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Recovering After Birth and Breastfeeding
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In one pass After a baby is born, the first job for the body is to stop the bleeding.
Educational content, not medical advice — consult a clinician.
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Chapter 1
How the womb recovers after birth
After a baby is born, the first job for the body is to stop the bleeding. When the placenta peels away from the lining of the womb, it leaves a large patch of open blood vessels. The muscle of the womb then tightens in waves and squeezes those vessels shut. The most common cause of heavy bleeding after birth is that this step fails: the womb does not contract well, and the vessels stay open (ACOG).
Over the next few weeks the womb slowly shrinks back and the place where the placenta was attached heals. The blood and discharge that come out during this time are called lochia. In a study that followed 477 breastfeeding mothers, lochia lasted a median of 27 days, much longer than the two weeks people often quote, and it often stopped and started again (Visness 1997). During a feed the lochia can turn redder and heavier and the lower belly can cramp, because breastfeeding makes the womb contract (NHS).
At the same time, the progesterone and estrogen that the placenta supplied in large amounts during pregnancy fall away once the placenta has left. That drop drives what happens next with milk and with mood (Pang 2007).
If you are bleeding heavily enough to soak two pads in an hour, passing large clots, or have a painful swollen leg, sudden breathlessness or chest pain, get medical care now or call emergency services. The chapter Warning signs that need care now lists every sign.
Over the next few weeks the womb slowly shrinks back and the place where the placenta was attached heals. The blood and discharge that come out during this time are called lochia. In a study that followed 477 breastfeeding mothers, lochia lasted a median of 27 days, much longer than the two weeks people often quote, and it often stopped and started again (Visness 1997). During a feed the lochia can turn redder and heavier and the lower belly can cramp, because breastfeeding makes the womb contract (NHS).
At the same time, the progesterone and estrogen that the placenta supplied in large amounts during pregnancy fall away once the placenta has left. That drop drives what happens next with milk and with mood (Pang 2007).
If you are bleeding heavily enough to soak two pads in an hour, passing large clots, or have a painful swollen leg, sudden breathlessness or chest pain, get medical care now or call emergency services. The chapter Warning signs that need care now lists every sign.
Myth · Bed rest and soup in the first month
Some confinement customs do not hold up once you set them against how the body works.Staying in bed for a month: pregnancy itself makes clots more likely to form in the deep veins of the legs, and the risk is highest just after the birth. Moving little, drinking little, a very long labor, a cesarean birth and losing a lot of blood after the birth all raise it further. The Royal College of Obstetricians and Gynaecologists (RCOG) advises staying as active as you can and drinking normal amounts of fluid (RCOG). So spending a month in bed adds one more risk during the very weeks when the risk is highest. Clots are still uncommon in pregnancy and the first 6 weeks after birth, at about 1 to 2 in every 1000 women (RCOG), but they belong to the kind that can kill.
Drinking only soup: a study that measured bone broths found no more than a few tens of milligrams of calcium per serving, under 5% of the daily recommendation (Hsu 2017). Soup is also not what drives milk supply; the chapter How breast milk is made explains what does.
Skipping vegetables and fruit: in a survey of Chinese mothers in Kuala Lumpur, more than seven in ten ate no vegetables and about half ate no fruit during confinement, and their vitamin A and vitamin C intakes fell below half the recommended amount (Poh 2005). Eaten Isn't Delivered takes apart several traditional Chinese beliefs about pregnancy and birth.
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Chapter 2
How breast milk is made
Making milk depends on two hormones: one to make it and one to move it.
During pregnancy the breast already has its milk-making cells ready, but high progesterone holds back a full flow. Once the placenta is delivered and progesterone falls, with prolactin and other hormones present, milk comes in fully over the first few days after birth (Pang 2007). Quite a few mothers feel their breasts become tight and tender on the third or fourth day (NHS).
The milk that has been made needs a second hormone to move it out. When the baby sucks, the brain releases oxytocin in pulses, and oxytocin makes a layer of cells around the milk sacs contract and squeeze milk into the ducts. This is the milk ejection reflex, often called the let-down. In early breastfeeding, more oxytocin pulses go with more milk, and stress reduces the pulses (Uvnäs Moberg 2020). The same oxytocin also makes the womb contract, which is why the lower belly can cramp during a feed.
In the end, the breast sets the amount itself: the more milk is removed, the faster it makes more afterward (Daly 1993). This is what people mean by supply and demand. When milk seems short, the first-line fix is more frequent, more effective feeding, not drinking large amounts of soup. How much extra to eat, and whether milk-boosting herbs work, are covered in Pregnancy & Lactation.
During pregnancy the breast already has its milk-making cells ready, but high progesterone holds back a full flow. Once the placenta is delivered and progesterone falls, with prolactin and other hormones present, milk comes in fully over the first few days after birth (Pang 2007). Quite a few mothers feel their breasts become tight and tender on the third or fourth day (NHS).
The milk that has been made needs a second hormone to move it out. When the baby sucks, the brain releases oxytocin in pulses, and oxytocin makes a layer of cells around the milk sacs contract and squeeze milk into the ducts. This is the milk ejection reflex, often called the let-down. In early breastfeeding, more oxytocin pulses go with more milk, and stress reduces the pulses (Uvnäs Moberg 2020). The same oxytocin also makes the womb contract, which is why the lower belly can cramp during a feed.
