A woman’s body goes through many physical changes while returning to its pre-pregnancy state. After childbirth, it may take about two months to begin to feel “normal” again. One of the most noticeable changes is a reduction in the size of your uterus, called involution. During this process, you may experience cramps, or afterpains. Over the course of six weeks, your uterus will gradually return to its normal size. In addition, there will be a post-birth vaginal discharge, called lochia, that occurs for several weeks.
Over 31% of infants in the United States are born via cesarean section. In addition to the above symptoms, mothers must also recover from surgery. A post-cesarean section care plan involves rest, pain management, and wound care. It is important to follow the instructions of your doctor for optimal healing, and to reduce the likelihood of post-operative complications.
Lochia
Lochia is the medical term for the uterine lining that is shed after giving birth. It is a normal part of the healing process, and not a cause for concern. It is a discharge consisting of blood, tissue, and mucous, very similar to a menstrual period. After a cesarean section, the amount of lochia is much less than what occurs following a vaginal delivery. The bleeding is heaviest immediately after birth, then slowly decreases over the subsequent days. During the first 48 hours, there may be heavy bleeding or clots that are passed while standing after periods of sitting or lying down. This movement does not cause the heavier flow; it instead is due to the release of blood that has accumulated and clotted within the vagina.
Furniture and bedding can be protected from accidental leaks with plastic-covered pads (chux) under your hips. Until the lochia stops completely, it is safer to wear sanitary pads instead of tampons. Tampons increase the risk of infection within the uterus, and should be avoided until fully recovered from your c-section. It is also important to recognize when uterine bleeding is lochia versus a sign of losing too much blood. Postpartum hemorrhage is the loss of more than 33 ounces (1000 mL) of blood in one day. 80 percent of cases occur within the first 24 hours after childbirth due to insufficient post-delivery uterine contractions. In other cases, there may be bleeding from a surgical incision or wound separation. Any area that doesn’t heal properly may continue to bleed. Women with a history of a blood clotting disorder are also at risk for hemorrhage.
Postpartum hemorrhage, however, can occur at any time. When it develops after the first 24 hours, it is likely caused by an intrauterine infection, re-opening of a sutured uterine incision, or retained piece of placenta. Most cases of uterine hemorrhage do not involve a large “gush” of blood. The blood loss is very gradual. For example, consider how fast a cup fills in the sink if you let the faucet drip, drip, drip. If your bleeding soaks a sanitary pad within 15 minutes or less, notify your doctor immediately. If it occurs after you have been discharged home, have someone take you to the emergency room, or call 911 if you are alone.
Too much activity such as going up and down stairs can cause a heavier lochia or bleeding from the surgical incision site. After movement or physical activity, if you develop a heavy lochia or oozing from your incision, this indicates a need to slow down or rest. Moms should avoid lifting anything heavier than the newborn baby. The use of stairs is typically not recommended after having a cesarean section because this activity pulls on the healing incisions. It may be better to set up a recovery area for you and your baby on the main floor of your home.
There are three stages of lochia. Knowing them is important in order to determine whether or not something may be wrong. The number of days in each stage is less significant than the gradual decrease in amount of flow. The color of lochia should also change from red to pink, then creamy or white.
Lochia Stages
1. Lochia rubra — first 2 to 4 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 around day 4 and lasts until day 12
• the color becomes pink or pinkish-brown
• there is less flow
• large blood clots or bright red blood during this time may be signs of a problem.
3. Lochia alba — from day 12 until up to 6 weeks
• the discharge is light yellow to a cream color
• the flow has nearly stopped and has no odor
• the presence of clots, a foul odor, or bright red blood are signs of a problem.
This progression of stages should always be in this order. The color should always become lighter as the amount of discharge decreases. If a red color develops after the flow has been 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 there are blood clots or bright red blood after the 4th day
☎ if the lochia has a foul odor (it should smell like your normal menstrual flow)
☎ if there is no lochia during the first 2 weeks postpartum
☎ if you experience severe cramps and heavy bleeding
☎ if you develop a fever over 100.4˚ F
☎ if you have severe pain in your lower abdomen
If you are not breastfeeding, your menstrual periods should return within four to eight weeks. The first menstrual flow tends to be heavy, and may contain blood clots. It can start, stop, then start again. The second menstrual period should be more or less as it was before your pregnancy. Breastfeeding mothers, however, may not resume menstruating for several months. When it does occur, it won’t interfere with breastfeeding.
Care of Your Incision
One of the obvious differences between a vaginal and a cesarean birth is the resulting surgical incision on your lower abdomen. In order to delivery the baby, incisions are made on the skin, underlying muscles, and uterus. Typically, it will take six weeks for all of these areas to heal. It is important to clean the skin incision as instructed by the doctor after your delivery.
In most cases, you will be discharged from the hospital within three to five days after a c-section. A follow up appointment should be scheduled with your doctor approximately 10 days from your delivery date. Rest and keeping the incision clean and dry are the primary goal for the first two weeks postpartum.
