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Postpartum care: What to expect after a vaginal birth

When caring for a newborn, you might forget to care for yourself. But that's important too. Learn what's involved as you recover from giving birth.

Pregnancy changes a body in more ways than you might expect. And that doesn't stop when you give birth. Here's what can happen physically and emotionally after a vaginal delivery.

Vaginal soreness

You might have had a tear in your vagina during delivery. Or your healthcare professional may have made a cut in the vaginal opening, called an episiotomy, to make delivery easier. The wound may hurt for a few weeks. Large tears can take longer to heal. To ease the pain:

• Sit on a pillow or padded ring.
• Cool the area with an ice pack. Or put a chilled witch hazel pad between a sanitary napkin and the area between your vaginal opening and anus. That area is called the perineum.
• Use a squirt bottle to spray warm water over the perineum as you urinate.
• Sit in a warm bath just deep enough to cover your buttocks and hips for five minutes. Use cold water if it feels better.
• Take a pain reliever that you can buy without a prescription. Ask your healthcare professional about a numbing spray or cream, if needed.
• Talk to your healthcare professional about using a stool softener. Or ask about taking a laxative. Those medicines may help prevent problems with bowel movements — a condition called constipation.

Tell your healthcare professional if you have intense pain, lasting pain or if the pain gets worse. It could be a sign of an infection.

Vaginal discharge

After delivery, a mix of blood, mucus and tissue from the uterus comes out of the vagina. This is called discharge. The discharge changes color and lessens over 4 to 6 weeks after a baby is born. It starts bright red, then turns darker red. After that, it usually turns yellow or white. The discharge then slows and becomes watery until it stops.

Contact your healthcare professional if blood from your vagina soaks a pad hourly for two hours in a row, especially if you also have a fever, pelvic pain or tenderness.

Contractions

You might feel contractions, sometimes called afterpains, for a few days after delivery. These contractions often feel like menstrual cramps. They help keep you from bleeding too much because they put pressure on the blood vessels in the uterus. Afterpains are common during breastfeeding. That's because breastfeeding causes the release of the hormone oxytocin.

To ease the pain, your healthcare professional might suggest a pain reliever that you can buy without a prescription. They include acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin IB, others).

Leaking urine

Pregnancy, labor and a vaginal delivery can stretch or hurt your pelvic floor muscles. These muscles support the uterus, bladder and rectum. As a result, some urine might leak when you sneeze, laugh or cough. The leaking usually gets better within a week. But it might go on longer. Leaking urine also is called incontinence.

Until the leaking stops, wear sanitary pads. Do pelvic floor muscle training, also called Kegels, to tone your pelvic floor muscles and help control your bladder.

To do Kegels, think of sitting on a marble. Tighten your pelvic muscles as if you're lifting the marble. Try it for three seconds at a time, then relax for a count of three. Work up to doing the exercise 10 to 15 times in a row, at least three times a day. To make sure you're doing Kegels right, it might help to see a physical therapist who specializes in pelvic floor exercises.

Hemorrhoids and bowel movements

If you notice pain during bowel movements and feel swelling near your anus, you might have swollen veins in the anus or lower rectum, called hemorrhoids. To ease hemorrhoid pain:

• Use a hemorrhoid cream or a medicine that you put into your anus, called a suppository, that has hydrocortisone. You can buy either without a prescription.
• Wipe the area with pads that have witch hazel or a numbing agent.
• Soak your anal area in plain warm water for 10 to 15 minutes 2 to 3 times a day.

You might be afraid to have a bowel movement because you don't want to make the pain of hemorrhoids or your episiotomy wound worse. Take steps to keep stools soft and regular. Eat foods high in fiber, including fruits, vegetables and whole grains. Drink plenty of water. Ask your healthcare professional about a stool softener, if needed.

Sore breasts

A few days after giving birth, you might have full, firm, sore breasts. That's because your breast tissue overfills with milk, blood and other fluids. This condition is called engorgement. Breastfeed your baby often on both breasts to help keep them from overfilling.

If your breasts are engorged, your baby might have trouble attaching for breastfeeding. To help your baby latch on, you can use your hand or a breast pump to let out some breast milk before feeding your baby. That process is called expressing.

To ease sore breasts, put warm washcloths on them or take a warm shower before breastfeeding or expressing. That can make it easier for the milk to flow. Between feedings, put cold washcloths on your breasts. Pain relievers you can buy without a prescription might help too.

Hair loss and skin changes

During pregnancy, higher hormone levels mean your hair grows faster than it sheds. The result is more hair on your head. But for up to five months after giving birth, you lose more hair than you grow. This hair loss stops over time.

Stretch marks on the skin don't go away after delivery. But in time, they fade. Expect any skin that got darker during pregnancy, such as dark patches on your face, to fade slowly too.

Mood changes

Childbirth can trigger a lot of feelings. Many people have a period of feeling down or anxious after giving birth, sometimes called the baby blues. Symptoms include mood swings, crying spells, anxiety and trouble sleeping. These feelings often go away within two weeks. In the meantime, take good care of yourself. Share your feelings, and ask your partner, loved ones or friends for help.

If you have large mood swings, don't feel like eating, are very tired and lack joy in life shortly after childbirth, you might have postpartum depression. Contact your healthcare professional if you think you might be depressed. Be sure to seek help if:

• Your symptoms don't go away on their own.
• You have trouble caring for your baby.
• You have a hard time doing daily tasks.
• You think of harming yourself or your baby.

Medicines and counseling often can ease postpartum depression.

Weight loss

It's common to still look pregnant after giving birth. Most people lose about 13 pounds (6 kilograms) during delivery. This loss includes the weight of the baby, placenta and amniotic fluid.

In the days after delivery, you'll lose more weight from leftover fluids. After that, a healthy diet and regular exercise can help you to return to the weight you were before pregnancy.

Postpartum checkups

The American College of Obstetricians and Gynecologists says that postpartum care should be an ongoing process rather than a single visit after delivery. Check in with your healthcare professional within 2 to 3 weeks after delivery by phone or in person to talk about any issues you've had since giving birth.

Within 6 to 12 weeks after delivery, see your healthcare professional for a complete postpartum exam. During this visit, your healthcare professional does a physical exam and checks your belly, vagina, cervix and uterus to see how well you're healing.

Things to talk about at this visit include:

• Your mood and emotional well-being.
• How well you're sleeping.
• Other symptoms you might have, such as tiredness.
• Birth control and birth spacing.
• Baby care and feeding.
• When you can start having sex again.
• What you can do about pain with sex or not wanting to have sex.
• How you're adjusting to life with a new baby.

This checkup is a chance for you and your healthcare professional to make sure you're OK. It's also a time to get answers to questions you have about life after giving birth.

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• Landon MB, et al., eds. Postpartum care and long-term health considerations. In: Gabbe's Obstetrics: Normal and Problem Pregnancies. 8th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed Sept. 6, 2023.
• American College of Obstetricians and Gynecologists' Presidential Task Force on Redefining the Postpartum Visit and the Committee on Obstetric Practice. Committee Opinion No. 736: Optimizing postpartum care. Obstetrics & Gynecology. 2018; doi:10.1097/AOG.0000000000002633.
• Berens P. Overview of the postpartum period: Normal physiology and routine maternal care. https://www.uptodate.com/contents/search. Accessed Sept. 6, 2023.
• Expert view. What to expect at a postpartum checkup — and why the visit matters. American College of Obstetricians and Gynecologists. https://www.acog.org/womens-health/experts-and-stories/the-latest/what-to-expect-at-a-postpartum-checkup-and-why-the-visit-matters. Accessed Sept. 6, 2023.
• Kegel exercises. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/urologic-diseases/bladder-control-problems-women/kegel-exercises. Accessed Sept. 7, 2023.
• Frequently asked questions. Labor, delivery, and postpartum care FAQ091. Postpartum depression. American College of Obstetricians and Gynecologists. https://www.acog.org/Patients/FAQs/Postpartum-Depression. Accessed Sept. 6, 2023.
• Berkowitz LR, et al. Postpartum perineal care and management of complications. https://www.uptodate.com/contents/search. Accessed Sept. 7, 2023.
• Postpartum care. Merck Manual Professional Version. https://www.merckmanuals.com/professional/gynecology-and-obstetrics/postpartum-care-and-associated-disorders/postpartum-care#. Accessed Sept. 7, 2023.
• Marnach M (expert opinion). Mayo Clinic. Sept. 11, 2023.

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HEATHER L. PALADINE, MD, MEd, CAROL E. BLENNING, MD, AND YORGOS STRANGAS, MD

Am Fam Physician. 2019;100(8):485-491

Related editorial: What Family Physicians Can Do to Reduce Maternal Mortality .

Related letter: Postpartum Relapse Prevention: The Family Physician's Role

Author disclosure: No relevant financial affiliations.

The postpartum period, defined as the 12 weeks after delivery, is an important time for a new mother and her family and can be considered a fourth trimester. Outpatient postpartum care should be initiated within three weeks after delivery in person or by phone, and may require multiple contacts with the patient to fully address needs and concerns. A full assessment is recommended within 12 weeks. Care should initially focus on acute needs and risks for morbidity and mortality and then transition to care for chronic conditions and health maintenance. Complications of pregnancy, such as hypertensive disorders and gestational diabetes mellitus, affect a woman's long-term health and require specific attention. Women diagnosed with gestational diabetes should receive a 75-g two-hour fasting oral glucose tolerance test between four and 12 weeks postpartum. Patients with hypertensive disorders of pregnancy should have a blood pressure check performed within seven days of delivery. All women should have a biopsychosocial assessment (e.g., depression, intimate partner violence) screening in the postpartum period, and preventive counseling should be offered to women at high risk. Additional patient concerns may include urinary incontinence, constipation, breastfeeding, sexuality, and contraception. Treating these issues during the postpartum period is important to the new mother's immediate and long-term health.

The 12 weeks after delivery, known as the postpartum period or the fourth trimester, are a critical time in the life of a mother and her infant. Maternal mortality, which is defined as deaths that occur during pregnancy and the first year postpartum, is highest in the first 42 days postpartum and represents 45% of total maternal mortality. 1 , 2 Early postpartum visits should evaluate complications from pregnancy as well as common postpartum medical complications. 3 – 5 Subsequent care should include a full biopsychosocial assessment and be tailored to individual patient needs going forward. 3 Family physicians should be aware of the importance of social determinants of health and disparities in maternal outcomes according to race, ethnicity, and public health insurance status.

Timing and Frequency of Postpartum Visits

Historically, physicians have performed a single postpartum visit between four and six weeks after delivery to close the prenatal care relationship. 1 There is a growing consensus to initiate care within the first three weeks postpartum, and to extend the postpartum period to transition to care of chronic conditions. 6 – 8 The American College of Obstetricians and Gynecologists (ACOG) recommends a postpartum evaluation within the first three weeks after delivery in person or by phone, with a complete biopsychosocial assessment to be completed within 12 weeks postpartum. 3 The World Health Organization recommends visits at three days, seven to 14 days, and six weeks postpartum, inclusive of newborn care. 3 , 9 A routine pelvic examination is not indicated unless there are patient concerns.

Postpartum Health Issues and Patient Concerns

Health issues in the postpartum period include medical complications, patient concerns, and conditions that may cause future health risks ( Table 1 ) . 4 , 10 – 52 Family physicians may need to continue to provide medical care for these conditions beyond 12 weeks after delivery. Complications that occur during the prenatal period may reveal areas for intervention and surveillance. 20 , 21

SECONDARY POSTPARTUM HEMORRHAGE

Secondary postpartum hemorrhage is defined as significant vaginal bleeding that occurs beyond 24 hours postpartum. Rates may be as high as 2%, 10 and retained placental tissue and infection are the most common causes. Women with secondary postpartum hemorrhage may need to be examined in the emergency department or hospital for prompt evaluation, including ultrasonography to investigate for retained placental tissue. 11 Treatment may include uterotonic medications, uterine curettage, or antibiotic treatment for endometritis. 12

ENDOMETRITIS

Women with a fever and tachycardia during the postpartum period should be evaluated for endometritis. Patients may also have uterine tenderness or vaginal discharge. Late postpartum endometritis occurs more than seven days after delivery. Risk factors include chorioamnionitis and prolonged rupture of membranes. 13 Endometritis usually requires treatment with intravenous antibiotics, with most evidence supporting the use of gentamicin and clindamycin. 14

THROMBOEMBOLIC DISORDERS

The risk of venous thromboembolic disease, including deep venous thrombosis and pulmonary embolism, is five times higher during the six weeks postpartum than during pregnancy. 17 A lesser degree of increased risk persists up to 12 weeks postpartum. 5 Additional risk factors are increasing age, cesarean delivery, postpartum hemorrhage or infection, and a history of preeclampsia. 15

Patients with a history of thromboembolism should be treated with anticoagulation for at least the first six weeks postpartum, and potentially longer if there are other risk factors. Warfarin (Coumadin) is teratogenic during pregnancy; however, it is minimally excreted in breast milk and is considered safe for women who are breastfeeding. There is a lack of data on the use of direct oral anticoagulants in breastfeeding, and they are not recommended for these patients. 16

HYPERTENSIVE DISORDERS

Up to 10% of women have elevated blood pressure during pregnancy, including chronic hypertension, gestational hypertension, and preeclampsia. Women with hypertensive disorders of pregnancy should have a follow-up blood pressure check within seven days of delivery and be evaluated for signs or symptoms of end organ damage such as hepatic injury or pulmonary edema. 4 , 18 Patients with new-onset blood pressure of 150/100 mm Hg or higher or with signs of end organ damage should be treated with antihypertensive medications. Patients with signs of end organ damage or a blood pressure of 160/110 mm Hg or higher should be hospitalized and treated with parenteral magnesium sulfate to prevent eclampsia. 18 Nonsteroidal anti-inflammatory drugs are preferred over opioid analgesia and have been shown to be safe for women with a history of hypertension in pregnancy. 19 , 53 , 54

Women with hypertensive disorders have an increased risk of cardiovascular events later in life. 18 , 55 , 56 They also have an elevated risk of cardiovascular disease, cerebrovascular disease, and venous thromboembolic disorders, and are at risk of these complications at an earlier age than the general population. All patients with a history of hypertensive disorders of pregnancy should be counseled on behavior modification and have blood pressure and body weight monitored at least once a year. 18 , 55

GESTATIONAL DIABETES MELLITUS

Gestational diabetes mellitus is a significant risk factor for the development of type 2 diabetes mellitus, hypertension, and subsequent heart disease. A woman with a history of gestational diabetes has an eight- to 20-fold risk of developing type 2 diabetes during her lifetime. 20 , 21 Women with gestational diabetes should be screened for impaired glucose tolerance with a 75-g two-hour fasting oral glucose tolerance test at four to 12 weeks postpartum , and should be evaluated for development of hypertension with blood pressure monitoring. 20 , 53 They should continue to be screened for diabetes every one to three years because the risk of type 2 diabetes is elevated. 21

THYROID DISORDERS

Postpartum thyroiditis can affect up to 10% of women during the first year postpartum, with similar rates of hyperthyroidism and hypothyroidism. 23 Postpartum hyperthyroidism is usually transient and does not need to be treated. Hypothyroidism is treated with thyroid hormone therapy. The risk of Graves disease is also increased postpartum, and women with a history of this disease are more likely to relapse. Positive thyroid-stimulating hormone receptor antibodies can distinguish Graves disease from postpartum thyroiditis. Infants of women who are breastfeeding and being treated for thyroid disorders should be monitored for growth and development; however, laboratory monitoring of infants' thyroid function is not necessary. 23 , 24 The American Thyroid Association recommends annual thyroid function screening in women with a history of postpartum thyroiditis. 23

POSTPARTUM DEPRESSION

Up to 10% of women will experience depression in the first year postpartum. The U.S. Preventive Services Task Force (USPSTF), ACOG, and American Academy of Pediatrics recommend one or more screening examinations for postpartum depression in settings where systems are in place to ensure diagnosis, treatment, and follow-up. 25 – 27 The American Academy of Pediatrics has specific recommendations for timing of screening at the one-, two-, four-, and six-month well-child visits. The Patient Health Questionnaire-2, Patient Health Questionnaire-9, and Edinburgh Postpartum Depression Scale are appropriate screening tools.

