area of focus:
What you should know about the days and weeks following birth.
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The Postpartum Period
*This article is divided into 3 sections. Carmelle Gentle has put together an in-depth (but not exhaustive) guide to the Postpartum period.
PART 1: What to Expect and Taking Care of Yourself in the Postpartum
Giving birth to your baby is a pivotal life-changing event. During your pregnancy, there is often a lot of focus around the build-up and preparation toward your labour and birth, yet, several studies and surveys conducted as well as anecdotal evidence, consistently show that women often feel that they enter the early postnatal period feeling unprepared both physically and emotionally.
The physical, mental and emotional changes that occur after birth can feel overwhelming for many women. The planning and preparation for your postpartum phase are as fundamental as preparing for your birth. In comparison to labour and birth, the postnatal period extends up to 8 weeks after your baby is born, and the impact of transitioning into motherhood can continue for some women, for far longer.
What should one expect/anticipate in the early days after birth?
Every birth experience is individually unique and the recovery phase will vary according to your birth events. Your body has and is experiencing remarkable changes, to aid your recovery pay particular attention to how your body feels and try to respond accordingly. It can be so easy to solely focus on your newborn and forget about yourself. You will feel tired, and in some instances exhausted as you adjust to waking up frequently at night with your baby. Notice the changes within your body and try to resist the temptation of overdoing things. Key things to remember to aid your recovery in the first 6-8 weeks include:
Rest and self-care
Factoring rest where possible can make a difference to how you feel both physically and mentally and emotionally. Sleeping when your baby sleeps although desirable is not always achievable. Having a moment of rest within your day is a good start particularly in the earlier days and weeks as you recuperate. When you feel ready to, find a period of the day for yourself, taking time out from the busyness of being a new parent enables you to give back to yourself and for a brief pause; for example going for a gentle walk, a warm bath, listening to music incorporating gentle movement, reading, meditation or anything else that you love to do for you. It can help to feel restored, refocused and grounded in the midst of it all.
The blood loss experienced after birth is known as the lochia, it is a combination of blood, tissue and mucous shedding from your womb. What can you expect to see from your lochia:
- Day 1-3 – heavier flow, fresh red to brownish red blood loss, small clots may be seen
- Day 3-6 moderate flow, pinkish/red to dark brown blood loss, smaller clots may be visible
- Day 6-10 lighter flow, light brown staining or pinkish loss, scanty/streaky/mucusy loss. You may notice your flow increases on overexertion or increased activity.
- Day 11-14 increasingly lighter flow observed, lighter brown/orangey or pinkish loss
- 3-6 weeks- pale/creamy discharge can last for several weeks
If you notice any large-sized clots, heavy blood loss saturating your sanitary wear, offensive smelling lochia or develop a fever, seek prompt medical attention.
Whilst you will spend a lot of your day feeding your newborn, feeding yourself is paramount. Nourishing yourself with a healthy varied diet of varied fruits, vegetables and wholesome foods is key to optimal well being. Having nutritious grazing snacks nearby can help to keep you going during feeding sessions with your baby. If you are breastfeeding, your caloric and energy levels will naturally be depleted so replacing this through your nutrition is essential.
The antenatal period can be a valuable time where nutritional dense foods can be prepared and frozen to use after birth. After birth you may feel that there is not enough time to do anything else in the early days, consider who is in your support network and who can bring food parcels over to help ease the pressure or if visitors do come over they can bring something prepared. The Department of Health recommends for all women to take a vitamin D supplement (10mcg per day), mothers often continue their prenatal supplements, however, it is not a requirement if you have a balanced and healthy diet.
You may feel incredibly thirsty after you have given birth, especially if you’re breastfeeding. How much to drink will vary from person to person, and may average around 2-3 litres and depends on whether you’re lactating or not. Be aware of how you are feeling and observe the colour of your urine, a lighter/clearer colour is a good marker for how hydrated you are.
Having a newborn is an exciting time for the wider family and friends, everyone wants to visit and embrace the new addition! You may feel an initial burst of energy after birth and having visitors may be desired at that moment, however, having an influx of guests may increase your instinct to host them, which over time can cause exhaustion. Protecting your space and minimising exerting your energy in that early postnatal period will benefit your recovery. If you choose to have visitors early on, plan it ahead of time so you feel most prepared, try not to be the host, delegate tasks that will be helpful for you such as shopping, food preparation, laundry etc. If you are establishing breastfeeding minimise your visitors holding the baby to sleep as you could miss your baby’s feeding cues as they feel warm and cosy thus sleeping for a longer duration. Ask your visitors to refrain from kissing your baby, as your baby is more vulnerable to the effects of transmitting herpes from a cold sore.