Hemorrhoids
Hemorrhoids are swollen veins of the rectum. Some remain within the rectum, but others can protrude through the anal opening. They are often painful, and can make passing a stool uncomfortable. They may develop during the third trimester of pregnancy due to the pressure of the baby’s head against the pelvis.
Regular application of ice packs, 20 minutes every four hours, can relieve pain, reduce hemorrhoid size, and facilitate the return of normal stooling. Ice should not be applied directly onto your skin because it could cause a freeze “burn.”. Add the ice to a plastic bag, then wrap it in a towel. Sitting in a bathtub of warm water, or a sitz bath, for 20 minutes can also reduce the discomfort of hemorrhoids. Cold witch hazel pads reduce minor discomfort and itching. If these measures do not provide relief, it is time to call a doctor.
Sitz Bath
Here’s how to do a sitz bath at home. You may want to do these two to three times a day, or per your doctor’s orders. Pick a time when the baby is asleep, or there are other caregivers present. After having a cesarean section, it is important to keep the area of your incision above water. Allowing it to become submerged keeps it too moist, and slows the process of healing.
• Wash your feet and legs, then rinse out the bath tub.
• Place a clean towel on the bottom surface of the tub, and add one to two inches of warm water. This should be just enough water to soak your perineum, but not your abdomen. NO SOAP or BUBBLE BATH.
• Sit on the submerged towel for 15 to 20 minutes. If the water becomes too cool, let some of it out, and replace it with warm water.
• After the sitz bath, stand up slowly to prevent feeling lightheaded or falling.
Other ways to speed the healing of hemorrhoids and make you more comfortable are:
- avoid standing or sitting for extended periods of time
- using a “donut: pillow or ring for sitting
- lying on your side while resting or napping.
Symptoms should begin to improve after a few days of Sitz baths and icepack applications. Dietary changes can also help. High fiber foods such as fruit, whole grains, and raw vegetables promote softer stools. Kiwi fruit is known to both soften stools, and improve intestinal motility. Drinking plenty of fluids can prevent the formation of hard stools which can irritate your hemorrhoids. It is recommended that lactating women drink between two to three liters of water daily.
To prevent straining that could impair the healing of your incisions, a stool softener may be recommended. Docusate (Colace) is safe to take while breastfeeding, and is not transmitted to the baby. If you cannot get relief from painful hemorrhoids with these measures, call your doctor.
Afterpains
Uterine contractions continue even after childbirth. They are normal, and allow the uterus to shrink to its pre-pregnancy size, a process called involution. These contractions are important because they constrict the blood vessels that were attached to the placenta, preventing postpartum hemorrhage. The discomfort felt from these contractions is called afterpains. They may be particularly uncomfortable after a c-section because of the incision that was made on the uterus and overlying muscles. Afterpains are particularly intense during the first 48 hours after delivery, and usually last three to four days. They are a good sign that your uterus is getting smaller.
Afterpains can be more intense while breastfeeding. The baby’s sucking releases a hormone, oxytocin, that causes the uterus to contract. This hormone also promotes breastmilk production, and maternal bonding with her infant. Ask your obstetrician if it is OK to take Tylenol 30 minutes to an hour prior to breastfeeding. If this does not provide relief, and the afterpains become too uncomfortable, call your doctor.
Incisional Pain
After a cesarian section, medications will initially be administered intravenously to manage your post-surgical pain. As the pain and your mobility improve, these will be changed to oral medications that may include acetaminophen (Tylenol), ibuprofen, or opiods. In addition, it is often too uncomfortable to void on the toilet, so a catheter will be placed into your bladder just prior to your surgery. Once you are able to get out of bed, the catheter will be removed. Voiding frequently to keep your bladder empty can reduce pressure on your uterus and healing incisions.
To provide support to your lower abdomen as you heal, it is often helpful to use a binder. These are elastic bands that are worn around the midsection of the body. The compression they provide can reduce incisional pain, and improve mobility after surgery.
Stretch Marks
Stretch marks may have formed on your abdomen during pregnancy, and may now be more noticeable. They will remain a red to purple color for a while. After six months they will become lighter on fair skin, or darker on more pigmented skin. A dermatologist can recommend topical creams and other treatments to help reduce the appearance of stretch marks.
When Does The Recovery Period End?
Some mothers are fully recovered from their c-sections by six weeks postpartum. Their incisions have fully healed, and they have a return of their pre-pregnancy muscle tone. For other women, it may take a few weeks longer. In some cases, there may be problems with how the incision heals or persistent abdominal pain. Post-operative infections are also possible. If your recovery is not progressing as expected, this should be discussed with your doctor.
More About Self Care After Cesarean Birth
Introduction to Self-care After Cesarean Birth
Preventive Self Care
Perineal Care
Physical Changes and Healing
Vaginal Birth After Cesarean (VBAC)
Breast Care
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
