INTRODUCTION — The postpartum period, also known as the puerperium and the "fourth trimester," refers to the time after delivery when maternal physiologic changes related to pregnancy return to the nonpregnant state. In addition to physiologic changes and medical issues that may arise during this period, health care providers should be aware of the psychological needs of the postpartum mother and be sensitive to cultural differences that surround childbirth, which may involve eating particular foods and restricting certain activities [1].

This topic will provide an overview of normal physiologic changes and routine maternal care during the postpartum period. An overview of postpartum disorders and complications and their management is available separately. (See "Overview of the postpartum period: Disorders and complications".)

DEFINITION OF THE POSTPARTUM PERIOD — There is consensus that the postpartum period begins upon delivery of the infant. The end is less well defined, but is often considered the six to eight weeks after delivery because the effects of pregnancy on many systems have largely returned to the prepregnancy state by this time. However, all organ systems do not return to baseline within this period, and the return to baseline is not necessarily linear over time. For this reason, the American College of Obstetricians and Gynecologists considers postpartum care to extend up to 12 weeks after delivery [2]. Some investigators have considered women to be postpartum for as long as 12 months after delivery.

POSTPARTUM FINDINGS AND CHANGES

Shivering — Postpartum shivering or chills are observed in 25 to 50 percent of women [3,4]. Shivering usually starts 1 to 30 minutes postdelivery and lasts for 2 to 60 minutes. The cause is unknown; it may be a response to a fall in body temperature following labor, fetal-maternal bleeding, micro-amniotic emboli, placental separation, anesthesia, bacteremia, or administration of certain drugs (eg, misoprostol).

Treatment is supportive with warm blankets and/or warm air. Anesthesia-related shivering can be treated pharmacologically. (See "Adverse effects of neuraxial analgesia and anesthesia for obstetrics", section on 'Shivering'.)

Uterine involution

Signs and symptoms — Immediately after delivery of the placenta, the uterus begins to return to its nonpregnant size and condition, a process termed uterine involution. Contraction of the interlacing myometrial muscle bundles constricts the intramyometrial vessels and impedes blood flow, which is the major mechanism preventing hemorrhage at the placental site. Myometrial retraction (brachystasis) is a unique characteristic of the uterine muscle that enables it to maintain its shortened length following successive contractions. Inadequate myometrial contraction will result in atony (ie, a soft, boggy uterus), which is the most common cause of early postpartum hemorrhage. In addition to myometrial contraction, large vessels at the placental site thrombose, which is a secondary hemostatic mechanism for preventing blood loss.

Immediately after delivery, the fundus is normally firm, nontender, globular, and located midway between the symphysis pubis and umbilicus. In the next 12 hours, it rises to just above or below the umbilicus, then recedes by approximately 1 cm/day to again lie midway between the symphysis pubis and umbilicus by the end of the first postpartum week. It is not palpable abdominally by two weeks postpartum and attains its normal nonpregnant size by six to eight weeks postpartum. This process is modestly affected by predelivery uterine overdistention, multiparity, and cesarean delivery (the uterus is slightly larger in these cases), and by breastfeeding (the uterus is slightly smaller at three months postpartum in women who are breastfeeding [5]). The weight of the uterus decreases from approximately 1000 g immediately postpartum to 60 g six to eight weeks later.

Although assessment of uterine size is routinely performed in the early postnatal period, there is no evidence that uterine size is predictive of complications [6,7].

Findings on ultrasound — The normal sonographic appearance of the postpartum uterus was illustrated by a prospective, longitudinal study that performed ultrasound examinations on postpartum days 1, 3, 7, 14, 28, and 56 in 42 women with uncomplicated vaginal term deliveries [8]. The uterus was most often empty in the early puerperium (days 1 and 3), fluid and debris were seen in the entire cavity in the middle part of the puerperium (day 14), while the late puerperium (days 28 and 56) was characterized by an empty cavity that appeared as a thin white line. Endometrial gas was occasionally seen. Gas in the uterine cavity may be seen after cesarean delivery or after manual evacuation of the placenta [9]. Others have reported that intrauterine echogenic material is commonly seen in the first 48 hours after vaginal delivery and is not associated with the amount or duration of bleeding [10-12].

These observations suggest that the presence of echogenic material can be a normal finding and need not change clinical management in patients who do not have heavy bleeding or signs of uterine infection. However, in women with fever and/or bleeding, an echogenic mass may represent retained products of conception (image 1) [13]. (See "Secondary (late) postpartum hemorrhage", section on 'Retained products of conception'.)

Lochia — The basal portion of the decidua remains after the placenta separates. This decidua divides into two layers: The superficial layer is shed and the deep layer regenerates new endometrium, which covers the entire endometrial cavity by the 16^th postpartum day [14]. Normal shedding of blood and decidua is referred to as lochia rubra (red/red-brown) and lasts for the first few days following delivery. Vaginal discharge then becomes increasingly watery, called lochia serosa (pinkish brown), which lasts for two to three weeks. Ultimately, the discharge turns yellowish white, the lochia alba. Microscopically, lochia consists of serous exudate, erythrocytes, leukocytes, decidua, epithelial cells, and bacteria.

The total volume of postpartum lochial secretion is 200 to 500 mL, which is discharged over a mean duration of one month [15]. Up to 15 percent of women continue to pass lochia when seen for a routine postpartum visit six to eight weeks after delivery [16]. The duration of lochia does not appear to be related to lactation or to the use of either estrogen-containing or progesterone-only contraceptives, but women with bleeding diatheses may be prone to a longer duration of passing lochia [17].

Cervix — After delivery, the cervix is soft and floppy. Small lacerations can be found at the margins of the external os. The cervix remains 2 to 3 cm dilated for the first few postpartum days and is less than 1 cm dilated at one week. The external os never resumes its pregravid shape; the small, smooth, regular circular opening of the nulligravida becomes a large, transverse, stellate slit after childbirth (figure 1). Histologically, the cervix does not return to baseline for up to three to four months after delivery [18].

