Postpartum Care and Long-Term Health Considerations

Uterus

The crude weight of the pregnant uterus at term (excluding the fetus, placenta, membranes, and amniotic fluid) is about 1000 g, making it approximately 10- to 20-fold heavier than the nonpregnant uterus. The specific time course of uterine involution has not been fully elucidated, but within 2 weeks after birth, the uterus has usually returned to the pelvis, and by 6 weeks, it is usually normal in size as estimated by palpation. The gross anatomic and histologic characteristics of the involutional process are based on the study of autopsy, hysterectomy, and endometrial biopsy specimens. The decrease in the size of the uterus and cervix during the puerperium has been demonstrated with serial magnetic resonance imaging, sonography, and computed tomography.

Immediately after delivery, the rapidly decreasing endometrial surface area facilitates placental shearing at the decidual layer. The average diameter of the placenta is 18 cm; in the immediate postpartum uterus, the average diameter of the site of placental attachment measures 9 cm. In the first 3 days after delivery, the placental site is infiltrated with granulocytes and mononuclear cells, a reaction that extends into the endometrium and superficial myometrium. By the seventh day, there is evidence of the regeneration of endometrial glands, often appearing atypical, with irregular chromatin patterns, misshapen and enlarged nuclei, pleomorphism, and increased cytoplasm. By the end of the first week, there is also evidence of the regeneration of endometrial stroma, with mitotic figures noted in gland epithelium; by postpartum day 16, the endometrium is fully restored.

Decidual necrosis begins on the first day; by the seventh day, a well-demarcated zone can be seen between necrotic and viable tissue. An area of viable decidua remains between the necrotic slough and the deeper endomyometrium. Sharman described how the nonnecrotic decidual cells participate in the reconstruction of the endometrium, a likely role given their original function as endometrial connective tissue cells. By the sixth week, decidual cells are rare. The immediate inflammatory cell infiltrate of polymorphonuclear leukocytes and lymphocytes persists for about 10 days, presumably serving as an antibacterial barrier. The leukocyte response diminishes rapidly after day 10, and plasma cells are seen for the first time. The plasma cell and lymphocyte response may last as long as several months. In fact, endometrial stromal infiltrates of plasma cells and lymphocytes are a sign (and may be the only sign) of a recent pregnancy.

Hemostasis immediately after birth is accomplished by arterial smooth muscle contraction and compression of vessels by the involuting uterine muscle. Vessels in the placental site are characterized during the first 8 days by thrombosis, hyalinization, endophlebitis in the veins, and hyalinization and obliterative fibrinoid endarteritis in the arteries. The mechanism for hyalinization of arterial walls, which is not completely understood, may be related to the previous trophoblastic infiltration of arterial walls that occurs early in pregnancy. Many of the thrombosed and hyalinized veins are extruded with the slough of the necrotic placental site, but hyalinized arteries remain for extended periods as stigmata of the placental site. Restoration of the endometrium in areas other than the placental site occurs rapidly, the process being completed by day 16 after delivery. The glandular epithelium does not undergo the reactivity or develop the pseudoneoplastic appearance noted in placental glands.

Postpartum uterine discharge or lochia begins as a flow of blood lasting several hours, rapidly diminishing to a reddish brown discharge through the third or fourth day postpartum. This is followed by a transition to a mucopurulent, somewhat malodorous discharge, called lochia serosa, requiring a change of several perineal pads each day. The median duration of lochia serosa is 22 to 27 days. However, 10% to 15% of women will have lochia serosa at the time of the 6-week postpartum examination. In most patients, the lochia serosa is followed by a yellow-white discharge, called lochia alba . Breastfeeding or the use of oral contraceptive agents does not affect the duration of lochia. Frequently there is a sudden but transient increase in uterine bleeding between 7 and 14 days postpartum. This corresponds to the slough of the eschar over the site of placental attachment. Myometrial vessels greater than 5 mm in diameter are present for up to 2 weeks postpartum and account for the dramatic bleeding that can occur with this phenomenon. Although it can be profuse, this bleeding episode is usually self-limited, requiring nothing more than reassurance of the patient. If the profuse bleeding does not subside within approximately 1 or 2 hours, the patient should be evaluated for possible retained placental tissue.