In the end, the breast sets the amount itself: the more milk is removed, the faster it makes more afterward (Daly 1993). This is what people mean by supply and demand. When milk seems short, the first-line fix is more frequent, more effective feeding, not drinking large amounts of soup. How much extra to eat, and whether milk-boosting herbs work, are covered in Pregnancy & Lactation.
Evidence · How a breast matches supply to demand
Each breast regulates itself (Daly 1993): researchers measured breast volume before and after every feed for 24 hours in the homes of 7 mothers. Babies rarely emptied the breast; on average they took 76% of the milk available. In 6 of 13 breasts, the more fully a breast had been emptied, the faster it then made milk, and how much a breast could store matched how much the baby took from that side. The authors' explanation is that each breast controls its own supply locally, so the two sides can differ. This is a physiological measurement in only 7 people.The let-down and oxytocin (Uvnäs Moberg 2020): this systematic review pooled 29 studies with 601 women. Oxytocin was released immediately after suckling and lasted about 20 minutes, in pulses early after birth. More pulses went with more milk and with breastfeeding for longer, and stress reduced the pulses. All the included studies were exploratory, so these are associations.
Does breastfeeding take the weight off? Making milk costs about 500 kcal a day, and about 170 kcal of that is paid for by fat stored in pregnancy, so the amount you actually need to eat on top is about 330 kcal (IOM 2005). But a systematic review of 45 observational studies found that most of them (27, or 63%) saw no clear link between breastfeeding and weight change after birth; of the 5 studies with the strongest methods, 4 did find breastfeeding linked to weight loss (Neville 2014). Breastfeeding may help a little, but it does not automatically remove the weight gained in pregnancy.
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Chapter 3
Which milk nutrients follow your plate
The nutrients in breast milk fall into two groups: some follow what the mother eats, and some the body holds steady whatever she eats.
Nutrients that follow the plate: iodine, choline, and several B vitamins (B1, B2, B6 and B12). When the mother eats more of them, there is more in the milk; when she eats less, there is less (Dror 2018). Around the world, the DHA in breast milk varies more than twentyfold, and the highest levels are found in coastal populations who eat a lot of seafood (Brenna 2007). In mothers who eat no animal foods at all, the baby may get very little B12 from the milk (CDC).
Nutrients the body holds steady: calcium, iron, zinc and folate. Eating or taking more of them generally does not raise their level in the milk (Dror 2018). The mother's bones pay for the calcium, as the chapter Calcium borrowed from bone, then repaid explains.
Vitamin D is the exception: there is little of it in milk to begin with, far less than a baby needs (Dror 2018). So the American Academy of Pediatrics recommends that breastfed babies, whether fully or partly breastfed, get a vitamin D supplement every day from the first few days of life; ask the pediatrician about the dose (Wagner 2008).
At the table, this means cooking with iodized salt, choosing low-mercury fish, and including eggs, milk, meat and beans. Mothers who eat a fully vegan diet should talk to a doctor about B12.
Nutrients that follow the plate: iodine, choline, and several B vitamins (B1, B2, B6 and B12). When the mother eats more of them, there is more in the milk; when she eats less, there is less (Dror 2018). Around the world, the DHA in breast milk varies more than twentyfold, and the highest levels are found in coastal populations who eat a lot of seafood (Brenna 2007). In mothers who eat no animal foods at all, the baby may get very little B12 from the milk (CDC).
Nutrients the body holds steady: calcium, iron, zinc and folate. Eating or taking more of them generally does not raise their level in the milk (Dror 2018). The mother's bones pay for the calcium, as the chapter Calcium borrowed from bone, then repaid explains.
Vitamin D is the exception: there is little of it in milk to begin with, far less than a baby needs (Dror 2018). So the American Academy of Pediatrics recommends that breastfed babies, whether fully or partly breastfed, get a vitamin D supplement every day from the first few days of life; ask the pediatrician about the dose (Wagner 2008).
At the table, this means cooking with iodized salt, choosing low-mercury fish, and including eggs, milk, meat and beans. Mothers who eat a fully vegan diet should talk to a doctor about B12.
Safety · Do coffee and alcohol reach the milk?
Alcohol: the alcohol level in breast milk is essentially the same as in the mother's blood. It peaks 30 to 60 minutes after a drink, and for each drink it can be detected in milk for about 2 to 3 hours (CDC). By this mechanism, alcohol leaves the milk only as the liver clears it from the blood, so expressing and discarding milk does not make it leave any faster. Newborns break down alcohol at about half the adult rate, and alcohol also suppresses the milk ejection reflex, so milk flow drops for a while (Haastrup 2014). The US Centers for Disease Control and Prevention (CDC) says that not drinking is the safest choice; up to one standard drink a day is not known to harm the baby, and after a single drink you can wait at least 2 hours before breastfeeding (CDC). How the body handles alcohol is covered in Alcohol Metabolism.Caffeine: the CDC counts up to 300 mg a day, about 2 to 3 cups of coffee, as a low to moderate amount. Irritability, poor sleep and jitteriness have been reported in babies, and preterm and newborn babies break caffeine down more slowly, so their mothers may want to have even less (CDC).