Vagina, hymen, pelvic muscles — The vagina is capacious and smooth immediately after delivery. It slowly contracts, but not to its nulligravid size; rugae are restored in the third week as edema and vascularity subside.

The hymen is replaced by multiple tags of tissue called the carunculae hymenales (myrtiformes).

Fascial stretching and trauma during childbirth result in pelvic muscle relaxation, which may not return to the pregravid state. (See "Effect of pregnancy and childbirth on urinary incontinence and pelvic organ prolapse".)

Abdominal wall — The abdominal wall is lax postpartum but regains most, if not all, of its normal muscular tone over several weeks; however, separation (diastasis) of the rectus abdominis muscles may persist. Long-term sequelae may include abdominal discomfort and cosmetic issues, which may be managed conservatively or surgically. (See "Rectus abdominis diastasis".)

hCG, hot flashes, resumption of ovulation

●Human chorionic gonadotropin (hCG) levels – The fall and disappearance of hCG postpartum follows a biexponential curve [19,20]. The median time of elimination was 12 days in pregnant women who underwent peripartum hysterectomy in one study [21]. However, the duration is longer when the uterus is left in situ: hCG values typically return to normal, nonpregnant levels two to four weeks after a term delivery, but this can take longer [19]. The most serious concern in women with rising hCG levels postpartum is gestational trophoblastic disease. (See "Hydatidiform mole: Epidemiology, clinical features, and diagnosis", section on 'hCG'.)

●Hot flashes – Some women report hot flashes in the postpartum period, with resolution over time [22]. The cause is unknown but may be due to thermoregulatory dysfunction, initiated at the level of the hypothalamus by estrogen withdrawal after delivery of the placenta. In addition, the initial hyperprolactinemic state associated with breastfeeding depresses estrogen production.

●Resumption of ovulation – Gonadotropins and sex steroids are at low levels for the first two to three weeks postpartum. In studies using urinary pregnanediol levels to measure ovulation in nonlactating women, the mean return of menstruation following delivery ranged from 45 to 64 days postpartum, and the mean time to ovulation ranged from 45 to 94 days but occurred as early as 25 days postpartum [23]. Seventy percent of women will menstruate by the 12^th postpartum week, and 20 to 71 percent of first menstruations are preceded by ovulation; thus, the cycle is potentially fertile.

The degree to which breastfeeding suppresses gonadotropin-releasing hormone (GnRH) secretion is modulated by the intensity of the breastfeeding and maternal nutritional status and body mass [24-26]. Lactation represents a metabolic energy burden. When nutrition is adequate and basal body mass and composition are normal, intensive lactation is less likely to result in prolonged suppression of GnRH [27,28]. When nutrition is inadequate to meet the energy demands of both daily living and lactation, GnRH suppression is more likely to persist for an extended time period, resulting in prolonged oligo- or anovulation. During exclusive breastfeeding, approximately 40 percent of women will remain amenorrheic at six months postpartum [29,30]. Amenorrhea during breastfeeding may be related, in part, to higher prolactin levels compared with women who become ovulatory while breastfeeding, since prolactin inhibits pulsatile GnRH release from the hypothalamus [31]. In one study, some women who exclusively breastfed (at least six episodes of suckling/day totaling more than 80 minutes in 24 hours) had elevated basal prolactin levels and amenorrhea for one year or more after delivery [32]. (See "Postpartum contraception: Counseling and methods", section on 'Other'.)

Breast engorgement — Breast engorgement results in breast fullness and firmness, which is accompanied by pain and tenderness. The affected area varies from primarily areolar involvement in some mothers, more peripheral involvement in others, and, in some mothers, both peripheral and areolar involvement. Primary engorgement is due to interstitial edema and onset of copious milk production. It typically occurs between 24 and 72 hours postpartum, with a normal range of one to seven days; peak symptomatology averages three to five days postpartum. Secondary engorgement typically occurs later if the mother's milk supply exceeds the amount of milk removed by her infant.

Breast engorgement is uncomfortable and may give rise to a mild temperature elevation for a short time; however, any fever should prompt an investigation to rule out an infectious source (see "Overview of the postpartum period: Disorders and complications", section on 'Fever/infection/wound complications'). The condition spontaneously resolves over a few days, but supportive care (warm compresses or a warm shower before feeding to enhance let-down and facilitate milk removal, cool compresses after or between feedings, reverse pressure breast softening, mild analgesics such as acetaminophen [paracetamol] or ibuprofen) is appropriate and reviewed separately. (See "Common problems of breastfeeding and weaning", section on 'Engorgement'.)

In women who are not breastfeeding, the use of a tight brassiere and avoidance of breast stimulation suppresses lactation in 60 to 70 percent of patients and is the recommended treatment; there are no high-quality studies comparing use of nondrug approaches with no treatment [33]. Drug therapy is not recommended for suppression of lactation because the risks associated with all of the currently available drugs outweigh any benefit. As an example, bromocriptine, which was used in the past, has been associated with various complications such as stroke, myocardial infarction, seizures, and psychiatric problems.

Skin and hair

●Striae, if present, fade from red to silvery but are permanent.

●Abdominal skin may remain lax if extensive rupture of elastic fibers occurred during pregnancy.

●Chloasma resolves, although the timing is not known.

●The increase in the ratio of "growing" or anagen hair relative to the "resting" or telogen hair during pregnancy reverses in the puerperium. Telogen effluvium is the hair loss commonly noted one to five months after delivery. It is usually self-limited with restoration of normal hair patterns by 6 to 15 months after delivery.

All of these changes and potential interventions, where available, are described in detail separately. (See "Maternal adaptations to pregnancy: Skin and related structures".)

Physiologic weight loss — The mean weight loss from delivery of the fetus, placenta, and amniotic fluid is 13 pounds (6 kg). Contraction of the uterus and loss of lochial fluid and excess intra- and extracellular fluid leads to an additional loss of 5 to 15 pounds (2 to 7 kg) during the puerperium. Approximately one-half of gestational weight gain is lost in the first six weeks after delivery, with a slower rate of loss through the first six months postpartum [34]. (See "Overview of the postpartum period: Disorders and complications", section on 'Postpartum weight retention'.)