The USPSTF also recommends preventive counseling for women at high risk of perinatal depression. 28 Risk factors include a personal or family history of depression, a history of intimate partner violence, stressful life events including unplanned or undesired pregnancy, poor social or financial support, and medical complications. A previous American Family Physician ( AFP ) article reviewed identification and management of peripartum depression. 29

INTIMATE PARTNER VIOLENCE

The USPSTF recommends screening women of reproductive age for intimate partner violence with a validated screening tool such as HARK (humiliation, afraid, rape, kick; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2034562/table/T1/ ) or HITS (hurt, insult, threaten, scream; https://www.aafp.org/afp/2016/1015/p646.html#afp20161015p646-t2 ), followed by referral to support services if indicated. 30 Interventions such as counseling and home visits can reduce intimate partner violence for women postpartum.

URINARY INCONTINENCE

In one large cohort study, 28.5% of women reported moderate or severe urinary incontinence in the first year postpartum. 32 Bladder training, fluid management, body weight loss, and pelvic floor muscle exercises improve symptoms for all types of urinary incontinence, but studies have included women who are perimenopausal and not postpartum. 34 It is uncertain whether pelvic floor muscle training during the postpartum period has an effect on urinary incontinence; however, it does reduce postpartum urinary incontinence by about one-third when initiated prenatally. 33

HEMORRHOIDS AND CONSTIPATION

Hemorrhoids may be caused by constipation or by pushing during the second stage of labor. Initial therapy involves treatment for constipation. 35 Up to 17% of women report constipation in the first six weeks postpartum. Iron supplements taken orally during pregnancy can be a contributing factor. First-line treatments include increased intake of water and fiber, and osmotic laxatives such as polyethylene glycol (Miralax) or lactulose. Patients with hemorrhoids should also be treated with stool softeners.

BREASTFEEDING PROBLEMS

A previous AFP article addressed breastfeeding recommendations and common problems. 36 The USPSTF found moderate evidence that primary care–based interventions to increase breastfeeding are beneficial. 37 Individual-level interventions have stronger evidence of effectiveness. These include professional support by physicians, midwives, or lactation counselors; peer support; or formal education sessions. A Cochrane review found that support by trained personnel (e.g., medical professionals, volunteers), face-to-face interventions, and interventions that took place over multiple encounters were more effective. 38

POSTPARTUM WEIGHT RETENTION AND METABOLIC RISK

Although data are limited on postpartum body weight retention, a National Academy of Sciences report estimates that most women at six months postpartum will weigh about 11.8 pounds (5.4 kg) more than their prepregnancy body weight. Risk factors for higher postpartum weight retention include more body weight gain during pregnancy, black race, and lower socioeconomic status. Postpartum weight retention is a risk factor for later metabolic risk including development of obesity, higher weight in future pregnancies, and type 2 diabetes in women who have previously had gestational diabetes. 39 Counseling about dietary modifications or dietary and exercise modifications together are effective in helping women lose weight postpartum. 40

SEXUALITY AND CONTRACEPTION

Libido and sexuality are common concerns during the postpartum period. 41 Some studies have shown that pre-pregnancy estrogen levels may not return for as long as one year postpartum, particularly in women who are breastfeeding, which may contribute to a low libido. 41 , 42 The length of time for women to wait to have intercourse following delivery is variable; the average is six to eight weeks in the United States. 41 , 42 No consistent correlation exists between delivery complications (e.g., vaginal lacerations) and a delay in resuming intercourse. 41 , 42 Because most patients report some type of sexual problem postpartum, 42 it is important to assess patients, validate concerns, address contributing factors, reassure when appropriate, and offer support including counseling.

The prenatal period is the best time to discuss postpartum contraception. A 2015 Cochrane review reported low-quality evidence for the effectiveness of birth control method education in the postpartum period; however, a more recent study demonstrated the effectiveness of motivational interviewing resulting in a decrease in rapid repeat pregnancy and a higher use of long-acting reversible contraception in pregnant adolescents. 43 , 44

Women who are breastfeeding may also use the lactational amenorrhea method, alone or with other forms of contraception. The woman must be breastfeeding exclusively on demand, be amenorrheic (i.e., no vaginal bleeding after eight weeks postpartum), and have an infant younger than six months. This method is less reliable once the infant starts eating solid food. The failure rate is less than 2% if these criteria are fulfilled. 45 , 46

This article updates a previous article on this topic by Blenning and Paladine . 1

Data Sources: PubMed searches were done using the terms postpartum care, secondary/late postpartum hemorrhage/hemorrhage, postpartum endometritis, postpartum thyroid, hypertensive disorders of pregnancy, postpartum thromboembolism, postpartum mood disorders, postpartum substance use, postpartum urinary incontinence, postpartum constipation, postpartum hemorrhoids, breastfeeding, postpartum weight, postpartum sexuality, postpartum contraception, maternal infant dyad, and postpartum complications. Also searched were the Cochrane database, Essential Evidence Plus, and recommendations from the American College of Obstetricians and Gynecologists, the Centers for Disease Control and Prevention, the U.S. Preventive Services Task Force, and the World Health Organization. Search dates: July and September 2018, and June 2019.

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von Sydow K. Sexuality during pregnancy and after childbirth: a meta-content analysis of 59 studies. J Psychosom Res. 1999;47(1):27-49.

Lopez LM, Grey TW, Hiller JE, et al. Education for contraceptive use by women after childbirth. Cochrane Database Syst Rev. 2015(7):CD001863.

Stevens J, Lutz R, Osuagwu N, et al. A randomized trial of motivational interviewing and facilitated contraceptive access to prevent rapid repeat pregnancy among adolescent mothers. Am J Obstet Gynecol. 2017;217(4):423.e1-423.e9.

Trussell J. Contraceptive failure in the United States. Contraception. 2011;83(5):397-404.

U.S. Department of Health and Human Services. Office of Population Affairs. Lactational amenorrhea method (LAM). Accessed March 19, 2019. https://www.hhs.gov/opa/pregnancy-prevention/birth-control-methods/lam/index.html

Averbach S, Kakaire O, Kayiga H, et al. Immediate versus delayed post-partum use of levonorgestrel contraceptive implants: a randomized controlled trial in Uganda. Am J Obstet Gynecol. 2017;217(5):568. e1-568.e7.

Levitt C, Shaw E, Wong S, et al.; McMaster University Postpartum Research Group. Systematic review of the literature on postpartum care: selected contraception methods, postpartum Papanicolaou test, and rubella immunization. Birth. 2004;31(3):203-212.

Turok DK, Leeman L, Sanders JN, et al. Immediate postpartum levonorgestrel intrauterine device insertion and breast-feeding outcomes: a noninferiority randomized controlled trial. Am J Obstet Gynecol. 2017;217(6):665.e1-665.e8.

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Carmo LS, Braga GC, Ferriani RA, et al. Timing of etonogestrel-releasing implants and growth of breastfed infants: a randomized controlled trial. Obstet Gynecol. 2017;130(1):100-107.

Lopez LM, Grey TW, Stuebe AM, et al. Combined hormonal versus nonhormonal versus progestin-only contraception in lactation. Cochrane Database Syst Rev. 2015(3):CD003988.

Blue NR, Murray-Krezan C, Drake-Lavelle S, et al. Effect of ibuprofen vs acetaminophen on postpartum hypertension in preeclampsia with severe features: a double-masked, randomized controlled trial. Am J Obstet Gynecol. 2018;218(6):616.e1-616.e8.

Viteri OA, England JA, Alrais MA, et al. Association of nonsteroidal anti-inflammatory drugs and postpartum hypertension in women with preeclampsia with severe features. Obstet Gynecol. 2017;130(4):830-835.

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Postpartum care of the new mother.

Diorella M. Lopez-Gonzalez ; Anil K. Kopparapu .

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Last Update: December 11, 2022 .

• Continuing Education Activity

The postpartum period begins soon after the delivery of the baby and usually lasts six to eight weeks and ends when the mother’s body has nearly returned to its pre-pregnant state. The postpartum period for a woman and her newborn is very important for both short-term and long-term health and well-being. This activity should help the interprofessional team on how to provide comprehensive postpartum care for the new mother.

• Review the guidelines regarding comprehensive postpartum care.
• Summarize the components of the postpartum care of the new mother.
• Outline the common medical conditions that women encounter during the postpartum period.
• Describe how interprofessional team coordination and communication can enhance patient outcomes when rendering a new mother's postpartum care.
• Introduction

The postpartum period begins soon after the baby's delivery and usually lasts six to eight weeks and ends when the mother’s body has nearly returned to its pre-pregnant state. [1]  The weeks following birth lay the foundation of long-term health and well-being for both the woman and her infant. Therefore, it is critical to establish a reliable postpartum (afterbirth) period that should be tailored into on-going, continuous, comprehensive care.  Most maternal and infant deaths occur in the first month after birth. Hence effective postpartum care is mandatory to improve both short-term and long-term health consequences of mother and newborn. [2]

Timing of Postnatal Visits

In April 2018, The American College of Obstetrics and Gynecology (ACOG) recommends12 weeks of support, rather than a single six-week postpartum visit. ACOG also recommends postpartum evaluation within the first 3 weeks after delivery in-person or by phone, which later is followed up with ongoing care as needed, concluding with a comprehensive postpartum visit no later than 12 weeks. [3]

Components of Postpartum Care

• Vaginal pain: Genital tract trauma is obvious with spontaneous vaginal delivery. [4]  Mild vaginal tears occur during delivery and take a few weeks to heal, whereas extensive tears might take longer to heal. Advice women to take over-the-counter medications such as ibuprofen or acetaminophen for pain, sit on a padded ring, or cool the area with an ice pack to relieve the pain. Health care providers should inform women about the signs of infection such as fever and encourage them to seek medical attention for persistent, severe pain. [5]  
• Vaginal bleeding/discharge: Bloody vaginal discharge (lochia rubra) is heavy for the first 3-4 days, and slowly it becomes watery in consistency and color changes to pinkish-brown (lochia serosa). After the next 10-12 days, it changes to yellowish-white (lochia alba).  Advise women to seek medical attention if heavy vaginal bleeding persists (soaking a pad or more in less than an hour). Women with heavy, persistent postpartum bleeding should be evaluated for complications such as retained placenta, uterine atony, rarely invasive placenta, or coagulation disorders. [6]   Endometritis may also occur, presenting as fever with no source, maybe accompanied by uterine tenderness and vaginal discharge. This usually requires intravenous antibiotics. This also should be explained and advise the mother to seek immediate medical attention.
• Breastfeeding: Breastfeeding is beneficial for the mother and the newborn. [7]  Breastfeeding women are less likely to get breast cancer, ovarian cancer, and type 2 DM. [8]  Providers should evaluate latch, swallow, nipple type and condition, and hold of infants for any problems.  Interventions include professional support, peer support, and formal education. [9]  Health care providers should strongly encourage women to breastfeed the newborn unless it is contraindicated. The World Health Organization (WHO) recommends at least four to six months, every three to four hours daily. Breastfeeding reduces the newborn’s risk for gastrointestinal tract infections, pediatric cancers, and atopic eczema. [8]  Breastfeeding should be evaluated at each postnatal visit. 
• Nutrition and exercise:  Women at higher risk for postpartum weight retention are those with higher gestational weight gain, black race, and lower socioeconomic status, which at the same time increase their risk of future obesity and type 2 diabetes. [10] Advise women to take a variety of healthy balanced diets and resume their normal dietary habits. All breast-feeding mothers need to take extra 500 calories per day. Avoid strenuous activities in the early postpartum period and take plenty of rest for the first 2-3 weeks and slowly start with non-impact activities such as walking and a gradual return to previous activities is recommended. [11]
• Breast engorgement: Women may experience full, firm, and tender breasts after the delivery. Frequent breastfeeding on both breasts is recommended to avoid engorgement. [12]  Advise women to use warm washcloths or warm showers or place cold washcloths between feedings to relieve the pain. For women who are not going to breastfeed, encourage them to use cold packs, using firm support of the breasts, take analgesics as needed, and mechanical extraction of milk. [13]
• Bladder and bowel function: Voiding must be encouraged and monitored to prevent asymptomatic bladder overfilling. Women are encouraged to use mild laxatives such as docusate, psyllium, bisacodyl if defecation has not occurred within 3 days of delivery. Another consideration is Osmotic laxatives as polyethylene glycol and lactulose. [14]
• Sexual relations: Libido may decrease after the delivery because of decreased estrogen levels. This may not return for as long as 1 year postpartum, particularly in women who are breastfeeding. Reassurance is usually appropriate.  Advice women to wait for their perineal area to heal before resuming sexual activity, and it may take 4-6 weeks for the perineal tears to heal completely. Health care providers should be more comfortable discussing women about sexuality during the early postpartum period. [15]  Address earlier return of sexual activity with contraception to avoid unintended, closely spaced pregnancy. [15]
• Contraception: The prenatal period is the best time to discuss postpartum contraception. In adolescents begin motivational interviewing, discussion of long-acting reversible contraception during pregnancy. [16]   For breastfeeding women, nonhormonal modalities are usually preferred. The American College of Obstetrics and Gynecologists (ACOG) recommend progestin-only contraceptives are the best hormonal contraceptive modality for breastfeeding women. Breastfeeding mothers should not use combination estrogen-progestin contraceptives as it can interfere with breast milk production. [17]  Among hormonal methods, combined estrogen-progestin vaginal rings can be used after 4 weeks postpartum. Hormonal methods such as progestin-only oral contraceptives, depot medroxyprogesterone acetate injections, and progestin implants are preferred, as they do not affect milk production. A vaginal diaphragm and cervical cap should be fitted only after complete involution of the uterus, at 6 to 8 weeks after delivery. Intrauterine devices are typically best placed after 4 to 6 weeks after delivery. Breastfeeding is not an effective contraceptive choice.  Lactational amenorrhea method alone or other forms of contraception has a failure rate of 2%, but a specific criterion has to be fulfilled. The woman must have to be breastfeeding exclusively on demand, be amenorrheic) i.e., no vaginal bleeding after 8 weeks postpartum), and have an infant younger than 6 months. This becomes less reliable as the infant starts to eat solid foods.  Both breastfeeding and non-breast-feeding women can use barrier contraceptives, intrauterine devices (IUDs; copper-releasing and hormone-releasing), and progestin-only contraception. WHO recommends breastfeeding women wait six weeks postpartum before starting progestin-only contraceptives. ACOG recommends combination hormonal contraceptive use should not start until 3 weeks postpartum because of the increased risk of thromboembolism. Women should wait at least 6-18 months before trying to become pregnant again.
• Education: Health care providers should provide essential education regarding newborn care, such as umbilical cord care, bathing, breastfeeding, and the importance of immunizations.
• Miscarriage, stillbirth, or neonatal death: For mothers who experience any pregnancy loss, it is essential to ensure follow-up. Key elements are to provide emotional support and bereavement counseling; referral, if appropriate, to counselor and support groups. Also review of any laboratory or pathology studies related to the loss and counseling regarding recurrent risk and future pregnancy planning. [18]
• Issues of Concern

Common Postpartum Concerns

• Postpartum blues: Transient depression (baby blues) is very common during the first week after delivery. [19]   Women may notice feeling down, anxious, mood swings, crying spells, irritability, and difficulty sleeping. Postpartum blues typically resolve within 2 weeks. Health care providers should advise them to seek medical attention if depressive symptoms continue beyond 2 weeks and having difficulty taking care of themselves or taking care of the newborn or having thoughts of harming themselves or the newborn baby. [20]   All women should be screened for mood and anxiety disorders using a validated tool (Edinburgh Postnatal Depression Scale).  The American Academy of Pediatrics recommends screening at the one-, two-, four- and six-month well visit. Encourage the partner and family members at least for the first week of the postnatal period to provide emotional support and to take care of the newborn. The National Institute for Health and Care Excellence recommends screening all postpartum women for resolution of the postpartum blues at 10 to 14 days after delivery. 
• Intimate partner violence: Use HARK (humiliation, afraid, rape, kick) or HITS (hurt, insult, threaten, scream) tools to evaluate for intimate partner violence. [21] Prioritize patient safety, consider referral to intimate partner violence prevention organizations.
• Incontinence: Stress incontinence occurs due to extensive stretch or injury to pelvic floor muscles during labor. Risk factors for urinary incontinence three months postpartum include obesity, parity, smoking, longer duration of breastfeeding, and use of forceps during vaginal delivery. Advise women to do Kegel’s exercises regularly to strengthen pelvic floor muscles. [22]  Other considerations also are bladder training and weight loss as part of first-line treatment. It is important to let the new mother know that more than ¼ of women experience moderate or severe urinary incontinence in the first year postpartum.
• Hemorrhoids: Caused by constipation and/or by pushing during the second stage of labor. [23] The first line of treatment includes an increase in water and fiber intake and stool softeners. Some may need excision or ligation of refractory hemorrhoids or grade III or higher.
• Clinical Significance

According to ACOG, at least 40% of women do not seek postpartum care. Several factors contribute towards this trend, such as cultural differences, lack of insurance, lack of adequate family support, low socioeconomic status, poor anticipatory guidance, race, lack of good transitional care management, and poor access to home visits. According to the Pregnancy Mortality Surveillance System (PMSS), Nonhispanic blacks have the highest maternal mortality. [24] [25] [26]

During the first week of the postnatal period, severe hypertension, severe bleeding, and infection are the most common contributors to maternal deaths, while the cardiovascular cause is the leading cause of late deaths. [27] When compared with other developed countries such as Norway and New Zealand, the US has significantly lagged behind with providing adequate prenatal care and US mortality and morbidity is significantly higher ( 17.4 % vs. 1.7 % ), and the US has a significantly lower number of maternal health care providers such as obstetricians and midwives ( 19 vs. 65 per 1000 live births ). Earlier postpartum visits are mandatory to evaluate for resolution of postpartum blues and other chronic medical conditions such as hypertension and diabetes and to improve both maternal and neonatal mortality and morbidity.

