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What Really Happens Postpartum? One OBGYN Tells All

The changes don't end after giving birth. Here's what to expect in the 4th trimester.

Medically reviewed in February 2022

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The period of time beginning immediately after birth and lasting for a few months is something not all new mothers prepare for, but experts say they should.

“The importance of the ‘4th trimester’ is often overshadowed by the 40-week pregnancy and labor and delivery”, says OBGYN April Mikes, DO at Weatherford Regional Medical Center. “And just as these timespans require frequent interaction with a health care provider, the postpartum period shouldn’t be overlooked, either.”

In fact, recognizing how important this 4th trimester is—and that nearly 40 percent of women do not attend postpartum doctor visits—the American College of Obstetricians and Gynecologists released guidelines in May 2018, later updated in 2021, stating that “patient-centered, maternal postpartum care has the potential to improve outcomes for women, infants and families and to support ongoing health and well-being.”

From sex to mental state to a host of other potential postpartum issues, Dr. Mikes breaks down what mothers can expect, plus what they can do to stay happy and healthy.

Medically reviewed in April 2021.

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There will be some bleeding—or maybe a lot of bleeding

While a little spotting can be normal during pregnancy, heavy bleeding is not. After birth, though, bleeding may be heavy at times, which can be a shock when you haven’t had substantial bleeding for 40 weeks or so.

One type of bleeding you’ll experience after birth is lochia, which may last for several weeks straight, says Mikes. And this is normal, although the timeline is different for everyone.

The bleeding is a natural process of shedding from the placenta site. For most women, bleeding will start dark red and transition to brighter red for the first couple of days. It may be heavy at times, accompanied by clots—some that may be as big as a plum. The lochia then turns into more of a pinkish-brown discharge with less volume that can last for a few weeks. Eventually, the discharge will appear whitish or yellowish before subsiding within four to six weeks. Most women notice the bleeding is heavier after moving around or while they’re breastfeeding.

Since this process is natural, it’s best to let your body work through it on its own, but if you have clots that are larger than a plum, bleeding that is bright red after about three days or really any concern, don’t hesitate to call your OBGYN.

Although rare, it’s possible to experience postpartum hemorrhage, or bleeding that usually occurs because the uterus isn’t contracting strongly enough, and the blood vessels bleed uncontrollably. Hemorrhaging is most likely to occur while you’re still in the hospital and can be treated right away, but call your doctor right away if you’re having heavy, uncontrolled bleeding, low blood pressure or an increased heart rate.

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Menstruation and ovulation will return

You haven’t had your period in what probably seems like forever, so you may be wondering when it’s going to return post-delivery. Mikes says it can occur as soon as 25 days after delivery, but most women won’t see a period for 45 to 94 days, and up to 6 months if they are breastfeeding. Seventy percent of women will usually menstruate within 3 months of giving birth, and 20 to 71 percent of these women will experience ovulation. And many women ovulate before the first menstruation, meaning they’re fertile well before they know it.

Every woman is different, so the return of your menstrual cycle is going to depend on your body. If you’re breastfeeding, you’ll have higher levels of the hormone prolactin, which inhibits the return of a period, says Mikes. It takes some women a year or more to get their period back. Meanwhile, it’s important to keep your OBGYN up to date.

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The pain is not over

Given the profound changes your body has been through, you can probably expect to experience some more pain post-delivery, but the amount and intensity depend on your individual labor and delivery experience.

Many women have episiotomies, a surgical tear made intentionally by your doctor to expand the vaginal opening during delivery. The perineum, the space between the vagina and anus, may feel sore until it heals. Follow the directions provided by your doctor for caring for this area, which often includes gentle cleansing techniques.

Uterine contractions are another source of post-birth pain. As early as a few hours after birth, the upper area of your uterus is up near the level of your navel but will slowly recede further down as the days go by. If you didn’t have any major complications in your delivery, your uterus should return to its normal size (about the size of a pear) within six to eight weeks.