Cardiovascular system — Physiologic changes in the cardiovascular system are particularly important in women with underlying cardiac disease. Within the first 10 minutes following a term vaginal delivery, the cardiac output and stroke volume increase by approximately 60 and 70 percent, respectively. At one hour postpartum, both the cardiac output and stroke volume remain increased (by approximately 50 and 70 percent, respectively) while the heart rate decreases by 15 percent; blood pressure remains unchanged. The increases in stroke volume and cardiac output most likely result from improved cardiac preload from auto transfusion of utero placental blood to the intravascular space. As the uterus decompresses following delivery, a reduction in the mechanical compression of the vena cava allows for further increases in cardiac preload.

A study that evaluated cardiac output and stroke volume in 15 healthy nonlaboring patients at 38 weeks of gestation and again at 2, 6, 12, and 24 weeks postpartum demonstrated a gradual diminution in cardiac output from 7.42 L/min at 38 weeks of gestation to 4.96 L/min at 24 weeks postpartum [35]. As early as two weeks postpartum, there were substantial reductions in left ventricular size and contractibility as compared with term pregnancies. (See "Maternal adaptations to pregnancy: Cardiovascular and hemodynamic changes", section on 'Postpartum hemodynamic resolution'.)

The prevalence of new-onset postpartum hypertension has been reported to be 0.3 to 7.5 percent [36]. Causes include intrapartum/postpartum volume overload, medications (eg, ergot derivatives), pregnancy-associated hypertension (eg, preeclampsia), and underlying medical disorders. In patients with antepartum/intrapartum preeclampsia, blood pressure typically decreases within 48 hours of birth, but can increase again three to six days postpartum. Because hypertension may present or recur after hospital discharge and may be asymptomatic, a blood pressure check soon after discharge is advised in high-risk patients, especially those with preeclampsia that appeared to be resolving.

Hematologic system — Pregnancy-related hematologic changes return to baseline by 6 to 12 weeks after delivery. Within this range, the rate and pattern of resolution of pregnancy-related changes of specific hematological parameters vary. Importantly, the prothrombotic state takes weeks to resolve, so postpartum women remain at increased risk for thromboembolic disease. (See "Maternal adaptations to pregnancy: Hematologic changes" and 'Prevention of venous thrombosis' below.)

ROUTINE MATERNAL CARE — Providing support and reassurance during the postpartum period helps to instill a sense of confidence in parents and can also help foster a healthy parent-child relationship. A systematic review of studies on women's expectations in the postnatal period found that they wanted to achieve positive motherhood (maternal self-esteem, competence, and autonomy), successfully adapt to the changes in intimate and family relationships, and (re)gain health and well-being for their baby and themselves [37].

Rooming in — Rooming in 24 hours a day is one component of the Baby-friendly Hospital Initiative launched by the World Health Organization and UNICEF. Keeping the newborn's crib by the side of the mother's bed rather than in a nursery is thought to improve successful breastfeeding, although a 2016 systematic review found little evidence to support or refute the practice of rooming in versus mother-infant separation on the duration of breastfeeding [38].

In the United States, the term "Baby-Friendly" is reserved for use by facilities who have demonstrated through an on-site assessment that they have met the criteria outlined in the most current version of the Guidelines and Evaluation Criteria.

Maternal monitoring — In addition to routine vital signs:

●The key components of identifying postpartum hemorrhage are fundal checks to assess uterine tone and perineal checks to assess for excessive vaginal bleeding. These assessments should be conducted by skilled nurses and are commonly performed hourly for the first 2 hours after delivery and then continued every 4 hours during the initial 24 hours postpartum. A normal postpartum fundus is firm and well-contracted, typically at or below the level of the maternal umbilicus. Excessive vaginal bleeding is a subjective assessment in the absence of hemodynamic instability. Fundal massage is a useful and expeditious intervention if the uterus is not firm. (See "Overview of postpartum hemorrhage", section on 'Definition/diagnosis'.)

●The suprapubic area is palpated to identify an overdistended bladder; a distended bladder is palpable abdominally. (See "Overview of the postpartum period: Disorders and complications", section on 'Voiding difficulty and urinary retention'.)

●The perineum is examined for signs of edema, purulent discharge, or dehiscence. (See "Overview of the postpartum period: Disorders and complications", section on 'Fever/infection/wound complications'.)

Laboratory testing — Evaluation of postdelivery hemoglobin should be individualized based on specific patient characteristics. Routine postdelivery hemoglobin testing is generally prudent, and is warranted in situations such as predelivery anemia or postpartum hemorrhage, and in the symptomatic patient. It may be omitted in patients who were not anemic upon admission, had an uncomplicated labor and vaginal delivery, had estimated blood loss <500 mL at delivery (which eliminates most cesarean deliveries), and are asymptomatic [39-42]. In one study, 11 percent of patients with measured postpartum blood loss <500 mL had a postpartum fall in hemoglobin ≥2 g/dL after vaginal delivery [43]. This could have been due to multiple factors, including inaccurate measurement of blood loss, bleeding after the patient left the delivery room, peripartum fluid shifts, and hemoglobin assessment in different laboratories.

Likewise, determination of the white blood cell count is not predictive of impending infection since leukocytosis as high as 15,000 cells/microL occurs frequently in postpartum patients [44,45]. Laboratory assessment of white blood cell count and differential should be reserved for patients in whom there is a clinical suspicion of infection.

Perineal care — There is a paucity of evidence-based information regarding care of the perineum after childbirth. A squirt bottle and sitz bath are commonly recommended for perineal care. Comfort measures include topical treatments (eg, cold or warm packs), topical anesthetics, and oral analgesics. Eating a high-fiber diet and drinking plenty of water, with stool softeners and laxatives as needed, are probably useful until perineal healing is nearly complete, especially in women with a disrupted anal sphincter. (See "Postpartum perineal care and management of complications".)

