Postpartum: Recovery, Breastfeeding, Mental Health, and Contraception After Birth

Introduction

The postpartum period (puerperium) begins immediately after delivery of the placenta and extends through approximately 6-12 weeks as the body undergoes physiological changes to return to the non-pregnant state. This period involves significant physical recovery, emotional adjustment, and establishment of infant feeding. The “fourth trimester” concept emphasizes that care extends well beyond the traditional 6-week visit.

Physical Recovery

Uterine Involution

Time Point	Uterine Fundal Height	Characteristics
Immediately postpartum	At or near umbilicus	Firm, contracted
12-24 hours	Umbilicus level	Midline
Day 3-4	2-3 cm below umbilicus	Still palpable
Day 7	Midway between umbilicus and pubic symphysis	Rapidly decreasing
Day 14	Non-palpable above pubic symphysis	Return to pre-pregnancy size
6 weeks	Normal pre-pregnancy size	Involution complete

Lochia

Phase	Timing	Color	Character	Composition
Lochia rubra	Days 1-4	Bright to dark red	Bloody	Blood, decidual tissue, fetal membranes
Lochia serosa	Days 4-10	Pinkish-brown	Serosanguinous	Blood, leukocytes, cervical mucus
Lochia alba	Days 10-28+	Yellowish-white	Whitish discharge	Leukocytes, bacteria, decidual cells

Perineal Care (After Vaginal Delivery)

Aspect	Recommendation
Pain management	Ibuprofen 600 mg q6h, acetaminophen 650 mg q6h; opioid if severe
Ice packs	First 24 hours to reduce swelling
Warm sitz baths	After first 24 hours, 2-3 times daily for 15-20 minutes
Perineal hygiene	Front to back wiping, peri-bottle with warm water, pat dry
Witch hazel pads (Tucks)	Cooling, soothing; placed on perineal pad
Perineal spray (Dermoplast)	Topical anesthetic for comfort
Stool softeners	Docusate 100 mg BID to prevent constipation and straining
Activity	Avoid prolonged standing, heavy lifting; rest with legs elevated
Episiotomy/laceration	Inspect daily for signs of infection (erythema, warmth, purulent drainage, dehiscence)

Cesarean Wound Care

Aspect	Recommendation
Incision inspection	Daily check for erythema, warmth, drainage, dehiscence
Showering	OK after 24-48 hours; pat dry (do not rub)
Bathing	No soaking (no bathtub, pool, hot tub) until incision healed (1-2 weeks)
Dressing	Remove 24-48 hours post-op if no drainage; wound may be left open to air
Abdominal binder	May provide comfort and support with movement
Lifting	Limit to <10-15 lb (4.5-7 kg) for 6 weeks
Driving	No driving while taking narcotics; typically 2-3 weeks after surgery

Breastfeeding

Benefits

For Infant	For Mother
Optimal nutrition: perfect balance of nutrients	Uterine involution (oxytocin release)
Immunologic protection (IgA, cells, cytokines)	Reduced risk of breast and ovarian cancer
Reduced risk of infections (GI, respiratory, UTI, otitis media)	Reduced risk of type 2 diabetes
Reduced risk of SIDS (50% reduction)	Caloric expenditure (300-500 kcal/day)
Reduced risk of allergies, asthma, eczema	Contraceptive effect (LAM if exclusive)
Reduced risk of childhood obesity	Convenience (always ready, correct temperature)
Enhanced bonding	Economic benefit (no formula cost)
Improved neurodevelopment	Environmental benefit

Latch and Positioning

Latch Key Points	Position Options
Baby’s mouth wide open	Cradle hold
Lower lip curled outward	Cross-cradle hold (good for newborns)
Chin touching breast	Football/clutch hold (good for cesarean, twins)
Nose free to breathe	Side-lying (for night nursing)
More areola visible above top lip than below	Laid-back/biological nursing
No pain (slight tugging OK)	Upright hold

