What really happens postpartum? One OBGYN explains

The first few weeks after your child is born can be a blur of exhilaration and exhaustion, getting to know your little one while also getting used to your new life. But it’s beneficial to take some time to focus on your own well-being during this postpartum period.

“The importance of the ‘4th trimester’ is often overshadowed by the 40-week pregnancy and labor and delivery,” says April Mikes, DO, an OBGYN in Weatherford, Texas. “And just as these timespans require frequent interaction with a healthcare provider (HCP), the postpartum period shouldn’t be overlooked, either.”

In fact, recognizing how important this 4th trimester is—and that nearly 40 percent of people who give birth do not attend postpartum healthcare visits—the American College of Obstetricians and Gynecologists (ACOG) released guidelines in May 2018, later updated in 2021, stating that “patient-centered, maternal postpartum care has the potential to improve outcomes for women, infants and families and to support ongoing health and well-being.”

From sex to mental health to a host of other potential postpartum issues, Dr. Mikes explains what parents can expect, plus what they can do to stay happy and healthy.

After not having a period throughout pregnancy, bleeding is common in the weeks after birth, and for some people it can be quite heavy.

One type of bleeding you may experience after birth is lochia, which may last for several weeks straight, says Mikes. This bleeding is a process of shedding from the placenta site. For most people, bleeding after giving birth will start dark red and transition to brighter red for the first couple of days. It may be heavy at times, accompanied by clots, some that could be as big as a plum. The lochia then turns into more of a pinkish-brown discharge with less volume that can last for a few weeks, though the timeline is different for everyone.

Eventually, the discharge will appear whitish or yellowish, before subsiding within four to six weeks. Bleeding may also be heavier after moving around or during breastfeeding. It’s best to let your body work through this natural process on its own, but if you have clots that are larger than a plum, bleeding that is bright red after about three days, or if you have any other concerns about bleeding, don’t hesitate to call your HCP.

Although rare, it’s possible to experience postpartum hemorrhage, which usually occurs because the uterus isn’t contracting strongly enough, and the blood vessels bleed uncontrollably. Hemorrhaging is most likely to occur while you’re still in the hospital, where it can be treated immediately. Call your HCP right away if you’re having heavy, uncontrolled bleeding, feel weak or dizzy, or have an increased heart rate.

Your period may return as soon as 25 days after delivery, says Mikes, but it can take much longer—up to 6 months—if you’re breastfeeding. That’s because breastfeeding on demand (when your baby is hungry) suppresses menstruation and ovulation.

Seventy percent of people who have gone through pregnancy will usually menstruate within 3 months of giving birth, and 20 to 71 percent of these people will experience ovulation. Ovulation can even occur before your first postpartum period, meaning you may be fertile well before you know it.

Every new parent is different, and the return of your menstrual cycle depends on your body. If you’re breastfeeding, you’ll have higher levels of the hormone prolactin, which inhibits the return of a period, sometimes for more than a year, says Mikes. Meanwhile, it’s important to keep your HCP up to date on your cycle so you can plan birth control accordingly.

Whether you had a vaginal delivery or a C-section, it will take some time for your body to heal after delivery. And while it is possible to bounce back soon after giving birth, most people will experience some amount of pain, depending on their labor and delivery experience.

If you had an episiotomy—a surgical tear made intentionally by your HCP to expand the vaginal opening during delivery—the perineum (the space between the vagina and anus) may feel sore until it heals. Follow the directions provided by your HCP for caring for this area, which often includes gentle cleansing techniques.

Uterine contractions are another source of post-birth pain. A few hours after birth, the upper area of your uterus is near the level of your navel, but it will slowly recede further down as the days go by. If you didn’t have any major complications in your delivery, your uterus should return to its normal size (about the size of a pear) within six to eight weeks.

These uterine changes can cause pain or cramping that may feel extreme at times but should only last about five minutes at a time. The purpose of these contractions is to stop the bleeding. Mikes says pain relief medications (particularly NSAIDs), heating pads, and warm, shallow baths can help relieve some of the discomfort.

During pregnancy, as your fetus grows, your uterus puts more and more pressure on your bladder. Laughing, sneezing, exercising, or other movements can often cause urine to slip out unintentionally.

Most of this incontinence will subside after delivery as the pressure is taken off of your bladder. But occasional leaking can continue. Delivery puts pressure on your pelvic tissues, and sometimes these tissues can tear or become stretched or damaged, which can increase the risk of leakage.

If you’re still experiencing incontinence six months after birth, see your HCP, says Mikes. Meanwhile, you can try limiting caffeinated beverages, since they may make you feel like you need to urinate more often. Adding Kegel exercises to your regular routine can also help: Tighten your pelvic floor muscles for five seconds then release for five seconds. Build up to 10 seconds tightened and 10 seconds relaxed. Work your way up to three sets of 10 repetitions per day, if possible.

