Knowing what to expect during your postpartum recovery is not discussed enough during your first pregnancy. The pregnancy experience is all so new! Your time is taken up dealing with new information, prenatal care, event planning (gender reveal party, baby shower, etc).
I found this particularly concerning, having seen many new moms go through the pregnancy experience from start to finish and beyond. What to expect after you are home with a newborn during the first six weeks is crucial. The transition from being pregnant with all the attention and activities to suddenly being home, often alone with a dependent newborn child is drastic and can be overwhelming.
This article will discuss the normal physical changes that occur during the first 6 weeks of your postpartum recovery, known as the puerperium. This is the time it takes for your body’s reproductive system to return to its pre-pregnancy state.
What To Expect During Your Postpartum Recovery:
There are problems that can arise during your 6-week postpartum course. We will discuss those complications at the end of this article. You should bring up any concerns with your prenatal provider right away. Bringing up concerns as soon as you notice them is essential so they can be addressed immediately. Routine follow-up visits (unless you had a cesarean section) will otherwise be at 6 weeks. Problems suggesting infection, etc.. cannot wait that long.
Normal changes that occur postpartum:
(This list is not all-inclusive.)
The uterus (womb)
- The uterus will go through a process called “involution” over the first 6 weeks, after which time the uterus will be back to its normal pre-pregnancy size. The following are the most significant details about uterine changes postpartum:
- Immediately postpartum your uterus will have decreased to approximately 20 weeks size. (Uterine size is often compared to the size of a pregnant uterus, even when describing non-pregnant uterine conditions). A uterus that is 20 weeks size is clinically up to the umbilicus or navel. During your postpartum care, normal uterine involution will be measured by your care provider relative to your navel.
- Though contractions will have stopped after delivery, the uterus will still contract or cramp for up to 3 days. These cramps are often referred to as afterbirth pains and can be severe especially if you are breastfeeding you will notice they are particularly intense due to the hormones (oxytocin) released during breastfeeding.
Lochia (postpartum vaginal discharge)
- The term used to describe the vaginal discharge you will observe postpartum is “Lochia”. This discharge is very different than normal vaginal discharge. It consists of a mixture of blood, mucus and tissue sloughing from the uterine lining known as “decidua”.
- It is assumed that the lochia being referred to is from a normal uncomplicated delivery where there has been no retained placental tissue. After the placenta separates and delivers during the 3rd stage of labor, the placenta is carefully inspected to be sure it is completely accounted for and no tissue has broken off remaining in the uterus. Even with the normal intact delivery of the placenta, the lining of the uterus still has a decidual lining that will have to pass with the postpartum discharge as the uterus involutes during the postpartum period.
- This article will discuss abnormal lochia when complications (signs and symptoms) are reviewed.
Vagina and Perineum
- Hormones thin out the vaginal lining (mucosa) during pregnancy. This is very important when it comes to postpartum recovery and is one of the reasons why you will be instructed to avoid vaginal intercourse until 6 weeks postpartum. The thinned vaginal lining needs time to return to its pre-pregnancy condition. This is not a minor issue. On two occasions, I have had to stitch vaginal wall tears caused by intercourse within two weeks postpartum.
- Assuming you had a vaginal delivery, depending on the duration of labor/pushing, the extent of tearing, if you did tear (1st, 2nd, 3rd or 4th degree) your recovery will vary.
- I have had deliveries occur within minutes, where the delivery was completely uneventful. The baby delivered rapidly, there was no pushing, no vaginal tears, and no labial swelling. The mother was up and around soon after the delivery and ready to go home.
- Then, I have had deliveries where the labor was long, there was pushing and labial swelling and in spite of every effort to avoid tears there was a 4h degree tear (a tear extending through the vaginal wall and up the rectum. This is not a common occurrence; however, when you do thousands of deliveries it is going to happen.
- The postpartum recovery course for the two delivery scenarios noted above is going to be drastically different. As will the potential for complications.
- How your breasts change postpartum will depend on whether you decide to breastfeed or not. If you breastfeed, you will receive the necessary assistance from your provider or a lactation consultant. As to how your breasts change or respond to breastfeeding is on individual bases.
- For women who do not breastfeed the changes in your breasts will be fairly predictable depending on whether or not you decided to breastfeed at all and what measures you take to stop breastfeeding. For women who are not going to breastfeed from day #1, the following routine is best to avoid the letdown of breast milk and most efficiently stop breast milk production.
- Apply ice packs to your breasts
- Wrap a tight binder around your chest or wear a tight bra
- Avoid any nipple stimulation
- Avoid hot showers or hot tubs
***The sound of your newborn crying will stimulate the hormonal release and breast milk production. The hormonal axis for breast milk production must be shut down completely before any of the steps listed above can be stopped.
- Swelling postpartum can be normal or related to problems associated with toxemia or preeclampsia. We are going to discuss only normal swelling.