Milk Production Timeline

Stage	Timing	Characteristics
Colostrum	Days 1-3 (pregnancy+)	Thick, yellowish, high protein, rich in IgA; small volume (30-60 mL/day)
Transitional milk	Days 3-7	Blends colostrum and mature milk; increasing volume
Mature milk	Day 7+	Foremilk (thin, high water/lactose) and hindmilk (creamier, higher fat)
Milk “coming in”	Days 2-5	Engorgement, warmth, fullness; resolves with feeding

Common Breastfeeding Problems

Problem	Cause	Management
Sore nipples	Poor latch, improper positioning	Correct latch, express a little milk first, varied positions, lanolin or hydrogel pads, APNO (all-purpose nipple ointment)
Engorgement	Milk accumulation, vascular congestion	Frequent feeding/pumping, warm compresses before feed, cold compresses after, reverse pressure softening
Plugged duct	Incomplete emptying, pressure on breast	Frequent feeding (starting on affected side), massage during feeds, warm compresses; continue breastfeeding
Mastitis	Bacterial infection (usually Staph aureus)	Continue feeding (antibiotics safe); dicloxacillin or cephalexin 10-14 days; warm compresses, NSAIDs; if abscess, drainage
Thrush (Candida)	Fungal overgrowth (nipple + baby mouth)	Nystatin cream (nipple) or APNO + nystatin suspension (baby mouth); treat both; sterilize pump parts
Low milk supply	Infrequent feeding, poor latch, supplementing, maternal stress, thyroid, medications	Increase feed/pump frequency, ensure good latch, galactagogues (domperidone, fenugreek limited evidence); lactation consult
Oversupply	Excess milk	Block feeding (same breast for 2-4 hour block); laid-back position; consult lactation
Nipple vasospasm	Circulation issue	Warmth, avoid cold; nifedipine if severe; rule out thrush

Pumping and Storage

Aspect	Recommendation
Pump timing	After feeds or between feeds; early morning best for supply
Frequency	8-12 times/day if exclusively pumping
Storage: room temp (77F/25C)	4 hours (fresh), less time for thawed
Storage: refrigerator (40F/4C)	4 days (fresh)
Storage: freezer (0F/-18C)	6-12 months (best by 6 months)
Thawing	Refrigerator overnight or warm water; do NOT microwave
Freezer bags	Leave room for expansion; lay flat to freeze

Postpartum Mental Health

Spectrum of Postpartum Mood Disorders

Condition	Prevalence	Onset	Duration	Key Features
Baby blues	50-80%	Days 2-4 postpartum	Resolves by day 10-14	Mild mood swings, crying, anxiety, insomnia; no functional impairment
Postpartum depression (PPD)	10-20%	Within 4 weeks (up to 12 months)	Weeks to months	Depressed mood, anhedonia, sleep/appetite changes, guilt, difficulty bonding
Postpartum anxiety	10-15%	Within 4 weeks	Variable	Excessive worry, panic attacks, hypervigilance, racing thoughts
Postpartum obsessive-compulsive disorder	2-3%	Within 4 weeks	Variable	Intrusive thoughts (harm to baby), compulsions (checking)
Postpartum post-traumatic stress disorder	1-6%	After traumatic birth	Variable	Flashbacks, nightmares, avoidance of birth-related triggers
Postpartum psychosis	0.1-0.2%	Days 1-4 (sudden)	Weeks-months	Delusions, hallucinations, confusion, disorganized behavior; EMERGENCY

Postpartum Depression (PPD) Diagnosis

Criteria	Description
Peripartum onset	Symptoms during pregnancy or within 4 weeks of delivery
Symptoms (5+ for 2+ weeks)	Depressed mood, anhedonia, weight/appetite changes, sleep disturbance, psychomotor changes, fatigue, guilt/worthlessness, poor concentration, suicidal thoughts
Specifiers	With anxious distress, with psychotic features
Edinburgh Postnatal Depression Scale (EPDS)	Score >10-12 suggests PPD; includes question about self-harm (question 10)

PPD Risk Factors

Category	Risk Factors
History	Prior PPD (25-50% recurrence), prior depression/anxiety, PMS/PMDD
Obstetric	Preterm birth, difficult delivery, NICU admission, cesarean, multiple birth
Psychosocial	Low social support, marital conflict, unintended pregnancy, adolescent pregnancy
Infant-related	Colic, poor latch, feeding difficulties, infant health problems
Life stressors	Financial strain, moving, job loss, death in family

