Postpartum Care & Complications
Sorting normal recovery from the fever, breast, mood, and hormone problems that need action
The normal puerperium and follow-up
Involution and lochia. The fundus sits at the umbilicus after birth, descends about 1 cm per day and is no longer palpable abdominally by about 2 weeks; the uterus nears its prepregnancy size by 6 weeks. Lochia rubra (blood and decidua) lasts 3–4 days, lochia serosa (pink-brown) continues to about day 10, and lochia alba (yellow-white, mostly leukocytes) can persist up to about 6 weeks. Afterpains with nursing (oxytocin), a brisk diuresis in the first week and early leukocytosis are all normal.
Bright-red bleeding that recurs or persists beyond the first week suggests retained products or subinvolution of the placental site.
Follow-up. Contact within the first 3 weeks and a comprehensive visit no later than 12 weeks cover mood, contraception, feeding and chronic disease. After a hypertensive disorder of pregnancy, blood pressure is checked within 7–10 days, or within 72 hours if it was severe.
Preeclampsia can first appear up to 6 weeks postpartum: a new severe headache, visual symptoms or BP ≥160/110 calls for magnesium sulfate and antihypertensives, not reassurance.
Contraception after delivery
| Method | Earliest start | Key point |
|---|---|---|
| Implant, progestin-only pill, DMPA | Immediately | No estrogen; acceptable while breastfeeding |
| Copper or LNG IUD | Within 10 minutes of placental delivery, or later | Immediate placement has more expulsions; not with postpartum sepsis or endometritis |
| Combined pill, patch, ring | Not before 21 days | Wait ≥30 days if breastfeeding and ≥42 days with other VTE risk factors |
| Lactational amenorrhea | From delivery | ~98% effective only while all three criteria hold |
Timing logic. Postpartum hypercoagulability plus estrogen makes combined methods unacceptable before 21 days; extra VTE risk factors (cesarean, age ≥35, BMI ≥30, smoking, preeclampsia, transfusion) push the start to 42 days, and estrogen may reduce milk supply. Women who do not breastfeed can ovulate by 3–4 weeks, before their first period, so contraception is planned before discharge.
Lactational amenorrhea. Suckling keeps prolactin high, which suppresses GnRH pulses and therefore ovulation. The method works only while the infant is younger than 6 months, menses have not returned and breastfeeding is exclusive or nearly so, day and night; when any criterion lapses, another method must start.
Postpartum fever
Endometritis. The leading cause of postpartum fever is polymicrobial infection of the decidua, including anaerobes such as Bacteroides. Cesarean delivery, especially after labor or membrane rupture, is the main risk (preincision cefazolin lowers it), along with prolonged rupture of membranes, chorioamnionitis and manual removal of the placenta. Fever 2–3 days after delivery with fundal tenderness, foul lochia and tachycardia is treated with IV clindamycin plus gentamicin until afebrile for 24–48 hours; no oral course follows.
Other sources. Cesarean wound infection appears around days 4–7 with erythema, induration and drainage: cellulitis is treated with antibiotics, while an abscess or infected seroma is opened, drained and packed. Also consider urinary tract infection after catheterization, pneumonia, DVT, drug fever, mastitis and retained products of conception.
- Examine and cultureFundus, incision, breasts, legs and lungs; urine and blood cultures
- Treat endometritisIV clindamycin plus gentamicin
- Still febrile at 48–72 hoursAdd ampicillin for enterococcus; image for abscess, hematoma or retained tissue
- No drainable sourceSuspect septic pelvic thrombophlebitis and add therapeutic heparin or LMWH
Septic pelvic thrombophlebitis. Infected thrombus in the pelvic veins, usually the right ovarian vein, follows cesarean delivery or endometritis. Fever keeps spiking despite appropriate antibiotics in a woman who looks well between spikes. CT or MRI may show the clot but is often negative, so it is a diagnosis of exclusion; adding anticoagulation brings defervescence that supports the diagnosis.
