Overview of the postpartum period: Disorders and complications

INTRODUCTION — The postpartum period, also known as the puerperium and the "fourth trimester," refers to the time after giving birth when maternal physiologic changes related to pregnancy return to the nonpregnant state. Numerous disorders and complications may occur in the immediate postpartum period or after discharge from the birth facility. Approximately 0.3 to 0.4 percent of patients experience de novo severe maternal morbidity (SMM) after discharge, and this accounts for approximately 15 percent of SMM [1]. (See "Severe maternal morbidity".)

This topic will provide an overview of postpartum disorders and complications and their management. Many of the specific problems, such as evaluation and treatment of infection or excessive bleeding, breastfeeding issues, contraception, and depression, are discussed in detail in separate topics. An overview of the normal physiologic changes and routine maternal care during the postpartum period is also available separately. (See "Overview of the postpartum period: Normal physiology and routine maternal care".)

DISORDERS AND COMPLICATIONS OF THE EARLY POSTPARTUM PERIOD — The following disorders may present in first few days after giving birth but also can present later.

Signs and symptoms associated with potentially life-threatening conditions

Headache — Pregnant patients with the headache characteristics listed in the table (table 1) may have a serious underlying disorder. Those with headaches having one or more of these features, especially if not typical of the patient's usual headache, should be evaluated immediately for an acute neurovascular event as well as preeclampsia.

However, most postpartum headaches are not associated with serious underlying pathology. The postpartum period is characterized by hormonal and other physiological changes, sleep deprivation, irregular food intake, psychological stress, and fatigue. In addition, many patients have had a neuraxial anesthetic for labor and delivery or have been given vasoactive drugs (eg, ergots). These are all risk factors for development of headache.

The evaluation and treatment of postpartum headache is reviewed separately. (See "Headache during pregnancy and postpartum", section on 'Diagnostic evaluation' and "Headache during pregnancy and postpartum", section on 'Postpartum patients'.)

Hypertension and/or seizures — Hypertension and/or seizures related to preeclampsia/eclampsia can first manifest clinically in the postpartum period. Most, but not all, of these cases occur within 48 hours of giving birth. (See "Preeclampsia: Clinical features and diagnosis" and "Eclampsia".)

Treatment of acute severe hypertension (systolic blood pressure ≥160 mmHg and/or diastolic blood pressure ≥110 mmHg) is always recommended because it reduces the risk of maternal stroke and other serious maternal complications. (See "Treatment of hypertension in pregnant and postpartum patients".)

Magnesium sulfate is the standard medication for prevention of initial and recurrent eclamptic seizures. Candidates for therapy and administration are reviewed elsewhere. (See "Eclampsia", section on 'Prevention of recurrent seizures' and "Preeclampsia: Intrapartum and postpartum management and long-term prognosis", section on 'Seizure prophylaxis'.)

Hemorrhage — We make the diagnosis of postpartum hemorrhage in postpartum patients with bleeding that is greater than expected and results in signs and/or symptoms of hypovolemia (table 2). The diagnosis may be delayed in symptomatic patients (eg, patients with tachycardia, hypotension) when bleeding is not observed, such as intraabdominal bleeding after a vaginal birth or after closure of the abdomen in a cesarean birth. Risk factors, causes, and management are reviewed separately. (See "Overview of postpartum hemorrhage" and "Postpartum hemorrhage: Medical and minimally invasive management".)

Uterine inversion — Uterine inversion (ie, collapse of the uterine fundus into the endometrial cavity turning the uterus partially or completely inside out) is a rare complication of the involuting uterus and is an obstetric emergency. If not promptly recognized and treated, uterine inversion can lead to severe hemorrhage and shock. (See "Puerperal uterine inversion".)

Dyspnea or chest pain — Pulmonary embolism should be suspected in patients with one or more of the following symptoms: acute-onset dyspnea, pleuritic pain, and hemoptysis. In a study of 38 pregnant patients with confirmed pulmonary embolism, the four most common presenting features were dyspnea (62 percent), pleuritic chest pain (55 percent), cough (24 percent), and sweating (18 percent) [2]. (See "Pulmonary embolism in pregnancy: Clinical presentation and diagnosis".)

Peripartum cardiomyopathy (PPCM) is characterized by dyspnea, cough, orthopnea, paroxysmal nocturnal dyspnea, pedal edema, and hemoptysis. Initial diagnosis may be delayed since symptoms such as nonspecific fatigue, shortness of breath, and pedal edema are similar to those observed in normal pregnancy. Risk factors include older age, multiparity, and Black race. Death due to PPCM is usually caused by progressive pump failure, sudden death, or thromboembolic events. (See "Peripartum cardiomyopathy: Etiology, clinical manifestations, and diagnosis" and "Peripartum cardiomyopathy: Treatment and prognosis".)