• Other Issues

Health Issues that Arise During Pregnancy

1. Pregnancy-induced hypertension: Hypertensive disorder risk is higher < 48hrs after delivery. An office visit is recommended within the first 7 days after delivery. Blood Pressure (BP) ≥150/100 mmHg can be treated with oral medication such as nifedipine or labetalol. Hospitalize if signs of end-organ (liver injury or pulmonary edema) or BP ≥ 160/110. Recommend lifestyle modification and annual BP and bodyweight monitoring follow-ups.  

2. Gestational diabetes mellitus (GDM): Women with GDM are at a very high risk of developing diabetes. ACOG recommends women with GDM should have a 75-g, 2-hour fasting oral glucose tolerance test 4 to 12 weeks postpartum to screen for type 2 DM. [28]  

3. Thyroid disorders: Mother can experience symptoms of hypo- or hyperthyroidism. The diagnosis of postpartum thyroiditis depends on clinical presentation and elevated free T4 and low TSH. Hyperthyroidism is transient and usually not treated. Beta-blocker can be used if needed for symptoms. Hypothyroidism is treated with levothyroxine. The American Thyroid Association recommends annual testing in women with hypothyroidism with a history of postpartum thyroiditis. [29]

• Enhancing Healthcare Team Outcomes

In 2013, WHO released the following  recommendations regarding the postpartum care:

1. Provide postnatal care in the first 24 hours to all mothers and babies-regardless of where the birth occurs.2. Ensure healthy women and their newborns stay at a health care facility for at least one day after the delivery. 3. All mothers and newborns need at least four postpartum visits in the first 6 weeks.4. If birth is at home, the first postnatal contact should be as early as possible, within 24 hours of birth.5. Ensure at least 3 postnatal visits for all mothers and babies, on day 3 (48 to 72 hours), between days 7 to 14, and 6 weeks after birth.6. All women should be educated about the physiological process of recovery after birth and mention that some health problems are common, with advice to report any health concerns to a health care provider, in particular, signs and symptoms of infection, postpartum hemorrhage, pre-eclampsia/eclampsia, and thromboembolism.7. The use of prophylactic antibiotics among women with a vaginal delivery and a third or fourth-degree perineal tear is recommended to prevent wound complications.8. Advise women to apply topical chlorhexidine application to the umbilical cord stump daily during the first week of life is recommended for newborns born at home in settings with high neonatal mortality (30 or more neonatal deaths per 1,000 live births).

• Nursing, Allied Health, and Interprofessional Team Interventions

Ultimately, providing the optimum level of healthcare and support for postpartum families will require local, state-wide, and national-level policy changes. Even though the affordable care act improved maternal care access, the US still needs a major change in policies to provide appropriate, evidence-based, and culturally competent universal access to maternity care. [30]

Expanding eligibility for Medicaid, which pays for almost half of U.S. deliveries, can improve postpartum coverage. [31] This should be facilitated through mutual support between healthcare providers and insurance platforms by appropriate reimbursement levels that support—and indeed fosters—postpartum care as a continuous, rather than an isolated, process, which undoubtedly leads to positive outcomes for the community as a whole. [32]

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Disclosure: Diorella Lopez-Gonzalez declares no relevant financial relationships with ineligible companies.

Disclosure: Anil Kopparapu declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Lopez-Gonzalez DM, Kopparapu AK. Postpartum Care of the New Mother. [Updated 2022 Dec 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Postpartum Care

• Postpartum Physiologic Changes |
• Routine Postpartum Care |
• Postpartum Preventive Care |
• Postpartum Complications |

Clinical manifestations during the puerperium (6-week period after delivery) generally reflect reversal of the physiologic changes during pregnancy (see table Normal Postpartum Changes ). When patients present for medical care during the postpartum period, these changes should be considered along with issues that are not pregnancy related.

The most common complications are

Immediate (primary) or late (secondary) postpartum hemorrhage

Postpartum endometritis

Wound infection or dehiscence

Urinary tract infections (cystitis and pyelonephritis)

Postpartum depression

Postpartum hypertensive disorders (postpartum preeclampsia or postpartum hypertension)

Postpartum Physiologic Changes

Clinical parameters.

Within the first 24 hours after delivery, pulse rate begins to decrease, and temperature may be slightly elevated.

Vaginal discharge is grossly bloody (lochia rubra) for 3 to 4 days, then becomes pale brown (lochia serosa), and after the next 10 to 12 days, it changes to yellowish white (lochia alba).

About 1 to 2 weeks after delivery, eschar from the placental site sloughs off and bleeding occurs; bleeding is usually self-limited. Total blood loss is about 250 mL. External pads may be used; to avoid infection, most clinicians advise against using tampons. Women should be told to contact their clinician if they are concerned about heavy or prolonged bleeding ( late postpartum hemorrhage ). These symptoms may be a sign of infection or retained placenta and should be evaluated.

The uterus involutes progressively; after 5 to 7 days, it is firm and no longer tender, with the fundus midway between the symphysis and umbilicus. By 2 weeks, it is no longer palpable abdominally and typically by 4 to 6 weeks returns to a prepregancy size. During the first few days postpartum, contractions of the involuting uterus may be painful (afterpains) and may require analgesics.

Laboratory parameters

During the first week, urine temporarily increases in volume and becomes more dilute as the additional plasma volume of pregnancy is excreted. Care must be taken when interpreting urinalysis results because lochia can contaminate the urine.

Because blood volume is redistributed, hematocrit may fluctuate, although it tends to remain in the prepregnancy range if blood loss is within the normal range. Because the white blood count (WBC) increases during labor, marked leukocytosis (up to 20,000 to 30,000/mcL) occurs in the first 24 hours postpartum; WBC count returns to normal within 1 week. Plasma fibrinogen and erythrocyte sedimentation rate (ESR) remain elevated during the first week postpartum.

Routine Postpartum Care

The woman and infant may be discharged from the hospital within 24 to 48 hours postpartum. Some obstetric units discharge patients as early as 6 hours postpartum if major anesthesia was not used and no complications occurred.

Serious problems are rare, but a home visit, office visit, or phone call within 24 to 48 hours helps screen for complications. A routine postpartum visit is usually scheduled at 3 to 8 weeks for women with an uncomplicated vaginal delivery. If delivery was cesarean or if other complications occurred, follow-up may be scheduled sooner ( 1 ).

Perineal care

If delivery was uncomplicated, showering and bathing are allowed, but vaginal douching is prohibited (douching is not recommended for any woman, regardless of pregnancy). The vulva should be cleaned from front to back. Some patients find it helpful to use a bottle with a spout to squirt warm water on the perineum.

Later, warm sitz baths can be used several times a day.

Cesarean wound care

Following cesarean delivery , patients should receive standard wound care and monitoring.

Typically, the bandage is removed within 1 to 2 days postoperatively. Patients may shower after the dressing is removed, but they are usually advised to defer immersing in a bath until the wound is fully healed. If surgical staples were used for wound closure and the skin incision is transverse, the staples can be removed after 4 to 6 days. Patients should be advised to call their clinician if there are signs of wound infection (erythema, induration, purulent discharge, fever) or dehiscence (separation of wound, serosanguinous discharge).

Pain management

Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective for both perineal discomfort and uterine cramping ( 2

3 ). Some women require opioids to relieve discomfort; the lowest effective dose should be used.

If pain is significantly worsening, women should be evaluated for complications, such as vulvar hematoma or post-cesarean complications.

Bladder and bowel function

Regional (spinal or epidural) or general anesthesia may delay defecation and spontaneous urination, in part by delaying ambulation.

Diet and exercise

After the first 24 hours, recovery is rapid. After delivery, a regular diet may be given as soon the patient desires. Ambulation is encouraged as soon as possible.

Exercise recommendations are individualized depending on the mode of delivery, complications, perineal lacerations or episiotomy, and the presence of other disorders. Usually, exercise can be started once the discomfort of delivery has subsided, typically within 1 day for women who deliver vaginally and later (typically after 6 weeks) for those who deliver by cesarean ( 4 ). Whether pelvic floor muscle exercises (Kegel exercises) are helpful is unclear, but these exercises can begin as soon as the patient is ready.

Breast engorgement

Milk accumulation may cause painful breast engorgement during early lactation.

For women who are going to breastfeed, the following are recommended until milk production adjusts to the infant's needs:

Expressing milk by hand in a warm shower or using a breast pump between feedings to relieve pressure temporarily (however, doing so tends to encourage lactation, so it should be done only when necessary)

Breastfeeding the infant on a regular schedule

Wearing a comfortable and supportive nursing bra 24 hours/day

For women who are not going to breastfeed, the following are recommended:

Tight binding of the breasts (eg, with a snug-fitting bra), cold packs, and analgesics as needed to control temporary symptoms while lactation is being suppressed

Firm support of the breasts to suppress lactation because gravity stimulates the let-down reflex and encourages milk flow

Refraining from nipple stimulation and manual expression, which can increase lactation

Suppression of lactation with medications is not recommended in the United States, but such medications are used in many countries ( 5 ).

Patients who develop mastitis will present with fever and breast symptoms: erythema, induration, tenderness, pain, swelling, and warmth to the touch. Mastitis is different from the pain and cracking of nipples that frequently accompanies the start of breastfeeding.

Sexual activity

Sexual activity after vaginal delivery may be resumed as soon as desired and comfortable and after healing of any laceration or episiotomy repair. Sexual activity after cesarean delivery should be delayed until the surgical wound has healed.

Contraception

Some data suggest that subsequent obstetric outcomes are improved by delaying conception for at least 6 months but preferably 18 months after delivery ( 6 ).

To minimize the chance of pregnancy, women who have sex with men should start using contraception before resuming sexual activity. If women are not breastfeeding, ovulation usually occurs about 4 to 6 weeks postpartum, 2 weeks before the first menses. However, ovulation can occur earlier; women have conceived as early as 2 weeks postpartum. Women who are breastfeeding tend to ovulate and menstruate later, usually closer to 6 months postpartum, although a few ovulate and menstruate (and become pregnant) as quickly as those who are not breastfeeding.

Women should choose a method of contraception based on the specific risks and benefits of various options.

Estrogen -progestin contraceptives can interfere with milk production and should not be initiated until milk production is well-established. Combined estrogen -progestin vaginal rings can be used after 4 weeks postpartum if women are not breastfeeding.

A diaphragm should be fitted only after complete involution of the uterus, at 6 to 8 weeks; meanwhile, condoms and spermicide should be used.

Intrauterine devices may be placed as soon as immediately after delivery of the placenta, but placement after 4 to 6 weeks postpartum minimizes risk of expulsion.

Women who do not desire future fertility may choose tubal sterilization ( 7 ). Tubal sterilization can be done immediately postpartum, at the time of cesarean delivery, or after the postpartum period. This procedure is considered permanent and irreversible. Because removing the fallopian tubes (salpingectomy) is associated with a decreased risk of ovarian cancer, patients undergoing tubal sterilization should be offered salpingectomy ( 8 ).

Routine postpartum care references

1. American College of Obstetricians and Gynecologists (ACOG) : ACOG Committee Opinion No. 736: Optimizing Postpartum Care.  Obstet Gynecol . 2018;131(5):e140-e150. Reaffirmed 2021. doi:10.1097/AOG.0000000000002633

2. Pharmacologic Stepwise Multimodal Approach for Postpartum Pain Management : ACOG Clinical Consensus No. 1.  Obstet Gynecol . 2021;138(3):507-517. doi:10.1097/AOG.0000000000004517

3. Altenau B, Crisp CC, Devaiah CG, Lambers DS Am J Obstet Gynecol 217 (3):362.e1–362.e6, 2017. doi: 10.1016/j.ajog.2017.04.030

4. Syed H, Slayman T, DuChene Thoma K : ACOG Committee Opinion No. 804: Physical Activity and Exercise During Pregnancy and the Postpartum Period.  Obstet Gynecol . 2021;137(2):375-376. Reaffirmed 2023. doi:10.1097/AOG.0000000000004266

5. Drugs and Lactation Database (LactMed®) [Internet]. Bethesda (MD)

6. Hutcheon JA, Moskosky S, Ananth CV, et al : Good practices for the design, analysis, and interpretation of observational studies on birth spacing and perinatal health outcomes [published correction appears in Paediatr Perinat Epidemiol . 2020 May;34(3):376].  Paediatr Perinat Epidemiol . 2019;33(1):O15-O24. doi:10.1111/ppe.12512

7. American College of Obstetricians and Gynecologists (ACOG) : ACOG Committee Opinion, Number 827: Access to Postpartum Sterilization.  Obstet Gynecol . 2021;137(6):e169-e176. doi:10.1097/AOG.0000000000004381

8. American College of Obstetricians and Gynecologists (ACOG) : ACOG Committee Opinion No. 774: Opportunistic Salpingectomy as a Strategy for Epithelial Ovarian Cancer Prevention.  Obstet Gynecol . 2019;133(4):e279-e284. Reaffirmed 2020. doi:10.1097/AOG.0000000000003164

Postpartum Preventive Care

During the postpartum period, either prior to discharge from the hospital or at an outpatient visit, certain preventive measures are required to prevent infection in the neonate or avoid complications in subsequent pregnancies. The postpartum visit can also be an opportunity for a patient to receive routine vaccinations, if indicated.

Prevention of Rh sensitization

If women with Rh-negative blood have an infant with Rh-positive blood but are not sensitized, they should be given Rho(D) immune globulin 300 mcg IM within 72 hours of delivery to prevent alloimmunization .

Vaccination

Vaccinations are given postpartum if

Vaccination was recommended but not received during pregnancy.

A patient is unvaccinated or is insufficiently vaccinated or nonimmune (eg, did not complete a full vaccine series or is seronegative despite prior vaccination), and the vaccine is contraindicated during pregnancy.

