Postpartum period

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.

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]}

Breastfeeding ^[6][7][8]

General considerations

• 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:
  • Prolactin; from the anterior pituitary: leads to stimulation of continued lactogenesis (milk production); and disruption of pulsatile GnRH secretion (causing lactational amenorrhea)
  • Oxytocin; from the posterior pituitary: leads to stimulation of milk ejection (letdown); and uterine contractions

Breast milk composition

Breast milk contains all the required nutrients (except vitamin D and vitamin K) for infants up to 6 months of age.

• Colostrum: the first milk produced during late pregnancy until 3–4 days postpartum; rich in proteins and immunoglobulins
• Mature milk is composed of:
  • Proteins, lactose and oligosaccharides, fats, minerals, trace elements, and vitamins
  • Proteins and cells that provide passive immunity in neonates
    • Immunoglobulins (secretory IgA), lactoferrin, lysozymes
    • Lymphocytes, macrophages
  • Bifidobacteria that contribute to the neonate's gastrointestinal flora

Benefits of breastfeeding ^[7]

• Infant benefits ^[9]
  • Decreased risk of middle-ear, respiratory, gastrointestinal, and urinary tract infections
    • Breast milk immunoglobulins (especially IgA); and white blood cells provide passive immunity for the child
  • Better gastrointestinal function and motility
  • Lower risk of asthma, allergies, obesity, and diabetes mellitus
• Maternal benefits
  • Faster uterine involution and post-partum weight loss
  • Lower risk of ovarian and breast cancers
  • Postpartum contraception (lactational amenorrhea)
  • Improved bonding with the infant
  • Reduced costs

Contraindications to breastfeeding ^[7][10]

• Absolute
  • Maternal factors: HIV infection (regardless of viral load or treatment)
  • Infant factors: galactosemia
• Temporary (relative)
  • Maternal factors
    • Infections: human T-cell lymphotropic virus, brucellosis, tuberculosis ; , active herpes simplex on the breasts
    • Current recreational substance use
    • Use of substances; that are excreted in milk (e.g., tetracycline, chloramphenicol, chemotherapy agents, lithium, alcohol, illicit drugs)
  • Infant factors: phenylketonuria, and maple syrup urine disease

Breastfeeding complications and problems

• Inadequate milk production or intake
• Breastfeeding jaundice
• Breast milk jaundice
• Mastitis
• Galactocele
• Nipple injury
  • 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
  • Management
    • Counseling on optimal nursing technique
    • Analgesia: acetaminophen use before feedings
    • Air dry nipples after feedings to prevent excessive moisture
    • Warm compresses prior to breastfeeding; cold compresses between feeds
    • Antibiotic ointments (e.g., bacitracin, mupirocin)
  • Complications: mastitis, anxiety, depression, early cessation of breastfeeding
  • Prevention: anticipatory lactation counseling
• Breast engorgement
  • Etiology
    • Primary: initial swelling due to increased milk production postpartum (during the transition from colostrum to mature milk)
    • Secondary: insufficient removal of breast milk (e.g., due to infrequent feeds, poor attachment, ineffective suckling, abrupt cessation of breastfeeding)
  • Clinical features: tenderness, firmness, and fullness of the breast
  • Management
    • Frequent breastfeeding with optimal nursing techniques
    • Warm compresses prior to breastfeeding; cold compresses between feeds
    • Analgesia
    • Careful expression of breast milk by hand or with a breast pump to alleviate pressure.
  • Complications: mastitis
• Mammary candidiasis ^[11]
  • Etiology: most commonly due to infection with Candida albicans
  • Clinical features
    • Deep stabbing and/or burning pain in breasts or nipples during breastfeeding
    • Flaky or shiny nipple skin that can be easily scraped off
    • Feeding difficulties in the infant
    • History of maternal vaginal yeast infection or mucocutaneous candidiasis in the infant (e.g., oral thrush, diaper dermatitis)
  • Diagnosis
    • Clinical diagnosis
    • Breast milk cultures are not routinely recommended.
  • Management
    • Topical antifungal agents (first-line treatment): e.g., nystatin, miconazole, clotrimazole
    • Simultaneous treatment of mother and infant to prevent persistent infection
    • Continuation of breastfeeding
    • All material that comes in contact with the breasts, breast milk, or the infant's mouth should be washed and/or sterilized.
    • Indications for systemic antifungal therapy (e.g., oral fluconazole)
      • Failure of topical treatment
      • Systemic candidiasis
      • Immunocompromised patients
  • Complications: systemic candidiasis, mastitis