Other foods: in general there is no need to avoid any particular food because you are breastfeeding (CDC).
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In practice · Planning meals while breastfeeding
Energy: eating a little more than before pregnancy is enough. The CDC's figure for well-nourished breastfeeding mothers is an extra 330 to 400 kcal a day (CDC), roughly one extra snack. Eat when you are hungry and drink when you are thirsty.Iodine: the recommendation the CDC cites is 290 micrograms a day while breastfeeding (CDC). Iodine passes into milk with the diet, so cook with iodized salt and eat seafood, eggs and milk regularly.
Fish: most fish contain mercury, which can pass to the baby through breast milk (CDC). The US Food and Drug Administration (FDA) and Environmental Protection Agency advise breastfeeding mothers to avoid the highest-mercury fish, such as shark, swordfish and king mackerel, and to choose low-mercury fish (FDA 2021).
Choline and B vitamins: these also pass into milk with the diet (Dror 2018); eggs, milk, meat and beans are everyday sources.
A vegan diet: the baby may get very little B12 from the milk (CDC), so talk to a doctor about how to supplement.
Calcium and iron: eating more does not put more calcium or iron into the milk (Dror 2018), so there is no need to double up for breastfeeding; the chapter Calcium borrowed from bone, then repaid explains why.
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Chapter 4
Calcium borrowed from bone, then repaid
The calcium in breast milk does not depend on how much the mother eats; it depends on the bones lending it. A mother who breastfeeds exclusively sends out an average of about 210 mg of calcium in her milk every day, and much of it is released from her skeleton: bone-dissolving cells (osteoclasts) speed up, and the bone cells buried inside the bone also take mineral from around themselves (Kovacs 2017).
So after 3 to 6 months of exclusive breastfeeding, in the lower spine falls by an average of 5% to 10% (Kovacs 2017). This is not a calcium shortage, and calcium supplements do not stop it. In a randomized trial of calcium or placebo in new mothers, spine bone density still fell in those who breastfed: by 4.2% with calcium and 4.9% with placebo, and the calcium in their milk did not rise (Kalkwarf 1997).
What is borrowed is paid back. After weaning, bone is rebuilt, and in both animal and human studies the mineral content and strength of the skeleton return to where they were. In most studies, women who have breastfed do not have a higher later risk of low bone density or fractures (Kovacs 2017).
So while breastfeeding, getting your usual amount of calcium is enough; there is no need to double it for the baby's sake. How bone is built and lost over a lifetime is covered in Osteoporosis.
So after 3 to 6 months of exclusive breastfeeding, in the lower spine falls by an average of 5% to 10% (Kovacs 2017). This is not a calcium shortage, and calcium supplements do not stop it. In a randomized trial of calcium or placebo in new mothers, spine bone density still fell in those who breastfed: by 4.2% with calcium and 4.9% with placebo, and the calcium in their milk did not rise (Kalkwarf 1997).
What is borrowed is paid back. After weaning, bone is rebuilt, and in both animal and human studies the mineral content and strength of the skeleton return to where they were. In most studies, women who have breastfed do not have a higher later risk of low bone density or fractures (Kovacs 2017).
So while breastfeeding, getting your usual amount of calcium is enough; there is no need to double it for the baby's sake. How bone is built and lost over a lifetime is covered in Osteoporosis.
Mechanism · How iron is rebuilt after birth
Iron works differently from calcium. There is little iron in milk to begin with, and eating or taking more iron does not raise it (Dror 2018). So after birth the iron question is mainly about the mother herself: blood was lost during the birth, and her iron stores from pregnancy may already be low.One thing helps: in the first 8 weeks of exclusive breastfeeding, periods rarely return (Visness 1997), so the iron that would leave with monthly bleeding is saved for the time being.
Where anemia in pregnancy is common, the World Health Organization says mothers may be given oral iron, or iron with folic acid, for 6 to 12 weeks after birth, whether or not they breastfeed. This is a context-specific recommendation based on low-certainty evidence, and whether to take it, and how, is for a doctor to decide (WHO 2022).
If you are always tired, look pale, feel your heart racing or get short of breath, or feel dizzy every time you stand up, get your hemoglobin checked; Iron-Deficiency Anemia explains how it is tested and treated. Dizziness bad enough that you might faint is a warning sign after birth: get medical care now (CDC).
Chapter 5
Leaks and separated belly muscles
The pelvic floor is a sling of muscle across the bottom of the pelvis. It holds up the bladder, womb and rectum and helps hold urine in. In pregnancy it carries extra weight for months, and a vaginal birth stretches it to its limit, so leaking a little urine when you laugh or cough after having a baby is common (NHS).
Pelvic floor muscle training means tightening and relaxing these muscles on a regular schedule. The evidence has to be read in parts. Women who do not leak and start training during pregnancy have a lower risk of leaking late in pregnancy and 3 to 6 months after birth. But when everyone starts training only after the birth, leaking has not clearly gone down (Woodley 2020). So the World Health Organization does not recommend routine training for every new mother as prevention, but for mothers who already leak, exercising on their own at home may help and is unlikely to cause harm (WHO 2022).