The tetanus-diphtheria-acellular pertussis (Tdap) vaccine is recommended between 27 and 36 weeks of each pregnancy; the Tdap vaccine helps boost the maternal immune response and passive transfer of antibodies to the neonate. If women have never been vaccinated with the Tdap vaccine (not during the current or a previous pregnancy nor as an adolescent or adult), they should be given Tdap before discharge from the hospital or birthing center, regardless of their breastfeeding status. If family members who anticipate having contact with the neonate have not previously received Tdap, they should be given Tdap at least 2 weeks before they come into contact with the neonate to immunize them against pertussis ( 1 ).

In August 2023, the U.S. Food and Drug Administration approved use of a respiratory syncytial virus (RSV) vaccine in pregnant patients between 32 and 36 weeks gestation, with a warning to avoid use prior to 32 weeks ( 2 ). There is no current recommendation to give the RSV vaccine postpartum to women who did not receive it during pregnancy.

The measles-mumps-rubella vaccine (MMR) and varicella vaccine are live attenuated vaccines and should not be given during pregnancy. Patients who are seronegative for antibodies for measles, rubella, or varicella should be vaccinated postpartum (usually on the day of discharge).

A postpartum hospital stay or outpatient visit also provides an opportunity for women to receive any needed routine vaccinations (eg, influenza, COVID-19, hepatitis B, human papillomavirus) that are recommended either for all patients or for certain patients based on risk factors for particular infections.

(See also Vaccines During Pregnancy , Guidelines for Vaccinating Pregnant Women , and  CDC: COVID-19 Vaccines While Pregnant or Breastfeeding .)

Postpartum preventive care references

1. American College of Obstetricians and Gynecologists (ACOG) : Committee Opinion No. 718: Update on Immunization and Pregnancy: Tetanus, Diphtheria, and Pertussis Vaccination.  Obstet Gynecol . 2017;130(3):e153-e157. Reaffirmed 2022. doi:10.1097/AOG.0000000000002301

2. U.S. Food and Drug Administration (FDA) : FDA Approves First Vaccine for Pregnant Individuals to Prevent RSV in Infants. FDA News Release, August 21, 2023.

Postpartum Complications

Risk of infection, hemorrhage, and excessive pain must be minimized. Women are typically observed for at least 1 to 2 hours after the third stage of labor and for several hours longer if regional or general anesthesia was used during delivery or if there were complications of the pregnancy or delivery.

Immediate postpartum hemorrhage

Minimizing bleeding is the first priority; measures include

Uterine massage

During the first hour after the third stage of labor, the uterine fundus is massaged through the abdomen periodically to ensure that it contracts, preventing excessive bleeding.

If severe bleeding continues, vital signs are monitored, and hemodynamic support with IV fluids and oxygen is given. A complete blood count and coagulation tests are done. Blood products are given if needed. Clinicians should monitor the patient for disseminated intravascular coagulation . If fever is present, antibiotics are given if appropriate.

After a vaginal birth, an internal uterine examination is done to check for retained membranes or placental fragments. After cesarean delivery, surgical complications are considered.

(For further information, see Postpartum Hemorrhage .)

Late postpartum hemorrhage

Patients may experience postpartum hemorrhage days or weeks after delivery. Late postpartum hemorrhage may be caused by retained products of conception, infection, or coagulation disorders. Patients should be educated about when to call a health care professional or go to an emergency department. Common guidance is that patients should seek medical care if they are soaking a pad or tampon every 1 to 2 hours, passing large (> 2.5 cm) blood clots and/or feeling faint.

When patients present with significant late postpartum bleeding, the history of the recent pregnancy is reviewed, including mode of delivery and any complications during pregnancy or delivery. Overall obstetric history and medical history are also reviewed, particularly for risk factors for bleeding disorders.

Patients are evaluated as for immediate postpartum hemorrhage, and hemodynamic support is given. For late postpartum bleeding, manual exploration of the uterus is not done. Pelvic ultrasonography may reveal retained products of conception that require surgical evacuation, uterotonics, or antibiotics.

Hypertensive disorders

Preeclampsia can develop after delivery. Signs and symptoms are similar to preeclampsia during pregnancy (new-onset hypertension) combined with new unexplained proteinuria and/or signs or symptoms of end-organ damage (eg, thrombocytopenia , impaired liver function, renal insufficiency, pulmonary edema, headache, visual symptoms). Women should be counseled to call their health care professional if they experience these symptoms postpartum.

The evaluation is similar to that done during pregnancy, including blood pressure monitoring and laboratory evaluation.

In cases that meet criteria for severe preeclampsia, patients are hospitalized and treated with IV magnesium sulfate for 24 hours to prevent seizures.

Patients with fever or other symptoms or signs of infection postpartum should be promptly evaluated and treated. Prior to discharge from the hospital, patients should be counseled about how to recognize symptoms of infection and when to seek medical attention.

Postpartum infections may include

Endometritis

Wound infection

Urinary tract infection (cystitis or pyelonephritis)

Clostridioides difficile colitis (in patients who received antibiotics during or after labor and delivery)

Endometritis , mastitis , and postpartum pyelonephritis are discussed in detail separately.

Wound infection of abdominal incisions may develop after cesarean delivery or postpartum tubal sterilization. Perineal repairs may also become infected. In severe cases, infection may cause cellulitis , abscess , or necrotizing fasciitis .

Thromboembolic disorders

Thromboembolic disorders — deep venous thrombosis (DVT) or pulmonary embolism (PE)—are a leading cause of maternal mortality.

Most pregnancy-associated thromboemboli develop postpartum and result from vascular trauma during delivery ( 2 ). The risk of developing a thromboembolic disorder is increased for about 6 weeks after delivery. Cesarean delivery also increases risk. Postpartum patients should be monitored for signs and symptoms of thromboembolism and counseled about how to recognize these signs and when to see medical attention.

Headache after neuraxial anesthesia (spinal headache)

Some patients experience a headache due to leakage of cerebrospinal fluid from spinal anesthesia or puncture of the dura during epidural anesthesia (referred to as spinal headache or postdural puncture headache). The headache is positional and should be differentiated from other etiologies (eg, preeclampsia).

3 ). If the headache is severe, it may be treated with an epidural blood patch ( 4 ).

Perineal repair complications

Women may develop the following complications of the perineal repair after perineal laceration or episiotomy:

Wound dehiscence

Chronic pain

Perineal, vulvar, or vaginal hematoma may develop after vaginal delivery. These complications typically present as a mass accompanied by increasing pain. Nonexpanding hematomas are managed conservatively with ice packs and observation. If a hematoma is expanding or there is suspicion of retroperitoneal bleeding, surgical intervention is required.

Perineal repairs may separate or become infected . In such cases, evaluation is done for infection and damage to the anal sphincter. Management may include antibiotics, debridement, re-suturing, and/or leaving the wound open to heal by secondary intention.

Some women experience chronic pain or dyspareunia at the site of perineal repair. First-line management is with pelvic floor muscle exercises. If exercises are not effective, the patient should be referred to a urogynecologist or other gynecologist experienced in chronic pain and pelvic reconstructive surgery.

Psychiatric disorders

Transient depressive symptoms (postpartum blues) are very common during the first week after delivery. Symptoms (eg, mood swings, irritability, anxiety, difficulty concentrating, insomnia, crying spells) are typically mild and usually subside by 7 to 10 days postpartum.

Clinicians should ask women about symptoms of depression before and after delivery and should be alert to recognizing symptoms of depression, which may resemble the normal effects of new motherhood (eg, fatigue, difficulty concentrating). They should also advise women to contact them if depressive symptoms continue for > 2 weeks or interfere with daily activities or if women have suicidal or homicidal thoughts. In such cases, postpartum depression or another psychiatric disorder may be present. During the comprehensive postpartum visit, all women should be screened for postpartum mood and anxiety disorders using a validated tool ( 5 ).

Patients with hallucinations, delusions, or psychotic behavior should be evaluated for postpartum psychosis . Women who have postpartum psychosis may need to be hospitalized, preferably in a supervised unit that allows the infant to remain with them. Antipsychotic medications may be needed as well as antidepressants.

A preexisting psychiatric disorder, including prior postpartum depression, is likely to recur or worsen during the puerperium, so affected women should be monitored closely.

Postpartum complications references

1. Committee on Practice Bulletins-Obstetrics . Practice Bulletin No. 183: Postpartum Hemorrhage.  Obstet Gynecol . 2017;130(4):e168-e186. doi:10.1097/AOG.0000000000002351

2. American College of Obstetricians and Gynecologists (ACOG) : ACOG Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin No. 196: Thromboembolism in Pregnancy [published correction appears in Obstet Gynecol . 2018 Oct;132(4):1068].  Obstet Gynecol . 2018;132(1):e1-e17. doi:10.1097/AOG.0000000000002706

3. Ona XB, Osorio D, Cosp XB : Drug therapy for treating post-dural puncture headache. Cochrane Database Syst Rev . 2015 Jul 15;2015(7):CD007887. doi: 10.1002/14651858.CD007887.pub3.

4. American College of Obstetricians and Gynecologists (ACOG) : Headaches in Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 3 [published correction appears in Obstet Gynecol. 2022 Aug 1;140(2):344].  Obstet Gynecol . 2022;139(5):944-972. doi:10.1097/AOG.0000000000004766

5. American College of Obstetricians and Gynecologists (ACOG) : Screening and Diagnosis of Mental Health Conditions During Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 4. Obstet Gynecol. 2023;141(6):1232-1261. doi:10.1097/AOG.0000000000005200

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Your postpartum checkups

A postpartum checkup is an important part of your medical care after you have a baby.

Postpartum care is important because new moms are at risk of serious and sometimes life-threatening health complications., get a complete postpartum checkup no later than 12 weeks after giving birth. during your visit, your provider will check to make sure you’re recovering well from labor and birth., if you had pregnancy complications or you have a chronic health condition, you may need extra postpartum checkups..

What is a postpartum checkup and why is it important?

A postpartum checkup is a medical checkup you get after having a baby to make sure you’re recovering well from labor and birth . In the United States, too many women experience serious and life-threatening health complications in the days and weeks after giving birth. Research shows that almost 40 percent of new moms miss their postpartum checkup. Even if you’re feeling fine, it’s important that you go to all your postpartum checkups. This allows you to share any concerns you have with your care team and allows them to look for warning signs of serious health problems, which can cause long-term health issues and even death, and provide treatment.

If you experienced a miscarriage , stillbirth , or your baby died , a postpartum checkup is especially important. A postpartum checkup may help your health care provider or other member of your care team, such as a genetic counselor, learn more about what happened and see if you may be at risk for the same condition in another pregnancy. A genetic counselor is a person who is trained to help you understand about genes, birth defects and other medical conditions that run in families, and how they can affect your health and your baby’s health.

What’s changed in postpartum care guidelines?

The American College of Obstetricians and Gynecologists (also called ACOG) has released new guidelines calling for changes to improve postpartum care for women. They now encourage that postpartum care be an ongoing process, rather than a one-time checkup and now recommend that all new moms: 

• Have contact with their health care provider within 3 weeks of giving birth
• Get ongoing medical care throughout the postpartum period, as needed
• Have a complete and full medical checkup no later than 12 weeks after giving birth

Many of the discomforts and body changes women have in the weeks after giving birth are normal. But sometimes they’re warning signs or symptoms of a health problem that needs treatment. Seeing your provider sooner and more often can help you and your provider spot these signs and symptoms and may help prevent serious medical problems. Your postpartum care should meet your personal needs so you get the best medical care and support.

What is a postpartum care plan?

A postpartum care plan is a plan that you and your health care provider make together. It helps you prepare for your medical care after giving birth. It’s best to make a postpartum care plan during pregnancy or at one of your prenatal care checkups. But if you didn’t get a chance to, it’s never too late. Your postpartum care plan should include:

• Contact information for your health care provider. How do you get in touch with your provider if you’re worried or have questions?
• The dates of all your postpartum checkups. Get in touch with your provider within 3 weeks of giving birth and schedule a complete checkup within 12 weeks of giving birth. Talk with your provider to make sure this timing is right for you. Find out if your health insurance plan covers all your postpartum checkups. Look at the company’s website or call the number on your insurance card.
• Health conditions or pregnancy complications that need treatment after you have your baby. Your provider can help you manage these conditions or may want to refer you to other providers who specialize in treating certain conditions.
• Common physical and emotional changes after pregnancy. What can you expect after giving birth? What’s normal and how do you know when something’s more serious? What are signs and symptoms of serious health conditions to look for after giving birth?
• Postpartum depression (also called PPD) and other mental health conditions after pregnancy. PPD is a kind of depression that some women get after having a baby. It’s strong feelings of sadness, anxiety (worry) and tiredness that last for a long time after giving birth. PPD is a medical condition that needs treatment to get better.
• Your reproductive life plan , including birth control. A reproductive life plan helps you think about if and when you want to have more children. For most women, it's best to wait at least 18 months (1½ years) between giving birth and getting pregnant again. Too little time between pregnancies increases your risk of preterm birth (birth before 37 weeks of pregnancy). Talk to your provider about the best birth control options for you. If you want to wait more than 18 months before getting pregnant again, talk to your provider about long-term reversible contraception, such as IUDs and implants. These types of birth control last for several years but can be stopped when you’re ready to get pregnant again.

What happens at a postpartum checkup?

Here’s what to expect at your postpartum checkup:

Physical exam

• Your provider checks your blood pressure, weight, breasts and belly. If you had a Cesarean birth (also called c-section), your provider may want to see you about 2 weeks after you give birth to check on your c-section incision (cut to ensure you’re healing well and without any problems .
• You get a pelvic exam. Your provider checks your vagina (birth canal), uterus (womb) and cervix. If you had an episiotomy or a tear during birth, your provider checks to see that it’s healed. An episiotomy is a cut made at the opening of the vagina to help let the baby out. Your provider can tell you when it’s safe to have sex again.
• Your provider checks on any health conditions, like diabetes and high blood pressure , you had during pregnancy. For example, if you had gestational diabetes , your provider may give you a blood glucose test to check your blood sugar. If your provider prescribes any medication and you’re breastfeeding, be sure to tell your provider at your visit since some medicines can affect your breast milk.  
• Your provider makes sure your vaccinations are up to date, including vaccinations for flu and pertussis. By getting vaccinated, you can help keep from getting sick and passing an illness to your baby.

Problems you had during pregnancy, labor and birth that may affect your health after pregnancy. This is the time to talk about how you may be able to prevent problems in future pregnancies, even if you’re not thinking about having another baby now. For example, if you had a preterm birth, you’re at higher risk for having another preterm birth in the future. Talk to your provider about what you can do to reduce risk of preterm birth and other complications in your next pregnancy. Even if you don’t plan to have more children, ask your provider if any problems you had during pregnancy may affect your health later in life.  For example, if you had a preterm birth, gestational diabetes, gestational hypertension (high blood pressure) or a condition called preeclampsia , you may be at increased risk of cardiovascular disease (also called heart disease) in the long-term. Heart disease affects the heart and blood vessels and can lead to serious problems, like heart attack or stroke.

Feelings about being a new mom. Tell your provider about how things are going. It’s normal to feel tired and stressed in the weeks after birth. You may have questions about breastfeeding and caring for your baby. Tell your provider if you have feelings of sadness or worry that last for a long time—these can be signs of PPD.

What is a postpartum care team?

A postpartum care team is a group health care providers and other postpartum care experts who help you get medical care and support after you give birth. Members of your postpartum care team can include:

• Your prenatal care provider. 
• Your baby’s health care provider.
• A case manager or coordinator, such as a social worker.
• A doula or other perinatal birth worker.
• Lactation specialist or breastfeeding counselor.
• A licensed mental health counselor or mental health care provider.
• Health care providers who treat women with pregnancy complications or chronic health conditions.

