Lochia is the name for vaginal discharge following delivery. For several days, vaginal bleeding will persist, similar to a heavy menstrual period (lochia rubra). Then, it will thin and become more pale in color (lochia serosa). By the 10th day, it will take on a white or yellow appearance due to the admixture of white blood cells (lochia alba). If it has a foul smell at any time, the odor suggests the presence of infection.

Maternal temperature should be periodically assessed. Any persistent fever (>100.4 twice over at least 6 hours) indicates the possibility of infection and should be investigated.

Blood pressure should also be checked several times during the first day and periodically thereafter. Abnormally high blood pressure can indicate late-onset pre-eclampsia. Low blood pressure may indicate hypovolemia.

For the first several days after delivery, the breasts produce a clear, yellow liquid known as colostrum. For nursing mothers, colostrum provides some nutrition and significant antibodies to their babies. Then, the breasts will swell (engorge) with milk, white in color, and containing more calories (fat) and volume. The initial engorgement can be uncomfortable. Nursing relieves this discomfort. For women not breast-feeding, firm support of the breasts and ice packs will help relieve the discomfort, which will disappear within a few days in any event. Nipples should be kept clean and dry.

It is important to establish bladder function early in the post partum phase. Because bladder distention due to post partum bladder atony or urethral obstruction is common, encourage the woman to void early and often.

Any evidence of significant urinary retention should be treated with catheterization and prompt resolution is expected. When cleansing the vulva, avoid rectal contamination of the vagina or urethra.

Aftercramps are common, crampy pains originating in the uterus. They are less common among first-time mothers, and more common when nursing. They are annoying but not dangerous and will usually disappear within a few days.

Oral analgesics, such as acetaminophen with codeine, or ibuprofen are appropriate and will ease the pain of vulvar lacerations, aftercramps, and the various muscle aches related to a physically demanding labor and delivery. Rarely will these medications need to be continued beyond the first few days.

Swelling of the hands, ankles and face in the first few days following delivery is common, particularly if IV fluid have been given. In the absence of other indicators of pre-eclampsia (elevated blood pressure and proteinuria), it is of no clinical significance, but may be distressing to the patient. Reassure the patient that this is a normal, expected event and will resolve spontaneously.

Rh negative women who deliver Rh positive babies should receive an injection of Rh immune globulin (Rhogam) to prevent Rh sensitization in later pregnancies. This is best done within 3 days of delivery. In operational settings where the Rh type of the infant is not known, it is safe to give Rhogam to all Rh negative women following delivery. Those with Rh positive babies will benefit and those with Rh negative babies will not be harmed.

After delivery, the mother needs time to rest, sleep, and regain her strength. She may eat whatever appeals to her and can get up and move around whenever she would like. Prolonged bedrest is neither necessary nor desirable. There are a few cautionary notes:

• While she may be up walking, strenuous physical activity will increase her bleeding and is not a good idea.
• The first time she gets up, someone should be with her to assist in getting her back down if she feels lightheaded.
• She may shower or bathe freely, but prolonged standing in a hot shower may lead to dizziness, in this setting of borderline hypovolemia and vasodilatation.

After 3 weeks, the uterine lining is normally completely healed and a new endometrium regenerated. At this point, most normal activities can be resumed, although strenuous physical activity is usually restricted until after 6 weeks.

In normal circumstances, women can resume sexual activities whenever they feel like it. Most women won’t feel like it for a while, and perineal lacerations generally take 4-6 weeks to completely heal. Even then, intercourse may be uncomfortable, due to residual irritation around any laceration sites, vaginal dryness due to the natural estrogen suppression after delivery, or psychological factors surrounding resumption of intercourse. Patients can be reassured that this is common, temporary, and very much improved with the use of water-soluble lubricants, such as KY Jelly or Surgilube.

Oral contraceptive pills, if desired, can be started any time during the first few days post partum and are compatible with breast feeding. Alternatively, their use may be postponed until the 6-week examination, a common time for follow-up care.

Postpartum Discharge Information

Following Vaginal Delivery

General Instructions for Comfort and Activity

1. Rest for about half your waking hours, alternating brief periods of activity with rest for a week.

2. Nap when the baby naps.

3. After the first week, take an afternoon rest of 1-2 hours each day.

4. You may shower or bathe freely.

5. Eat three balanced meals a day.

6. For painful stitches, you may soak in the tub (sitz bath) for 15 minutes, three times a day. Apply anesthetic spray or ointment as needed.

7. For hemorrhoids, use 15 minute sitz baths several times a day. Keep your stool soft by drinking plenty of fluids and eating fruits and vegetables. You may use stool softeners, mineral oil, Tucks or suppositories as prescribed by your doctor.

8. For constipation, increase fluid intake, use mineral oil or Milk of Magnesia. Call your doctor if you have not had a bowel movement by the 4th day following delivery.

9. Do not douche, use tampons or vaginal suppositories for 6 weeks.

10. Do not engage in sexual intercourse for 6 weeks.

11. Climb whatever stairs are necessary.

12. You may drive a car whenever you feel like it. Long distance travel is not recommended for the first few weeks unless absolutely necessary.

13. Avoid strenuous physical activity, including exercise workouts, for 6 weeks following the delivery.

14. Call your doctor’s office to make an appointment to be seen about 6 weeks after delivery.

Medications

1. Continue a daily multivitamin for as long as you breastfeed. If bottle feeding, continue the multivitamins daily for three months.

2. If needed, your doctor will order additional iron pills

3. You may safely use acetaminaphen (“Tylenol”), ibuprofen (“Motrin”), or any other medication prescribed by your physician. Before taking any other medication, check first with your doctor.

Bleeding

1. You may experience blood tinged or brownish discharge for 3 to 6 weeks.

2. Your first menstrual period may occur any from four to eight weeks after delivery, longer if you are breastfeeding.

3. Your first period may be heavier than usual.

Breast Care

1. Call at the first sign of a breast infection (pain, redness or fever).

2. If not breastfeeding, use a tight, supportive bra for five days after discharge, avoid breast stimulation, and use ice packs to help with engorgement.

3. If breastfeeding, keep the breasts clean with frequent warm water rinses to clear dried milk from the nipples. It is generally better to avoid the use of soap on the breasts. If you need soap, use a very mild one and rinse well so no soap is left for the baby.

Danger Signs

1. Continuous abdominal pain

2. Bad smelling vaginal discharge

3. Heavy bleeding (a full sanitary napkin in an hour)

4. Pain or redness in the leg

5. Difficulty urinating

6. Temperature greater than 100.4 degrees

7. Tenderness or localized redness of the breasts