PART 2: Taking care of yourself
Maternal health and Well-being
Your health and wellbeing are essential so you can feel well and physically able to meet the growing demands of parenting your newborn.
The NICE guidelines to postnatal care 2006, sets out the signs and symptoms of potentially life-threatening conditions to observe for in the postnatal period up to 8 weeks:
Stay mindful of the changes and adjustments occurring within your body after birth, at the earliest sign that something is not feeling or seeming right you should seek medical attention immediately.
Depending on how you gave birth you may experience some perineal pain or discomfort during the postnatal period. The perineum is the area between the vagina and the anus, the pressure exerted to this area during a vaginal or instrumental birth can leave the area feeling swollen and uncomfortable whilst healing occurs.
If you had a caesarean section you will have had an abdominal incision which is usually horizontal and below the bikini line, approximately 10-20cm length. Other types of abdominal incisions are rare and would be specific to the individual circumstances and discussed with your obstetrician.
You may have experienced spontaneous tearing or a cut (episiotomy) to the perineum which can take up to 4 weeks to fully heal internally. Pain or discomfort to the perineum can occur whether a tear/cut has occurred or not. Haemorrhoids may also occur during your birth which were not present beforehand, they can take several weeks to heal.
Smaller spontaneous tears to the perineum may not have required suturing, your midwife or doctor will have made the decision based on the presentation of the tear at the time of your birth, the observation that tear is healing well is key, you can ask your midwife to assess the healing during your postnatal care visits.
Tears or cuts that have been sutured (stitches applied to close the wound) are often done in a way to minimise irritation to the skin, a continuous stitch will be used with the majority being internal. The sutures are absorbed by your body and do not need to be removed, with the healing usually taking place between 2-4 weeks. During this time observe how the perineum feels whilst it is healing, any pain should subside gradually and mobility should be improving day by day.
If you notice an increase in pain, inflammation/swelling, offensive smell or if a fever occurs this could be a sign of wound infection. See your GP, midwife or care provider for an assessment if you are concerned so they can investigate, and where required appropriate treatment can be given.
To minimise the risks of infection and to aid healing of your wound, maintain personal hygiene, changing sanitary wear regularly, and observe how it feels and your comfort levels, seek prompt advice if you are concerned.
Your abdominal wound can take at least 6 weeks to heal, although you may feel ok before 6 weeks with pain and movement the internal healing of your wound is still occurring. You may experience tenderness, bruising or numbness around the incision whilst it heals. Avoid overexerting yourself whilst you are recovering.
Most wounds will have internal stitches and one longer stitch to the skin with a bead on each end, it can be common that one side feels more tender than the other. Your midwife will be able to assess how your wound is healing during your postnatal visits. Around day 5 your midwife will remove the skin stitch which can feel like a bit of a relief; the wound continues to heal internally.
Rarely an obstetrician will have used staples to close the wound; these will often be removed by your midwife around 5-7days after birth.
Observe how your wound is healing and ask your midwife to assess if you have any concerns, keep the wound clean and dry, dabbing gently after showering. Wear loose, comfortable clothing ensuring minimal friction or irritation to the wound site. Observe any red appearance to or around the wound, increased pain or fever which could indicate signs of infection. Remember to take your prescribed pain relief as directed to avoid breakthrough pain, gradually reducing as your pain reduces overtime. Driving is not advised in the first 6 weeks following the caesarean section.
The pelvic floor muscles help to prevent the leakage of urine, wind and stools. During pregnancy and birth, these muscles have been stretched during this time and need to be strengthened again to regain the tone to this area. This is important for the longer-term health of keeping control of your bladder in later life. You can discuss how to practise your pelvic floor exercises with your midwife if you have concerns you can discuss further with your GP to seek a referral to a physiotherapist.
By remembering to do your pelvic floor exercises you will increase the blood flow to your perineum thus aid the healing of your perineal wound. It is not easy to remember to do them, so some mothers aim to do it every time they feed their baby, identifying a regular prompt can be helpful.
