Thursday, December 27, 2012

Timeline of Postpartum Recovery

So you’ve just had a baby? Congrats! I bet you’re raring to get back to your aerobics class and daily jogs (huh? who are you telling to shut up?), but hold the sit-ups. Your body has its own timeline for recovery, and it’s important to take heed.

In less than a year, you conceived, developed and delivered a beautiful, living creature. To perform this feat your body underwent some tremendous changes. Even after birth, you'll experience more.

Whether you had a vaginal delivery or caesarean section, this timeline is for you. Being informed of the process of postpartum recovery will help you to appreciate the phenomenal transformation your body is undergoing.

Day 1:

  • You're already 9 to 12 pounds lighter now that you're no longer carrying a 6 to 8 pound baby, 1 or 2 pounds of placenta weight, and 2 pounds of blood and amniotic fluid.
  • The process of delivery has slowed the movement of food through the intestines, which may cause you to feel bloated or constipated.
  • After a vaginal delivery your vagina will be stretched open and may be swollen and bruised.
  • Vaginal bleeding as heavy as (and often heavier than) your menstrual period will occur. This is called lochia and is a byproduct of your uterus shrinking back into your pelvis and shedding the lining and any cells that are left from the placenta. This includes all the extra tissues, blood vessels, muscles and ligaments, which grew and developed during pregnancy, dissolving through a process of self-digestion and shrinking, called autolysis and involution (Tiran 2006). A sudden gush when you stand up in the first few days is normal. Because blood and the occasional clot are the predominant ingredients of lochia during these early days, your discharge can be quite red. Maternity towels, not tampons, should be used to absorb the flow. You have an open internal wound at the site where the placenta was attached to the uterine wall, and like any wound, this one is vulnerable to infection. Tampons could introduce bacteria.
  • Your uterus is shrinking rapidly in an effort to control bleeding and return to its pre-pregnancy state. You will experience abdominal cramps (afterpains) as your uterus contracts and shrinks (from about 1kg to just 50g) and makes its normal descent back into the pelvis. Breastfeeding will speed up this process, shrinking the uterus back to its normal size more quickly while pinching off exposed blood vessels at the site where the placenta separated from the uterus.
  • During pregnancy, your internal organs gradually shift around to make room for your growing baby. Now that your baby has suddenly gone from your uterus, your organs have to make their way back to their prepregnancy position. This can make you feel like your organs are just hanging in space. This feeling will pass over the next week or so, as your abdominal muscles regain some of their tone and your organs shift back into place.
  • Aside from the obvious lack of sleep and aftermath of gruelling labour, low potassium levels can contribute to a feeling of exhaustion. Eat plenty of potassium-rich foods, such as bananas, tomatoes, dried apricots, and plain yogurt.
  • You are likely to experience perineal discomfort, pain, numbness, if you had a vaginal delivery (especially if you had stitches).
  • You will experience discomfort sitting and walking if you had an episiotomy or a repair of a tear. Walking is, however, the best activity during this immediate postnatal period, and a gentle daily walk is recommended (Coulson 2012).
  • Difficulty urinating will occur. Some women feel no urge at all; others feel the urge but are unable to satisfy it. However it is essential that you empty your bladder within six to eight hours of delivery to avoid urinary tract infection, loss of muscle tone in the bladder from over-distension, and bleeding (because an overfull bladder can get in the way of your uterus as it attempts the normal postpartum contractions that staunch bleeding).
  • You may have haemorrhoids continued from pregnancy, or new from pushing. These are various veins in your ass that can be sore, itchy, bleed and generally make you feel your ass has turned inside out.
  • All-over achiness especially if you did a lot of pushing.
  • You may have swelling in your legs and feet. Reduce it by keeping your feet elevated when possible.
  • You may have bloodshot eyes from pushing.
  • Sweating and lots of it, particularly at night.
  • You can shower or take a bath as usual, but always use mild, unscented soap or just water when washing the perineum.
  • Bladder control may be practically non-existent in these first forty-eight hours or so, and decidedly dodgy for some time after. The cradle of muscles that supports your bladder and womb has been stretched by pregnancy and childbirth and it needs tightening up. Answer: do pelvic floor exercises (otherwise known as kegels).
  • Exercise: The pelvic floor muscles are the ones that you use when you want to urinate or defecate, and are the muscles you used to push your baby out if you had a vaginal birth. Strengthen the muscles by contracting the area around your vagina and anus. Hold it for 30 seconds. Do 8 contractions each time. Don’t worry if you cannot feel yourself doing them; the area will be numb at this early stage.
  • Caesarean section: Most women will require strong and effective analgesia for the first 48 hours after the operation.
  • Caesarean section: Within six to eight hours after delivery, your carers will be there to help you to sit up, get you sitting on the side of the bed, and start you walking short distances. Becoming mobile as quickly as possible is the best advice for post-cesarean mothers. The surgery and the anesthesia can cause fluids to accumulate, which may lead to pneumonia, so movement is very important.
  • Caesarean section: The lochia is frequently less heavy after a c-section, because the surgeon usually cleans out the uterine cavity with swabs before stitching up the walls of the uterus, thereby removing blood clots, pieces of membrane, placenta and other debris. Nonetheless, you will have lochia for several weeks and may pass small blood clots and experience some after pains when breastfeeding.
  • Caesarean section: The catheter that was inserted before your caesarean will usually be removed once you can walk to the bathroom. The IV line you had inserted before the operation will be kept in place until your ifntestines begin to work again. You will know this is happening when you start to experience rumbling in your stomach and gas pains. Ease the gas pains by avoiding carbonated drinks, or drinks that are very hot or cold.
  • Exercise: For mothers who have had a caesarean, medical professionals recommend gentle coughing to stimulate the area around the stitches. This stimulation will promote healing around the wound. Do this several times a day.