Breast problems
| Feature | Engorgement | Lactational mastitis | Breast abscess |
|---|---|---|---|
| Timing | Days 2–5, as milk comes in | Usually the first 6 weeks | Mastitis not improving after 48–72 hours of antibiotics |
| Findings | Bilateral, diffuse firmness and tenderness; low-grade or no fever | Unilateral wedge of erythema, high fever, myalgias | Tender fluctuant mass, persistent fever |
| Cause | Milk stasis | S. aureus most often | S. aureus, including MRSA |
| Management | Frequent feeding, cold packs, analgesics | Continue breastfeeding; dicloxacillin or cephalexin (clindamycin if MRSA suspected) | Ultrasound, then ultrasound-guided aspiration plus MRSA-active antibiotics; incision and drainage if large |
Keep milk moving. Nursing from the affected breast is safe for the infant and speeds recovery, whereas abrupt weaning during mastitis promotes abscess formation. Redness that persists despite treatment needs biopsy to exclude inflammatory breast cancer.
Postpartum mood disorders
| Feature | Postpartum blues | Postpartum depression | Postpartum psychosis |
|---|---|---|---|
| Frequency | Most new mothers | About 1 in 7 | 1–2 per 1,000 births |
| Onset and course | Days 2–3; resolves within 2 weeks | In pregnancy or the months after birth; ≥2 weeks of symptoms | Usually within 2 weeks; abrupt |
| Features | Tearful, labile, anxious; functioning, not suicidal | Major depressive symptoms, impaired function, possible suicidal ideation | Confusion, delusions about the infant, hallucinations, rapid mood swings |
| Management | Reassurance, support, follow-up | Psychotherapy ± SSRI; zuranolone or brexanolone | Hospitalize; antipsychotic plus mood stabilizer; ECT if refractory |
Screening and treatment. Screen with the Edinburgh Postnatal Depression Scale (EPDS) in pregnancy and postpartum, and ask every positive screen about suicidal thoughts and thoughts of harming the infant; prior depression is the strongest risk factor. Cognitive behavioral or interpersonal therapy suits mild to moderate illness; moderate to severe illness adds an SSRI, with sertraline favored for low milk transfer, and breastfeeding continues. Zuranolone, an oral neuroactive steroid that enhances GABA-A signaling, is taken for 14 days with no driving for 12 hours after a dose; brexanolone is a related IV infusion.
Psychosis. Often the first episode of bipolar disorder, postpartum psychosis carries risks of suicide and infanticide: hospitalize, never leave the mother alone with the baby, exclude organic causes, and treat with antipsychotics plus lithium or another mood stabilizer.
Intrusive, unwanted images of harming the baby that horrify the mother suggest postpartum obsessive-compulsive disorder rather than psychosis.
Endocrine and bladder complications
Postpartum thyroiditis. Painless autoimmune thyroiditis in women with anti-TPO antibodies occurs within the first year. A thyrotoxic phase at about 1–4 months comes from release of stored hormone (small nontender goiter, negative TSH receptor antibodies, low radioiodine uptake, a test avoided while breastfeeding) and needs only a β-blocker, since thionamides do not help. A hypothyroid phase at about 4–8 months is treated with levothyroxine if symptomatic or planning pregnancy. Permanent hypothyroidism can follow, so TSH is checked yearly, and recurrence after later pregnancies is common.
Sheehan syndrome. Severe postpartum hemorrhage with hypotension infarcts the pituitary, which is enlarged in pregnancy by lactotroph hyperplasia. Failure to lactate is the first clue, followed by absent menses, fatigue, hypotension, hyponatremia, hypoglycemia, cold intolerance and loss of axillary and pubic hair. Low pituitary and target hormones confirm it, and MRI later shows an empty sella. Replace glucocorticoids before levothyroxine to avoid precipitating adrenal crisis.
Urinary retention. Epidural analgesia, operative vaginal delivery, a prolonged second stage, perineal trauma or hematoma and first births predispose. A woman who has not voided within about 6 hours of delivery or catheter removal gets a bladder scan and intermittent or indwelling catheterization. An overdistended bladder displaces the fundus and causes uterine atony, so it is emptied before more uterotonics are given.