Postpartum Care

Part of Midwifery and Childbirth

Care for the mother in the days and weeks after delivery — physical recovery, breastfeeding support, and mental health.

Why This Matters

Birth is not the end of obstetric risk — it is the beginning of the postpartum period, which carries its own constellation of potentially lethal complications. The majority of maternal deaths that occur after delivery happen in the first 24 hours (hemorrhage, eclampsia) and the first week (sepsis, hemorrhage from retained products). A birth attendant who delivers a healthy baby and then disappears has completed only part of the work.

In traditional societies, the postpartum period was recognized as a distinct phase requiring community support, dietary care, and social protection. Modern medicine rediscovered this wisdom through evidence: women who receive structured postpartum care have dramatically lower rates of maternal mortality, postpartum depression, and breastfeeding abandonment. In a collapse scenario, the new mother is often isolated precisely when she most needs skilled observation.

Postpartum care in a resource-limited setting requires no special equipment — it requires presence, systematic observation, and the knowledge to distinguish normal recovery from developing emergency.

The First Two Hours: Highest Risk Period

The two hours immediately after placental delivery carry the greatest risk of postpartum hemorrhage. The uterus must contract firmly and maintain that contraction to compress the bleeding vessels at the placental site. A uterus that fails to contract (uterine atony) will bleed continuously and silently until the mother is in shock.

Monitoring in the first two hours:

Every 15 minutes:

1. Assess the uterus: Place a hand on the abdomen at the level of the umbilicus. The uterus should be palpable as a firm, round mass (like a grapefruit). If it feels soft or boggy, massage immediately until it firms.
2. Estimate blood loss: Count soaked cloths or pads. Normal blood loss is up to 500 mL in the first hour; ongoing heavy flow beyond this is abnormal.
3. Check maternal pulse: Elevated heart rate (>100 bpm) with ongoing bleeding indicates hemorrhage, even if the mother doesn’t feel unwell yet. The body compensates for blood loss by increasing heart rate before blood pressure drops.
4. Check blood pressure if possible: Falling blood pressure indicates significant blood loss.
5. Ask about symptoms: Dizziness, faintness, nausea.

Uterine massage: If the uterus is soft (atonic):

1. Place one hand flat on the lower abdomen just above the pubic bone (to steady the uterus from below)
2. Cup the other hand around the fundus (top of the uterus)
3. Massage with a firm, circular motion until the uterus firms
4. Do not stop until the uterus is firm — a temporarily firmed uterus that softens again when massage stops will continue to bleed
5. Encourage the baby to suckle — oxytocin released by breastfeeding is a powerful uterotonic

Postpartum hemorrhage response: If blood loss is excessive (soaking large cloths within 15-30 minutes, or the mother is showing signs of shock):

1. Massage the uterus continuously
2. Express any clots that may be preventing contraction
3. If oxytocin is available: administer 10 units intramuscularly immediately
4. Ensure the bladder is empty — a full bladder prevents uterine contraction (catherize if necessary)
5. Bimanual compression (internal and external hands compressing the uterus) can be a lifesaving temporizing measure
6. Tranexamic acid (1g IV or oral) reduces bleeding if available

Days 1-7: Early Postpartum

Normal physical changes:

Lochia: Postpartum vaginal discharge evolves predictably:

• Days 1-3: Lochia rubra — bright red, like a heavy period; may contain clots
• Days 4-10: Lochia serosa — pink-brown, lighter
• Days 10-14+: Lochia alba — white or yellow, much lighter
• Breastfeeding intensifies discharge temporarily (oxytocin contracts the uterus, expelling more)
• Abnormal: foul-smelling lochia, sudden increase in bright red bleeding, large clots after day 3

Uterine involution: The uterus contracts back to its pre-pregnancy size over 6 weeks. The fundus (top) should be at the umbilicus on day 1, descending about 1 cm per day. By day 10, it should not be palpable above the pubic bone.

Afterpains: Uterine cramping, especially during breastfeeding, is normal in the first days and stronger with each subsequent pregnancy. Warmth (hot water bottle on the abdomen) provides relief.

Daily assessment checklist:

System	What to check	Abnormal finding
Uterus	Firm? At expected level?	Soft, tender, not involuting
Lochia	Normal progression?	Foul smell, increasing bright red
Perineum	Healing?	Increasing pain, pus, spreading redness
Legs	Any pain, swelling, redness?	Calf pain, warmth — DVT
Temperature	Below 38°C?	Fever on days 2-10 = infection
Breasts	Soft, then full at day 3-4?	Cracked nipples, hard red area
Mental state	Engaged, coping?	Extreme sadness, confusion
Urination	Passing urine normally?	Unable to urinate, pain

Hydration and nutrition: A postpartum woman needs generous fluids and nutrition. Breastfeeding requires 500 extra calories per day. Iron-rich foods should be prioritized to replace blood loss. Avoid restrictive dietary practices that eliminate major nutrient groups.