Day 2:

  • Now the first 24 hours have passed, you should contact your doctor if you have a temperature of over 37.8.C that lasts for over a day. This could signal an infection.
  • You may find yourself urinating a lot now (an astounding 3 quarts a day!) as the excess fluids of pregnancy is excreted.
  • Getting urine (which is naturally acidic) on raw skin will be traumatic and painful, and this is likely to continue until 2 weeks have passed.
  • If your bowels have taken a bashing, or your pelvic floor is letting you down, you might find that excess wind is a problem. Leaking poop (postpartum faecal incontinence) can also be an issue for the same reasons. If you're suffering in this department, rest assured this should right itself as you regain strength down bellow.
  • Your uterus has shrank about a finger’s width since yesterday. It will continue to do this every day.
  • Exercise: Breathing deeply will help you get rid of any lingering anesthetic and will also help you get in touch with how your stomach feels (particularly useful if you’ve had a caesarean). Start with gentle breathing and gradually build up to deeper and deeper breaths. Deep breathing encourages your lungs to inflate fully after having been compressed by the baby and your diaphragm.
  • Exercise: Your blood clotting mechanism changed toward the end of pregnancy in an attempt to prevent excess haemorrhage during labour, which means that you are more at risk of blood clots (thrombosis) during these early days after delivery. Getting up and about and ensuring that you do ankle-circling exercises will help to prevent this but if you experience any discomfort in your calf, inform a medical professional as soon as possible (Tiran 2008).
  • Caesarean section: The sterile dressing that covers your incision will usually be changed today. 

Day 3:

  • Constipation should be easing.
  • Your blood pressure, temperature, heart rate and breathing have all returned to normal. 
  • Up until now, your baby has been extracting small amounts of colostrum, and your breasts have been easily handling the workload. Then it happens, your milk comes in. Your breasts become swollen, hard and tender. You may also develop a brief low-grade fever (less than 37.8.C) but this should last no longer than 24 hours.
  • Nipple soreness for a few days is normal as your breasts adjust to their new role (see 'Timeline of a Breastfed Baby'). Establishing an effective latch as soon as possible is important.
  • You can now feel the top of your uterus at or a few finger widths below the level of your belly button.
  • Caesarean section: Staples or clips are usually removed today. You may be able to return home.
  • Caesarean section: You will experience some pain around the incision as the anaesthesia wears off. The level of pain will depend upon your personal pain threshold and how many caesarean deliveries you’ve had (the first is usually the most uncomfortable).
  • Exercise: Mothers who have had a caesarean will particularly benefit from simple stomach pull-ins. Lie down and contract your pelvic floor muscles then try to pull in your abdominals. In these early days you may find these pull-ins hard, as any feeling in this area will be limited. Although the lower layers of the incision will be healing fast, there will be numbness around the area of the scar itself.