Support for breastfeeding and breast care — Human milk is recognized as the optimal food for all infants because of its proven health benefits to both infants and their mothers. Multiple issues related to breastfeeding are discussed in detail separately.

●(See "Infant benefits of breastfeeding" and "Maternal and economic benefits of breastfeeding".)

●(See "Breastfeeding: Parental education and support".)

●(See "Initiation of breastfeeding".)

●(See "Maternal nutrition during lactation".)

●(See "Common problems of breastfeeding and weaning".)

●(See "Breastfeeding the preterm infant".)

Problems such as mastitis lead many women to discontinue breastfeeding. The occurrence of mastitis can be minimized by frequent, complete emptying of the breast and by optimizing breastfeeding technique (eg, breast massage before latching, correct infant position and attachment, alternating the breast that feeds are started from). (See "Lactational mastitis".)

Prevention of venous thrombosis — Thromboembolic events are a leading cause of direct maternal mortality worldwide, especially in high income countries. Venous thromboembolism (VTE) is more common in pregnant women than nonpregnant women, more common postpartum than antepartum, and more common after cesarean than vaginal birth [46,47]. The risk is highest in the first few weeks postpartum and then gradually declines to baseline by 12 weeks postpartum [48]. Several factors increase the risk, including but not limited to previous VTE, inherited or acquired thrombophilia, certain medical comorbidities (eg, sickle cell disease), obesity, smoking, cesarean delivery, and postpartum hemorrhage [49].

Prophylaxis is recommended for women at high risk of having a thromboembolic event, although specific criteria to identify these women vary among institutions and guidelines. Indications for postpartum thromboprophylaxis and drug regimens are reviewed separately:

●(See "Cesarean birth: Preoperative planning and patient preparation", section on 'Thromboembolism prophylaxis'.)

●(See "Deep vein thrombosis and pulmonary embolism in pregnancy: Prevention".)

●(See "Inherited thrombophilias in pregnancy", section on 'Prevention of VTE'.)

●(See "Antiphospholipid syndrome: Pregnancy implications and management in pregnant women", section on 'Postpartum care'.)

Routine immunizations — Indications and procedures for vaccination of postpartum women are similar to those described for the general population. Both inactivated and live vaccines (except smallpox vaccine) may be administered to nursing mothers. Postpartum women, including those who are breastfeeding, should receive all recommended vaccines that could not be, or were not, administered during pregnancy (eg, measles/mumps/rubella, varicella, Tetanus toxoids diphtheria acellular pertussis [Tdap], human papillomavirus, influenza, COVID-19). Postpartum immunization is discussed in detail separately. (See "Immunizations during pregnancy", section on 'Postpartum immunization'.)

All household members in the newborn's home should also have up-to-date immunizations to create a protective "cocoon" around the infant and thus minimize newborn exposure to infection; Tdap, influenza, and COVID-19 vaccines are particularly important in this respect. (See "Standard immunizations for nonpregnant adults" and "Standard immunizations for children and adolescents: Overview", section on 'Infants and children'.)

Anti-D immune globulin — RhD-negative mothers of RhD-positive infants should be given anti-D immune globulin as soon as possible after delivery and within 72 hours. We suggest routinely testing all RhD-negative women for excessive fetomaternal bleeding at the time of delivery to ensure that they receive an adequate dose of anti-D immune globulin. (See "RhD alloimmunization: Prevention in pregnant and postpartum patients".)

Pelvic muscle exercises — Pelvic floor muscle exercises (PFME) performed during pregnancy help to decrease the short-term risk of urinary incontinence in women without prior incontinence, but a long-term benefit has not been established. PFME in the immediate postpartum period may be contraindicated in women who sustain injury to the levator ani muscle complex at childbirth because exercise may be harmful in the early phase of injury recovery. In women with obstetrical anal sphincter injuries, postpartum pelvic floor physical therapy after two weeks appears to improve pelvic floor symptoms by 12 weeks postpartum compared with standard care [50,51]. (See "Effect of pregnancy and childbirth on urinary incontinence and pelvic organ prolapse", section on 'Prophylactic pelvic floor muscle exercises'.)

Pain management

Afterpains — Afterpains occur in 50 percent of patients within 48 hours of vaginal or cesarean delivery due to hypertonic uterine contractions [52]. The pain is intermittent and often more intense during nursing due to the release of oxytocin associated with suckling. It is more common in multiparous women, women in whom the uterus was overdistended before delivery (eg, multiple gestation, polyhydramnios), and women with a history of dysmenorrhea. Afterpains usually spontaneously resolve by the end of the first postpartum week.

Mild analgesics (eg, acetaminophen [paracetamol], ibuprofen, diclofenac suppositories) are effective [53]. Nonsteroidal anti-inflammatory drugs (NSAIDs) appear to be as effective as acetaminophen (paracetamol), and the two drugs can be used in combination if a single drug is inadequate. Opioids are unnecessary and should be avoided. Severe afterpains after vaginal delivery are atypical and should prompt an evaluation for another source.

Vaginal delivery — NSAIDs or acetaminophen are the preferred initial analgesics after a vaginal delivery. Prescribing opioids following vaginal delivery is associated with future persistent opioid use and misuse, even after adjustment of confounding factors [54]. After a vaginal delivery, the risk that an opioid-naïve woman exposed to opioids will become a persistent opioid user has been reported to be 0.59 percent [55] and 1.7 percent [56]. In women who have an epidural and require an operative vaginal delivery or extensive perineal repairs, the addition of a long-acting agent to the epidural may reduce postpartum opioid use [57,58].

If these measures are ineffective, the next step would be the addition of a low dose of a low potency opioid (eg, codeine, hydrocodone, oxycodone, tramadol, morphine) for a short duration; however, infant effects need to be considered in breastfeeding patients. (See 'Breastfeeding issues' below.) If ineffective, a higher potency opioid (eg, hydromorphone, fentanyl) may be added, but the need for such agents is unusual after an uncomplicated vaginal birth so the reason for severe pain should be investigated (eg, previously unsuspected vaginal hematoma).