On the belly, the two long muscles down the front are pushed apart during pregnancy and the gap between them widens. This is called diastasis recti. In a study that followed 300 first-time mothers, 60.0% had it 6 weeks after birth and 32.6% still had it at 12 months; women with and without it had about the same rates of low back and pelvic pain (Sperstad 2016).
If leaking does not improve with the exercises, tell the doctor at your postnatal check (NHS). How to work back up to exercise after birth is covered in Pregnancy + exercise.
Pelvic floor muscle training means tightening and relaxing these muscles on a regular schedule. The evidence has to be read in parts. Women who do not leak and start training during pregnancy have a lower risk of leaking late in pregnancy and 3 to 6 months after birth. But when everyone starts training only after the birth, leaking has not clearly gone down (Woodley 2020). So the World Health Organization does not recommend routine training for every new mother as prevention, but for mothers who already leak, exercising on their own at home may help and is unlikely to cause harm (WHO 2022).
On the belly, the two long muscles down the front are pushed apart during pregnancy and the gap between them widens. This is called diastasis recti. In a study that followed 300 first-time mothers, 60.0% had it 6 weeks after birth and 32.6% still had it at 12 months; women with and without it had about the same rates of low back and pelvic pain (Sperstad 2016).
If leaking does not improve with the exercises, tell the doctor at your postnatal check (NHS). How to work back up to exercise after birth is covered in Pregnancy + exercise.
Evidence · What pelvic floor training trials show
This Cochrane systematic review included 46 trials with 10832 women from 21 countries. Most trials were small to moderate in size, and many had a moderate to high risk of bias (Woodley 2020).Prevention: in women who did not leak and started training during pregnancy, the risk of leaking late in pregnancy was 62% lower (moderate-quality evidence), and 29% lower 3 to 6 months after birth (high-quality evidence).Treatment: in women who kept leaking after birth, training made no clear difference at 6 to 12 months after birth (low-quality evidence). When everyone started training after the birth, whether or not they leaked, the effect was also uncertain.The authors' contrast: training is more clearly effective for leaking in women in midlife than around pregnancy and birth, where it remains uncertain. Training targeted at the women most likely to benefit may work better, but that still needs to be tested in trials.
On this basis the World Health Organization does not recommend routine training for every new mother to prevent leaking. Women who already leak should be told that training may help; exercising on their own at home may be beneficial and is unlikely to cause harm (WHO 2022).
Diastasis recti (Sperstad 2016): in 300 first-time mothers, a gap of 2 or more finger widths between the two long belly muscles counted as separation. It was present in 33.1% at 21 weeks of pregnancy, 60.0% at 6 weeks after birth, 45.4% at 6 months and 32.6% at 12 months. Women who lifted heavy loads 20 or more times a week were more likely to have it. At 12 months, women with and without it reported the same amount of low back and pelvic pain.
Chapter 6
Broken sleep and mood swings
In the first months after birth, sleep is not always shorter, but it is chopped into pieces. In a study that measured sleep with wrist monitors in 50 mothers, total sleep each night from week 2 to week 16 averaged about 7.2 hours. That sounds like plenty, but it was interrupted so often that it was as fragmented as in people with sleep disorders. Sleep efficiency rose from about 80% at week 2 to about 90% only by week 16 (Montgomery-Downs 2010).
Mood also rises and falls as the hormones withdraw. Feeling low, tearful or irritable in the first few days is very common. This is called the baby blues, and it usually passes within two weeks. If it has not passed after two weeks, or if at any point in the first year you have a lasting low mood, lose interest in things or struggle to feel close to your baby, it may be postnatal depression and you should see a doctor. Partners can get it too (NHS).
Why do some people sink into it? In a very small experiment, 16 women were first given high pregnancy-like hormone levels, which were then suddenly withdrawn. Five of the 8 women with a history of postnatal depression developed clear depressive symptoms, and none of the other 8 did (Bloch 2000). This suggests that some people are unusually sensitive to a sudden hormone drop; it is not a matter of willpower.
If you have thoughts of harming yourself or your baby, get help now: in mainland China, call the national psychological assistance hotline 12356; wherever you are, you can go to your local emergency department.
Mood also rises and falls as the hormones withdraw. Feeling low, tearful or irritable in the first few days is very common. This is called the baby blues, and it usually passes within two weeks. If it has not passed after two weeks, or if at any point in the first year you have a lasting low mood, lose interest in things or struggle to feel close to your baby, it may be postnatal depression and you should see a doctor. Partners can get it too (NHS).
Why do some people sink into it? In a very small experiment, 16 women were first given high pregnancy-like hormone levels, which were then suddenly withdrawn. Five of the 8 women with a history of postnatal depression developed clear depressive symptoms, and none of the other 8 did (Bloch 2000). This suggests that some people are unusually sensitive to a sudden hormone drop; it is not a matter of willpower.
If you have thoughts of harming yourself or your baby, get help now: in mainland China, call the national psychological assistance hotline 12356; wherever you are, you can go to your local emergency department.
Clinical · Screening and preventing postnatal depression
The World Health Organization recommends asking every mother about her mood at each postnatal check, and screening for postnatal depression and anxiety with a validated questionnaire, such as the Edinburgh Postnatal Depression Scale (EPDS) or the nine-question depression self-rating scale PHQ-9. Women who screen positive should be followed up with diagnosis and treatment (WHO 2022).It also recommends psychosocial or psychological support during pregnancy and after birth to prevent postnatal depression and anxiety, such as learning to cope with stress and building a network of people to call on (WHO 2022).