Day 4:

  • A midwife will intermittently visit you at home between now and day 10 to make regular checks on you and your baby (UK).
  • Around now, oestrogen levels plummet and are replace by floods of the mothering hormone, prolactin. These hormonal changes can lead to emotional mood swings commonly known as the ‘baby blues’. Symptoms include, feeling weepy, irritable or resentful toward your new lifestyle, fearful over the baby’s health, tired or disappointed by your birth experience. 80% of women will experience the baby blues (Murkoff 2009; Stoppard 2008).
  • Vaginal swelling starts to go down, and your vagina begins to regain muscle tone.
  • Caesarean section: You will now be sitting up and getting out of bed each day. Although walking is still likely to be uncomfortable and tiring, you will find that you can go a little farther each time you get up.

Day 5:

  • Lochia will change from bright red to darker in colour. The diagram shown here depicts how your lochia will change over the coming days and weeks.
  • Don’t overdo it. If you do you will feel weepy and you may notice an increase in lochia.
  • Caesarean section: Individual or continuous sutures are usually removed today.
  • Caesarean section: Your scar will appear rather red and raised at this stage and will also be tender to the touch. You may have quite a hard ridge along the incision, but it will gradually soften as it heals.
  • Caesarean section: You should always be careful during these early days of your healing when getting into a sitting or standing position. When you are lying down, do not reach for something above your head, which makes you pull across diagonally, as this motion will put strain on your scar. Always use both hands to push yourself up to an upright position.

Day 7:

  • It should be easier to sit down now if you previously had a tender perineal.
  • Afterpains will have eased significantly.
  • Your uterus now weighs a little over a pound – half of what it weighed just after you gave birth (Baby Center 2012).
  • Breast engorgement will be settling down.
  • By now you’ve lost about 4 to 6 pounds of water weight (Baby Center 2012).
  • General aches in the pelvis, chest, tailbone, back and legs are all normal.
  • If you suffered from puffy ankles, face and hands in the build-up to the birth, they will soon begin to go down.
  • The physical trauma of delivery may encourage the development of a bladder infection.
  • You may also experience urinary incontinence. This is because pregnancy, labour, and delivery weakens the muscles around your bladder and pelvis, making it harder for you to control the flow of urine. Plus, as your uterus shrinks in the weeks following delivery, it sits directly on the bladder, compressing it and making it more difficult to stem the tide. Hormonal changes after pregnancy can also batter your bladder.
  • Caesarean section: Most of your incision pain should have dissipated.
  • Caesarean section: The skin around your scar may become dry and itchy now. A light dressing may protect it from irritation, and you will probably be more comfortable wearing loose clothing that doesn’t rub.
  • Caesarean section: The area of skin around the womb may be quite numb because the nerves that innervate the skin have been cut. This superficial numbness is normal and is likely to continue for several months while the nerves grow back. Some women never get all the feeling back in the area around their scar.
  • Caesarean section: The upper edge of your scar is likely to be rather bumpy and sometimes overhang the lower edge when you are standing upright. This is normal and reflects the fact that the surgeon cut through several muscle layers and these take time to knit together again and provide a flat muscular wall.

Day 10:

  • By now you'll have only a small amount of white or yellow-white discharge, which will taper off over the next two to four weeks. Some women may continue to have scant lochia or intermittent spotting for a few more weeks.
  • The site of a laceration or episiotomy should be almost healed.
  • Your midwife will hand-over your care to the health visitor around now (UK).
  • If you had ‘rectus diastasis’ it should correct itself now. Rectus diastasis occurs when, instead of stretching over your baby as she grows, the rectus abdominal muscles in the front of your stomach pull away from the midline and separate (see diagram).