Postpartum chest pain can be due to cardiovascular, pulmonary, gastrointestinal, or musculoskeletal disease, or due to a presenting symptom of panic disorder or depression. Although the absolute incidence is small, pulmonary embolism, acute myocardial infarction, and possibly aortic dissection occur more often in pregnant/postpartum patients compared with aged-matched nonpregnant females. (See "Evaluation of the adult with chest pain in the emergency department".)

Fulminant colitis — Clostridioides difficile may colonize the human intestinal tract after the normal gut flora has been altered by antibiotic therapy, which many patients receive intrapartum or postpartum [3]. Clinical manifestations of fulminant colitis due to C. difficile include diarrhea, lower quadrant or diffuse abdominal pain, abdominal distention, fever, hypovolemia, lactic acidosis, hypoalbuminemia, elevated creatinine, and marked leukocytosis (up to 40,000 white blood cells/microL or higher). (See "Clostridioides difficile infection in adults: Clinical manifestations and diagnosis", section on 'Severe and fulminant colitis'.)

Severe painful vulvar edema — Rare cases of severe vulvar edema (both unilateral and bilateral) associated with maternal mortality have been reported [4,5]. In some of these cases, obstetric procedures such as forceps-assisted vaginal birth and proctoepisiotomy were performed and perineal trauma occurred. The combination of worsening vulvar edema, induration, perineal pain, and significant leukocytosis (>20,000/mm²) with a left shift characterized patients who had a fatal outcome. These cases may represent life-threatening underlying conditions, such as necrotizing fasciitis or group A streptococcal (GAS) infection, although high fever and an immediately identifiable bacterial cause of infection were not always present. Such patients should be monitored closely and given early empirical treatment with broad-spectrum antibiotics that cover GAS. (See "Pregnancy-related group A streptococcal infection".)

Necrotizing fasciitis must be considered in the differential diagnosis of the postpartum patient with vulvar edema and severe vulvar pain, particularly when associated with fever, erythema, tachycardia, and hypotension. Surgical debridement is mandatory. (See "Necrotizing soft tissue infections".)

Non-life-threatening disorders and complications — The following disorders in postpartum patients are generally not life-threatening, although serious morbidity and mortality (rarely) may be within the spectrum of the disease and its complications.

Voiding difficulty and urinary retention — Postpartum urinary retention (PUR) appears to be due to injury to the pudendal nerve during the birth process. Prolonged pudendal nerve terminal motor latency has been demonstrated after giving birth and can last for two to three months postpartum [6-8]. Rare patients have long-term dysfunction.

●Definition – PUR has various definitions and therefore widely reported rates [9-11]. Overt PUR refers to the absence of spontaneous micturition within six hours of vaginal birth or within six hours of removal of an indwelling catheter after cesarean birth [12]. Covert PUR refers to a postvoid residual bladder volume of at least 150 mL after spontaneous micturition, as verified by catheterization or ultrasound.

●Risk factors – Epidural anesthesia, primiparity, instrument-assisted delivery, and episiotomy were risk factors for overt PUR in a systematic review of 24 observational studies [11].

●Clinical findings – Patients may be asymptomatic or have small voided volumes, urinary frequency or urgency, a slow or intermittent stream, hesitancy, bladder pain or discomfort, urinary incontinence, straining to void, sense of incomplete emptying, or no sensation to void [13]. Bladder distension can be palpated or visualized by ultrasound; an automated bladder ultrasound machine is available that calculates residual volume and can be used by clinicians not trained in ultrasound.

●Management – The treatment of overt PUR is intermittent catheterization. Pharmacological therapies are not effective. Catheterization is indicated if the bladder can be palpated abdominally and the patient is unable to void or voids only small amounts that are suggestive of overflow.

There is no standard protocol for catheterization. In general, catheterization is performed every four to six hours or when the patient has an urge to void but is unable. If the patient is able to void a small volume, then they are instructed to perform self-catheterization to determine the residual volume.

It is reasonable to discontinue catheterization when the residual urine volume is <150 mL and the patient no longer has significant symptoms of voiding difficulty. These criteria are empiric; there is no evidence-based standard [11,14]. Antibiotic prophylaxis is unnecessary with intermittent self-catheterization [15]. (See "Postoperative urinary retention in females", section on 'Clean intermittent catheterization'.)

●Course – Urinary retention is typically a self-limited disorder that can be expected to resolve within one week in most patients [11,16]. In observational studies of patients with covert PUR, 96 to 100 percent had normalization of the postvoid residual volume within two to five days [11,12].

