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Your body goes through many physical changes postpartum while it is returning to its non-pregnant state. You have been through a wonderful process and now it will take your body about 2 months for you to start feeling “normal” again. One of the most noticeable changes is the return of the uterus to normal, called involution. You can feel the changes in the uterus as cramps, called afterpains. You can see the changes as your abdomen gets smaller. You should also see a discharge, called lochia, that usually lasts about 3 weeks, but may last as long as 6 weeks.
Lochia is the lining of the uterus that is shed after giving birth. It is a normal part of the healing process and not a cause for concern. The lochia is made of blood, tissue, and mucous similar to a menstrual period. The bleeding is heaviest right after birth and slowly decreases over the following 3 or 4 days. For the first few days, you may notice heavier bleeding when you stand up after you have been sitting or lying down for a while. Standing up does not cause the heavier flow. The heavier flow comes from the release of blood that collects in the vagina while you are sitting or lying down.
Protect your furniture and bedding from accidents by using plastic-covered pads under your hips. Until the lochia stops completely wear sanitary pads, not tampons. Tampons increase the risk of infection in the uterus. It is important for you to recognize when bleeding is a normal part of the lochia and when bleeding is a possible sign of hemorrhage. Most hemorrhages happen right after delivery when the uterus does not begin shrinking right away. However, hemorrhaging can happen anytime during the postpartum period.
Hemorrhage during this time can be caused by infection in the uterus or a piece of placenta can stick to the uterus and keep the uterus from healing in that spot. The spot that doesn’t heal keeps bleeding. Since the unhealed area is small, you probably won’t see a “gush” of blood. Instead, you would see a steady drip, drip, drip which can become a serious problem—just think how fast a cup fills in the sink if you let the faucet drip, drip, drip. If you have bleeding that soaks a pad in 15 minutes or less, call your doctor immediately. If you cannot get in touch with your doctor have someone take you to the emergency room, or call 911 if you are alone.
Too much activity, like going up and down stairs, can cause a heavier blood flow. If you have been active and notice a heavier flow of lochia, it’s a signal to slow down or rest. So try not to lift anything heavier than your baby. Don’t be going up and down stairs often, and when you must, then go up and down slowly. If you normally need to use stairs at home, then while you recover, set up a recovery area for you and your baby so you only have to go up and down stairs once in the morning and once again at night. Dining rooms make great recovery areas because they aren’t used much. If your bleeding starts to get heavier, get off your feet and rest. Small blood clots, up to the size of a plum are normal. However, clots and heavy bleeding that doesn’t stop with rest aren’t normal—if this happens call your doctor.
There are 3 normal stages of lochia. It is important for you to know the stages so you can tell whether something may be wrong. How many days each stage lasts isn’t as important as whether the amount of lochia keeps getting less and less as the color gets lighter as it changes from red to pink to creamy or white.
These are the normal stages of lochia.
1. Lochia rubra — first 2 to 3 days after delivery
• the lochia is mostly blood
• the blood looks bright red
• the blood flow can be heavy to moderate
• you may see small blood clots
2. Lochia serosa — starts about day 4 and lasts until day 10
• the color changes to pink or pinkish-brown
• the flow is much less
• blood clots or bright red blood during this time may be signs of a problem.
3. Lochia alba — from about day 10 until day 21
• the color is light yellow to a cream color
• the flow has almost stopped and does not smell
• the presence of clots, a bad smell, or bright red blood may be signs of a problem.
The progression from lochia rubra to lochia serosa to lochia alba should not reverse. The color should always turn from red to pink to white as the amount of discharge gets less and less. If you see a red flow after the flow has turned pink or white, call your doctor right away.
Also, call your doctor right away:
☎ if you have heavy bleeding that soaks more than 1 pad per hour for 3 hours
☎ if you see blood clots or bright red blood after the 4th day
☎ if the lochia smells bad (it should smell like your normal menstrual f low)
☎ if you do not see any lochia during the first 2 weeks
☎ if you have bad cramps and heavy bleeding
☎ if you have a fever over 100.4˚ F
☎ if you have severe pain in your lower abdomen
If you are not breastfeeding, you can expect to have your periods return within 4 to 8 weeks. The first menstrual flow tends to be heavy and contain blood clots; your period may start, stop, start again. The second period should be more or less normal. As long as you are breastfeeding, your period will not ordinarily appear. If it does, it won’t interfere with breastfeeding.
Perineal Swelling and Soreness
You will have some swelling and soreness in the perineum due to pressure and stretching in the perineum during birth. However, this area will be more sensitive if you have stitches from an episiotomy or tears. The discomfort from your stitches usually last about 5 or 6 days.
During the first 24 hours after delivery, swelling can be kept down by applying ice to the area. Ice also acts as a local pain killer. After the first 24 hours apply dry or moist heat for 20 minutes 3 to 4 times a day. Moist heat can be from a sitz bath or a warm moist cloth. Heat increases circulation to the area, reduces swelling, and speeds healing. (see Perineal Care)
Here’s how to do a sitz bath at home. Do these 2-3 times a day or as your doctor orders. Pick a time when your baby is asleep or someone else is watching her.