2 weeks:

  • Your uterus now weighs 11 ounces and is located almost entirely within your pelvis (Baby Center 2012).
  • You will still look quite pregnant at the moment. This is due to your still-enlarged uterus and left-over fluids, which should be flushing out soon. Another reason for your protruding postpartum abdomen is that your muscles and skin are stretched out and will take some effort to tone up. However it is important to avoid intense exercises such as sit-ups, crunches or curl-ups until you are four to six months postpartum. It will take this long for the connective tissues between the two bands of the main tummy muscle – the rectus abdominus – to strengthen to their original state.
  • If you have stitches they will become tighter as the skin surrounding them swells and the wound starts to heal. This can make sitting down uncomfortable.
  • If your stitches are dissolvable, they will dissolve around now.
  • Lochia will have now turned from red to a watery pink.
  • If you decided not to breastfeed, you will probably experience breast involution (shrinkage) around now. Involution refers to the process where the ductular-lobular-alveolar systems diminish in size because they are no longer required. This gives a sagging appearance. You may still experience sporadic leaking despite not breastfeeding.
  • The baby blues should be easing up now. If feelings of sadness persist into the second month you may have postpartum depression. You can take an online test HERE. This is the same tests doctors use to identify PPD sufferers. Postpartum depression is thought to affect around one in 10 women (and up to four in 10 teenage mothers) (NHS 2011).
  • 5 to 10 percent of women will experience 'postpartum thyroiditis', an inflammation of the thiroid gland. Postpartum thyroiditis causes no pain but produces a number of symptoms, including anxiety, emotional instability, muscle fatigue, lack of energy and depression, very much like PPD.
  • Your body still contains the hormone relaxin after the birth. This makes your ligaments more liable to strain, so don’t even think about doing aerobic or strenuous exercise until at least your six week check-up, though up to three months if you’ve had a c-section.
  • Caesarean section: You’ll properly be mobile now, and it is especially important that you protect your back. Your core muscles – your abdominal and lower back area –will be very weak, leaving you vulnerable to lover back injury or strain.
  • Caesarean section: There will be some pink, watery drainage from the incision. If the discharge continues for more than six weeks you should tell your doctor, as you may have an infection.

3 weeks:

  • If your lochia is still bright red, seek medical attention.
  • Your bump will have stretched the skin on your stomach, so it is likely to feel and look loose and floppy. It may even hang down when you stand or lie on your side. Don't be fooled by celebrities who appear to have poured themselves back into skintight leather within a month of birth and want you to think they didn't try hard to achieve it: they almost certainly nearly killed themselves to get there, and furthermore, they would have had a personal trainer providing motivation, and paid help to look after their baby while they did so.
  • You are unlikely to have gotten your waistline back yet.
  • If you had an episiotomy, the incision will have healed by now.

4 weeks:

  • A tear should have healed by now.
  • The darker pigmentation around your nipples will fade slightly now but will never completely vanish.
  • Most women find that their linea nigra begins to fade.
  • Only 7 percent of women claim to have resumed their sex lives by this point (McGolerick 2012). If you are one of them, avoid using condoms with colourings, flavourings or fragrances as these can cause irritation in the early weeks after delivery. Female condoms (that line the whole vaginal cavity) can be painful with stitches, and are unreliable in this early postnatal period due to stretching of the vaginal wall - wait 6-8 weeks (Tiran 2008).
  • Your uterus is now close to its pre-pregnancy weight of 3.5 ounces or less (Baby Center 2012).
  • You can now increase the intensity of exercise to incorporate gentle stretching, longer walks, moderate yoga and/or light aerobic activity.
  • Any stretch marks on your stomach, thighs or breasts will still be red and angry-looking.
  • If you had perfectly clear skin during pregnancy you may find yourself experiencing breakouts around now.
  • Decreasing estrogen levels may cause your hair to thin during this time, but only temporarily. In a couple of months, it should grow and thicken.
  • Some sources suggest that, “It’s not a good idea to have your hair permed in the first months after birth; Results are very unpredictable” (Ashworth et al 2004).
  • Caesarean section: You may experience occasional sensations of pulling or twitching and other brief pains around the incision site, particularly around the two end points of the scar, when you move around or pick things up. Some women will continue to feel this tension around their scars for several years, but it should not be painful, merely a physical reminder.
  • Caesarean section: If you decide to jump in the sack, you will experience less discomfort during sex compared with mothers who had a vaginal birth. However, in 2 months time, there will be little difference between moms (Barrett et al 2005). 