Ultrasound may be helpful in the management of abnormal postpartum bleeding, serving to detect whether tissue or clot has been retained and, therefore, whether uterine evacuation and curettage would be called for. The empty uterus with a clear midline echo can often be distinguished from the uterine cavity expanded by clot (sonolucent) or retained tissue (echo dense) ( Fig. 24.1 ). Nevertheless, a generally echogenic endometrium may be seen even if no retained products are present. Serial ultrasound examinations of postpartum patients showed that in 20% to 30%, there was some retained blood or tissue within 24 hours after delivery. By the fourth postpartum day, only about 8% of patients showed endometrial cavity separation, some of whom eventually had abnormal postpartum bleeding because of retained placental tissue. Those with abnormal postpartum bleeding who have an empty uterine cavity may respond to therapy with oxytocin or methylergonovine.

Cervix

During pregnancy, the cervical epithelium increases in thickness and the cervical glands show both hyperplasia and hypertrophy. Within the stroma, a distinct decidual reaction occurs. These changes are accompanied by a substantial increase in the vascularity of the cervix. Colposcopy performed after delivery has demonstrated ulceration, laceration, and ecchymosis of the cervix. Regression of the cervical epithelium begins within the first 4 days after delivery; by the end of the first week, edema and hemorrhage within the cervix are minimal. Vascular hypertrophy and hyperplasia persist throughout the first week postpartum. By 6 weeks postpartum, most of the antepartum changes have resolved, although round cell infiltration and some edema may persist for several months.

Fallopian Tubes

The epithelium of the fallopian tubes during pregnancy is characterized by a predominance of nonciliated cells, a phenomenon that is maintained by the balance between the high levels of progesterone and estrogen. After delivery, in the absence of progesterone and estrogen, there is further extrusion of nuclei from nonciliated cells and diminution in height of both ciliated and nonciliated cells. The number and height of ciliated cells can be increased in the puerperium by treatment with estrogen.

Fallopian tubes removed between postpartum days 5 and 15 demonstrate inflammatory changes of acute salpingitis in 38% of cases, but no bacteria are found. The specific cause of the inflammatory change is unknown. Furthermore, there is no correlation between the presence of histologic inflammation in the fallopian tubes and puerperal fever or other clinical signs of salpingitis.

Ovarian Function

Most women who breastfeed their infants have amenorrhea for extended periods of time, often until the infant is weaned. Several studies using a variety of methods to indicate ovulation have demonstrated that ovulation occurs as early as 27 days after delivery, with the mean time being about 70 to 75 days in nonlactating women. Among women who are breastfeeding their infants, the mean time to ovulation is about 6 months.

Menstruation resumes by 12 weeks postpartum in 70% of women who are not lactating. Depending on the population as well as social and nutritional factors of the lactating women, regular menstruation may be delayed as long as 36 months. The duration of an ovulation depends on the frequency of breastfeeding, the duration of each feed, and the proportion of supplementary feeds. The likelihood of ovulation within the first 6 months postpartum, in a woman exclusively breastfeeding, is 1% to 5%.

The hormonal basis for puerperal ovulation suppression in lactating women appears to be the persistence of elevated serum prolactin levels. Prolactin levels fall to the normal range by the third week postpartum in nonlactating women but remain elevated into the sixth week postpartum in those who are lactating. Estrogen levels fall immediately after delivery in both lactating and nonlactating women and remain depressed in lactating patients. In those who are not lactating, estrogen levels begin to rise 2 weeks after delivery and are significantly higher than in lactating women by postpartum day 17. Follicle-stimulating hormone (FSH) levels are identical in breastfeeding and nonbreastfeeding women, suggesting that the ovary does not respond to FSH stimulation in the presence of increased prolactin levels.