PPD Treatment

Severity	First-Line	Second-Line	Notes
Mild	Psychotherapy (CBT, IPT), support groups, sleep, exercise	Watchful waiting (2 weeks)	Cognitive behavioral therapy and interpersonal therapy are equally effective
Moderate	SSRIs (sertraline, fluoxetine, paroxetine, citalopram) + psychotherapy	Different SSRI, add psychotherapy	Most SSRIs safe during breastfeeding
Severe	SSRIs + psychotherapy; consider hospitalization	ECT (severe, refractory)	Risk of untreated PPD exceeds medication risk
Refractory	Brexanolone (Zulresso) - IV infusion over 60 hours	ECT, TMS	FDA-approved for PPD; requires monitored infusion center
Suicidal or psychotic	EMERGENCY hospitalization	N/A	N/A

Postpartum Psychosis (Emergency)

Feature	Description
Onset	Rapid (days 1-4 after delivery)
Symptoms	Delusions (often religious, grandiose, or about baby), hallucinations (auditory, visual), mood swings, disorganized behavior, confusion, catatonia
Risk	Infanticide (4%), suicide (5%)
Treatment	Psychiatric hospitalization; mood stabilizers + antipsychotics; ECT for severe
Prognosis	Good outcome with treatment; 50% recurrence risk in subsequent pregnancies

Screening Recommendations

Guideline	Recommendations
USPSTF (2019)	Screen all pregnant and postpartum women for depression
ACOG	Screen at least once in perinatal period using EPDS or PHQ-9
AAP	Screen mothers at infant well-child visits (1, 2, 4, 6 months)
Timing	During pregnancy, at postpartum visit (4-6 weeks), and at well-baby visits

Postpartum Checkup (4-6 Week Visit)

Assessment	Details
Physical exam	Vital signs, abdominal exam (fundus), breast exam, perineal/incision healing
Pelvic exam	Cervical healing, vaginal support, uterine size
Mood screening	EPDS, PHQ-9, assess for anxiety, OCD, psychosis
Contraception	Plan for contraceptive method
Breastfeeding	Assess latch, supply, problems; referral if needed
Bowel and bladder	Assess for constipation, hemorrhoids, incontinence
Thyroid	If symptoms (fatigue, weight changes, hair loss)
Vaccinations	Tdap (if not during pregnancy), MMR (if rubella non-immune), influenza
Interval history	Sleep, fatigue, bleeding, pain, sexual activity, return to work

Postpartum Contraception

Contraception After Birth

Method	Timing of Initiation	Lactation Safety	Notes
Lactational amenorrhea (LAM)	Immediate	Yes	Effective only if exclusive breastfeeding, amenorrhea, <6 months; 98% effective
Progestin-only pill (POP)	Can start immediately postpartum (no estrogen)	Yes	Must take at same time daily
Progestin-only implant (Nexplanon)	Can be inserted immediately postpartum	Yes	3-year efficacy
Progestin-only injectable (DMPA)	Can start immediately postpartum	Yes	Every 13 weeks
LNG-IUD (Mirena, Kyleena)	Insertion within 10 minutes of placental delivery or delayed (4-6 weeks)	Yes	Higher expulsion rate if immediate post-placental insertion
Copper IUD (Paragard)	Same as LNG-IUD	Yes	No hormones
Barrier methods (condoms, diaphragm)	After lochia resolves; diaphragm needs re-fitting	Yes	No systemic effects
Combined OCP/patch/ring	Start at 3 weeks postpartum (if no VTE risk)	May reduce milk supply	Avoid in breastfeeding for first 3 weeks; estrogen effect on milk production

Postpartum Contraception: US MEC

Method	Breastfeeding <1 month	Breastfeeding >1 month	Non-breastfeeding
Combined hormonal (estrogen-containing)	4 (do not use)	3 (caution 3 weeks - 3 months); 2 after 6 months	4 (<21 days); 2 (21-42 days); 1 (>42 days)
Progestin-only (POP, implant, DMPA)	2	1	1
LNG-IUD	2 (any time)	1	1
Copper IUD	1	1	1