6 weeks:

  • It might not feel that way, but your energy levels have now returned to normal (Cattanach 2007). In fact, your aerobic capacity increases up to 20 percent in the first six weeks postpartum! (Bilich 2012).
  • You may get sick more often due to the effects of chronic sleep deprivation on your immune system.
  • Your vagina will have contracted and regained much of its muscle tone.
  • You will have a six week postnatal check now. Medical staff will measure your blood pressure and your abdomen will be examined to check that the uterus is well contracted.
  • If you aren’t breastfeeding your periods would normally kick in between now and 12 weeks.
  • This is the earliest you can safely use a tampon.
  • For most women, it is safe to resume sexual relations now (however if healing has been slow or you have had an infection your doctor may recommend waiting longer). When you start having intercourse, you'll probably find that you have less vaginal lubrication than you did when you were pregnant, due to lower levels of estrogen. This dryness will be even more pronounced if you're breastfeeding, because nursing tends to keep estrogen levels down (Baby Center 2012).
  • If you plan on using a diaphragm and your cervix has recovered, you will be fitted for one (throw away your old one, because it won’t fit properly anymore).
  • 50 to 60 percent of women still experience pain during sex at this point (Lev-Sagie 2012).
  • Lochia will have turned from a watery pink colour to brown, and the quantity should be significantly reduced.
  • By now, hemmorrhoids should have decreased or disappeared.
  • Afterpains will have ceased.
  • By now your uterus has shrunk from the size of a watermelon to an orange, and is now at pre -pregnancy size.
  • Your cervix will be on its way back to its pre-pregnant state but will still be somewhat engorged.
  • Backache (from weak abdominal muscles and from carrying baby) may continue. Half of all women experience backache for several weeks after delivering their baby (Murkoff 2009).
  • You may also still be experiencing joint pain (from joints loosened during pregnancy in preparation for delivery).
  • Hair loss may intensify.
  • Other changes to your hair may occur such as: new fluffy hair may begin to grow around the hairline, curly hair can straighten and straight hair can begin to wave; blondes often notice that their hair is darker. Luckily most changes are temporary.
  • The hormone relaxin has been affecting your connective tissue throughout your pregnancy and particularly if you are breastfeeding, it is still present in your body. This hormone softens and loosens the cartilage, ligaments, and tendons. Prime areas for injury during this postpartum period are the sacroiliac joints. If you trace the bones of your hips with your fingers, up and over the curve at the side and follow the downward curve at the back you will find two little hollows. These are your sacroiliac joints. Take note of this area and always treat it with respect.
  • Caesarean section: You will experience diminishing incision pain and continuing numbness.
  • Caesarean section: For insurance and health reasons, this is the earliest you will be able to drive.
  • Exercise: Gentle stationary cycling is a suitable low impact activity for this time period, provided that your pelvic and genital regions have healed  (Coulson 2012).
  • Exercise: Squats and calf raises will help with your postpartum circulation and strength  (Coulson 2012).

2 months:

  • A reduced sex drive is normal, particularly if you are breastfeeding. Nature is doing her best to furnish you with the most reliable contraceptive of all – abstinence.
  • 50 percent of women claim to have resumed their sex lives by this point (McGolerick 2012).
  • Although all new parents are sleep-starved, if you feel beyond worn out day after day, ask your doctor to check for anemia.
  • Any postpartum vaginal bleeding should end.
  • Caesarean section: If the scar is healing as it should, you will experience itching rather than pain. Try not to scratch as this could cause an infection.
  • Caesarean section: If your menstrual cycle has returned, you may find that the scar becomes tender around the time of your period.