These uterine changes will cause pain or cramping that may be extreme at times but should only last for about five minutes. The purpose of these contractions is to stop the bleeding. Mikes says pain relief medications (particularly NSAIDs), warm, shallow baths or heating pads can help relieve some of the discomfort.

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It’s likely you’re going to deal with urinary incontinence

It’s not uncommon to experience some form of incontinence during pregnancy. After all, your baby is growing, your uterus is getting larger and this expansion may put pressure on the bladder. Laughing, sneezing, exercising or other movements can often cause urine to slip out unintentionally.

The good news is that most incontinence will subside after delivery as the pressure is taken off of your bladder. But if occasional leaking does continue, don’t panic. Delivery puts pressure on your pelvic tissues, and sometimes these tissues can tear or become stretched or damaged, which can increase the risk of incontinence.

Mikes says if you’re still experiencing incontinence six months after birth, see your OBGYN.

You shouldn’t be too hard on yourself if you do experience urinary incontinence. But there are a few ways you can improve the symptoms:

  • Limit caffeinated beverages, since they may make you feel like you have to urinate more.
  • Add Kegel exercises to your regular routine: tighten your pelvic floor muscles for five seconds then release for five seconds. Build up to 10 seconds tightened and 10 seconds relaxed. Work your way up to three sets of 10 repetitions per day, if possible.
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Although you want to lose it, give yourself time to work off the extra weight

Shortly after birth, many women want to know when they’ll lose the baby weight, says Mikes. And while it’s an understandable question, remember that your first priority should be giving your body time to heal. “It took you 40 weeks to grow a baby and it will often take the same amount of time to get back to a pre-pregnancy state,” she says.

While it is important to set reasonable expectations and pursue a healthy lifestyle, says Mikes, at some point you may want to turn your attention to losing the excess weight.

“About 13 pounds is lost after delivery from baby, the placenta, amniotic fluid, blood loss and other things, but the swelling often remains for a couple of weeks and may even worsen in the postpartum period.”

This swelling will usually subside and you’ll continue to lose weight due to retained fluids in the first week after birth. The remainder of baby weight, however, is stored fat.

But you can’t rely solely on breastfeeding for dropping pounds. A combination of healthy eating and exercise (once it’s safe for you to do so,) is the best way to take charge of your weight, post-delivery. It is reasonable to expect to lose one pound per week if you are active and eating a nutritious diet. The extra weight will typically come off sometime between 6 to we months postpartum. In fact, most women lose about half of gestational weight gain in the first six weeks postpartum.

Every woman’s body is different so don’t compare your postpartum progress to anyone else. Just stick to your goals. Remember—your body just grew a baby for 40 weeks. Be kind to it.

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It’s possible to get back into the swing of exercising

Once it’s safe for you to exercise and you feel up to it, start slow, and listen to your body. If something doesn’t feel right or causes pain, it’s best to stop. If you had a normal, vaginal delivery, you may be able to start moving gently as soon as a few days after birth; for a C-section, you’ll want to ask your doctor.

Start with 20 to 30 minutes of activity per day. Walking is one of the easiest ways to squeeze in movement throughout the day, and you can even bring your infant along in the stroller! If you want to incorporate strength training, focus on toning your different muscle groups, especially your abdominal and back muscles since these will be weak after pregnancy.

Always talk with your OBGYN before you start exercising. If you were a vigorous exerciser before pregnancy, it’s very likely you’ll be able to work your way back up within a matter of months.

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Sex may be the last thing on your mind

Like exercise, sex is often an afterthought post-delivery—and that’s okay. There are also a lot of factors at play when it comes to having safe intercourse again, says Mikes. “Vaginal and perineal lacerations, cesarean deliveries, bleeding, return of libido, vaginal atrophy due to breastfeeding and fatigue all play into your ability and desire to have sex,” she notes.