If you have a chronic health condition, you may need to see other providers after pregnancy to treat those conditions. Chronic health conditions include:

• High blood pressure (also called hypertension) .  Uncontrolled high blood pressure can lead to heart, disease, kidney disease and stroke.
• Obesity . If you have an excess amount of body fat and your body mass index (also called BMI) was 30.0 or higher before pregnancy, you’re considered to have obesity. BMI is a measure of body fat based on your height and weight. To find out your BMI, use the CDC's BMI calculator . 
• Preexisting diabetes (type 1 or type 2 diabetes) . Uncontrolled diabetes can damage organs in your body, including blood vessels, nerves, eyes and kidneys.
• Thyroid conditions . The thyroid is a gland in your neck that makes hormones that help your body store and use energy from food. If it makes too little or too much of these hormones, you can have health problems.
• Kidney disease . If you have chronic kidney disease (also called CKD), your kidneys can’t filter blood like they should. This can cause waste to build up in your body. Untreated kidney disease can lead to kidney failure.
• Mood disorders . A mood disorder is a mental health condition that affects your emotions and needs treatment to get better. Depression (also called major depression or clinical depression) is an example of a mood disorder. It can cause feelings of sadness, and a loss of interest in things you like to do .

Last reviewed: September, 2023

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Postpartum Care: A Guide to Taking Care of a Body That Just Delivered

• First 24-Hours Instructions
• Days and Weeks After Birth
• Coping Through Changes
• Postpartum Follow-Up
• Resources and Support

The postpartum period, the time after giving birth, is a crucial time for recovery and the long-term health of the parent and baby. It's also a time of intense physical and emotional changes.

It is normal and expected to experience several physical symptoms like swelling, cramping, breast tenderness , constipation , and leaking milk. It is also common to experience emotional changes like feeling sad and overwhelmed.  

This article discusses postpartum care, what to expect, and how to care for yourself. 

Yoss Sabalet / Getty Images

Postpartum Care: Instructions for the First 24 Hours

The first 24 hours after birth can feel like a whirlwind. Your focus is both on healing physically and caring for your newborn. 

Physical symptoms you may experience in the first 24 hours include:

• Perineum soreness : If you had a vaginal birth , the area between the vagina and the rectum may feel sore or painful. This is because of stretching or tearing during labor and delivery.  
• C-section pain : If you had a surgical deliver known as a cesarean section (C-section), you may feel exhausted and pain around your incision. Rest is crucial. 
• Afterbirth pains : After giving birth, your uterus will begin to shrink back to its original size, which may cause abdominal cramping.
• Vaginal discharge : Vaginal bleeding after delivery is expected. However, call your provider if you have heavy, bright red bleeding or are passing golf ball–sized blood clots.
• Breast engorgement : This occurs when the breasts fill with milk a few days after delivery.
• Swelling : Pregnancy causes water retention in the body, especially the hands, feet, and face. It may also be a sign of preeclampsia and should be discussed with a medical provider.
• Constipation : It may feel difficult to have a bowel movement after giving birth. 
• Pain with urination : If you had vaginal tearing with birth, you may experience pain or burning with urination, leaking, and incontinence .
• Fatigue : Your body will feel tired from the exertion of childbirth, blood loss, and a lack of sleep.  

It's common to feel overwhelmed and exhausted or down and sad. The "baby blues" are typical feelings that come after having a baby and are typical for up to two weeks.  

Postpartum Care in Days and Weeks After Birth

The days and weeks after giving birth can be emotional. You will likely not feel like yourself because of your physical recovery, changing hormone levels, and caring for a newborn. 

It is important to see your healthcare provider during the postpartum period. Your provider can help keep you and your newborn healthy.  

Healing From Birth 

Giving birth is physically exhausting and requires time to heal.  There are many symptoms you might feel during the postpartum period. Fortunately, there are ways to help relieve them.

Postpartum sleep can be challenging. You will likely feel tired in the weeks and months after giving birth. To help your body heal, focus on resting as much as possible. Sleep when your baby sleeps. Consider limiting visitors to help you catch up on rest. If some of your loved ones have offered to help you, ask them to take over household chores so you can use that time to rest.

Mental Health

It's common to feel sad, anxious , or irritable for up to two weeks after giving birth. When frequent feelings of sadness, anxiety, hopelessness, or anger last longer than two weeks, you may have postpartum depression .  

Postpartum depression affects about 1 in 8 people in the postpartum period. Symptoms may include:

• Feeling angry, sad, hopeless, guilty, or worthless much of the time
• Eating more or less than usual
• Sleeping more or less than usual 
• Crying frequently 
• Losing interest in favorite activities 
• Withdrawing from friends and family 
• Having thoughts of hurting yourself or your baby 

If you are concerned about your mood, talk with your healthcare provider right away. Fortunately, postpartum depression is treatable with therapy support groups, medication, and support. Other measures that may help include:

• Rest as much as possible.
• Ask for help.
• Make time to see friends and family.
• Share your experience with fellow parents or a support group.
• Avoid making significant life changes.

Contraception

It may seem too soon to start thinking about future pregnancies, but it is important to have a contraception plan when you are postpartum. Most healthcare providers recommend abstaining from sex for about four to six weeks after giving birth. This is how long it usually takes to heal.

Once you are ready to have sex again, talk with your provider about a contraception plan. You may consider barrier methods like condoms and diaphragms or hormonal methods like pills , patches, intrauterine devices (IUDs), or shots.  

Coping Through Postpartum Changes 

The postpartum period brings countless changes. It may be helpful to make a plan for changes in this new chapter of life. 

Physical and Self-Esteem

The physical exertion of childbirth, lack of sleep, and other factors may make you uncomfortable. Focus on rest and recovery. Caring for a newborn requires a lot of time, but aim to eat, sleep, and shower daily. 

Plan to wear a sanitary pad in the days and weeks after birth due to vaginal bleeding. Drink plenty of water, and add healthy, fresh foods to your meals when possible.  

Talk with your healthcare provider about an exercise plan. There are several benefits to working out in the postpartum period, including increased energy, better sleep, stress relief, and stronger muscles. Start slow, taking 10-minute walks, and work up from there.  

Adjusting to Parenthood

Adjusting to life as a new parent (or a parent with another child) takes time. Try to focus on small things that help you feel like yourself. Sleep whenever you can, and spend time resting throughout the day. Talk to your partner, friends, or loved ones about how they can support you.

It's normal to not feel like yourself at first or to feel sad and overwhelmed in the postpartum period. If you find yourself feeling this way for more than two weeks, speak to your healthcare provider because you could be experiencing postpartum depression.  

Learning how to feed your newborn takes time and may be challenging. If you are using formula to feed your baby, discuss recommendations with your child’s pediatrician. 

If breastfeeding , seek support from a lactation consultant, midwife, or healthcare provider. They can help with any breastfeeding challenges or questions. It's important for people who breastfeed to drink water throughout the day and consume an extra 500 calories daily.  

When your milk first comes in, it may cause engorgement when the breasts fill with milk and feel full and tender. Frequent feedings, breast massage, and warm showers can help. See your healthcare provider if you develop a fever or chills while breastfeeding. Mastitis is a common infection in breastfeeding people and can be treated with antibiotics.  

Going Back to Work

Going back to work is an emotional experience after having a baby. If possible, start planning your return to work while pregnant. Talk with your employer about any accommodations you may need, like a flexible schedule or breaks to pump breast milk. 

It is also important to develop a childcare plan ahead of time. Decide if you will need to hire a babysitter or nanny or take your baby to a daycare in a home or facility.

As your return to work gets closer, practice for the big day. It may help to have a morning in which you get ready as if for work and think through any possible issues that could come up. If you are planning to continue breastfeeding after going back to work, practice with the breast pump ahead of time. 

When you return to work, remember it’s normal to feel different. You have undergone changes. Try to be patient with yourself and those around you. This is a big transition, and it will take time. 

Postpartum Follow-Up 

It is important to continue seeing your healthcare provider after giving birth. Healthcare providers recommend checking in within three weeks of giving birth and seeing them for a visit within 12 weeks. Most people see their providers about six weeks after giving birth. About 40% of people do not attend their postpartum visit.

During your follow-up visit, your provider will ask about your physical and emotional health. They will talk with you about your mood and any symptoms you are experiencing. Your provider will likely examine your incisions if you have them and will perform a pelvic exam to determine if you have healed from birth. Talk with your provider about any concerns you have. 

Resources and Support 

Everyone needs support during the postpartum period. If you have friends and family members offering to help, take them up on it. If you do not have people in your life to help you, there are still resources available. These resources include:

• Postpartum: The Birth Injury Center , Centering Pregnancy/Parenting
• Breastfeeding: La Leche League , American Academy of Family Physicians
• Mental health: 988 Suicide & Crisis Lifeline (phone or text 988), National Domestic Violence Hotline , Live Another Day
• Healthy food: Women Infant Children , Cooking Matters
• Affordable housing: Volunteers of America , Catholic Charities  

If a loved one recently gave birth, you may wonder how best to support them. Ways to show support include:

• Listening to their concerns
• Learning the signs of postpartum depression
• Providing rides to medical appointments 
• Offering to help care for the baby
• Assisting with daily chores

The postpartum period is an intense time of life. You will likely experience several changes, both physical and emotional. It is important to focus on your health and well-being in addition to your newborn. 

It is normal and expected to experience several physical symptoms like swelling, cramping, breast tenderness, constipation, and leaking milk. Emotional changes like feeling sad and overwhelmed are common, too. There are resources available to help you during the postpartum period.

MedlinePlus. Postpartum care .

American College of Obstetricians and Gynecologists. Optimizing postpartum care .

Adams YJ, Miller ML, Agbenyo JS, Ehla EE, Clinton GA. Postpartum care needs assessment: women's understanding of postpartum care, practices, barriers, and educational needs . BMC Pregnancy Childbirth . 2023;23(1):502. doi:10.1186/s12884-023-05813-0

Centers for Disease Control and Prevention. Pregnant and postpartum women .

Paladine HL, Blenning CE, Strangas Y. Postpartum care: an approach to the fourth trimester . Am Fam Physician . 2019;100(8):485-491.

Nemours Kids Health. Recovering from delivery .

Reichner CA.  Insomnia and sleep deficiency in pregnancy .  Obstet Med . 2015 Dec;8(4):168-71. doi:10.1177/1753495X15600572

Office on Women’s Health. Postpartum depression .

American College of Obstetricians and Gynecologists. Postpartum birth control .

Office on Women’s Health. Recovering from birth .

American College of Obstetricians and Gynecologists. Exercise after pregnancy .

Centers for Disease Control and Prevention. Partners, friends, and family of pregnant or postpartum women .

By Carrie Madormo, RN, MPH Madormo is a health writer with over a decade of experience as a registered nurse. She has worked in pediatrics, oncology, chronic pain, and public health.

Your Postpartum Checkups

Medical review policy, latest update:.

Added FAQs to the article with updates to sourcing and check on text for #BumpDay 2023.

What is a postpartum checkup?

When is my first postpartum checkup, is there still a six-week postpartum checkup, read this next, how to prepare for your postpartum checkups, can i bring my baby to my postpartum checkups, what happens at my postpartum checkup, give you an annual exam, examine your post-pregnancy body, make sure no serious health issues have cropped up since you delivered, get the go-ahead of when to start working out again and go back to normal activities, discuss your mental health and how you're feeling, talk about resuming sex after baby and get you back on birth control, chat about any future baby plans (if applicable).

Remember: Your health is important, and taking good care of yourself helps you take good care of your baby. That's why it's necessary to schedule and attend your postpartum doctor's appointments. An added bonus? You'll probably feel better and more reassured after the visit with your practitioner too.

Postpartum Checkup FAQs

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Postpartum Care

Postpartum coverage extension resources.

• States that have Extended Postpartum Coverage (Map)
• Improving Maternal Health and Extending Postpartum Coverage in Medicaid and CHIP (December 2021 Webinar Slides)
• Improving Maternal Health and Extending Postpartum Coverage in Medicaid and CHIP (SHO 21-007)  
• Frequently Asked Questions (FAQs) Improving Maternal Health and Extending Postpartum Coverage in Medicaid and the Children’s Health Insurance Program (CHIP) (SHO #21-007)

Improving Postpartum Care

Postpartum care is an important part of the continuum of reproductive care across the life cycle. Care during the postpartum period involves not just a single postpartum visit but a series of visits beginning with the birthing event and transitioning to ongoing general healthcare. More than half of pregnancy-related deaths occur in the postpartum period, and 12 percent occur after six weeks postpartum. Medicaid and CHIP programs should engage in opportunities to improve postpartum care and work to eliminate preventable maternal mortality, severe maternal morbidity (SMM), and inequities. The Centers for Medicare & Medicaid Services (CMS) offers quality improvement (QI) technical assistance to help states increase access, quality, and equity of postpartum care in Medicaid and Children’s Health Insurance Program (CHIP).

The technical assistance has two components:

• QI resources to help state Medicaid and CHIP staff and their QI partners begin improving postpartum care for their beneficiaries
• CMS’s Improving Postpartum Care learning collaborative , including approaches to improving postpartum care and state examples

For more information on these materials and other QI technical assistance, please email  [email protected] .

Improving Postpartum Care: QI Resources

Here are some technical assistance tools to help states get started in developing their own QI project to improve postpartum care:

• New: Increasing Access, Quality, and Equity in Postpartum Care in Medicaid and CHIP: A Toolkit for State Medicaid and CHIP Agencies . This toolkit provides practical information to help state Medicaid and CHIP agencies maximize the use of existing authorities to increase postpartum care access, quality, and equity for Medicaid and CHIP beneficiaries. The toolkit also includes a strategy checklist and suggestions for partnering with Medicaid and CHIP managed care plans (MCPs) to implement QI strategies.
• Improving Postpartum Care for Medicaid and CHIP Beneficiaries: Getting Started on Quality Improvement . This video provides an overview of how Medicaid and CHIP agencies can start a QI project to improve postpartum care. The Model for Improvement begins with small tests of change, enabling state teams to “learn their way” toward strong programs and policies.
•   Improving Postpartum Care Driver Diagram and Change Idea Table . A driver diagram is a visual display of what “drives” or contributes to improvements in postpartum care. This example of a driver diagram shows the relationship between the primary drivers (the high-level elements, processes, structures, or norms in the system that must change to improve postpartum care) and the secondary drivers (the places, steps in a process, time-bound moments, or norms in which changes are made to spur improvement). The document also includes change idea tables, which contains examples of evidence-based or evidence-informed postpartum care QI interventions. The change ideas were tailored for Medicaid and CHIP.
• Improving Postpartum Care Measurement Strategy . This measurement strategy provides examples of measures that can be used to monitor postpartum care QI projects.
• Postpartum Coverage Extension Improving Maternal Health During the Postpartum Period ( video ) ( transcript ). In March 2022, CMS presented a webinar that described the clinical and social risks postpartum individuals face that contribute to their morbidity and mortality and strategies to improve postpartum care and outcomes. This webinar also looked at how the American Rescue Plan’s Medicaid and CHIP 12-month postpartum extension option provides the time and access to care needed to better meet the needs of postpartum individuals.

Improving Postpartum Care Learning Collaborative

In 2021, CMS launched the Improving Postpartum Care learning collaborative to support state Medicaid and CHIP agencies’ efforts to improve health outcomes among postpartum people. The learning collaborative included a webinar series and an affinity group. Links to the webinars are listed below.

Kentucky, Georgia, Oklahoma, South Carolina, Texas, Kansas, Missouri, Montana and Wyoming participated in the action-oriented affinity group where teams designed and implemented a postpartum care quality improvement (QI) project in their state. Results from states that participated are featured in the highlights brief and state spotlights webinar (below).