You can resume having sexual intercourse as soon as you feel ready to after you have given birth. You are most fertile in the first 6 weeks, so you may want to consider a contraceptive method most suitable for you. Discuss with your GP regarding the most appropriate contraceptive to take especially if you are breastfeeding.
As well as your physical wellness, your mental well-being is of utmost importance. The overwhelm of adjusting to motherhood, disrupted sleep patterns and an array of hormonal changes are occurring in the early days and weeks after birth, it can feel, at times like an emotional roller-coaster.
Having a supportive network around you and sharing how you’re feeling with your caregiver can help to identify any deteriorating factors in your mental well-being and signpost you to the additional support services if the need arises.
If you have a previous history of anxiety, depression or other mental health concerns you may be receiving additional support from the perinatal mental health team, this support will usually continue during the perinatal period and your community midwife and health visitor provide additional support. This is to ensure your overall wellbeing is supported and you have access to support should your mental health be triggered or deteriorate after birth.
Baby blues can occur in the first week to days after birth, typically around day 3-6 when your milk is ‘coming in’. The surge of hormones can make you feel a range of emotions and you may cry for what feels like something minor at random times. This is a temporary response to the hormonal and physical changes occurring in your body as well as transitioning to motherhood and meeting the sudden changing demands that it brings. You may experience a temporary low mood, feel tearful and emotional, this usually lasts for a few days before you feel better again. Share with your support person and your midwife how you are feeling to help make sense of what you’re experiencing during this time.
Is experiencing a deeper depression after your baby is born, for a longer duration. It can begin at any stage with the first year, typically commencing around 6 weeks. If you experienced depression during your pregnancy you may have an increased chance of feeling depressed after birth too, but this is not always the case. Staying in tune with how you are feeling is important and to continue sharing how you’re feeling with those who you feel best able to share with.
The thought of sharing your feelings may provoke added concerns on how you think you may be viewed or judged by healthcare professionals. For example, not being able to cope, fear of having your baby taken away or not being a ‘good’ mother. This is not the case, the earlier you feel able to share how you are feeling, the sooner the correct support can be put in place
Signs and symptoms that you may be experiencing depressions include:
- down, upset or tearful
- restless, agitated or irritable
- guilty, worthless and down on yourself
- empty and numb
- isolated and unable to relate to other people
- finding no pleasure in life or things you usually enjoy
- a sense of unreality
- no self-confidence or self-esteem
- hopeless and despairing
- hostile or indifferent to your partner
- hostile or indifferent to your baby
- suicidal feelings
PANDA is a free peer to peer support network for you and your family to access should you need to talk to someone, you or your family member can contact them directly on 0808 1961 776.
If, not pre-existing anxiety can be induced after you have had your baby. Sometimes your birth events can trigger the feelings of anxiety, or the overwhelming responsibility of taking care of your newborn, seeing that they remain safe and well and to protect them. As well as how you feel about yourself. Signs and symptoms of anxiety (Mind, 2020):
- a churning feeling in your stomach
- feeling light-headed or dizzy
- pins and needles
- feeling restless or unable to sit still
- headaches, backache or other aches and pains
- faster breathing
- a fast, thumping or irregular heartbeat
- sweating or hot flushes
- finding it hard to sleep, even when you have the chance
- grinding your teeth, especially at night
- nausea (feeling sick)
- needing the toilet more or less often
- changes in your sex drive
- having a panic attack
The ongoing signs and symptoms of anxiety can begin to impact one’s mind and mental wellbeing, there is support and treatment available, such as talking therapy and CBT and where required your GP may discuss medical treatment. Seeking help and advice in the first instance is key for your ongoing support in managing your symptoms.
The onset of psychosis is usually sudden, it is a combination of psychosis, depression and mania (Mind, 2020). You may not recognise this is happening to you, but the people and support network around you may observe that something has changed, and maybe best able to seek support for you. Signs and symptoms to observe:
- Rapid mood changes (severely depressed to feeling elated)
- Confusion or disorientated
- Unable to sleep
- Unable to concentrate
If you have a family history of psychosis or mental health problems, have experienced traumatic birth or pregnancy, a history of bipolar or schizophrenia or have had postpartum psychosis before, you may be at an increased risk of psychosis after your birth. However, it can also occur with no history of the above at all.
You can and will be supported through this, your GP and community perinatal mental health team will support you and advise an appropriate plan of care. In severe cases, mother and baby units are available to enable more specialist care and support to be provided.
