stool softeners 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 br ...
(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, health visitor,
monthly nurse A monthly nurse is a woman who looks after a mother and her baby during the postpartum or postnatal period. The phrase is now largely obsolete, but the job continues under other names and various conditions around the world. Historically, wome ...
, 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, and in rare cases,
postpartum psychosis Postpartum psychosis, also known as puerperal psychosis, involves the abrupt onset of severe mental illness shortly following childbirth. While symptoms of postpartum psychosis have long been observed in mothers, the phenomenon eventually came t ...
. 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 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 should have a blood pressure check within three to ten days postpartum. More than one half of postpartum
strokes A stroke 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, due to bleeding. Both cause parts of the brain to stop funct ...
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, 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 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 of ...
, 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 between 2 ...
should undergo counseling and evaluation for cardiometabolic disease, as lifetime risk of cardiovascular disease 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 of ...
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 ac ...
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 scar ...
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 churches), Hinduism (whose temples ...
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 c ...
", 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, most ...
s used to use this phrase, as in the
General Lying-in Hospital The General Lying-In Hospital was one of the first maternity hospitals in Great Britain. It opened in 1767 on Westminster Bridge Road, London and closed in 1971. Lying-in is an archaic term for childbirth (referring to the month-long bed rest pr ...
.) 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 (law), paternity, and adoption leave; or may be used distinctively from "maternity leave" and ...
* Postpartum physiological changes * Puerperal disorder * Sex after pregnancy


References


External links


eMedicine: Normal and Abnormal Puerperium

Patient UK: Postnatal Care (Puerperium)
* NHS
Postnatal post-traumatic stress disorder

Postpartum 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