Learning Collaborative Webinar Series

• State Spotlights: Improving Postpartum Care ( video , transcript ).  From April 2021 through April 2023, the CMS Medicaid and CHIP quality improvement technical assistance program supported nine states participating in the Improving Postpartum Care affinity group with information, tools, and expert support to improve postpartum care for Medicaid and CHIP beneficiaries. This May 2023 webinar spotlighted several state QI projects from the affinity group, highlighting their strategies, partnerships, and lessons learned.
• Maintaining Coverage and Access to Care During the Postpartum Period ( audio , transcript ). This January 2021 webinar described strategies to ensure coverage and access to care during the postpartum period for women at high risk of postpartum complications. Shannon Lovejoy and Jessica Stephens from CMCS described existing Medicaid and CHIP requirements for continuing coverage in the postpartum period including beyond 60 days after delivery.  Tom Curtis from the Michigan Department of Health and Human Services presented Michigan’s approach to reporting visit rates by race and ethnicity to monitor disparities in postpartum care visit attendance as a performance measure. 
• Improving the Content of Care During the Postpartum Period ( audio , transcript ). This webinar focused on the changing concept of postpartum care and the emphasis on risk reduction for maternal health, both in the immediate postpartum period and in the extended postpartum period up to one year after delivery. Beth Tinker and Judy Zerzan from the Washington State Health Care Authority and Cameual Wright from an Indiana Medicaid managed care plan presented best practices to improve postpartum care visit rates and the content of care including contraceptive care, management of chronic diseases, and social risks as well as opportunities for value-based care. Presenters highlighted the need to address risks in specific high-risk populations.
• Models of Women-Centered Care ( audio , transcript ). This webinar focused on strategies for providing women-centered care for Medicaid and CHIP beneficiaries and offer state examples of how these models can improve postpartum care for women at high risk of postpartum complications and also eliminate disparities in maternal and infant health outcomes. Susan Beane and Rashi Kumar from a New York Medicaid managed care plan, Mary LeMieux from the Montana Department of Public Health and Human Services, and Nathan Chomilo from the Minnesota Department of Human Services discussed the use of doulas, team-based care, group care, and community partnerships to improve care. The presenters also discussed payment strategies to support these care models.

Postpartum Care Action Learning Series

The focus of the series from 2013-2014 was to build Medicaid/CHIP capacity for quality improvement by providing voluntary training and support for teams that wanted to get started or continue implementing a specific quality improvement (QI) project around maternal and infant health. Teams were guided in implementing rigorous QI projects designed to start producing results within a ten-month timeframe.

Materials from the series include:

• Engaging Stakeholders
• Designing Interventions and Measuring Improvements
• Planning and Doing
• Sharing Lessons Learned
• Sharing Lessons Learned, Part II
• QI 201 Team Summary Brief
• Improving Postpartum Care: State Projects Conducted through the Postpartum Care Action Learning Series and Adult Medicaid Quality Grant Program
• Lessons Learned About Payment Strategies to Improve Postpartum Care in Medicaid and CHIP

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Why are prenatal and postnatal care so important an ob-gyn explains., doctor: have a plan, understanding and support from the beginning.

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When parents are expecting a baby (or babies!), there’s so much to look forward to. Part of what can make the delivery process as smooth as possible is to ensure mom and baby have good prenatal care. It’s crucial for mom to have postnatal care and a support system, as well.

Dr. Nichole Van de Putte, maternal medical director at Methodist Hospital | Metropolitan, said the importance of prenatal care can’t be understated enough. The management of care before giving birth can be critical to the overall outcome.

“Prenatal care is the best way to reduce maternal morbidity associated with labor and delivery, and it creates an opportunity for open dialogue and communication to ask important questions,” she said.

Optimizing each pregnancy based on the unique medical conditions of the mom is essential, as is mindfulness of the bigger picture.

“If there’s an emergency, I want to be able to take care of you as quickly as possible,” she said. “It’s important to support one another and understand that there could be medical conditions innate to the mom or complications associated with the pregnancy.”

Van de Putte said it’s important patients understand there’s plenty that can go right just like there are times when things can take a turn in the wrong direction. While women shouldn’t anticipate complications, they should know it’s a possibility. Prenatal care is the time to prepare for that.

“Women and families can spend a lot of time and a lot of energy on the what ifs, and that can cause an enormous amount of anxiety for women,” she said. “What I try to do in taking care of my patients is empower them on what they have control over and the ways they can take ownership, understand what roads may come along and then discuss an action plan. The goal is always the safest delivery for you, the safest delivery for the baby, and that we’re all on the same page from the get-go.”

The prenatal period is also the time to have discussions with your doctor about what to expect from delivery and what preferences you might have, like pain management.

“I want to be able to support you and I don’t want you in pain,” she said. “If women say, ‘I want to experience this without any of those medications; I don’t want an epidural; I don’t want IV pain medication,’ I’m there to support you and be your cheerleader, but I want you to know your options.”

Van de Putte said regardless of what the plan is, things can change. A mom who set out determined not to have an epidural or pain medication might decide she’s ready for some assistance once she gets into labor.

“It’s great if we’ve had a discussion ahead of time on what those options are,” she said. “Our bodies really can facilitate labor in healthy pregnancies, but it’s about supporting one another, and that management is important. I also want to provide feedback on what’s important in your labor experience and how can I help support that.”

Postnatal care: What to expect following labor and delivery

In the hours, days, weeks and months that follow labor and delivery, there is so much that can change for new moms.

Ultimately, Van de Putte said, mom’s body is recovering from the birthing experience, but they should be feeling better physically every day.

“If they had a cesarean delivery, their body’s recovering from that; if they had a vaginal delivery, their body’s recovering from that, so there could be some soreness, pressure and pain,” she said. “There’s also discomfort associated with breastfeeding, such as breast engorgement.”

It’s also important for women to monitor things like pregnancy-induced hypertension that could occur during the postpartum period.

Some symptoms of pregnancy-induced hypertension include, but are not limited to:

• A headache that doesn’t go away.
• Pain under the ribs or over the liver.
• Sudden nausea and vomiting.
• Visual changes.
• Significant swelling in the feet or hands.
• Chest discomfort.
• Shortness of breath.

“Those could be all signs of preeclampsia with severe features,” Van de Putte said. “The postpartum period is an important time to monitor those symptoms, and if any of those symptoms occur, reach out to the health care provider immediately.”

The recommendation is for any mom who has had a risk factor for hypertension or was diagnosed at any point during pregnancy to be seen within seven days following hospital discharge.

“Make sure you have a follow-up visit with your OB-GYN,” she said.

In addition to awareness of physical health, new moms must also pay attention to their emotional wellbeing.

“The postpartum period can feel isolating. There are the stressors of sleep deprivation, the frequent feeding intervals and all the needs of a newborn,” she said. “It’s important to reach out to support people to talk about it in the event some changes in emotion are causing an effect that’s impacting quality of life or mom feels like maybe she’s getting depressed.”

Van de Putte said some indications of postpartum depression can include a lack of joy, difficulty bonding with your baby and things that are a little more concerning than just feeling a little sad or emotional.

“We’re talking about things that are really impacting the relationship you have with your newborn and your family,” she said. “If you are truly feeling depressed, you need to seek medical attention right away. There are treatments and interventions that we can do to help support moms during this time.”

Van de Putte said women who have an underlying history of depression, anxiety or mental health concerns should discuss it with their doctor before the labor experience.

“They have a higher incidence of encountering postpartum depression, and medications can often take a month or several months to work,” she said. “For patients who have experienced postpartum depression previously, we will often start them on some medication prior to their delivery. That will hopefully support them better in the postpartum period, as there is a very high incidence of recurrence in that setting.”

Van de Putte said it all comes down to moms having plenty of support.

“It’s OK for you to say, ‘I need help,’ and we’re here to support you through this,” she said.

Following delivery, you should schedule a follow up visit with your OB-GYN as they recommend.

“That follow-up appointment after delivery is so important, as well as knowing those signs of acuity on the mental health side and the medical,” Van de Putte said.

The importance of postnatal care all comes back to the prenatal care, as it’s crucial to have these conversations before the birth experience.

Methodist Healthcare doesn’t stop caring for you after you give birth. Their team is dedicated to providing you with care and support, even after you’ve returned home. Whether it’s your first baby or your fifth, they want to help you and your family adjust to life with your new addition.

To learn more about their postpartum care services, please call the Methodist Healthcare HealthLine at 210-575-0355.

You can also learn about Methodist Healthcare’s options for delivery at one of its hospitals, by clicking here .

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Strategies to improve postpartum engagement in healthcare after high-risk conditions diagnosed in pregnancy: a narrative review

• Open access
• Published: 24 May 2024

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• Naomi C. A. Whyler   ORCID: orcid.org/0000-0001-8227-992X 1 ,
• Sushena Krishnaswamy 1 ,
• Sarah Price 2 , 3 &
• Michelle L. Giles 1 , 3 , 4  

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Transition from antepartum to postpartum care is important, but often fragmented, and attendance at postpartum visits can be poor. Access to care is especially important for individuals diagnosed antepartum with conditions associated with longer-term implications, including gestational diabetes (GDM) and hypertensive disorders in pregnancy (HDP). Strategies to link and strengthen this transition are essential to support people to attend recommended appointments and testing. This narrative review evaluates what is known about postpartum transition of care after higher-risk antepartum conditions, discusses barriers and facilitators to uptake of recommended testing, and outlines strategies trialled to increase both postpartum attendance and testing. Barriers to attendance frequently overlap with general barriers to accessing healthcare. Specific postpartum challenges include difficulties with transport, coordinating breastfeeding and childcare access. Systemic challenges include inadequate communication to women around implications of health conditions diagnosed in pregnancy, and the importance of postpartum follow up. Uptake of recommended testing after a diagnosis of GDM and HDP is variable but generally suboptimal. Strategies which demonstrate promise include the use of patient navigators, focused education and specialised clinics. Reminder systems have had variable impact. Telehealth and technology are under-utilised in this field but offer promising options particularly with the expansion of virtual healthcare into routine maternity care. Strategies to improve both attendance rates and uptake of testing must be designed to address disparities in healthcare access and tailored to the needs of the community. This review provides a starting point to develop such strategies from the community level to the population level.

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Current recommendations for postpartum care

The postpartum period begins at birth and is defined as the first 6 [ 1 ] to 12 [ 2 ] weeks after delivery, sometimes referred to as the fourth trimester. Postpartum review with a healthcare practitioner plays a significant role in supporting those with immediate health needs including contraception, breastfeeding, peripartum mental health, and wound care [ 1 , 3 ]. Most guidelines recommend this visit takes place at or prior to 6 weeks’ postpartum [ 1 ].

Despite this recommendation, documented low attendance rates at the postpartum visit suggest that many people do not receive this important review in a timely manner [ 4 ]. Contributing factors to this include inconsistently defined care pathways supporting people in the transition from antepartum to postpartum care, fragmented communication between healthcare providers and competing priorities.

Many pregnant people are diagnosed for the first time with a medical condition during pregnancy. Conditions such as gestational diabetes (GDM) and hypertensive disorders of pregnancy (HDP) have implications for longer term health and ongoing engagement in healthcare and postpartum testing is recommended following these diagnoses. GDM, defined as the first presentation of hyperglycaemia in pregnancy, affects 14% of pregnancies worldwide [ 5 ] and is predictive of an increased risk of metabolic disorders including a seven- to ten-fold risk of type 2 diabetes within 10 years [ 6 ]. An oral glucose tolerance test (OGTT) is recommended for those with a diagnosis of GDM within the first 12 weeks’ postpartum [ 2 ] and at regular intervals thereafter to provide opportunity for early diagnosis and treatment of type 2 diabetes mellitus.

The spectrum of HDP includes gestational hypertension, pre-eclampsia, eclampsia, chronic hypertension and pre-eclampsia superimposed on chronic hypertension [ 7 ]. Global prevalence is estimated at 116 cases per 100,000 women of childbearing age, with the highest rates seen in low-income countries at 286 cases per 100,000 compared with 70 cases per 100,000 in high-income countries [ 8 ]. HDP are associated with long-term cardiovascular, cerebrovascular and renal disease [ 9 , 10 ], and blood pressure review is recommended in the first 7–10 days postpartum [ 7 ]. Testing for persistent hypertension, markers of organ dysfunction (e.g. urinalysis for proteinuria, renal and liver function testing), ambulatory blood pressure monitoring, metabolic screening with fasting glucose, lipid profile and body mass index measurement, within 3–6 months is advised, and at regular intervals thereafter [ 11 ].

Both chronic medical illness [ 12 ] and new antepartum diagnoses of medical conditions [ 13 ] are associated with poorer peripartum mental health. Those with GDM have a significantly increased risk of postpartum depressive symptoms, with an estimated pooled relative risk of 1.32 [ 14 ]. Pre-eclampsia has been identified as a risk factor for depression both during the postpartum period, and beyond [ 15 ]. The relationship between other HDP and poor peripartum mental health is less clear, but trends towards increased risk of depression, anxiety and post-traumatic stress disorder have been reported [ 16 ]. Postpartum review provides an important opportunity for screening and support for peripartum mental health disorders.

This state of the science review summarises what is known about rates of postpartum engagement in care both nationally and internationally, as defined by attendance at the 6-week postpartum visit, and uptake of recommended testing in those with medical diagnoses of GDM and HDP during pregnancy. We outline the strategies trialled to date to improve attendance at postpartum visits and improve adherence to recommended testing; the barriers and facilitators to uptake of recommended testing; and discuss gaps in the literature for future research.

Attendance postpartum: what is known?

Attendance rates for postpartum care vary significantly between different cohorts, countries, and healthcare systems. Whilst a 6-week appointment is recommended, few studies report attendance rates at this time point. Attendance rates of 42% at the maternal 6-week check have been reported in the United Kingdom (U.K.) by 6–8 weeks postpartum, increasing to 62% by 12 weeks [ 17 ]. In the United States (U.S.), reported rates vary from 54% in the first year postpartum amongst veterans [ 18 ], to 72% in a recent systematic review [ 4 ], and to more than 80% by 90 days postpartum amongst women with funded postpartum care [ 19 ]. In Australia, 81% attendance at a general practitioner visit was reported in a South Australian cohort in the first 9 months postpartum [ 20 ]. Disparities in attendance rates exist within these countries, with significantly lower attendance rates in the U.S. among those of Black/African American (52%), Asian (45%) and Hawaiian/other Pacific Islander (48%) race and ethnicity [ 18 ]. Similarly, in Australia attendance was lower (48%) amongst Aboriginal and Torres Strait Islander people attending rural health services [ 21 ], suggesting multiple factors contributing to non-attendance. Access to health insurance in countries such as the U.S. also impact on attendance at postpartum visits, with Medicaid-insured women less likely to attend than those with private insurance [ 4 ]. Concurrent existence of a chronic condition has also been found to reduce the likelihood of attending the postpartum visit [ 4 ].

What strategies have been trialled to increase postpartum attendance?

A variety of strategies have been trialled in different settings to increase postpartum attendance. The different types of approaches are discussed by Phillips et al. [ 22 ] in their recent review of postpartum transition of care, and strategies trialled to date were described by Stumbras et al. [ 23 ] in their 2016 narrative review. As these summaries provide an excellent overview of strategies to improve postpartum transition of care, an in-depth analysis is not repeated in our review. For the purposes of understanding what has been identified to date, Table  1 summarises these strategies with examples of their use to increase postpartum attendance.

Patient incentives, patient education and home visits have generally shown mixed success at increasing attendance. Patient navigator systems appear more successful at increasing attendance as well as other parameters including vaccination uptake and screening for depression [ 33 ]. This may be due to the ability to tailor such strategies towards individual needs. A systematic review and meta-analysis by Bowden et al. [ 34 ] of strategies in high-income countries and their impact on antepartum and postpartum care found that people who received enhanced support with individualised care were significantly more likely to attend their postpartum visit. This conclusion was based on aggregate data using two very different strategies: patient incentives [ 27 ] and patient navigators [ 29 ]. The use of administrative assistance such as pre-discharge appointment scheduling has also been associated with promising results [ 24 ] but has yet to be trialled prospectively as a strategy in its own right.

More recently, the use of technology has allowed the opportunity to expand strategies beyond reminder-based messaging alone, for example to incorporate remote blood pressure monitoring [ 35 ], and education delivery [ 32 ]. Use of technology within the postpartum setting to specifically increase attendance rates has yet to be explored definitively particularly in high-income settings. Preliminary findings from a series of qualitative interviews for people who received text-based messaging from their postpartum healthcare provider indicated that this approach was viewed positively by participants [ 32 ].