Symptomatic hemorrhoids — Symptomatic hemorrhoids are common postpartum, occurring in approximately one-third of patients [17-19]. The treatment approach depends on the specific symptoms (pruritus, bleeding, pain, or prolapse); drug options are summarized in the table (table 3) and discussed in more detail separately. (See "Home and office treatment of symptomatic hemorrhoids".)

Malodorous lochia — The most common cause of malodorous lochia is a gauze sponge inadvertently left in situ after repair of an episiotomy or lower genital tract laceration. Removal of the foreign body will lead to resolution of the purulent malodorous discharge.

Incontinence — Postpartum incontinence of urine, flatus, or feces is common in the immediate postpartum period and generally improves over the subsequent weeks, but may persist long term.

Postpartum patients should be asked about incontinence as they may not bring the issue up themselves [20].

Evaluation and treatment of urinary and anal incontinence are discussed separately.

●(See "Effect of pregnancy and childbirth on urinary incontinence and pelvic organ prolapse" and "Fecal and anal incontinence associated with pregnancy and childbirth: Counseling, evaluation, and management".)

●(See "Female urinary incontinence: Evaluation" and "Female urinary incontinence: Treatment".)

●(See "Obstetric anal sphincter injury (OASIS)".)

Symptomatic lower extremity varicose veins — Pregnancy is a risk factor for varicose veins, which may appear and become symptomatic anytime during the antepartum or postpartum period [21,22]. Leg elevation, exercise, and compression therapy improve oxygen transport to the skin and subcutaneous tissues, decrease edema, reduce inflammation, and compress dilated veins. Varicose veins are a risk factor for superficial phlebitis and thrombosis. Evaluation and management are discussed in detail separately. (See "Overview of lower extremity chronic venous disease".)

Mild vulvar edema — Mild vulvar edema is not uncommon after giving birth and, in most circumstances, can be managed with ice packs and other comfort measures to provide symptom relief. It has been associated with prolonged second stage of labor, preeclampsia, and use of tocolytics for treatment of preterm labor [23].

After resolution of bilateral labial edema, labial agglutination may occur but is rare [24].

Rarely, vulvar edema can be a manifestation of hereditary angioedema. (See "An overview of angioedema: Clinical features, diagnosis, and management".)

Bothersome peripheral or generalized edema — Lower extremity edema is common during pregnancy and may worsen or become generalized postpartum as a result of intrapartum fluid administration and increased pressure in pelvic veins. Pathologic causes include peripartum cardiomyopathy, preeclampsia, and venous thrombosis. In the absence of a pathologic disorder requiring specific treatment, management is typically expectant as the edema will resolve over time. Interventions that may hasten the process include whole body water immersion (bathing, swimming), compression stockings, reflexology, and/or leg elevation.

Diuretics are not used since edema is self-limited, they can have serious side effects (eg, hypokalemia), and there is concern that they may reduce milk supply if the patient is breastfeeding. In a very rare situation in which a patient with bothersome severe edema strongly desires medication, a short course (≤5 days) of a low dose of furosemide (≤20 mg orally daily) may be considered in the absence of hypokalemia and with counseling to monitor milk supply/neonatal weight if breastfeeding. Although diuretics have been used postpartum for treatment of cardiovascular conditions (hypertension, pulmonary edema, cardiomyopathy), there is no published literature on use of diuretics for bothersome edema alone.

Fever/infection/wound complications — The United States Joint Commission on Maternal Welfare defined postpartum febrile morbidity as an oral temperature ≥38.0°C (≥100.4°F) on any two of the first 10 days postpartum, exclusive of the first 24 hours [25]. The first 24 hours were excluded because low-grade fever during this period is common and often resolves spontaneously, especially after vaginal birth. This definition has been in use for decades.

The following conditions should be considered in the differential diagnosis of postpartum fever and are usually readily differentiated by history and physical examination, with additional laboratory evaluation and imaging studies, as indicated:

●Surgical site infection (eg, episiotomy, laceration, abdominal incision) – In a systematic review, the rate of childbirth-related perineal wound infection ranged from 0.1 to 24.0 percent, and the rate of wound dehiscence ranged from 0.2 to 25.0 percent [26].

Perineal infections, and subsequent breakdown of previously repaired lacerations or episiotomies, are usually localized to the skin and subcutaneous tissue. On examination, the area appears swollen and erythematous with a purulent exudate. Treatment consists of opening the wound, drainage, irrigation, and debridement of foreign material and necrotic tissue. Antibiotics are unnecessary unless there is accompanying cellulitis. The area will heal by granulation, but large defects may be resutured when the wound surface is free from exudate and covered by pink granulation tissue. (See "Approach to episiotomy", section on 'Complications' and "Delayed surgical management of the disrupted anal sphincter".)