On the sleep side, broken sleep is normal in these months, and sleep efficiency recovers only around week 16 (Montgomery-Downs 2010). So what the people around a new mother can do is share the night-time care during these months and recognize a low mood that has not passed after two weeks.
The hormone-withdrawal experiment (Bloch 2000) had only 16 people. It helps explain why some people are unusually sensitive to the hormone changes after birth; it cannot predict whether any one person will become depressed.
Chapter 7
Warning signs that need care now
In the year after giving birth, do not wait if any of the following happens: get medical care now, and if you cannot reach your doctor, call emergency services or go to the emergency department. Tell the staff that you recently had a baby.
Bleeding: bleeding heavy enough to soak two pads in an hour, or passing large clots. Dizziness or fainting, a fast heartbeat, or pale, clammy skin also need care now. Heavy bleeding after birth usually happens within 24 hours, but it can happen as late as 12 weeks later (ACOG).
Clots: a leg that is swollen, red and painful, or sudden breathlessness, chest tightness, chest pain or coughing up blood (CDC, RCOG).
Blood pressure: a headache that will not go away or keeps getting worse, blurred vision or seeing spots, severe swelling of the face and hands, pain in the upper right belly, or severe nausea and vomiting. This may be postpartum preeclampsia, which usually comes within a few days of birth but can appear as late as 6 weeks (ACOG).
Infection: a temperature of 38°C (100.4°F) or higher, chills, belly pain that does not go away, or bad-smelling lochia (ACOG, CDC). A red, hot, painful area of the breast with flu-like feelings may be mastitis: keep breastfeeding, and see a doctor if it is not better after 12 to 24 hours of home care (NHS).
Mood: if you have thoughts of harming yourself or your baby, get help now: in mainland China, call the national psychological assistance hotline 12356; wherever you are, you can go to your local emergency department (CDC).
This story is education and does not replace postnatal checks or a diagnosis.
Bleeding: bleeding heavy enough to soak two pads in an hour, or passing large clots. Dizziness or fainting, a fast heartbeat, or pale, clammy skin also need care now. Heavy bleeding after birth usually happens within 24 hours, but it can happen as late as 12 weeks later (ACOG).
Clots: a leg that is swollen, red and painful, or sudden breathlessness, chest tightness, chest pain or coughing up blood (CDC, RCOG).
Blood pressure: a headache that will not go away or keeps getting worse, blurred vision or seeing spots, severe swelling of the face and hands, pain in the upper right belly, or severe nausea and vomiting. This may be postpartum preeclampsia, which usually comes within a few days of birth but can appear as late as 6 weeks (ACOG).
Infection: a temperature of 38°C (100.4°F) or higher, chills, belly pain that does not go away, or bad-smelling lochia (ACOG, CDC). A red, hot, painful area of the breast with flu-like feelings may be mastitis: keep breastfeeding, and see a doctor if it is not better after 12 to 24 hours of home care (NHS).
Mood: if you have thoughts of harming yourself or your baby, get help now: in mainland China, call the national psychological assistance hotline 12356; wherever you are, you can go to your local emergency department (CDC).
This story is education and does not replace postnatal checks or a diagnosis.
References · 22
- American College of Obstetricians and Gynecologists (Ogunyemi, D.). (2022). 3 conditions to watch for after childbirth (patient education; last updated January 2022, last reviewed February 2026). Postpartum preeclampsia most often happens within a few days after delivery but can occur up to 6 weeks later; call the doctor right away for blood pressure of 140 systolic or 90 diastolic or higher, vision changes, a headache that won't go away, shortness of breath, swelling of the face or hands, upper-right belly pain, nausea or vomiting. Postpartum hemorrhage is bleeding much heavier than usual, soaking through two pads an hour for more than 1 to 2 hours; it usually happens within 24 hours but can occur up to 12 weeks later; the most common cause is uterine atony, when the uterine muscles do not contract normally so blood vessels do not tighten after delivery; signs include large clots, pale or clammy skin, feeling faint or dizzy, confusion and a rapid heart rate. Endometritis usually happens 2 to 10 days after delivery (up to 6 weeks): fever and chills, abdominal pain, foul-smelling discharge. If you cannot reach your ob-gyn or need immediate care, call 911 or go to the hospital. www.acog.org/womens-health/experts-and-stories/the-latest/3-conditions-to-watch-for-after-childbirth
- Visness, C. M., Kennedy, K. I., & Ramos, R. (1997). The duration and character of postpartum bleeding among breast-feeding women. Obstetrics & Gynecology, 89(2), 159-163. Prospective cohort of 477 experienced breast-feeding women in Manila who kept a bleeding diary. The median duration of lochia was 27 days and did not vary by age, parity, infant sex or weight, breast-feeding frequency or supplementation. More than one-fourth had a bleeding episode separated from the lochia by at least 4 bleeding-free days and beginning by postpartum day 56. Lochia lasted substantially longer than the conventional 2 weeks, and bleeding often stopped and started again. Return of menses is rare among fully breast-feeding women in the first 8 weeks postpartum. 10.1016/S0029-7844(96)00482-6