• Wash your feet and legs and rinse out the bath tub.
• Put a clean towel in the bottom of the tub and add 4 to 5 inches of warm water. NO SOAP or BUBBLE BATH.
• Sit in the tub on the towel for 15 to 20 minutes. If the water starts getting cool, then let some water out and add new warm water.
• When you finish, stand up slowly so you won’t get dizzy.
Bladder distention is the over stretching of the bladder caused by the bladder being full of urine. It happens often in women who have epidural anesthesia and/or episiotomy during childbirth for several reasons:
• the perineal area is swollen and the opening where urine comes out, the urethra, swells shut.
• the anesthesia puts the nerves asleep and the muscles do not relax and allow urine to flow.
• the bladder is so full it can’t contract to squeeze out the urine.
This is a common problem and there is nothing you can do to prevent it. You can help the situation by keeping your bladder empty during labor. An ice pack on your perineum in the first 24 hours can help reduce swelling. Try to relax. Some other things to try:
• squirt warm water over your perineum
• run water, sometimes hearing running water helps
• bear down a little when you try to pee
• rub your belly and gently press on your bladder to try to start the urine flow
If you still can’t urinate, you’ll have a catheter inserted into your bladder to drain off the urine. You’ll likely be able to urinate on your own from then on.
Hemorrhoids are swollen veins of the rectum. Hemorrhoids can be caused by pressure from your baby’s head or your pushing during the final stage of labor. It’s easy to confuse pain from your stitches for pain from hemorrhoids.
Try applying ice for 20 minutes every 4 hours to relieve pain, shrink hemorrhoids, and speed return of normal bowel function. Don’t put ice directly on your skin. Put the ice in a plastic bag and then wrap it in a towel. Sitting in a bathtub of warm water or sitz bath (see Sitz Bath above), or using cold witch hazel pads can reduce minor discomfort and itching. Take 20 minute tub or sitz baths often; a tub or sitz bath that last longer than 20 minutes doesn’t make healing any faster.
Discomfort from hemorrhoids should start getting better once you begin treatment with the sitz baths and ice. Eating foods high in fiber (fruit, whole grains and raw vegetables) and drinking plenty of fluids (6 to 8 glasses a day) can prevent hard stools that can irritate your hemorrhoids. Ask your doctor about using a stool softener (Colace) to make stool easier to pass without straining. If you are breastfeeding, taking a stool softener may cause loose stools in your baby, too. Holding a pad of toilet paper against your stitches during a bowel movement can help relieve pain from the stitches.
A hemorrhoid may come from inside the rectum to the outside of the anus. If so, wash your hands, lubricate your finger, and gently push the hemorrhoid back into the rectum. Wash your hands afterwards. If you cannot get relief from the pain or the pain gets worse call your doctor.
Even after labor and delivery are over you will have contractions in the uterus. These contractions are normal and happen as the uterus shrinks to its nonpregnant size—called involution. Contractions are important because they pinch off the blood vessels where the placenta was attached to the uterus and stop the bleeding. These contractions may cause cramps called afterpains. Afterpains decrease in severity after 48 hours, usually last about 3 or 4 days, and are a good sign that your uterus is getting smaller.
Afterpains can range from mild to somewhat uncomfortable. Afterpains may be worse if you delivered a large baby, more than one baby, or if this isn’t your first baby. This is because the more the uterus has to stretch the more it has to shrink. Your doctor may give you Tylenol to ease the afterpains. It will help to keep your bladder empty, or lie on your stomach with a pillow under your abdomen.
Afterpains can be more intense if you are breastfeeding. Your baby’s sucking releases a hormone that causes the uterus to contract. Ask your pediatrician if it is OK for you to take Tylenol 30 minutes to an hour before breastfeeding to ease the afterpains while nursing. If the afterpains are not relieved by Tylenol and become too uncomfortable for you, call your doctor.
Other Physical Changes
The vagina stretches to a larger than normal size during birth, but will almost return to its prepregnant size during the first 6 weeks after birth. Doing Kegel exercises can help speed up the return of strength and tone to the vagina.
Stretch marks might have formed on your abdomen during your pregnancy. You may notice them more now since they are not stretched out flat. Stretch marks will stay red to purple for a while. Over the next 6 months they will get lighter on white skin and darker on black skin, but they will never go away completely.
More About Self Care After Vaginal Birth
Introduction to Self-care After Vaginal Birth
Preventive Self Care
Physical Changes and Healing
Activities and Healthy Exercise
Nutrition and Diet
Family Planning and Birth Control
Normal “Baby Blues” or Postpartum Depression
Your Postpartum Check-Up
Get as Much Rest as You Can
When to Call Your Doctor
If you use one of the microwave gel packs, don’t apply the heated pack directly to the skin.
If you call your doctor about any type of pain, tell him where the pain is coming from, such as your perineum or your abdomen, and how much pain you are having. This information will help determine if the pain is to be expected or a possible warning sign.
If you must strain to move your bowels, support your stitches by gently pressing against them with a pad of toilet paper as you bear down. This support will reduce the discomfort from your stitches.