Perineal pain — Comfort measures include oral analgesics (eg, acetaminophen [paracetamol], ibuprofen) and topical treatments (eg, cold or warm packs applied for 10 to 20 minutes) as first-line therapies; some patients benefit from topical anesthetics. Opioids should be avoided, although a minority of women may need a short course if they are experiencing moderate pain unrelieved by these measures and another source for the pain has been ruled out. (See "Postpartum perineal care and management of complications", section on 'Pain management'.)

Cesarean delivery — Multimodal strategies for postoperative pain control after cesarean delivery should be employed to promote rapid recovery, allow the patient to care for her newborn, and minimize the need for postoperative opioids (table 1) [59]. A step-wise approach should be employed using agents with different mechanisms of action. Patients who receive neuraxial anesthesia can benefit from neuraxial morphine or hydromorphone. (See "Post-cesarean delivery analgesia".)

Multiple factors affect the patient's experience of post-cesarean pain and adequate relief of this pain is a metric of patient satisfaction. However, opioid use for acute pain, although effective, is associated with an increased risk of long-term opioid use: After a cesarean delivery, the reported risk that an opioid-naïve woman exposed to opioids will become a persistent opioid user has been reported to be 0.33 percent [60], 0.84 percent [55], and 2.2 percent [56]. The rationale for limiting opioid prescriptions and a strategy for prescription of opioids for acute pain in opioid-naïve patients based on severity and expected duration of pain can be found separately. (See "Management of acute perioperative pain".)

Safety of common analgesics in breastfeeding women — Most analgesics are safe for breastfeeding women, with the following caveats. Detailed information on specific drugs can be found in the UpToDate drug information database (each drug includes a section on breastfeeding implications) or in LactMed.

●Preferred drugs:

•Acetaminophen (paracetamol) – Acetaminophen (paracetamol) enters breast milk but is considered compatible with breastfeeding by the Academy of Breastfeeding Medicine (ABM) [61]. It is the preferred analgesic for breastfeeding women.

•NSAIDs – Ibuprofen and diclofenac suppositories, which have a short half-life (<6 hours), have relative infant doses of less than 1 percent and are considered compatible with breastfeeding by ABM [61]. Naproxen should be avoided because alternative NSAIDs are available and it has a long half-life (>6 hours), thus a greater potential to accumulate in the infant's plasma. All NSAIDs should be avoided if the breast-fed infant has a ductal-dependent cardiac lesion [62].

Intravenous or oral ketorolac can be used with acetaminophen or ibuprofen to treat moderate pain in breastfeeding women [59]. The concentration in breast milk is likely to be minimal. The combination of ketorolac and acetaminophen or ibuprofen may achieve adequate analgesia so that opioids can be avoided.

●Use of opioids for patients with severe pain – Adequate treatment of maternal pain is an important factor for improving breastfeeding outcome; however, opioid analgesia postpartum may affect infant alertness and suckling vigor [61]. When opiates are prescribed for severe postpartum pain, the clinician should review medication risks and benefits with the family, including newborn signs of toxicity (eg, reduced muscle tone [limpness], not feeding well, not waking up to be fed). Use of all opioids should be limited to the lowest effective dose and prescribed for the shortest time required to control acute pain. Patients requiring any opioid should be switched to a nonopioid alternative as soon as the level of pain permits. Multimodal pain control with the use of regional anesthetic techniques, anesthetic blocks (such as transverse abdominis plane or quadratus lumborum), and scheduled dose acetaminophen and NSAIDs can reduce use of opioids and, in turn, risks associated with these drugs.

•Preferred drug choices – The Committee on Drugs of the American Academy of Pediatrics prefers use of butorphanol, morphine, or hydromorphone over other opiates [62].

Levels of butorphanol and hydromorphone are very low in milk and thus are not likely to affect nursing infants. Morphine has limited transport into milk and poor oral bioavailability in infants. Morphine is preferable to meperidine or pethidine for postpartum analgesia during lactation [61]. The weight-adjusted relative infant dose of hydromorphone is 0.67 percent, so hydromorphone is unlikely to reach the infant in clinically significant levels. However, high doses of this drug should be used cautiously and the infant monitored for sedation since the drug is a strong opioid.

Maternal use of oxycodone or hydrocodone does not appear to have the same risks as those reported for codeine and tramadol, which are described in the following bullet. Only two case reports have described infant opioid overdose thought to be attributable to transfer of oxycodone or hydrocodone through breastmilk and reversed by naloxone [63,64]. Based on the available data, the Society for Obstetric Anesthesia and Perinatology (SOAP) does not believe that a shift from oral oxycodone or hydrocodone to butorphanol, morphine, or hydromorphone is warranted [65]. Prolonged, frequent, and high-dose administration of any opioid may lead to neonatal sedation.

•Agents warranting caution

-Codeine, tramadol – We suggest avoiding use of these drugs in breastfeeding women. The concern during breastfeeding is related to alterations in metabolism of the drugs due to genetic variations in cytochrome CYP2D6. This can result in high serum metabolite levels (ultra-rapid metabolizers) with potential transfer of these active metabolites into maternal milk causing excessive infant sedation and fatal overdoses in extreme cases [61,66-70]. The frequency of this mutation varies based on ethnic background with an overall frequency in the United States population of 4 to 5 percent [71,72]. In 2017, the US Food and Drug Administration (FDA) issued warnings and contraindications for the use of codeine and tramadol for pain management in all children <12 years old and in breastfeeding women [70]. Similar warnings have been issued by other agencies, including Health Canada [73], European Medicines Agency [74], and ACOG [59]. If these drugs are used, use should be limited to a few days and the lowest effective dose, with close infant monitoring. The mother should stop use and call her provider if the infant appears to be sleepier, has increased difficulty with breastfeeding or breathing, or appears to be weak.

Maternal risk guidelines state that central nervous system depression in the infant of women breastfeeding while taking codeine appears to worsen after four days, likely due to accumulation of morphine from metabolism of codeine, so if possible, codeine should not be used for longer than four days [75]. If persistent pain necessitates its use, then an attempt should be made to decrease the dose or to switch to noncodeine analgesics.