Weight Loss

The immediate loss of 10 to 13 lb can be attributed to the delivery of the infant, placenta, and amniotic fluid as well as to blood loss. However, most women will not manifest that loss until 1 to 2 weeks postpartum because of fluid retention immediately after delivery. The physiologic stress of labor and delivery induces hormonal changes, including increased antidiuretic hormone, that lead to a short period of sodium and water retention. With operative birth or epidural anesthesia with fluid boluses, the total body water increases dramatically. Mild pedal edema is also common as the extra fluid moves temporarily into the third space. Women may be reassured that this temporary dependent edema is secondary to this fluid retention. The short period of weight gain from fluid retention that occurs immediately after delivery is sometimes referred to as the ebb phase of physiologic response. The diuresis at 4 to 7 days is sometimes called the flow phase. It is not uncommon to have a newly delivered mother express mild anxiety about “gaining weight” after delivery.

For most women, weight loss postpartum does not tend to compensate for weight gain during gestation. By 6 weeks postpartum, only 28% of women will have returned to their prepregnant weight. The remainder of any weight loss occurs from 6 weeks postpartum until 6 months after delivery, with most weight loss concentrated in the first 3 months. Women with excess weight gain in pregnancy (>35 lb) are likely to have a net gain of 11 lb. Breastfeeding has relatively little effect on postpartum weight loss. With a program of diet and exercise, weight loss of about 0.5 kg/week between 4 and 14 weeks postpartum in breastfeeding overweight women did not affect the growth of their infants. Similarly, aerobic exercise has no adverse effect on lactation provided that adequate hydration is maintained. In a longitudinal study of pregnancy weight gain, 540 women were followed for 5 to 10 years (mean 8.5 years) after their index pregnancy. Women who returned to prepregnancy weight by 6 months after delivery were much more likely to have gained less weight at the 5- to 10-year follow-up compared with women who retained their pregnant weight gains. In this cohort, breastfeeding and aerobic exercise were associated with a significantly lower weight gain over time. A study of 1656 deliveries in a retrospective cohort found that pregnancy weight gain greater than the recommended amount was directly related to the increased weight of women 1 year later. Postpartum exercise programs improve long-term effects on health and risks for chronic disease. Phelan emphasized that pregnancy and postpartum are teachable moments, ideal for counseling women about weight control. Given the epidemic of obesity in western society, dietary counseling and recommendations for exercise are important additions to health maintenance. However, as might be expected, interventions are more effective for postpartum weight loss and the retention of weight loss. A Cochrane Review analyzed the literature on weight loss programs. The analysis found that diet and diet plus exercise were most effective for postpartum weight loss.

Thyroid Function

Thyroid size and function throughout pregnancy and the puerperium have been quantitated with ultrasonography and thyroid hormone levels. Thyroid volume increases about 30% during pregnancy and regresses to normal gradually over a 12-week period. Thyroxine and triiodothyronine, which are both elevated throughout pregnancy, return to normal within 4 weeks postpartum. For women taking thyroid medications, it is appropriate to check thyroid levels at 6 weeks postpartum to adjust dosing. It is now recognized that the postpartum period is associated with an increased risk for the development of a transient autoimmune thyroiditis that may in some cases evolve into permanent hypothyroidism. The relationship of subclinical thyroid dysfunction and postpartum depression is controversial. Postpartum thyroiditis (PPT), an autoimmune disease that may present with hyperthyroid or hypothyroid symptoms, occurs in 2% to 17% of women, with a mean incidence about 10%. Women with type 1 diabetes have up to a 25% risk for PPT. Women with gestational diabetes and type 2 diabetes also have a slightly increased risk. Only that subset of women who develop symptoms should be treated. Puerperal hypothyroidism often presents with symptoms that include mild dysphoria; consequently thyroid function studies are suggested in the evaluation of patients with suspected postpartum depression occurring 2 to 3 months after delivery. Hyperthyroid symptoms are best treated with β blockers and hypothyroid symptoms with thyroid supplementation. Both are acceptable with breastfeeding. Methimazole and propylthiouracil are also safe with lactation. From 5% to 30% of women with PPT eventually develop hypothyroidism. If a woman becomes symptomatic and is treated, it is reasonable to stop medications after 1 year and reevaluate thyroid status before she considers becoming pregnant again.