- The ankles are where most of the swelling settles and this is largely due to the forces of gravity. The reason there can be a great deal of swelling for the first two weeks postpartum is large IV fluids are administered during pregnancy to maintain a stable blood pressure,
- During the first few days postpartum, this fluid has to be mobilized out of the tissues and back into the bloodstream so it can be excreted through the kidneys. Diuresis often will take place while you are sleeping. This is because your legs are elevated and this allows the fluid in your tissues to move into your bloodstream and get filtered through the kidneys. Getting up frequently the first number of days postpartum is not unusual.
Diastasis Recti (Abdominal wall laxity with separation of the midline rectus muscles)
There are two main reasons why diastasis recti develop during pregnancy:
1. A very large pregnancy or twins/triplets resulting in extreme attenuation of the abdominal wall.
2. An inherent weakness of the supportive structures of the abdominal wall. Explains why some women can have triplets with no diastasis problems and another can have a very small preemie pregnancy and develop diastasis.
Hair Loss (Postpartum Alopecia)
- There are many hormonal changes that occur postpartum. Some of these changes will affect your body in different ways until you get back to your baseline hormonal status. Not all physiologic changes correct in the first 6 weeks. Hair loss happens to be one of these changes that can occur as a result of the decrease in circulating estrogen after pregnancy, so don’t be alarmed. After delivery, hair loss may not be apparent for 3 months and typically the hair growth cycle will be restored in 6 to 12 months.
- Hair loss after delivery is a problem that is often referred to dermatologists. Primarily because they deal with this issue often and in the event, there is another contributing factor, such as thyroid, etc., it can be addressed properly.
- There is a normal amount of “baby blues” described by many women during the immediate postpartum period. Hormonal changes are no doubt a contributing factor; however, this can be compounded by the demands placed on a mother just returning home with a new addition to the family. As mentioned earlier, the postpartum maternal changes being discussed are what are considered to be normal occurrences. Of all the topics discussed, it is hard to put the topic of Postpartum depression in the abnormal category as it is common.
- Postpartum depression is discussed often and for good reason. It is common and is simply a continuum or more severe case of the baby blues.
- Baby Blues are considered feelings of sadness that are similar to depression but less severe. Usually, this emotional state will be short, lasting from Day 2 to 2 weeks from delivery.
- Postpartum Depression has the symptoms of depression and when severe can include suicidal ideation and an inability to care for your baby.
Seek help for postpartum depression:
- Whether you feel you just have the blues or postpartum depression, do not hesitate to get help immediately, If you have a history of depression or want to be prepared just in case, arrange any and all resources for help that will be available to you. This includes family, your medical providers/therapists and community/hospital programs.
- This is not a time to feel you can get through things alone. It is ok that you may need help, this problem is extremely common and you should not avoid help out of embarrassment or the feeling that others will not understand. Postpartum depression is well understood and treatment is effective when accessed.
- It is important to note that if you have a support network in place as a result of a prior history of depression, make sure you have made arrangements to be cared for and evaluated postpartum.
Postpartum Recovery After Cesarean Section
Many of the topics previously discussed pertain to both vaginal births and cesarean sections. However, if you had a c-section, there are some differences that will need to be addressed during your postpartum recovery. The following is a list of some of these differences and what to expect:
- Vaginal bleeding will likely not be as heavy since the uterine cavity is inspected and cleaned at the time of delivery. This leaves less decidual discharge and often less bleeding.
- Your incision will limit how hard you can press on your uterus or any other abdominal manipulation.
- Additionally, your incision will need to be observed for any signs of infection.
- Ambulation and lifting will need to be limited until the abdominal incision has had time to heal.
Postpartum Concerns: When to call the doctor: (This list is not all-inclusive.)
- Heavy vaginal bleeding
- Temperature over 100.4.
- If you had a cesarean section any signs of infection of incision (redness, firmness, warmth, drainage, separation or fever.)
- If breastfeeding, any signs of mastitis. Fever, tenderness, redness, firmness or persistent lump in the breast after feeding. (Mastitis can progress rapidly, so do not delay evaluation if you have concerns about infection or persistent lump after emptying breast. Any lumps that do not go away need to be evaluated to rule out cancer. Breastfeeding can mask cancer so always discuss any concerns with your provider.
- Abnormal Lochia (vaginal discharge). If vaginal discharge develops a bad odor or becomes bright red blood, call the office. Pain, redness, swelling, firmness or warmth in the thigh or legs call the office. Blood clots can develop postpartum.
- If you have any concerns about labial/vaginal healing while doing perineal care (sitz-baths, etc.) call the office.
Though there are always exceptions, the following is a list of the problems you can encounter postpartum. This list is not all-inclusive. What is most important about all of these complications is the importance of accessing immediate medical care day or night. Infections, blood clots, bleeding, etc. are not conditions that can wait until the morning or until you can book an appointment. Your medical providers know that these problems occur and are ready to deal with them urgently:
1. Phlebitis or Deep Vein Thrombosis (vein inflammation / blood clots)
2. Heavy Vaginal Bleeding (Retained Tissue, etc.)
3. Infection (Mastitis, Uterine Infection, Urinary Tract Infection, Incision infection)
4. Postpartum Depression
** The information in this article is not all-inclusive and is for educational purposes only. If you have any concerns about you or your baby call your providers the same day and discuss any symptoms you may be experiencing.
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