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Postpartum Recovery
After delivery of the baby and placenta, approximately 6 to 8 weeks is needed for the effects of pregnancy on the many
body systems to return to a pre-pregnant state. Immediately after delivery, we recommend early contact between the
mother and baby including skin-to-skin contact when possible.
Physical Changes:
Many normal anatomical and physiologic changes occurred during the postpartum period. 25 to 50% of women
experience “postpartum chills” or a postpartum shivering phenomenon after a normal delivery. The shivering usually
starts at one to 30 minutes after delivery, may last for two to 60 minutes and usually improves with a warm blanket;
some patients will need a small dose of Demerol to improve the shakes. The uterus will begin a unique myometrial
retraction using successive contractions to shorten and return to a pre-pregnant size. You, your nurse and physician will
keep close monitoring of the contracting uterus after delivery; the “uterine massage” may be uncomfortable but very
important to prevent excessive blood loss. Right after delivery the uterus should feel like a firm globular ball located in
the lower half of your abdomen. At one week after delivery the uterus is located halfway between the pubic bone and
the umbilicus. By two weeks after delivery, most women are not able to palpate the top of the uterus. The size of the
uterus after delivery is not predictive of any complications. You should report if you are bleeding or passing lochia
more than soaking one maxi pad an hour for two hours straight. Approximately 1 week after delivery, you may notice
an increase in cramping and discharge associated with passing of a clot called the decidual cast from the inside lining of
the uterus associated with pregnancy. Approximately 15% of women continued to pass lochia for 6 to 8 weeks after
delivery. The cervix is usually 1 cm dilated at one week after delivery to allow for lochia to pass. The average weight
loss from delivery of the baby, placenta and amniotic fluid is approximately 13 pounds. As the uterus contracts and
fluid retention resolves an additional 5 to 15 pounds is lost over the next 6 weeks.
Postpartum recovery procedures are routine for your safety but completely individualized. Your medical team will
assess your specific needs and encourage each stage of recovery as appropriate. Vital signs will be monitored regularly
for blood pressure problems. Your nurse will inquire regarding: bladder function, amount of bleeding, neuromuscular
function, reaction to medications, signs of infection, signs of blood clotting and pain control issues. As soon as you are
stable, a regular diet and ambulation will be encouraged. Stool softeners are often prescribed and a personalized diet
encouraged. Routine blood tests after a normal vaginal delivery are not required.
Women who are not immune to rubella will be offered a vaccine prior to discharge; even if breastfeeding. Due to a
recurrence in “Whooping Cough or Pertussis,” postpartum women will be offered a Whooping Cough Booster vaccine
shot (Tdap) given before discharge from CPMC if they have not had one previously or during the pregnancy (inform us
if you have had a tetanus shot in the last two years.) All adults caring for a newborn baby will be encouraged to have a
whooping cough booster. Flu vaccination is strongly recommended for all pregnant women and will be offered
postpartum if not taken during pregnancy. Rh negative mom’s with Rh positive infant’s will be given an immune
globulin after delivery.
Afterbirth pains or cramps are common after nursing particularly when the woman has had more than one baby.
Ibuprofen and or Nocor is effective in treating these cramps which are usually gone by the first week after delivery.
Breast engorgement occurs between one to 7 days after delivery and averages between 3 to 5 days postpartum. Breast
engorgement is uncomfortable and may give a slight rise in temperature for short period of time. If a fever develops
please call our office to assess for signs of a breast infection. Patient to decide not to breast-feed will need to wear a
tight brassiere and use cold compresses along with pain medications for several days.
The most common postpartum complications include a urinary tract infection and mastitis or breast infection. Less
common are uterine or incisional wound infections. Postpartum urinary retention can occur after delivery. If you are
not able to void within 6 hours after delivery the nurse will perform a simple catheterization. Usually this is all that is
needed. Hemorrhoids are common during pregnancy and occur in 35% of patients after delivery. Thrombosed external
hemorrhoids are treated initially with local treatments based on symptoms. Due to the increased mobility of the pubic
symphysis and sacroiliac joints, patients may experience a “pelvic girdle syndrome” after delivery with different levels
of severity in musculoskeletal pain that limits mobility. This is usually self resolved and treated with oral pain
medications.