Cardiovascular System, Immunity, and Coagulation

Blood volume increases throughout pregnancy to levels in the third trimester about 35% above nonpregnant values. The greatest proportion of this increase consists of an expansion in plasma volume that begins in the first trimester and amounts to an additional 1200 mL of plasma, representing a 50% increase by the third trimester. Red blood cell volume increases by about 250 mL.

Immediately after delivery, plasma volume is diminished by about 1000 mL secondary to blood loss. By the third postpartum day, the plasma volume is replenished by a shift of extracellular fluid into the vascular space. In contrast, the total blood volume declines by 16% of the predelivery value, suggesting a relative and transient anemia. By 8 weeks postpartum, the red cell mass has rebounded and the hematocrit is normal in most women. As total blood volume normalizes, venous tone also returns to baseline. In a prospective evaluation of 42 women, at 4 and 42 days postpartum, significant reductions in deep venous vessel size and concomitant increases in venous flow velocity in the lower extremities were observed.

Pulse rate increases throughout pregnancy, as does stroke volume and cardiac output. Immediately after delivery, these remain elevated or rise even higher for 30 to 60 minutes. Following delivery, there is a transient rise of about 5% in both diastolic and systolic blood pressures throughout the first 4 days postpartum. Data are scant regarding the rate at which cardiac hemodynamics return to prepregnancy levels. Early studies suggested that cardiac output had returned to normal when measurements were made 8 to 10 weeks postpartum. Clapp and Capeless performed longitudinal evaluations of cardiac function at bimonthly intervals in 30 healthy women using M-mode ultrasound before pregnancy; during gestation; and at 12, 24, and 52 weeks postpartum. Cardiac output and left ventricular volume peaked at 24 weeks of gestation. There was a slow return to prepregnancy values over the year of the study. However, even 1 year after delivery, there was a significantly higher cardiac output in both nulliparous and multiparous women as compared with prepregnancy values. The authors suggested that this “cardiac remodeling” from pregnancy may last for an extended time in healthy women. Anecdotally, elite athletes have tried to take advantage of this physiologic boost to cardiac function by planning pregnancies a year before major sporting events.

Pregnancy is known to be a time of significantly increased coagulability, which persists into the postpartum period. The greatest level of coagulability is observed immediately postpartum through 48 hours. Fibrinogen concentrations gradually diminish over the first 2 weeks postpartum. Compared with antepartum values, there is a rapid decrease in platelets in some patients and no change or an increase in others. Within 2 weeks after delivery, the platelet count rises, possibly as a marker of increased bone marrow output as red cell mass is replaced. Fibrinolytic activity increases in the first 1 to 4 days after delivery and returns to normal in 1 week, as measured by levels of plasminogen activation inhibitor 1. D-dimer levels are increased over pregnancy levels and are poor markers of thrombus formation. Protein-S levels and activated protein-C resistance are decreased for up to 6 weeks or longer. In general, tests for thrombophilia and hemostasis should be delayed, if possible, for 10 to 12 weeks. The changes in the coagulation system together with vessel trauma and immobility account for the increased risk for thromboembolism noted in the puerperium, especially when an operative delivery has occurred. A large multicenter study over a 4.5-year period in California found that in 1,688,000 primiparous deliveries, the incidence of thrombotic events was higher in the first 6 weeks after delivery compared with the same period 1 year later (OR, 10.8; CI, 7.8–15.1). However, the authors noted that the risk remained increased between 7 and 12 weeks postpartum (OR, 2.2; CI, 1.5–3.1). The risk of a thrombotic event increased to 22.1 per 100,000 deliveries from delivery to 6 weeks postpartum and was increased by 3.0 per 100,000 from 7 to 12 weeks.