Wound infection is diagnosed in 2.5 to 16 percent of patients after cesarean birth [27], generally four to seven days after surgery. Management of wound complications is reviewed separately. (See "Basic principles of wound management" and "Cesarean birth: Postoperative care, complications, and long-term sequelae", section on 'Wound complications'.)

●Endometritis – Key clinical findings, which are present in most patients, include postpartum fever, tachycardia that parallels the rise in temperature, midline lower abdominal pain, and uterine tenderness. The diagnosis is clinical and largely based upon the presence of postpartum fever that cannot be attributed to another etiology after a thorough history and physical examination. (See "Postpartum endometritis".)

●Pelvic abscess – Pelvic abscess is rare after cesarean birth and very rare after a vaginal birth [28-31]. Endometritis, postoperative pelvic hematoma, and inadvertent retention of a foreign body are potential risk factors. Symptoms are nonspecific and include lower abdominal pain, fever and chills, nausea, and malodorous genital bleeding. Abscess should be suspected in patients with persistent symptoms, particularly persistent spiking fever, despite antibiotic therapy. Computed tomography is preferred for diagnosis but ultrasound imaging is acceptable. Treatment often requires drainage, which can be performed percutaneously. (See "Posthysterectomy pelvic abscess".)

●Mastitis or breast abscess – Lactation mastitis typically presents as a firm, red, and tender area of one breast with a maternal temperature that exceeds 38.5°C. A tender, fluctuant area is more indicative of an abscess. Systemic complaints may be present and include myalgia, chills, malaise, and flu-like symptoms. Differential diagnosis includes plugged ducts, galactocele, and rarely inflammatory breast cancer. Mastitis that does not respond promptly to adequate breast drainage and antibiotics should prompt investigation for an underlying abscess or a resistant organism such as methicillin-resistant Staphylococcus aureus (MRSA). (See "Common problems of breastfeeding and weaning", section on 'Breast infections'.)

●Urinary tract infection (cystitis, pyelonephritis) – Cystitis symptoms include dysuria, frequency, urgency, suprapubic pain and/or hematuria but not fever if infection is isolated to the bladder. Dysuria alone in the first few days postpartum is not uncommon after vaginal birth with a laceration or episiotomy. Pyelonephritis may be associated with cystitis but is characterized by fever (>38°C), chills, flank pain, costovertebral angle tenderness, and nausea/vomiting. (See "Acute complicated urinary tract infection (including pyelonephritis) in adults and adolescents".)

●Septic pelvic thrombophlebitis – Patients present with one of two somewhat distinctive syndromes (see "Septic pelvic thrombophlebitis"):

•Patients with ovarian vein thrombophlebitis are usually acutely ill, with fever and abdominal pain within one week after giving birth; thrombosis of the ovarian vein (usually on the right side) can sometimes be visualized radiographically.

•Patients with deep septic pelvic thrombophlebitis present more subtly with isolated fever in the early postpartum period and notably do not have abdominal or pelvic tenderness, and radiographic imaging typically does not identify thrombosis of a specific vein.

●C. difficile infection – C. difficile-associated diarrhea has been reported in pregnant and, more commonly, postpartum patients [32,33]. Manifestations of the disease include watery diarrhea up to 10 or 15 times daily with lower abdominal pain cramping, low grade fever, and leukocytosis. These symptoms generally occur in the setting of recent antibiotic administration (table 4). Initial treatment generally involves cessation of the causative antibiotic and initiation of oral therapy with vancomycin, fidaxomicin, or metronidazole (table 5). Diagnosis and treatment are discussed in detail separately. (See "Clostridioides difficile infection in adults: Clinical manifestations and diagnosis" and "Clostridioides difficile infection in adults: Treatment and prevention".)

●Drug fever – Drug fever is usually a diagnosis of exclusion. Rash may be present. (See "Drug fever".)

Neuropathy — Postpartum neuropathy complicates approximately 1 percent of deliveries [34]. Postpartum nerve deficits are usually mononeuropathies that result from compression, stretch, transection, or vascular injury. The most commonly injured nerve is the lateral femoral cutaneous nerve, but injuries may also involve the femoral nerve, peroneal nerve, lumbosacral plexus, sciatic nerve, and obturator nerve [34]. Rarely, neuropathic symptoms can reflect complications that directly result from neuraxial anesthesia, such as epidural hematoma and epidural abscess [35].

Risk factors for postpartum neuropathy include fetal macrosomia or malpresentation, sensory blockade (can impair recognition of discomfort), prolonged lithotomy position, prolonged second stage of labor, extremes of maternal weight, and improper use of leg stirrups or retractors [36]. However, many of these factors are interdependent (eg, prolonged lithotomy position and prolonged second stage).