Formula feeds ^[12][13][14]

• Supplementation with formula is only recommended if:
  • Neonate loses > 7% of birth weight during the first 10 days of life
  • Neonatal urine output is decreased
  • Neonatal stool output is decreased (< 3 small stools per day)
  • Maternal breast milk production is inadequate
  • Breastfeeding is contraindicated
• Lactose protein-based formulas should be fortified with iron to satisfy the infant's iron needs.

Supplementation

• Vitamin D supplementation ^[15]
  • Exclusively breastfed infants should receive 400 IU vitamin D supplementation daily. ^[16]
  • 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 ^[17]
  • Is provided to premature infants (because of the lower iron stores and increased iron demands)
  • Should be used daily until 6 months of age, to avoid iron deficiency anemia
• Vitamin B₁₂ supplementation: if the mother has vitamin B₁₂ deficiency (e.g., due to vegetarian diet) ^[18]

Weaning ^[19][20]

• 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.

Uterine

Postpartum endometritis ^[21][22][23]

• Definition: : inflammation of the endometrium, possibly also including the myometrium and parametrium
• Risk factors
  • Cesarean delivery
  • Prolonged labor
  • Multiple cervical examinations
  • Retained products of conception after delivery, miscarriage, or abortion
  • Meconium in amniotic fluid
  • Low socioeconomic status
• Etiology: : mostly polymicrobial (2–3 ascending organisms, e.g., Gardnerella vaginalis, Staphylococcus epidermidis, group B Streptococcus, Escherichia coli, 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
  • Fever
  • Lower abdominal pain, uterine tenderness
  • Chills, malaise
  • Foul-smelling lochia
• Diagnostics: primarily clinical; in some cases, the following tests can be used to confirm the diagnosis:
  • Gram stain or wet mount of vaginal discharge
  • Blood and urine cultures
  • Histology: plasma cells in chronic endometritis
• Treatment
  • Antibiotic treatment: IV clindamycin and gentamicin
    • Ampicillin-sulbactam is a reasonable alternative if resistance to clindamycin is a concern.
  • Uterine curettage to remove retained products of conception.
  • Hysterectomy in case of life-threatening complications or no response to conservative therapeutic measures.
• Further complications
  • Surgical site infection
  • Peritonitis
  • Intra-abdominal abscess

Postpartum sexual dysfunction

• Definition: the decline of sexual function after delivery that may not return to its baseline levels during the postpartum period
• Risk factors
  • Prepregnancy dyspareunia
  • Delivery mode (e.g., vacuum-assisted vaginal delivery, emergency cesarean delivery)
  • Perineal trauma (e.g., second and third-degree perineal tears)
  • Episiotomy
  • 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
• Retained placenta
• Postpartum hemorrhage

Thromboembolic

Septic pelvic thrombophlebitis ^[24][25][26]

• Definition: : a rare condition characterized by inflammation and thrombosis of the pelvic veins that most commonly occurs in the postpartum period
• Risk factors
  • Cesarean deliveries
  • Pelvic infections (e.g., endometritis, chorioamnionitis)
  • Abortion
• Etiology
  • Pregnancy-induced hypercoagulability
  • Postpartum pelvic venous stasis
  • Endothelial damage due to an infection (e.g., endometritis) or bacteremia
• Clinical features: Onset is usually within one week of delivery.
  • Patients are acutely unwell with fever and abdominal pain and tenderness on the side of the affected vein; a palpable cord may be present.
  • Approx. 90% of cases involve the right ovarian vein.
• Diagnostics
  • Contrast CT or MRI
    • Visualization of dilation and thrombosis of the affected vein confirms the diagnosis.
    • Most commonly ovarian vein thrombosis
  • Blood culture: most commonly streptococci, Enterobacteriaceae, and anaerobes
• Treatment: antibiotics (e.g., clindamycin, gentamicin) and anticoagulation (e.g., LMWH or UFH)
• Complications: Pulmonary emboli are rare.