The Action on Postpartum Psychosis Charity has a series of guides available for you and your support person if this is your experience, and can provide additional support for your family.
PART 3: You and Your Baby
The frequency at which your newborn feeds can sometimes come as a shock for new parents, theoretically it is known that newborns feed frequently, yet the reality and intensity of feeding can often feel immense. You can expect your newborn to feed approximately 2-3 hours during the early days/weeks including at night time, it is biologically normal and studies have shown that frequent waking is an innate protective mechanism against SIDS.
Choosing to breast or formula feed your baby is a decision made dependent upon your circumstances/experiences, information received and researched and discussions had with your partner/support network and with your midwife, health visitor or caregiver. What we do know is that the vast majority of women who choose to breastfeed felt they had stopped quicker than they would have liked to. In one study, 80% of mothers who stopped breastfeeding wanted to continue. If you have doubts about whether to breastfeed or not or feeling the need to stop sooner than you would like to, you can speak to a lactation specialist to discuss your feelings around breastfeeding.
Breastfeeding can be challenging for many women, it is a learnt skill and can take up to 6-8 weeks to feel ‘second nature’. Having access to skilled support can be necessary to support the continuation of breastfeeding.
How do you know that feeding is going well? The concerns around how much your baby is getting, and how much they should be having is commonplace. Signs that will help to reassure you that feeding is going well, include:
- Adequate urine output increasing from the day of birth
- Changing stools from meconium to green to brown and then yellow seedy stools.
- Your baby settling after most of their feeds
- Adequate weight gain approx 20-30g per day (your midwife/health visitor/caregiver will observe your baby’s weight gain periodically)
If you are concerned about how feeding is going or you notice a change or deterioration in some way, do seek advice and support at the earliest opportunity from your healthcare professional, lactation specialist, local feeding groups and UK national helplines.
Whether this is your first baby or a new addition to your family, having a newborn brings about a period of adjustment through what feels like a steep learning curve.
You are learning everything about your baby at an accelerated pace with no two days being the same. Your newborn wholly depends upon you and communicates through their cries. During the early days and weeks as you respond to your baby’s needs for nourishment, daily care, warmth, closeness and comfort, you are learning and attuning to what works for your baby, their cries and what it is they need from you.
Your baby is adjusting to extra-uterine life and they are physically and biologically going through a period of adaptation. What can you expect in the initial postnatal period:
A newborn physical examination will take place usually within 72 hours after birth, this is a screening assessment which assesses the physical wellbeing of your newborn. A thorough head to toe check is performed by your healthcare professional, including assessment of the heart sounds, eyes, primitive reflexes, and hips, taking note of your family history, antenatal history and any ultrasound scanning in pregnancy. If any abnormalities have been identified the appropriate referrals and investigations can be sought. Between 6-8 weeks your GP will offer you the same assessment to assess whether any changes have occurred as well as assessing developmental milestones.
Newborn Blood Spot Screening
You will be offered a screening blood test for your baby, which is taken between day 5 and day 8. This blood test screens for specific metabolic conditions and will be discussed with you by your midwife or caregiver. If you choose to accept the screening test, four spots of blood are taken from your baby’s heel and blotted onto the screening card, it is sent off for analysis. If there are any concerns you will be notified usually in the first week. If you have not heard back it often means the screening was negative and you will receive confirmation in the post. In some cases, the screening needs to be repeated if an insufficient sample is received, or erroneous information was written on the card, your midwife will inform you if this happens.
Jaundice is a common physiological change occurring in newborns, where there is too much bilirubin in their bloodstream, which can make them appear yellow. Typically it can occur around day 2- 3 and will usually resolve without any treatment as it flushes out of your baby’s system through feeding. Your midwife or caregiver will inform you whether your baby needs to be assessed further depending on how they assess your baby. You can observe whether you think you need to have your baby assessed further, if you notice:
- Increased lethargy
- Difficult to rouse for feeding and not waking with a nappy change
- Floppy muscle tone
You can take your baby to A&E for further investigations, as well as liaise with your community midwife or health visitor if you are concerned. Jaundice can take a couple of weeks to subside if you are breastfeeding, jaundice can be prolonged up to 6 weeks, you may be referred to the prolonged jaundice clinic for monitoring.