●Clinical findings – Patients present with pain, weakness, and/or sensory abnormalities in the lower extremities. The precise presentation depends on the nerve affected:

•Patients with significant femoral neuropathy develop weakness involving the quadriceps muscle group with sparing of adduction. In addition to muscle weakness, sensory loss over the anterior thigh and most of the medial thigh is typical.

•The lateral femoral cutaneous nerve does not contain motor fibers; thus, neurologic symptoms are restricted to sensory changes. Lateral hip pain accompanied by paresthesias (burning pain) or hypesthesias (numbness and tingling) over the upper outer thigh is the classic presentation of compression of this nerve. (See "Neurologic disorders complicating pregnancy", section on 'Meralgia paresthetica'.)

•Peroneal nerve compression results in foot drop. It can be caused by prolonged squatting, sustained knee flexion, or pressure on the fibular head from stirrups or palmar pressure during pushing.

•Obturator neuropathies are an uncommon complication of giving birth and present with medial thigh pain and adductor weakness.

●Evaluation – Evaluation generally includes a detailed physical examination of the lower extremities with a focus on musculoskeletal, vascular, and neurologic function [35]. The back examination includes range of motion, palpation, and maneuvers that aggravate radicular pain. A focused neurologic examination can define the pattern of motor and sensory impairment. Neurologists will generally suggest spinal imaging in patients with significant back pain with unexplained fever, worsening neurologic symptoms, coagulopathy, and immunosuppression, or in patients whose motor/sensory symptoms localize to the spinal cord. Imaging can identify an epidural hematoma, abscess, demyelination, and disc herniation.

●Treatment – Treatment depends on the symptoms. For pain, nonsteroidal anti-inflammatory drugs are the first line therapy [35]. Additional pain treatment can include neuropathic pain medications (must assess for compatibility with breast feeding), topical patches, or peripheral nerve block (for intractable pain). A physical therapist can examine muscle weakness, assess patient safety issues (eg, need for support braces, physical activity in the home), and teach muscle strengthening exercises.

●Prognosis – Most patients will have spontaneous resolution of their symptoms over days to weeks; the median time for recovery is eight weeks [34,37].

Vaginal dryness — Symptoms of vaginal dryness can be managed by regular use of vaginal moisturizing agents with supplemental use of vaginal lubricants for sexual intercourse. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment", section on 'Initial therapy with moisturizers and lubricants'.)

If these measures fail, low-dose topical vaginal estrogen is often successful in alleviating symptoms until reproductive hormone levels increase. If estrogen is used in the early postpartum period, breastfeeding mothers should be counseled to monitor milk supply because systemic absorption of estrogen theoretically can decrease milk supply. (See "Overview of the postpartum period: Normal physiology and routine maternal care", section on 'hCG, hot flashes, resumption of ovulation' and "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment", section on 'Preparations: Cream, tablet, capsule, ring'.)

Pelvic girdle and other musculoskeletal pain — Pain from increased mobility of the pubic symphysis, as well as from pelvic girdle syndrome (pain in all three pelvic joints) or unilateral/bilateral sacroiliac joint pain, may occur before or after giving birth. Several other musculoskeletal disorders may develop or flare during pregnancy or the postpartum period (eg, rheumatoid arthritis). Diagnosis and treatment are discussed separately. (See "Maternal adaptations to pregnancy: Musculoskeletal changes and pain".)

Complications of neuraxial anesthesia — Postdural puncture headache (also called postspinal headache) after neuraxial analgesia is due to leakage of cerebrospinal fluid through a dural rent, traction on cranial structures, and cerebral vasodilation. The pathognomonic quality of this headache is its positional nature, worsened by sitting or standing and relieved by lying down. If the headache does not have this quality, other causes of headache should be sought. (See "Adverse effects of neuraxial analgesia and anesthesia for obstetrics", section on 'Post dural puncture headache'.)

Epidural abscess or meningitis are uncommon complications of neuraxial block.

POSTDISCHARGE ISSUES AND COMPLICATIONS — The following disorders present or usually present after the patient has been discharged from the hospital.

Emergency department visit and readmission

●Short term (≤90 days) – In a review of database including over one million deliveries, 8.3 percent of postpartum patients had an emergency department visit in the 90 days postdischarge [38]. The most common diagnostic codes were "complications of puerperium," urinary tract infection, wound complication, gallbladder disease, genitourinary tract infection, delayed postpartum hemorrhage, abdominal pain, headache, and inflammatory breast disease.