The immune system, which is mildly suppressed during pregnancy—particularly cell-mediated immunity—rebounds after delivery. This rebound may lead to flare-ups of autoimmune disease and latent infections with inflammatory reactions. The latter reactions are often the cause of the clinical symptoms. Autoimmune thyroiditis, multiple sclerosis, and lupus erythematosus are examples of some of the diseases that may show an increase in activity in the first few months postpartum. Large cross-sectional studies of population databases have noted hospital admission rates after delivery to be higher than expected for age-matched controls. The readmissions are related to hypertensive disorders and infections such as pneumonia, cholecystitis, and appendicitis. Postpartum readmission rates vary from 0.8% to 1.5% for vaginal delivery and 1.8% to 2.7% for cesarean birth.

Urinary Tract and Renal Function

It is generally accepted that the urinary tract becomes dilated during pregnancy, especially the renal pelvises and the ureters above the pelvic brim. These findings, demonstrated 70 years ago, affect the collecting system of the right kidney more than that of the left and are caused by compression of the ureters by the adjacent vasculature and enlarged uterus combined with the effects of progesterone. Ultrasound studies of the urinary tract also document enlargement of the collecting system throughout pregnancy. A study of serial ultrasound examinations of the urinary tract in 20 women throughout pregnancy included a single postpartum examination 6 weeks after delivery. The overall trend was that of dilation of the collecting system throughout pregnancy, estimated by measurements of the separation of the pelvicaliceal echo complex from a mean of 5 mm (first trimester) to 10 mm (third trimester) in the right kidney and from 3 to 4 mm in the left collecting system. Measurements in all but two patients had returned to prepregnancy status at the time of the 6-week postpartum examination. With serial nephrosonography on 24 patients throughout pregnancy and the puerperium at 12 weeks postpartum, more than half of the patients demonstrated persistence of urinary stasis, described as a slight separation of the renal pelvis. This finding is evidence of hyperdistensibility and suggests that pregnancy has a permanent effect on the size of the upper renal tract. Intravenous urography studies also suggest that subtle anatomic changes take place in the ureters that persist long after the pregnancy has ended. Ureteral tone above the pelvic brim, which in pregnancy is higher than normal, returns to nonpregnant levels immediately after cesarean delivery.

Studies in which water cystometry and uroflowmetry were performed within 48 hours of delivery and again 4 weeks postpartum demonstrated a slight but significant decrease in bladder capacity (395.5 to 331 mL) and volume at first void (277 to 224 mL) in the study interval. Nevertheless, all the urodynamic values studied were within normal limits on both occasions. The results were not affected by the weight of the infant or by an episiotomy. However, prolonged labor and the use of epidural anesthesia appeared to diminish postpartum bladder function transiently.

The most detailed study of renal function in normal pregnancy is that of Sims and Krantz, who studied 12 patients with serial renal function tests throughout pregnancy and for up to 1 year after delivery. Glomerular filtration, which increased by 50% early in pregnancy and remained elevated until delivery, returned to normal nonpregnant levels by postpartum week 8. Endogenous creatinine clearance, similarly elevated throughout pregnancy, also returned to normal by the eighth postpartum week. Renal plasma flow increased by 25% early in pregnancy, gradually diminished in the third trimester (even when measured in the lateral recumbent position) and continued to decrease to below normal values in the postpartum period for up to 24 weeks. Normal values were finally established by 50 to 60 weeks after delivery. The reason for the prolonged postpartum depression of renal plasma flow is not clear. Because of the variable changes in renal clearance, mothers who are taking medications in which doses have been changed (because of the physiologic adaptations of pregnancy) will have to have medication levels rechecked. This should be done at 4 to 6 weeks postpartum.

Other Changes

Hair growth is altered in pregnancy and postpartum. After delivery, there is a more rapid hair turnover for up to 3 months. As a greater percentage of hair begins to undergo the growth phase, more hair falls out with combing and brushing. The loss is in a diffuse, not balding, pattern. This transient phenomenon is called telogen effluvium, and patients may be reassured that their hair growth will return to normal within a few months and that regrowth will replace the hair lost in the comb or brush.