3 months:

  • Lochia is likely to be a yellowish white colour now.
  • Excessive sweating should have ceased.
  • Any excess hair you developed during pregnancy should now have disappeared.
  • You may still be experiencing urinary incontinence.
  • 40% of women still do not welcome sex 3 months after childbirth (Cohen 2001)
  • You can now increase the intensity of exercise and to incorporate more regular activity. However...
  • Your body will still be vulnerable to the lingering affects of relaxin, the hormone that’s released during pregnancy to loosen the joints and ligaments, increasing the risk of strain and injury. For this reason, high-impact sports, such as aerobics or running, are best avoided for six to nine months after birth in favour of low-impact activities, such as swimming or power walking.
  • Exercise: During your pregnancy your back was put under a lot of stress and strain, and your ligaments will have been softened by the hormone relaxin, so you are likely to have experienced some backache. You should now introduce some back-strengthening exercises to your daily routine. Lie flat on your front and put your hands on your head or behind your back. Lift your head and shoulders off the floor as far as you can. Hold for a second then release. Repeat 8 times.
  • Caesarean section: Your final check-up will occur around now.  Your blood pressure will be taken to check that it is normal. The incision scar will be examined to see that it has healed, and your abdomen will be felt to see if your uterus has reduced in size and shrank back into the pelvic cavity. Other checks may include urine and bladder function.

4 months:

  • If you are exclusively breastfeeding, most mothers experience the return of their periods between now and six months (Murkoff 2009).
  • You may find you have a tendency to gain weight around your stomach and back area now because your body is still in pregnancy mode. Keep working on your fitness regime and you will eventually manage to get rid of this excess weight.
  • By now your fitness regime can incorporate exercising at an intensity that makes you breathe pretty heavily and feel somewhat winded. You should, however, still be able to chat to your baby or sing to any music you are listening to (Gallagher-Mundy 2009).
  • Lochia is likely to have ceased by now. 
  • Exercise: Now lochia has ceased, swimming can be resumed. However, avoid breaststroke leg motion if pelvic girdle pain is still present  (Coulson 2012).
  • Exercise: Now you are ready to perform full curl-ups (also known as ‘crunches’). Be meticulous with each lift you do, checking that you have lifted your shoulder blades off the floor and that you are pulling in on your abdominals as well.

6 months:

  • You can now exercise as you did pre-pregnancy. You’ll find that your baby is awake much more now, so you can include her in your work-out sessions. THIS book, written for fitness instructors, features some great exercises you can do while holding your baby. Think of your baby as an ever-increasing dumbbell – as she gets bigger and stronger, so do you because you are lifting more weight.
  • Most women have regained full bladder control by now (Murkoff 2009).
  • An Australian study found that women’s dissatisfaction with their postpartum body peaks at around 6 months after giving birth (Jolin 2009).
  • Stretch marks begin to fade (Heyworth 2007).
  • Up to 20 percent of women still report pain during sex at this point (Lev-Sagie 2012).
  • Exercise: You can now begin to up the intensity of your stomach exercises (even if you’ve had a caesarean). When you add twists and reaches to your stomach curls, you are bringing in the oblique muscles that wrap around the sides of your torso and support your back.

9 months:

  • It is safe to participate in high-impact sports now.
  • “9 months on, 9 months off” is a mantra you’ve probably heard. It refers to the common belief that “most women take about nine months to regain their pre-pregnancy shape” (Baird 2010).

1 year:

  • Your hair will be back to its prepregnant state. Any hair loss will no longer be noticeable.
  • Still not lost all the baby weight? You’re in good company. 60 percent of mothers are still carrying at least a few extra pounds at this stage (Baby Center 2010).
  • You may have a ‘bulbous tire’ around your middle. 86 percent of mothers say their belly still hasn't returned to normal by this stage (Baby Center 2010).
  • By now, you may notice a distinct difference in your body shape. Motherhood can turn an apple into a pear or a skinny "boy" bod into that of a mushy mommy. Even if/when you lose all the weight, some parts may have shifted and may not necessarily fall back into the same places.
  • Only now will your spine, skeleton and the large muscles in your body be fully recovered from pregnancy (Tiran 2006).

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