●Longer-term (≤180 days) – In a review of a database including over 200,000 postpartum patients observed from delivery through 180 postpartum days found that 1.2 percent were readmitted within six weeks (0.83 percent after vaginal birth and 1.8 percent after cesarean birth) [39]. The most common reasons for readmission were hypertension and uterine and wound complications, particularly infection and bleeding. Gallbladder disease, urinary tract infection, mastitis, and specific medical/surgical conditions were the next most common reasons for readmission. After cesarean birth, deep venous thrombosis, cardiomyopathy, and pneumonia were relatively common. Appendicitis was significantly more common in the first six weeks postpartum than in the next 20 weeks.

Hypertension — Patients with severe hypertension diagnosed in the peripartum period should have follow-up for blood pressure evaluation within 72 hours of discharge while those with mild peripartum hypertension can be seen within seven days postpartum. In a large study of patients with peripartum hypertension, 4.7 percent subsequently required readmission for hypertension, but this risk was reduced in those discharged with nifedipine. Other risk factors for readmission included a systolic blood pressure ≥140 or a diastolic blood pressure ≥90 mmHg within 12 hours of discharge, especially if untreated [40]. One study observed that patients initially discharged on labetalol were more likely to require readmission when compared to those discharged on nifedipine [41]. (See "Preeclampsia: Clinical features and diagnosis" and "Eclampsia".)

Sexual dysfunction — Postpartum sexual dysfunction (including dyspareunia) is common [42,43]. In a study of over 1400 primiparous Australian patients who returned a postpartum questionnaire, 89 percent reported sexual health issues in the first three months postpartum and approximately one-half reported ≥3 sexual health concerns [42]. Factors that can contribute to postpartum sexual dysfunction include a history of a chronic pain condition; perineal trauma; emergency cesarean birth or instrument-assisted vaginal birth; low estrogen level and insufficient vaginal lubrication, particularly in breastfeeding individuals; and postpartum mood changes, fatigue, and time constraints [43,44]. Although this study reported that problems such as lack of lubrication and pain returned to prepregnancy levels by 12 months postpartum, the rate of low libido remained higher compared with prepregnancy (51 and 42 percent, respectively) [42].

Since postpartum issues, particularly low libido, may not resolve with time, clinicians should continue to question patients about their sexual function at follow-up visits, even if sexual function is not the indication for the visit. Evaluation and management of sexual dysfunction are discussed in detail separately. (See "Overview of sexual dysfunction in females: Epidemiology, risk factors, and evaluation", section on 'Pregnancy and childbirth' and "Overview of sexual dysfunction in females: Management".)

Mental health issues — Postpartum mood disorders are common. It is important that postpartum care includes routine screening for postpartum depression and anxiety using a validated tool at all postpartum visits, such as the self-report, 10-item Edinburgh Postnatal Depression Scale (figure 1A-B). Patients with a history of a prepregnancy mental health condition are more likely to experience postpartum depression. Additional early postpartum follow-up visits for mood and adjustment assessment should be considered in patients at high risk for postpartum mood disorders, such as those with a prior history of depression (postpartum or unrelated to pregnancy), anxiety, bipolar disorder, or other psychiatric conditions requiring treatment. Clinicians should have local resources available to provide additional support when indicated.

●Blues and depression – Postpartum blues (maternity blues or baby blues) refer to a transient condition characterized by several mild depressive symptoms such as sadness, crying, irritability, anxiety, insomnia, exhaustion, and decreased concentration, as well as mood lability that may include elation [45-47]. Symptoms typically develop within two to three days of giving birth, peak over the next few days, and resolve within two weeks of onset [46]. (See "Postpartum blues".)

Depressive symptoms such as dysphoria, insomnia, fatigue, and impaired concentration can appear in both postpartum blues and postpartum major depression. However, the two disorders are distinguished in that the diagnosis of postpartum blues does not require a minimum number of symptoms, whereas major depression requires a minimum of five symptoms (table 6). In addition, the symptoms of postpartum blues are generally self-limited and resolve within two weeks of onset. By contrast, the diagnosis of major depression requires that symptoms must be present for at least two weeks. The validated questionnaire most commonly used for screening pregnant and postpartum individuals is the Edinburgh Postnatal Depression Scale (figure 1A-B), but other validated tools can be used (table 7). (See "Postpartum unipolar major depression: Epidemiology, clinical features, assessment, and diagnosis", section on 'Assessment' and "Postpartum unipolar major depression: Epidemiology, clinical features, assessment, and diagnosis", section on 'Diagnosis'.)

●Posttraumatic stress disorder (PTSD) – The prevalence of postpartum PTSD varies depending on the definition used and time of assessment after giving birth [48]. In a systematic review, mean prevalence was 4.0 percent (95% CI 2.77-5.71) in the general obstetric population; patients in high-risk groups (eg, complicated pregnancy or birth, history of sexual/physical trauma) were at higher risk: 18.5 percent (95% CI 10.6-30.38) [49].