Your baby’s skin is adjusting to life outside of your womb and many cases have lost the protective layer of vernix at this stage. Sometimes the skin can appear to be dry and flaky. It is best to avoid any perfumed/fragranced bath products or lotions. Plain water is most suited during the first 6-8 weeks, and regular bathing is not required at this stage. A top and tail with water and cotton wool are sufficient. You can discuss with your caregiver any products you may be considering.
You may notice red blotches over on your baby’s skin, they may appear to appear suddenly and can disappear just as quick too. These blotches are known as erythema toxicum neonatorum (newborn rash), almost 50% of babies may develop this, it is thought to occur as a result of your baby’s immune system ‘kick-starting’, you do not need to do anything as it will commonly resolve spontaneously.
Milia are small white spots which appear on your baby’s face, quite often seen around their nose, cheeks or eyes this is as a result of dead skin cells getting trapped under the skin. They will resolve without any treatment.
If you are concerned about a rash on your baby please seek prompt medical attention.
The stub of your baby’s cord will usually fall off in the first 2 weeks, most often it occurs within the first week. You do not need to treat it directly, but take care and observe how it is healing during this time. You should notice that it turns black as it dries out and may become a bit oozy as it prepares to fall off. Whilst it is healing:
- Allow air to get to it by rolling the nappy underneath it
- Clean with plain water if urine or stools get on it
- Keep clean and dry
Observe for any offensive smell, red tracking line around the skin area or any other signs of infection occurring, and seek advice/medical attention at the earliest signs or symptoms.
Once the cord falls off, the navel can still be a bit wet at the base and can take an additional few days to a week to heal. If a pink fleshy bit of skin remains once the cord falls off, this might be what’s known as an umbilical granuloma. If it doesn’t resolve spontaneously in a couple of weeks you can speak to your GP or health visitor who can advise a home treatment method to heal it.
Your baby’s stools will be changing daily in the initial 6-8 days, as they take on more volume through feeding. What should you expect to see?
- Day 0-1 – passing of meconium, which is sticky and tar-like
- Day 1-2 – looser consistency changing from black to dark green
- Day 2-3 – green pesto colour stool
- Dau 3-4 – brown colour stool
- Day 5-6 – yellow soft seedy stool
If feeding has been challenging there may be a slight delay in the changing of your baby’s stools. If there is a prolonged delay, discuss with your midwife and have your feeding assessed to ensure your baby’s wellbeing. All being well you will expect your baby to have a daily bowel movement up to 6-8 nappies a day for some babies, and in some cases more frequently.
Sleep is essential for your newborn’s growth and development. During the first 6-8 weeks, they will usually sleep after most of their feeds. With short bursts of awake time. In the first couple of weeks, you may notice your baby sleeps quite soundly during the day time and seems to be awake and alert during the late evening or early hours of the morning. If you reflect on your pregnancy you may notice your baby had a similar sleep/wake time pattern in your womb. This is a normal response to their adaptation, it is also a time that your prolactin hormone increases and your baby may cluster feed to stimulate and increase your milk production if you are breastfeeding.
You may notice that your baby seems to settle well on you, particularly at nighttime but the moment you put your baby in their sleeping space they wake up. They are used to being close to you in your womb and suddenly being in their own space is a huge adjustment for them.
The current recommended safe sleeping position is for your baby to be positioned on their back, with their feet at the end of their bed, with nothing else in the sleeping space. Your baby will have on appropriate layers depending on the room temperature and to remove any hats when sleeping. These safer sleeping guidelines are in place to reduce the risk of Sudden Infant Death Syndrome (SIDS).
Co-sleeping is intended choice for some families, the key points to remember when co-sleeping is to:
- Position your baby onto their back to sleep
- Remove your duvet or bed covering and pillows away from your baby
- Follow the safer sleeping guidelines
Co-sleeping is not advised if:
- You or your partner smoke
- Use of alcohol or illicit drugs have been used or medications that might cause drowsiness
- You or your partner are extremely exhausted
- Sleeping on the sofa or armchair with your baby is never advised, as this increases the risk of SIDS.
You can find further information and videos on safer sleep and co-sleeping at the Lullaby Trust.
Carmelle is an Independent midwife and tongue tie practitioner, and specialises in infant feeding. She holds a Maters in Public Health and is the founder of Gentle Births and Beyond; providing a holistic approach to families during the antenatal and postnatal period. She is a full member of the Association of Tongue Tie Practitioners.
Carmelle can be found at Gentle Birth and Beyond