Postpartum Issues: Although women who are completely breast-feeding and have amenorrhea have a reduced fertility;
there is still a 2% chance of pregnancy. Over 50% of women interviewed at 3 months postpartum describe the lower
interest in sexual activity. Particularly if breast-feeding, patients are encouraged to use a lubricant when resuming
activity. If you have concerns regarding excessive dryness and pain please notify us for a prescription to increase
moisture and pliability. Patients are usually unaware of a transient fluctuation in the thyroid function during the first
half-year after delivery. Approximately 1 to 4 months after delivery, some women may experience and elevation or
drop in thyroid hormone levels due to postpartum thyroiditis.
Postpartum follow-up visits are routinely scheduled at 6 weeks after delivery. Woman who have delivered by cesarean
section are also instructed to return to office in two weeks after delivery. If there are any issues or concerns patients are
welcome to come in at any time after delivery.
The decision regarding future pregnancies is an individual choice. One studies suggested that the optimum interval
between births to reduce the risk of low birth weight and premature birth is 18 to 23 months. Another study showed that
an inter-pregnancy interval of less than 6 months has an increased risk for preterm delivery. Women who have had a
cesarean section can wait 2 years before their next pregnancy but this is individualized, particularly if you are over 35
years of age.
Postpartum Contraception: Ovulation can occur as early as 25 days postpartum among non-breastfeeding women.
2011 revised guidelines for the postpartum women attempts to prevent unintended pregnancy and short birth intervals,
which are associated with greater risks for low birth weight and preterm birth. The new WHO guidelines are more
stringent since women in the first 42 days of the postpartum period have a 22-fold to 84-fold increased risk for VTE or
embolism, especially in women who had other risk factors for VTE. The CDC precludes the use of combined hormonal
contraceptives in the first 21 days after delivery. Although the risk for pregnancy is very low during the first 21 days
postpartum, it increases thereafter, and ovulation before first menses is common. From 21 to 42 days after delivery,
women with risk factors for VTE generally should not use combined hormonal contraceptives, but these are thought to
be safe during this period for women without risk factors for VTE. Risk factors for VTE include: age 35 years or older,
previous VTE, thrombophilia, known thrombogenic mutations, immobility, transfusion at delivery, body mass index of
at least 30 kg/m2, postpartum hemorrhage, peripartum cardiomyopathy, post cesarean delivery, preeclampsia, or
smoking. The CDC has issued no restrictions on the use of combined hormonal contraceptives in women who delivered
more than 42 days previously.
The CDC recommends: progestin-only contraceptives (progestin-only pills, depot medroxyprogesterone acetate
injections, and implants), IUDs, and contraceptive methods other than combined hormonal contraceptives can be started
immediately after delivery and are safe for postpartum women, including those who are breast-feeding. Combined
hormone contraceptives may hinder successful breast-feeding due to the effect of reducing the milk supply by 25% or
more. Most women tolerate a progesterone only pill while nursing without a reduction in milk supply.
Insertion of IUDs, including the levonorgestrel-releasing IUD and copper-bearing IUD, immediately after delivery, is
not associated with an increase in complications. Rates of IUD expulsion are somewhat higher when they are inserted
within 28 days of delivery; but continuation rates at 6 months are similar, regardless of whether IUD insertion takes
place immediately postpartum or is delayed. Condoms can be safely used at any time, but use of the diaphragm and
cervical cap should be delayed to 6 weeks postpartum. Another option in women who have completed their childbearing
is to consider postpartum sterilization.
Pearl W. Yee MD/ Patient Information Update October 26, 2011