Several investigators have reported on bone mineral changes with lactation and the associated amenorrhea. After delivery, there is a generalized decrease in bone mineralization; this is temporary and resolves by 12 to 18 months postpartum in most women. Bone loss appears to be greater in the femoral neck than in other areas of the skeleton. Calcium supplementation does not seem to ameliorate the bone loss because it is not a problem of inadequate calcium stores, nor does exercise prevent it. For almost all women, the bone loss is self-limited and reversible. Recent investigations have found that postpartum aerobic exercises decrease the bone loss associated with lactation.

Management of the Puerperium

For most parturients, the immediate puerperium is spent in the hospital or birthing center. The ideal duration of hospitalization for patients with uncomplicated vaginal births has been controversial and often culturally determined. During World War II, early discharge with nurse follow-up was initiated to support the “war bride” baby boom. In the 1950s, the lying-in period after delivery was 8 to 14 days. At present, most women stay in the hospital for 24 to 48 hours after a vaginal birth. For patients with an uncomplicated postoperative course following cesarean delivery, the postpartum stay is 2 to 4 days. The optimal time is dependent on a patient's needs and home support. About 3% of women who have vaginal deliveries and 9% of women who have cesarean deliveries have at least one childbirth-related complication requiring longer hospitalization after delivery or readmission to the hospital. Studies that have evaluated the safety and outcomes of discharge before 48 hours have relied on nurse or midwife home visits. Patients should be encouraged to check with their insurers for coverage of this type of service.

In one study, 1249 randomly selected patients were questioned 8 weeks after delivery about health problems that occurred during the puerperium. Eighty-five percent reported at least one problem during their hospitalization, and 76% noted at least one problem that persisted for 8 weeks. The patients reported a wide range of problems, including a painful perineum, difficulties with breastfeeding, urinary infections, urinary and fecal incontinence, and headache. Of the total, 3% had been rehospitalized, most commonly for abnormal bleeding or infection. This study draws attention to a substantial amount of symptomatic morbidity that occurs during the puerperium. Although longer hospitalization may not improve perineal pain or incontinence, open lines of communication with patients between discharge and the 6-week visit can improve patient self-care and promote a more positive patient experience. A study of 597,000 women who were delivered in New Zealand over an 8-year period documented that shorter postpartum hospital stays had no effect on readmission rates. In this study, lactation/breast problems, delayed postpartum hemorrhage, and postcesarean wound infections were the major causes of readmission. Except for an increased incidence of rehospitalization of some neonates for hyperbilirubinemia, there are few disadvantages to postpartum hospitalization of less than 48 hours for many patients.

In particular, for women who elect to breastfeed, lactation consultation while in the hospital may help to improve effective breastfeeding, and consideration should be given to offering this service to all breastfeeding women prior to discharge. It is also important to provide outpatient resources for continued lactation assistance and support after discharge, such as breastfeeding support groups and one-on-one appointments with local breastfeeding experts.

Assuring that women have adequate support at home, helping them gain confidence with infant care and feeding and making them aware of danger signs to look for in either the infant or themselves are important things to accomplish while the patient is in the hospital. One-on-one nursing education but also written and video presentations are efficient means of patient education. To be most helpful, educational material should be presented both before delivery, sometime in the late third trimester, and at the postpartum discharge. Home nursing visits can be helpful in providing support, education, and advice to mothers in selected situations. Written materials or handouts are particularly necessary because memory is often temporarily affected by the sleep deprivation that is the rule in the first few weeks after delivery.

Before discharge, women should be offered any vaccines that may be necessary to protect immunity. Measles, mumps, and rubella (MMR) vaccine is given to rubella nonimmune mothers. Hepatitis B; tetanus, diphtheria, and pertussis (Tdap); MMR; and influenza are the four most common vaccines given. All are safe with breastfeeding. As recommended in 2012 by the CDC, Tdap should be administered during pregnancy to all pregnant women regardless of the interval since the last Tdap. If Tdap was not given during pregnancy, it should be given immediately postpartum. The varicella vaccine should be initiated postpartum in those with a negative varicella titer.