-Meperidine – Meperidine should be avoided by nursing women because of consistent reports of dose-related neonatal sedation; its metabolites have a long half-life and may accumulate [76,77]. (See "Evaluation and management of pain in children", section on 'Agents not recommended'.)

-Aspirin – Aspirin should be used with caution in breastfeeding women because of the theoretical risk of Reye's syndrome. Reye's syndrome is associated with aspirin administration to infants with viral infections, but the risk from salicylate in breastmilk is unknown: There is a single case report of metabolic acidosis in an infant whose mother was taking a high dose of aspirin [78]. Daily low-dose aspirin (75 to 325 mg daily) is associated with low salicylate levels and does not appear to be excreted into breastmilk; thus, it is an option for use in breastfeeding women who require antiplatelet therapy [79]. The National Reye's Syndrome Foundation recommends against use of aspirin in breastfeeding women [80].

Safety of NSAIDs in women with hypertension — Although NSAIDs are known to cause elevations in blood pressure in nonpregnant hypertensive individuals, available evidence in hypertensive postpartum patients has not shown harmful effects. ACOG suggests considering NSAIDs as first-line agents for management of postpartum pain in all individuals, including those with hypertension [59]. Data on the effects of NSAIDs on blood pressure in postpartum women with hypertension are discussed in detail separately. (See "Treatment of hypertension in pregnant and postpartum patients", section on 'Management'.)

DISCHARGE PLANNING — The American College of Obstetricians and Gynecologists (ACOG) recommends development of a postpartum care plan with pregnant women during the prenatal period. This plan is updated as needed and reviewed with the woman after delivery. ACOG has also created a comprehensive list of the components of postpartum care [2]. Tables of the components are available online. In addition, the Alliance for Innovation on Maternal Health developed a maternal safety bundle of a set of strategies that health care professionals can use to improve the health and well-being of postpartum women (available online) [81].

Length of stay — Sparse, low- and moderate-quality evidence on the optimal length of stay after delivery suggests a lack of adverse maternal or newborn effects from early discharge of healthy mothers and healthy term newborns [82]. Although atypical, discharge as early as one day after scheduled cesarean delivery has been reported to be safe for mothers and infants and satisfactory to mothers in some populations [83].

An expert panel of the World Health Organization agreed with most published guidelines that state a mother and healthy, term baby of an uncomplicated delivery should be observed by a skilled attendant for 24 to 48 hours after birth [84]. If the mother and baby are discharged from the birth facility before 48 hours, then assessment by a qualified professional or skilled attendant within 24 to 48 hours after discharge should be encouraged. Based on epidemiologic data, the first 24 to 48 hours are the most critical time for the woman and the baby; therefore, individualized skilled care during the immediate postnatal period can be lifesaving.

ACOG recommends that, in cases of postpartum discharge prior to 48 hours after a vaginal delivery or 72 hours after a cesarean delivery (excluding the day of delivery), certain criteria should be met [85]. These include normal maternal vital signs, normal lochia, firm fundus, adequate urinary output, ability to tolerate diet, adequate pain control, ability to ambulate and care for herself and the newborn, no evidence of infection or impaired wound healing, and no abnormal physical or emotional findings. In addition, all laboratory results should have been addressed, including need for anti-D immune globulin if appropriate; instruction should be given for normal postpartum activities/exercise; and support resources for the new mother should be identified prior to discharge. Warning signs of serious maternal and infant postdelivery complications, including how to contact their health care provider, should be reviewed.

Patient education — Prior to the patient's discharge, she should be instructed on expected normal postpartum changes and care of herself (breasts, perineum, etc) and the newborn. (See "Overview of the routine management of the healthy newborn infant".)

Patients should also be instructed about signs of possible complications that should prompt them to seek further medical advice; these include, but are not limited to the following:

●Excessive postpartum bleeding (eg, bleeding that saturates a peripad within an hour).

●Fever.

●New or worsening perineal or uterine pain.

●Dysuria.

●Breast problems – (See "Common problems of breastfeeding and weaning".)

●Dyspnea, chest pain, leg pain or swelling – (See "Clinical presentation and diagnosis of the nonpregnant adult with suspected deep vein thrombosis of the lower extremity".)

●Significant mood disturbance (eg, affecting relationships or normal activity) – (See "Postpartum unipolar major depression: Epidemiology, clinical features, assessment, and diagnosis".)

Severe pain in any location (eg, head, chest, abdomen) is a cause for concern, as in any individual.

Use of dietary supplements — There is little scientific evidence on the value of routine postpartum use of dietary supplements, such as prenatal vitamins or multivitamins, iron, and micronutrients in women with a healthy diet and no specific nutritional deficiencies or anemia [86-91]. We advise most women to continue their prenatal vitamin and/or supplemental iron for six to eight weeks following delivery, especially if they are breastfeeding. Iron is prescribed for women with anemia, and we discuss strategies to manage constipation, which may be caused by the iron supplementation. (See "Anemia in pregnancy", section on 'Postpartum'.)

Diet and supplements for breastfeeding women are reviewed separately. (See "Maternal nutrition during lactation".)

Activity — There are no data on which to base recommendations regarding postpartum physical activity. In particular, there are no high-quality data on which to base restrictions on lifting, climbing stairs, bathing, swimming, driving, or resuming vaginal intercourse, exercise, or work after delivery [92].

A reasonable approach is to tell the mother to resume activities such as housework, driving, exercise, and sexual intercourse when she is comfortable performing these activities, and she should limit or avoid activities that cause pain or excessive fatigue. She should not engage in activities that require mental alertness (eg, driving or operating potentially dangerous equipment) until she has stopped using narcotic analgesics.

Vaginal intercourse can probably be resumed safely in most women as early as two weeks postpartum, as long as the perineum is healed, contraception is available, and the patient is ready. However, most women will not be ready to resume coitus this soon after delivery because of fatigue, low sexual desire, pain, vaginal dryness or discharge, religious/cultural practices, psychological factors, or possibly postpartum blues or depression.