Possible risk factors for PTSD include prepregnancy stress (eg, sexual/physical trauma, history of PTSD or other mental health disorders), a negative pregnancy experience (eg, fear of childbirth, low support, perceived lack of control, maternal morbidity, pregnancy complications), and delivery issues and complications (lack of social support, emergency cesarean, instrument-assisted vaginal birth, postpartum hemorrhage, stillbirth or poor neonatal outcome), but available data are not robust or consistent [49-52].

PTSD screening tools have been useful for screening and validated in nonpregnant populations (table 8), but they have not be studied postpartum. Nevertheless, screening and treatment should be considered [53]. Asking questions such as: What was your birth experience like? Do you wish things had gone differently? Have you had upsetting thoughts in general since the birth? can be helpful in identifying patients at risk [54]. Providing advice and support, as well as referral when needed, can reduce the risk of PTSD developing.

Treatment interventions include debriefing, structured psychological interventions, expressive writing interventions, encouraging skin-to-skin contact with healthy newborns immediately postpartum, and holding or seeing the newborn after stillbirth [55]. Pharmacologic interventions are also available. (See "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical features, assessment, and diagnosis" and "Posttraumatic stress disorder in adults: Treatment overview".)

●Postpartum psychoses – Postpartum psychoses are less common than depression and PTSD but are serious and potentially life-threatening disorders. (See "Postpartum psychosis: Epidemiology, clinical features, and diagnosis" and "Bipolar disorder in postpartum women: Epidemiology, clinical features, assessment, and diagnosis" and "Treatment of postpartum psychosis" and "Bipolar disorder in postpartum women: Treatment".)

●Substance use disorder – Patients identified as having a substance use disorder require postpartum counseling with referral and treatment as appropriate, especially those with opioid use disorder. Treatment and recovery facilities that allow for care of the newborn are ideal. (See "Substance use during pregnancy: Screening and prenatal care".)

Overdose mortality rates have increased substantially (81 percent) between 2017 and 2020 for pregnant and postpartum individuals; the risk appeared to be greater in the late postpartum period [56]. In addition to encouraging adherence to treatment, availability of naloxone in the home of patients with substance use disorder should be discussed. (See "Opioid use disorder: Treatment overview".)  

Thyroid disease — The prevalence of both painless thyroiditis (postpartum thyroiditis) and Graves' disease is increased postpartum, occurring in approximately 8 percent of the general obstetric population [57]. In one Japanese study, 86 percent of patients developing thyrotoxicosis in the first three months postpartum had thyroiditis, while after 6.5 months, all the patients had Graves' disease [58]. The risk is increased more than twofold in patients with type 1 diabetes and more than fivefold in patients with antithyroid peroxidase antibodies.

Approximately 20 to 30 percent of patients with postpartum thyroiditis have the characteristic sequence of hyperthyroidism, which usually begins one to four months after giving birth and lasts two to eight weeks, followed by hypothyroidism, which also lasts from two to eight weeks, and then recovery. However, 20 to 40 percent have only hyperthyroidism, and the remaining 40 to 50 percent have only hypothyroidism, which begins two to six months after giving birth. Symptomatic patients should undergo laboratory evaluation and usually undergo treatment if hyper- or hypothyroidism is confirmed. (See "Postpartum thyroiditis".)

Persistent vaginal bleeding — Vaginal bleeding that persists for more than approximately eight weeks after giving birth is unusual and may be due to infection, retained products of conception, a bleeding diathesis, or, rarely, choriocarcinoma or a uterine vascular anomaly, as well as other causes. A temporary increase in bleeding at this time may represent menses; in such cases, bleeding should stop within a few days. New bleeding several weeks after giving birth could also be related to a new pregnancy. The evaluation and management of excessive or prolonged late postpartum bleeding are reviewed separately. (See "Secondary (late) postpartum hemorrhage", section on 'Definition/diagnosis'.)

Cervical cancer screening — Cervical cancer screening is performed according to standard schedules. (See "Screening for cervical cancer in resource-rich settings".)

Management of abnormalities is the same as in nonpregnant patients. (See "Cervical cancer screening: Risk assessment, evaluation, and management after screening" and "Cervical cytology: Evaluation of atypical and malignant glandular cells".)

Postpartum weight retention — Weight retained after pregnancy is defined as the difference between postpartum and prepregnancy weight. The National Academy of Medicine (NAM) estimated that, at six months postpartum or later, mean postpartum weight retention was 5.4 kg (11.8 pounds), approximately half of individuals retained more than 4.5 kg (10 pounds), and one-quarter retained more than 9.1 (20 pounds) [59]. This weight gain exceeds that observed in comparable nulliparous females over the same time period [60].