- NHS. (2024). Your body after the birth (page last reviewed 25 April 2024). Bleeding (lochia) is quite heavy at first; it may be redder and heavier when you breastfeed because breastfeeding makes the womb contract, with cramps like period pains; it carries on for a few weeks, gradually turns brownish and stops. Tell your midwife if you are losing blood in large clots. Leaking a bit of pee when you laugh, cough or move suddenly is quite common after having a baby; pelvic floor exercises can help, and tell the GP at your postnatal check if they are not helping. On the third or fourth day the breasts may feel tight and tender as they start to produce milk. www.nhs.uk/pregnancy/labour-and-birth/your-body
- Pang, W. W., & Hartmann, P. E. (2007). Initiation of human lactation: secretory differentiation and secretory activation. Journal of Mammary Gland Biology and Neoplasia, 12(4), 211-221. Review. Lactation starts in two stages: secretory differentiation in pregnancy, when mammary epithelial cells become lactocytes able to make milk constituents such as lactose (requiring a lactogenic hormone complex of estrogen, progesterone, prolactin and metabolic hormones), and secretory activation, the onset of copious milk secretion. The withdrawal of progesterone triggers secretory activation, but prolactin, insulin and cortisol must also be present. Milk ejection is the expulsion of milk already secreted; milk secretion is a separate, continuous process. 10.1007/s10911-007-9054-4
- Bloch, M., Schmidt, P. J., Danaceau, M., Murphy, J., Nieman, L., & Rubinow, D. R. (2000). Effects of gonadal steroids in women with a history of postpartum depression. The American Journal of Psychiatry, 157(6), 924-930. Experimental simulation in 16 euthymic women (8 with and 8 without a history of postpartum depression): hypogonadism induced with leuprolide, supraphysiologic estradiol and progesterone added back for 8 weeks, then both withdrawn under double-blind conditions. Five of the eight women with a history of postpartum depression (62.5%) and none of the comparison group developed significant mood symptoms during withdrawal. The authors read this as direct evidence that estrogen and progesterone are involved in postpartum depression in a subgroup of women who are differentially sensitive to them. Very small study. 10.1176/appi.ajp.157.6.924
- Centers for Disease Control and Prevention. (2024). Urgent maternal warning signs (Hear Her campaign; last updated May 15, 2024). Be aware of urgent maternal warning signs during pregnancy and in the year after delivery, and seek medical care immediately for: a headache that won't go away or gets worse; dizziness or fainting; changes in vision; fever of 100.4°F or higher; extreme swelling of the hands or face; thoughts about harming yourself or your baby; trouble breathing; chest pain or fast-beating heart; severe nausea and throwing up; severe belly pain that doesn't go away; vaginal bleeding or discharge after pregnancy; severe swelling, redness or pain of a leg or arm. Tell providers if you were pregnant within the last year. www.cdc.gov/hearher/maternal-warning-signs/index.html
- Royal College of Obstetricians and Gynaecologists. (2015). Reducing the risk of venous thrombosis in pregnancy and after birth (patient information, August 2015). Pregnancy increases the risk of deep vein thrombosis, with the highest risk being just after the baby is born; venous thrombosis is still uncommon in pregnancy or in the first 6 weeks after birth, occurring in only 1-2 in 1000 women. Risk is higher with immobility, dehydration, a very long labour (more than 24 hours), a caesarean section, losing a lot of blood after the birth or a blood transfusion. Stay as active as you can and keep hydrated by drinking normal amounts of fluids. Sudden unexplained difficulty in breathing, tightness in the chest or chest pain, coughing up blood, or feeling very unwell or collapsing may mean a pulmonary embolism: seek help immediately. www.rcog.org.uk/for-the-public/browse-our-patient-information/reducing-the-risk-of-venous-thrombosis-in-pregnancy-and-after-birth
- Uvnäs Moberg, K., Ekström-Bergström, A., Buckley, S., Massarotti, C., Pajalic, Z., Luegmair, K., Kotlowska, A., Lengler, L., Olza, I., Grylka-Baeschlin, S., Leahy-Warren, P., Hadjigeorgiu, E., Villarmea, S., & Dencker, A. (2020). Maternal plasma levels of oxytocin during breastfeeding: a systematic review. PLoS ONE, 15(8), e0235806. Systematic review of 29 exploratory studies (601 women). Breastfeeding induced an immediate, short-lasting (20 minutes) oxytocin release, pulsatile early postpartum. The number of oxytocin pulses in early breastfeeding was associated with greater milk yield and longer lactation and was reduced by stress. Breastfeeding-induced oxytocin release was associated with higher prolactin and lower ACTH and cortisol. All included studies were exploratory. 10.1371/journal.pone.0235806
- Daly, S. E., Owens, R. A., & Hartmann, P. E. (1993). The short-term synthesis and infant-regulated removal of milk in lactating women. Experimental Physiology, 78(2), 209-220. Breast volume was measured before and after every feed over 24 h in seven mothers at home. Short-term milk synthesis rates varied markedly between breasts and between feeds, and for six of thirteen breasts were positively related to how far the breast had been emptied. Infants rarely emptied the breast (mean 76% of available milk removed), and the storage capacity of a breast was related to the demand for milk from that breast. Milk supply is linked to infant demand through local (autocrine) control in each breast. Small physiological study. 10.1113/expphysiol.1993.sp003681