While there is no set amount of time you need to wait, according to ACOG, most doctors, including Mikes, recommend waiting about six weeks before you resume having intercourse. If you had an episiotomy, your OBGYN is likely to recommend that you wait until the area has totally healed. Talk with your doctor about the birth control options right for you when you do plan to start having sex again.

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Mental health

In addition to the physical changes your body is going through, your mental health may waver, too, and Mikes says this is one of the most important issues to discuss with your doctor.

Postpartum emotions are nothing to be ashamed of, but they are something to keep an eye on, especially if symptoms are severe or persist.

Hormone fluctuations, specifically estrogen and progesterone, can contribute to feelings of depression, as can the fatigue the postpartum period involves. Women with a history of depression are more at risk.

Here’s a breakdown:

Postpartum blues: You may feel depressed, anxious, sad or angry two to three days after birth. It’s common to start crying for no apparent reason or to have trouble sleeping or eating. You may also second guess whether you’re able to care for your baby.

These thoughts and feelings can come and go for a few days, but typically only last for one or two weeks.

Postpartum depression: This type of depression can bring sadness, anxiety or feelings of hopelessness that interfere with your daily routines. Although this type of depression is most common immediately after childbirth (usually one to three weeks), it can emerge up to a year after delivery.

It’s important that you see your doctor if you’re experiencing postpartum depression. Antidepressants and other treatments like talk therapy can help.

Postpartum psychosis: Although rare, you may be at risk of postpartum psychosis if you have a history of psychosis, bipolar disorder or schizophrenia. You may also have a heightened risk if this is your first pregnancy or if you stopped taking certain medications used to treat a mental illness during pregnancy.

Hallucinations, delusions, strange behavior and confusion are some signs of postpartum psychosis, and you should see your doctor right away if you’re having any of these symptoms.

Although it can be normal to experience some feelings of sadness after delivery, it’s best to talk to your doctor right away about any mental health concerns you have. Untreated depression can interfere with your daily routines like sleep and eating, and in some extreme cases, may lead to thoughts of harming yourself or your baby.

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Your doctor is there to help

Most women will have a postpartum checkup within about six weeks after delivery, but if you have concerns before then, Mikes wants you to know that your OBGYN should be there for you. “Our job doesn’t end after delivery,” she says, “and part of our job is making sure our patients are aware of this fact.”

Remember to be open and honest with your doc about any symptoms you’re experiencing or any concerns that you have. You can discuss any residual pain or bleeding, when it’s safe for you to exercise or have sex and any emotional changes you’ve had.

“The 4th trimester is not to be ignored, but rather embraced and given as much credence as the first three trimesters,” Mikes says. “Talk to your provider, ask questions, and continue on your journey of maternal health together.”

Sources
American College of Obstetricians and Gynecologists. “Optimizing Postpartum Care.” May 2018.
Committee Opinion No. 666. “Optimizing Postpartum Care.” Obstetrics & Gynecology: June 2016. Volume 127. Issue 6
Cleveland Clinic. “Pregnancy: Physical Changes After Delivery.” January 1, 2018.
Massachusetts General Hospital Center for Women’s Mental Health. “Postpartum Psychiatric Disorders.” Accessed May 21, 2021.
Pampers. “FAQ: Vaginal Postpartum Bleeding (Lochia).” Accessed May 21, 2021.
Mayo Clinic. “Labor and delivery, postpartum care.” March 11, 2020.
Thomas Bouchard, Richard J. Fehring, Mary Schneider. “Efficacy of a New Postpartum Transition Protocol for Avoiding Pregnancy.” The Journal of the American Board of Family Medicine. Jan 2013.
Pamela Berens. “Overview of postpartum care.” UpToDate. May 26, 2017.
American Pregnancy Association. “Uterus Size During Pregnancy.” July 25, 2020.
Mayo Clinic. “Weight loss after pregnancy: Reclaiming your body.” July 31, 2020.
Medline Plus. “Losing weight after pregnancy.” November 7, 2019.

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