Many programmes combine two or more of these approaches within their postpartum care set-up. For example, Health Beyond Pregnancy [ 30 ] used text-based reminder systems to prompt postpartum follow-up, with additional motivational messaging via video and text, and also used a cash incentive which was provided to those who attended their visit. This multi-approach focus may be helpful in broadening the reach of individual programmes; however, there is insufficient evidence to identify which combinations of approaches are most likely to be successful in increasing attendance rates. Feasibility assessment and economic evaluation of these combined approaches are also an essential part of service evaluation and data remains sparse on this topic.

Uptake of postpartum testing: what is known?

Recommended postpartum testing for those with GDM includes an OGTT within the first 12 weeks [ 2 ], and for those with HDP, a blood pressure measurement within 7–10 days [ 7 ], followed by more comprehensive testing with proteinuria analysis, ambulatory blood pressure testing and metabolic screening [ 11 ]. However, postpartum testing rates after antepartum diagnoses such as GDM and HDP are frequently suboptimal.

A systematic review of studies analysing postpartum testing rates after GDM identified aggregate rates of 48% [ 36 ], with a further systematic review focusing on studies published in the U.S. setting since 2011 finding testing rates of 58% at best, and frequently lower, by 3 years postpartum [ 37 ]. Analysis from a large university-insurance collaborative data repository in the U.S. identified much lower testing rates after GDM diagnosis with just 6% undergoing any type of glucose testing by 8 weeks postpartum, 22% by 1 year and 51% by 3 years [ 38 ]. Blood pressure screening within 6 weeks of delivery after HDP also varies, with observational studies from the U.S., reporting ranges from 33.5% [ 39 ], to 52% [ 40 ]. A further evaluation of women attending a 3-month study visit found that despite high rates of blood pressure testing (98%) in this group, far fewer (< 60%) had further testing with lipid screening [ 41 ]. National data in other high-income settings is sparse.

In Australia, those diagnosed with diabetes are encouraged and assisted to register with the National Diabetes Services Scheme (NDSS); registrants are invited to being contacted for research purposes using an opt-in model of consent [ 42 ]. A survey of responses among those registered to the NDSS with GDM identified that 73% underwent postpartum diabetes testing, but of these, only 27% underwent OGTT prior to 8 weeks’ postpartum [ 42 ]. Lower rates were reported in more remote regions of Australia, with 14% of Indigenous people, and 28% of non-Indigenous people undergoing OGTT by 6 months postpartum [ 43 ]. Health inequities in this study were identified beyond testing rates, with Indigenous people experiencing significantly longer times to any postpartum glucose test [ 43 ]. A large retrospective study reviewed the follow up of over 10,000 women with GDM from an estimated 12 weeks’ postpartum, until over 4 years postpartum, and found that 29% had not been assessed for diabetes [ 44 ]. This study excluded the postpartum period in order to highlight practices of long-term screening, finding that longer term follow-up also remains suboptimal [ 44 ]. The authors also found that 6% of the whole cohort received a new diagnosis of diabetes within this timeframe, highlighting the importance of testing in the postpartum period and beyond [ 44 ]. In terms of follow up of HDP in the postpartum period, 94.5% of a group of women with diagnosis of pre-eclampsia in the previous 2 years reported blood pressure measurement since birth, but screening for metabolic abnormalities occurred in less than half [ 45 ].

Factors associated with adherence to recommended testing

In order to identify why some strategies work better than others, it is essential to understand the facilitators and barriers for uptake of testing. Several individual, sociodemographic and systemic factors contribute to the ability and prioritisation of engagement in care (Table  2 ).

Many of the identified barriers are frequently associated with worse health outcomes across the life course, and often co-exist with each other. For example, people with GDM of high socioeconomic status are more easily able to overcome financial barriers to undergoing oral glucose tolerance testing [ 53 ], and those who live rurally [ 52 ], or in an area of deprivation [ 47 ], are more likely to experience barriers to uptake of testing. Black and Hispanic individuals are over-represented among people with the diagnosis of GDM and HDP [ 54 ] yet have lower rates of uptake of postpartum testing [ 55 ]. The presence of structural racism within policy and institutional practices may exacerbate such disparities [ 54 ]. There is a need to provide tailored, culturally sensitive strategies which factor in social determinants of health.

For many, the logistics of attending for testing present barriers, for example accessibility issues for those requiring childcare and breastfeeding facilities [ 49 ], and the time involved in undergoing an OGTT [ 50 ]. There is conflicting data on the relationship between undergoing postpartum testing, and factors such as maternal age [ 28 , 36 , 37 , 40 , 42 , 47 ], requirement for insulin for GDM management [ 36 , 46 , 47 , 56 ], and the timing of first presentation for antepartum care [ 37 , 51 ].

What strategies have been trialled to improve postpartum testing rates in higher-risk groups?

Table 3 presents an overview of strategies trialled within the antepartum and postpartum periods with the aim of increasing postpartum testing after GDM and HDP.

A limited number of strategies have been implemented in the antepartum period with the aim of improving postpartum testing rates. These include focused antepartum education [ 55 ], and use of care co-ordinators [ 46 , 57 ], and in all studies have improved testing rates. Strategies implemented postpartum have been more widely trialled. Reminder systems (to people with GDM or HDP, their clinicians or both) have been examined with mixed outcomes [ 56 , 60 , 61 , 62 , 63 , 68 ]. Reminder systems where clinicians also received reminders, and which were implemented in the early postpartum period, appeared to achieve better testing rates.

Other successful approaches include the use of postpartum patient care co-ordinators and patient navigators. These roles may overlap: we define care co-ordination as a role that focuses on the provision of individualised care such as co-ordinating appointments and following up to ensure attendance, but which does not necessarily extend to in-person assistance; whereas patient navigators provide longitudinal care, often attending appointments with women, and provide a more culture-specific service. Both these strategies have been found to increase postpartum GDM testing [ 28 ] and early surveillance in people with chronic hepatitis B infection, another condition frequently diagnosed antepartum requiring long-term co-ordination of care [ 59 ].

Administrative assistance in booking testing and appointments has not been trialled extensively and understanding of the potential benefits of this approach remain limited. One study found improvement in testing rates in a small population with GDM when this approach was combined with patient incentives [ 58 ]. Specialist postpartum clinics have been trialled in those with HDP to facilitate transition to ongoing primary care follow-up, with financial viability and attendance rates of 85% demonstrated in one clinic providing intensive monitoring in the early postpartum period, including provision of home blood pressure monitoring resources [ 48 ]. Another multidisciplinary clinic providing both in-person and virtual care to women at a median of 11 weeks postpartum, had attendance rates of 80%, and included blood pressure testing for all attendees at the time of the visit, and lipid panel testing forms provided for metabolic screening [ 64 ]. Uptake of lipid testing for clinic attendees was low, at 53%, although no baseline rate was available for comparison [ 64 ]. No difference was identified in clinic attendance rates, nor postpartum lipid testing between those who attended virtually versus face to face [ 64 ]. Finally, models of care which integrate parent and infant postpartum visits into the same appointment have demonstrated variable success in improving rates of postpartum glucose testing [ 65 , 67 ].

The use of Telehealth provides opportunities for flexible modalities of service delivery. As discussed, a hybrid clinic found no difference in either uptake of clinic use as measured by attendance rates, nor in metabolic screening, between participants who received virtual versus face to face care [ 64 ]. Use of remote monitoring of blood pressure has also been trialled for people with HDP, with successful outcomes in early testing [ 35 ] but not 6-week visit attendance [ 66 ]. Integration of technology as part of multi-approach programmes may enhance overall outcomes and is deserving of further attention.

Tailoring strategies to optimise adherence to testing

Higher adherence to testing recommendations were seen with strategies which personalised healthcare, provided education and addressed individual barriers, such as through use of patient navigators, provision of environments which supported childcare and breastfeeding, and reduced time burden of testing [ 49 ]. This suggests that consumers are motivated to engage in healthcare when they are supported to do so according to their individual needs. Personalised healthcare, for example by use of a patient navigator to support individual needs, can also address a number of the barriers to accessing care, and care can be tailored in a way that allows equitable access.

Telehealth provides an opportunity to overcome the time and financial burden associated with travel and childcare, but introduces risk of further inequity via the digital divide if cost of technology and device access is placed on the individual [ 69 ]. For women who do not speak English, the logistics of ensuring adequate access to interpreters within the telehealth setting can add another layer of complexity. Furthermore, there may be unintended consequences of telehealth appointments including missed opportunities for screening, vaccination and physical examination. Care must be taken when designing and evaluating initiatives to ensure that unintended consequences that widen gaps in healthcare access do not occur.

Limited qualitative data exists on what consumers of postpartum care want and need after diagnosis of high-risk conditions to enable them to access recommended testing. A cross-sectional telephone survey of people with GDM in Australia explored the barriers to post-partum screening in detail [ 49 ]. Logistic challenges such as the time burden of doing a two-hour OGTT and childcare access featured prominently. These concerns were echoed in an earlier study which also identified that many participants either perceived they were ‘healthy’ or were fearful about receiving a diagnosis of type 2 diabetes after postpartum glucose testing [ 70 ]. With any programme designed to improve engagement in healthcare, it is essential to understand the needs and wishes of the intended consumers. Involvement of consumers in the developmental stages of such programmes, and feedback from those who receive care as part of an evaluation process, are recommended.

Key findings

The postpartum period, or the ‘fourth trimester’, provides a unique healthcare opportunity, when otherwise mostly healthy people access healthcare regularly. Many pregnant people will receive an antepartum diagnosis associated with potential longer-term adverse health outcomes. Primary prevention can be implemented to reduce these risks and/or delay onset. However, this must be provided equitably and address disparities in healthcare access within the highest risk populations.

Despite several different strategies trialled in a wide variety of populations, there is not conclusive data on the best method to improve attendance at postpartum appointments and to engage those with high-risk conditions in longer-term follow-up.

Strategies that have shown promise include: focused antepartum education , for example with a diabetes educator [ 55 ], nutritionist, or with education booklets [ 57 ]; use of patient care co-ordinators providing assistance with booking testing appointments and following up those who did not attend to arrange in-home testing [ 28 , 46 ]; and patient navigators providing individualised assistance with education, co-ordination of testing, and assistance to attend [ 59 ].

In addition, creating environments for postpartum testing which support the unique needs of parents with young infants, such as provision of breastfeeding-friendly spaces with options for childcare, may help reduce inequities in access [ 49 ]. Systems which facilitate remote testing opportunities, for example blood pressure measurements, can help reduce geographical and transport barriers. The expanding field of telemedicine has yet to be fully realised in this area of healthcare but has potential to enhance systemic provision of care.

Avenues for future research

Several gaps have been identified requiring further research. Firstly, the data around both rates of postpartum follow-up at the routine postpartum check and uptake of recommended testing in those at higher risk of long-term conditions is limited to a small number of geographical areas and does not capture national rates. Estimations of the scale of these issues are essential to healthcare and resource planning.

Secondly, careful thought is required about how to provide effective, scalable strategies to support people at this uniquely challenging time, and which provide an opportunity to empower them in managing their immediate and longer-term health. Thirdly, many programmes employ nursing and allied health practitioners such as social workers and administrative staff to provide education and care, with most of these based within the hospital system. Integration with existing community services beyond primary care practitioners may help broaden access, such as through community pharmacists and pathology testing centres.

Further, the role of telemedicine requires further exploration particularly in settings with geographical barriers to care and for those with challenges to in-person attendance such as childcare needs. The potential for remote monitoring, for example with blood pressure and blood glucose level testing, are areas of promise.

Finally, the needs of populations with specific health, cultural and equity imbalances must be reviewed in depth, and consumers from these groups included in co-design and evaluation of strategies.

Quick points

Postpartum pathways of care are poorly defined and attendance at recommended visits is often suboptimal

Uptake of recommended testing after high-risk conditions including gestational diabetes and hypertensive disorders of pregnancy is low

Barriers to uptake of testing include individual, sociodemographic and systemic factors which often overlap with drivers of inequity in access to healthcare in general

Strategies to improve adherence to recommended testing include specialist postpartum clinics, patient education and the use of patient navigators

Further research into engagement with healthcare, and optimal strategies to support postpartum populations including through a culturally sensitive and equitable lens are urgently required

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Whyler, N.C.A., Krishnaswamy, S., Price, S. et al. Strategies to improve postpartum engagement in healthcare after high-risk conditions diagnosed in pregnancy: a narrative review. Arch Gynecol Obstet (2024). https://doi.org/10.1007/s00404-024-07562-7

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My Baby’s Doing Fine, Thanks for Asking. But What About Me?

After I gave birth, people only checked in on my daughter—until a therapist told me I needed to check into a hospital.

After I had my daughter, Ava, I realized that everyone is a liar. Especially with social media, everyone wants you to feel like you’re missing out. When talking about becoming a mom, they’ll post things like: “This is the most sensational feeling of my life, “I’m loving every moment, “It’s like my heart is beating outside of my body.”

But when I pushed my baby out, I just thought, I’ve made a mistake. What is the return policy?

I know it’s taboo to say things like this. But nobody tells you that you’ll be in diapers for weeks after giving birth or that sex is painful or that your body, ahem, parts are never the same. (I’ll leave what it looks like to your imagination.) Show me those pictures on Instagram. Put that struggle on Snapchat.

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All people seem to care about is whether or not your body returns to “normal.” Everyone kept saying to me: “Wow, you had a baby, and you look exactly the same!” Well, my body snapped back, and my mind snapped; I kept my body, but I lost my mind.

When I became a mom, I went on what I like to call a 10-day vacation at a little resort in Pasadena called the Las Encinas psychiatric facility. I was having what my therapist called “intrusive thoughts.” My mind was playing an endless game of “what if”? What if I drop my baby? What if she stops breathing? What if a monster comes in and steals her?

I was scared to tell anyone these feelings, because I thought they would worry about Ava’s safety. So I kept quiet. Nobody had told me this might happen, and I thought I was going crazy. Mostly, I was ashamed.

When I finally told my therapist what was going on in my head, she didn’t worry about Ava’s safety. She worried about mine. After I gave birth, everyone had been asking, “How’s the baby?” This was the first time someone had asked—or thought—about me. I hadn’t even thought about me.

But my therapist took one look at me and said, “You need to check into a hospital.” My first thought was: Can I sleep there?

The psych ward allowed me to sleep, yes, but really, it awarded me honesty for the first time. That’s what I had been missing. In mom groups, everyone’s so busy competing to be the best mom that you’re not going to interrupt a debate on the texture of poop to be like: “Sometimes I think about abandoning my family… Does anyone else have that?”

For me, and I’m assuming other women of color, postpartum depression and anxiety can feel like a white woman’s issue. We’re taught in our communities to keep it moving. We have to keep going, because we don’t have the luxury to care about our mental health. We need permission to break down.

In the hospital, I found my permission slip to not be okay.

So I wanted to create a space for other women to do the same. I founded Spicey Moms , which works to provide emotional, physical, and informational support that is vital during pregnancy, birth, and especially postpartum. I wanted to create a space where moms feel seen, understood, and validated. Through that work, I was connected to United States of Care. This organization looks at a woman’s maternal care journey not as one relegated to 40 weeks, but 100 weeks, which captures the months of being postpartum. As part of the organization’s work, United States of Care spoke to women across the country, who consistently mentioned that they needed more support after their pregnancy and into the postpartum period. Their stories sounded like mine: health care providers were unavailable, information on postpartum care was hard to find, and no one seemed to ask about their emotional well-being. They felt forgotten. It made me realize my experience was not rare.

And because so few women know that the issues they experience postpartum are normal, I also learned how many women didn’t know the options available to them. I had amazing insurance that covered my therapist, who knew the warning signs and flagged the problems, and insurance that eventually covered my hospital stay. But most women think this kind of care is out of reach. And, often, it is.