The time from delivery until complete physiologic involution and psychologic adjustment has been called “the fourth trimester.” As a part of postpartum education, patients should understand that lochia will persist for 3 to 8 weeks and that on days 7 to 14, there is often an episode of heavy vaginal bleeding, which occurs when the placental eschar sloughs. Tampons are permissible if they are comfortable upon insertion and are changed frequently and if there are no perineal, vaginal, or cervical lacerations, which preclude insertion of a tampon until healing has occurred. Physical activity—including walking up and down stairs, lifting moderately heavy objects, riding in or driving a car, and performing muscle-toning exercises—can be resumed without delay if the delivery has been uncomplicated. Minig and associates reviewed the scientific evidence behind many postpartum recommendations. They noted that very few if any of the traditional recommendations are based on evidence. Lifting, sexual activity, driving, and exercise do not have to be overly restricted, although some modification may be indicated for women who have had cesarean births. Instructions regarding exercise are patient specific. Studies have found that exercise postpartum has no effect on lactation and may decrease anxiety levels as well as decrease symptoms of postpartum depression. As such, exercise may have benefits beyond the mother's desire to “get back into shape.” The most troublesome symptoms are lethargy and fatigue. Consequently, every task or activity should be a brief one in the first few days of the puerperium. Mothers whose lethargy persists beyond several weeks must be evaluated, especially for thyroid dysfunction and postpartum depression.

Sexual activity may be resumed when the perineum is comfortable and bleeding has diminished. The desire and willingness to resume sexual activity in the puerperium varies greatly among women, depending on the site and state of healing of perineal or vaginal incisions and lacerations, the amount of vaginal atrophy secondary to breastfeeding, and the return of libido, which is greatly affected by sleep patterns, among other new issues. The median time to vaginal intercourse after delivery is 6 weeks, with 90% of women resuming sexual activity by 3 months. As many as 80% of women have sexual problems, including painful intercourse at 8 to 12 weeks. In a substantial number, dyspareunia lasts for a year or more. Signorello and coworkers noted a 2.5-fold increased risk for dyspareunia 6 months after operative vaginal delivery compared with other subsets of postpartum women. For all women, breastfeeding at 6 months is associated with a more than fourfold increase in dyspareunia. Similarly, a large review of studies examining postpartum sexuality noted the greatest incidence of sexual dysfunction to be associated with operative vaginal delivery. Cesearean delivery is associated with a decreased incidence of dyspareunia compared with vaginal birth only for the first 6 months, after which the rates become similar. In contrast, 25% of all women reported heightened sexual pleasure 6 months after delivery.

Postpartum dyspareunia is not always related to vulvar trauma and occurs in some women who have a cesarean delivery. In a study of 50 parturients, Ryding found that 20% had little desire for sexual activity 3 months after delivery, and an additional 21% had complete loss of desire or aversion to sexual activity. This variation in attitude, desire, and willingness must be acknowledged when women are being counseled about the resumption of sexual activity. Women who breastfeed tend to begin intercourse later than average, and women who deliver by cesarean section tend to begin sooner. Clinicians commonly advise pregnant women on the use of vaginal lubricants for sexual activity in the first few months postpartum because of the decreased natural lubrication with lower estrogen levels. This may be included in the written handouts given to patients when they go home. If dyspareunia persists, a small amount of estrogen cream applied daily to the vagina may be helpful in breastfeeding women with atrophic changes.

Many patients return to work situations outside the home after their pregnancies. Frequently, the physician must complete insurance or employer forms to establish maternity leave for patients. Women will often experience discomfort, fatigue, and breast soreness well beyond 6 weeks. Similar to the return to exercise and sexual activity, the return to work should be individualized if possible. National standards for returning to work after giving birth differ from country to country. In the United States, returning to work after 6 to12 weeks is common. In China, 30 days is the norm, whereas in western Europe and Canada, maternity leave from several months to a year is the expectation.