Risk factors for weight retention include the following:

●Excessive weight gain during pregnancy – Patients who gain more than the NAM guideline are twice as likely to retain ≥9 kg postpartum [61,62].

●Black race – Black patients retain more weight than White patients, despite comparable prepregnancy body mass index (BMI) or weight gain during pregnancy [61,63].

●Obesity – An increasing BMI correlates with an increased tendency to postpartum weight retention [61].

●Smoking cessation – Patients who quit smoking during pregnancy and do not resume postpartum are at high risk of retaining weight [64].

Other factors that appear to be associated with postpartum weight retention are maternal age (adolescents are at high risk), parity, ethnicity, marital status, pregnancy interval, and return to work [61].

Excessive weight gain during pregnancy and failure to lose weight postpartum appear to predict higher BMI and increased risk for hypertension and cardiovascular disease long after giving birth [65-69]. A study with long-term follow-up reported that individuals who attained their prepregnancy weight by six months postpartum had less increase in long-term weight gain than those who did not (2.4 versus 8.3 kg) [66]. In another series, individuals who had large weight gains during the first pregnancy and/or retained weight after delivery were at higher risk of doing so in subsequent pregnancies, thereby increasing their long-term risk for obesity with each pregnancy [67].

The best strategy for achieving postpartum weight reduction has not been determined. In a 2013 systematic review of the effect of diet and/or exercise for postpartum weight reduction, diet or diet and exercise facilitated postpartum weight loss and appeared to be safe for both breastfeeding and non-breastfeeding individuals and their infants [70]. The use of exercise has advantages such as improvement of maternal cardiorespiratory fitness and preservation of fat-free mass, while use of diet alone reduces fat-free mass. The appropriate rate of return to prepregnancy weight is unclear; some experts suggest an interval of six months to one year, or 0.5 kg/week [68,71,72]. (See "Obesity in adults: Overview of management".)

Breastfeeding may help to avoid long-term postpartum weight retention. Data from the Special Supplemental Nutrition Program for Women, Infants, and Children showed a slight benefit: Individuals breastfeeding for ≥20 weeks began their second pregnancy with 0.39 kg less retained weight than their non-breastfeeding counterparts [73]. A more clinically significant effect was observed in a prospective cohort study that found 0.5 kg postpartum weight retention at three years for individuals exclusively breastfeeding for six months versus 4.8 kg for those who never exclusively breastfed [74].

Interpregnancy weight gain — A large interpregnancy weight gain has adverse effects on a subsequent pregnancy, even in individuals with low prepregnancy BMI [75,76]. A cohort study of over 200,000 individuals who had two consecutive singleton pregnancies within 10 years (mean interval two years) determined the change in maternal prepregnancy BMI between first and second pregnancies and evaluated whether this change was associated with the outcome of the second pregnancy [75]. Compared with individuals whose BMI changed -1.0 to +0.9 units, a three unit increase in BMI (approximately 9 kg for a female of average height) between pregnancies was associated with significantly increased risks of preeclampsia, gestational hypertension, gestational diabetes, cesarean birth, large-for-gestational age newborn, and stillbirth in the second pregnancy. The increase in risk was related linearly to the amount of weight gained in the interpregnancy interval, and was also noted in individuals who gained weight but whose BMI remained in the normal range. The effect of a modest to large weight loss (more than -1 BMI units or at least 3 kg) between pregnancies could not be evaluated because there were too few individuals in this subgroup.

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".)

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 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: Health and nutrition during breastfeeding (Beyond the Basics)" and "Patient education: Pumping breast milk (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Overview – Postpartum care should focus on identifying patients at risk for significant short-term morbidity and mortality. (See 'Introduction' above.)

●Signs and symptoms of major concern – Postpartum patients with headache, new or worsening hypertension, seizure, excessive bleeding, dyspnea or chest pain, severely symptomatic or worsening abdomen pain, or vulvar symptoms should be evaluated promptly. (See 'Signs and symptoms associated with potentially life-threatening conditions' above.)

●Other adverse events – A variety of adverse events may occur after giving birth, including urinary retention, hemorrhoids, incontinence, neuropathy, anesthesia-related morbidity, and several types of infections. (See 'Non-life-threatening disorders and complications' above.)

Disorders that may present after discharge or the initial postpartum visit include sexual dysfunction, mental health issues, thyroiditis, breastfeeding concerns, and problems managing weight. (See 'Postdischarge issues and complications' above.)

●Depression screening – In accordance with guidelines from multiple organizations, we screen all patients for postpartum depression. The Edinburgh Postnatal Depression Scale (figure 1A-B) is widely used. Programs that combine screening and adequate support systems improve clinical outcomes in pregnant and postpartum patients. (See 'Mental health issues' above.)