The abdominal wall regains most, if not all, of its normal muscular tone over several weeks. An abdominal exercise program can be started, if desired, any time after vaginal birth. Exercise may prevent abdominal muscle separation (rectus abdominis diastasis), but the extent to which exercise or other measures resolve or hasten resolution of diastasis has not been established. (See "Rectus abdominis diastasis", section on 'Spontaneous resolution'.)

Activity after cesarean delivery is discussed separately. (See "Cesarean birth: Postoperative issues", section on 'Ambulation/diet'.)

Contraception — Most women resume sexual relations by six weeks postpartum, which is the most common time for a postpartum office visit; therefore, contraceptive plans should be discussed before the woman leaves the hospital. Postpartum contraception counseling improves use and leads to fewer unplanned pregnancies [93].

In women not exclusively breastfeeding, ovulation can occur as early as 25 days after delivery, so contraception should be initiated no later than the third postpartum week. In exclusively breastfeeding women, return of ovulation occurs later and is less predictable. During the first six months following birth, if a women breastfeeds exclusively, uses no supplements, minimizes intervals without breastfeeding during the day and night, and remains amenorrheic, the risk of pregnancy is <5 percent in most populations [94]. Pregnancy rates rise among exclusively breastfeeding women after six months following birth, so contraception should be initiated.

Timing of initiation of contraceptive in the early postpartum period depends on the contraceptive method as some hormonal methods may affect lactation. For example, estrogen-progestin contraceptives should be avoided in breastfeeding women who are less than 30 days postpartum. (See "Postpartum contraception: Counseling and methods".)

Intrauterine contraception — Placement of intrauterine contraception within 10 minutes of placental delivery is an effective, long-term, but reversible alternative to sterilization. The device can be placed after vaginal or cesarean birth. The frequency of expulsion, however, is higher than with placement after the uterus has returned to its normal size. (See "Postpartum contraception: Counseling and methods", section on 'Intrauterine devices'.)

Tubal ligation — Sterilization (also called permanent contraception) can be performed postpartum or as an interval procedure. Ideally, postpartum procedures are performed within 24 hours of delivery but after the initial period of mother-infant breastfeeding and attachment. (See "Overview of female permanent contraception" and "Postpartum permanent contraception: Procedures".)

Follow-up visits

Timing and location — Available evidence does not allow clear conclusions regarding the optimum frequency, content, or sites (home versus office versus telephone contact) for postpartum follow-up [95,96]. An early postpartum visit at one to two weeks postpartum should be considered for women with cesarean delivery, medical issues that require close follow-up and women at risk for postpartum depression (eg, past episodes of depression, family history of mood disorder, concurrent stressful life events). (See "Postpartum unipolar major depression: Epidemiology, clinical features, assessment, and diagnosis".)

Traditionally, the postpartum visit had been recommended at four to six weeks after delivery. In 2018, ACOG recommended that women have an encounter (in person or by phone) with a maternal care provider within the first three weeks postpartum to address acute issues, with ongoing care as needed and a comprehensive postpartum visit no later than 12 weeks after delivery [2]. The World Health Organization recommends routine postpartum evaluation at 3 days, 1 to 2 weeks, and 6 weeks [97]. Women with hypertensive diseases during pregnancy benefit from education regarding signs and symptoms of hypertensive complications, blood pressure monitoring, and early postpartum blood pressure follow-up within the first two weeks after discharge depending on severity of disease [98].

The Pregnancy Risk Assessment Monitoring System reported 89 percent of United States women had a postpartum care visit, although the rate was significantly lower in some subgroups (71 percent for women with <8 years of education, 66 percent for women who had not received prenatal care) [99]. Counseling about the importance of the postpartum visit during prenatal care, scheduling the visit before hospital discharge, and providing reminders (mail, phone, text) may be useful in improving attendance at this visit.

Patient assessment — The provider should assess the patient's adjustment to life with the new infant and update her history. Any problems that the patient perceives should be addressed. Routine topics that are readdressed at the follow-up visit include the health of the infant, patient's mood, contraceptive plan (if not already in place), return to sexual activity, and any difficulties with breastfeeding.

Physical examination at the postpartum visit includes assessment of vital signs, thyroid, breasts (fissures, tenderness, lumps, skin changes), abdomen (diastasis, hernias), external genitalia/perineum (wound healing, fistulas), vagina (pelvic support), cervix, uterus/adnexa (size, tenderness, masses), and extremities.

Counseling — Complications that occurred during the pregnancy or postpartum should be reviewed in terms of the cause, risk of recurrence, and prevention, if possible (refer to individual topic reviews on pregnancy complications). Any underlying medical conditions that were present prior to or during the pregnancy should be addressed at the postpartum visit. Care coordination is an important part of this process [100]. Timing of appropriate follow-up examinations should be reviewed. (See 'Screening' below.)

Plans for future pregnancy should be discussed. Both short (less than six months) and long (greater than 60 months) interpregnancy intervals are associated with increased risks of adverse outcome. The optimal interpregnancy interval is approximately 18 to 59 months. However, prolonging the interpregnancy interval may not be the best option for women over age 35 or those with a strong family history of early menopause. (See "Interpregnancy interval: Optimizing time between pregnancies".)

Screening

Mental health conditions, including suicide, homicide, and substance use disorder, are leading causes of maternal mortality in the United States.

●Depression – We screen all women for postpartum depression, as recommended by ACOG, the American Academy of Pediatrics, and the United States Preventive Service Task Force Recommendation Statement [101-104]. The validated questionnaire most commonly used for screening pregnant and postpartum women is the Edinburgh Postnatal Depression Scale (figure 2 and figure 3), but other validated tools can be used. The rationale for screening include that postpartum depression is common, the combination of screening and adequate support improves clinical outcomes, and treatment (particularly with cognitive behavioral therapy) is associated with symptom remission [101]. Direct and indirect evidence support a net benefit from screening and an absence of harm. Depression screening is performed at the routine postpartum visit, but consideration should be given to additional earlier screening and follow-up in patients at high risk for depression. Screening is appropriate whether or not the patient has a prior history of depression or depressive disorder. (See "Postpartum unipolar major depression: Epidemiology, clinical features, assessment, and diagnosis", section on 'Assessment'.)