- Foong, S. C., et al. (2020). Oral galactagogues for increasing breast-milk production in mothers of non-hospitalised term infants. Cochrane Database of Systematic Reviews, CD011505.pub2. Evidence for fenugreek and other galactagogues is low to very-low certainty; effective, frequent milk removal is first-line. 10.1002/14651858.CD011505.pub2
- Dror, D. K., & Allen, L. H. (2018). Overview of nutrients in human milk. Advances in Nutrition, 9(suppl_1), 278S-294S. Review of how each nutrient in milk varies with lactation stage, maternal intake, status and supplementation. Thiamin, riboflavin, vitamin B-6, vitamin B-12, choline and iodine concentrations in milk are associated with maternal intake, and milk fatty acid composition depends on the mother's intake and status. Milk iron is not associated with maternal intake and iron supplementation does not raise it; zinc is refractory to maternal status, intake and supplementation; milk folate is unrelated to maternal folate status or intake; neither maternal status nor calcium or vitamin D interventions have shown an effect on milk calcium (dietary calcium may matter only where habitual intake is low). In well-nourished women, vitamin A intake or supplementation has much less influence on milk. Breast milk supplies the exclusively breastfed infant with only about 15 IU/d of vitamin D activity. 10.1093/advances/nmy022
- Brenna, J. T., Varamini, B., Jensen, R. G., Diersen-Schade, D. A., Boettcher, J. A., & Arterburn, L. M. (2007). Docosahexaenoic and arachidonic acid concentrations in human breast milk worldwide. The American Journal of Clinical Nutrition, 85(6), 1457-1464. Descriptive meta-analysis of 65 studies (2474 women). Mean breast-milk DHA was 0.32% of fatty acids by weight (range 0.06-1.4%), lower and more variable than arachidonic acid (0.47%, range 0.24-1.0%). The highest DHA concentrations were mainly in coastal populations and were associated with marine food consumption. 10.1093/ajcn/85.6.1457
- Centers for Disease Control and Prevention. (2026). Maternal diet and breastfeeding (breastfeeding special circumstances; last updated August 25, 2026). An additional 330 to 400 kcal per day is recommended for well-nourished breastfeeding mothers. Guidelines recommend 290 mcg of iodine daily during lactation. A low to moderate caffeine intake is about 300 mg or less per day, about 2 to 3 cups of coffee; irritability, poor sleeping patterns, fussiness and jitteriness have been reported in infants, and preterm and younger newborns break caffeine down more slowly, so their mothers might consume even less. Most fish contain mercury that can pass to the infant through breast milk. Breastfed infants of women who eat no animal products may have very limited vitamin B12. Women generally do not need to limit or avoid specific foods while breastfeeding. www.cdc.gov/breastfeeding-special-circumstances/hcp/diet-micronutrients/maternal-diet.html
- Wagner, C. L., Greer, F. R., American Academy of Pediatrics Section on Breastfeeding, & American Academy of Pediatrics Committee on Nutrition. (2008). Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics, 122(5), 1142-1152. Clinical report. Rickets from inadequate vitamin D intake and low sun exposure is still reported. Because natural dietary sources are limited and adequate sun exposure is hard to judge and may raise skin-cancer risk, all infants, including those exclusively breastfed, and all children and adolescents should have a minimum daily vitamin D intake beginning soon after birth. Breastfed and partially breastfed infants should be supplemented beginning in the first few days of life, continuing unless weaned to at least 1 L/day of vitamin D-fortified formula or whole milk; nonbreastfed infants taking less than 1000 mL/day of fortified formula or milk should also be supplemented (a stated dose; this site leaves the dose to the paediatrician). 10.1542/peds.2008-1862
- Kovacs, C. S. (2017). The skeleton is a storehouse of mineral that is plundered during lactation and (fully?) replenished afterwards. Journal of Bone and Mineral Research, 32(4), 676-680. Perspective review. Women who breastfeed exclusively lose an average of 210 mg calcium in milk each day (twins or triplets double or triple it), and skeletal calcium released during lactation provides much of it. Lumbar spine BMD declines by a mean of 5% to 10% during 3 to 6 months of exclusive lactation; mostly cortical sites lose half that or nothing. Losses come from osteoclast-mediated resorption and osteocytic osteolysis. After weaning the skeleton is fully restored to its prior mineral content and strength in animals and humans, despite persistent microarchitectural changes; the factors driving recovery are unclear. In most studies a history of lactation does not increase, and may protect against, low BMD and fragility fractures. 10.1002/jbmr.3090