Mikes reports that many of her patients ask how soon after giving birth they can lose their pregnancy weight. “It took you 40 weeks to grow a baby and it will often take the same amount of time to get back to a pre-pregnancy state,” she says, adding that a new parent’s first priorities should include self-care.

“About 13 pounds are lost immediately after delivery from the baby, the placenta, amniotic fluid, blood loss and other things, but the swelling often remains for a couple of weeks and may even worsen in the postpartum period,” she says. This swelling will usually subside and you’ll continue to lose weight due to retained fluids in the first week after birth. The remainder of pregnancy weight, however, is stored fat.

Whether or not you breastfeed (which can help with weight loss), the best way to manage weight post-delivery is to follow a healthy eating plan and add in exercise (once it’s safe for you to do so, is). The extra weight will typically come off sometime between 6 to 12 months postpartum. In fact, most people lose about half of gestational weight gain in the first six weeks postpartum.

Many new parents don’t feel like doing anything more strenuous than rocking and feeding their newborn the first few weeks, and that’s perfectly fine. Your body is recovering. Once you feel ready to begin exercising, start slow and listen to your body. If you experience any significant pain or anything feels “off,” stop and check in with your HCP. If you had a vaginal delivery without any complications, you may be able to start moving gently as soon as a few days after birth. For a C-section, you’ll want to check with your HCP about when it’s safe to start exercising.

Start with 20 to 30 minutes of activity per day. Walking is one of the easiest ways to fit in movement throughout the day, and you can even bring your infant along in the stroller. If you want to incorporate strength training, focus on toning your different muscle groups, especially your abdominal and back muscles, since these may be weak after pregnancy.

If you were a vigorous exerciser before pregnancy, it’s very likely you’ll be able to work your way back up within a matter of months.

As with exercise, it can take time before you feel ready to have sex again post-delivery. In addition to exhaustion and the need to wake for feeding every few hours, there are many physical factors at play when it comes to being ready for intercourse again, says Mikes. “Vaginal and perineal lacerations, cesarean deliveries, bleeding, return of libido, and vaginal atrophy due to breastfeeding all play into your ability and desire to have sex,” she notes.

While everyone will have their own timeline for feeling ready for sex, most HCPs, including Mikes, recommend waiting at least six weeks before you resume having intercourse. If you had an episiotomy, your HCP is likely to recommend that you wait until the area has totally healed. Talk with your HCP about birth control options that are right for you when you do plan to start having sex again.

In addition to the physical changes your body is going through, your mental health may be affected, too. Mikes says this is one of the most important issues to discuss with your HCP. Hormone fluctuations, specifically estrogen and progesterone, can contribute to feelings of depression, as can fatigue during the postpartum period. The changes to your lifestyle and your sense of who you are as a person and as a parent can also feel overwhelming. Those with a history of depression are more at risk for mood disorders during the postpartum period.

There is a range of mental-health experiences after giving birth:

• Postpartum blues: You may feel depressed, anxious, sad, or angry two to three days after birth. It’s common to start crying for no apparent reason or to have trouble sleeping or eating. You may also second-guess whether you’re able to care for your baby. These thoughts and feelings can come and go for a few days, but typically only last for one or two weeks.
• Postpartum depression: This type of depression can bring sadness, anxiety, or feelings of hopelessness that interfere with your daily routines. Although this type of depression is most common immediately after childbirth (usually one to three weeks), it can emerge up to a year after delivery. It’s important that you see your HCP if you’re experiencing postpartum depression. Antidepressants and other treatments such as talk therapy can help.
• Postpartum psychosis: Although rare, you may be at risk of postpartum psychosis if you have a history of psychosis, bipolar disorder, or schizophrenia. You may also have a heightened risk if this is your first pregnancy or if you stopped taking certain medications used to treat a mental illness during pregnancy. Hallucinations, delusions, strange behavior, and confusion are some signs of postpartum psychosis. You should see an HCP right away if you’re having any of these symptoms.

Although it is very typical to experience some feelings of sadness after delivery, it’s best to talk to your HCP right away about any mental health concerns you have. If you have any thoughts of harming yourself or your baby, call your HCP or 911 right away or chat, text, or call the 988 Suicide & Crisis Lifeline.

Your HCP will schedule you for a postpartum checkup within about six weeks after delivery, but if you have concerns before then, your provider should be there for you, says Mikes. “Our job doesn’t end after delivery,” she says, “and part of our job is making sure our patients are aware of this fact.”

Remember to be open and honest with your HCP about any symptoms you’re experiencing or any concerns that you have. You can discuss any residual pain or bleeding, when it’s safe for you to exercise or have sex, and any emotional changes you’ve had.

Your HCP will also want to monitor you for signs of diabetes and high blood pressure, particularly if you experienced gestational diabetes or preeclampsia during your pregnancy. (Preeclampsia is a condition characterized by higher-than-normal blood pressure during pregnancy or after giving birth.)

“The fourth trimester is not to be ignored, but rather embraced and given as much credence as the first three trimesters,” Mikes says. “Talk to your provider, ask questions, and continue on your health journey together.”