●Substance abuse – We recommend universal screening for postpartum use of nicotine, alcohol, and abuse of prescription narcotics and illicit substances. We screen all women for drug abuse using a standardized screening tool (table 2), such as the NIDA quick screen (table 3), followed by a brief intervention in patients who screen positive, and then referral for treatment as indicated. (See "Brief intervention for unhealthy alcohol and other drug use: Goals and components" and "Brief intervention for unhealthy alcohol and other drug use: Efficacy, adverse effects, and administration" and "Approach to treating opioid use disorder".)

●Intimate partner and domestic violence – We recommend screening all postpartum women for intimate partner violence and domestic violence. Ideally, screening should be performed at the initial prenatal visit, at least once per trimester, and again during postpartum care [105]. Screening should be routinely performed for women who have not accessed prenatal care or who have concerning signs or symptoms (table 4). Multiple validated screening tools are available. (See "Intimate partner violence: Diagnosis and screening".)

●Human trafficking – We recommend screening for human trafficking in appropriate situations [106].

●Diabetes – Approximately six to eight weeks after delivery, women with gestational diabetes should undergo an oral glucose tolerance test. They should be counseled about the increased risk of future diabetes, even when the postpartum glucose tolerance test is normal. These women may benefit from lifestyle changes, such as weight loss if they are obese. (See "Gestational diabetes mellitus: Glycemic control and maternal prognosis", section on 'Follow-up'.)

●Cardiovascular risk – Women with gestational diabetes, pregnancy-related hypertension, or preterm birth are at increased risk of future cardiovascular disease, even if postpartum blood pressures and glucose tolerance testing are normal. (See "Gestational diabetes mellitus: Glycemic control and maternal prognosis", section on 'Long-term risk' and "Preeclampsia: Management and prognosis", section on 'Prognosis' and "Preterm birth: Risk factors, interventions for risk reduction, and maternal prognosis", section on 'Long-term maternal consequences'.)

ACOG recommends that clinicians make women with these complications of pregnancy aware of their increased risk for developing cardiovascular disease [2]. Including this information in their health record can facilitate ongoing monitoring and risk assessment. For women with preeclampsia, this may include yearly assessment of blood pressure, lipids, fasting blood glucose, and body mass index (see "Atherosclerotic cardiovascular disease risk assessment for primary prevention in adults: Our approach"). Increased awareness about her cardiovascular risk may increase the woman's motivation to reduce modifiable risk factors, if present, by adopting a healthy lifestyle. (See "Overview of primary prevention of cardiovascular disease".)

●Cervical cancer – Screening for cervical cancer should follow standard guidelines for cervical cancer screening, unless compliance with follow-up is an issue. (See "Screening for cervical cancer in resource-rich settings" and "Cervical cancer screening tests: Techniques for cervical cytology and human papillomavirus testing".)

●Breast cancer – Screening mammography should be discussed in women age 40 and older. (See "Screening for breast cancer: Strategies and recommendations".)

Breastfeeding issues — For the patient who is continuing to breastfeed at the postpartum visit, encouragement from the health care provider and discussion aimed at resolving breastfeeding challenges at this time has been correlated with improved breastfeeding continuation rates at four months postpartum [107]. Women planning to return to work outside the home can be instructed on techniques for breast milk expression and storage while away from the child [108]. The mother who has decided not to breast pump during work hours should be encouraged that partial breastfeeding continues to provide the infant with health benefits. (See "Breastfeeding: Parental education and support" and "Common problems of breastfeeding and weaning".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Postpartum infection" and "Society guideline links: Postpartum care" and "Society guideline links: Breastfeeding and infant nutrition".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Labor and delivery (childbirth) (The Basics)")

●Beyond the Basics topics (see "Patient education: Deciding to breastfeed (Beyond the Basics)" and "Patient education: Common breastfeeding problems (Beyond the Basics)" and "Patient education: Maternal health and nutrition during breastfeeding (Beyond the Basics)" and "Patient education: Pumping breast milk (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●The postpartum period (the "fourth trimester") begins upon delivery of the infant; the end is often considered the six to eight weeks after delivery because the effects of pregnancy on many systems have largely returned to the prepregnancy state by this time. (See 'Definition of the postpartum period' above and 'Postpartum findings and changes' above.)

●Routine postpartum care has several components, including rooming in, maternal monitoring, pain management, perineal care, and, in some cases, prophylaxis against thromboembolism and Rh alloimmunization. (See 'Routine maternal care' above.)

●Most patients do not require opioids for pain control after a vaginal delivery. Multimodal strategies for postoperative pain control after cesarean delivery should be employed to promote rapid recovery, allow the patient to care for her newborn, and minimize the need for postoperative opioids. (See 'Pain management' above.)

●Postpartum laboratory testing should be based on specific indications, not routine. In addition, appropriate immunizations should be offered. (See 'Laboratory testing' above and 'Routine immunizations' above.)

●Ovulation can occur as early as 25 days after delivery; therefore, the contraceptive desires of the couple should be addressed prior to hospital discharge and appropriate prescriptions given. (See 'Contraception' above.)

●Traditionally, the postpartum visit was at four to six weeks after delivery. The American College of Obstetricians and Gynecologists recommends an encounter (in person or by phone) with a maternal care provider within the first three weeks postpartum to address acute issues, with ongoing care as needed and a comprehensive postpartum visit no later than 12 weeks after delivery. The World Health Organization recommends routine postpartum evaluation at three days, one to two weeks, and six weeks. (See 'Follow-up visits' above.)

●Outpatient follow-up care should address patient mood (eg, depression screening), sexual activity, contraception, preexisting medical conditions, infant feeding method, and the timing of future visits for health care screening. (See 'Follow-up visits' above.)