- Kalkwarf, H. J., Specker, B. L., Bianchi, D. C., Ranz, J., & Ho, M. (1997). The effect of calcium supplementation on bone density during lactation and after weaning. The New England Journal of Medicine, 337(8), 523-528. Two randomized placebo-controlled trials of calcium in postpartum women (lactation study: 97 lactating and 99 nonlactating women from about 2 weeks postpartum; weaning study: 95 weaning and 92 nonlactating women). Lumbar spine bone density fell 4.2% in lactating women given calcium and 4.9% with placebo over 6 months, while it rose in nonlactating women. After weaning it increased 5.9% with calcium and 4.4% with placebo. Calcium had no effect on breast-milk calcium. Conclusion: calcium supplementation does not prevent bone loss during lactation and only slightly enhances the gain in bone density after weaning. 10.1056/NEJM199708213370803
- Woodley, S. J., Lawrenson, P., Boyle, R., Cody, J. D., Mørkved, S., Kernohan, A., & Hay-Smith, E. J. C. (2020). Pelvic floor muscle training for preventing and treating urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database of Systematic Reviews, 5, CD007471. 46 trials, 10,832 women, 21 countries; many trials at moderate to high risk of bias. Continent pregnant women doing antenatal PFMT probably have a lower risk of urinary incontinence in late pregnancy (62% less; RR 0.38; moderate quality) and slightly lower risk 3-6 months postpartum (29% less; RR 0.71; high quality). For postnatal women with persistent incontinence there is no evidence PFMT makes a difference at 6-12 months (RR 0.55, 95% CI 0.29-1.07; low quality), and the effect of PFMT started after delivery in a mixed population is uncertain (RR 0.88). Authors: early structured antenatal PFMT in continent women may prevent incontinence; a population approach to postnatal PFMT is not likely to reduce it; uncertainty surrounds PFMT as treatment in antenatal and postnatal women, in contrast with its more established effectiveness in mid-life women. 10.1002/14651858.CD007471.pub4
- World Health Organization. (2022). WHO recommendations on maternal and newborn care for a positive postnatal experience. Geneva: WHO (ISBN 9789240045989). Rec. 7: starting routine pelvic floor muscle training after childbirth to prevent urinary and faecal incontinence is not recommended; women who leak small volumes of urine after childbirth should be advised of its potential benefits, and unsupervised home exercises may be beneficial and are unlikely to cause harm. Rec. 18: screening for postpartum depression and anxiety with a validated instrument (such as EPDS or PHQ-9), with diagnosis and management for women who screen positive, is recommended; every woman should be asked about emotional well-being at each contact. Rec. 19: psychosocial and/or psychological interventions to prevent postpartum depression and anxiety are recommended. Rec. 20 (context-specific, from a 2016 conditional recommendation on low-certainty evidence): oral iron, alone or with folic acid, may be given for 6-12 weeks after birth where gestational anaemia is a public-health concern, irrespective of lactation. Rec. 21: postpartum vitamin A supplementation is not recommended. iris.who.int/handle/10665/352658
- Sperstad, J. B., Tennfjord, M. K., Hilde, G., Ellström-Engh, M., & Bø, K. (2016). Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. British Journal of Sports Medicine, 50(17), 1092-1096. Prospective cohort of 300 first-time pregnant women; DRA defined as a palpated separation of 2 or more fingerbreadths. Prevalence was 33.1%, 60.0%, 45.4% and 32.6% at gestation week 21 and 6 weeks, 6 months and 12 months postpartum. Women reporting heavy lifting 20 or more times a week were more likely to have DRA (OR 2.18). Women with and without DRA reported the same amount of lumbopelvic pain 12 months postpartum. 10.1136/bjsports-2016-096065
- Montgomery-Downs, H. E., Insana, S. P., Clegg-Kraynok, M. M., & Mancini, L. M. (2010). Normative longitudinal maternal sleep: the first 4 postpartum months. American Journal of Obstetrics and Gynecology, 203(5), 465.e1-465.e7. Wrist actigraphy in 50 mothers over postpartum weeks 2-13 and 24 mothers over weeks 9-16. Nocturnal sleep time was 7.2 h and did not change across weeks 2-16, but sleep efficiency improved from 79.7% at week 2 to 90.2% at week 16 as fragmentation fell. Total sleep was higher than expected, but it was highly fragmented (similar to fragmenting sleep disorders) and inefficient. 10.1016/j.ajog.2010.06.057
- NHS. (2026). Postnatal depression: overview (page last reviewed 18 March 2026). Feeling down, anxious or irritable for a few days after the birth is very common, sometimes called the baby blues, and usually goes away within 2 weeks. Postnatal depression can begin in pregnancy, soon after birth or up to a year after; symptoms include persistent low mood, lack of enjoyment and interest, trouble bonding with the baby, sleep problems, and thoughts of suicide or of harming yourself or your baby. Speak to a GP, midwife or health visitor if you think you might have it; fathers and partners can also have depression after having a baby. www.nhs.uk/mental-health/conditions/post-natal-depression/overview
- NHS. (2023). Mastitis (page last reviewed 17 March 2023). Mastitis is when the breast becomes swollen, hot and painful; it is common in breastfeeding women because it can be caused by a build-up of milk. It usually affects one breast and comes on quickly: a hot, painful swollen area, a wedge-shaped lump, burning while breastfeeding, and flu-like symptoms such as aches, a high temperature and tiredness. Keep breastfeeding regularly, check the baby's attachment, use cold compresses and painkillers; see a GP if symptoms do not improve 12 to 24 hours after treating it at home, or 48 hours after starting antibiotics. www.nhs.uk/conditions/mastitis