Bowel movements: First bowel movement after delivery may be delayed 2-3 days and is often feared by women with perineal sutures. Reassure that the sutures are strong. Encourage dietary fiber and adequate fluid. Straining against repaired tissue is uncomfortable but will not rupture properly placed sutures.

Deep Vein Thrombosis and Pulmonary Embolism

Blood clots in the legs (DVT) or lungs (pulmonary embolism) are a significant cause of maternal death in the postpartum period. Pregnancy increases clotting factors; the postpartum state maintains this hypercoagulable state.

Risk factors: Cesarean delivery, prolonged immobility, dehydration, obesity, previous DVT.

Signs of DVT:

• Pain, swelling, warmth, and redness in one calf
• The affected leg may feel harder than the other
• Homan’s sign (pain in the calf on dorsiflexion of the foot) is neither sensitive nor specific but may be present

Signs of pulmonary embolism (emergency):

• Sudden shortness of breath out of proportion to any other finding
• Chest pain, especially on breathing in
• Rapid heart rate
• Coughing up blood
• Collapse

Prevention:

• Encourage early ambulation — getting out of bed and walking within hours of delivery
• Adequate hydration
• Leg exercises (ankle circles, heel lifts) if full ambulation is not possible

Treatment: Without anticoagulant medication (heparin, warfarin), DVT and PE cannot be reliably treated. If anticoagulants are available, they are indicated immediately. Prevention is far more realistic than treatment in resource-limited settings.

Breastfeeding Support

Common problems in the first week:

Nipple pain: Normal for the first 30-60 seconds of each feed while the nipple adjusts. Pain throughout the feed indicates poor latch. Observe a feeding and correct latch before any other intervention.

Engorgement: Milk “coming in” on days 3-4 causes the breasts to feel very full and hard. Feed frequently (8-12 times per day). Warm compresses before feeding encourage let-down. Cold compresses after feeding reduce inflammation. Engorgement resolves as supply regulates to demand within 1-2 weeks.

Blocked duct: A hard, tender area in one breast without fever. Massage the area while feeding. Feed from the affected side first. Do not stop breastfeeding — emptying the breast is the treatment.

Mastitis: Breast infection — red, hot, painful area in one breast with fever (>38°C) and flu-like symptoms. Continue breastfeeding (breast milk is safe for the baby). Antibiotics (if available: amoxicillin-clavulanate or dicloxacillin) are indicated. Most cases resolve without forming an abscess if treated promptly.

Breast abscess: A fluctuant (soft, wave-like), extremely painful collection of pus. Requires surgical drainage. Breastfeeding from the affected side should pause during drainage; the unaffected side continues.

Mental Health in the Postpartum Period

Maternal mental health is not a luxury concern — postpartum depression impairs the mother’s ability to care for the infant, contributes to infant malnutrition and mortality, and significantly increases the risk of maternal suicide.

Normal emotional changes:

• “Baby blues” — mood swings, tearfulness, anxiety in the first week, affecting up to 80% of women. Resolves spontaneously. Support, rest, and acknowledgment are sufficient.

Postpartum depression: Persistent low mood, tearfulness, inability to enjoy time with the baby, exhaustion beyond physical recovery, feelings of being a failure as a mother, difficulty sleeping even when baby sleeps. Onset typically 2-8 weeks postpartum but can appear up to 1 year.

Signs requiring attention:

• Persistent sadness for more than 2 weeks
• Inability to bond with or care for the infant
• Thoughts of harming herself or the baby
• Complete withdrawal from social contact

Postpartum psychosis: Rare (1-2 per 1000 births) but a true psychiatric emergency. Rapid onset (usually within first 2 weeks) of confusion, hallucinations, delusions, and severely disorganized thinking. Risk of infanticide and suicide is significant. This is not a condition that can be managed at home — the mother requires constant supervision and, if possible, psychiatric care.

Support measures for postpartum mental health:

• Presence of family support
• Realistic expectations — acknowledge that newborn care is genuinely exhausting
• Practical help (meals, household work) so the mother can rest
• Encouraging the mother to express feelings without judgment
• For significant depression: where available, counseling and antidepressant medication (SSRIs are generally safe during breastfeeding)

The Six-Week Postpartum Assessment

A final formal evaluation at approximately 6 weeks assesses complete recovery and readiness to resume normal life.

Physical assessment:

• Uterus fully involuted and not palpable
• Lochia resolved
• Perineal wounds healed
• Breastfeeding established and going well
• Blood pressure returned to normal

Counseling:

• Return to sexual activity: generally safe after 6 weeks when perineal wounds have healed and the woman is emotionally ready
• Contraception: Fertility returns rapidly postpartum, especially in women who are not exclusively breastfeeding. Breastfeeding is not reliable contraception beyond 6 months. Discuss appropriate family planning.
• Iron-rich diet: Continue through breastfeeding

The six-week visit is also an opportunity to identify postpartum depression that may have developed after discharge, address ongoing breastfeeding challenges, and ensure the mother has support as she transitions to independent parenting.