Access to postpartum care first starts with having the information and knowing what resources are out there. But then, importantly, it’s about having the insurance coverage to receive that care. Most states have extended Medicaid coverage to one year postpartum , which is a good first step, but what services are actually covered under that care? And what about everyone else who isn’t on Medicaid? Coverage for postpartum care is fragmented as is, and there is no systemic effort underway to ensure women are getting the care they need after pregnancy. We need to change this.

May is Maternal Mental Health Awareness Month. What I’ve learned is that being a good mom means taking care of yourself first. I’ve given myself permission to do that. And I’m giving other women permission to do the same. Remember: You’re not alone; they just lied.

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Postpartum depression: DC hospital offers intensive treatment

At medstar georgetown university hospital, medical professionals are helping women get the mental health support they need, without having to spend time in the hospital away from their babies, by erika gonzalez, news4 anchor/reporter and patricia fantis • published may 29, 2024 • updated on may 29, 2024 at 6:02 pm.

For mothers struggling with their mental health, a new program in D.C. offers a lifeline.

The Mother-Baby Intensive Outpatient Program at MedStar Georgetown University Hospital is the first of its kind in the region. Patients can get the help they need and take their babies with them.

Stream News4 now: Watch NBC4 newscasts for free right here, right now.

Here’s how it works and how it’s already getting support from families who know postpartum depression first-hand.

A family’s heartbreak and drive to help others

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It’s been almost 10 years since Fairfax County Officer Shelane Gaydos died by suicide . She was just 35. Two weeks before her death, she suffered a miscarriage as she expected her fourth child.

“Shelane was my oldest, my firstborn, and she was the light of my life,” her mother, Joanne Bryant, told News4.

Photos show Gaydos’ happiness with her three little girls. But her family had no idea how badly she was suffering after her miscarriage.

“Because she was a police officer, too, I think she kept a lot of that inside. She, you know, she didn't want to come across as someone that was weak,” Bryant said.

Gaydos’s family was heartbroken. In the months and years that followed, they’ve worked to turn their pain into purpose, raising money and awareness about postpartum depression, which affects 1 in 5 mothers.

‘Getting in a room with other women that are feeling the same’

At MedStar Georgetown University Hospital, medical professionals are helping women get the mental health support they need, without having to spend time in the hospital away from their babies.

“For pregnant and postpartum individuals who are very, very stressed [and] very, very symptomatic, feeling very alone and isolated and not sure where to turn, we now have a place where they can get treatment,” said program director Dr. Aimee Danielson.

Patients are in treatment for nine hours per week, “learning skills to care for themselves, to improve their coping skills, to manage and overcome scary thoughts,” Danielson said.

The Mother-Baby Intensive Outpatient Program incorporates individual and group therapy, medication management and psychiatry, all under one roof.

The first pill for postpartum depression is finally getting to patients. Doctors say it's working.

Pregnant workers may get longer breaks, more time off and other accommodations as new law takes effect

Bryant said she knows the work will save lives.

“Just getting in a room with other women that are feeling the same makes such a difference,” she said.

The program can take up to 10 women at a time.

If you’re struggling or know someone who is, you can sign up through the hospital’s website .

If you or someone you know is in crisis, call or text 988 to reach the Suicide and Crisis Lifeline or chat live at  988lifeline.org . You can also visit  SpeakingOfSuicide.com/resources  for additional support.

After Gaydos’ death in 2015, her family organized an annual event to honor her. They hold Shelane’s Run each October to help raise awareness about postpartum depression. The proceeds go to Postpartum Support Virginia , which offers financial grants to women and families so they can access treatment.

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Out of the Centre

Savvino-storozhevsky monastery and museum.

Zvenigorod's most famous sight is the Savvino-Storozhevsky Monastery, which was founded in 1398 by the monk Savva from the Troitse-Sergieva Lavra, at the invitation and with the support of Prince Yury Dmitrievich of Zvenigorod. Savva was later canonised as St Sabbas (Savva) of Storozhev. The monastery late flourished under the reign of Tsar Alexis, who chose the monastery as his family church and often went on pilgrimage there and made lots of donations to it. Most of the monastery’s buildings date from this time. The monastery is heavily fortified with thick walls and six towers, the most impressive of which is the Krasny Tower which also serves as the eastern entrance. The monastery was closed in 1918 and only reopened in 1995. In 1998 Patriarch Alexius II took part in a service to return the relics of St Sabbas to the monastery. Today the monastery has the status of a stauropegic monastery, which is second in status to a lavra. In addition to being a working monastery, it also holds the Zvenigorod Historical, Architectural and Art Museum.

Belfry and Neighbouring Churches

Located near the main entrance is the monastery's belfry which is perhaps the calling card of the monastery due to its uniqueness. It was built in the 1650s and the St Sergius of Radonezh’s Church was opened on the middle tier in the mid-17th century, although it was originally dedicated to the Trinity. The belfry's 35-tonne Great Bladgovestny Bell fell in 1941 and was only restored and returned in 2003. Attached to the belfry is a large refectory and the Transfiguration Church, both of which were built on the orders of Tsar Alexis in the 1650s.  

To the left of the belfry is another, smaller, refectory which is attached to the Trinity Gate-Church, which was also constructed in the 1650s on the orders of Tsar Alexis who made it his own family church. The church is elaborately decorated with colourful trims and underneath the archway is a beautiful 19th century fresco.

Nativity of Virgin Mary Cathedral

The Nativity of Virgin Mary Cathedral is the oldest building in the monastery and among the oldest buildings in the Moscow Region. It was built between 1404 and 1405 during the lifetime of St Sabbas and using the funds of Prince Yury of Zvenigorod. The white-stone cathedral is a standard four-pillar design with a single golden dome. After the death of St Sabbas he was interred in the cathedral and a new altar dedicated to him was added.

Under the reign of Tsar Alexis the cathedral was decorated with frescoes by Stepan Ryazanets, some of which remain today. Tsar Alexis also presented the cathedral with a five-tier iconostasis, the top row of icons have been preserved.

Tsaritsa's Chambers

The Nativity of Virgin Mary Cathedral is located between the Tsaritsa's Chambers of the left and the Palace of Tsar Alexis on the right. The Tsaritsa's Chambers were built in the mid-17th century for the wife of Tsar Alexey - Tsaritsa Maria Ilinichna Miloskavskaya. The design of the building is influenced by the ancient Russian architectural style. Is prettier than the Tsar's chambers opposite, being red in colour with elaborately decorated window frames and entrance.

At present the Tsaritsa's Chambers houses the Zvenigorod Historical, Architectural and Art Museum. Among its displays is an accurate recreation of the interior of a noble lady's chambers including furniture, decorations and a decorated tiled oven, and an exhibition on the history of Zvenigorod and the monastery.

Palace of Tsar Alexis

The Palace of Tsar Alexis was built in the 1650s and is now one of the best surviving examples of non-religious architecture of that era. It was built especially for Tsar Alexis who often visited the monastery on religious pilgrimages. Its most striking feature is its pretty row of nine chimney spouts which resemble towers.

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• by Melissa Hammam
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Hands up if you’re ready to be dazzled! From a ceremony structure designed to float on water to a jaw-dropping reception room with flowers blooming from every service, we’re swooning over every bit of this wedding. If you can believe it, that’s just the beginning. Julia Kaptelova artfully shot every detail, like the ballet performance guests were treated to and snow falling from the ceiling for the first dance! Prepare to be amazed and take a visit to the full gallery .

From About You Decor … Our design is a symbol of dawn and a distant endless horizon. Ahead is a long, happy life without any borders. An international couple, Pavel and Cherry, met in London and have been walking together for many years.

From the Bride, Cherry… My husband and I we decided to have our summer wedding in Moscow because the city is where his roots are. As we knew we were going to have the other wedding ceremony in China, we wanted our Moscow one to be very personal and intimate. We’ve known each other since we were fourteen, together with many of our friends whom we’ve also known for a decade.

I didn’t want to walk down the aisle twice so the plausibility of my request quickly came into discussion. The open pontoon stage was constructed in order to facilitate the bridal entrance on water, although there were concerns about safety as the last thing we wanted was probably a drowned bride before she could get on stage, picture that! I have to say on that day it wasn’t easy to get on the pontoon stage from the boat, in my long gown and high heels. Luckily my bridesmaids still noticed even though they stood the furthest from me on the stage, and helped me out without prior rehearsal. My girls could just tell whenever I needed a hand or maybe they were just so used to my clumsiness. Who knows 😂

We all love our photographer Julia! She’s so talented and her style is so unique. Our beloved host Alex is exceptional who made everyone laugh and cry. It was truly a blessing to have so many kind and beautiful souls on our big day. Thank you all!

[iframe https://player.vimeo.com/video/384992271 600 338]

Photography: Julia Kaptelova Photography | Wedding Planner: Caramel | Cake: Any Cake | Invitations: Inviteria | Rings: Harry Winston | Band: Menhouzen | Grooms attire: Ermenegildo Zegna | Wedding Venue: Elizaveta Panichkina | Bridesmaids’ dresses: Marchesa | Bridesmaids’ dresses: Alice McCall | Bride’s gown : Jaton Couture | Bride’s shoes: Manolo Blahnik | Decor : About you decor | Earrings: Damiani | Muah: Khvanaco Studio | Video: Artem Korchagin

More Princess-Worthy Ballgowns

I’m still not convinced this Moscow wedding, captured to perfection by  Sonya Khegay , isn’t actually an inspiration session—it’s just  that breathtaking. From the beautiful Bride’s gorgeous lace wedding dress and flawless hair and makeup to the pretty pastel color palette and stunning ceremony and reception spaces, this wedding is almost too good to be true. Do yourself a favor and see it all in The Vault now!

From Sonya Khegay … It was the last day of April and still very cold in the morning. The weather forecast wasn’t pleasing and no one expected that the sun would come out, but miracles happen and light rain gave way to the warm rays.

I love how all the details went together, you could feel the harmony in everything throughout the entire wedding day from the morning until the fireworks.

A gentle look of the bride, elegant but so airy and unique decor, the fresh and light atmosphere of early spring and, of course, true happiness in the eyes. My heart becomes so warm from these memories, it is always a pleasure to see the birth of a new family of two loving hearts.

Photography: Sonya Khegay | Event Design: Latte Decor | Event Planning: Ajur Wedding | Floral Design: Blush Petals | Wedding Dress: La Sposa | Stationery: Special Invite | Bride's Shoes: Gianvito Rossi | Hair + Makeup: Natalie Yastrebova | Venue: Rodniki Hotel

• by Elizabeth Greene

You really can’t go wrong with simple: a beautiful Bride , perfectly pretty petals , loved ones all around. But add in an amazing firework show  to cap off the night and simple just became downright extraordinary. Captured by Lena Elisseva , with assistance by  Katya Butenko , this rustic Russian celebration is simply fantastic. See it all in the Vault right here !

From Lena Eliseeva Photo …  This cozy and warm summer wedding of gorgeous Natalia and Anton was in the middle of June. The young couple decided to organize their wedding themselves, and the day was very personal and touching. I am absolutely in love with rustic outdoor weddings, and this one is my favourite because of the free and easy atmosphere.

All the decor excluding the bride’s bouquet was made by a team of ten friends of the bride and groom. And it was charming – a light and beautiful arch, eco-style polygraphy and succulents, candy-bar with caramel apples and berries – sweet joys of summer.

At the end of ceremony the guests tossed up white handkerchiefs embroidered by Natalia’s own hands.

The most touching moment was the happy eyes of the groom’s grandmother, the most estimable person on the wedding. And the fireworks were a bright end to that beautiful day.

Photography: LENA ELISEEVA PHOTO | Floral Design: Katerina Kazakova | Hair And Makeup: Svetlana Fischeva | Photography - Assistance: Katya Butenko

These photos from Lena Kozhina are so stunningly beautiful – as in you can’t help but stop and stare – it’s hard to believe it’s real life. But these pics are proof of this gorgeous Bride and her handsome Groom’s celebration at Moscow’s Fox Lodge , surrounded by vibrant colors and breathtaking blooms . Oh, and the idea of prepping for your Big Day outside in the sun ? Brilliant. See more bright ideas right here !

From Lena Kozhina … When we met with the couple for the first time, we immediately paid attention to Dima’s behavior towards Julia. There was a feeling of tenderness and awe, and we immediately wanted to recreate this atmosphere of love, care and warmth on their Big Day.

Later, when we had chosen a green meadow and an uncovered pavilion overlooking a lake as the project site, it only highlighted a light summer mood with colorful florals and a great number of natural woods. The name of the site is Fox Lodge and peach-orange color, as one of the Bride’s favorites, set the tone for the whole design – from the invitations, in which we used images of fox cubs to elements of serving guest tables and other decorative elements with the corresponding bright accents.

Photography: Lena Kozhina | Event Planning: Ajur Wedding | Wedding Dress: Rosa Clara | Shoes: Marc Jacobs | Catering: Fox Lodge | Makeup Artist: Elena Otrembskaya | Wedding Venue: Fox Lodge | Cake and Desserts: Yumbaker | Decor: Latte Decor

The Unique Burial of a Child of Early Scythian Time at the Cemetery of Saryg-Bulun (Tuva)

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Pages:  379-406

In 1988, the Tuvan Archaeological Expedition (led by M. E. Kilunovskaya and V. A. Semenov) discovered a unique burial of the early Iron Age at Saryg-Bulun in Central Tuva. There are two burial mounds of the Aldy-Bel culture dated by 7th century BC. Within the barrows, which adjoined one another, forming a figure-of-eight, there were discovered 7 burials, from which a representative collection of artifacts was recovered. Burial 5 was the most unique, it was found in a coffin made of a larch trunk, with a tightly closed lid. Due to the preservative properties of larch and lack of air access, the coffin contained a well-preserved mummy of a child with an accompanying set of grave goods. The interred individual retained the skin on his face and had a leather headdress painted with red pigment and a coat, sewn from jerboa fur. The coat was belted with a leather belt with bronze ornaments and buckles. Besides that, a leather quiver with arrows with the shafts decorated with painted ornaments, fully preserved battle pick and a bow were buried in the coffin. Unexpectedly, the full-genomic analysis, showed that the individual was female. This fact opens a new aspect in the study of the social history of the Scythian society and perhaps brings us back to the myth of the Amazons, discussed by Herodotus. Of course, this discovery is unique in its preservation for the Scythian culture of Tuva and requires careful study and conservation.

Keywords: Tuva, Early Iron Age, early Scythian period, Aldy-Bel culture, barrow, burial in the coffin, mummy, full genome sequencing, aDNA

Information about authors: Marina Kilunovskaya (Saint Petersburg, Russian Federation). Candidate of Historical Sciences. Institute for the History of Material Culture of the Russian Academy of Sciences. Dvortsovaya Emb., 18, Saint Petersburg, 191186, Russian Federation E-mail: [email protected] Vladimir Semenov (Saint Petersburg, Russian Federation). Candidate of Historical Sciences. Institute for the History of Material Culture of the Russian Academy of Sciences. Dvortsovaya Emb., 18, Saint Petersburg, 191186, Russian Federation E-mail: [email protected] Varvara Busova  (Moscow, Russian Federation).  (Saint Petersburg, Russian Federation). Institute for the History of Material Culture of the Russian Academy of Sciences.  Dvortsovaya Emb., 18, Saint Petersburg, 191186, Russian Federation E-mail:  [email protected] Kharis Mustafin  (Moscow, Russian Federation). Candidate of Technical Sciences. Moscow Institute of Physics and Technology.  Institutsky Lane, 9, Dolgoprudny, 141701, Moscow Oblast, Russian Federation E-mail:  [email protected] Irina Alborova  (Moscow, Russian Federation). Candidate of Biological Sciences. Moscow Institute of Physics and Technology.  Institutsky Lane, 9, Dolgoprudny, 141701, Moscow Oblast, Russian Federation E-mail:  [email protected] Alina Matzvai  (Moscow, Russian Federation). Moscow Institute of Physics and Technology.  Institutsky Lane, 9, Dolgoprudny, 141701, Moscow Oblast, Russian Federation E-mail:  [email protected]

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