7.5: Postpartum
- Page ID
- 144817
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For patients with an uncomplicated vaginal delivery, hospitalization typically lasts 24-48 hours to monitor for acute postpartum complications. Following a cesarean section, the usual length of stay is 48-72 hours. Medical or obstetric complications may necessitate longer admission. During hospitalization, clinicians monitor for postpartum hemorrhage, infection, hypertensive complications, and adequate pain control.
After discharge, patients should have early postpartum follow-up within the first 3 weeks to assess physical recovery, mental health, breastfeeding, and overall wellbeing. A comprehensive postpartum evaluation is generally performed at 6–8 weeks, including pelvic examination and counseling on optimizing interpregnancy intervals and long-term health.
Patients with gestational diabetes require postpartum screening with a 2-hour oral glucose tolerance test, as they are at increased risk of developing type 2 diabetes. Those with gestational hypertension or pre-eclampsia should transition to primary care follow-up for long-term cardiovascular risk assessment. Counseling should also address the implications of the recent pregnancy on future maternal risks and appropriate interpregnancy planning.
7.5.2 Uterine Changes
Immediately after delivery, uterine involution begins as the myometrium contracts to compress blood vessels and reduce hemorrhage risk. Patients often experience “afterpains,” which may intensify with breastfeeding due to oxytocin-mediated uterine contractions.
Postpartum lochia, a mixture of blood and decidual tissue, is expected for up to 5 weeks, though typically lessens over the first 2 weeks. The endometrium is generally restored within 2–3 weeks, and the uterus returns to its nonpregnant size by approximately 6 weeks postpartum.
7.5.3 Lactation and Breastfeeding
During pregnancy, the breasts undergo hypertrophy and hyperplasia in preparation for milk production. Although prolactin stimulates milk synthesis, high estrogen and progesterone levels inhibit milk release before delivery. After birth, estrogen and progesterone fall sharply, allowing oxytocin (stimulated by infant suckling) to trigger contraction of myoepithelial cells and milk ejection.
The first milk is colostrum, rich in protein, immunologic factors, and vitamins but produced in small quantities. Over the ensuing days to weeks, colostrum transitions to higher-volume, higher-calorie mature milk.80
7.5.3.1 Lactational Mastitis
Lactational mastitis results from ascending bacterial infection, often facilitated by milk stasis. It typically occurs within the first 6 weeks postpartum. Patients present with localized erythema, tenderness, warmth, and swelling—classically in a wedge-shaped distribution along the affected duct. (Figure 7.57 forthcoming)
Systemic symptoms may include fever and chills. Treatment includes continued breastfeeding, which helps drain the affected duct, and oral antibiotics targeting common pathogens. Without treatment, mastitis may progress to breast abscess.
7.5.3.2 Lactational Amenorrhea
High prolactin levels suppress gonadotropin-releasing hormone, leading to decreased ovulation and amenorrhea in patients who are exclusively breastfeeding. Menstrual cycles may be delayed or irregular when they resume. The lactational amenorrhea method (LAM) can serve as temporary contraception but becomes progressively less reliable over time.
7.5.4 Mood Changes
The postpartum period involves profound physical, hormonal, and psychosocial transitions. Many patients experience transient “baby blues”—mild mood lability within the first 2 weeks postpartum.
More severe and persistent symptoms may indicate postpartum depression, postpartum anxiety, or (rarely) postpartum psychosis, all of which can significantly affect maternal and infant health. Risk factors include prior psychiatric conditions, family history, limited support, and stressful life circumstances.
Screening for postpartum depression is recommended at the postpartum visit, with typical treatment involving selective serotonin reuptake inhibitors (SSRIs) and psychotherapy.81 Postpartum psychosis constitutes a psychiatric emergency requiring immediate inpatient care.
7.5.5 Contraception and Family Planning
ll postpartum patients should receive counseling on safe birth spacing, ideally beginning during pregnancy. The American College of Obstetricians and Gynecologists recommends an interpregnancy interval of 18–24 months, as shorter intervals are associated with increased risks of fetal growth restriction, preterm birth, and perinatal mortality.82
Immediately postpartum, estrogen-containing contraceptives are contraindicated due to heightened thromboembolic risk. This restriction decreases over time and resolves by 6 weeks postpartum. Progesterone-only methods and nonhormonal contraception are safe for immediate use after delivery.83
Footnotes
- Jozsa, Felix and Jennifer Thistle. Anatomy, Colostrum. [Updated 2025 Dec 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513256/. This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/).
- Garapati, Jyotsna, Jajoo Shubhada, Deeksha Aradhya, Lucky Srivani Reddy, Swati M. Dahiphale and Dharmesh J. Patel. Postpartum Mood Disorders: Insights into Diagnosis, Prevention, and Treatment. Cureus. 15, No. 7 (Jul 19, 2023):e42107. doi: 10.7759/cureus.42107. PMID: 37602055; PMCID: PMC10438791. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
- Ni, Wanze et al. Birth spacing and risk of adverse pregnancy and birth outcomes: A systematic review and dose-response meta-analysis. Acta Obstet Gynecol Scand. 102, No. 12 (Dec 2023):1618-1633. doi: 10.1111/aogs.14648. Epub 2023 Sep 7. PMID: 37675816; PMCID: PMC10619614. This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.
- Nguyen, Antoinette T. et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recomm Rep 73, No. RR-4 (2024):1–126. DOI: http://dx.doi.org/10.15585/mmwr.rr7304a1.