Other thromboembolic complications

• Deep vein thrombosis
• Cerebral venous thrombosis

Puerperal sepsis ^[27]

• Definition: maternal sepsis that develops in the timeframe between birth and 6 weeks postpartum
• Risk factors ^[28]
  • Obesity
  • Diabetes mellitus
  • Immunosuppression
  • Prolonged spontaneous rupture of membranes
  • Amniocentesis and other invasive procedures (e.g., cervical cerclage)
  • Abnormal vaginal discharge, pelvic infection history
  • Vaginal trauma
  • Cesarean delivery
  • Retained products of conception
• 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 ^[28]
  • Gram positive: S. pyogenes, S. aureus (including MRSA), S. pneumoniae
  • Gram negative: E. coli, K. pneumonia ^[29]
  • Other: Clostridium septicum, Morganella morganii
• Clinical features: two or more of the following should be present ^[27]
  • Fever
  • Pelvic pain
  • Abnormal vaginal discharge
  • Abnormal smell/foul odor discharge
  • Delay in uterine involution
• Diagnostics
  • Clinical features and pelvic examination
  • Laboratory studies
    • CBC (leukocytosis or leukopenia)
    • Comprehensive metabolic panel and electrolytes
    • Serum lactate
    • Blood and urine cultures
  • Imaging studies to find the source of infection (e.g., pelvic ultrasound, x-ray chest)
• Treatment
  • Broad-spectrum antibiotics (ideally within the first hour of diagnosis)
  • For more detailed information, see “Management” in “Sepsis.”
• Complications
  • Septic shock
  • Clostridial myonecrosis ^[30]
  • Death

Urinary

• Urinary insufficiency: See “Urinary incontinence in pregnancy.”

Postpartum urinary retention (PUR) ^[31][32]

• Definition: inability to void after delivery
  • Overt PUR: inability to void 6 hours after vaginal delivery or, in case of cesarean section, 6 hours after removal of urinary catheter
  • Covert PUR: post-void residual bladder volume ≥ 150 mL following micturition (assessed by ultrasound or catheterization)
• Risk factors ^[33]
  • Prolonged labor
  • Perineal lacerations
  • Macrosomia
• Clinical features
  • Potentially asymptomatic
  • Bladder pain/discomfort
  • Bladder distention
  • Small void volumes
  • Straining to void
  • Slow stream
  • Urinary frequency
• Treatment
  • Intermittent catheterization in symptomatic patients
• Prognosis: typically self-limited (resolves within 1 week)

Psychiatric

• Postpartum depression
• Postpartum psychosis

Other

Diastasis recti

• Definition: a > 2 cm separation of the right and left rectus abdominis muscles resulting in protrusion of abdominal organs on straining
• Risk factors
  • Conditions that increase intraabdominal pressure (e.g., pregnancy, abdominal surgery)
  • Aneurysmal disease
• Clinical features
  • Some patients may be asymptomatic.
  • Abdominal pain and discomfort
  • Pelvic instability and lumbar pain
  • Urinary and/or fecal incontinence
• Diagnostics
  • Physical examination: distortion or extension of the linea alba
  • Ultrasound: confirms the diagnosis
• Treatment
  • 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)
    • Patients with severe, recurring, and symptomatic diastasis recti
    • If conservative treatment fails after > 6 months
• Complications: pelvic organ prolapse

Pubic symphysis diastasis ^[34]

• Definition: a rare complication of the peripartum period characterized by a widening of the pubic symphysis beyond the physiological width (≤ 10 mm).
• Risk factors include:
  • Macrosomia
  • Cephalopelvic disproportion
  • Prolonged second stage of labor
  • Previous pelvic trauma
  • Forceps delivery
• Clinical features
  • Potentially asymptomatic
  • Pain and tenderness of the pubic symphysis
    • Worsens with walking, climbing stairs, lifting heavy objects, and standing on one leg
    • May radiate to the sacroiliac area and anterior and/or lateral part of the thigh
  • Destot sign: labia majora hematoma
• Diagnostics
  • Ultrasound and MRI; are preferred during pregnancy.
  • Pelvic x-ray and CT scan; may be used after childbirth.
• Treatment
  • Conservative: analgesia, pelvic belt, and physiotherapy
  • Surgery should be considered if conservative therapy fails: open reduction with internal fixation